TH SEPTEMBER 2015 AT 1PM BOARDROOM ARTHOUSE SQUARE …€¦ · Clare Duggan 2.5 Public Health...

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP

GOVERNING BODY TUESDAY 8TH SEPTEMBER 2015 AT 1PM

BOARDROOM ARTHOUSE SQUARE (lunch to be provided at 12.30pm)

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

held on 11th August 2015 All 1.3 Matters Arising All Part 2: Updates 2.1 Feedback from Committees: Report no: GB 60-15

Quality Safety & Outcomes Committee - Dave Antrobus 18th August 2015

Primary Care Commissioning Committee - Dave Antrobus 21st August 2015

Finance Procurement & Contracting Committee Tom Jackson 25th August 2015

Committees in Common - 2nd September 2015 Katherine Sheerin

2.2 Feedback from CCG Network - 2nd September 2015 Report no: GB 61-15 Katherine Sheerin

2.3 Chief Officer’s Update Verbal Katherine Sheerin 2.4 NHS England Update Verbal Clare Duggan 2.5 Public Health Update Verbal Dr Sandra Davies 2.6 Update from Health & Wellbeing Board Verbal Dr Nadim Fazlani

of 2 11

Part 3: Performance 3.1 CCG Performance Report Report no: GB 62-15 Stephen Hendry Part 4: Strategy & Commissioning

4.1 Healthy Liverpool Investments – Report no: GB 63-15 Assistive Technology and PHR Investment Case Dr Maurice Smith/

Tony Woods

Part 5: Governance

5.1 Corporate Risk Register Report no: GB 64-15 Stephen Hendry

5.2 NHS Liverpool CCG Complaints, Concerns Report no: GB 65-15 And Compliments Policy (August 2015) Stephen Hendry

5.3 NHS Liverpool Clinical Commissioning Group Report no: GB 66-15

Quality Strategy (2015 – 2017) Jane Lunt

6. Questions from the Public

7. Date and time of next meetings: Extra-ordinary meeting: Tuesday, 29 September 2015 at 2pm, Boardroom, Arthouse Square Tuesday 13th October 2015 at 1pm Boardroom, Arthouse Square

For Noting: Quality Safety & Outcomes Committee – 2nd June 2015 Finance Procurement & Contracting Committee 4th August 2015 Committees in Common – 5th August 2015

Exclusion of Press and Public: that in view of the confidential nature of the business to be transacted, members of the public, press and non voting members be excluded from the

meeting at this point.

of 2 22

Report no: GB 60-15 NHS LIVERPOOL CLINICAL COMMISSIONING GROUP

GOVERNING BODY TUESDAY 8TH SEPTEMBER 2015

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

Maureen Williams Senior Management Team Lead

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

Report Author(s)

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

Summary The purpose of this paper is to present the key issues discussed, risks identified and mitigating actions agreed at the following committees: Quality Safety & Outcomes Committee - 18th

August 2015 Primary Care Commissioning Committee -21st

August 2015 Finance Procurement & Contracting Committee -

25th August 2015 Committees in Common - 2nd September 2015

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

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

committees

Impact on improving health outcomes, reducing inequalities and promoting

As per each Committee’s Terms of Reference

Page 1 of 12

2525

financial sustainability Relevant Standards or targets

Page 2 of 12

2626

QUALITY SAFETY AND OUTCOMES COMMITTEE

TUESDAY 18TH AUGUST 2015 3PM TO 5PM ROOM 2 4TH FLOOR ARTHOUSE SQUARE

A G E N D A

1. Welcome & Introductions ALL

2. Declaration of Interests ALL

3. Minutes and Action notes from 2nd June 2015 Chair

4. Matters Arising:

4.1 Safeguarding Capacity Flow Chart

5. Trust Contract Quality - Early Warning Dashboard QSOC 22-15

Kellie Connor

6. Liverpool Community Health – Pressure Ulcer reporting QSOC 23-15 and the management of Serious Incidents Denise Roberts 7. Liverpool Community Health Quality Review QSOC 24-15

Kerry Lloyd

8. Health Care Acquired Infection (HCAI) in the Liverpool QSOC 25-15 Health Economy (2015-2016 YTD) Kerry Lloyd

9. Safeguarding Service Report QSOC 26-15

Esther Golby

10. Update regarding Care Quality Commission QSOC 27-15 Inspections Kellie Connor

11. Care Act Update QSOC 28-15 Helen Smith

Page 3 of 12

2727

12. Liverpool Clinical Laboratories Verbal Denise Roberts

13. NHS Liverpool CCG Complaints, Concerns and QSOC 29-15 Compliments Policy (August 2015) Steve Hendry

14. Risk Register QSOC 30-15 Jane Lunt

15. Liverpool CCG Quality Strategy 2015-2017 QSOC 31-15

Kerry Lloyd

16. Discharge Planning – Internal Hospital Standards QSOC 32-15 Jane Keenan

Date & Time of next meeting Tuesday 20th October 2015 3pm to 5pm Meeting Room 2 Arthouse Square

Page 4 of 12

2828

LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Quality, Safety & Outcomes Committee

Meeting Date: 18th August 2015 Chair: Dave Antrobus

Key issues: Risks Identified: Mitigating Actions: 1. Poor discharge planning from acute

trusts.

• Patient flow within acute trusts is impeded.

• Poorer outcomes for patients due to

poor assessment.

• Lack of ownership at ward level.

• Hospital based discharge standards approved and implemented within acute trusts.

• Wider work around “discharge to

assess” approach continues.

2. Liverpool Community Health – current national approach to Serious Incidents process challenges ability to embed change regarding pressure ulcer prevention.

• Current Serious Incident process focusses on individualised approach to each incident – reducing potential for system learning and change.

• Future management will take a system approach – aggregating themes with one action plan to support improvement in pressure ulcer prevention and subsequent reduced incidence.

3. Liverpool Community Health in

enhanced surveillance due to requirement to improve quality of provision for some services.

• Difficult to assess pace of improvement due to internal and external influences – such as internal restructuring.

• Quality Review, led by NHS England late July 2015.

• Commissioners, NHS England and

LCH determine common understanding of current position.

• LCH remains on Enhanced

Surveillance.

• Review in 6 months – monitoring of improvement plan by CCGs.

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

Page 5 of 12 2929

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP PRIMARY CARE COMMISSIONING COMMITTEE

EXTRAORDINARY MEETING FRIDAY 21ST AUGUST 2015 AT 1PM

BOARDROOM – ARTHOUSE SQUARE

A G E N D A

Part 1: Introductions and Apologies 1.1 Declarations of Interest All Part 2: Strategy & Commissioning 2.1 Development of The Liverpool GP Provider PCCC 13-15 Organisation Katherine Sheerin 3. Any Other Business ALL 4. Date and time of next meeting: Tuesday 15th September 2015 10am Boardroom, Arthouse Square

Page 6 of 12 3030

LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Primary Care Commissioning Meeting Date: 21 August 2015 Chair: Dave Antrobus

Key issues: Risks Identified: Mitigating Actions:

1. The development of the Liverpool GP

Foundation • That the GP Federation does not

materialise in time to support delivery of enhanced Primary Care

• To recruit a senior manager (employed by the CCG) for 12 months to support the development of the GP Federation with accountability to the CCG.

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

Page 7 of 12 3131

FINANCE, PROCUREMENT AND CONTRACTING COMMITTEE TUESDAY 25 AUGUST 2015 AT 10:00am – 12:30pm

ROOM 2 – ARTHOUSE SQUARE

AGENDA

1. Welcome and Introductions All 2. Declaration of Interests (form available) All 3. Minutes and action notes of previous meeting held on 4 August 2015 Chair 4. St Helens & Knowsley Overperformance Report no:FPCC48-15

Teresa Clark / Derek Rothwell

5. Healthy Lung Pilot Report no:FPCC49-15 Michelle Timoney

6. Transition of Adult Services for Children & Report no: FPCC50-15

Young People with complex needs Jane Lunt/Alison Williams

7. Finance & Contract Performance update Report no:FPCC51-15 Phil Saha

8. Contract Update Verbal Alison Picton/ Derek Rothwell

9. Any Other Business All

Page 8 of 12 3232

Date of next meeting(s): 2015 monthly meetings: 4th Tuesday of the month 10am – 12:30pm

Room 2 – Arthouse Square

Tuesday 22 Sept 2015 10am-12.30pm

Room 2 Arthouse Square

Tuesday 27 October 2015 10am-12.30pm


Tuesday 24 November 2015 10am-12.30pm


Tuesday 22 December 2015 10am-12.30pm


Tuesday 26 January 2016 10am-12.30pm


Tuesday 23 February 2016 10am-12.30pm


Tuesday 22 March 2016 10am-12.30pm


Page 9 of 12 3333

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

Meeting Date: 25 August 2015 Chair: Dr Nadim Fazlani

Key issues:

Risks Identified: Mitigating Actions:

1. Implementation of Healthy Lung Pilot

• Procurement route for an innovative and evolving pilot may hamper implementation

• 6 monthly iterative contracts, potentially for the 3 years of the pilot.

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

Page 10 of 12 3434

HEALTHY LIVERPOOL PROGRAMME RE-ALIGNING HOSPITAL BASED CARE

COMMITTEE(S) IN COMMON (CIC)

KNOWSLEY, LIVERPOOL AND SOUTH SEFTON CCGS

WEDNESDAY 2nd SEPTEMBER 2015 Civic Suite, Runcorn Town Hall, Heath Road, Runcorn WA7 5TD

Time 4:00pm – 5:30pm

1. Welcome and Introductions All

2. Minutes / Actions from the 5th August 2015 Meeting All

3. Healthy Liverpool Programme overview T Jackson

4. Strengthening commissioning across CCGs K Sheerin

5. Update from NHS England (Specialised Commissioning) A Bibby

6. Key Next Steps All

7. Any other business All

8. Date of Next Meeting – Wednesday 7th October 2015 4:00pm - 5:30pm (venue same as the CCG Network)

Page 11 of 12 3535

LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: Healthy Liverpool Committees

in Common Meeting Date: 2 September 2015 Chair: Dr Nadim Fazlani

Key issues: Risks Identified: Mitigating Actions: 1. Joint working across Knowsley, South

Sefton and Liverpool CCGs in commissioning hospital services

• Lack of alignment of plans leading to poorer quality services

• Map of current work/plans across key areas

• Agree common approach • Meet jointly with providers to share

plans Recommendations to NHS Liverpool CCG Governing Body:

1. Note the key issues and risks

Page 12 of 12 3636

Report no: GB 61-15

NHS LIVERPOOL CLINICAL COMMISSIONING GROUP GOVERNING BODY

TUESDAY 8TH SEPTEMBER 2015

Title of Report Feedback from Merseyside Clinical Commissioning Groups Network

Lead Governor Dr Nadim Fazlani, Chair

Senior Management Team Lead

Katherine Sheerin, Chief Officer

Report Author

Katherine Sheerin, Chief Officer

Summary The purpose of this paper is to present the key issues discussed, risks identified and mitigating actions agreed at the Merseyside CCG Network on 2nd September 2015. This will ensure that the Governing Body is fully engaged with the work of the Merseyside CCG Network and reflects sound governance and decision making arrangements for the CCG.

That Liverpool CCG Governing Body: Considers the reports and recommendations

from Merseyside CCG Network

Impact on improving health outcomes, reducing inequalities and promoting financial sustainability

By working collaboratively with CCGs across Merseyside we will ensure that opportunities are maximised for Liverpool patients and the consequence of commissioning services understood and managed.

Relevant Standards or targets

Standards of Good Governance Putting Patients First 2014 – 16 Everyone Counts: Planning for Patients 2014/15

Page 1 of 3 3737

JOINT CHESHIRE & MERSEYSIDE CCG NETWORK Wednesday 2nd September 2015, 13.00 pm to 16.00pm

Lunch available from 12.30pm. Civic Suite, Runcorn Town Hall Heath Road, Runcorn, WA7 5TD

Time No

Item

Verbal or

Report

Lead

13:00 15/124 Welcome Verbal Simon Banks

13:05 15/125 AQUA Verbal Dave Fillingham

13.20 15/126 DOS Benchmarking Review Paper Ian Davies

13.35 15/127 Liverpool City Region Verbal All

13.50 15/128 Future of MSK Services Verbal Sharon Elliott

14.05 15/129 Neuro Rehab Update Verbal Martin Stanley

14.20 15/130 NWCSU Transition Verbal Martin Stanley

14.35 15/131 Specialised Commissioning Follow Up Verbal Simon Banks

14.50 15/132 Maternity Review Verbal Simon Banks

15.05

15/133

Updated On Call Arrangements

Verbal

Dianne Johnson

15.20

15/134

Divert/ Deflect Policy

Paper

Simon Banks

15.35

15/135

C&M Strategic Clinical Networks Business Plan 2015-16

Paper

Simon Banks

15.50

15/136

Collaborative Stroke Network

Verbal

Dave Sweeney

16:00

15/137

Any Other Business

Verbal

Simon Banks / All

Page 2 of 3

3838

LIVERPOOL CCG CORPORATE GOVERNANCE TEMPLATE – COMMITTEE MINUTES Committee: CCG Network

Meeting Date: 2 September 2015

Chair: Simon Banks (NHS Halton CCG)

Key issues:

Risks Identified: Mitigating Actions:

1. Need to consider future joint working across CCGs to maximise commissioning potential.

• Loss of local identity • Loss of existing areas of good practice

• Options to be considered by CCG Network/each CCG.

• Paper to be developed by K Sheerin.

2. Strategic Clinical Networks Business • Lack of coherence/alignment across commissioners/SCNs leading to duplication of effort/delays in agreeing service changes.

• Meeting with SCN lead to explore how commissioners/SCNs can support and complement each other.

Recommendations to NHS Liverpool CCG Governing Body:

1. Agreement to create a joint approach to developing stroke services across Merseyside, with implementation on a North and Mid Mersey footprint

Page 3 of 3 3939

Report no: GB 62-15


GOVERNING BODY


Title of Report CCG Corporate Performance report

Lead Governor Dr Nadim Fazlani


Stephen Hendry, Acting Head of Operations and Corporate Performance

Report Author


Summary The purpose of this paper is to report to the Governing Body key aspects of the CCG’s performance in delivery of quality, performance and financial targets for month 4 (July) 2015/16.

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

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


The report provides evidence of the progress being made across the organisation at both an organisational and individual service provider level.


NHS Outcomes Framework 2015/16; The Forward View Into Action: Planning for 2015/16; CCG Assurance Framework 2015/16

Page 1 of 22

41

LIVERPOOL CCG PERFORMANCE REPORT SEPTEMBER 2015 1. PURPOSE The purpose of this paper is to report to the Governing Body key aspects of the CCG’s performance against delivery of quality, performance and financial targets for the financial year 2015/16. 2. RECOMMENDATIONS That Liverpool CCG Governing Body: Notes the performance of the CCG in delivery of key national performance

indicators and the recovery actions taken to improve performance, if required. 3. BACKGROUND The CCG is held to account by NHS England for corporate performance against delivery of key indicators within the CCG Outcome Indicator Set of the NHS Outcomes Framework 2015/16 and operational standards expected from the NHS Constitution. For the financial year 2015/16, the CCG also has to demonstrate how it is to fulfil the vision set out in the NHS Five Year Forward View whilst continuing to deliver high quality and timely care for the people of Liverpool. The CCG therefore has to be assured that the services we commission are delivering the required quality standards and that any risks and issues relating to service quality and patient safety are identified; with positive action taken to address areas of sub-optimal performance. The CCG has established robust governance frameworks and committee structures in order to monitor performance and provide assurance to the Governing Body that key risks to the organisation are being identified and effectively managed. For example, the Quality, Safety and Outcomes Committee has responsibility for quality and performance issues within its commissioned services, whereas the Finance, Procurement and Contracting Committee has responsibility for financial monitoring and contract activity. The Performance Report for the financial year 2015/16 will provide a summary of CCG performance in relation to the NHS Outcomes Framework 2015/16 (including newly

Page 2 of 22

42

introduced Mental Health access waits indicators) and performance analysis against key Public Health/local outcomes; providing the Governing Body with an integrated report structure which maps progress against statutory reporting requirements, measurement across the priority programme areas of Mental Health; Healthy Ageing; Long Term Conditions; Children; Learning Disabilities, Urgent Care and Cancer. Due to the way in which these indicators are measured, a high proportion of these elements will be reported on a quarterly and annual basis, or as and when key data is made available/refreshed. Due to the transitional direction of commissioning support services, some issues in relation to the quality, timing and accuracy of some data flows still remain. The CCG Business Intelligence (BI) Team continue to work closely with CSU to ensure continuity and stability of key information areas. The structure, content and presentation of the Corporate Performance report continues to develop in 2015/16 with the aim of presenting a more detailed analysis in terms of quality and patient safety. The report is based on the published and validated data available as at 31st July 2015. As a consequence of the timing of submissions to meet NHS Liverpool CCG’s governance reporting and data schedules, this report updates the Governing Body with a combination of data up to the end of May and/or June 2015. 4. NATIONAL PERFORMANCE MEASURES NHS Liverpool CCG is committed to ensuring that patient rights under the NHS Constitution are consistently upheld. National Performance Measures are reflective of the key priority areas detailed in the NHS Outcomes Framework 2015/16 and include measurements against Quality (including Safety, Effectiveness and Patient Experience) and Resources (including Finance, Capability and Capacity). In addition to analysing local performance against these indicators, CCGs are expected to achieve improvements against indicators across the five domains as detailed in the NHS Outcomes Framework and NHS Operational Planning Measures 2015/16 which represent the high-level national outcomes the NHS is expected to be aiming to improve. Headline commentary is provided below to draw the Governing Body’s attention to specific areas of performance which represent risks to delivery, and to the relevant assurances on internal control measures in place to mitigate those risks.

Page 3 of 22

43

4.1 Access & Waiting Times 4.1.1 Good Performance Indicator Narrative A&E Waits - % of patients who spend 4 hours or less in A&E (cumulative) 95% threshold GREEN

A&E (all types) performance data for July 2015 has the CCG performing at 96.5%, maintaining a ‘Green’ rating for the third consecutive month. At Trust level the Royal Liverpool achieved 96.7% (all types) for July 2015 whilst Aintree Hospital maintained its positive performance at 96.3% (all types). Provisional trust data released for August 2015 for A&E Type 1 performance however suggests that the Royal Liverpool Hospital was below target at 92.40% for August 2015 (91.67% year-to-date) whilst Aintree Hospitals Type 1 performance was 89.04%. The A&E performance trajectory dashboard was not available for July or August 2015 and is therefore not included as an appendix to this report.

Assurance on CCG control measures Aintree Hospitals and the Royal Liverpool A&E performance continue to be discussed formally by the System Resilience Group (SRG). Focus now moves from recovery to supporting sustained achievement of the 4hr standard at both Trusts (the RLBUHT Recovery Plan continues to be monitored closely by the CCG).

Page 4 of 22

44

Indicator Narrative Ambulance Response Times. GREEN

Individual CCG performance for July 2015 (which was not available for the August 2015 Governing Body Performance Report) is summarised below:

• Red 1: 8 minute response - 88.2% against 75% target (87.3% year-to-date)

• Red 2: 8 minute response - 84.3%% against 75% target (year-to-date 85.3%)

• All Reds: 19 minute response – 96.4% against 95% target (year-to-date 97.6%)

At Trust level, NWAS performance through August 2015 has held up well overall, with the three national targets delivered at both a North West and Cheshire & Merseyside level (CCG Specific level data for August is not yet available).

• Red 1: NW 77.64%; C & M 79.10% • Red 2: NW 75.50%; C & M 76.57% • All Reds: NW 95.12%; C & M 96.84%

Assurance on CCG control measures The Trust continues to work closely with commissioners to maximise the opportunities of ‘heal and treat’ and ‘see and treat’ responses as an alternative to conveyance to hospital.

Indicator Narrative Diagnostics - Percentage of Patients waiting for more than 6 weeks for a diagnostic test (target – 1%) GREEN (July 2015)

June CCG performance against the diagnostic measure is below the 1% threshold for the second consecutive month, with June 2015* figures reported at 0.43% (only a slight increase from 0.39% in May 2015).As with RTT, there is no updated CCG position for diagnostics due to NHS England aligning the publication dates of performance data which is anticipated to delay release for 6-7 weeks. July 2015 data will therefore be included in the October 2015 Performance Report. Validated June 2015 performance* at provider level (not previously reported) shows the Royal Liverpool as achieving 0.67% and Aintree Hospitals at 0.41%. Alder Hey has recovered to perform below 1% for the first month since March 2015 at 96%. *Commissioner level data is historically published one month ahead of provider level data.

Assurance on CCG control measures June 2015 diagnostic performance for Alder Hey confirms that the backlog issues have been addressed through the Trust’s recovery plan. The CCG will, however, continue to monitor the situation and ensure that sustained performance is achieved for the remainder of 2015/16.

Page 5 of 22

45

Indicator Narrative Referral To Treatment (18 Weeks) Referral to Treatment (52 Weeks) GREEN (July 2015)

Liverpool CCG’s performance for June 2015 was reported as ‘Green’ across all six RTT measures. Unfortunately, there is no updated CCG position for RTT due to NHS England aligning the publication dates of performance data, which is anticipated to result in a 6-7 week delay in data being published. July 2015 data will be published in October 2015 and will therefore be included in the October 2015 Performance Report. Exception reporting of RTT performance data at provider level for June 2015* is as follows: • Liverpool Heart and Chest Failed two of the three RTT targets at

Catchment level for the third consecutive month. For June 2015 the Trust reported 79.5% for Admitted Patients and 87.86% for Non-Admitted. An agreement was in place with Monitor to fail the Quarter 1 Admitted target. As previously reported, the Trust has experienced a backlog of cardiac cases (attributed to an increase in referrals from September 2014) which resulted in non-compliance of the ‘Incomplete’ target.

*commissioner level data is published one month ahead of provider level

Assurance on CCG control measures (RTT) Liverpool Heart & Chest has continued with its recovery plans to address demand and reduce the backlog, and anticipates that the RTT target will be achieved for Quarter 2 2015/16.

Page 6 of 22

46

Indicator Narrative Cancer Waiting Times (All measures) GREEN (with alert for 2

measures)

Although The CCG has met (and indeed exceeded) all cancer targets in-month for June 2015, year-to-date performance is rated as ‘Amber’ against the two following measures: Amber

Amber

Provider level under-performance driving the above areas relate to the following Trusts; Maximum two-month (62-day) wait from urgent GP referral to first definitive treatment for cancer: Liverpool Heart and Chest – Although Trust performance has increased quite substantially from the 58.1% in May to 84.4% in June 2015 it is still marginally below the 85% target. The Trust is also below the year-to-date target, with cumulative performance at 72.4%. Breaches in June were within admitted care. The majority of breaches to date have been attributed to late referrals between trusts. Liverpool Heart & Chest is also underperforming against the ‘consultant’s decision to upgrade’ 85% measure; both in-month (72.2%) and year-to-date (82.9%). Liverpool Women’s – Although the Trust has increased performance to 83.3% in June 2015 it still falls below target. Year-to-date performance is also marginally below the 85% target at 82.9%. Numbers of breaches are small, however and should be considered within the context of the percentage figures reported.

Assurance on CCG control measures Lung services continue to struggle with delivery of the 62 day target due to clinical pathway complexity, tertiary referrals, and some pathway variation across the network. As previously reported, a Lung Pathway Group has been established at network level to critically review and analyse lung pathways, and promote best practice. Performance is regularly reviewed at Trust level and focus is on reducing time to decision to treat and understanding variation across the network. Action plans are completed for all cancer breaches, and performance monitored closely every month at Trust level.

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer – YTD performance is below the 85% threshold at 83.3% In the period April – June 2015 a total of 43 out of 255 patients have breached the standard (although the majority of these cases have been attributed to late referrals between Trusts).

Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers) - CCG in-month performance for June reached 90% but YTD is measured at 81.8%. In the period April-June 2015 a total of 6 breaches have occurred out of a cohort of 34 patients.

Page 7 of 22

47

Indicator Narrative Diagnostics - Percentage of Patients waiting for more than 6 weeks for a diagnostic test (target – 1%) GREEN (July 2015)

June CCG performance against the diagnostic measure is below the 1% threshold for the second consecutive month, with June 2015* figures reported at 0.43% (only a slight increase from 0.39% in May 2015).As with RTT, there is no updated CCG position for diagnostics due to NHS England aligning the publication dates of performance data which is anticipated to delay release for 6-7 weeks. July 2015 data will therefore be included in the October 2015 Performance Report. Validated June 2015 performance* at provider level (not previously reported) shows the Royal Liverpool as achieving 0.67%, Aintree Hospitals 0.41%. Alder Hey has recovered to perform below 1% for the first month since March 2015 at 96%. *Commissioner level data is historically published one month ahead of provider level data.

Assurance on CCG control measures June 2015 diagnostic performance for Alder Hey confirms that the backlog issues have been addressed through the Trust’s recovery plan. The CCG will, however, continue to monitor the situation and ensure that sustained performance is achieved for the remainder of 2015/16.

4.2 NHS Outcomes Framework - Helping People to Recover from Episodes of Ill Health or following Injury 4.2.1 Good Performance Indicator Narrative TIA – % patients assessed and treated within 24 hours (Target 60%) GREEN

Liverpool CCG continues to demonstrate good performance against this standard with an achievement of 100% for June 2015*. The CCG therefore maintains the ‘Green’ rating against this key measure in terms of year-to-date performance. *Local sourced data is made available direct from provider organisations to facilitate early indication of performance reported to NHS England.

Page 8 of 22

48

Indicator Narrative Stroke – (% of patients spend at least 90% of their time on a Stroke Unit (Target 80%) GREEN

CCG performance against the 90% Stroke measure for June 2015* is positive with an achievement of 84.62%. *Local sourced data is made available direct from provider organisations to facilitate early indication of performance reported to NHS England.

4.3 Ensuring People Have a Positive Experience of Care 4.3.1 Good Performance Indicator Narrative Mixed Sex Accommodation – zero tolerance of breaches GREEN

No new Mixed Sex Accommodation breaches relating to Liverpool CCG were reported in July 2015 (maintaining zero LCCG cases for the year-to-date). At provider level, the following breaches were reported but not related to Liverpool patients: Liverpool Heart & Chest recorded six breaches in July 2015, bringing the total reported by the Trust in 2015/16 to 14 cases. The causes of breaches continue to be attributed to inability to transfer out of Critical Care.

Assurance on CCG control measures The Trust issues with patient flow out of Critical were reported to the LHC Board in May 2015. Financial penalties will continue to be applied where appropriate and progress against the Trust Action Plan will be monitored through the Clinical Quality and Performance Meetings.

Page 9 of 22

49

4.3 Health Care Acquired Infection (HCAI) 4.3.1 Good Performance Indicator Narrative Incidence of Healthcare Acquired Infections – C.difficile Monthly plan tolerance of 11 Annual plan of 138 for 2015/16 GREEN

The CCG had 11 new cases of C.Diff reported in July 2015, bringing the year-to-date total to 48 (four above plan accumulatively expected for this point of the year). Of the 11 cases reported in July 2015, five have been reported as ‘Acute acquired’ with the remaining six attributed to community. Provider level reporting is summarised as follows: • Royal Liverpool - (1 Acute, 6 Community); • Aintree Hospitals - (2 Acute); • Alder Hey - (1 Acute) • St Helens & Knowsley (1 Acute) •

Assurance on CCG control measures (C.diff) The CCG has supported the development of a Root Cause Analysis tool to determine any lapses in care across the health economy and identify potential areas for improvement. This tool will be piloted piloting in September/October 2015 following evaluation by Edge Hill University. The CCG continues to hold C.Difficile appeals panels to review any cases where the Trust concerned considers there to be no ‘lapse in care’ episodes, although no further panels have been required for the Acute Providers at this time (most providers are under trajectory). Each provider has submitted the relevant documentation pertinent to C.diff cases for year-to-date review (as per NHS England guidance). Liverpool CCG also continues to support South Sefton CCG in relation to cases submitted by Aintree Hospitals. 4.3.2 Areas for Improvement Indicator Narrative Incidence of Healthcare Acquired Infections – MRSA (Plan tolerance of 0) RED

Two new confirmed cases of MRSA affecting Liverpool patients were reported in July 2015. Year-to-date total is now four cases against a plan tolerance of zero. Both cases were reported by Aintree Hospitals and categorised as ‘community acquired’. As a result of the validation process, the two cases allocated to Alder Hey in June 2015 have now been removed, bringing down the total cases reported by the Trust in 2015/16 to two.

Page 10 of 22

50

Assurance on CCG control measures (MRSA) Each MRSA case reported is subject to robust Post Infection Review (PIR) processes with appropriate remedial action plans put in place to address any gaps in quality or safety and prevent recurrences. 4.6 NHS Outcomes Framework - Treating and Caring for People in a Safe Environment 4.6.1 Good Performance Indicator Narrative Never Events (Plan of Zero) GREEN

The CCG is rated as ‘Green’ for the month of July 2015 and for year-to-date 2015/16 against a ‘zero tolerance’ for Never Events. No new Never Events have been reported at provider level during July 2015

Assurance on CCG control measures (Never Events) All providers who report Never Events triangulate each incident where there is evidence of non-compliance of the WHO checklist. The CCG works closely in partnership with providers to ensure that all Serious Incidents/Never Events result in organisational and system-wide learning from their Root Cause Analysis. At a system-wide and regional level, NHS England has established a Quality & Safety Forum/Patient Safety Collaborative which has recently focused on Never Events and the learning from these incidents (Liverpool Community Health recently presented their findings from internal reviews of community dental Never Events to the Forum to disseminate learning across the wider health economy).

Page 11 of 22

51

4.6.2 Areas for Improvement Indicator Narrative Serious Incidents – reporting within 48 hours (national target) The 48 hour national timescale is in place to ensure that providers of healthcare services alert commissioners to each event where a patient has suffered significant harm or death as a result of their care. The early detection and reporting of Serious Incidents is essential for both providers and commissioners in order to agree immediate actions to prevent further harm occurring. AMBER

A total of 18 Serious Incidents (SIs) were assigned to Liverpool CCG in July 2015, bringing the CCG year-to-date total to 72. At provider catchment level, a total of 38 Serious Incidents were reported on the Strategic Executive Information System (StEIS); 32 within the national 48hr timescale. Overall provider performance has continues to be affected by Liverpool Community Health, with the Trust reporting nine out of 17 incidents occurring in-month within the 48 hour timeframe. Provider catchment level data is as follows: • The Royal Liverpool reported 7 incidents for July 2015 (19

reported year-to-date). Once incident was reported outside of the 48hr standard.

• Alder Hey reported zero incidents during July 2015 (6 year- to-date). All incidents were reported within 48hrs;

• Liverpool Women’s Hospital reported two Serious Incidents for the month of July 2015, both within 48hrs. The Trust has reported a total of 7 incidents year-to-date.

• Liverpool Community Health reported 19 SIs in June 2015 (52 year-to-date);

• Mersey Care reported 14 SIs in July 2015 (46 year-to-date) all within the 48hr timescale;

• Liverpool Heart & Chest reported one incident in July (2 year-to-date) both within 48hrs

• Spire Hospital both reported zero incidents in-month and have zero incidents year-to-date

Assurance on CCG control measures (Serious Incidents) This indicator aims to provide the Governing Body with a measurable level of assurance that all Serious Incidents are reported within nationally determined timescales and that provider investigations into the root causes are commenced at the earliest possible opportunity. There has been a significant improvement in the reporting of Serious Incidents within the 48 hour timeframe across all providers; the only outlier for this is Liverpool Community Health although work is ongoing between the CCG and LCH to improve this key area of performance..

Page 12 of 22

52

Indicator Narrative Serious Incidents –Submission of investigation reports within 60 days (national timescale) The 60 day national timescale is in place to ensure that providers of healthcare services conduct timely and thorough Root Cause Analysis (RCA) investigations into Serious Incidents. Within this standard is the requirement for providers to submit outcomes-based action plans to improve the quality and safety of services and to limit or eliminate recurrences of incidents. Where extensions of time have been agreed with the provider the new deadline is used as the performance measure. RED

During the month of June 2015, a total of 38 Root Cause Analysis investigation reports were due for submission to commissioners. Overall provider compliance with the 60 day standard is again rated as ‘Red’ with 15 reports submitted inside of the stipulated 60 day timescale. Individual provider performance for June is summarised below: • Royal Liverpool - five RCA investigation report due for

submission in-month, one of which was submitted outside of the deadline;

• Alder Hey – two RCA reports due in-month, zero submitted within the timescale;

• Liverpool Women’s Hospital - one RCA report due in-

month and submitted within the timescale; • Mersey Care A total of 16 RCA reports due in July 2015

with 6 of those submitted within the national timescale; • Liverpool Community Health – 14 investigation reports

due in-month, with 7 meeting the deadline. A total of 8 Serious Incidents were ‘closed’ by commissioners during the month of July 2015; half of which of related to Liverpool Community Health. A total of 285 Serious Incidents currently remain open (from 1st April 2015).

Assurance on CCG control measures Liverpool Community Health remains as an outlier for this measure and the CCG is actively engaged with the Trust work stream focussing on Pressure Ulcer incidents and learning gathered. The CCG has well-established, clinically led internal performance management arrangements of all Root Cause Analysis reports received for co-ordinating commissioner review. Incidents are not authorised to be ‘closed’ unless the report complies with a nationally recognised checklist and all improvement actions are evidentially assured and signed off by the relevant organisation. Joint working arrangements with CCG colleagues across Merseyside are also in place where patient flow crosses geographical and organisational boundaries.

Page 13 of 22

53

5. INTEGRATED PERFORMANCE OUTCOMES INDICATORS Integrated CCG Outcomes Indicators have been developed from NHS Outcomes Framework and Public Health indicators and are intended to provide clear and comparative information on progress against local priorities for quality improvement and to demonstrate where the CCG is achieving gains in health outcomes for the population of Liverpool. Data for these outcomes are generally refreshed on a quarterly basis. The next set of outcomes related measures will be included in the October 2015 Governing Body Performance Report. 6. CCG QUALITY PREMIUMS The Quality Premium will be paid to Liverpool CCG in 2016/17 to reflect the quality of the health services we commission, improvements in health outcomes and reduction in health inequalities during 2015/16. Payments will be made based on CCGs’ achievement of the following measures, which cover a combination of national and local priorities. The updated Quality Premium Dashboard is included as Appendix 4. Due to the revised data flows and reporting schedule of the Quality Premium, it is proposed that the updated Quality Premium Dashboard will be routinely included in the report appendices each month, but will only be accompanied by a more detailed analysis/narrative on the CCG’s position on a quarterly basis. Premium Quarterly Reporting for the remainder of the financial year 2015/16 is presented below:

• Q2 2015/16 - November 2015 Governing Body • Q3 2015/16 - February 2016 Governing Body • Q4 2015/16 -May 2016 Governing Body (includes final position for measures

where CCG can provide a final position) 7. NHS TRUST CLINICAL QUALITY AND NHS CONSTITUTIONAL RIGHTS In line with the recommendations of the National Quality Board (NQB) the Quality, Safety and Outcomes Committee have established a Quality Early Warning Dashboard. The purpose of this dashboard is to provide the CCG with a system to identify any issues and risks relating to patient quality and safety; particularly for those areas identified by the NQB as potential indicators of quality and safety issues. The dashboard covers all NHS Trusts within the Merseyside area and includes Risk Profiles for each organisation issued by the Care Quality Commission (CQC) and Monitor Risk and Financial Ratings. Where risks have been identified they will be actively managed through CCG governance arrangements overseen by the Quality, Safety and Outcomes Committee,

Page 14 of 22

54

Trust Clinical Quality and Performance Meetings and collaborative commissioning arrangements with Merseyside CCGs. 7.1 Care Quality Commission and Monitor Warning/Issue Notices & Inspections Where providers are not meeting essential standards, the CQC has a range of enforcement powers to protect the health, safety and welfare of people who use the service (and others, where appropriate). When the CQC propose to take enforcement action, the decision is open to challenge by the provider through a range of internal and external appeal processes. Although further information in relation to follow-up inspections or reports by the CQC is not available, the CCG has continued to work closely with all providers recently subjected to improvement notices. 7.2 CQC Inspections of Liverpool GP Practices Since the August 2015 Corporate Performance report The Care Quality Commission has published two reports relating to Liverpool GP practices, summaries of which are detailed below.

• Princes Park Health Centre (SSP Health) – Overall Rating ‘Inadequate’

The CQC carried out an announced comprehensive inspection at Princes Park Surgery on 16th April 2015. Overall the practice was rated as inadequate and required improvements for the safe, effective treatment of patients, how caring and responsive the practice was and how well the practice was led. Summarised findings from the CQC Inspection Report are as follows:

The provider did not deploy sufficient numbers of GPs to meet the

demands of patients, including in response to their urgent needs. The high usage of locum and agency GPs resulted in a lack of continuity of care, increasing the risk of patient incidents and complaints;

There were insufficient numbers of patient appointments to meet the demands of the local population. Patients regularly had to wait outside the practice before it opened to ensure they got an appointment for later that day;

Staff understood their responsibilities to raise concerns, and to report incidents and near misses;

Reviews and investigations were not thorough enough and lessons learned were not communicated widely enough to support improvement;

Page 15 of 22

55

No system in place to ensure locum GP’s were monitored closely enough to ensure any changes to a patients care and treatments was actioned;

The CQC has also requested that the practice develop an action plan to increase the practice performance for cervical smear updates. A full version of the report can be downloaded at: http://www.cqc.org.uk/sites/default/files/new_reports/AAAC0986.pdf

7.3 CQC Hospital Monitoring Intelligence Reports The CQC developed this set of indicators through consultation and testing to replace Quality Risk Profiles. ‘Intelligent Monitoring’ uses a set of indicators for monitoring risks to the quality of care and measure outcomes that have a high impact on people who use services (and relate to the five key questions that are asked during CQC inspections, namely are services safe, effective, caring, responsive, and well-led? The CCG, through individual Clinical Quality and Performance Groups (CQPGs) maintains a focus on those areas that are not included in the Quality Schedule and are highlighted within the Hospital Monitoring Intelligence Reports. Each report contains a dashboard which provides a rating of ‘risk’ or ‘elevated risk’ to the five key questions. The CQC has not published any further dashboards since 29th May 2015 (which were reported to the Governing Body in the July 2015 Performance Report). Summaries of updated dashboards will be presented to the Governing Body when made available. 8. CCG FINANCIAL POSITION The financial statements for the month ended 31st July 2015 showed an under spend against budget totalling £6.4m. As at 31st July 2015 the CCG total allocation was £849.7m, including £62.3m in respect of Primary Care Co-commissioning (additional funding of £0.5m was transferred to the CCG in July 2015). Total Running Cost Allowance is £10.4m and the remaining allocation of £839.3 relates to programme funding. No significant risks to the achievement of the planned £14m surplus have been identified in the year to date.

Page 16 of 22

56

http://www.cqc.org.uk/sites/default/files/new_reports/AAAC0986.pdf

http://www.cqc.org.uk/sites/default/files/new_reports/AAAD6052.pdf

The summary position is described in the tables below:

Area Commentary Rating - Year to Date Rating – 31 March 2016

Balanced Position On track

Surplus No significant issues

2% Non recurrent Investment No significant issues

Running Cost AllowanceRunning Costs expected to be fully util ised in 2015-16

Annual Budget

Year to Date

BudgetActual Variance Variance

£'000 £'000 £'000 £'000 %

Operating Cost Statement - 31st July 2015

Total Expenditure

Total Allocation 849,772 275,058 275,058 0 0.00

825,299

10,429

YEAR TO DATE POSITION

835,728 270,376 263,978 -6,398 -2.37

260,646 -6,398 -2.40

Running Cost Allowance 3,332 3,332 0 0.00

Total Programme Costs 267,044

Page 17 of 22

57

9. SUMMARY Where performance is at variance to plan action is underway with Trusts to deliver corrective action to improve performance in 2015/16 with contractual levers utilised to support improvements. These improvements are actively led by CCG Clinicians.

Stephen Hendry Acting Head of Operations & Corporate Performance

1st September 2015

Vendor type

Total Number

of Invoices

Paid

Total Paid

within Target %age

Total Value of Invoices

Paid£'000

Value Paid

Within Target £'000 %age

NHS 997 966 96.89% 185,777 185,188 99.68%

NON NHS 4,275 4,105 96.02% 36,739 35,822 97.51%

Better Payment Practice Code - April to July 2015

Page 18 of 22

58

Appendix 1 – Corporate Performance Dashboard

Page 19 of 22

59

of 22

60

APPENDIX 2 – CCG HOSTED PROVIDERS DASHBOARD

Page 21 of 22

61

APPENDIX 3 – QUALITY PREMIUM DASHBOARD

Page 22 of 22

62

Report no: GB 63-15


TUESDAY 8th SEPTEMBER 2015

Title of Report Assistive Technology and PHR Investment Case

Lead Governor Dr Simon Bowers, Clinical Director, Digital Care and

Innovation Programme


Tony Woods, Programme Director, Community and Digital Care Programmes

Report Author

Dave Horsfield, Programme Manager, Digital Care and Innovation Programme

Summary This investment case details the funding requirements to deliver the objectives of the Assistive Technology and Person Held Record components of the Digital Care and Innovation Programme. The investment is for £15,055,311 over the next 3.5 years (to 31st March 2019).

Recommendation That Liverpool CCG Governing Body:

• Approves the investment of £15,055,311 over the next 3.5 years to enable delivery of the Digital Health workstream of Healthy Liverpool.


The programme impacts on improving health outcomes by supporting:-

• Reduction in emergency admissions • Increase in self care • Improve health literacy • Increase clinical productivity • Increase digital inclusion • Increase economic growth of SME sector in eHealth

Page 1 of 2 6565

• Reduce social isolation • Improve quality of life for patients and carers


Supporting requirement of NHS Five Year Forward View

Page 2 of 2 6666

1

Investment Proposal

Programme Digital Care & Innovation (Assistive Technology and PHR)

Outline of Proposal Programme description and Scope This investment proposal follows the work undertaken by the ‘more independent’ or Mi programme, co-‐funded by Innovate UK and Liverpool Clinical Commissioning Group (and previously Liverpool PCT) over the past three years. The programme was initially high-‐risk in nature bringing together health, community, housing, social care and technology sectors to demonstrate how assisted living technologies and supported services can promote self-‐care, integrated care and independent living, provide top quality health and social care, and enhance people’s wellbeing. The approaches utilised by the Mi programme of combining community assets, existing health services and technology have yielded great success and despite pre-‐dating the Healthy Liverpool Programme (HLP), Mi’s aspirations, targets and achievements have been found to be entirely convergent with those of HLP. This is a comprehensive, multi-‐faceted, structured and integrated programme designed to develop, deliver, improve and continuously assess LCCG’s digital care and innovation agenda. It builds on the Mi programmes activity, experience and evidence base. This supports continuity, enables success factors to be incorporated and lessons learnt to be reflected in the next phase of activity. Specifically, the health technology dimension builds on the introduction of successful pathways, content and procedures to further scale up and enhance the telehealth programme and the introduction of the “Flo”, simple telehealth initiative. It exploits the foundations laid for the scaling up of care technology in people’s homes and care settings that support self-‐care, promote healthy lifestyles and enable people to live independently for longer. It draws on lessons learnt from ground-‐breaking initiatives designed to create the infrastructure that can support the development of a consumer market in smart solutions for people’s ageing, independent living and care. It builds on current foundations that will provide quick wins in setting up and rolling out person-‐centred, electronic health records and systems for utilising the potential of predictive analytics. It also expands to fill the gaps in the stakeholder and programme eco-‐system that can best assure the achievement of the array of strategic objectives outlined above, build sustainability, stimulate innovation, support scaling up and generate outcomes and impacts that not only benefit LCCG but also the wider health, social care and innovation economy across Liverpool and the wider region. Whilst key elements of the MI programme will be developed and sustained, some aspects of Mi will not be taken forward. These relate to aspects of the programme that were completed, are no longer appropriate or are no longer a priority. The key elements of Mi have been integrated into a wider Digital Care and Innovation Programme, one of the five transformation programmes under the Healthy Liverpool Programme (HLP). The Digital Care and Innovation Programme adopts a structured and integrated approach aimed at transforming the delivery of care in Liverpool. It brings together previous technology programmes

6767

2

such as iLinks and Mi and integrates this work with leading edge digital projects such as predictive analytics that are truly capable of transforming the future delivery of health and care services. These elements have been brought together as the impact of these technology themes are not only greater when combined and operated in tandem, but each theme is mutually dependent on the other to fully enable the achievement of HLP goals. There are many drivers that together not only build a requirement for LCCG to engage fully with digital technology, but for any NHS body to successfully utilise technology it must build and maintain pace in its ability to adapt services and adopt new solutions. The digital care and innovation programme will provide a platform for this continuous development and will support programmes across the organisation to become technology ready. This investment case relates to two of the four main digital themes across the programme: Assistive Technology and Person Held Records. The reason these two elements are combined is due to the inextricable link between ‘app’ based assistive technology and physical devices. The diagram below (fig 1) illustrates the overarching programme and the themes addressed in this proposal.

The digital care and innovation programme

What is Assistive Technology? Assistive technology is any item, piece of equipment, software or product that is used to increase, maintain, or improve the functional capabilities of individuals. It is often associated with disability or age but is not limited to this scope. Assistive technology can be used by all of our citizens directly as well as health and care professionals to increase self care, reduce admissions, improve quality of life, reduce health inequalities, increase clinical productivity and reduce social isolation. There are many assistive technology products on the market and more being developed constantly. Common examples include:

Fig 1:

6868

3

What is a Person Held Record (PHR)? The term PHR has been used broadly to define anything from web based patient access to medical records to an online or smartphone based patient health diary and/or health plan. It is therefore better to define what a PHR is in terms of the digital care and innovation programme. During the development of our Mi programme it became apparent that a patient record was not sufficient to either engage or add obvious value to the day-‐to-‐day lives of citizens. Therefore, the Mi PHR is far more than a record, it is in fact a platform that will enable the following key digital features:

• Increase the ability to self care through access to a copy of the primary care record (depending on what is made available by the GP)

• Improve health literacy and reduce incorrect use of health services via a marketplace of apps developed by industry and constantly updated, which the patient can use to self-‐care or use information from their copy of the medical record to support their care or the person they care for.

• Improved clinical productivity via a referral mechanism for direct access to some services and for professionals to refer to a service or prescribe an app.

• Provision of a verified online identification approved by government for true online services • Secure cloud based storage of information not reliant on individual app providers

The Programme Structure Programme has 5 main, mutually enforcing, pillars: § Pillar 1: Scaling up smart solutions for health and social care § Pillar 2: Skills for digital care and innovation § Pillar 3: Developing and testing leading-‐edge innovations

Telehealth Mobile/GPS Household devices

Telecare: Fall detection

Medication management

Apps & Automation

6969

4

§ Pillar 4: Development of a multi-‐sector eco-‐system and international markets § Pillar 5: Intelligence and evaluation Experience from the Mi programme has taught us that an effective digital care and innovation agenda that places the Liverpool health and care economy at the forefront of innovation driven health outcomes and good practice, requires investment in a comprehensive programme rather than a piece-‐meal project approach. Each of the pillars provides key building blocks for (a) developing the digital care and innovation infrastructure/eco-‐system and “getting things right”; (b) boosting capacity needed to make a difference at scale; (c) producing, commissioning and implementing smart services and products; (d) securing better health for people in Liverpool and contributing to the achievement of Healthy Liverpool Programme goals.

Investment Proposal scope

Fig 2: Digital Care & Innovation Programme and investment proposal scope

7070

5

Key elements within each pillar are: Pillar 1: Scaling up smart solutions for health and social care This pillar will address the demand-‐side, supply-‐side and investment capacity required to roll out digital care and innovation solutions at scale. It will build on Mi’s success in delivering wide-‐scale implementation of health technology through Motiva and Flo systems and draw on key lessons from its activity in developing the infrastructure for an ehealth consumer market. At the outset, this pillar will provide the vehicle for the further roll out of health technology (specifically, Motiva and Flo) telecare (specifically, fall detector and alarm systems) and the development and implementation of the electronic person held record (PHR). In future, it will also provide a framework for the public procurement and consumer market availability of additional digital care and innovative solutions developed through pillar 3 (locally developed innovations) or being adopted through pillar 5 (imported good practice and state of the art). Importantly, this pillar will also focus on boosting the resources available for procurement and consumer market stimulation and so maximise reach, impact and health outcomes. It will seek to utilise LCCG investment to lever European, national and private sector finance through traditional (grant funding) and innovative (impact investment) funding pathways. This pillar will, therefore: A. Help to transform the provision of health and care services by embedding innovation and

technology within existing services at scale: scaling up demand for technology (including remote health monitoring, self-‐care and person held record (PHR)) and providing the infrastructure to support this technology to be used effectively. It will provide, through the PHR, an open marketplace for people to access health and care apps from a safe and secure platform whilst enabling access to health records to enhance self care.

B. By taking the lessons learnt from Mi’s roll out of health technology at scale, provide the infrastructure to adopt technology at scale across all services, providing solutions to key issues such as increasing the capacity of existing services at current staffing levels and moving to intelligence led health and care services.

C. Lever in additional and new forms of finance that can boost demand, R&D potential and

productive capacity. This will include attracting complementary national and European resources that support pre-‐commercial procurement and public procurement of innovation. And, working with and supporting CORAL (Community of Regions for Assisted Living) European partners to raise awareness about and develop impact investment opportunities such as social impact bonds and philanthropic venture capital that can benefit city-‐region procurers and SMEs.

Pillar 2: Skills for digital care and innovation: This pillar will build the skills capacity for a technology enabled care and health workforce. In particular, it will address the skills and qualification gap that limits the potential to scale up smart solutions for health, care and well-‐being. The shortfall of training opportunities for health and social care practitioners in assisted living and other digital technologies and the lack of a recognised qualification for competence in their suitability and use acts as a brake on professional engagement. It will also provide support to citizens and “turn them on” to technology, develop their digital skills,

7171

6

build confidence and an appetite for technology and technology enabled services that can support people to self-‐care, adopt healthy lifestyles and live independently for longer. Skills and qualifications development will focus on: A. Develop the skills of the current and future workforce to take advantage of technology,

understand its use in current and future care pathways and fully exploit technology for the benefit of the patient and the service.

B. Developing courses and recognised professional qualifications in this field to provide incentives for health and social care professionals to add value to their CVs and their professional expertise and support their role in stimulating demand for smart solutions for assisted living.

C. Providing tailored training to enable local implementation of locally developed and other

state of the art innovations and unblock commercially viable export opportunities where training of key personnel is required to support role out if innovations and good practice – such as the House of Memories training programme and App.

D. Building upon work already underway across the City region, to address digital inclusion by

increasing digital skills amongst citizens via volunteering and championing activities and improving free access to online resources to reduce digital exclusion.

Pillar 3: Developing and testing leading-‐edge innovations: In the health, well-‐being and social care context, solutions must ‘fit’ the needs and expectations of the citizens. This pillar will contribute to building a local infrastructure for creating innovative products and services for health, care and well-‐being and developing them to the market-‐ready and widespread adoption stage. Combining living labs with city-‐region health and social care “testing grounds” will provide the basis for innovating, evaluating likely impact and producing business models and cases. This pillar will, therefore: A. Build the city-‐region’s living-‐lab capacity and quality to support the development and initial

testing of innovative services and products capable of addressing key health and care issues; B. Provide access to, knowledge of and influence the development of state of the art solutions

to real, on the ground needs and front line requirements that will enable the aspirations of the HLP.

Pillar 4: Development of multi-‐sector eco-‐system and international markets: The activity in this pillar has been fundamental to the previous success of the Mi programme. To fully benefit from the use of existing and new technology, it is necessary to build maintain and grow the eco-‐system essential for the creation of an effective digital and innovation agenda that can combine cost effectiveness within the health and care sector, improved health and well-‐being benefits for local people and wider benefits for the local digital and innovation economy. This pillar has 2 strands:

7272

7

A. It will provide support for co-‐ordinating relationship building between local SMEs, city-‐

region academic and research institutions, care, health and community organisations, citizens and larger technology companies to strengthen the City’s smart health and well-‐being economic cluster and act as a catalyst for innovation and growth.

B. Accessing new markets: engaging with leading European regions and, potentially, global

markets (with their own eco-‐systems), including through the Coral (Community of Regions for Assistive Living) and ECHA (European Connected Health Alliance) to open up new eHealth markets for existing and start-‐up companies.

Pillar 5: Intelligence and evaluation The digital care and innovation agenda will be informed, enhanced and assessed through several key strands that will provide intelligence for programme managers, policy developers, clinical decision-‐makers and front-‐line staff and strengthen the development and implementation of pillars 1 through 4. Pillar 5’s 3 strands are: A. Predictive analytics infrastructure, providing the necessary mechanisms for data transfer and

access to data science resources to allow a full predictive analytics programme (via separate investment case) to be developed. This work is at the leading edge of health science providing the capability to predict future episodes of care at both population and individual levels;

B. State of the art identification and good practice evidence -‐ learning from others and feeding knowledge into the Mi health and well-‐being strategic and delivery processes;

C. Micro and macro evaluation to demonstrate impact and to inform programme and project

level actions -‐ conducting local research, monitoring and evaluation that is directly linked to HLP priorities, informs delivery and assesses impact.

Outline objectives (in line with Digital Care and Innovation Strategic Decision Case) Assistive Technology: • Delivery of telehealth and telecare to support Liverpool people in emerging and established pathways to keep them out of hospital and in their own homes

• Delivery of a digital innovation hub and local economic development through a leading role in the Local Enterprise Partnership Regional Development Plan

• Maintenance of local academic and key industrial partnerships

• Identification and adoption of innovative digital technologies in the delivery of care

• Ensure Liverpool is recognised as a leading economy in Europe with access to key leaders and European funds

Person Held Records: • Implementation of person held records for Liverpool people

• Creation of person held record platform

7373

8

• Linking systems for patient access to integrate with the health and social care record

• Implementation of citizen identity initiative in partnership with NHS England, the Government Digital Service (Cabinet Office) and the Health and Social Care Health Information Centre (HSCIC) to enable access to records with a fully verified identity online.

• Creating a marketplace of self care and support apps

• Developing a vibrant SME economy to continuously innovate for health and care

• Develop new ways of working with industry to leverage innovation and sustainable funding models.

Funding requested A full breakdown of costs can be found in the finance section. This programme requests the following funds Year by Year Cost Summary

2015 (7 months) 2016 2017 2018

£ £ £ £

2,802,051 3,994,218

4,084,420 4,174,622 Total over 3.5 years: £15,055,311

Lead Approval (signed) Date Governing body lead (Simon Bowers/Maurice Smith) SMT Lead (Tony Woods) Programme lead (Dave Horsfield) Finance lead (Philip Saha)

7474

9

1. Strategic Case

a. Strategic Context

This programme aligns with local, national and European strategic and policy agendas. National, and particularly LCCG (Healthy Liverpool Programme) and European health and care agendas have a strong digital and innovation focus. In part, these are responses to concerns that Liverpool, the UK and Europe face considerable challenges if they are to ensure the sustainability and affordability of national health and social care systems and if they are to maintain and enhance people’s quality of life. At the same time, they recognise that opportunities exist to exploit innovative solutions to address these challenges whilst boosting the health sector’s potential to drive economic growth.

European strategic context

LCCG’s digital care and innovation agenda aligns with several key European strategic and policy drivers. Notably:

EU Health Strategy: The twin pillars of the EU’s health strategy are:

§ Fostering good health in an ageing Europe with the focus on a public health strategy to promote healthy living and prevent chronic diseases. It emphasises tackling the determinants of health including lifestyle factors. It aims to ensure society caters to the needs of the elderly and sets out a framework to promote active and healthy lifestyles.

§ Supporting dynamic health systems and new technologies emphasises exploiting the potential of new technologies to contribute to the efficiency and sustainability of health systems whilst enhancing access to high quality healthcare.

European Innovation Partnership on Active and Healthy Ageing (EIP on AHA): Launched in 2012, its agenda is to support the scaling up of smart solutions for active and healthy ageing, independent living and self-‐care. The overarching target of the partnership is to increase the average healthy lifespan by two quality adjusted life years by 2020.

Digital agenda: The European Commission’s digital agenda for health is set out in its eHealth Action plan for 2014-‐2020, which focuses on addressing the barriers to the deployment of eHealth. A recent European Commission Green Paper on an EU framework for mobile health and health and well-‐being applications, is a key part of the Action plan.

A raft of funding programmes –that have relevance to LCCG’s digital care and innovation agenda and are accessible by LCCG -‐ flow from these strategic initiatives. They include: Horizon 2020, the Active and Assisted Living Programme, the EU Health Programme, Erasmus +, Interreg and the European Structural and Investment Funds (ESIF)

LCCG and the Mi Programme already has a high profile in this European policy area. It has a leading role in the Coral (Community of Regions for Assisted Living) network (a strategically

7575

10

prominent network of leading regions and their multi-‐sector stakeholders), has established effective links with numerous European regions and is widely recognised as a prominent eHealth player – notably through its designation as a European Reference Site within the European Innovation Partnership on Active and Healthy Ageing– making Liverpool a “go to region” for good practice.

The digital care and innovation programme is also being built into the Liverpool City Region Innovation Plan – which provides the framework for ESIF funding. Led by LCCG, the Mi Smart Health and Well-‐Being Delivery Programme (Health and Well-‐Being is one of 5 city-‐region strategic priorities for innovation) mirrors much of the Digital Care and Innovation Programme. LCCG has the potential to provide match resources that would lever ESIF resources and add considerable value to LCCG activity and strengthen this business case.

National strategic context

The national digital health agenda is being driven by the National Information Board (NIB), formed by delegation from the Department of Health. The NIB defines and agrees strategy, requirements and priorities for digital technology and informatics across the system. It is chaired by NHS England’s National Director for Patients and Information, Tim Kelsey.

The National Information Board has set out a vision for how technology should work harder and better for patients and citizens by 2020. This framework is called ‘Personalised Health and Care 2020: A Framework for Action’. The Digital Care and Innovation programme will offer the ability to respond to the national direction and also shape delivery to ensure the local needs defined by HLP are fully met.

The vision in this framework commits to giving everybody online access to their GP records, viewed through approved apps and digital platforms by 2015, with further development for people to access to all of their health records – held by hospitals, community, mental health and social care services – by 2018.

The framework creates a roadmap in order to deliver both the national digital agenda and a response to the NHS five year forward view to ensure the required enablers are in place to support progress. The NIB states:

‘Better use of data and technology has the power to improve health, transforming the quality and reducing the cost of health and care services.

It can give patients and citizens more control over their health and wellbeing, empower carers, reduce the administrative burden for care professionals, and support the development of new medicines and treatments.’

The key stages and targets in the framework are shown below:

7676

11

NHS England Five Year Forward View

The key expectations expressed in the five-‐year forward view are listed below with the expected links under the digital programme (assistive technology and PHR)

7777

12

LCCG and HLP strategic context

The Digital Care and Innovation Programme is one of five LCCG “Transformational Programmes” designed to drive change, impact on the six Healthy Liverpool Programme system drivers (healthy ageing, mental health, long-‐term conditions, children, cancer and learning disability) and deliver key HLP health outcomes. This investment proposal sets out the key integrated components that are designed to transform how digital care and innovation can contribute to LCCG and HLP priorities. It will do this in particular, by developing the innovation eco-‐system, building skills, stimulating innovation, testing and scaling up smart solutions, levering additional finance and maximising learning from local and wider experience, this programme will transform how digital care and innovation can make a substantive and measurable impact on key HLP targets and priorities. For instance:

NHSE%Expectation Ref Mi%Activity Mi%Role Lead Notes

Self%care Lead

Carers Lead

Engagement2&2social2marketing Support LCC2PH

Technology Lead

PHR Support iM

Helping2citizens2into/staying2in2work

LEP2activity Lead

Digital2records Support iM

Digital2inclusion2 Lead

Active2citizens2(Champions+) Lead

Digital2inclusion2 Lead

Digital2tools Lead

Co%Design Support TL

Self%care2(in2built) Support

Carers2(in2built) Support

Training2(for2technology) Support HR

PHR2inc.2self%assessment2of2change Support iM

LEP2activity Support iM

4%9 Patient2Safety Care2technology Support LCC

12%19 Parity2for2mental2health Challenge Support TL

20% Tranforming2care2for2people2with2LD

Care2technology Support TL

Access2to2GP2records Support iM

Access2to2electronic2prescriptions Support iM

Expand2and2improve2provision2of2online2services Support iM

Availability2of2online2appointments Support iM

Electronic2referrals2between2GPs2and2other2services

Support iM

Fully2interoperability2of2digital2records Support iM

Supporting2citizens2to2engage2digitally Lead

Training2(for2technology) Support HR2

New2kinds2of2worksforce2(co%design) Lead

Feeder2activity2inc.2volunteering Lead

13%15 Accelerating2useful2innovation Lead

14 NHSE%will%develop%a%deployment%model%for%new%technologies%9%goal%is%to%develop%a%"structured%method%for%introducing%new%technologies"%

PIG2activity Lead

4 More2productive2and2efficient2NHS "Through%technological%advancement%and%improvement%to%service%delivery"

Lead

6 Staff2health2and2technology Technology,2services/support2and2dunding/bids2 Support HR

Care2technology Support

Champions Lead

Social2marketing2 Support LCC2PH

Step2down Support TL

2 Creating2new2relationships2with2"citizens"2and2communities

Getting2serious2about2prevention21%7

Empowering2patients

Engaging2Communities

3 Co%creating2new2models2of2care

8%13

14%18

4.1 "The%only%purpose%of%developing%the%new%models%of%care….is%to%improve%outcomes:better%health%for%the%whole%population,%increased%quality%of%care%for%all%patients%and%better%value%for%the%tax%payer"

*%Need%to%identify%and%agree%local%priorties*%Opportunity%EOI%for%test%bed%sites%for%new%models%of%care

6 Driving2efficiency2gains

Joint2working2between2commissioners2and2providers

11%16

4 Priorities2for2operational2delivery

5 Enabling2change Harnessing2the2info2revo2and2transparency

Modern2care2&2health2workforce

1%8

9%12

7878

13

§ Innovations that will enhance healthy lifestyles, boost mental well-‐being and support self-‐care can help to secure additional quality life years and improve the quality of life for people with long-‐term conditions;

§ The extensive deployment of health and care technology within people’s homes and through mobile devices will reduce emergency admissions at a population level;

§ Improved experience of health and care services by patients who feel more engaged and in touch with practitioners who, in turn, are more enabled to provide the right care at the right time.

§ The digital and innovation agenda will play a key role in delivering person-‐centred care -‐ including through the development of electronic person held record and exploitation of predictive analytics;

§ Utilising technology to share information and work collaboratively across settings of care and organisations.

Impact on health inequalities

Health outcomes for Liverpool residents, despite some notable improvements in recent years, are often worse than in other urban areas in the UK and there are also disparities within the city. The Digital Care and Innovation Programme will contribute to the HLP’s “whole-‐system” approach to reducing health inequalities within the city and compared to other parts of the UK. The ambition for Liverpool to become one of the top 10 digitally advanced health and social care economies in Europe will be a key factor in closing the health outcomes gap with the rest of the UK. Equally, addressing intra-‐city health inequalities will include involving local people and communities (through co-‐creation) in developing, testing and rolling out innovative products and services (to ensure that they fit with individual and community needs, capacity and wishes) and ensuring that the scaling up of smart solutions for health, well-‐being and social care is accessible for people living in areas with poor health outcomes.

Potential to lever additional resources

The comprehensive fit of LCCG’s digital care and innovation agenda with strategies at European through to local levels provides a powerful capability to attract further resources, including from health, social care, employment and economic policy sectors, links local action with best practice, is supportive of securing benefits from partnerships beyond the city region and, together with LCCG’s current status, provides a platform for further raising LCCG and city profiles as European leaders in the digital care and innovation field. The latter in turn providing further impetus to attracting resources, high quality partners and expertise that can contribute to LCCG and HLP priorities, outcomes and targets.

7979

14

b. The Case for Change

Digital technologies such as the internet and ‘apps’ are transforming our society. Every day, many of the people we provide care for and support use these technologies to talk to one another, work together and organise their lives. The impact that this technology can have on healthcare is equally as profound. Improved access to and greater quality of data allows us to better understand the root cause of disease and likely prevalence, whilst linking data, beyond the patient and through to carers, research bodies and industry can unlock the whole system rather than being restricted to isolated episodes of care. Beyond this, the ability to remotely diagnose diseases, monitor vital signs, predict admissions and even test blood are no longer in the realm of science fiction.

Regardless of the organisation or sector, the use of digital technology allows us to work more efficiently, more quickly and gain better results. Both individuals and professionals alike have, at one stage or another, experienced duplication in the health and social care system, with paper based recording, different information sharing agreements and computer systems in place across care providers making communication particularly difficult and in some cases impossible. Beyond this, access to and the use of patient data for better self care and joined up services are only part of the digital picture. Technologies that allow the monitoring of patient vital signs, form part of diagnosis pathway and state of the art sensors to detect specific cells in the blood stream will form a new set of tools that allow clinicians to gain access to key patient telemetry faster to avoid exacerbation and manage more patients, with more accuracy, at any one time.

Problems and opportunities

The health and social care system is under pressure – in Liverpool, in the UK and internationally. Continuing fiscal austerity combined with an ageing population – and the consequent increasing demands on health and social care services from multiple and long-‐term conditions – means that new solutions need to be found to boost the cost-‐effectiveness of health and care provision whilst maintaining the quality of people’s health, care and well-‐being.

Digital innovation and smart solutions provide an opportunity to address these key challenges. Many have the potential to improve health and care services, efficiency and outcomes, enhance the capacity of people to self-‐care and live independently for longer and boost satisfaction with health and care services and have positive impacts on their health and well-‐being. At the same time, local knowledge institutes and companies could benefit significantly from local support to boost technology sector expansion that, in turn, would generate employment and income growth within the city.

Within this macro-‐level picture, there are many specific aspects of the digital care and innovation programme that could overcome existing problems and exploit opportunities to benefit residents along with the health and care and technology sectors:

8080

15

§ The focus on skills development will address difficulties in securing professional engagement (health and social care) to help people to use and accept the adoption of assisted living technologies. Mi’s experience suggests that the shortfall of training opportunities for health and social care practitioners in assisted living technologies and the lack of a recognised qualification for competence in their suitability and use acts as a break on professional engagement. Moreover, the absence of a recognised professional qualification in this field reduces the incentive for health and social care professionals to add value to their CVs and their professional expertise and mitigates against their potential role in stimulating demand for smart solutions for assisted living.

§ There are shortfalls in the infrastructure that can help to create innovative products and services for health, care and well-‐being and develop them to the market-‐ready stage. Developing living labs and testing grounds would address this gap and create the opportunity to produce innovative smart solutions that ‘fit’ the needs and expectations of citizens. At the time of writing this report, LCCG have been shortlisted by NHS England as part of the national ‘test beds’ programme.

§ Constraints on public funding limits the health and social care sector’s capacity to provide the best quality services, for all those that need them when they need them. The potential to lever additional resources from various sources provides an opportunity to make in-‐roads into these fiscally imposed limitations.

§ Mi’s success in scaling up it’s Motiva health technology service has led to over 1600 residents benefiting from the service in Liverpool – it makes LCCG the city with one of the largest health technology services in Europe. Evidence of its benefits to users and the health sector has been established with wider benefits beginning to emerge. There is an opportunity to further widen the reach of the service, benefiting more people with COPD, heart disease and diabetes, in Liverpool, continue to build the evidence base around impact and to further refine and enhance the service to maximise benefits – including integrating the service with the Flo simple telehealth service which is just becoming active.

§ Mi has established the infrastructure for rolling out care technology through health and social care provider and consumer market routes – see below. The further scaling up of care technology will be enabled through closer working and joint procurement of care technologies offering economies of scale and more seamless working.

§ The introduction of an electronic person held record offers the ability to truly transform delivery of self-‐care services. Providing a platform rather than simply access to health records, the PHR will provide a consumer marketplace of apps developed by industry to meet the needs of patients and capable of reacting to trends far faster than anything led directly by the NHS could. The PHR will enable not only access to apps and online tools to support health and care, but it will also enable the prescribing of apps by professionals and will keep patient data safe and away from commercial use unless consent is given. The PHR was designed with representatives from industry to enable interoperability of systems allowing patients to view and maintain information from telehealth and other similar systems after they have discontinued the service to support continued self-‐care. Liverpool CCG is leading development in this area nationally as part of a partnership with partnership with NHS England, the Government Digital Service (Cabinet Office) and the Health and Social Care Health Information Centre (HSCIC) to enable the online verification of identity sufficient to share a medical record without further checks. Truly ground-‐breaking, the system will be capable of supporting innovation and maintaining pace with the latest developments to provide a digital platform to host present and future digital healthcare solutions.

8181

16

§ In working to build the consumer market infrastructure for “telecare” products and services, Mi has made considerable progress in identifying end user aspirations and needs, motivations and barriers, preferences and how to generate demand along with insight into health and care professionals’ awareness and attitudes to adopting new approaches. It has also sought to build demand through targeted marketing and promotion and through raising awareness through community based champions and health and social care professionals. Moreover, Mi has focused on bridging the infrastructure gap to enable a consumer market to grow through creating real and virtual retail spaces, and establishing consumer information portals. Building on this progress and on lessons learnt positions LCCG and its Mi partners to realise mutual ambitions to realise consumer market growth.

Current situation

LCCG’s current digital care and innovation activity for assistive technology and PHR is based on learning and evidence from the Mi Programme. This programme has received £7.7m from Innovate UK’s dallas programme and been supported by LCCG investment totalling £5m. The programme began in 2012 and the funding from Innovate UK ended in June 2015.

Currently, for each of the 5 pillars, within this section of the Digital Care and Innovation Programme, there is an existing foundation to build on. Overall, there is:

§ a health and social care workforce that is becoming increasingly aware of the relevance and potential benefits of smart services and products that can improve service provision and benefit patients -‐ but a lack of appropriate training and qualifications (pillar 1);

§ an existing, growing health technology service, a nascent care technology programme, the beginnings of a consumer market in smart solutions for self-‐care, independent and healthy living, and foundations for introducing an electronic person held record (pillar 2);

§ experience in living lab methodologies for stimulating innovation (pillar 3);

§ an eco-‐system of partners (meeting the multi-‐sector model of public sector, knowledge institutes, private companies and community organisations) together with strong links to leading European regions, networks and partners in this field (Pillar 4);

§ ready access to learning opportunities about the state of the art and good practice together with an indigenous knowledge and experience acquired through the Mi programme.

In all cases, in order to meet transformational objectives we must develop the infrastructure and enhance the activities within each pillar, to fill current gaps and to maintain and expand current services whilst stimulating new innovations. Only this approach will align with the aim to achieve the broader programme objectives and contribute to transformational change and to LCCG and HLP outcomes and targets. Simply maintaining elements of current activity – such as the health technology and care technology services would have some value but it would generate a project-‐based and fragmented approach and be less likely to achieve the goals set. Certainly, it would fall short of the ambition for to Liverpool to become one of the top 10 most digitally advanced health and social care economies in Europe by 2020. Failing to invest at all, or minimally, in the digital and innovation agenda would see Liverpool

8282

17

fall behind other parts of the UK and further afield and would lead to reduced health and care services that involve technology to benefit local people and lower levels of innovation.

2. Economic/Financial Case

a. Options

As mentioned above, in order for each of the aspects of the programme to be successful, an element of investment is required to support each pillar. Therefore, three options have been considered:

Option 0: Minimal further investment in digital care and innovation

Option 1: Limited Investment in the programme to maintain less than current activity

Option 2: Investment in comprehensive assistive technology and PHR programme

Weighting and scores for key objectives in relation to each option

Option 0 Option 1 Option 2

Programme Element Weighting Basic score Weighted score

Basic score Weighted score

Basic score Weighted score

Pillar 1:

Scaling up smart solutions for health and social care

5 0 0 2 10 5 25

Pillar 2:

Skills for digital care and innovation

4 1 4 2 8 4 16

Pillar 3:

Developing and testing leading-‐edge innovations

4 0 0 3 12 4 16

Pillar 4: Development of multi-‐sector eco-‐system and international markets

3 1 3 2 8 4 16

Pillar 5:

Intelligence and evaluation

3 0 0 1 4 3 12

TOTAL 7 42 85

Key to weighting:

8383

18

Minimum score: 1 = minor or less important

Maximum score: 5 = critical to success

Key to basic scoring:

Minimum score: 1 = minimal impact/return on investment

Maximum score: 5 = maximum impact/return on investment

Conclusion

As the programme is multifactorial, it is difficult to disaggregate individual pillar activity and assess impact. For example, failing to invest in the digital skills of the workforce will have a detrimental affect on the scaling up of technology even if that element is fully funded. Therefore the approach taken is to consider a uniform level of investment across all pillars.

Minimal further investment

As indicated in the scoring, minimal investment provides little or no benefit and almost no return on investment, as technology is most efficient and effective when deployed at scale. Minor use and investment becomes very expensive when compared to outcomes achieved.

Limited Investment

A case can be made for limited investment where technology is used very narrowly in very specific use cases. Here, the return on investment can be improved but the impact demonstrated on the current telehealth deployment (see evidence section) could not be achieved. Outcomes for this level of investment would not align with HLP aims for wider transformation and impacting on health inequalities would be limited or not achieved. Limited use of online digital services with minimal support will result in very limited use of those services by the public. In this scenario, innovation could not be supported outside of individual use cases and LCCG would adopt a stance of following rather than leading in the areas selected to support.

Comprehensive Investment

It is clear from the scoring that a comprehensive programme would be capable of supporting the full range of HLP aims and offer the best return on investment. This is largely due to the economies and efficiencies gained from deployment of technology at scale and supporting a digitally enabled workforce capable of gaining maximum impact from that technology. A full investment provides for utilisation of and access to state of the art technology and the ability to shape innovation to best suit local needs. This option provides sufficient investment to shape a digital health economy and react to future needs yet undiscovered. This option is recommended.

8484

19

b. Benefits, Outcomes and Outputs

Intervention Outputs Outcomes Contribution to strategic goals

Pillar 1: Scaling up smart solutions for health and social care

A. Public and 3rd sector procurement: health technology; care technology; electronic person held record

Health technology: Minimum 1200 patients provided with full remote health technology and service per year 1400 patients provided with Flo simple telehealth service per year

Increase in patients self-‐monitoring their health and self-‐caring. Increased patient knowledge of how to live more healthily and manage their condition Improved medication adherence Reduced visits to GP practices Reduction in emergency admissions Improved quality of life for people with long-‐term conditions Improved health and well-‐being amongst service users Improved health literacy Increased clinical productivity Increased digital inclusion

Improved use of NHS services Increase in population life expectancy Improvement in quality of life for chronic and older patients Increased capacity in community services Greater consistency of care

Care technology: 450 individuals/homes provided with care technology products and service per year.

Increased capacity for people to live longer and independently at home Reduction in falls

Person Held Record: Person Held Record platform and system introduced 5000 people accessing Person Held Record per year (from yr 2) Increase in high quality health apps aimed at self care

Greater levels of self care Better use of NHS services Improved communication with patients Market led health support capable of rapid response to consumer trends

B. Consumer market development

2000 users of electronic product guide per year 5 retail outlets linked to electronic product guide

Increased capacity for people to live independently at home Growth in digital care and

Improvement in quality of life for chronic and older patients Improved use of NHS

8585

20

200 people purchasing products and services per year 10 innovation firms selling to other businesses per year

innovation economic sector Improved health and well-‐being for employees Reduced visits to GP practices Reduction in emergency admissions Improved quality of life for people with long-‐term conditions Increased numbers of people self-‐caring Improved health and well-‐being amongst those accessing the consumer market in smart solutions for health, care, well-‐being and independent living

services Better use of community services

C. Levering new finance 4 proposals to national and European funding programmes per year 2 links made to impact investment organisations

1 proposal securing additional resources from funding programmes 1 investment made by impact investors into health and social care sector and to SMEs.

More financial capacity to achieve strategic goals Greater opportunity to support higher risk/higher reward projects Robust leadership in establishing the health benefits of non-‐clinical determinants

Pillar 2: Skills for digital care and innovation

A. Raising awareness 300 professionals from health and social care sectors and 1000 patients with increased awareness

Expanded awareness of innovative technologies, their suitability and benefits

The enhanced skills capacity for a technology enabled care and health workforce will support digital care and innovation programme’s contribution to achieving HLP targets. Without this enabler, no other aspects of technology and digital solutions can succeed. EU wide curriculum development possible due to Erasmus+ successful funding bid.

B. Course development 1 new course 1 new or expanded professional qualification

Curriculum, course and training infrastructure to support health and social care engagement in smart solutions for health, care, well-‐being and independent living

C. Tailored training 300 health and social care professionals trained 100 health and social care professionals receiving accredited qualifications (Yr 2)

Health and social care workforce equipped and motivated to engage with, promote and deliver smart solutions for health, care, well-‐being and independent living

D. Digital skills for communities

1000 people acquiring new digital skill capacity per year

Enhanced access to and confidence in using digital resources for people in disadvantaged

Contribution to reducing health inequalities through improved accessibility and confidence in using digital

8686

21

communities with increased ability to self care and access resources for mental health and social inclusion.

services and products (compliance with statutory duty) Increased capacity for citizens to self-‐care, adopt healthy lifestyles and live independently

Pillar 3: Developing and testing leading-‐edge innovations

A. Build living lab capacity Development of state of the art living lab infrastructure 15 SMEs accessing living lab to develop new innovations 3 University R&D Institutes utilising living lab 20 new innovations developed via a living lab process 50 citizens involved in co-‐creation process

State of the art living lab providing a continuous resource for innovation 2 new innovative products and/or services developed to testing phase Smarter working technology developed to create solutions to workforce demands. Ability to shape the direction of innovations e.g. specific health apps.

New fit for purpose innovations will contribute to HLP targets to secure additional quality life years, improve quality of life for people with LTCs and to reduce emergency admissions. Creating solutions to work smarter, not harder. New living lab and testing ground infrastructure will attract innovation companies bolstering goal for Liverpool to become a leading digitally advanced health and social care economy. Combined with pillar 1, living lab and testing ground infrastructure will strengthen capacity to export to new markets

B. Testing grounds for piloting and evaluating smart solutions

2 SMEs/R&D institutes being tested and assessed in real world environments to market ready stage per year

2 new innovative products and/or services developed to market ready stage per year

Pillar 4: Development of multi-‐sector eco-‐system and international markets

A. Building the eco-‐system New partners in smart health and well-‐being economic cluster including: § 40 SMEs § 3 University/College

departments § 5 public organisations § 10 community

organisations

Expanded and strengthened quadruple-‐helix eco-‐system Greater engagement in health by wider sectors and industries to offer new or greater methods of promoting health, wellbeing and self-‐care.

Catalyst for innovation and growth in health, social care and technology sectors. Supporting the development and expansion of non-‐clinical determinants of health

C. Accessing new markets Access to international Increased exports from Supporting the local

8787

22

markets for 10 local firms

Liverpool City Region economy – health is wealth

Pillar 5: Intelligence and evaluation

A. Predictive analytics Plan and develop the required data architecture, transfer protocols and sharing agreements to enable predictive analytics.

Ability to engage leading data science institutes to support analytics aims.

Develop an intelligence led NHS aiming the right resources at the right people at the right time. Reduce health inequalities Smarter working

B. State of the art and good practice

2 professional development /study visits to leading exemplars 4 case studies of good practice to inform intervention and programme development Process developed for feeding evidence, state of the art and good practice to programme leads

More knowledge and evidence-‐based intelligence to maximise impact of investment in digital care and innovation agenda. Improved processes and outcomes More efficient intervention development (avoidance of mistakes and not reinventing wheels) in line with best practice and latest knowledge

Support to “get things right” for intervention and programme development. Put and maintain LCCG and Liverpool at leading edge of digital care and innovation field. More knowledge capacity to achieve strategic goals

C. Intervention and programme evaluation

5 interventions evaluated annually Programme evaluation

8888

23

c. Supporting Evidence

Telehealth and Health Technology to Monitor & Care for Patients at Home

The use of telehealth at scale across a health economy and specifically in primary care is unique to Liverpool CCG. There have been several academic studies using small scale telehealth deployments utilised in very specific settings and the ‘Whole System Demonstrator’ that undertook a large scale study across multiple economies as a randomised control trial. These studies are described briefly below but each suffer significant limiting factors in the design of the study as the results are most heavily influenced by how the technology is implemented, the patient group that is targeted and how that group is engaged by a service rather than the effect of the technology alone.

As such, the Mi programme has undertaken an analysis of the large-‐scale deployment in Liverpool utilising patients from primary care. The results of this analysis and the methodology utilised are below:

LCCG Telehealth Implementation Analysis

Introduction

This analysis report has been produced to provide the latest findings in relation to telehealth (TH) patient cohorts for Liverpool CCG. It is based on telehealth patients up to 15 March 2015 and estimates impact from monthly risk extracts and SUS data. It uses matched controls to correct for regression to the mean. The data presented is preliminary because:

• Not all patients recruited to the MI programme have yet been included. This due to a three month delay in the data collection of the risk extracts.

• The algorithms for the selection of the control group are being updated to establish a closer match with the intervention group.

This report also includes an assessment of potential programme scale in future years and programme design.

Headlines

• The risk model in Liverpool is well implemented and performs as well as or better than, models in use elsewhere. For the top 0.1% of the population the positive predictive power is 75%.

• Matched controls have been used for people on telehealth to correct for ‘usual care’, ‘regression to the mean’ and for changes to the service model.

• People with risk > 25% according to the risk stratification tool, representing half of all those on TH have 23% reduction in admissions, 20% reduction in cost (A&E, Out Patients, In Patients) and 18% reduction in visits (A&E, Out Patients) in comparison with the control group. The results are statistically significant.

8989

24

• Off all patients 91% feel more in control, are more confident and/or better able to cope with their long-‐term condition.

Risk Model Performance

The figure and table show the result of comparing the risk scores of all people in Liverpool between October 2013 and October 2014. Shown for each risk bracket are the number people in that risk bracket and also how many of those people move out of the risk bracket over the year.

As can be seen there is a substantial amount of movement between risk brackets. This is particularly true in the high-‐end risk brackets where most people move down rather than up. A common way to describe this is ‘regression to the mean’. More work is needed to clarify that all change in risk can be attributed to this. This is important in several ways. It means that the risk of admission in not (necessarily) an inherent, an even less a permanent, feature of a person and it means the number of admissions a person has over a year does not necessarily reflect the risk that person had at the beginning of the year.

Similar results on risk churn have already been reported in June 2013 by Kent and Medway Public Health Observatory 1 which reports that 30% of patients move out of the very complex risk band (0.5% of the population) within one month; 50% after five months and 80% after one year. Thus risk stratification results quickly become outdated. That report proposes that prediction of a ‘crisis year’ and preventive intervention or approaches for the complex risk group could have a more significant impact on reducing unplanned admissions. We intend to investigate if the Liverpool dataset enables the prediction of risk changes or a crisis year.

The 304 people in the top risk bracket in October 13, represents the top 0.1% of the population. Of these people, 227 (75%) experienced one more emergency admissions between Oct13 and Oct14. Therefore if being in the top 0.1% is taken as a test for admission risk, the positive predictive value (PPV) of that test is 75%. Similarly, of the 2025 people with a risk above 60% (0.5% of the population), 63% had emergency admissions between Oct13 and Oct14. Hence the PPV for R>60% is 63%. These preliminary numbers indicate the performance of the risk model in Liverpool and can be

1 www.kmpho.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=303855

5% -‐ 345,655 11,632 357,287 437,768 15% 1,297 41,768 11,113 54,178 80,481 25% 2,441 7,348 4,844 14,633 26,303 35% 1,886 1,819 1,813 5,518 11,670 45% 1,406 565 734 2,705 6,152 55% 883 225 314 1,422 3,447 65% 544 117 181 842 2,025 75% 388 65 92 545 1,183 85% 226 57 51 334 638 95% 194 110 -‐ 304 304

# people staying in band

# people moving up

# total of people

# pople moving down

risk band midpoint

9090

25

compared with documented values from the original Wales Model documentation and of other models. The table below gives an overview. As can be seen the Wales Model in Liverpool compares favourably to other models. The ‘Optimized W model in Lpool’ in the table refers to a calculation in which the same parameters are used but the coefficients (odds ratios) recalculated using Liverpool outcomes.

Prevalence PPV (0.1%)

PPV (0.5%)

AUC (C-‐stat)

Welsh model in Liverpool 6.9% 75% 63% 0.74

Optimized W model Lpool 6.9% 77% 67% 0.75

WM in WM documentation 74% 52%

CPM as reported in WM doc 6.90% 60% 46%

CPM as reported in CPM doc 74% 30%

CPM as reported in DM doc 60% 49%

DM as reported in DM 8.9% 73% 59% 0.78

Telehealth cohort characterisation

Nearly 1600 patients in Liverpool have now been recruited to TH. The results in this note are mainly based on the 1064 patients recruited between October 2013 and March 2015 and who remained on service for at least 1 month. The two slides in this section summarise the characteristics of the TH cohort.

The average risk is 26%. This means that only 1 in 3 of the patients in the telehealth cohort is expected to have an emergency admission in the next 12 months. Also, 50% of telehealth patients have not had an admission in the 12 months. Consequently we must be realistic about the impact on admissions of telehealth for the cohort as a whole.

9191

26

Another important factor is the changing nature of the telehealth cohort with time. In the initial months of the project (when patients were recruited primarily from Community Matron Case load) there were more high-‐risk patients whereas in more recent times (enrolments from GP practice case finding) a lower average is seen. The changing nature of the cohort is also reflected in the length that people have been on Telehealth. The Length on Service (LoS) has changed from 8 months for patients at the beginning of the month to an average of 5 months towards the end. Note that the LoS figures for Jan 15 to Mar 15 do not reflect the end of service, but the end of the time period of this snap-‐shot.

Matched controls

We build a control group for the telehealth cohort by finding in the de-‐identified risk dataset, 3 matches for each person enrolled in telehealth. The matching occurs on a person by person and month by month basis. Hence for someone enrolled on Motiva in October 2013 we find 3 records in the October 2013 data that match the data of the Motiva recipient (the principal). The controls have the same long term long term conditions (COPD, HF and/or diabetes) and are within a set distance in terms of age, risk, number of admissions, deprivation and the polypharmacy parameter of the risk model. This set distance has to be chosen with some care. If it is too large, the controls cannot be considered a close match to the principal and there will be a poor correlation between principals and controls. If the set distance it is too small there is a risk that no suitable matches are found. This will result in a high failure rate. The table in the slide summarises the results for the control considered in this note2. The square of the correlation (R2) is 0.97 and the failure rate 1.9%. The controls are assigned the same Motiva enrolment and disenrollment dates as the principals and hence the same month by month enrolment table is created as for the intervention group. No control is included twice in the group and controls are not drawn from the telehealth population.

2 Code named DisCd14 for reference.

9292

27

Note that the controls are not matched on geography (GP practice) or gender. It is possible in principle to do this, but this will either mean an increase in failure rate or, if the set distance is increased, a poorer match in terms of admissions, age and risk. Another effect to note is that, because the intervention group has (on average) higher than age, risk and admissions than the population that the controls are drawn from, the matching algorithm has a bias towards lower age, risk and admissions. We are however continuing to look for ways to improve the matching algorithm and correct against this bias.

Other limitations of the control group are that we cannot know if the controls would be suitable or indeed would have consented to telehealth. Indeed controls are found in the overall Liverpool data sets, the control group will include patients from practice lists that are already participating in the telehealth programme and some may well have been offered telehealth and refused.

Impact of Telehealth

We can now study the impact of telehealth and compare this with changes in the control group. In contrast to previous evaluation note, here we do this on the basis of the pseudonimised SUS (secondary usage statistic data) that Liverpool CCG has access to3. The pseudonymisation codes in the SUS data set are the same as those in the risk extracts.

The advantage of using SUS data rather than the data in the risk extract data is that it contains more utilisation parameters (In-‐patient admission & cost, Out patient visits, A&E attendance), contains

3 Thanks to Andrea Hutchinson for performing the SUS searches for both intervention and control sets.

9393

28

accurate time stamps and covers a larger period (pre October 2013). The figure below illustrates the before/after comparison done for intervention and control group. For each patient, a fixed period starting one year before the start of telehealth is compared with the same period after the start of telehealth. This approach compensates for seasonality.

Many different comparisons can be made in this way for different time periods, healthcare activity parameters and subsets of the intervention (and control group). The table illustrates one such comparison. In the 8 month period one year before start of telehealth patients with a risk above 50% have on average 2.1 admissions. In the 8 months after starting telehealth they have on average 1.0 admissions. This represents a reduction of 1.1. The reduction in the control group is 0.4 giving a net reduction of 0.7, or 33% with respect to the 2.1 admissions in the 8 month period one year before start of telehealth. The result is statistically significant with p value of 0.01.

Having established, slightly laboriously, the impact on admissions for the subset of people with r>50%, we can now track the impact of different parameters for different groups. The figures below illustrate the results for 8 month periods for admissions, IP/OP cost and OP/AE visits. The blue lines present the net reduction in comparison with the control group (left hand axis); the red lines illustrate the p-‐values (right hand axis). As can be seen the results tend to be significant in the risk range 20%-‐70%. Above that range the effect may be large but there are not enough subject to establish statistical significance, below the range the effect is too small to be sufficiently powered even with the relatively large patients numbers in the cohort. This may improve as we include more patients in the analysis.

Taking r>25%, the median risk as a convenient reference point, representing half of all those on TH. The figure show a statistically significant, 23% reduction in admissions, 20% reduction in cost (AE,OP,IP) and 18% reduction in visits (AE/OP) in comparison with the control group.

9494

29

Self-‐reported outcomes

Patients on Motiva are asked to answer an engagement and satisfaction questionnaire toward their time on Motiva. It contains 21 questions and provides useful information on how patients experience the system, whether they see changes in the way they manage their disease and whether they attribute this to Motiva. Feedback is generally positive and the questionnaire shows that a large majority of patients gain increased confidence, a sense of being in control of their health or an ability to cope better with their disease.

For instance 91% of people feel more in control or more confident or better able to cope with their condition. Also about half report that they have made changes in their lifestyle in terms of diet or exercise. These results indicate that the Mi programme can move the needle, although more is needed to link this to the formal tools used in the CCG evaluation criteria. Further analysis is also needed to demonstrate that the increased confidence, ability to (self) manage and changes in lifestyle are linked to reductions in healthcare as demonstrated in SUS and GP data.

Implications for future design

Building on the fantastic engagement with GPs in Liverpool and the operational assets that have been created in Mi, telehealth should be continued to be offered to large patient groups, but a more proactive segmentation into patient cohorts is needed for a sustainable and economically viable service.

To bring the demonstrated impact and cost of service in closer agreement it makes sense to encourage consenting patients with a low risk score to enrol in Flo/Guide. The monitoring and regular review that is part of Flo/Guide means that patients can be stepped up if needed. A risk cut-‐off of 25% is proposed as a guide to suggest Flo/Guide or Monitor. This would mean that half the patients would go on each service level. The cut-‐off is for guidance; final decision which service is most appropriate for a patient will be a matter of clinical insight and patient choice.

The table below provides an example as to what the scaled up telehealth design would mean for the City of Liverpool. According to the April 2015 risk extract there are 25,081 people diagnosed with

Flo/Guide Motiva Motiva0%-‐25% 25%-‐50% 50%-‐100%

Number of people in risk band with COPD, HF or Diab (all ages) 25,081 7,754 2,175 Engagement / identification / recruitment succes rate 6% 15% 12%

Expected number of people on service 1505 1163 261For reference, people recruited to Motiva between Oct 13 and Mar 15 534 (2.1%) 434 (5.6%) 96 (4.4%)

Cost per patient (assuming 6 months on Motiva and 6 months on flo for r>25%) £300 £900 £900

Total cost

risk bandDescription

£1,733,148

9595

30

diabetes, COPD or HF, with a risk between 0% and 25%. On the other hand 534 people in that risk bracket were recruited to TH between Oct 13 and Mar 15. This represents 2.1% of that city wide LTC group. This 2.1% penetration is the total product of the engagement work, the case finding process and the recruitment process in calls, visits and installations that has taken place over the last 18 months. It clearly has scope to increase. The percentages for the 25%-‐50% and 50%-‐100% brackets, given in the table, are 5.6% and 4.4% respectively. Again there is considerable scope for expansion.

The TH programme has so far engaged with about a 1/3 of the GP practices in Liverpool. It would not seem unreasonable therefore to aim to raise the penetration rates to 6%, 15% and 12% respectively. This would set the ambition to make the programme truly city wide. At the same time the penetration rates are still modest enough to be achievable even if some practices remain disengaged and some patients remain hard to reach. The table illustrates what this will mean for patient numbers.

We suggest that people with above median risk (>25%) will (on average) receive 6 months on Motiva and then 6 months on Flo/Guide. People with below median risk (<25%) will (on average) receive 12 months on Flo/Guide. The total costs for the programme is indicated.

Projected Benefits

To estimate the potential benefits, we assume (conservatively) that a 15% reduction overall reduction in healthcare utilisation occurs for people r>25%. Broken down to 25% for r>50% and 12% for 25%<r<50%. We assume no short term calculable benefit for r<25%.

We now want to calculate what that reduction would be in monetary terms

We use three sources of information to estimate this:

• Cost vs risk for elective and non-‐elective admissions. Richard Houghton’s report4 provides data on IP/OP spend per risk bracket in Liverpool.

• LCCG expenditure breakdown. According to its annual report, Liverpool spent £426,692k on the Acute sector in 2014, on the other hand, the total sum of IP/OP spend for all risk brackets in Houghton’s report is £298,300k. We speculate that the difference of £426,692-‐£298,300 = £128,392k is due to bulk contracts and fixed costs, but can still be amortized to individual health care activity

• Cost and setting for relevant episodes of care: Secondary analysis of the Symphony project in Somerset5 has shown that a factor of 152% can be applied to the acute cost to include to

4 “Integrated Care: Risk of Admission Population Analysis” Richard Houghton, Liverpool CCG, 4th June 2013. The paper contains aggregate data analysis on 404,477 patients from 18 neighbourhoods (74 practices) contributing to the April 2013 risk stratification extract.

9696

31

include Community, Continuing and Primary Care for the disease areas of interest here (Diabetes, HF, COPD and Hypertension)

Putting these numbers together results in the table below. We acknowledge that there are brave assumptions here and question of whether the full cash releasing benefit is 100% possible has not been addressed.

A key element not yet evaluated is the impact of telehealth on the workforce. Currently the telehealth hub, consisting of three nursing staff can monitor and triage between 600 and 700 patients at any one time. Compared to current models of care based on nurses travelling to patient homes this is a significant increase in capacity. When set against the forecast increase in the elderly population and correlating increase in patients with chronic conditions, telehealth holds far greater potential for saving in the health system than in reducing admissions alone.

Further work is planned to map the impact of telehealth on workforce levels over the next 15 years and the potentially significant savings that can be realised by maintaining rather than significantly growing the clinical workforce.

Brief Review of Evidence in literature on Telehealth

Important evidence for telehealth comes from the Whole System Demonstrator (WSD), a randomized control trial with 3230 patients in Newham, Kent and Cornwall conducted in 2008/2009. As reported by Steventon et al6 “telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs”. However the WSD is not without its limitations. As acknowledged in other papers from the trial team, there was in fact no system redesign and patient 5 "The Importance of Multimorbidity in Explaining Utilisation and Costs Across Health and Social Care Settings: Evidence from South Somerset’s Symphony Project" Panos Kasteridis, Andrew Street, Matthew Dolman, Lesley Gallier, Kevin Hudson, Jeremy Martin and Ian Wyer [York, Sommerset] CHE Research Paper 96, available at http://www.york.ac.uk/media/che/documents/papers/researchpapers/CHERP96_multimorbidity_utilisation_costs_health_social%20care.pdf February 2014 (2014) 6 "Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial" Adam Steventon, Martin Bardsley, John Billings, Jennifer Dixon, Helen Doll, Shashi Hirani, Martin Cartwright, Lorna Rixon, Martin Knapp, Catherine Henderson, Anne Rogers, Ray Fitzpatrick, Jane Hendy and Stanton Newman [Nuffield] BMJ 2012;344:e3874 doi: 10.1136/bmj.e3874 (2012)

25%-‐50% 50%-‐100%

£963 £7,041

£2,741,958

Cost in risk bracket cost tab (corresponds to Houghton's report)

Scaled acute cost per patient in risk bracket to match costs reported in annual report.

Scaled cost per patient to include Community,Continuing and Primary Care.

Savings £904,257

939

12%

£8,024 £28,162

25%

261

£1,837,701

Impact Rate

Expected number of people on service

Risk Band

£2,526 £8,864

£5,244 £18,407

Savings Per Person

9797

32

selection was not done on the basis of suitability for remote care7, neither was this study able to demonstrate a positive economic result.

A recent meta-‐analysis8 of RCTs and observational studies of readmission reduction in patients with heart failure found a general reduction in readmissions although there was also one paper in which the control group did better than the intervention group. Interestingly the authors observe that the impact of remote monitoring depends on the quality of the ‘usual care’ in any particular study. These results confirm an earlier Cochrane review9 which concluded that telemonitoring of patients with heart failure reduced the rate of death from any cause by 44% and the rate of heart-‐failure–related hospitalizations by 21%. However, the quality of the methods used in the reviewed studies was variable, and many of them were small.

Another review10 from the Cochrane collaboration on telehealth for COPD also found broadly positive results and concluded that telehealth in COPD appears to have a possible impact on the quality of life of patients and the number that attend the emergency department and the hospital.

A very extensive overview11 of studies on “Interventions to reduce unplanned hospital admission” by the Bristol and Cardiff groups, which is available online found that “There was evidence that education/self-‐ management, exercise/rehabilitation and telemedicine in selected patient populations, and specialist heart failure interventions can help reduce unplanned admissions. However, the evidence to date suggests that majority of the remaining interventions included in these reviews do not help reduce unplanned admissions in a wide range of patients.”

We stress that the proposed telehealth service in Liverpool is both about monitoring and education. Although common sense suggests that education is a good thing, solid evidence for a beneficial impact is limited. A trial in Spain with the Philips Motiva system demonstrated a positive result12 and a recent paper13 in the Journal of the American Geriatrics Society found that Care management coupled with content-‐ driven telehealth technology has potential to improve health outcomes.

A recent paper14 in the BMJ on a trial in Lothian acknowledges that “the heterogeneity of interventions thatusetelemonitoringcontributestothedifficultyininterpretingoutcomes”. The

7 "An organisational analysis of the implementation of telecare and telehealth: the whole systems demonstrator" Jane Hendy, Theopisti Chrysanthaki, James Barlow, Martin Knapp, Anne Rogers, Caroline Sanders, Peter Bower, Robert Bowen, Ray Fitzpatrick, Martin Bardsley, Stanton Newman [Imperial] BMC Health Services Research 12:403 doi:10.1186/1472-‐6963-‐12-‐403 (2012) 8 “Remote monitoring after recent hospital discharge in patients with heart failure: a systematic review and network meta-‐analysis” Abdullah Pandor, Tim Gomersall, John W Stevens, Jenny Wang, Abdallah Al-‐Mohammad, Ameet Bakhai, John G F Cleland, Martin R Cowie, Ruth Wong Heart 2013; 99:1717-‐1726 doi:10.1136/heartjnl-‐2013-‐30381 9 "Structured telephone support or telemonitoring programmes for patients with chronic heart failure" Ingis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF. [] Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD007228. DOI: 10.1002/14651858.CD007228.pub2 (2010) 10 "Telehealthcare for chronic obstructive pulmonary disease" Susannah McLean, Ulugbek Nurmatov, Joseph LY Liu, Claudia Pagliari, Josip Car, Aziz Sheikh [] Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD007228. DOI: 10.1002/CD007718.CD007228.pub2 (2011) 11 http://www.bristol.ac.uk/primaryhealthcare/docs/projects/unplannedadmissions.pdf 12 "Noninvasive remote telemonitoring for ambulatory patients with heart failure: effect on number of hospitalizations, days in hospital, and quality of life" Domingo M, Lupón J, González B, Crespo E, López R, Ramos A, et al. CARME (Catalan Remote Management Evaluation) Study. Rev Esp Cardiol vol 64 pp277-‐85 (2011) 13 "Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data" Laurence C. Baker, Dendy S. Macaulay, Rachael A. Sorg, Melissa D. Diener, Scott J. Johnson, Howard G. Birnbaum [] Journal of the American Geriatrics Society vol 61 (9) pp 1532-‐5415 (2013) 14 "Effectiveness of telemonitoring integrated into existing clinical services on hospital admission for exacerbation of chronic obstructive pulmonary disease: researcher blind, multicentre, randomised controlled trial" Hilary Pinnock, Janet Hanley, Lucy McCloughan, Allison Todd, Ashma Krishan, Stephanie Lewis, Andrew Stoddart, Marjon van der Pol, William MacNee, Aziz Sheikh Claudia Pagliari, Brian McKinstry BMJ 2013;347:f6070 (2013)

9898

33

investigators responded to that observation by creating an RCT in which the issue of telehealth technology is purely an add-‐on to existing services. They find, in the words of an accompanying editorial, that telehealth “adds little to well supported self-‐management”. That does not mean however, that telehealth does not have a role in comprehensive service redesign and efficiency savings.

The importance to get the delivery model (as well as the technology) right is also highlighted in the UK government change in direction for its 3 million lives programme15. This has been done to create closer ties with integrated care and social care agendas. Although this has led to some bad press16

the real message is that telehealth should not be seen in isolation but as part of coordination and integration with the wider health and social care services, so they become a mainstream service, not a side-‐line proposition.

In conclusion, the literature is generally poor but that the overall view supports the view that telehealth, as part of a well-‐ designed service and well supported self-‐management, can deliver substantial benefits in terms of admission reduction and outcome improvements.

Telecare

Demographic Case

Ageing populations and the rise in chronic diseases are major societal challenges for the UK, Europe and beyond. The growing numbers and proportion of elderly people are likely to increase the incidence of chronic diseases and will place considerable financial and capacity pressures on health and social care services and the wider economy. In Liverpool City Region, these challenges are exacerbated by health and well-‐being indicators that -‐ despite some notable improvements in recent years -‐ remain worse than national averages.

Figures within the Joint Needs Assessment for 2012 show there are an estimated 469,700 people living in Liverpool, which is a 6.3% increase since the low point in population levels of 2001. The Chart below shows the projected population change between 2012 and 2021. This projection shows the expected increase in the older population especially the 85+ age group.

15 "New technology can improve the health services delivered to millions of people" Rachel Cashman [] NHS England news archive November 2013 http://www.england.nhs.uk/2013/11/15, accessed 9 Dec 2013 (2013) 16 http://www.pulsetoday.co.uk/commissioning/commissioning-‐topics/telehealth-‐/nhs-‐england-‐drops-‐plan-‐to-‐have-‐100000-‐ telehealth-‐users-‐this-‐year/20005150.article

9999

34

In addition, Dementia UK estimates that 63.5% of people with late onset dementia live in private households (in the community) and 36.5% live in care homes. The proportion living in care homes rises steadily with age, from 26.6% among 65–74 year olds to 60.8% among ages 90 and over. Based on these estimates of dementia it is thought that 3,161 people with dementia live in the community in Liverpool and 1,651 require a care home.

With these demographic pressures and a significant reduction in public sector funding, there is a drive towards integrated services and the need to deliver health and social care in innovative ways to meet the growing needs of the ageing population. Technology can be an ‘enabler’ in this context and the use of care technology (traditionally known as Telecare) can help keep people independent in the community longer, reduce instances of delayed discharge from acute and intermediate services and reduce the burden of care costs.

Supporting Evidence of Telecare

Despite the considerable drive towards technology enhanced care services, there is relatively little published evidence providing a comprehensive review of care technology (telecare) compared to other areas such as health technology (telehealth).

Two studies which have informed the current drive towards technology supported care services are: An Assessment of the Development of Telecare in Scotland by the Joint Improvement Team and A Review of the Evidence Base for Telecare commissioned by the Department of Health.

The latter review must be considered compromised to some extent as the data gathered was self reported from a range of smaller local studies an evaluations. The overview report was produced for the Department of Health in 2006 by the Evidence Working Group of the Telecare Policy Collaborative, which reported:

100100

35

• Telecare helped West Lothian achieve the lowest proportion of delayed hospital discharges of older people in Scotland and reduced the average stay in private care homes from 36 to 18 months’

• The ‘Safe at Home’ scheme in Northampton ‘suggested that telecare helped people (with dementia) to keep living independently in their own homes for longer’

• Data from Birmingham’s community alarm service ‘showed that a substantial return on investment in the form of reduced hospitalisation costs and reduced residential care could be achieved over a ten year period

• Evidence from a telecare scheme for frail older people in North West Surrey ‘shows that telecare focused on safety and security could reduce the number of people entering residential care by 11% in the fifth year after implementation or perhaps 25% in year 20

There are many similar reports and papers revealing results that are positive in terms of quality of life and useage of services (efficiencies gained by service providers or commissioners).

One such report is based on the Aktive Project. The report, ‘The role of telecare in meeting the care needs of older people’17 concluded that based on a review of literature the implications of telecare for individual service users, care workers and carers:

‘…. Recent policy statements have highlighted the potential of telecare to provide support, reassurance and peace of mind to both people with disabilities and carers, helping the former to maintain their independence and the latter to sustain their caring and other roles. The available empirical evidence from studies of service users and their carers lends considerable support to this view, although researchers note that data have often been collected by service providers or are based on small studies whose findings cannot be generalised to wider populations of telecare users. A key theme in the literature is that telecare provides a sense of security and confidence for service users, particularly those with dementia, as well as for their carers. Carers in a range of studies have reported benefits in using telecare, including: increased independence; greater peace of mind; improved health and well-‐being; reduced pressure on carers; and improvements in their relationship with the person they look after. Research on care workers is limited and presents a less clear picture. Some studies have reported that using telecare enables care workers to carry out their job roles more effectively, while others highlight challenges in using these technologies among service users, carers and care workers…’

This evidence should also be considered against the randomised control trial ‘The Whole System Demonstrator’ as discussed in the telehealth evidence section. The report looking at the effect of telecare on health and social care services18 found no statistically significant reduction in service use 17 “The Role of Telecare in meeting the Care Needs of Older People: themes, debates and perspectives in the literature on ageing and technology” AKTIVE Consortium AKTIVE Research Report Vol.1 (2013), online publication: www.aktive.org.uk/publications.html 18 " Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial" Adam Steventon, Martin Bardsley, John Billings, Jennifer Dixon, Helen Doll, Michelle Beynon, Shashi Hirani, Martin Cartwright, Lorna Rixon, Martin Knapp, Catherine Henderson,Anne Rogers, Jane Hendy, Ray Fitzpatrick, Stanton Newman Age and Ageing 2013; 0: 1–8 doi: 10.1093/ageing/aft008

101101

36

when undertaken as a randomised control trial over 12 months. This again highlights the key issue that technology cannot be effectively evaluated as an RCT as the greatest impact is realised through the utilisation of that technology and the way that it is implemented into an overall service. This does not however mask the lack of empiracle evidence in this area. This is likely to be due to the need for technology to be integrated into services and as such it is rarely evaluated in its own right. Often, direct reports from integrated services evaluating a wider service evidence results that show clear benefit. An example of particular note is work between Havering Council, Havering CCG and (Mi Partner) Tunstall, demonstrating significant impact on health and care services:

http://www.adass.org.uk/uploadedFiles/adass_content/events/ncasc_2014/2014_Presentations/TI5 Better Care Technology.pdf

Community Model and Support Services

The development of community services described in this investment proposal has been built upon learning from LCCG’s lead of Mi Liverpool. As the programme ended in June 2015, both Innovate UK’s evaluation (by University of Glasgow) and Mi internal evaluations are currently being prepared. In the interim, evidence and information used in the design of the services has included: a. Insight activity undertaken at the beginning of the programme in partnership with LCC Public

Health colleagues provides understanding of: • lifestyle • motivations/barriers to staying healthy and independent • perceptions of wellbeing, quality of life and independence • peoples wants, needs, attitudes, behaviours, motivations and barriers towards

health, self-‐care and technology • characteristics of people who are more receptive to self-‐care and technology • for people with long term (health) conditions, what would help them better self-‐

care, how to support self-‐ ownership of care

A key insight for Liverpool is that people will not engage in dialogue about health, self-‐care and/or technology until they feel physically well and secure. Health becomes a secondary concern to issues of debt, poor housing, caring responsibly etc.

102102

37

Based on this insight, the Mi programme developed a range of community assets and activity to engage with citizens (through the things they need and like to do) to:

a) provide advice about technology supported self care b) raise awareness of and appetite for self-‐care and technology (including lifestyle

planning) c) reduce digital exclusion across the City d) increase levels of active citizenship e) support families and informal carers with technology f) co-‐design and test new forms of service and technology

In addition to the local evaluation and insight, externally there is a range of evidence to support the continuation and expansion of community activity including: Review of evidence to support the benefits of making greater use of digital technologies

http://www.scie-‐socialcareonline.org.uk/local-‐government-‐in-‐the-‐digital-‐age-‐a-‐local-‐government-‐knowledge-‐navigator-‐evidence-‐review/r/a11G0000004GbdYIAS

Impact of low income upon access to digital and digital services

http://www.scie-‐socialcareonline.org.uk/beyond-‐virtual-‐inclusion-‐communications-‐inclusion-‐and-‐digital-‐divisions/r/a1CG0000000Ga4uMAC

Benefits of volunteering and active citizenship

http://www.scie-‐socialcareonline.org.uk/who-‐benefits-‐from-‐volunteering-‐variations-‐in-‐perceived-‐benefits/r/a1CG0000000GcvEMAS

Public health benefits of volunteering

http://www.biomedcentral.com/content/pdf/1471-‐2458-‐13-‐773.pdf http://www.volunteering.org.uk/images/stories/Volunteering-‐England/Documents/HSC/volunteering_health_impact_full_report.pdf

103103

38

Person Held Record This area of health is very new both in terms of development and research. Evidence in this area is focussed around patients access to health records via a specific portal aimed at affecting a specific condition rather than the use of a platform available for multiple apps and conditions.

A basic PHR system was developed in Liverpool through the Mi programme as a proof of concept to assess what a PHR should be and what would be required to develop a solution in full. This work has found that for an NHS economy, a record, diary or plan alone is not sufficient or sustainable. The investment required in app development and web design to maintain relevance to the public would be prohibitive. These are painful lessons learned from the NHS ‘Healthspace’ development that was closed in March 2013, where it was estimated that £98 million would be required to further develop a useful solution for patients. Added to this, it was reported in the BMJ19 in a study of the abandoned central ‘Healthspace’ PHR that ‘unless personal electronic health records align closely with people’s attitudes, self management practices, identified information needs, and the wider care package (including organisational routines and incentive structures for clinicians), the risk that they will be abandoned or not adopted at all is substantial. Conceptualising such records dynamically (as components of a socio-‐technical network) rather than statically (as containers for data) and employing user centred design techniques might improve their chances of adoption and use.’

The Mi PHR platform is based on these key finding in order to avoid the inherent failure found in providing access to records alone. As a result, the PHR in Liverpool has been designed as a platform to work with industry to host apps and online resources developed by the market, not by the NHS. This allows a limitless number of apps aimed at any number of conditions or care needs to be hosted and utilise the information in existing health and care records.

19 Greenhalgh T et al. Adoption, non-‐adoption, and abandonment of a personal electronic health record: case study of HealthSpace. BMJ [Internet]. 2010. [Accessed 2015 Jun 18]; 341:c5814. Available from: http://dx.doi.org/10.1136/bmj.c5814

104104

39

d. Financial Impact (incl. recurrent costs, non-‐recurrent costs and planned savings)

The tables below indicate the financial breakdown for the investment case. Attached as an appendix to this investment case (appendix 1) are sensitivity analysis reports for the key cost centres.

Required Programme Budget:

Year by Year Cost Summary

Pillar Pillar Name Description 2015

(7 months) 2016 2017 2018 Pillar total

£ £ £ £ in 2018(£)

1 Scaling Up Solutions Care Technology (Telecare) 110,115 260,178 350,379 440,581

1 Scaling Up Solutions Health Technology (TeleHealth) 1,081,536 1,877,612 1,877,612

1,877,612

1 Scaling Up Solutions PHR Apps and Platform 500,000 400,000 400,000 400,000

1 Scaling Up Solutions Infrastructure Mgmt/System Support 165,000 330,000 330,000 330,000 3,048,193

2 Digital Skills Digital Skills development 50,000 50,000 50,000 50,000

2 Digital Skills Digitise patient self care support 135,000 50,000 50,000 50,000

2 Digital Skills Asst Tech and App Support Helpline 29,400 79,000 79,000 79,000

2 Digital Skills Tech equality/accessibility 100,000 100,000 100,000 100,000 279,000

3 Dev/Test Innovations New technology PoC 250,000 250,000 250,000 250,000 250,000

4 Multi-‐sector Community Support & Engagement 75,000 250,000 250,000 250,000

4 Multi-‐sector EU Best Practice 76,000 87,429 87,429 87,429 337,429

5 Intelligence & Evaluation Digital Insight & social Marketing 100,000 100,000 100,000 100,000

5 Intelligence & Evaluation Evaluation for scale 30,000 60,000 60,000 60,000

5 Intelligence & Evaluation Predictive Analytics Support 100,000 100,000 100,000 100,000 260,000

2,802,051 3,994,218 4,084,420

4,174,622

Certainty of costs

The assessment of costs has been based on experience of providing the services and an understanding of the associated costs of the services from either the existing direct provider or those enabling services that are needed for a service to be made available. Where necessary, soft market testing has been undertaken to assess likely costs and prices. The costs indicated are considered to be certain based on current market values.

Variations in costs are most likely to occur where the service demand is uncertain. Here, the telehealth and telecare services are most at risk and carry the largest financial variance. The attached sensitivity analysis shows the impact of variation in costs for these services. Analysis indicates that telehealth can be controlled through varying recruitment targets as service users are predominantly selected via a case finding process. Therefore it is likely that telehealth costs can be controlled and kept within budget through normal monitoring processes (analysis based on current technology provided by existing supplier).

105105

40

Telecare services offer the greatest financial risk as this service is entirely driven by referrals from general practice and secondary care. The attached sensitivity analysis indicates the cost variance based on service use and amount of equipment required (as the two main cost factors). For this service, demand cannot be controlled via recruitment methods easily without introducing assessment based on non-‐clinical criteria (see risks). Some of the cost variance can be controlled by limiting the scope of equipment available (e.g. fall detection only) which can be controlled and scrutinised through normal contract monitoring processes and changes to referral guidelines.

Appendix 2 shows a slightly more detailed budget breakdown.

Savings Analysis

A full review of the telehealth service and potential savings are fully explored in the evidence section. Current estimates show an annual potential saving of approx. £2.74m per annum based on targeted usage at scale. Further work is on-‐going to provide figures based on the cash releasing capability of the service and the impact of telehealth on future workforce size and cost.

Telecare services have not been sufficiently scaled and provided for a long enough period to assess savings. The evidence section reviews reports from other areas, and in particular work in Havering where a similar approach has yielded impressive results, such as:

-‐ reduced hospital admissions from falls -‐ reduced admission to residential care

In other areas of the proposal, it is not possible to estimate potential savings as innovation and new developments cannot be evaluated prior to deployment. This proposal does follow national policy on the adoption of digital services where policy makers are committed to the use of technology as a means of cost reduction.

106106

41

e. Risks

Due to the highly varied nature of the services covered by the investment case, the risks identified are those affecting the programme elements at a strategic level and those that pose significant financial or reputational risk whilst basic operational risks will be managed at service delivery level.

Risk Category Description Response Likelihood (1 to 5)

Impact (1 to 5)

Risk Rating

1. Financial

The budget figures for the programme are based on best estimates utilising previous experience and market testing with no overall contingency amounts included. This creates a risk of overspend (mostly) and underspend as costs can be affected by many factors as a number of services operate in an immature market.

-‐ Work within the proposed budget, to encourage a ‘Value for Money’ approach. -‐ Work with CCG Finance to regularly review latest forecasts against budget. -‐ Seek HLP re-‐approval if any budget costs are found to have been significantly under-‐estimated.

3 3 9

2 Scope

Scaled-‐up services have been sized as a balance between current experience and our ambition for the next few years. There is a risk that actual demand exceeds the proposed budget.

-‐ The sensitivity analysis shows how demand changes affect the likely costs of the services. -‐ Continue to investigate links and potential use of social care FACS (needs and finance) assessment should demand become unsustainable.

2 3 6

3 Financial There is a risk that the proposed investment does not release comparable funds elsewhere in the Liverpool health economy.

-‐ Use Outcome-‐based rewards where possible to ensure costs relate directly to the benefits achieved. -‐ Where possible, build the innovations into existing service provision, rather than as an ‘extra’ cost. -‐ The CCG needs to accept the financial risk that investment in prevention activities now should yield savings in the longer-‐term.

4 2 8

107107

42

4 Safety

Providing advice and technology to enable self-‐care carries the risk that people will not seek medical support when they really should.

-‐ Ensure all advice and instructions are carefully vetted to follow best-‐practice guidance and reduce possibility of misunderstanding. -‐ Ensure that self-‐care and AT is portrayed as complementary to clinical support, rather than a substitute. -‐ Maintain clinical oversight via the clinical reference group

1 4 4

5 Legal

People will be allowed access to Personal NHS data on the basis of having their ID authenticated by either the Cabinet Office Verify scheme or by local GP practices vouching for individuals. There is a risk of technical errors or mistakes.

-‐ The government’s Identity Providers (such as Experian) should accept liability if they identify someone incorrectly. Likewise, HSCIC will be developing the service to match the Verified ID to their NHS number, so they should accept responsibility for any technical errors in this. -‐ The legal liabilities for GP practices making mistakes when vouching for a person will need to be reviewed. From a practical perspective, the CCG may need to accept some of this risk, providing GP practices have followed best practice guidance.

1 4 4

6 Scope There is a risk that the NHS services in Liverpool cannot absorb the desired rate of change/ innovation.

-‐ Ensure that CCG service leads and provider trusts are fully engaged in selecting potential ideas, and that this aligns with HLP activities. -‐ Ensure stakeholder management and communications activities support the desired changes. -‐ Ensure scaling-‐up activities are linked to change management plans for services in the HLP programme.

4 3 12

7 Technology

By their nature, projects involving innovative technology involve an amount of uncertainty and general risk of failure.

-‐ Ensure that due diligence checks are carried out on the efficacy and reliability of any new technology before it is trialled in Liverpool. -‐ Ensure the risks inherent in each project are understood and managed. -‐ Ensure that each trial is objectively evaluated and that there is sufficient evidence to support any Business Case to scale it up.

2 2 4

108108

43

8 Time There is a risk that timescales are over-‐optimistic and that both delivery and spend slip.

-‐ Ensure each project is planned and coordinated within HLP programme. -‐ Use monthly Programme Board to address any slippage or resource conflicts

3 3 9

9 Security By opening up access to NHS services and data on-‐line, there is a risk that Personal Data may be compromised.

-‐ Ensure systems use latest security measures (comparable to on-‐line banking). -‐ Conduct a thorough, independent assessment of system designs, security measures, and operating protocols to minimise this risk.

1 4 4

10 Procurement The programme depends on several significant OJEU procurements. There is a risk that these are delayed or challenged.

-‐ Work with CCG and CSU Procurement to ensure that the specification and process is robust. -‐ Ensure service continuity options are in place for existing services.

2 4 8

11 Procurement With technology improving all the time, there is a risk that we procure services that become out-‐dated quite quickly.

-‐ Ensure service specifications and subsequent contracts allow for on-‐going innovation and flexibility. -‐ Ensure contracts focus on outcomes so that suppliers are incentivised to adopt the latest technology where it has greater benefits.

2 2 4

12 Governance

The programme is likely to take the CCG and other organisations into new aspects/areas of governance, and there is a risk that the governance debates stifle the innovation.

-‐ Capitalise on the synergy between HLP and NHSE ambitions, to seek national guidance to overcome local resistance. -‐ Enlist Senior CCG management support in navigating the different Governance structures and projecting a ‘can do’ attitude.

3 3 9

109109

44

3. Commerical Case

a. Procurement Route Multiple contracts and services will be procured. A breakdown of these services and the expected procurement route is provided in the table below: Service Description Estimated Value and

contract length Procurement Route Justification

Health Technology – telehealth provision, installation and monitoring/triage of patients.

£5M contract over 3 year period.

Full (OJEU) procurement in the open market.

This is a high value contract and Liverpool is seen as a leader in this area attracting significant attention. Anything less than a full market test would not satisfy legal requirements and the likelihood of challenge would be very high.

Care Technology – telecare service including provision and monitoring of a wide range of equipment.

£800k to £1M over a three year period

Full procurement in the open market as a joint service between LCCG and Liverpool City Council.

A joint procurement would create a much higher value contract. LCC has agreed to lead the procurement of this service.

Person Held Record platform development and maintenance

£150 to £350k annual contract (dependent on level of development required)

Procurement via G-‐Cloud framework.

Services are available via the government procurement framework providing a faster and more cost effective method of procurement. Annual or at most bi-‐annual contract preferred to maintain best value for money and most suitable provider.

Community support and engagement – provision of community support services for technology and self care and skills.

Value will vary depending on market analysis as services may be split across multiple providers. 3 year contract(s) with a maximum single contract value of £750k

Dependent of contract value and length. Multiple contracts with local providers under SFI limits will be selected by a minimum of 3 quotes. A single larger contract will require a full market procurement.

Route depends on market analysis.

All other minor contracts

Other contracts are expected to be 1-‐2 years in length and below SFI levels for tendering.

3 quotes (all expected to be below SFI levels for tendering).

All contract procurements to comply with SFI’s.

110110

45

4. Management Case

a. Monitoring and Evaluation

Monitoring

The monitoring process in place for the programme consists of:

(a) Contract monitoring On a day to day basis the digital care and innovation team will monitor contractor performance, quality of service and risks. Experience from the Mi programme will be used to determine levels of scrutiny of the services based on service and financial risk, for example:

(i) Telehealth and similar clinical services will be monitored weekly (as per current arrangements) by forming a task force led by LCCG and including the clinical and technical organisations. The meetings rotate between telephone and face to face to address issues on an on-‐going basis and to categorise the risk and level of resource required where issues are found.

(ii) Community based services with a low risk are monitored monthly based on pre-‐agreed targets or proxy measures for outcomes

(b) Clinical monitoring Continuing the Clinical Reference Group (CRG) established under the Mi programme, all clinical decisions and matters where technology or changes to services can affect clinical information, decisions or service quality are assessed by the CRG. This group is attended by GP’s (also chaired by GP), programme management, nursing and informatics representatives and reports to the Digital Care and Innovation Programme Board.

(c) Performance monitoring The performance of the programme against targets set, the quality of services provided, contractual performance of providers and overall impact against HLP targets will be undertaken by the Digital Care and Innovation Programme Board bi-‐monthly, which in turn will report to the HLP Programme Board. Any matters of significance may then be referred to Governing Body when required. A risk and issues log will be maintained by the Board.

111111

46

Evaluation In particular where new innovations are being scaled-‐up or new technology is being assessed, external evaluation of these projects will be undertaken to assess a variety of parameters including:

• Impact on health and wellbeing (e.g. EQ5D) • Impact of service quality • Impact on workforce • Improvement in key performance measures (reduction in health inequalities,

increased independence, reduction in admissions, improved quality of life, increased efficiency or economy etc.)

• Economic potential • Strategic alignment

b. Exit Strategy/Continuation Strategy

With the nature of the services and experience in these technologies to date, a complete failure in achieving outcomes is very unlikely. In this circumstance, contract terms would allow for a discontinuation of a service most likely through a ‘wind down’ to bring patients off the service rather than an immediate halt. Any decision to cease a service will be made by the Digital Care an Innovation Programme board Where poor performance is detected during ongoing monitoring (most likely scenario), measures will be put in place to rectify the deficit or targets and costs will be reviewed and put before the programme board for amendment. Any below standard performance that is not capable of simple rectification will be reported to the following programme board meeting. Decisions regarding service continuation will also be affected by interdependencies with other elements of the digital care and innovation programme outside of the scope of this investment proposal. These interdependencies will be brought to the attention of the programme board when poor performance is reported. Key services such as telehealth, telecare and the PHR are very likely to have people dependent on them (especially telecare). In these circumstances, services would be wound down over a period of time to allow alternative services to be selected.

112112

47

Review, Approval and Feedback Approval Body Date Approved

Y/N Comments

LCCG Governing Body Development Session (informal review)

21/8/15

N/A

Initial presentation for review, questions and feedback.

LCCG Senior Management Team

1/9/15

Y

LCCG Governing Body

8/9/15

113113

48

114114

49

115115

50

116116

51

117117

52

Appendix 2 – Further Budget Breakdown

Digital 'Pillar'Item Name/Project Title Comment

Care Technology Telecare monitoring service 76,515 202,578 292,779 382,981 Care Technology Telecare Equipment 33,600 57,600 57,600 57,600 Health Technology Telehealth clinical triage/support 350,000 600,000 600,000 600,000 Health Technology 600 TH + 700 Flo users each 6 months 675,536 1,181,612 1,181,612 1,181,612 Health Technology GP patient assessments for TH 21,000 36,000 36,000 36,000 Health Technology Supplementrary TH equip 35,000 60,000 60,000 60,000 PHR Development Further PHR & App Development 500,000 400,000 400,000 400,000 Informatics Support General iM support to scale up 165,000 330,000 330,000 330,000 Digitise Info Digitise existing Materials 100,000 -‐ -‐ -‐ Digitise Info Deliver Digital Material 25,000 30,000 30,000 30,000 Digitise Info Kit to deliver digital material 10,000 20,000 20,000 20,000 Tech training Health Practitioner Digi Skills Dev 50,000 50,000 50,000 50,000 Citizen Support AT + App support & Promotion 29,400 79,000 79,000 79,000 Citizen Support Technological Equality/Accessibility 100,000 100,000 100,000 100,000

Dev/test Innovations Health Innovation New technology PoC support 250,000 250,000 250,000 250,000 Citizen Engagement Community Support & Engagement 75,000 250,000 250,000 250,000 LEP eHealth Cluster E-‐health Cluster engagement maint 40,000 40,000 40,000 40,000 ESIF Innovations Prog Match/elligibility expertise + launch 20,000 20,000 20,000 20,000 ESIF Innovations Prog Additional Admin/PM resources? 16,000 27,429 27,429 27,429 Digital Insight/Eval Digital Insight & social Marketing 100,000 100,000 100,000 100,000 Digital Insight/Eval Evaluation for scaling 30,000 60,000 60,000 60,000 Predictive Analytics Predictive Analytics Support 100,000 100,000 100,000 100,000

2,802,051 3,994,218 4,084,420 4,174,622

Digital Skills

Quadruple Helix

Intelligence & Evaluation

20116-‐17Budget

20117-‐18Budget

20118-‐19Budget

Sep-‐2015 to Mar-‐2016Budget

Scaling Up Solutions

Multi-‐Sector & International Markets

118118

Report no: GB 64-15


GOVERNING BODY

TUESDAY 8th September 2015

Title of Report Corporate Risk Register Update September

2015 Lead Governor Maureen Williams


Stephen Hendry, Acting Head of Operations & Corporate Performance

Report Author

Joanne Davies, Corporate Services Manager (Governance)

Summary The purpose of this paper is to update the Governing Body on the changes to the Corporate Risk Register for September 2015

Recommendation That the Governing Body: Notes the risks (C009, CO12 and CO37)

recommended for removal from the Corporate Risk Register;

Notes the new risks added to the Corporate Risk Register (CO49 and CO50);

Satisfies itself that current control measures and the progress of action plans provide reasonable/significant internal assurances of mitigation, and;

Agrees that the risk scores accurately reflect the level of risk that the CCG is exposed to given current controls and assurances.


The Corporate Risk Register provides evidence of the progress being made across the organisation in the management of operational and strategic risks against achieving improved health outcomes, reducing health inequalities and financial duties/sustainability.

Page 1 of 5

119119


The Health and Social Care Act states that: “The main function of the governing body will be to ensure that CCGs have appropriate arrangements in place to ensure they exercise their functions effectively, efficiently and economically and in accordance with any generally accepted principles of good governance that are relevant to it.”

Corporate Risk Register Update (as at 31st August 2015)

1. PURPOSE The purpose of this paper is to highlight updates and amendments to the CCG’s Corporate Risk Register and the key organisational responsibilities for the mitigation of risks to the delivery of strategic, quality, performance and financial objectives for the financial year 2015/16 and risks carried over from the financial year 2014/15. 2. RECOMMENDATIONS That the Governing Body: Notes the risks (C009, CO12 and CO37) recommended for removal

from the Corporate Risk Register; Notes the new risks added to the Corporate Risk Register (CO49 and

CO50); Satisfies itself that current control measures and the progress of action

plans provide reasonable/significant internal assurances of mitigation, and;

Agrees that the risk scores accurately reflect the level of risk that the CCG is exposed to given current controls and assurances.

3. BACKGROUND NHS Liverpool CCG aims to achieve its overall objectives, ambitions and maintain its reputation via effective and robust risk management procedures. As a public body, the CCG has a statutory commitment to manage any risks that affect the safety of its employees, patients and its

Page 2 of 5

120120

commissioned, financial and business services by adopting a proactive approach to the management of risk. The Corporate Risk Register is a structured framework underpinned by concepts of effective governance and other systems of internal control that enable the identification and management of acceptable and unacceptable risks. Opportunities for improvement in controls and assurances are translated into action plans under specific named lead/managerial control so that monitoring, tracking and reporting can be supported, with clear target dates and milestones identified where appropriate. 4. OVERVIEW OF THE CORPORATE RISK REGISTER: MARCH 2015 As at 1st September 2015 a total of 31 risks are recorded on the CCG’s Corporate Risk Register. The CCG’s risk profile (low – extreme) is summarised below:

Risk Category

Score Range Total Risks

Change +/-

Extreme 15-25 8 -1 High 8-12 19 +3

Moderate 4-6 4 -1 Low 1-3 0 none

Analysis of the direction of travel for risks since the last Governing Body update (July 2015) can be summarised as follows:

Total Change +/-

▲ Risk increased 1 +1 ▼ Risk reduced 5 -4 ► No change (static) 23 +1 New risks 2 +1

Total 31 A total of 16 risks out of the 22 ‘static’ entries as at 31st August 2015 carry an ‘unacceptable’ risk status (no change from the July 2015 update). The risk reduction of five entries in August 2015 and recommended removal of three risks from the CRR is evidence that control measures and action plans

Page 3 of 5

121121

in place are effective. However, a stronger focus on the movement of static risks is recommended heading into the third quarter of 2015/16 and a more detailed analysis of such risks will be provided in the November 2015 Governing Body update. As with previous reporting periods, no ‘Extreme’ risks carry an acceptable rating. The continued zero tolerance of risks which compromise service quality and/or patient safety is also evidenced in the August 2015 updated Corporate Risk Register. Chart 1 below highlights the risk ‘themes’ for the August 2015 Corporate Risk Register: Chart 1 – Risk Themes as at 31st August 2015

There has been little change in the ‘thematic’ composition of the Corporate Risk Register from 1st April 2015. ‘Quality Assurance of Providers’ continues to carry the highest proportion of risks with 7 (the majority with a ‘high’ or ‘extreme’ risk rating).

2

7

3

4 4

1

1

3

4 2

Corporate Systems & Policies

Quality Assurance of providers

Performance Targets

Access to services/waiting times

Financial duties/resources

Commissioning

Transformation

CSU Support

Primary Care Commissioning

Partnership working

Page 4 of 5

122122

4.1 Risks recommended for removal by the Governing Body Three risks are recommended for removal by the Governing Body as at 31st August 2015. These are:

• C009 – The risk to the CCG financial allocations from specialist commissioning allocations. NHS England has developed a ‘new’ approach to commissioning specialist services. It is recommended that this risk is removed and the situation should continue to be monitored as NHS England further develop their approach to specialist commissioning.

• CO12 – Delivery of commissioned services to patients by LWH. Surveillance has been stepped down to enhanced surveillance with routine surveillance continuing.

• CO37 – The SHMI rate at Aintree Hospital is considered sustainable and actions are embedded across the organisation. A mortality action plan is in place and discussed at Clinical Commissioning Forums on a monthly basis. SHMI is a standard agenda item at Clinical Quality and Performance meetings. A Liverpool CCG GP attends the Aintree Mortality working group.

5. SUMMARY The Corporate Risk Register continues to be monitored on a monthly basis. Action plans put in place against each risk identified are reviewed monthly by the appropriate sub-committee of the CCG Governing Body with first-line assurance of controls and actions conducted by the Senior Management Team on a bi-monthly basis. Strategic risks to corporate objectives are monitored on a monthly basis by the Senior Management Team. Where legal issues arise from individual risks the Corporate Risk Register will include plans to mitigate them. There are no inherent legal implications associated with the Corporate Risk Register in August 2015.

Joanne Davies Corporate Services Manager (Governance) 27th August 2015.

Ends

Page 5 of 5

123123

124124

1

LIVERPOOL CCG: CORPORATE Risk Register August 2015 (September Governing Version: v2.0

RefOrganisational Values & Objectives

Date Entered

Objective Description of Risks Current Controls Assurance in Controls L CCurrent

Risk (score)

Current risk

accepted

Management Actions re gaps in controls and assurance or unacceptable risk rating

L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date

Progress since last update

C009 FPCC

To maximise value from our financial resources and focus on interventions that will make a major difference

28/05/2013 Effective management of specialist commissioning financial risk

Risk to CCG financial allocations from specialist commissioning allocations and management by NHS England

Collaborative Commissioning Agreement entered into with NHS England;Monthly mechanism and controls established to assess in year spend and agree appropriate action; Standing agenda item on the Audit and Finance, Contracts and Procurement Committees.

Monitoring by Chief Finance Officer and Audit, Risk and Scrutiny Committee (oversight maintained by Governing Body via committee exception reporting)

Implications of 2015/16 planning guidance continues to be reviewed.

3 3 9 N NHS England is developing a 'new' approach to commissioning specialist services and this is likely to be piloted in Cheshire & Mersey. A dialogue continues with NHSE to understand the new approach; risk has been reduced in light of revised position and will be reviewed further in August 2015.

It is recommended that this risk is removed and the situation will continue to be monitored as NHS England further develop their approach to specialist commissioning.

2 3 6 TJ on-going Aug-15 ▼

C011GB

To hold providers of commissioned services to account for the quality of services delivered

11/06/2013 Delivery of commissioned services to patients by Aintree University Hospital NHS FT meets commissioning requirements (service and quality) and compliance with Monitor 'operating licence'

Some aspects of patient care and service delivery falling below an acceptable and safe standard and commissioner expectations /standards. Trust in potential breach of Monitor 'operating licence'

Formal collaborative commissioning arrangements in place with South Sefton and Knowsley CCGs. AED and mortality monitored via CPQG (holding provider to account for service delivery).

NHS England continue to monitor via 'STAR Chamber' on a monthly basis.

Mortality Action Plan remains in place monitored via CQPG/ Collaborative Commissioning Forum (CCF).

Monthly reporting to Governing Body; regular reporting through Regional Quality Surveillance arrangements;CCF reviews action plans at each meeting.

Single Item Quality & Safety Group actions and reports from QSG continue to be monitored by Collaborative Commissioning Forum & reported to Governing Body by exception.

4 5 20 N Monthly meetinfs now in place to address Star Chamber Action Plan / Tripartite. DTOC and medically optimised patients remain problematic. Operational issues identified in Clock View - Completion of Mental health Assessmentsand delays in AED as a consequence. System Resilience Group taking this issue forward. The national CQUIN for AED will also support mental health and acute providers in understanding the challenges and barriers when patients attend AED as the first point of call. A&E performance - massive improvement in AED 4 hour target. Type 1 achieved 94% which is a vast improvement from the previous month. The figure for all types is around 95% although the Trust has not demonstrated achievement against the entire quarter. Medworks system to be commissioned for Aintree - funding under discussion at contract review meeting.

Linked to Risk CO37

2 5 10 KS Monthly review via

CPQG/ QSG

Sep-15 ►

125125

2


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


C012 To hold providers of commissioned services to account for the quality of services delivered

01/05/2013 Delivery of commissioned services to patients by Liverpool Women's Hospital NHS FT meets commissioning requirements (service and quality) and compliance with Monitor 'operating licence'

Concerns raised regarding quality of some services. CQC inspections in July 13, Sept 13, May 14 & Sept 14 confirmed continued issues relating to staffing, supporting workers, care delivered, complaints and assessing and monitoring the quality of service provision.

CPQG meets regularly and has oversight against compliance of the CQC action plans. Regular reporting to the Merseyside QSG. CCG officers meet regularly with LWH regarding key workstreams

Quality Review meeting held in March 2015 with the Trust, CCG and NHS England colleagues in attendance. Key lines of enquiry following CQC inspection were discussed and decision made to reduce surveillance from

CPQG, reporting to Governing Body and Chief Officer; regular reporting through Regional Quality Surveillance arrangementsQuality of service provision reviewed by the CPQG against the Trust action plan, reporting into the Quality Safety & Outcomes Committee & exception reports to CCG Governing Body

4 5 20 N Trust received an overall 'Good' rating following CQC inspection (Feb 2015).

CCG is working closely with NHS England on local version of National Maternity Review - progress will be reported to Governing Body as and when available.

Meeting with NHS England and other Mersey commissioners took place at end of June 2015 to discuss Serious Incidents at Trust in order to gain insight into maternity trends of SIs.

NHS England will be producing a Merseyside response to the 'Kirkup Review' (including SI data) in Q2

It is recommendedthat this risk is removed as surveillance has been stepped down to enhnaced surveilllance. Routine surveiallance will continue.

2 3 6 KS on-going Sep-15 ►

126126

3


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO14 We will act with honesty and transparency in all our actions. We are committed to a teamwork environment, where every member of the CCG is valued, encouraged to contribute and recognised for their efforts.

29/07/2013 Resolution of all outstanding Continuing Health Care restitution, review and appeals cases

Financial risk from cases (financial settlements and interest); reputational risk due to significant delays to resolution; Formal Ombudsman investigation into delays. 'Remodelling' has seen increase of 52% in likely 'panel' cases and potential increase in financial liability from £2.4M to £4M. (under current rules CCG liability is limited to £2.8M, subject to change

CSU commissioned to manage all outstanding cases and to clear the backlog/legacy cases - it is now expected that all claims will not be cleared before 2016/17

The CCG continues to work with the CSU to ensure that the current work plan and performance target for processing claims is met whilst a long-term solution is sought.

Monthly progress reports from CSU, complaints monitoringRisk reviewed bi-monthly with exception reporting to Governing Body via FPCC if risk increases/ decreases.

Monitored and assured via monthly contract meetings with CSU; oversight by CCG Chief Nurse)

4 5 20 N Liverpool CCG is currently going through a procurement process to determine the new provider for the CHC service.

5 5 25 JL / ID Mar-17 Nov-15 ►

127127

4


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO14b We will act with honesty and transparency in all our actions. We are committed to a teamwork environment, where every member of the CCG is valued, encouraged to contribute and recognised for their efforts.

16/04/2015 Resolution of current/new (2015/16) CCG commissioned Continuing Health Care review and appeals cases under core service

CSU lacks capacity and adequate resources to deliver core CHC service, with significant reliance on bank staff temporary bank staff and lack of leadership capacity. High potential of increasing backlog of cases for financial years 2014/15 and 2015/16 leading to poor service delivery, complaints and criticism and/or financial remedy instruction from Health Service Ombudsman

Linked to Risks CO14, CO40

Monthly Contract Meetings with CSU

Monthly progress reports from CSU, complaints monitoring; CCG has initiated an on-going review of Health Service Ombudsman findings (nationally) to identify areas for learning and improvement of internal processes.

Risk reviewed bi-monthly with exception reporting to Governing Body via FPCC if risk increases/ decreases.

5 4 20 N Liverpool CCG is currently going through a procurement process to determine the new provider for the CHC service.

Risk score remains unchanged at this time.

5 4 20 JL on-going Nov-15 ►

128128

5


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO15 To hold providers of commissioned services to account for the quality of services delivered

06/08/2013 CCG use and reliance upon quality and timely performance data

Poor quality data leading to inaccurate monitoring and assessment of providers, operational and financial risk

CSU is commissioned to provide business intelligence support including data processing and validation. CSU held to account for delivery of data required standard quality matters raised at monthly performance meeting with CSU leadershipData issues with individual providers being taken up via contract meetings.

'in house' analyst capacity increased to review data accuracy and mitigate risk

Monthly performance meetings with CSU - escalation to Finance & Procurement Committee by exception with oversight by Governing Body

4 5 20 N Specifications for the 'new' service have been released and through the lead provider framework a new provider is currently being procured.

Data issues continue to be experienced during this transition period and the CCG in house team continues to take action to mitigate this impact.

Linked to risk number CO40

4 3 12 TJ/ID on-going Nov-15 ▲

129129

6


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO18 We accept responsibility for our actions. We make and support business decisions through experience, evidence and good judgement, and we will deliver against our promises

01/10/2013 Deliver the transformation of health and health & care services across the city through the Healthy Liverpool Programme

Failure to agree model of care; establishment of programme leads and infrastructure; delivery of the transformational programme; failure to communicate and engage with stakeholders and to gain understanding and support for the programme; reputational risk due to high profile of NHS change and reconfiguration programmes.

Programme Advisory Board established; Governing Body commitment to HLP; officer-led delivery group in place; Additional senior resource sourced to manage communication, stakeholder management and engagement. Clinically-led settings and programme groups in place;

List of Programme roles necessary to mobilise produced with prioritisation of roles assessed to mitigate risks to delivery.

HLP governance infrastructure formally approved by Governing Body and all groups established. CCG Governing Body, Programme Advisory Board maintain assurance links

NHS England service change and reconfiguration tracker (formal assurance process)

MiAA review of governancearrangements to oversee the delivery of the Healthy Liverpool programme included in CCG Audit Plan 2015/16

2 5 10 Y Enhanced arrangements have been put in place (effective 1st June 2015) that significantly galvanise the support to HLP. Key developments include the designation of Clinical Leads and Senior Responsible Officers (SRO) for each Transformational Programme and creation of Programme Management Office (PMO) model.

Strategic Direction Case (SDC) is currently being finalised and will be submitted to the Extraordinary September Body meeting on 22nd Sept 2015.

Work is continuing to finalise the draft SDC which will now be formally presented to an extraordinary Governing BOdy meeting on the 29th September 2015. Recruitment has commenced to strengthen the programme teams and the PMO.

2 5 10 NF, KS On-going Nov-15 ►

CO19 To maximise value from our financial resources and focus on interventions that will make a major difference

01/12/2013 To agree with Liverpool City Council the 'Better Care Fund' (formally Integration Transformation Fund) for 2014-16, including individual schemes, outcomes and performance.

Failure to agree with the City Council the investment schedule and associated outcomes, including the performance element of the Fund, threatening: 'retention' of the BCF resources in the City; service delivery and continuity; and relations with the City Council

Section 75 agreement in place with LCC

National guidance published & embedded in CCG.

Negotiations with LCC led by the Chief Finance Officer, regular updates to SMT and, briefings to Governing Body.

The CCG plan has been externally assessed and "Approved with Support" by NHS E and determined as putting the CCG in a strong position to meet the challenges in delivery with no high areas of risk.

2 5 10 Y Risk continues to be monitored/managed as a strategic risk in 2015/16 due to the continued challenges and risks faced by CCG in reducing Emergency Admissions.

1 5 5 KS, TJ & TW

On going Nov-15 ►

130130

7


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



06/01/2014 To deliver effective information governance processes

Failure to comply with requirements of the Information Governance Toolkit leading to restrictions placed on the CCG on the handling of weekly psuedomynised data, adversely affecting key business functions

MIAA is supporting the CCG in meeting the level 2 requirements of the Toolkit.

IG Steering Group in place with formal & approved Terms of Reference - exception reporting to Governing Body via minutes.

1 4 4 Y MiAA review of adequacy of policies, systems and operational activities to complete, approve and submit the IG Toolkit scores included that CCG has demonstrated a reasoned approach to the collation of its IG Toolkit return for 2014/15. Overall assurance rating of 'Significant'.

Remains on CRR as a strategic risk until end of financial year 2015/16 & submission of IG Toolkit

1 4 4 TW Mar-16 Nov-15 ►


01/03/2014 Delivery of commissioned services to patients by Liverpool Community Health meets commissioning requirements (service and quality)

Concerns raised as to the safe and effective delivery of some services to local residents. Confirmed by 2 separate CQC inspections in October 13 and May 14 resulting in enforcement action being required for a number of areas.

Trust decision in Feb 2015 to withdraw from the FT Pipeline presents a further potential risk to the continuity & quality of delivery of community health services for 2015/16.

CCG Collaborative Forum established with other commissioners of services from LCH, CPQG has new GP chair and format of agenda includes 'deep dives' into areas of potential concern and oversight of the remedial action plan. Regular assurance updates to Merseyside QSG (inc. pressure ulcer reporting levels)

CPQG, reporting to Governing Body and Chief Officer; regular reporting through Regional Quality Surveillance arrangements

Trust remedial actions monitored and followed up through the regular Clinical Quality and Performance meetings - exception reporting to QSOC & Governing Body.

4 5 20 N CCG continues to gain assurance against the delivery of the service improvement plans and resolution of specific quality/safety issues through established control mechanisms.

The 'next phase' of the options development will be the 'second gateway' process with recommendations to the TDA Board in mid-late September 2015.

4 5 20 KS Monthly review via CPQG/ QSG

Nov-15 ►

131131

8


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO26 QSOC

To hold providers of commissioned services to account for the quality of services delivered

12/03/2014 Delivery of commissioned services to patients by Alder Hey NHS FT meets commissioning requirements (service and quality) and compliance with Monitor operating licence

Concerns raised as to the safe and effective delivery of services to local residents from Whistleblowing allegations regarding theatre staffing and sickness levels and from recent CQC inspection.

Specialist Commissioners and CCGs working together to understand the concerns raised and determine with the Trust a sustainable improvement plan.

LCCG part of Collaborative Commissioning Forum CCF) which oversees workstreams to address quality and safety concerns

Specific issues re: Theatre and Whistleblowing have now been addressed and sustainability of improvement continue to be monitored through CQPG

4 4 16 Y Follow-up visit by CQC took place in June 2015 - currently awaiting the published report which will be reviewed at relevant CCF (still awaiting publication of the CQC report as at 1st Sept 2015).

Risk score will remain unchanged until publication of CQC report & consideration of findings.

2 4 8 JL Ongoing - Monthly

review via CPQG/ QSG

Nov-15 ►


01/06/2014 Delivery of the commissioned 4 hour target in AED to patients by Royal Liverpool & Broadgreen University Hospitals NHS Trust meeting the commissioning requirements (service and quality) and compliance with TDA requirements

Failure to meet the 95% 4 hour target in AED 2014/15, leading to patients potentially receiving delayed care and treatment.

Remedial Action Plan in place; previous 'contract query' remains open and subject to fortnightly review.

Contract Query remains open as Type 1 A&E performance continues to be challenged. The CCG continues to work closely with the Trust in order to secure sustainable delivery of the 4hr Target (including Type

CCG internal Trust oversight group and contract review meetings continue in 2015/16 as per established control measures.

Current remedial action plan monitored through the formal contract query process and by the TDA.

Agreement with NHS England that RLBUHT performance can take into account Walk-in Centre activity

Governing Body Corporate Performance Report provides updates/assurance on CCG controls on a monthly basis

4 4 16 N We are receiving early indication that the Trust will be allowed to include current type 2 and 3 performance in its overall figure. If direction on this matter is confirmed by NHS England this could mean the contract query may be lifted by end of 2015/16.

3 4 12 ID Ongoing Nov-15 ►

132132

9


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO29b We accept responsibility for our actions. We make and support business decisions through experience, evidence and good judgement, and we will deliver against our promises

01/05/2015 To support operational resilience and performance within LCCG Emergency & Urgent Care System

Contract Query issued to LCCG by RLBUHT on 17/03/2015 in relation to increase in A&E attendances and increase in patients ready for discharge but unable to be discharged. Trust cites these two factors as impacting on their ability to deliver A&E 4hr standard. Reputational risk for LCCG reputation and negative impact on Healthy Liverpool Programme strategic direction.

Standard NHS Contract 2015/16 (General Condition 9.LCCG has been invited to undertake a Joint Investigation (JI) with RLBUT to understand issues behind increased A&E attendances and reasons for impeding patient flow/discharge of patients ready to go. Terms of Reference for JI to be negotiated between parties

Direct formal engagement between Contracts Management Team, Urgent Care Team & Finance - reporting to Governing Body by exception.

3 4 12 N Liverpool CCG due to meet with Trust in September 2015 to take receipt of findings of joint investigation. Initial findings still relate mainly to issues out of the CCG's control.

Contract query meeting to be held on 4th September 2015

3 4 12 JK/DR Sep-15 Nov-15 ►


19/08/2014 To manage RLBUHT over performance against contracted levels for 2014/15

The forecast outturn for RLBUHT is £11.5m over performance as at M3 2014/15, 50% of over performance relates to Non Elective admissions, 25% for diagnostics and 25% over planned care and high cost drugs . This is significantly over planned levels for 2014/15 and continued performance at the current levels will add pressure to LCCG finances.

LCCG are utilising contract levers to understand the drivers behind the over performance. An Activity Query Notice has been issued and the Trust are providing a response to set out for the reasons for the increase in over performance. There has been clinical involvement throughout the contract query process.

LCCG utilising NHS standard contract levers to manage performance as a standard process.

5 4 20 N The external audit review of emergency activity has been concluded with the final report being evaluated. The CCG is currently in dispute with the Trust as to financial extrapolation of the findings of the audit to the 2014/15 performance with discussions ongoing.

A further re-audit is scheduled for early September 2015. RLBUHT still to agree to the Terms of Reference.

5 4 20 TJ/DR Ongoing Nov-15 ►

133133

10


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



29/08/2014 Delivery of RTT waiting times in line with NHS Constitution and contractual requirements at Alder Hey NHS Foundation Trust

Failure to agree and implement elective care operational resilience and capacity plan

Elective care operational resilience and capacity plan submitted to NHS England by the Trust as required.

Trust plan has been subject to external review by the NHS IMAS Elective Intensive Support Team

Governing Body receipt of monthly Corporate Performance Report provides oversight of provider performance and assurances of CCG controls

4 3 12 N Trust was meeting RTT targets as at June 2015 - July 2015 data won't become available until second week of October 2015 due to NHS England alignment of data flows. From October 2015 changes to RTT measures will also take place.

Risk should remain on the LCCG risk register until after the Trust move from their current premises to the new build in September 2015 and there is evidence that performance has stabilised and is sustainable.

3 3 9 JL/DR Ongoing Nov-15 ►


13/10/2014 Delivery of the commissioned 4 hour target in AED to patients by Aintree University Hospital NHS Foundation Trust meeting the commissioning requirements (service and quality) and compliance with Monitor requirements

Failure to meet the 95% 4 hour target in AED 2015/16, leading to patients potentially receiving delayed care and treatment.

Remedial Trust plans in place;

Contract Query remains in place as at Jul 15 and is subject to fortnightly review.

Trust performance reviewed by Collaborative Commissioning Forum and System Resilience Group to gain assurance for improved 4hr performance for 2015/16

Current remedial action plan monitored through the formal contract query process, Collaborative Commissioning Forum (CCF) and by Monitor

NHS England continue to monitor via 'STAR Chamber' on a monthly basis.

4 4 16 N Trust performance against 4hr A&E standard during Q1 has improved although improvements week on week have not been sustained. The CCG and Collaborative Commissioning Forum continue to support the Trust.

We are receiving early indication that the Trust will be allowed to include current type 2 and 3 performance in its overall figure. If direction on this matter is confirmed by NHS England this could mean the contract query be lifted by end of 2015/16.

3 4 12 ID Ongoing Nov-15 ▼

134134

11


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



13/10/2014 Delivery of commissioned services is able to meet likely adverse weather and 'winter' demands 2015/16 (risk from 2014/15 financial year transferred to current)

Failure to meet patient demand leading to a fall in performance and a potential adverse impact upon service responsiveness and quality

Additional national and local resources released to enhance and strengthen service resilience and capacity.

North Mersey SRG has agreed the allocation of baseline resources for winter 2015/16.

Oversight of the plans via the CCG Urgent Care Team and the North Mersey System Resilience Group.

Mersey Internal Audit Agency (MiAA) commissioned by CCG to strengthen performance management and monitoring of winter schemes in-year. Risk score remains unchanged for 2015/16 financial year and will be reviewed in Sept/Oct 2015.

3 4 12 Y The North Mersey System Resilience Group is currently undertaking an assurance assessment (as required by NHS England) to review prepardeness and risk. This will be submitted to NHS England by early September 2015.

3 4 12 ID Ongoing Nov-15 ►


31/10/2014 Delivery of the commissioned services to patients by Aintree University Hospital NHS Foundation Trust meets the commissioning requirements (service and quality).

Higher than expected number of deaths in hospital as measured by SHMI (Summary Hospital-level Mortality Indicator - ratio between the actual number of patients who die following hospitalisation and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated.

National data monitoring has highlighted that the Trust has a higher than expected SHMI value and is identified as a "repeat outlier" for this key indicator.

Health & Social Care Information Centre (hscic) summary of SHMI deaths associated with hospitalisation April 2013 - March 2014 (published 23rd October 2014)

Published data continues to be subjected to review by the CCG and the Collaborative Commissioning Forum / CPQG. Risk is also consistently assessed by Governing Body

3 4 12 N 2 4 8 JL Ongoing Sep-15 ▼It is recommended that this risk is removed as the SHMI rate is sustainable and actions are embedded across the organisation.

Mortaility action plan is in place and discussed at Clinical Commissioning Forums monthly.

Standard Agenda Item at Clinical Quality and Performance Meetings.

CCG GP attendance at Aintree Mortaility working group. It is recommended that this risk is removed as the SHMI rate is sustainable and actions are embedded across the organisation.

Linked to Risk C011GB

135135

12


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



09/12/2014 Delivery of commissioned services to patients by Liverpool Women's NHS Trust meets the required standard in terms of quality & safety in compliance with safeguarding standards

The Trust had an overall Red RAG rating on Safeguarding Standards during the last 3 quarters of 2013/14 contractual year.

On-going reporting to CQPG;Reporting by CCG Safeguarding Service into QSOC;Trust required to report against safeguarding KPIs on a quarterly basis to the CCG Safeguarding Team with remedial actions agreed by group.

Exception reporting from QSOC to Governing Body;Chief Nurse Update standing agenda item for all Governing Body Meetings ;Safeguarding supervision provided to the Head of Safeguarding via the CCG Safeguarding Service Leads. Regular monthly meetings with LWH shows progress in addressing the issues: new head of safeguarding in post with support staff and complete review of systems, processes and governance re safeguarding

5 4 20 N Continues to be standing agenda item for CQPG (next meeting scheduled for September 2015).

3 4 12 JL On-going Nov-15 ►


09/12/2014 Delivery of commissioned services to patients by Alder Hey Children's Hospital NHS Foundation Trust meets the required standard in terms of quality & safety in compliance with safeguarding standards

The Trust had an overall Red RAG rating on Safeguarding Standards during 3 quarters of 2013/14 contractual year.

On-going reporting to CQPG;Reporting by CCG Safeguarding Service into QSOC;Trust required to report against safeguarding KPIs on a quarterly basis to the CCG Safeguarding Team with remedial actions agreed by group.

Exception reporting from QSOC to Governing Body;Chief Nurse Update standing agenda item for all Governing Body Meetings ;Safeguarding supervision provided to the Head of Safeguarding via the CCG Safeguarding Service Leads.

5 4 20 N A Business Case proposal from the Trust to consider gaps in funding is expected to be presented at the CQPG meeting in Sept 2015 for consideration (Business Case has not yet been received).

CCG awaiting review of Q1 data which may show improvement.


136136

13


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



27/01/2015 Effective provision of commissioning support services to the CCG

The NWCSU has failed to secure a place on the national framework agreement. This has the potential effect of their services ceasing to be available to the CCG by the end of 2015/16 and the CCG required to find alternative means of providing the support services commissioned from the CSU.

Service Level Agreement / Contract in place with the NWCSU to provide support services including (Business Intelligence, continuing and complex heath care management, EPRR, comms, UCAT)CCG has reviewed commissioning support service requirements going forward and Transition Plan is now in place.

Monthly performance monitoring of current service delivery, including monthly 'scoring' of individual service delivery elements.

Mersey CCGs are continuing to work collaboratively to ensure delivery in the short term.

5 2 10 Y Specifications for the 'new' service have been released and through the lead provider framework a new provider is currently being procured with a likely implmentation date of November 2015.

Data issues continue to be experienced during this transition period and the CCG in house team continues to take action to mitigate this impact.

5 2 10 DR Ongoing Nov-15 ►

CO41a To hold providers of commissioned services to account for the quality of services delivered

27/01/2015 Effective provision of commissioning support services to the CCG and primary care contractors.

National outsourcing of primary care support services from 1st July 2015 will leave a gap in provision which is detrimental to the CCG and local primary care contractors with regard to delegated commissioning of primary care medical services.

Standing agenda item for Finance, Procurement & Contracting Committee and Primary Care Commissioning Committee

Limited assurance on control measures due to uncertainty in terms of gaps.

Minutes of committee meetings & exception reporting to Governing Body

NHS England awarded contract (22 Jun 2015) to Capita to establish a 'single provider framework' for primary care administrative support functions

3 3 9 N Primary Care Team strengthened in anticipation of increased workload.

3 3 9 AO/ CM Ongoing Nov-15 ►

137137

14


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO41b To hold providers of commissioned services to account for the quality of services delivered

01/04/2015 Effective provision of commissioning support services to the CCG and primary care contractors.

National outsourcing of primary care support services due to take effect from 1st July 2015; new contract restrictions took effect from 1st April 2015. will leave a gap in provision which is detrimental to the CCG and local primary care contractors with regard to payments for local enhanced services.

Standing agenda item for Finance, Procurement & Contracting Committee and Primary Care Commissioning Committee

Limited assurance on control measures due to uncertainty in terms of gaps.

Minutes of committee meetings & exception reporting to Governing Body

5 3 15 N Primary Care Transition Group in place. Action plan includes quantification of impact of out of scope functions

3 3 12 AO/ CM Jul-15 Nov-15 ►

CO42 To maximise value from our financial resources and focus on interventions that will make a major difference. To hold providers of commissioned services to account for the quality of services delivered

27/01/2015 To accept from NHS England delegated responsibility for the commissioning of primary care medical services

That the CCG acceptance of delegated authority to commission primary care medical services progresses without a full and proper due diligence exercise to assess the potential risks including financial, staffing and any pre-existing liabilities to the detriment of the CCG.

Transition Group in place with approved Terms of Reference and meeting on weekly basis.

Primary Care Co- Commissioning Manager in post

Exception reporting to the Governing Body through Transition Group and Primary Care Commissioning Committee

CCG has signed the Scheme of Delegation with NHS England and confirmation assurances from the Director of Finance, NHS England Cheshire & Merseyside Sub-Regional team that there is sufficient resource.

4 4 16 N The Primary Care Commissioning Committee is fully established and has formally convened twice in Q1. Process and guidance in relation to delegated commissioning responsibilities continues to evolve. Risk will be re-assessed in Nov 2015.

3 4 12 KS / TJ Ongoing Nov-15 ▼

138138

15


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO42b To hold providers of commissioned services to account for the quality of services delivered

16/04/2015 To accept from NHS England delegated responsibility for the commissioning of primary care medical services

Acceptance of delegated authority to commission primary care medical services potentially does not allow for necessary timescales for re-procurement of 12 Liverpool APMS practices (current provider SSP) once contract expires on 31st March 2016. Risks are that decision to either extend or cease the contract without full and proper consultation could impact negatively on service delivery to patients

Standing agenda item on Primary Care Commissioning Committee

Exception reporting from PCCC to Governing Body

Practice contracts continue to be monitored via normal reporting processes

5 4 20 N An Interim Provider Policy has been developed approved by the Primary Care Commissioning Committee (June 2015).

3 4 12 CM/DR on-going Nov-15 ▼

139139

16


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



16/04/2015 Mental Health Access Waits - waiting time standards for people entering a course of treatment in adult IAPT services.

Transfer of service to new provider on 1st April 2015 revealed inherited backlog of an estimated 1,700 patients waiting for IAPT treatment. Patients waiting to be seen at Step 2 and Step 3 (the majority are Step 3) and although clinical risk is relatively low, it is unlikely that the CCG will be able to deliver against IAPT waiting time contract standards for this cohort of patients, which could result in negative impact on individual patients and lead to public/media/ MP scrutiny. The waiting list also needs to be addressed effectively to ensure the CCG is compliant with 2015/16 IAPT waiting

d d

Data cleansing exercise immediately commenced by new provider to quantify backlog for commissioners

New' patients/referrals will be monitored against IAPT standards separately from those on inherited waiting list to ensure proportionate provider delivery against standard and monitor progress of recovery plan to address backlog.

Contract Review Meetings with exception reporting to Governing Body on key risks & progress with actions to reduce waits

CCG working collaboratively with NHS England IAPT Intensive Support Team to ensure robust recovery plan is delivered

4 4 16 N The Trust has commenced recruitment of additional staff to flex resources with the aim of offering treatments from August 2015.

Negotiations about payment are ongoing between the Head of Contracts and Procurement and Mersey Care Director of Finance.

In addition to robust contract monitoring the CCG has also set up a monthly steering group with representation from all key stakeholders and service users to ensure the best possible care, experience and outcomes and to promote a culture of safety, effectiveness, service improvement and innovation.

NHS England have also agreed some additional funding to assist with cleansing the waiting list and the CCG is able to bid for additional funds to support clearance in preparation for delivering waiting standards by April 16.

4 4 16 TW Mar-16 Nov-15 ►

CO46 To build successful partnerships which promote system working and integrated service delivery

16/04/2015 Maintain safe & effective Vaccination & immunisation provision for local patients

Transfer of Vaccination & Immunisation provision to General Practice could lead to reduced uptake across the city as not all General Practice staff are adequately trained or prepared to access transfer.

Audit underway of General Practice preparedness to take on transfer

Standing agenda item on Primary Care Quality Committee, oversight conducted by PCCC

Primary Care Quality Team continuing to work with Locality/N'hood teams to quantify risk and establish capacity gap.

Exception reporting from PCCC to Governing Body

5 3 15 N Options for service delivery of vaccinations/immunisations post April 2016 will be agenda item for Primary Care Commissioning Committee in September 2015

Practices alerted to the need to undertake necessary training ASAP; CCG planning to mitigate risks of non transfer by costing up a contingency model

5 3 15 CM/JL on-going Nov-15 ►

140140

17


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


CO47 To build successful partnerships which promote system working and integrated service delivery

16/04/2015 Delivery of comprehensive Health Visiting service to all practices & registered patients across the city

Local Authority led commissioning of Health Visiting Services is restricted to patients resident within city boundaries of Liverpool, as opposed to patients registered with a Liverpool GP but who live in other Local Authority areas.

National Specification for Health Visitors

Local Authority Contracting Strategy

LCC Director of Social Care attendance as non-voting member of Governing Body ensures effective reporting/ assurance

Director of Public Health attendance as non-voting member of Governing Body has DoPH report as standing agenda item

3 4 12 N Transition of Health Visiting service delivery to Local Authority resident footprints commenced on the 1st July 2015 in Merseyside. All Merseyside Local Authorities continue to collaborate at this early stage to ensure an effective solution so that Health Visitor Provision matches patient's registered practice & removes the need for GP practices to potentially engage with multiple Local Authorities regarding provision.

Transition work is ongoing.



06/07/2015 To secure a new Headquarters premises for the CCG

That the building works to fit out the new HQ are delayed beyond the deadline at which the CCG must vacate the current Arthouse Headquarters.

Letter of instruction sent ot the developer to commence construction works on the 29/05/15 which would allow sufficient time for the works to be completed; funding for the works lodged with Hill Dickinson LLP in an 'escrow' account to be released upon phased completion of the works

Legal Advisers and Liverpool Sefton Health Partnership both acting on behalf of the CCG to expedite matters; NHS Property Services as current landlord supporting the process. Briefing provided to the Finance, Contracting & Procurement Committee June 2015.

3 4 12 N Teleconference held on the 18th June 2015 with the developer and financial backers for the new development to expedite matters and seek to develop contingency plans in the event that the building works are further delayed. Further meetings to be held to explore the options available w/c 6th July, position then to be reviewed.

Building works have now fully commenced with a scheduled completion date of 13th November 2015, occupation of the new premises to follow thereafter. Negotiations continue with the Receiver to allow the CCG to remain in Arthouse Square to the end of November. The latter is however subject to NHS Property Services securing agreement on the outstanding dilapidations. Contingency measures are being explored if the latter is not resolved.

4 4 16 ID Nov-15 Nov-15 ►

141141

18


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date



31/07/2015 Respond to Monitor Pricing Enforcement complaint regarding the pricing of CHC care home services

Financial risk - potential of penalty fine from Monitor if an investigation finds in providers favourFinancial risk - impact of having to back date payments to providers from 1 April 2014 if investigation finds against LCCGReputational - impact if

Immediate Review of all CHC payments for patients in care homes to assess financial impact. Legal advice sought to support response to Monitor. Current reprocurement CHC NW framework services to commence mid

Regular review of CHC payments.

4 4 16 N LCCG Compliance statement submitted to Monitor. Now await response from Monitor to confirm if an investigation will be undertaken.

3 4 12 DR/JL Ongoing Nov-15 New risk

CO50We accept responsibility for our actions. We make and support business decisions through experience, evidence and good judgement, and we will deliver against our promises.

23/07/2015 Stability of commissioning support services during reprocurement

Timescale and potential loss of service up to transition and during mobilisation

Robust transition plan from new provider and exit plan from incumbent

Weekly transition board meetings to monitor progress and highlight any risks. Monthly steering group meetings

3 4 12 N LPF tender issued submissions due to be return 28th September - award of new supplier November 2015.

3 4 12 DR Ongoing Nov-15 New risk

142142

19


Date Entered


Risk (score)

Current risk

accepted


L CResidual

Risk (score)

Lead Officer

Completion Date

Review Date


KEY:

Updates to existing risks in 'blue' new risk Recommended for removal

► Risk Unchanged

▲ Risk increased

▼ Risk decreased

143143

144144

Report no: GB 65-15



Title of Report NHS Liverpool CCG Complaints, Concerns and

Compliments Policy (August 2015)

Lead Governor Jane Lunt, Chief Nurse/Head of Quality



Report Author


Summary The purpose of this paper is to provide the Governing Body with an overview of the revised NHS Liverpool CCG Complaints Policy (August 2015) which accompanies this report.

Recommendation That the Governing Body: Notes the contents of the report and the

accompanying policy; Approves the LCCG Complaints Policy August

2015 as a corporate policy for immediate implementation and dissemination/publication;


The NHS Constitution for England (July 2015) establishes the principles and values of the NHS in England. It sets out the rights to which patients, public and staff are entitled and pledges that the NHS is committed to achieving. It also determines the necessary responsibilities to ensure that the NHS operates fairly and effectively and carries the pledge to encourage and welcome feedback on health and care experiences and use this to improve

Page 1 of 4 145145

services and the patient experience. The CCG’s complaints system is intrinsically linked to those rights and pledges contained within the NHS Constitution.


Local Authority Social Services and NHS Complaints (England) Regulations 2009; Guide to good handling of complaints for CCGs (NHS England 2013); Principles of good complaint handling (Parliamentary and Health Service Ombudsman);

NHS LIVERPOOL CCG COMPLAINTS, CONCERNS AND COMPLIMENTS POLICY (AUGUST 2015)

1. PURPOSE The purpose of this paper is to provide the Governing Body with an overview of the revised NHS Liverpool CCG Complaints Policy (August 2015) which accompanies this report. 2. RECOMMENDATIONS That the Governing Body: Notes the contents of the report and the accompanying policy; Approves the LCCG Complaints Policy August 2015 as a corporate policy

for immediate implementation and dissemination/publication. 3. BACKGROUND Any individual contacting NHS Liverpool CCG to raise a concern or a complaint can expect to be given the opportunity to discuss the most appropriate way to handle their complaint, agree a reasonable and proportionate timescale and express their desired or preferred outcome. Comments, compliments, concerns and complaints will therefore always be considered as invaluable sources of information from our local population; offering real-time feedback on the quality of the care we commission and helping support our drive to make the best and most effective use of local NHS resources. Since the CCG’s Authorisation in 2013, the local healthcare system has developed considerably. Liverpool has a

Page 2 of 4 146146

complex provider landscape with multiple interdependencies and relationships with neighbourhood health facilities, private acute providers along with a diverse market of nursing, residential home and domiciliary care providers. Ensuring that people and communities have a better experience of care and support means that it is essential to provide an easy to understand, accessible and impartial system for patients, carers and family members to raise concerns or complaints when things go wrong; be that a commissioning decision/omission by the CCG or where patient care at the point of delivery falls below expected standards. Positive feedback and compliments are also vital to the NHS as this highlights where we are getting things right and can share good practice. The Liverpool CCG Complaints Policy (August 2015) aims to provide an outcomes driven local resolution process, which is based on individual needs, reasonable and proportionate response times and assurances that lessons learned from complaints will ultimately improve patient experience, patient safety and the quality of healthcare. 4. SUMMARY OF MOST SIGNIFICANT CHANGES All NHS and social care organisations have to comply with the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (the Regulations) and there is little flexibility in terms of creating a ‘unique’ process outside of this legislative framework. However, the Regulations do promote a flexible and outcomes driven approach, which places the patient/complainant at the centre of all negotiation and decision making in the local resolution process. The revised CCG Complaints, Comments and Compliments Policy therefore focuses on the agreement of a complaints ‘action plan’ between the CCG and individual patient/complainant; a plan which manages expectations at an early stage by identifying their ‘preferred outcome’ and whether this can be achieved through the complaints system. The most significant change to be noted is the move away from a standardised 35 working day timescale of the CCG’s 2013 policy. The 2015 policy ensures that response times are based more on negotiation, risk assessment and proportionality to the complaint; meaning that timescales become more focused on the quality and thoroughness of the investigation and response rather than a standardised ‘one size fits all’ limitation on time (which can quite often have a negative impact on the outcome of local resolution). Organisational roles and responsibilities have also been strengthened in terms of reporting, governance structures and process to reflect the changes in the CCG’s overall governance structure since Authorisation in 2013.

Page 3 of 4 147147

5. NEXT STEPS The CCG has recruited to the role of ‘Customer Relations Lead’ with a commencement date of 1st October 2015 now agreed. It is proposed that the post-holder will take a significant role in the implementation, application and promotion of the revised complaints policy; with a particular focus on socialising and promoting awareness of the policy amongst our providers and stakeholders should the Governing Body ratify the document. Stephen Hendry Acting Head of Operations and Corporate Performance 28th August 2015 ENDS

Page 4 of 4 148148

COMPLAINTS, CONCERNS and COMPLIMENTS POLICY

2015-2016

V 2.1

August 2015

149149

Version:

2.1

Ratified by:

Date ratified:

Name of originator/author:

Stephen Hendry, Senior Corporate Services Manager (Performance & Operations)

Name of lead:

Ian Davies, Head of Operations & Corporate Performance

Date issued/published:

Review date:

30th September 2016

Target audience:

Organisation wide policy

Any changes to this policy should be outlined and recorded in the version control table below. In the event of any changes to relevant legislation or statutory procedures or duty this policy will be automatically updated to ensure compliance without approvals being necessary.

Version no. Type of change Date Description of change 2.1 Edit 14/08/2015 • Amendments made to Healthwatch

contact details; • Insertion of responsibilities of

Engagement & Patient Experience Advisory Group

150150

Contents

Page 1. Introduction 1 2. Purpose and Scope of this Policy and Associated Processes 1 3. Associated Policies and Documents 2 4. Definitions 2 5. Roles and Responsibilities 3 6. Complaints Procedure 6 7. Correspondence from Members of Parliament 17 8. Confidentiality 17 9. Consent 18 10. Learning from Complaints and Stakeholder Feedback 18 11. Monitoring of Commissioned Services 19 12. Advocacy Services 19 13. Customers with Additional Communication Requirements 19 14. Record Keeping 20 15. Publicity 20 16. Education and Training 20 17. Monitoring Compliance with this Policy 21 18. Policy Review Arrangements 23 19. Equality & Diversity Statement 23 Appendices: A Complaints/Risk Grading Tool 24 B NHS Liverpool CCG Procedure for Management of Complaints 27 C Standard Consent Form 28 D Guidance on Handling Unreasonably Persistent and/or Habitual

Complaints 30

151151

1. INTRODUCTION NHS Liverpool Clinical Commissioning Group (hereafter referred to as NHS Liverpool CCG or simply ‘the CCG’) is committed to commissioning high quality care for the people of Liverpool. All feedback concerning local health services, our commissioning decisions or plans will be routinely recorded. We recognise that it is essential to provide an easy to understand, accessible and impartial system for patients, carers and family members to raise concerns, complaints. Positive feedback and compliments are also vital to the NHS as this highlights where we are getting things right and can share good practice. Comments, compliments, concerns and complaints will always be considered as invaluable sources of information from our local population; offering real-time feedback on the quality of the care we commission and helping support our drive to make the best and most effective use of local NHS resources. The CCG will always welcome and indeed encourage concerns, complaints and suggestions for improvement regarding local health services or our commissioning decisions and actions. All feedback given to the CCG will be responded to confidentially and in an open, fair and transparent way. Complex enquiries, matters of concern and complaints will be investigated fully to identify learning which will ensure that unsatisfactory experiences are not repeated, and the patient experience is enhanced as a result. NHS Liverpool CCG’s approach to handling complaints will be based consistently around the individual needs of the patient and/or complainant. Any individual contacting the CCG to raise a concern or a complaint can expect to be given the opportunity to discuss the most appropriate way to handle their complaint, agree a reasonable and proportionate timescale and express their desired or preferred outcome. The CCG is committed to equality of opportunity and any person expressing concerns/raising a complaint will be treated no differently to any other on the grounds of race, disability, age, religion or belief, gender or sexual orientation. 2. PURPOSE AND SCOPE OF THIS POLICY & ASSOCIATED PROCESSES This policy is an organisational-wide policy and must be followed by all CCG staff, including those on temporary contracts, secondments, volunteers or student placements (collectively referred to as ‘staff’ throughout this policy document). The policy describes the structures in place to effectively manage concerns from individuals personally affected by the provision of NHS services and/or the CCG’s commissioning decisions or actions. It outlines the procedures in place for investigating and responding to a complaint /concerns made by individual patients or on their behalf by a suitable representative. This policy covers complaints received by NHS Liverpool CCG relating to the following:

• Services provided on behalf of or commissioned by NHS Liverpool CCG (as co-ordinating commissioner);

• Other NHS or social care organisations with whom the CCG contracts or has formal service level agreements;

1

152152

• Independent providers of NHS services, and; • Primary Care Medical Practitioners or contractors (from 1st April 2016)

The CCG has a statutory obligation to investigate complaints within its remit under the Local Authority Social Services and NHS Complaints (England) Regulations 2009 (hereafter referred to as ‘the Regulations) and is committed to meeting the standards laid down in these Regulations, the NHS Constitution and the recommendations from both the Francis report (2013) and Clwyd Hart review (2013). 3. ASSOCIATED POLICIES AND DOCUMENTS This policy should be read in conjunction with the following key documents:

• Principles of good complaint handling (Parliamentary and Health Service Ombudsman);

• Listening, Improving Responding – a guide to better patient care (DoH) 2009 • The NHS Constitution; • The Patients Association – Handling Complaints with a Compassionate and

Human Touch (2014); • Guide to good handling of complaints for CCGs (NHS England 2013); • NHS England Complaints Policy (September 2014); • NHS Outcomes Framework: Domain 4 – Ensuring that people have a positive

experience of care; • NPSA Being Open document; • NHS Liverpool CCG Quality Strategy 2015-2017 • NHS England - Safeguarding Vulnerable People in the Reformed NHS (2013)

4. DEFINITIONS

Definitions of what constitutes a complaint, a concern or a query are often subjective and can be interchangeable. However, for the purposes of this policy and associated procedures, the following definitions will apply:

• Complaint - an expression of dissatisfaction communicated verbally, electronically, or in writing which requires a response.

• Concerns and enquiries – problems communicated verbally, electronically or in writing which can be resolved/responded to immediately. Concerns and enquiries resolved within one working day/24hours will not usually be treated as a complaint unless the individual raising them expressly states that they wish for it to be recorded as one.

• MP enquiry – concerns, complaints or queries about local health services or commissioning decisions/omissions submitted by a Member of Parliament (usually on behalf of a constituent).

• Serious Incident (SI) - an incident or near miss occurring on health service premises or in relation to health services provided, resulting in death, serious

2

153153

injury or harm to patients, staff or the public, significant loss or damage to property or the environment, or otherwise likely to be significant public concern.

5. ROLES AND RESPONSIBILITIES All those working within the CCG have a responsibility to contribute, directly or indirectly, to the achievement of the CCG’s objectives through the effective application of this policy. Specific accountabilities, roles and responsibilities for complaints management are set out below and provide a structure that supports an open, accessible and fair complaints system. Where appropriate these are reflected in individual job descriptions and roles. 5.1 The CCG Governing Body The Governing Body is accountable for ensuring compliance with the Local Authority Social Services and NHS Complaints (England) Regulations 2009 and is committed to providing the appropriate resources and support systems necessary to support the CCG’s complaints process. It has a duty to assure itself that the CCG complaints procedure is fair, accessible, inclusive and transparent. 5.2 The Chief Officer The Chief Officer has ultimate responsibility and accountability for the management of complaints relating to CCG functions and local commissioning decisions affecting the delivery, safety or quality of care to Liverpool residents, ensuring that an effective complaints policy and procedure is in place. The Chief Officer will take responsibility for the authorising and signing of all response letters to complaints against NHS Liverpool CCG and/or other healthcare providers (where a complainant has requested that the CCG coordinate or lead the investigation). In the absence of the Chief Officer, all response letters will be signed off by the nominated deputy. 5.3 The Head of Operations and Corporate Performance The Head of Operations and Corporate Performance has delegated responsibility from the Chief Officer for corporate governance and is responsible for the overall operational management, promotion and delivery of the CCG’s complaints process and any new policy developments. The Head of Operations and Corporate Performance will also act as lead CCG contact for internal and external audits of complaints/risk management processes and corporate governance. 5.4 The Quality, Safety & Outcomes Committee The Quality, Safety and Outcomes Committee is responsible for overseeing quality and safety processes across all commissioned services; ensuring alignment with delivery of the NHS Outcomes Framework and for assuring the Governing Body that quality and patient safety activity is coordinated and transparent ensuring a coherent and systematic review of the system The Quality, Safety & Outcomes Committee will act as the Governing Body committee for receiving reports which triangulate

3

154154

complaints, Serious Incidents (SIs) and other ‘quality’ intelligence such as Health Care Acquired Infection incidents, for thematic analysis. Members of the Quality, Safety & Outcomes Committee will consider and determine any further action necessary to improve the quality of care commissioned by Liverpool CCG. 5.5 The CCG Customer Relations Lead The CCG Customer Relations Lead will act as a point of contact for individuals wishing to make face to face, telephone or email complaints and is responsible for ensuring that all statutory and organisational requirements are met (i.e. that complaints are investigated with appropriate thoroughness and impartiality and that all complaints receive a full, high quality and timely response that delivers the best outcome for the complainant and for the service involved). The CCG Customer Relations Lead will also ensure that:

• Clinical Leads or other appropriate professional advisors review complaints and, where necessary provide a response to the issues raised by a complaint;

• Complaints handling/customer care training is provided to CCG staff who have direct contact with patients or the public;

• Systems are in place to monitor the implementation of any recommendations

and disseminate lessons learned to CCG member practices, CCG staff and other health or social care organisations as necessary;

• Complaints responses are authorised by the Chief Officer (or nominated

deputy) within agreed timescales; • Meetings with complainants and/or their representatives and staff are

facilitated to encourage local resolution wherever possible;

• Any potential/actual risks to patient safety or safeguarding issues identified as a result of complaints investigations are escalated to the Chief Nurse, Deputy Chief Nurse and/or the Quality, Safety & Outcomes Committee.

5.6 Clinical & Programme Leads CCG Clinical and Leads will contribute to the complaints process by:

• Providing expertise and/or professional comments on the clinical aspects of a complaint (where this is necessary for the resolution process);

• Using information and lessons learned from complaints to inform or influence future clinical commissioning plans, decisions or transformational programmes.

5.7 The CCG Chief Nurse The Chief Nurse is the professional lead with organisational responsibility for safeguarding adults and children, Clinical Governance, Health & Safety and Infection, Prevention and Control (IPC). The Chief Nurse also has responsibility for

4

155155

ensuring that assurance processes are in place with regard to all aspects of clinical risk management within commissioned services (including complaints and patient safety). Complaints received by the CCG which highlight risks or failings in any of these areas will be escalated to the Chief Nurse (or Deputy Chief Nurse) immediately.

5.8 Engagement & Patient Experience Advisory Group

The CCG is legally required to involve patients and members of the public in developing policies, planning, designing, commissioning and de-commissioning of services. The Engagement & Patient Experience Advisory Group will collate and review patient experience in a systematic manner and will receive reports on complaints activity, trends, themes and risks to inform engagement methodologies and feed into wider patient experience work.

5.9 NHS Liverpool CCG Staff

All employees are expected to fully cooperate and assist in complaints process when required, although it is recognised that the majority of CCG employees will not have public facing roles or direct patient contact. All staff should, however, ensure that in rare situations where complaints are raised directly with them, they are fully conversant with this policy and the CCG’s process for complaints management (including MP enquiries).

Switchboard/ Reception Staff are responsible for ensuring that members of the public who contact the CCG either by telephone or in person and who want to make a formal complaint are put through to the Customer Relations Lead/Corporate Services Team.

5.10 CCG Member Practices/Primary Care Medical Practitioners

All CCG Member Practices are required to have their own practice-based complaints system (which meets the requirements of the Regulations) to resolve concerns, complaints and queries in-house. In the majority of cases complaints will be successfully resolved at this local level. Under current legislation however, individual complainants have the right to approach the appropriate commissioner of the service to request that they consider their complaint, and all Member Practices will therefore be expected to cooperate with the CCG’s complaints process should a complaint about primary care medical services initially be raised with the CCG.

5.11 Other Specialist Expertise In some cases, the CCG may need to obtain expertise or advice from both internal and external sources in the investigation/resolution process. This will usually be coordinated by the CCG Customer Relations Lead. Sources of expertise can include:

• NHS England; • Public Health England;

5

156156

• Parliamentary & Health Service Ombudsman; • NHS Protect/Local Counter Fraud Specialist; • NHS Litigation Authority (NHSLA);

5.12 Responsibilities of Contractors, agency and locum staff

Contractors, agency and locum staff working for the CCG will be expected to comply with all relevant policies and procedures. Where necessary, information and training will be provided to enable Contractors, agency and locum staff to fulfil this responsibility. This expectation will also be extended to all work placement students and vocational trainees.

6. COMPLAINTS PROCEDURE

The aim of the CCG’s complaints process is to ensure that all individuals accessing it achieve a satisfactory outcome and that lessons learned from complaints are used to improve healthcare services. The process is based on the principles of openness, transparency, negotiation and is built around the needs of the individual person, and not the organisation. Concerns and complaints can be made either verbally, in writing or electronically via email to the CCG’s dedicated complaints email address [email protected] The NHS complaints procedure operates at two stages:

1. Local resolution of complaint through investigation and response by NHS Trust, provider or commissioner, and;

2. Independent Review of complaint by Parliamentary and Health Service Ombudsman (PHSO)

The CCG will endeavour to successfully resolve all complaints at a local level, and will only refer individuals to the Parliamentary & Health Service Ombudsman where it is specifically requested that the complainant wishes to or if the CCG considers that referral to the PHSO would be beneficial for all parties. The PHSO will not usually investigate a complaint until all avenues to resolve it have been exhausted locally. 6.1 Who can complain? Anyone who is receiving, or has received, NHS treatment or services or who is affected (or is likely to be affected) by an action, omission or decision of an NHS body can make a complaint. This includes services provided by independent contractors who have a contract with the CCG to provide NHS services and any services that are provided by independent providers as part of an NHS contract. If a patient is unable to complain in person then a representative (i.e. a relative or friend) can complain on their behalf providing written consent is given (the CCG standard consent form can be found at Appendix A). Where the complainant is the parent or guardian of a child under the age of 18 (to whom the complaint relates) in

6

157157

mailto:[email protected]

some cases the CCG will seek assurances that there are reasonable grounds for the complaint being made by the representative instead of the child. If a patient is unable to act, for example due to physical incapacity or lack of capacity within the meaning of the Mental Capacity Act (2005) consent will generally not be required if the representative can provide evidence of their relationship with the patient and of their suitability to act on the individual’s behalf. This will be agreed on an individual/case-by-case basis between the ‘representative’ and the CCG Customer Relations Lead. Complaints concerning a patient who is deceased must be made by a suitable representative (for example the next of kin or the executor of estate). Where ‘suitability’ cannot be evidenced, the complaint maybe declined and a recommendation made that another person acts on the deceased patient’s behalf. All individuals will be informed in writing of the CCG’s decision to decline a complaint on grounds of suitability and of the options available to them to complaint about the decision. 6.2 Verbal complaints The CCG’s complaints process is inclusive and verbal complaints will be treated no differently to those submitted in writing or electronically. To ensure that the CCG can address the complaint properly and agree a bespoke action plan with individuals accessing the complaints process, they should always contact the CCG Customer Relations Lead in the first instance. When a verbal complaint is made a brief written account will be taken from the complainant; in most cases this will generally include all the salient points and issues discussed (including the preferred outcome). Verbatim statements will not usually be taken from complainants unless there are exceptional reasons (i.e. where an individual has a specific communication need). If a communication need is identified at the planning stage the CCG may seek agreement with the complainant to refer them to local advocacy services for appropriate support. The written account will be sent to the complainant asking them to make any changes to ensure it is an accurate reflection of their complaint. The complainant will then be asked to sign and return the statement to the CCG Customer Relations Lead. All complainants will be advised that their complaint cannot be progressed until the signed statement is returned. There will be some instances where the complexity of the complaint means that it would not be appropriate or practical to be taken over the telephone. In these circumstances the CCG may offer a face-to-face meeting with the individual(s) to clarify the issues or, with the complainant’s permission, refer the matter to a local advocacy service. Clear information about the complaints process and who to contact is made available to patients, the public and staff via the CCG’s website www.liverpoolccg.nhs.uk

7

158158

http://www.liverpoolccg.nhs.uk/

6.3 Written complaints It is expected that written complaints will generally be addressed directly to the Chief Officer (as highlighted on all corporate public-facing complaints material). However, in some cases CCG staff may receive written complaints addressed to them; for example if they are identified as a clinical lead or programme manager in a press release or other media briefings. In these circumstances the complaint should be immediately forwarded to the CCG’s complaints email account [email protected] for action. The CCG will acknowledge all written complaints within 3 working days of the date of receipt (verbal acknowledgements are considered suitable for this purpose as long as a record is made of the contact). 6.4 Time limit for making a complaint A complaint must be within 12 months of the date on which a matter occurred, or within 12 months of the complainant becoming aware that there is a complaint to make. The Regulations do have provisions where the NHS or social care body can use discretion to investigate complaints beyond this timescale, providing the complainant can evidence that there are valid reasons which prevented them from raising it earlier. Where it is still practical and possible to investigate the complaint beyond these timescales, the CCG will endeavour to take the matter forward (for example, if the care records still exist and individuals implicated are still able to comment). If there are known limitations which would affect the investigation and agreed preferred outcome of the complaint, the CCG will notify the complainant, in writing of the potential impact on the resolution and asking whether they still wish to proceed. Where the CCG determines that a complaint is ‘out of time’ and it is not practical or possible to investigate the complaint, the CCG Customer Relations Lead will inform the complainant of the CCG’s decision, the reasons for it and of the complainant’s right to take their complaint to the PHSO if they are unhappy with the decision. 6.5 Issues that cannot be addressed by the CCG’s complaints procedure Although the CCG aims to provide an open and easily accessible complaints system, there are specific areas which the Regulations exclude from being considered under the NHS process, including the following:

• Complaints concerning privately funded treatment. Where treatment is a mixture of private & NHS, only the NHS elements can be investigated under this policy;

• Complaints made by a responsible body about another responsible body. For example, disputes on contractual matters between the CCG and a provider or disputes between independent contractors/CCGs;

• Any verbal complaints which are resolved at a local level within one working

day/24 hours of the CCG’s receipt will not be considered as a complaint under this policy, as per the Regulations;

8

159159


• Any complaints which have already been fully investigated by the CCG under this process and a full/final response given. The CCG will only consider cases where issues are identified which were not included in the original complaint. In the majority of cases this will be treated as a new complaint;

• Complaints that are being/have been investigated by the Parliamentary &

Health Service Ombudsman (PHSO);

• Complaints made relating to an alleged failure by the CCG to comply with a request for information made under the Freedom of Information Act (2000). The CCG will, in all cases direct individuals to the Information Commissioner’s Office as appropriate;

• Complaints or grievances made by a CCG employee about any matter

relating to their contract of employment (these matters will be managed by established Human Resources procedures);

• Complaints disputing CCG funding decisions where there is an agreed and

appropriate appeals process (for example Individual Funding Requests and continuing healthcare);

• Complaints relating to the administration of the NHS Superannuation Scheme;

Where the CCG determines that a complaint cannot be addressed due to any of the reasons highlighted above, the individual complainant will be notified in writing of the CCG’s decision not to investigate, the reasons behind the decision and of their right to take their case to the Parliamentary and Health Service Ombudsman should they be dissatisfied with the decision. Any allegations of fraud or financial misconduct should be referred to the National Fraud Reporting Line at NHS Protect. Full details of the methods for reporting are on the NHS Protect website: https://www.reportnhsfraud.nhs.uk/ 6.6 Process by which complaints will be handled by the CCG The CCG recognises that when someone makes a complaint, the initial contact is crucial in setting the right tone and ensuring that a positive outcome is reached. Whilst there has to be a structured process in place, each complaint will be managed on a case-by-case basis with a consistent focus on successful outcomes. Following initial contact with the CCG, the Customer Relations Lead will discuss with the complainant the most appropriate way forward (the action plan), considering factors such as whether the issues relate to the CCG itself or a commissioned service. During this initial phase, the CCG Customer Relations Lead will establish:

• How the complainant wants to be addressed and whether they have any particular access or communication preferences/needs;

• If consent will be required (for those cases where an individual is acting on the patient’s behalf). Where consent is necessary the patient will be asked to provide this in writing;

9

160160

https://www.reportnhsfraud.nhs.uk/

• If a specific NHS provider is involved, whether the complainant prefers their

complaint to be coordinated by the CCG (as commissioner). Where another organisation is implicated, consent will be sought from the complainant to share the complaint with the organisation involved before any further action is taken (see 6.7);

• Their preferred outcome (if this is not stated) and an agreement on whether

this would be feasible, achievable and/or realistic;

• A broad plan of action, including the method by which the complainant will receive a response (e.g. in writing, via face-to-face meeting), how they will be updated on progress and who will be investigating the complaint;

• A proportionate and appropriate timescale for response. This will consistently

be achieved through negotiation and a risk assessment of the complaint itself; (The grading matrix can be found in Appendix A)

• If an early local resolution meeting facilitated by the CCG would be

appropriate and beneficial to all parties concerned;

• If advocacy services would facilitate resolution the Customer Relations Lead will sign-post individuals to appropriate support services (e.g. Healthwatch Liverpool);

• The role of the Parliamentary and Health Service Ombudsman in the

complaints process should local resolution not be successful. Once the above elements have been agreed between the individual complainant, the CCG and any other third parties involved in the complaint, the Customer Relations Lead will provide written confirmation of the actions, timescale for response and preferred outcome to all parties concerned. Where consent is required the complaint will not be taken forward until this is received and validated and the agreed timescale for response will commence from the date on which written consent was received. 6.7 Complaints concerning commissioned services and other organisations The CCG recognises that complaints are generally best dealt with as close to the source as possible. All NHS bodies and providers of NHS care have a statutory requirement to operate their own complaints process and the CCG will endeavour to promote the local resolution of complaints at this level in order to give providers the opportunity to respond. It is also recognised, however that the public have the right to raise their complaint with the commissioner of the service should they wish to do so, and the CCG will take a balanced and proportionate approach to the management of these requests on a case-by-case basis and depending on the seriousness of the issues raised (for example risks to patient safety, poor initial complaints handling and/or an emerging trend or theme).

10

161161

Where Liverpool CCG agrees to coordinate/handle complaints against a commissioned service or other organisations with which the CCG has an NHS contract, the process described in paragraph 6.6 will apply with the following additional measures:

• The ‘action plan’ will include the name of the complaints lead at the NHS Trust/organisation or provider involved;

• The individual complainant’s consent will be sought to share their complaint with the relevant organisation, with the understanding that relevant medical information will be in turn shared with the CCG for response purposes;

• The CCG will notify the complainant of the date on which their complaint was

received by the provider/organisation;

• A first draft of the response letter/investigation report will be forwarded to the CCG from the provider prior to release to the complainant. Responses will then be reviewed by the CCG to ensure all points have been addressed, expected outcomes have been met (where possible) and appropriate actions have been implemented to prevent a recurrence. Where appropriate, a clinical view will be obtained from the relevant CCG clinical lead and/or Chief Nurse by the Customer Relations Lead to inform the quality assurance process and to assess any residual risks to patient care/safety;

• Long-term action plans will be monitored via the relevant Clinical Quality &

Performance Group or equivalent quality assurance mechanism and their closure communicated to the complainant.

Where a complainant does not provide their written consent to share information or for the CCG to coordinate the complaint on their behalf, they will be informed in writing of the limitations placed on the investigation and those elements which will not be responded to. The agreed timescale for response will begin from the date on which written consent was received. The CCG will allow a reasonable timescale for consent issues to be resolved on the mutual understanding that the complaint will not be taken forward until it is received. The complaint will be considered as ‘closed’ if no further contact with the CCG is made after a period of 3 months from the date of the last correspondence. 6.8 Complaints about Primary Care Medical Practitioners & Member Practices Liverpool CCG has delegated responsibility from NHS England for the commissioning of primary care medical services and as described in 6.7, there is a statutory right for the public to approach the commissioner of an NHS service to raise a complaint. Under the current terms of this delegation agreement and at the time of writing this policy however, NHS England has reserved its functions in relation to complaints management and in this regard, retains the responsibility as ‘commissioner’ under the interpretation of the Regulations. To ensure an integrated and customer focused approach to primary care complaints, the CCG will act as an access point and will provide local leadership, sign-posting, support and bespoke resolution brokerage to achieve successful outcomes for those patients who initially approach the CCG to make a complaint. It is essential that complainants do not feel

11

162162

as though they are being deterred from making a complaint as a result of a complex commissioning framework and referring on to another organisation. All member practices are required to operate their own practice-based complaints system (based on the NHS procedure) to resolve matters in-house and it is generally expected that the majority of complaints will be resolved at this level. Where individuals contact the CCG to raise a complaint or concerns regarding a member practice, the Customer Relations Lead will, with the consent of the patient concerned refer the matter to the practice manager (or NHS England) for investigation. Should the patient/complainant specifically request that the CCG provides brokerage, the process described in paragraphs 6.6 and 6.7 will be applied (in full or in part) subject to agreement reached between the member practice concerned, NHS England and the CCG. Themes, trends, outcomes and lessons learned from primary care complaints for which the CCG has provided brokerage will be captured and reported monthly to the Primary Care Quality Committee under its commitment and responsibility to improve the quality of Primary Care Medical Services for the population of Liverpool. 6.9 Complaints concerning Dentists, Community Pharmacists and Opticians As NHS England are commissioners for dental, pharmaceutical and ophthalmic practices complaints received by Liverpool CCG regarding these local services will be referred to NHS England for local resolution (should the individual not wish to approach the relevant practice directly). NHS England’s National Customer Contact Centre acts as the single point of contact for these complaints and the CCG will routinely sign-post members of the public to the following contact details where referral to the relevant practice is declined:

• NHS England, PO Box 16738, Redditch, B9 9PT Telephone: 0300 311 2233 Email: [email protected]

NHS England’s Complaints Procedure can be accessed electronically at: http://www.england.nhs.uk/wp-content/uploads/2015/01/nhse-complaints-policy.pdf 6.10 Joint NHS and local authority complaints Where complaints concern both health and local authority services the two organisations will co-operate to ensure a single, coordinated response is provided within an agreed timescale (assuming consent to share the complaint has been gained). As part of the initial action planning stage, the appropriate ‘lead organisation’ will be identified although each will investigate the complaint in accordance with its own procedures. If the complainant expresses a wish for separate responses, this will be facilitated as appropriate. 6.11 Complex/multi-agency complaints Some complaints can span several organisations and be particularly complex in nature. These types of complaints raise a number of governance issues in relation to

12

163163

http://www.england.nhs.uk/wp-content/uploads/2015/01/nhse-complaints-policy.pdf

consent, responsibility for response, assurance of a co-ordinated approach and multiple, investigations taking place simultaneously (which will invariably carry different timescales for completion). Where feasible, the CCG will ensure that there is a coordinated approach to multi-agency complaints; the CCG may take the ‘lead role’ in terms of the coordinated response, although any decisions made will depend on the wishes of the complainant, the result of discussions with the various parties involved and which organisation is considered to have the greater part in the complaint. An agreement on the lead organisation will be detailed in the complaints action plan in addition to a mutually agreeable timescale between all parties for a coordinated response. The CCG may (with the complainant’s consent) choose to co-ordinate the response or lead in the investigation rather than a third party where serious patient safety/quality issues have been identified or if there is a risk to local health service delivery. Where a coordinated approach is determined to be unachievable, the CCG will ensure that the complainant is informed of the options available to take the matter forward and of the limitations of any subsequent investigation. In cases where the complaint is (in part) relating to care commissioned by NHS England, it is generally expected that NHS England will assume the role of co-ordinator on behalf of the CCG although this will be determined on a case-by-case basis and in full consultation with the complainant. 6.12 Timescales for investigation and response to complaints As described in 6.6, the initial discussion between the individual complainant and the CCG will include an agreement on a ‘proportionate and appropriate timescale for response’. Timescales will be agreed in ‘working days’ and will be based on a number of factors including (but not limited to):

• A risk assessment of the complaint itself (the grading matrix can be found in Appendix A);

• The complexity/severity of the complaint; • The number of agencies involved, and; • Whether a clinical opinion is required.

During the investigation, the CCG will keep the complainant informed (as far as practicably reasonable) as to the progress of the investigation and of any delays that will impact on the timescale. In the event that the timescale needs to be extended, agreement of an extension of time will be obtained from the complainant first, and the reasons for the delay and request for an extension fully explained and documented. Where agreement cannot be reached with the complainant (either for the original timescale or an extension of time) this will be managed on a case-by case basis by the Customer Relations Lead, who will determine the limitations of the investigation, the likely impact on the outcome and whether early referral to the PHSO would be beneficial for all parties concerned.

13

164164

If the timescale for response exceeds a period of 6 months from the date of receipt of the complaint, the CCG will notify the complainant of the reasons why and of their right to refer their case to the PHSO should they be dissatisfied with the way in which it has been managed. Complaints responses exceeding the 6 month period will be routinely reported to the Quality, Safety & Outcomes Committee (and CCG Governing Body) together with a summary of the reasons behind the delay and any learning from the process which could be used to improve local complaints handling. 6.13 Responses to complaints All responses will be signed by the Chief Officer (or nominated deputy in their absence). Responses to complaints will consistently reflect the principles of this policy in terms of maintaining a focus on meeting the expected outcomes and addressing the issues agreed in the broad action plan at the start of the complaints process. A copy of the investigation report will be included with the response in all cases where one has been made available. All complaints responses and investigation reports will be expected to:

• Be sympathetic and conciliatory in tone, explain how the complaint has been considered and details of any limitations placed on the investigation;

• Be written in plain English, free of jargon or abbreviations and with all technical/clinical references fully explained;

• Address all the issues which were raised by the complaint, offering a rationale or reason for any areas not addressed;

• Provide a full explanation of what happened and where things went wrong; • Include an apology (where appropriate); • Have been shared with any staff involved or implicated in the complaint; • Explain the conclusions reached in relation to the complaint, and whether the

CCG is satisfied that remedial actions are proportionate and will prevent recurrences;

• Provide a summary of the lessons learned from the complaint and assurances of how these will be disseminated/implemented (including how long-term actions will be addressed and how the complainant will be informed of their closure);

• Explain the options available for further local resolution (such as conciliation) or, if all attempts to resolve the matter have failed, the details of the PHSO or Local Government Ombudsman (where the complaint relates in part to the functions of the local authority).

Responses which do not meet the above criteria will be returned to the originator for re-writing and re-submission. If this is likely to impact on the agreed response time, or if any reason a response cannot be made within the agreed timescale (e.g. key staff are absent) the Customer Relations Lead will inform the complainant of the delay (and the reasons behind it) and negotiate a reasonable extension of time as detailed in 6.11. All extensions of time agreed with the complainant will be documented within the individual complaints file. Aggregate figures relating to extensions of time agreed will be reported to the CCG Governing Body as part of the Corporate Complaints Reporting mechanism.

14

165165

6.14 Further local resolution & closing of complaints It is acknowledged that not all complaints will be resolved following the first attempt at local resolution. Further attempts may be necessary to achieve the desired outcome and could involve a number of strategies and different solutions depending on the outstanding issues (e.g. other remedy, including financial redress). If the complainant is satisfied with the outcome of their complaint and do not wish to take the matter further, the complaints file will be ‘closed’ from the date resolution is agreed between the CCG and the individual complainant. The causes and contributing factors of the complaint will be recorded by the CCG (in addition to lessons learned and changes to future practice/service improvement), which will in turn be consistently fed into the overall complaints review cycle. Any long-term actions which are considered as crucial to the resolution process will be monitored by the CCG and fed back to the complainant once completed or signed off. If, however, the complainant remains dissatisfied following the response, the CCG will ensure every effort is made to achieve a satisfactory outcome at a local level by:

• Gaining agreement on the outstanding issues and remaining grievances; • Exploring other options for local resolution such as involving a conciliator,

requesting further written response or a revised remedial action plan; • Managing expectations of what can (and can’t) be achieved through further

local resolution. Arrangements for conciliation will be facilitated by Liverpool CCG who will access fully trained/Disclosure and Barring Service (DBS) checked lay conciliators. 6.15 Referral to the Parliamentary and Health Service Ombudsman (PHSO) If following all attempts to resolve the complaint locally the complainant remains dissatisfied, the CCG will notify the individual (in writing) that local resolution is at an end and that they have the right to ask the PHSO to consider their case. Contact information for the PHSO will be routinely provided at the conclusion of the complaints process or at the point when all avenues to resolve the complaint have been exhausted. Generally, the PHSO may investigate a complaint where:

• A complainant is not satisfied with the result of the investigation undertaken by Liverpool CCG;

• The complainant is not happy with the response from Liverpool CCG and does not feel that their concerns have been resolved;

• The CCG has decided not to investigate a complaint on the grounds that it was not made within the required time limit (as described in 6.4);

• The CCG has decided not to investigate the complaint due to the

When informed that a complainant has approached the PHSO, Liverpool CCG will cooperate fully and provide all relevant information requested in relation to the complaint investigation (usually the complaints file). The Head of Operations and

15

166166

Corporate Performance will be informed that a request for investigation has been made so that the relevant parties can be informed. In some cases Liverpool CCG may refer a complaint to the Parliamentary Health Service Ombudsman for a final decision where this is seen as beneficial for all parties involved or where the relationship between the CCG and complainant is considered to have irreparably broken down. 6.16 Safeguarding and the CCG Complaints Process The Francis Report highlights the need to eradicate complacency about poor care by detecting and exposing unacceptable care immediately and effectively. The CCG forms part of a system wide partnership with local authority, NHS England and local health provider colleagues to ensure consistently safe, effective and respectful care is maintained and that robust processes are in place to learn lessons from cases where children or adults die or are seriously harmed and where abuse or neglect is suspected. All health providers are required to have arrangements in place to safeguard vulnerable children and adults and to assure themselves, regulators and their commissioners that these are effective. Where a complaint (verbal or written) raises concerns, suspicions or allegations of abuse or neglect of children or adults, it will immediately be brought to the attention of the CCG’s Chief Nurse who will then determine the most appropriate course of action, including:

• Whether the concerns should reported through formal external safeguarding processes;

• If Police involvement is necessary; • Communication of any referral made to the patient/family/NHS Trust,

healthcare provider or staff as appropriate, and; • Next steps in terms of an investigation. This may require advice from multiple

internal and external stakeholders. In some cases safeguarding processes may take precedent over the complaints process, although the Chief Nurse and the Customer Relations Lead will continue to ensure family contact/liaison is co-ordinated and consistent. Where safeguarding processes are invoked and this impacts on the timing of the complaints response, re-negotiation regarding timescales may be necessary to allow for the completion of the safeguarding investigation first. In all cases an agreement will be reached with the individual parties involved as to what process will provide the material response, or what elements of the complaint can/will be answered outside of the safeguarding process. 6.17 Redress and Ex-Gratia Payments The PHSO’s Principles for remedy are clear that where there has been maladministration or poor service, the public body restores the complainant to the position they would have been in had the maladministration or poor service not occurred. Whilst financial redress or ex-gratia payments will not be appropriate in every case, the CCG will consider proportionate remedies for those cases where complainants have incurred additional expenses as a result of maladministration or

16

167167

poor service. This will not apply, however, to requests for compensation or allegations of personal injury where a claim is indicated. 6.18 Complaints and Disciplinary Processes The complaints procedure is concerned with resolving complaints raised by patients and the public and ensuring that lessons are learned to improve healthcare. The complaints process will not be used for investigating disciplinary matters as the CCG has approved HR policies and procedures for dealing with matters such as capability, misconduct, work performance, whistleblowing and disputes between organisations. These procedures may be invoked as a result of the findings of a complaints investigation but are not part of them. Resolution of the complaint will always take precedence where internal disciplinary procedures are invoked following investigation. The outcome of the disciplinary process will not be shared with the patient/complainant; only information confirming that the process has been concluded will be communicated. If a complaint results in a potential need for referral to any of the following:

• A professional regulatory body (e.g. General Medical Council); • An independent inquiry into a Serious Incident; • Referral to relevant police force if a breach of law/criminal act has occurred

The Customer Relations Lead (or other appropriate CCG Officer) will ensure that the information is passed to the Responsible Person, who will determine whether to initiate any further actions separate to the complaints policy. 7. CORRESPONDENCE FROM MEMBERS OF PARLIAMENT Correspondence received by the CCG from Members of Parliament who are raising concerns or making enquiries on behalf of constituents will be handled consistently and proportionately in relation to the nature of the issue. The majority of MP enquiries/concerns can and often will be dealt with under a reasonable timescale of approximately 10-25 working days. Appropriate consent will be sought from the constituent only should it be necessary to contact other organisations involved in their care in order to respond fully. Should a Member of Parliament submit a complaint on behalf of a constituent as defined within this policy, then it will be handled in line with the CCG Complaints Policy and Procedure. 8. CONFIDENTIALITY Complaints will be handled in the strictest of confidence in accordance with CCG and wider NHS Confidentiality policies. Care will be taken that information should only be disclosed to those who have a demonstrable need to have access to it. Suitable arrangements are in place for the handling of patient identifiable data (PID) to meet the compliance of the Data Protection Act (and other legal obligations such as the Human Rights Act 1998 and the common law duty of confidentiality).

17

168168

The Caldicott Report sets out a number of general principles that health and social care organisations should use when reviewing its use of patient or client information. Confidentiality will be maintained in such a way that only managers and staff who are leading the investigation know the contents of the case. Disclosure of information to third parties who are not directly involved in the complaint may be dealt with under the CCG’s disciplinary procedures. 9. CONSENT It is generally expected that when obtaining consent for the use and sharing of information, the patient has made an informed decision and clearly understands the processing and potential for sharing of their medical information. Information will not be disclosed to third parties unless the complainant (or appropriate authorised party who has provided the information) has given consent to its disclosure. Where consent is requested, the complainant will be informed of the reasons for the request and that the investigation will not proceed until consent is established. Timescales negotiated as part of the initial action planning stage will not commence until consent has been received. The template CCG Consent form is included as Appendix B 10. LEARNING FROM COMPLAINTS AND STAKEHOLDER FEEDBACK It is widely acknowledged that meaningful, comparable complaints information can be used positively to help drive continuous improvement in healthcare and strengthen the quality and safety of services for patients and the public. Learning from the ‘four C’s’ of complaints, comments, concerns and compliments significantly contributes to enhancing patient experience and should be the cornerstone of any patient feedback system. Lessons learned from complaints will be systematically analysed and disseminated by the CCG both internally and across organisational boundaries where appropriate with the aim of contributing to a shared, Mersey-wide profile of trends, themes and patterns which identifies risks and areas where service improvement/transformation should be targeted. This information will be routinely analysed and reported to the CCG Governing Body and the Quality, Safety & Outcomes Committee through established corporate reporting schedules (as described in 7.1) Providers are also expected to identify their own trends, themes and patterns through routine contract/quality reporting, and demonstrate how they have learned from the complaints they have received. As commissioners, Liverpool CCG will hold its providers to account for ensuring this is done effectively and will use complaints intelligence reports to identify which providers are failing to learn from complaints and formulating an appropriate response as necessary. The CCG will also work in partnership with Healthwatch Liverpool to share anonymised lessons learned and to develop systems which will make benchmarking between services more readily available; particularly in terms of effective complaints handling and successful resolution. Ultimately, patients and the public should be able to make better informed choices about their healthcare based on a range of comparable data and profiles, of which complaints and lessons learned are a key component.

18

169169

The Governing Body has overall accountability for complaints and will receive a report bi-annually summarising complaints where the CCG is the ‘respondent’ or cases where the CCG conducts a commissioner led investigation. The report will identify trends, themes, patterns and operational/strategic risks, in addition to key learning outcomes and details of any cases referred to the PHSO. 11. MONITORING OF COMMISSIONED SERVICES

All commissioned services will be expected to submit a quarterly complaints activity report containing the following information as a minimum:

• Numbers of compliments, complaints, comments, concerns, and PALS cases received by the organisation in total and broken down by specialty and category (where possible);

• Trends, themes and patterns identified and what key improvement actions have been taken as a result of patient feedback;

• Evidence of the service applying lessons learned as a result of trends identified to evidence service improvement;

• Performance against agreed response times to complainants. • Number of complaints referred to the PHSO and the outcome of the

referral or investigation. The Quality, Safety and Outcomes Committee has responsibility for the dissemination of intelligence gained through complaint investigation/analysis, along with information collected through other means such as patient surveys and engagement activities, to influence commissioning decisions and ensuring services continue to meet the needs of the local population.

12. ADVOCACY SERVICES The CCG will routinely provide the contact details of local independent advocacy services that provide a free and confidential service designed to help people understand their rights and make informed choices about the way in which they wish to pursue a complaint. For the city of Liverpool, independent advocacy for NHS complaints can be accessed through Healthwatch Complaints Advocacy using its Freephone Helpline number (0300 7777 007) or by email [email protected] Patients and their representatives will be signposted to this service in all complaints acknowledgements but made aware that using this service is entirely optional. 13. CUSTOMERS WITH ADDITIONAL COMMUNICATION REQUIREMENTS The CCG will ensure that the complaints process is inclusive and accessible to everyone who wishes to use it. Copies of this complaints policy and procedures can be provided in other languages, Braille and large print on request. Individual communication needs for advocacy, updates, responses and meetings will also be established during the initial complaints action planning phase.

19

170170


14. RECORD KEEPING The CCG will maintain accurate and up-to-date electronic complaints files for each case processed. Complaints files created by Liverpool CCG will be retained for a minimum period of ten years (from the date of creation) as per NHS records management guidelines. Liverpool CCG will take actions as necessary to comply with the legal and professional obligations set out for records, and in particular:

• Public Records Act 1958; • Data Protection Act 1998; • Freedom of Information Act 2000; • Access to Health Records Act 1990; • Regulation of Investigatory Powers Act 2000; • Records Management: NHS Codes of Practice (Part 1 and 2), and; • NHS Information Governance: Guidance on Legal and Professional

Obligations Primary complaints records will be created and stored electronically on the CCG’s ‘Datix’ system and accessible only to authorised users. 15. PUBLICITY The CCG will ensure that there is effective publicity for its complaints arrangements and will take reasonable steps to ensure that members of the public are informed of arrangements for dealing with complaints and key contact details. Information on how to make a complaint is included in the CCG’s public facing CCG website. www.liverpoolccg.nhs.uk

The CCG will expect all providers with whom it commissions to include within their public complaints information leaflets a statement which informs patients of their right to refer their complaint to the CCG should they wish to do so.

16. EDUCATION AND TRAINING Not all CCG staff will require training in complaints handling, customer care, de-escalation techniques/conflict resolution training. However, a Training Needs Analysis (TNA) will be conducted by each CCG department to identify which staff would benefit from training (linked to their Personal Development Plan process where possible). Any CCG staff who act in the capacity of lead investigators or in a clinical advisory role for complaints management will be required to attend bespoke training, which the CCG will provide annually.

Induction for new staff will include an overview of the CCG’s complaints process and individual responsibilities. A one day training course in root cause analysis of incidents and complaints may be held periodically within the CCG, or as part of a wider network or regional events.

20

171171


17. MONITORING COMPLIANCE WITH THIS POLICY The CCG Governing Body will monitor compliance with this policy through the structured governance arrangements summarised in the table below: No. Monitoring/audit

arrangements of compliance with policy and methodology

Reporting Source Committee Frequency

1. The CCG has an approved documented process for responding to complaints Policy review and internal audit against current statutory requirements and best practice.

CCG Complaints Policy; audit of sample case files; numbers of complaints about CCG complaints process; PHSO reviews

CCG Governing Body (Assurance) Audit, Risk & Scrutiny Committee (Approval)

Annually

2. % of complaints answered within agreed timescales (CCG) Review and analysis of time of case open to closure (for CCG coordinated cases). Aggregated data used to measure performance against locally set 95% threshold. Sample audit against national 3 working day timescale for acknowledgement

Datix collated data Complaints files Internal Audit findings

Governing Body Quarterly

3. Process for ensuring patients, relatives and/or carers are not treated differently as a result of raising a complaint Monitoring of service user feedback collected after local resolution has concluded; regular, consistent and timely contact with clients.

Real-time feedback, customer questionnaires

Quality, Safety & Outcomes Committee

Quarterly

4. Compliance with safeguarding arrangements Review of cases where

safeguarding issues have been flagged – time measurement from initial alert to Chief Nurse to action taken

Datix collated data Complaints files


Quarterly

No. Monitoring/audit

arrangements of compliance with policy and methodology

Reporting Source Committee Frequency

5. Analysis of complaint trends and themes Numbers of complaints received by subject matter reviewed, analysed & aggregated Analysis of numbers of

Datix collated data CPQG reports

Quality, Safety & Outcomes Committee Governing Body

Quarterly

Bi-annually/ 21

172172

complaints referred to PHSO KO41 Reports Annual Report

6. Accurate, contemporaneous complaints record keeping in line with IG requirements & Data Protection Act Sample audit of complaints files against quality measurement checklist

Datix Internal Audit

Audit, Risk & Scrutiny Committee

Annually

7. Monitoring of commissioned services Review/aggregated review of complaints reports submitted as per contractual obligations & analysis of themes, trends & patterns described in para 10.

CPQG reports Datix collated data

Quality, Safety & Outcomes Committee CPQG

Monthly & Annual Report

8. Learning from complaints and provider compliance with action plans Monthly monitoring of provider action plans through CCG internal performance management process Review & analysis of data in relation to key service improvement areas

Datix collated data CPQG reports

Quality, Safety & Outcomes Committee Governing Body

Monthly

Bi-annually/ Annual Report

9. Education & Training % of staff undergoing

complaints/customer care/de-escalation as identified in Training Needs Analysis Numbers of induction sessions completed where complaints awareness has been included

ESR records/PDP information Induction Programme feedback

HR Committee

Annually

10. Dissemination & Publicity Checklist for dissemination

amongst CCG internal & external stakeholders New policy is included prominently in CCG Internet and Intranet sites with previous version archived – included in CCG newsletter

Document Control Sheet Internet/Intranet


Annually

Compliance with this policy will also be assured and reported/evidenced through the following specific mechanisms:

• CCG Annual Report; • Annual Governance Statement; • Corporate Risk Register (also acts as Assurance Framework); • Risk Management Reports; • Internal and External Audit Reports; • Minutes from related committees and groups, and; • Performance/exception reports.

22

173173

18. POLICY REVIEW ARRANGEMENTS

This policy and associated procedures will be reviewed annually by the Head of Operations and Corporate Performance or upon changes in legislation or new guidance issued. No policy or procedure will remain operational for a period exceeding three years without a review taking place.

The Governing Body will ensure that archived copies of superseded policy documents are retained in accordance with ‘Records Management: NHS Code of Practice 2009.

19. EQUALITY & DIVERSITY STATEMENT

NHS Liverpool CCG aims to design, commission, procure and implement services, policies and measures that meet the diverse needs of our population and workforce, ensuring that none are placed at a disadvantage over others. All policies and procedures should be developed in line with the Single Public Sector Equality Duty to eliminate discrimination, harassment and victimisation, advance equality of opportunity and foster good relations.

Every individual approaching the CCG to make a complaint will be treated fairly and equally regardless of their age, disability, race, culture, nationality, gender, sexual orientation or beliefs.

Appendix A COMPLAINTS/RISK GRADING TOOL

Table 1 – Likelihood score (L)

What is the likelihood of the risk occurring?

23

174174

Likelihood score 1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost certain

Frequency This will probably never happen/recur

Do not expect it to happen/recur but it is possible it may do so

Might happen or recur occasionally

Will probably happen/recur but it is not a persisting issue

Will undoubtedly happen/recur, possibly frequently

Table 2 - Consequence Score (C)

Consequence Score Level Descriptor Impact Description

1 Negligible Unsatisfactory experience not directly related to care or commissioning decision. No impact or risk to future provision and no harm to the patient.

2 Minor Unsatisfactory experience related to care or commissioning decision. Can be a single resolvable issue with minimal impact and relative minimal risk to the provision or care of a particular service. No real risk of litigation or adverse publicity.

3 Moderate Patient experience below reasonable expectations in several areas but no lasting detriment or harm. Issues in complaint present potential impact on future service provision/delivery across dimensions of quality/safety. Often a justifiable complaint with slight potential of legal action against provider with reputational risk for CCG if event leads to adverse local external attention e.g. HSE, media, external bodies.

4 Major Significant issues raised in relation to standards/quality/safety of care, denial of rights. Clear quality assurance and/or risk management implications which require investigation with high probability of litigation. Risk to CCG reputation in the short term with key stakeholders, public & media.

5 Catastrophic Complaints which describe serious adverse events, significant safety issues, long-term damage, grossly substandard care, professional misconduct or death of patient which carry high probability of legal action and strong possibility of adverse national publicity.

Table 3 – Event Grading Matrix

Risk scoring = likelihood x consequence ( L x C )

Likelihood

Consequence Score 1 2 3 4 5

24

175175

Rare Unlikely Possible Likely Almost certain

5 Catastrophic 5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

For grading risk, the scores obtained from the risk matrix are assigned grades as follows:

1 – 3 Low risk

4 – 6 Moderate Risk

8 – 12 High Risk

15 – 25 Extreme Risk

25

176176

Table 4 - Complaint Grading Tool/Timescale Matrix (Commissioned Services)

RAG Rating Complaint actions Suggested Timescale for Response

RED (Extreme)

CCG coordinated complaint with commissioner of service taking lead. Investigated by provider at Executive level (CEO, Medical Director or equivalent). Report signed-off by CEO (or equivalent) of each agency involved and sent to CCG Chief Officer. Review by relevant Governing Body Lead Clinician before sign-off by Chief Officer. Action Plans monitored by CCG (through CQPG) until all closed/complete. Lessons learned identified & disseminated through Quality Team.

Customer Relations Lead negotiates timescale of 45-60 working days. Extensions of time may be sought as long as maximum period of 6 months in total from acknowledgement of complaint or receipt of consent is not exceeded.

AMBER (High)

CCG coordinated complaint with commissioner of service taking lead. Investigated by provider at Executive level (Medical Director or equivalent). Report signed-off by CEO (or equivalent) of each agency involved and sent to CCG Chief Officer. Review by relevant Governing Body Lead Clinician before sign-off by Chief Officer. Action Plans monitored by CCG (through CQPG) until all closed/complete. Lessons learned identified & disseminated through Customer Relations Lead/Quality Team.

Customer Relations Lead negotiates timescale of 25 – 45 working days. Extensions of time may be sought as long as maximum period of 6 months in total from acknowledgement of complaint or receipt of consent is not exceeded.

YELLOW (Moderate)

CCG negotiates involvement as limited to ‘honest brokerage’ and puts in place monitoring systems for ensuring local resolution and successful outcomes. Response to complainant direct from provider with copy to CCG for information. Action Plans monitored by CCG through CPQG until all closed/complete & learning outcomes disseminated through Customer Relations Lead/Quality Team.

Customer Relations Lead negotiates timescale of 10 working days. Extensions of time may be sought only where justification can be evidenced (e.g. staff absence, recall of records) with maximum period of 25 working days set from acknowledgement of complaint or receipt of consent.

GREEN (Low)

CCG Customer Relations Lead will encourage patient/complainant to approach provider directly & will offer advice on complaints process. Response to complainant direct from provider with copy to CCG for information purposes where dealt with under complaints process (if not resolved within 24 hours of provider receipt).

Agreement reached between complainant & Customer Relations Lead on way forward for local resolution within 3-5 working days from acknowledgement of complaint.

26

177177

APPENDIX B

NHS LIVERPOOL CCG PROCEDURE FOR MANAGEMENT OF COMPLAINTS

Complaint received Resolved within 24 hours?

Outcome and learning captured on DATIX. Recorded as an ‘issue of concern’

YES NO Complaint ‘Risk’ Graded &

entered on DATIX

RED (Extreme)

Amber (High)

Yellow (Moderate)

Green (Low)

Telephone/face to face contact with patient/complainant to agree: • Main issues & action plan • Consent & org lead if multi-agency • Timescale (45-60 w/days Red, 25-45

Amber)) • Desired outcome • Immediately copied to Chief

Nurse/Head of Quality (if commissioned service)

Telephone/face to face contact with patient/complainant to agree: • Main issues & action

plan • Consent & org lead if

multi-agency • Timescale (10 w/days) • Desired outcome

Telephone/face to face contact with patient/complainant to agree: • Local resolution ‘best fit’

(i.e. provider/practice) • Desired outcome • Timescale for response (if

CCG complaint or where CCG provides brokerage)

Investigation at Executive level (CCG complaint or provider)

Investigation at Senior Manager level (CCG/provider)

Brokered/coordinated by Customer Relations Lead

Response reviewed & quality assured by Chief Officer/Clinical

Lead

Reminder sent to lead investigator by Customer Relations Lead at 10

w/days before deadline

Reminder sent to lead investigator by Customer Relations Lead at 10

w/days before deadline

Response agreed?

YES NO

Written/telephone response by

Customer Relations Lead or service

manager Response reviewed & quality assured by Customer Relations

Lead

Response sent to client with options for further LR given

Returned to investigator, extension of time agreed Complainant satisfied?

Outcome and learning captured on DATIX.

Action plans monitored via CQPG/Quality Team

Further LR action plan implemented

NO YES

27

178178

Appendix C

CONSENT FORM

I, name, consent to Liverpool Clinical Commissioning Group accessing my medical records in order to investigate my complaint. I understand that these records may be seen by both clinical and non-clinical staff involved in the investigation of my complaint, and the facilitation of a response. If involving other organisations: I also consent to Liverpool Clinical Commissioning Group sharing information about my complaint with name of organisation; and for that organisation to provide my confidential medical information to Liverpool Clinical Commissioning Group. If involving 3rd party: I consent to name and relationship to patient pursuing this complaint on my behalf. I understand that they will receive a written response which may include my confidential medical information. Full Name ……………………………………………………………….

Address ……………………………………………………………...

………………………………………………………………

Tel. No .………………………………………………………………

Date of Birth……………………………………………………………..

GP Practice………………………………………………………………

Signed .........................................................................................

Date: ………………………………………………………………..

Please send completed form to: Customer Relations Lead NHS Liverpool CCG 1 Arthouse Square Liverpool L1 4AZ

28

179179

APPENDIX D

Guidance on Handling Unreasonably Persistent and / or Habitual Complainants

The CCG is committed to treating all complaints equitably and recognises that it is the right of every individual to pursue a complaint. The CCG therefore endeavours to resolve all complaints to the complainant’s satisfaction. However, on occasions CCG staff may consider that a complaint is unreasonably persistent or habitual in nature. These complaints are often symptomatic of other underlying issues and the complaints procedure may not be the most appropriate means of dealing with these cases. Complainants (and/or anyone acting on their behalf) may be deemed to be unreasonably persistent or habitual complainants where previous or current contact with them shows that they meet one or more of the following criteria:

• Persist in pursuing a complaint when the complaints procedure has been fully and properly implemented and exhausted;

• Changed the substance of a complaint or continually raise new issues, or seek to prolong contact by continually raising further concerns or questions (but care must be taken not to discard new issues which are significantly different from the original complaint);

• Continue to pursue a complaint with the CCG after appropriate consent has been sought to forward the complaint to the provider for investigation and the outcome of that investigation is still pending;

• Are unwilling to accept documented evidence of treatment given as being factual (i.e. patient record) or deny receipt of an adequate response in spite of correspondence specifically answering questions or do not accept that facts can be difficult to verify when a long period of time has elapsed;

• Do not clearly identify the issue they wish to be investigated, despite reasonable efforts and/or where concerns identified are not within the remit of the CCG to investigate;

• Focus on a matter to an extent which is disproportionate to its significance and continues to focus on this point (although it is recognised that this can be subjective and careful judgement must be used);

• Have in the course of addressing a complaint had an excessive number of contacts with the CCG or the Complaints Service, placing unreasonable demands on staff (this can be by telephone, fax, email, letter or in person);

• Are known to have recorded meetings or face-to-face/telephone conversations without the prior knowledge and consent of other parties;

• Displayed unreasonable demands or expectations and fail to accept that these may be unreasonable (e.g. insist on responses to complaints or enquiries being provided more urgently than is reasonable or feasible or normal recognised practice);

• Used inappropriate verbal or written language against employees of the CCG or Complaints staff.

If a member of staff, either in the CCG or in the Complaints Service, feels that a complaint or complainant is unreasonably persistent or habitual they can request that the complainant be dealt with as such. The Customer Relations Lead will consider the request, taking into account any dealings that the complainant has

29

180180

had with other organisations/services and the views of other colleagues who may have had dealings with the individual concerned. If the Chief Officer agrees that the complaint should be classed as unreasonably persistent/habitual a suitable way to deal with the complainant will be agreed. If an action plan for dealing with the complainant is agreed it will be shared with the complainant so that they are aware of how the CCG will deal with any communication from them. If a complainant who has been classed as unreasonably persistent and/or habitual has a new complaint, it should be dealt with according to this policy Once a complainant has been deemed as unreasonably persistent and/or habitual the complainant will be informed of this in writing by the Chief Officer, along with the arrangements the CCG intends to invoke to manage future contact from the individual. The status of ‘unreasonably persistent and/or habitual’ will be withdrawn at a later date by the Chief Officer if, for example, the complainant subsequently demonstrates a more reasonable approach or, if they submit a further complaint for which the normal complaints procedure would appear appropriate. Discretion should be used at all times in both determining and removing this status. If it becomes apparent (through the course of investigating a complaint) that staff have been subjected to inappropriate personal or abusive verbal or written comments, the complainant will be advised in writing by the Chief Officer that it is unacceptable and will not be tolerated with any future communications the person may have with CCG or Complaints staff. Staff will be encouraged to report any such incidents to their line manager or via the CCG’s Incident Reporting System.

Complaints of a discriminatory nature/harassment

These are complaints made against an individual on the basis of their racial background, gender, marital status, ethnic origin, colour, nationality, national origin, disability, sexuality, religion or age. At an early stage, the CCG will adopt a zero tolerance approach to any complaints which amount to harassment or discrimination. The CCG will, in all cases, write to the individual complainant informing them that harassment and discrimination of staff will not be tolerated and that their behaviour will be dealt with under Local Security Management arrangements.

Any complaints couched in discriminatory language but which raise legitimate issues about clinical practice, procedures and/or communication will be investigated under this policy, without prejudice to the outcome of the investigation. However, as detailed above, where a complaint is investigated that is couched in discriminatory language, the complainant will be advised that discriminatory language will not be tolerated and an appropriate warning issued as per the NHS Zero Tolerance policy.

30

181181

182182

Report no: GB 66-15



Title of Report NHS Liverpool Clinical Commissioning Group

Quality Strategy (2015 – 2017)

Lead Governor Jane Lunt – Chief Nurse/Head of Quality


Jane Lunt - Chief Nurse/Head of Quality

Report Author

Kerry Lloyd – Deputy Chief Nurse

Summary This strategy outlines the current framework for ensuring that quality is integral to the commissioning process within Liverpool CCG (LCCG). The document is built around the improvement priorities identified by LCCG for commissioning high quality healthcare services for its residents. It describes how the activities of the CCG support and challenge provider organisations to improve outcomes for patients at a time of increasing demand for services and limited resources. The purpose of this paper is to seek endorsement from the Governing Body of NHS Liverpool CCG Quality Strategy (2015-2017) and allow for its wider circulation.

Recommendation That Liverpool CCG Governing Body: Notes the content of the strategy Makes recommendations as to additional

content Endorses the strategy and its wider circulation

subject to any requested amendments.

Page 1 of 2 183183


High quality health care will improve health outcomes, reduce inequality and support cost effectiveness.


NHSE Domains 1-5

NHS Liverpool Clinical Commissioning Group Quality Strategy (2015 – 2017)

1. PURPOSE

The purpose of this paper is to seek endorsement from the Governing Body of NHS LCCG Quality Strategy (2015-2017) to allow for its wider circulation.

2. RECOMMENDATIONS

That Liverpool CCG Governing Body: • Notes the content of the strategy • Makes recommendations as to additional content • Endorses the strategy and its wider circulation subject to any

requested amendments. 3. BACKGROUND

The quality strategy has been developed with cross organisational support from all directorates. It should clearly describe how and why LCCG commission high quality services for the registered Liverpool population. It should support better understanding of quality assurance systems and processes, as well as the mechanisms through which LCCG drive quality improvement in commissioned services.

Kerry Lloyd Deputy Chief Nurse 20th August 2015 ENDS

Page 2 of 2 184184

NHS Liverpool Clinical Commissioning Group

QUALITY STRATEGY

2015 – 2017

Our Vision

• By 2020, health outcomes for the people within Liverpool will have improved

relative to the rest of England, and health inequalities within Liverpool will have

narrowed.

• The quality of health care received by Liverpool patients will be consistent and

of high quality. They will be measured by patient feedback, provider assessment,

and external review processes. 1

1Healthy Liverpool Prospectus for Change November 2014, Liverpool CCG Constitution March 2015

Page Page 1 of 40

185185

Approved : Ratified : For Review : April 2017

Quality Strategy v11 – 11th August 2015 Page 2 of 40

186186

Version Control

Version No. Date Who Status Comment

1 02/12/201

4

Alison Williams Draft Circulated for initial

Comment and feedback

2 22/04/15 Julia Stoddart Draft Checked in with KL

3 27/04/15 Julia Stoddart Draft Checked in with JH




7 02/06/15 QSOC Draft Given to end of June for

comments

8/9 06/07/15 Julia Stoddart Draft Cut down and

reformatted. Submitted to

KL

10 11/08/15 QSOC Draft Minor amendments then

GB approval

11

INPUT

Who Department Date How

Kellie Connor Quality 06/05/15 Meeting √

Stephen Hendry Performance

reports

11/05/15 √ √

Sarah Dewar 3rd Sector 13/05/15 √ √

Scott Aldridge GP Services 07/05/15 √ √

Michael Martin Serious Incidents 07/05/15 √ √

Jo Davies Complaints 12/05/15 √ √

Carole Hill Governance 14/05/15 √ √

Andrew Lynch Healthwatch 13/05/15 √ √

Keely Stasik Care Homes 01/05/15 √ √

Zafi Bisti HR 07/05/15 √ √

Alison Picton Contracts 23/04/15 √ √


187187

Ian Davies Operations √ √

Colette Morris Primary Care

Team

19/05/15 √ √

Derek Rothwell Contracts &

Procurement

22/05/15 √ √

Jacqui Campbell Neighbourhoods 22/05/15 √ √


188188

CONTENTS PAGE

Our Vision 1

Version Control 3

Foreword 7

SECTION 1: WHAT DO THE CCG MEAN BY QUALITY? What is Quality 8

The Dimensions of Quality 8

Vision for Quality 9

Our Responsibilities/Principles 9

The Challenge 10

Quality and Provider Organisations 11

Care Quality Commission 11

Individual healthcare professionals 12

Liverpool CCG as lead commissioner 12

The Liverpool Provider Landscape 12

Commissioning and Quality 14

SECTION 2: EMBEDDING QUALITY IN LIVERPOOL

Governance Arrangements 15

Member Practices 15

CCG Governing Body Reporting 16

Quality, Safety and Outcomes Committee 16

Risk Management 17

The Audit, Risk & Scrutiny Committee 17

Identifying and Managing Risks in Commissioned Services 18

Quality Surveillance Groups 19

Healthwatch 19

Safeguarding Children and Adults 20

Complaints 21

Equality 22

Serious Incidents & Never Events 22

Fig: Overview of Serious Incident Management Process 24

Local Residents and Patients Engagement 24

CQUINS 25 Page 5 of 40

189189

SECTION 3: QUALITY MOINTORING IN ACTION

Quality and Contracting in NHS Contracts 27

Fig: Meetings involving both CCG and Provider representatives 28

Contract Review Meetings (CRM) 28

Clinical Quality Performance Group (CQPG) 28

Measuring Quality 29

CQUIN Setting in Liverpool 30

CQUIN Monitoring 30

External Scrutiny 30

Quality and Contracting with Care Homes 31

Quality and Primary Care Services 32

Quality and Contracting VCSE Sector 33

Healthy Liverpool Community Grants 33

Quality & Contracting North West Ambulance Service 34

Quality and Contracting Individuals Funding Requests 34

Quality and Workforce 35

SECTION 4: FUTURE CHALLENGES

LCCG Action Plan for future Challenges 37

Page 6 of 40

190190

Foreword

‘The CCG must commission services that provide the best care to everyone,

irrespective of where they live in Liverpool, to a consistently high standard.

Quality of care has to be foremost. Without the focus on quality, the CCG will

not achieve the improved health outcomes we aspire to for the people of

Liverpool. All the proposed reforms under consideration over the next few

years will therefore need to be underpinned by a rigorous approach to

standards and quality.'

Dr. Nadim Fazlani Chair, NHS Liverpool Clinical Commissioning Group,

Jane Lunt - Chief Nurse/Head of Quality.

Page 7 of 40

191191

SECTION ONE: WHAT DO THE CCG MEAN BY QUALITY?

What is Quality? Quality as a term has been used in the NHS for a number of years. It is most often

defined using the work of Lord Darzi in 2008 – which centred around the NHS being

of high quality when it is:

• Safe

• Effective

• Positively Experienced

Quality improvement should be viewed as a continuous process that allows for

advances in medicine, technology and clinical practice. It is a key requirement within

the NHS, supported by initiatives such as quality accounts and the Commissioning

for Quality and Innovation (CQUIN) payment framework.

The Health Foundation2 regards quality as the degree of excellence in healthcare.

This excellence is multi-dimensional. For example, it is widely accepted that

healthcare should be safe, effective, person-centred, timely, efficient and equitable.

The Dimensions of Quality

1.Safe

Avoiding harm to patients from care that

is intended to help them.

Timely

Reducing waits and sometimes

harmful delays.

Effective

Providing services based on evidence

and which produce a clear benefit.

Efficient Avoiding waste.

Person-centred

Establishing a partnership between the

CCG, practitioners and patients to ensure

patients’ needs and preferences are

respected.

Equitable

Providing care that does not vary in

quality because of a person’s

characteristics.

2Quality improvement made simple Second edition, August 2013.

Page 8 of 40

192192

These are the domains that Liverpool CCG will use whenever it considers quality;

these domains should be viewed as the 'golden thread' which runs throughout the

commissioning cycle.

Vision for Quality This strategy outlines the current framework for ensuring that quality is at the heart of

everything the CCG do as a commissioning organisation.

The document is built around the improvement priorities identified by NHS Liverpool

Clinical Commissioning Group (CCG) for commissioning high quality healthcare

services for its residents. It describes how the activities of the CCG supports and

challenges provider organisations to improve outcomes for patients at a time of

increasing demand for services and limited resources.

Our Responsibilities/ Principles The CCG assumes responsibility for Quality Assurance by holding providers to

account for the delivery of their contractual obligations and quality standards. The

CCG will work closely with providers with a relational contracting approach to ensure

service delivery continually improves upon health outcomes.

As a membership organisation the CCG has a duty to support member GP practices

and wider primary care to quality assure current standards, whilst recognising that

each provider and member practice remains accountable for the quality of services

within their own organisation.

Individual CCG members/staff have a responsibility to report incidents and respond

to patient feedback in an open and transparent way in order to support improvement

in our services

The Challenge Liverpool is the most deprived local authority in England (IMD 2010). Often

increasing levels of deprivation are commensurate with an increasing burden of

disease. There is a significant gap in life expectancy between Liverpool and

England, with males in the city living 3.1 years less and females living 2.8 years less.

Through monitoring different causes of death it is possible to identify which

Page 9 of 40

193193

conditions are driving this gap, enabling commissioners and policy makers to target

those areas where the greatest impact can be made.

Cancer accounts for the majority of the gap with an estimated 585 excess deaths

among men and 418 excess deaths among women. Lung cancer accounts for the

bulk of these. Circulatory diseases, such as heart disease and stroke, are the

second major cause of the life expectancy gap among males in Liverpool. However,

among females, respiratory diseases such as COPD play a much larger role,

accounting for 20 percent of the life expectancy gap, compared to 14% among men.

The Healthy Liverpool Programme published the 'Healthy Liverpool Prospectus for

Change' in November 2014. This is a programme of transformational change which

aims to radically change the way health care is delivered in the city. Our goals for the

Healthy Liverpool Programme are:

• A 24% reduction in years of life lost

• An increase to 71% in the measurement of the quality of life for people

with long term conditions.

• A 15% reduction in avoidable emergency hospital admissions.

• To deliver a patient experience in our hospitals that puts us in the top

10 of CCGs nationally

• To provide a community-based care experience that puts us in the top

5 of CCGs nationally.

Achieving these aims is more challenging today than it has ever been, as NHS

funding is only increasing marginally and local authority funding is reducing year on

year. At the same time, clinicians are telling us that it is not always possible to

deliver the highest level of care within the constraints of the current system. These

factors create significant service and financial pressures on our health and social

care economy, and an impetus for change that the CCG must respond to decisively.

In order to achieve the Healthy Liverpool vision the CCG need to identify new ways

of working and to design services that support and deliver its ambitions. A

transformation and governance programme is in place to support the development of

new ways of working. The focus on quality within this transformation programme is a

key component. The recently announced delegated responsibility for commissioning Page 10 of 40

194194

GP services will give the CCG a great opportunity to transform local health services

in Liverpool as part of the Healthy Liverpool programme, through continued

investment in expanded primary care and community services, both of which are

fundamental to the success of Healthy Liverpool.

It will also give the CCG greater scope to reduce health inequalities and improve

health outcomes for the people of Liverpool by delivering safe, effective and quality

services across primary and secondary care.

Quality and Provider Organisations As the landscape of health provision changes, healthcare professionals and clinical

teams, their ethos, values and behaviours, obviously remain the first line of defence

in safeguarding quality.

The leadership within organisations remain ultimately responsible for the quality of

care being delivered by their organisation, across all service lines.

The provider relationship with Liverpool CCG is vital – the provider leadership team

should be able to raise concerns it may have with its commissioners, and the

commissioners should respond to and work with the provider to address shortfalls in

the provision of care in a timely and proportionate way.

Care Quality Commission

The Care Quality Commission is the independent regulator of all health and adult

social care in England established by the Health and Social Care Act 2008. They

ensure essential quality standards are being met everywhere and they help to

improve quality. Providers of ‘regulated activities’ must be registered with CQC to be

able to operate.

CQCs guidance about compliance: Essential standards of quality and safety3 sets

out guidance for providers and the outcomes people should experience when the

standards are being met.

3Quality in the new health system – maintaining and improving quality from April 2013

Page 11 of 40

195195

Where providers are not meeting essential standards, the CQC has a range of

enforcement actions it may employ to protect the health, safety and the welfare of

people who use the services (and others, where appropriate).

Individual healthcare professionals

Whereas the CQC is responsible for monitoring the compliance of provider

organisations with the ‘essential standards of quality and safety’, it is the role of the

professional regulatory bodies to set and uphold standards for individual healthcare

professionals. There are nine UK health professions regulators which are

responsible for setting standards of competence, practice, conduct and ethics for all

registered healthcare professionals. Although the codes of conduct for the different

professional groups all vary to some extent, broadly speaking all registered

healthcare professionals must:

• Ensure that patient safety and patient interests are paramount;

• Take action to protect patient safety, including reporting concerns about

patient safety / the actions of colleagues where necessary; and

• Protect confidentiality where any concerns are raised.

Liverpool CCG as Lead Commissioner Liverpool, as a geographic area, has a number of provider trusts that provide

services for the wider population of Merseyside. It therefore leads or co-commissions

with these Trusts in partnership with neighbouring CCGs. These co-commissioners

are invited to share in the performance data and are offered formal and informal

opportunities to raise any issues in a range of fora.

The Trusts that operate in Liverpool are diverse in size and character, this diversity

requires a tailored approach to the management of quality issues, underpinned by

the common principles described earlier -are services safe, effective, positively

experienced, timely, equitable and efficient?

The Liverpool Provider Landscape Alder Hey Children’s NHS Foundation Trust is a children’s specialist tertiary provider,

it is an acute hospital with accident and emergency services, 246 beds and is

currently undergoing a rebuild which is due to open in September 2015.

Page 12 of 40

196196

Royal Liverpool Hospital and Broadgreen University Hospital NHS Trust is the

largest hospital in Merseyside and Cheshire, split across two sites with the main site

based close to the city centre, providing emergency, general and specialist treatment

to patients from across the region. It is currently undergoing a rebuild which is due to

open in 2017. The Broadgreen site is the main location for all planned general,

urological and orthopaedic surgery, diagnosis and treatment, together with specialist

rehabilitation. The Trust is currently working towards foundation trust status.

Liverpool Heart Chest Hospital NHS Foundation Trust is a specialist provider of

cardiothoracic surgery, cardiology and respiratory medicine, including adult cystic

fibrosis and diagnostic imaging, both in the hospital and out in the community.

Liverpool Women’s NHS Foundation Trust is one of two specialist hospitals

nationally dedicated to women, children and families. The Trust has recently

published information as to the financial challenges it is experiencing and is working

closely with staff, patients, the public and commissioners to develop services that will

support future generations.

Aintree University Hospital NHS Foundation Trust is a provider of general acute

services located in the North of the city. Although Liverpool CCG is not the lead

commissioner for Aintree it works closely with colleagues in South Sefton CCG to

oversee the quality of its services.

Mersey Care NHS Trust is a specialist provider of mental health services. They

provide specialist inpatient and community mental health, learning disabilities,

addiction management and acquired brain injury services for the people of Liverpool,

Sefton and Kirkby. The Trust also provides secure mental health services for the

North West of England, the West Midlands and Wales. The Trust is currently working

towards foundation trust status.

Liverpool Community Health NHS Trust deliver community health services to people

in their own homes and across 70 community locations. Services include community

nursing, health visiting, school nursing, podiatry, physiotherapy, treatment and walk

in centres.

Page 13 of 40

197197

Spire Liverpool Hospital is a private provider of elective medical and surgical

procedures. Liverpool CCG commission a range of NHS procedures via the hospital

based in the south of the city.

Specific collaborative commissioning arrangements are in place for key Trusts and

services which deliver services across multiple CCG boundaries and populations.

Examples of the latter include the Collaborative Commissioning Forum for Aintree

University Hospital and the wider North West arrangements effecting the

commissioning of ambulance services and NHS 111.

The CCG has continued to build a strong relationship with the NHS England

Cheshire & Merseyside Sub Regional Team, including specialist services

commissioners.

The CCG is an active participant in and supporter of the Merseyside CCG Network –

this provides a valuable forum for Chief Officers, Chairs and Chief Finance Officers

to meet monthly and discuss matters of common interest and concern,

recommending actions or interventions to Governing Bodies.

Commissioning & Quality

The Commissioning model or cycle is not a stepped process that ends with the

award of a contract. Contract or Service Level Agreement variations can and should

be acted upon when commissioners have knowledge of intelligence around changing

needs, changes in populations, community feedback or provider performance

warrants action.

Page 14 of 40

198198

SECTION TWO: EMBEDDING QUALITY IN LIVERPOOL

Governance Arrangements The CCG operates within the wider governance arrangements of the NHS.4

4http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstructure.aspx

Page 15 of 40

199199

Acknowledging that the NHS through the CCG cannot effect significant improvement

in the health of the population alone, effective relations with Liverpool City Council

are critical to the delivery of health services and health improvements across the city.

At the strategic level, the CCG Governing Body membership includes the Deputy

Mayor and the Director of Public Health, with the Director of Adult Social Care also in

attendance. The CCG also continues to fully support the work of the Mayoral Health

Commission and is a member of the Health & The Wellbeing Board.

The importance of this relationship is evidenced by the commitment of the CCG to

the ‘Better Care Fund’ and continued expansion of the formal Partnership Agreement

(Section 75) between the Council and CCG, alongside the further development of

our joint approach to personalised health budgets. The Joint Health & Wellbeing

Strategy 5 was jointly produced and informed the CCG’s own 2 and 5 year

commissioning plans and strategy.

The CCG regularly attends meetings of the City Council Adult Social Care and

Health Select Committee and provides the Committee with updates and progress

reports on key actions and activities. The Chief Nurse acts as vice-chair for both the

adult and children's safeguarding board.

Member Practices The CCG has developed a locality based structure, with three localities (North,

Central and Matchworks) that provide, via their locality Chairs and Lead GPs, direct

input into the Governing Body, supported by regular locality meetings. The localities

themselves are underpinned by eighteen neighbourhoods that provide a direct link

into member Practices. At least twice a year all member Practices are brought

together for city wide development and engagement events.

5http://liverpool.gov.uk/council/strategies-plans-and-policies/adult-services-and-health/health-and-the CCGllbeing-strategy/

Page 16 of 40

200200

CCG Governing Body Reporting The Governing Body’s main function is ensuring that the CCG has appropriate

arrangements in place to exercise its functions effectively, efficiently and

economically and in accordance with the CCGs principles of good governance.

A corporate performance report that includes the quality aspects of performance is

presented monthly to the Governing body. The report provides evidence of the

progress being made across the organisation at both an organisational and

individual service provider level, as well as providing a summary of CCG

performance in relation to the NHS Outcomes Framework. It also allows for

performance analysis against key Public Health/local outcomes; providing the

Governing Body with a report structure which maps progress against statutory

reporting requirements and measurement across the priority programme areas of;

Mental Health; Healthy Ageing; Long Term Conditions; Children; Learning Disabilities

and Cancer. This allows the clinical leads in each of these areas, who all have a

place on the Governing Body, to be kept fully informed.

Due to the way in which these indicators are measured, the majority of these

elements will be reported upon on a quarterly and annual basis. Where possible,

Liverpool is benchmarked against other ‘Core City’ CCGs and ranked against

relevant NHS Outcome ambitions

Quality, Safety and Outcomes Committee Appointed by the Governing Body, this committee makes recommendations to the

Governing Body on quality and safety processes across all commissioned services.

The committee should ensure that quality and patient safety is coordinated and

transparent, with a coherent and systematic review of the system.

In line with the recommendations of the National Quality Board (NQB), the Quality,

Safety and Outcomes Committee (QSOC) have established a Quality Early Warning

Dashboard. The purpose of this dashboard is to provide the CCG with a system to

identify any issues and risks relating to patient quality and safety; particularly for

those areas identified by the NQB as potential indicators of quality and safety issues.

Page 17 of 40

201201

The dashboard covers all NHS Trusts within the Merseyside area and includes Risk

Profiles for each organisation issued by the Care Quality Commission (CQC) and

Monitor Risk and Financial Ratings. Minutes of Trust level CQPG meetings will be

reviewed at QSOC.

Where risks have been identified they will be actively managed through CCG

governance arrangements overseen by the Quality, Safety and Outcomes

Committee, individual Trust Clinical Quality and Performance Meetings and

collaborative commissioning arrangements with Merseyside CCGs.

Underpinning the work of the Quality, Safety and Outcomes Committee and CQPGs

are the CCG Quality Team, led by the CCG Chief Nurse/ Head of Quality. This team

provides strategic and operational leadership for key components of the quality work

stream.

Risk Management Commissioning healthcare inevitably carries risk. As a public body, the CCG has a

statutory commitment to manage any risks that affect the safety of its employees,

patients and its commissioned, financial and business services by adopting a

proactive approach to the management of risk. A Risk Management Strategy6 sets

out the CCGs intentions and arrangements for the effective evaluation and

management of risk. It is recognised that inadequately managed risks within

commissioned services have the potential to prevent the CCG from achieving its

objectives and may directly (or indirectly) cause harm to those it cares for, employs

or otherwise affects as well as incurring loss relating to assets, finance, reputation,

goodwill, partnership working or public confidence.

The Audit, Risk & Scrutiny Committee The Audit, Risk & Scrutiny Committee is a formal sub-committee of the CCG

Governing Body. It provides an ‘independent’ assurance and scrutiny function on

behalf of the Governing Body of the effectiveness of the CCGs systems and

6www.liverpoolccg.nhs.uk

Page 18 of 40

202202

processes for governance and internal control. As such it should be viewed as ‘out

with’ a hierarchical Committee structure. The Audit, Risk & Scrutiny Committee has

delegated authority to approve the CCGs risk management arrangements and

monitor on-going compliance; ensuring that the risk assurance procedures are being

followed and reviewed on an annual basis.

Identifying and Managing Risks in Commissioned Services The CCG has a statutory duty to secure continual improvement in the quality of

services and to assist/support NHS England in relation to its duty to improve the

quality of primary medical services. The CCG is committed to its responsibility to

monitor the safety and quality of services it commissions and taking action where

there are significant concerns (depending on the circumstances, this could be

alongside the relevant regulatory body). The Governing Body will discharge this

function through its committee structure (and the Chief Nurse) by maintaining

oversight of the assurance processes in place for commissioned services with regard

to clinical risk management, including (but not necessarily limited to) the following:

• Safeguarding of adults and children;

• Clinical Governance;

• Information Governance;

• Health & Safety;

• Infection Prevention & Control (IPC) and;

• Performance management of Serious Incidents (SI) reported by

commissioned healthcare services.

Where there are concerns that there may be a serious safety or quality failure within

a provider organisation which cannot be dealt with through established

operational/governance systems, the CCG’s Chief Officer may take one or more of

the following actions:

• Notify the Care Quality Commission;

• Notify NHS England;

• Organise a risk committee.

Page 19 of 40

203203

Quality Surveillance Groups On a wider health economy level, NHS England, through its’ Cheshire & Merseyside

Sub-Regional Team has established a Quality Surveillance Group (QSG) of which

NHS Liverpool CCG is an active member, along with each of the Merseyside CCGs

and other key partners and stakeholders. QSG act as an important mechanism for

the sharing and analysis of significant information and intelligence about

commissioned services. This enables early detection of deteriorating quality and an

‘early warning’ of potential risks to patient safety. Where necessary, the QSG will

conduct enhanced surveillance of providers until evidential assurance of sustained

quality improvement is demonstrated.

Enhanced surveillance, ‘Quality Reviews’ and ‘Risk Summits’ can be triggered by a

number of factors; such as an unacceptably high risk rating following the outcome of

a Care Quality Commission inspection, combined intelligence and quality data which

highlights serious issues, aggregated thematic reviews of Serious Incidents and

complaints or a continued failure to achieve minimum quality targets. Although led by

the Sub-Regional Team of NHS England, both the Quality Review and Risk Summit

process involve a range of partners, such as the CQC, Health Education England

and Local Authorities to ensure that an informed and inclusive view of the issues can

be considered and proportionate actions to improve quality can be taken forward and

monitored.

Healthwatch7 Healthwatch Liverpool is based in the independent voluntary sector and takes on the

role of patients champion for local health and social care service. It engages with the

CCG on a number of levels in order to contribute to the local quality

agenda. Healthwatch Liverpool also works alongside various other commissioning

and regulatory bodies to scrutinize the quality of a wide range of local health and

social care service providers. Healthwatch Liverpool provides a patients perspective

on both the quality of the CCG itself and on the quality of the services that it

commissions.

7http://www.healthwatch.co.uk/

Page 20 of 40

204204

Healthwatch Liverpool currently attends a number of meetings relevant to LCCG in

order to carry out its role: NHS England Quality Surveillance Group, The local Health

and Wellbeing Board, LCCG Board (non-voting), The LCCG Patient Engagement

and Experience Group and Primary Care Commissioning Committee (non-voting).

Healthwatch Liverpool also comments on the annual Quality Accounts of local NHS

Trusts. It also engages with LCCG regarding the Equality Delivery System

submissions of both local NHS Trusts and LCCG itself. They have their own systems

for independently gathering intelligence regarding the quality of local health and

social care providers, and additional to regular dialogue on this subject with LCCG

colleagues; Healthwatch Liverpool publishes an annual report detailing its work.

Safeguarding Children and Adults The protection of vulnerable children and adults at risk from abuse and neglect is

fundamental to delivering health and wellbeing, and core to delivering the quality

agenda. Our approach is contained in a Safeguarding Declaration.8

The CCG Safeguarding Service is hosted by Halton CCG and covers the Merseyside

footprint of Knowsley, Halton, Liverpool, Southport and Formby, South Sefton and St

Helens CCG areas.

NHS Liverpool Clinical Commissioning Group ensures that organisations

commissioned to provide services have appropriate safeguarding systems, including

clear accessible policy and procedure, safe recruitment, training and governance

systems. The principle philosophy is that safeguarding is everybody’s business and

all staff will respond and act to raise safeguarding awareness and address any

emerging issues.

The CCG is an active partner on the Liverpool Children’s Safeguarding Board and

the Liverpool Adult Safeguarding Board, with membership representation at

governing body level on both of these.

8http://www.liverpoolccg.nhs.uk/About_Us/Publications.aspx

Page 21 of 40

205205

Primary Care as a sector is receiving specific support from the CCG in the form of a

designated GP lead for safeguarding, whose role it is to work directly with GPs,

practice managers and practice nurses.

Complaints Liverpool Clinical Commissioning Group aims at all times to provide local resolutions

to complaints and takes all complaints seriously. When dealing with complaints the

main purpose for the CCG is to remedy the situation as quickly as possible and

ensure the individual is satisfied with the response they receive. It is important that

individuals feel that they have been fairly listened to, treated with respect and any

issues raised have been satisfactorily resolved within agreed timescales.

The time limit for making a complaint, as laid down in the Local Authority Social

Services and National Health Service Complaints (England) Regulations 2009, is

currently 12 months after the date on which the subject of the complaint occurred or

the date on which the matter came to the attention of the complainant. An

acknowledgement of the received complaint is made within 3 working days, to

acknowledge the complainant’s concerns. The CCG aims to provide a formal

response to complaints received within 35 working days, however depending on the

complexity of the complaint, longer may be required. Any time extensions are

agreed the complainant is kept informed of progress throughout the investigation.

The CCG aims to remedy complaints locally through investigation and meetings if

appropriate, however if the complainant remains dissatisfied they have the right to

refer their complaint to the Parliamentary and Health Service Ombudsman (PHSO)

as the second stage. The Chief Officer personally signs off complaint responses.

Equality The Equality Act 2010 requires us to meet our Public Sector Equality Duty across a

range of protected groups including age, gender, race, sex, sexual orientation,

religion/belief, gender identity, marital/civil partnership status and

pregnancy/maternity status.

Promoting equality is at the heart of NHS Liverpool CCGs core values; ensuring that

‘everyone counts’ and that the CCG commission services fairly and inclusively and Page 22 of 40

206206

with no community or group marginalised in the improvements that will be made to

health outcomes across the city.

Our published Equality Objectives are:

• To make fair and transparent commissioning decisions;

• To improve access and outcomes for patients and communities who

experience disadvantage;

• To improve the equality performance of our providers through robust

procurement and monitoring practice

• To empower and engage our workforce

The key functions that enable Liverpool CCG to make commissioning decisions and

monitor the providers have considered the needs of protected groups (in an

auditable manner) include:

• Commissioning processes;

• Consultation and engagement;

• Procurement functions including Pre-Qualification Questionnaire (PQQ)

and Invitation to Tender;

• Contract specifications;

• Quality contract and performance schedules, and;

• Governance systems.

Failure to comply has legal, financial and reputational risks. The CCG will continue to

work internally, and in partnership with our providers, community and voluntary

sector and other key organisations to ensure that the CCG advance equality of

opportunity and meet the requirements of The Equality Act 2010.

Serious Incidents & Never Events Liverpool CCG follows the national Serious Incident framework for recognising,

reporting and investigating when things go wrong. 9 All Serious Incidents are

managed on the Strategic Executive Information System, commonly referred to as

STEIS. The system enables electronic logging, tracking and reporting of Serious

Incidents.

9https://www.england.nhs.uk/ourwork/patientsafety/serious-incident

Page 23 of 40

207207

The review process at CCG level considers the investigation report and associated

action plan. Action plans should contain clearly articulated actions and

recommendations that follow logically from the findings of the investigation to inform

any lessons to be learned. Actions should be designed and targeted to significantly

reduce the risk of recurrence of the incident. The CCG will close incidents on receipt

of the final investigation report and action plan if they are satisfied that the

requirements outlined within the serious incident framework are fulfilled.

Additionally the CCG uses the Clinical Quality and Performance Group meeting

arrangements (see Section Three) to gain assurances that lessons have been learnt

and improvements are sustained.

‘Never events’ are a specific type of serious incident and are key indicators that

reveal failures that providers and commissioners need to learn from to eradicate

them entirely from NHS care. NHS England ensures openness and transparency

through the publication of patient safety data by the monthly publishing of data on

Never Events on the NHS England the website.

Page 24 of 40

208208

Local Residents and Patients Engagement Liverpool CCG is committed to effective engagement, involvement and consultation

with Liverpool’s communities. The CCG recognise that understanding people’s

experiences and perspectives can be used to improve services, health and the

wellbeing and to reduce differences in people’s health experiences. The CCG has

created several ways to ensure the CCG hear views from all Liverpool’s diverse

communities to help shape the health system and services the CCG need for the

future. Page 25 of 40

209209

A Lay member of the Governing Body has formal responsibility for the oversight and,

if required, challenge to the approach to involvement and engagement being taken.

Liverpool Patient and Public Service Engagement Group meets on a six weekly

basis, chaired by the Lay member of the Governing Body which ensures a strategic

drive to the work.

In addition Liverpool Healthwatch has a formal and monthly invitation to attend

meetings of the Governing Body, providing the opportunity for transparency and a

further scrutiny of our approach. Members of the public are also the welcomed to

attend formal meetings of the Governing Body and these include an ‘open’ question

session for members of the public.

Individual member Practice Patient Participation Groups (PPG) are also encouraged

and supported, with the majority of GP practices in the city having PPGs established

and operational, which link into Patient Forums at a locality level.

City wide engagement events provide the opportunity for strategic input and

engagement. Individual clinical programmes benefit from patient and public

involvement in the service design and procurement of new or changed services. A

full programme of these can be found at www.liverpoolccg.nhs.uk.

SECTION THREE: QUALITY MONITORING IN ACTION

Quality & Contracting in NHS Contracts NHS Standard Contracts cover the range of services provided by the large providers

or Trusts servicing the population of Liverpool which are;

• Royal Liverpool and Broadgreen University Hospitals

• Aintree University Hospital

• Liverpool Community Health NHS Trust

• Mersey Care NHS Trust

• Liverpool Women’s NHS Foundation Trust

• Alder Hey Children’s NHS Foundation Trust

• St Helens & Knowsley NHS Trust

Page 26 of 40

210210


• Spire Liverpool Hospital

• Liverpool Heart Chest Hospital NHS Foundation Trust

The NHS Standard Contract is the key lever for Commissioners to secure

improvements in quality and cost-effectiveness in their secondary care contracts.

There is an expectation10 that commissioners should enforce the standard terms of

the contract, fairly and consistently including the application of sanctions.

There is flexibility within the NHS Standard Contract to vary the application of

sanctions by local agreement. Sanction variations should be agreed in advance, as

part of a deliberate set of measures to create more effective local incentives to

improve services.

The quality of all Liverpool CCG contracts with the above providers will be managed

through the processes outlined in the diagram below;

Sub-Group:Clinical Quality & Performance Group

(CQPG)• Service/Quality Issues where performance is

at risk• SDIPs– current and planning for future• CQUIN• Acts as Clinical Reference Group• Issues reported to LCCG Quality Committee

Sub-Group:Contract Review Meeting (CRM)

• Contract Compliance • Performance Indicators by Exception• Contract Variations• Issues reported to LCCG Contract and

Procurement Sub Committee• Management of MoA items

Commissioner Governing Bodies

Refers Performance Issues

Refers Contractual Issues

/ommissioning Lntentions

(all parties)

KEY /hbTwA/TUAL aEETLbDS

wefers items for /ommissioner decisions

Decisions communicated to contract groups

wefers items for /ommissioner decisions

Collaborative Forum/ontracting trinciples 2015/16

Sub-Group:Information Sub Group

• DQIP• Data quality• Monitor schedule 6 of

Contract

10Everyone Counts: Planning for Patients 14/15 to 18/19 http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

Page 27 of 40

211211

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

Meetings involving both CCG and Provider representatives

Contract Review Meetings (CRM) Individual provider negotiated Terms of Reference are agreed for these monthly

meetings to allow for membership and the scope of service provision variations.

Standard agendas are agreed within the terms of reference which include quality and

CQUIN examination by exception rather than the full review.

The CRM will review minutes of CQPG meetings and vice versa, considering the

contractual implications of any decisions, proposals or recommendations agreed at

CQPG meetings. Clinical issues raised at the CRM will be referred to the CQPG

meetings for review and recommendation.

Clinical Quality Performance Group (CQPG) Monthly CQPG meetings are held with individual local Provider Trusts to monitor and

manage quality matters. This is the forum where detailed discussions are held on

quality issues/concerns from intelligence gathered or shared by the provider; to

debate and monitor how the provider is performing against CQUINs and quality

metrics. It provides opportunity for commissioners and providers to promote and

share good practice across front line services.

These meetings are where Liverpool CCG will challenge poor quality and look to

gain assurances regarding plans to improve quality. Contractual levers can be

utilised to support improvements. These improvements are actively led by CCG

Clinicians. According to the Liverpool CCG agreed process, formal notice is to be

issued by the co-ordinating commissioner’s contract signatory notifying the Provider

that a breach has been identified and that the contractual financial sanction will be

applied. Minutes of CQPG meetings will be reviewed by QSOC to ensure system

wide overview.

Measuring Quality There are national metrics that are included in provider contracts that sit under the

'banner' of quality. These include the Darzi principles of Effectiveness, Experience

and Safety metrics, but they have been further developed in Liverpool so that the Page 28 of 40

212212

Quality Schedule within an NHS Standard Contract brings together the growing

plethora of national and local quality initiatives and drivers.

The Quality Schedule sets out standards across providers and the overarching aim

of the Quality Schedule is to support the health care system in achieving their high

level objectives of improving health care.

The Quality Team is responsible for reviewing all national and locally determined Key

Performance and Quality Compliance indicators. The team must evaluate and

rationalise the expectations of these indicators, reduce areas of duplication and

provide an overall structure to aid quality. The structured approach will address the

CQC inspection framework indicators of:

• Are they safe?

• Are they effective?

• Are they caring?

• Are they responsive?

• Are they the well-led?

Monitoring of indicators takes place on a monthly basis using the mechanisms

described above, with performance reports being presented at the respective CQPG

meeting and any other appropriate CCG meeting. Stretch targets are also applied

where appropriate.

CQUIN Setting in Liverpool

A 3 stage approach is being taken locally;

• Gathering Insights and Intelligence – Evaluation of current CQUIN scheme to

determine the potential and direction for further scheme development.

Provider organisations are required to submit a list of CQUIN intentions

against a framework developed by the CCG.

• Identify Local Schemes – Prioritise and agree the local schemes to maximise

quality improvement across the health system. Commence the engagement

process with clinical and programme leads to determine the expected

outcomes, deliverables and quarterly milestones to effectively monitor and

manage performance in year.

Page 29 of 40

213213

• Develop CQUIN Proposal – Goals should be agreed between commissioners

and providers, with clinical engagement locally, and should reflect both local

priorities and priority areas. Contract negotiation commences through

engagement and consultation at the CQPG meetings.

CQUIN Monitoring Progress against the CQUIN Scheme is monitored on a quarterly basis and

performance is reviewed and evaluated at the CQPG meetings. A financial

evaluation is generated by the CCG and submitted to the provider on a quarterly

basis demonstrating the total amount of CQUIN monies earned against the total

amount available based on the expected deliverables and achievement required

within that reporting period. Performance is also noted at the CRM.

External Scrutiny All Liverpool NHS providers of care are required by statute to produce an annual

Quality Account if they deliver services under an NHS Standard Contract, have staff

numbers over 50 and a turnover greater than £130k per annum.

Quality Accounts allow healthcare organisations to assess quality across the entire

range of their healthcare services, with an eye to continuous quality improvement. It

is not a compliance tool, but rather a means for providers to:

• Demonstrate an organisation’s commitment to continuous, evidence-

based quality improvement across all services;

• Set out to patients where they will and need to improve;

• Receive challenge and support from local scrutineers on what they are

trying to achieve; and

• Be held to account by the public and local stakeholders for delivering

quality improvements

Each year, Liverpool CCG in collaboration with South Sefton CCG, Southport and

Formby CCG and Knowsley CCG invites each trust to present and discuss their

proposed Quality Account with local commissioners.

Page 30 of 40

214214

The Quality accounts need to be shared, in draft, with the local Health-Watch and

Overview and Scrutiny Committee in the local authority area in which the provider

has its registered or principle office located. NHS England and local Healthwatch

teams may wish to inform their responses to a provider's quality accounts by

discussing it within their QSG. Comments from local scrutinisers need to be included

in the final quality account.

The Quality accounts produced by the NHS providers are uploaded to their quality

account on their NHS Choices by 30 June each year. By uploading their quality

account on NHS Choices, providers have fulfilled their statutory duty to submit their

quality account to the Secretary of State.

Quality & Contracting with Care Homes The North West Commissioning Support Unit (NWCSU) is responsible for the

performance and quality monitoring for Nursing Homes and are commissioned to

assess for Continuing Healthcare (CHC) and Funded Nursing Care (FNC) and

complex care, for the resident population of Liverpool, on behalf of Liverpool Clinical

Commissioning Group.

Quality Assurance meetings are scheduled monthly in order to provide a holistic

overview of Care Home concerns, sharing of safeguarding information and

improvement projects. These meetings enable closer liaison with Liverpool City

Council and operational and strategic partners. They have led to the formation of bi-

monthly Care Quality Commission meetings, aiding in the provision of preventative

risk management across the entire care home arena.

Care Home monitoring development work is on-going across Liverpool, in order to

ensure further transparency in service provision and provide robust monitoring in

promoting consistent quality improvement across the Care Home sector. Clinical

quality is currently monitored through the collection of Commissioning for Quality and

Innovation (CQUIN) information, and in undertaking joint quality compliance visits

with Liverpool City Council, as per the annual quality review schedule. This work is

very much in its infancy, though to date it has improved working relationships,

enhanced integrated practice and enabled sharing of information.

Page 31 of 40

215215

The Nursing Home Integrated Dashboard Tool is developing and aims to give

professionals access to valuable information captured at a local level, in a visual and

practical format. This enables required information to be viewed, highlighting early

warning signs and areas of concern at a glance. The tool is also being used to

compare local information alongside relevant national metrics, in order to inform best

practice guidelines.

The current collected information will change over time in order to provide the most

appropriate quality data applicable to Nursing Homes. Once the integrated

dashboard is fully populated with all relevant data it will create a single point of

access document, in order to increase transparency in service provision, whilst

providing holistic warning signs, in order to proactively respond to and provide

necessary support. Work on the Integrated Dashboard is currently on-going and

dependant on receipt of requested quality information.

Quality & Primary Care Services The quality of General Practice primary care services has continued to be a key

priority for the CCG and is overseen by the Primary Care Quality Improvement

Committee which is chaired by the CCG Chair. The CCG has developed a range of

methods to build a two-way dialogue with its 93 member practices. All practices are

engaged within neighbourhoods and information flows to and from the locality

leadership team.

The Primary Care Quality Framework, which was introduced in April 2013 and based

on the original Liverpool General Practice Specification, aims to drive continuous

improvement through supporting practices to deliver high quality primary medical

services (and at the same time providing assurances to the NHS England Sub-

Regional Team that Liverpool CCG practices are providing high quality care). Equally

fundamental to this framework is ensuring that every Liverpool general practice plays

their part in realising the CCGs vision.

The Framework consists of 66 evidenced based indicators covering prevention,

cancer, cardiovascular disease (CVD), long term conditions, children’s, urgent care,

planned care and patient experience. With the support of the CCG primary care

team via regular practice visits, GP neighbourhood meetings and Locality Leadership

Teams, practices are presented with opportunities to review performance, identify Page 32 of 40

216216

priorities, receive support from peers and showcase best practice. A quarterly report

is also presented to the Primary Care Quality Committee to monitor progress and

allow localities to share best practice.

The now the well-established locality and neighbourhood infrastructure facilitates

and assures a local approach to managing quality and variation, as well as

identifying training and education needs (G.P, Practice Managers and Practice

Nurses) and crucially member practice input into the development of clinical

pathways. Localities have reviewed where progress has not been as good as

expected, and actions are set out in the 14 individual Locality Plans to address these

areas.

Quality & Contracting VCSE Sector Recognising the contribution of the Voluntary Community and Social Enterprise

(VCSE) sector, a specific form of Service Level Agreement (SLA) has been

developed to encourage their participation in the health economy and recognise their

organisational differences and ability to respond to requests for large amounts of

data connected to a small amount of funding. This is used with the VCSE sector for

matters where the anticipated contract value (over its life, including any possible

extensions) does not exceed £111,000.

Where their value exceeds £111,000, commissioners will revert to using the standard

NHS Terms for the Purchase of goods or services. The SLA is also not suitable for

use in connection with the commissioning of any clinical services – in such

circumstances the NHS Standard Contract will then be used.

Healthy Liverpool Community Grants Liverpool CCG has a grant programme which aims to create a healthcare system

which empowers individuals and communities to influence health services, to take

control of their own health and to access the right medical help when needed.

Large grants (up to £70 k over 2 years) and small grants of up to £10k are distributed

through an application process with distinct funding rounds. All successful groups will

sign up to specific terms and conditions and all their work will be subject to an

evaluation so impact can be recorded and learning from innovative approaches

gathered by commissioners.

Page 33 of 40

217217

Quality & Contracting North West Ambulance Service The North West Ambulance Service (NWAS) is provided on a North West basis for

the Paramedic and Emergency Service (PES) and for Patient Transport Services

(PTS). NWAS hold four of the five county level contracts including that for

Merseyside.

Commissioning is led by Blackpool CCG who act as lead with 'county' leads in each

area. The county commissioning lead for Merseyside is Liverpool CCG Head of

Operations.

The contracts are formally managed via a monthly meeting of the Strategic

Partnership Board (SPB) that includes the Blackpool team as lead, county

commissioners and the NWAS executive team. This meeting holds the provider to

account and monitors performance and delivery.

Merseyside as a county, have a monthly meeting that includes managerial and

clinical leads from all the CCGs that looks at local performance and delivery.

Performance and delivery data is made available monthly and the CCG also has

access to the online data portal hosted by NWAS that allows ready access to

performance information.

Quality & Contracting Individual Funding Requests

The CCG needs to make arrangements for the management of applications for

funding for residents which fall outside the commissioning groups’ contracts with

their local, regional and national providers of clinical services or are exceptional

cases.

Liverpool CCG, in collaboration with the other Cheshire and Merseyside CCGs has

delegated the North West Commissioning Support Unit (NWCSU) through a service

level agreement to performance manage and deliver the service in a timely and co-

ordinated process within the scope of one organisation. This has resulted in:

• A region wide comprehensive and consistent managed service,

including an appropriate panel considered application and appeals

process with standardised policies.

Page 34 of 40

218218

• A standard IEFR application form/referral process developed and

endorsed by representative clinicians from across the CCGs.

• A strong clinical involvement by professionals trained and experienced

in managing applications for individual care packages.

As this is a service for referring clinicians to make applications for treatments and

interventions that are not routinely commissioned, the service is cognisant of

relevant CCG resource allocation principles or policies when processing applications

for funding non-contract activity to ensure that resources are deployed to achieve

optimal health gain for the population.

The service does not provide a Medicines Management review component. All

applications are clinically triaged via Liverpool CCG Medicines Management Team.

The service provided by the NWCSU is reviewed by the CCG at quarterly Service

level agreement meetings. The CCG agreed two KPIs for the year 2014-2015:

• 95% of all IEFR applications are processed with 56 days of receipt by

the CSU

• 100% of IEFR decision letters will be sent out within 10 working days of

the clinical decision (from triage or panel) being made. These letters

are sent out on behalf of the CCG.

The tolerance of 95% was agreed as some very complex cases may require longer

than the 56 days particularly if additional specialist opinion is sought in order to be

able to make an informed decision.

Activity reports are produced by the NWCSU on a monthly, quarterly and annually

basis to the CCG for inclusion in their performance reports.

Quality & Workforce To enable the CCG to provide the highest possible standard of service and deliver

against its strategic objectives there is a requirement to ensure that it recruits, retains

and develops staff within a culture of education and learning. The CCG needs to

ensure that it has the appropriate mix of knowledge and skills at all tiers of the

organisational structure. The organisation is therefore committed to the development

of its employees and aims to support them through this process.

Page 35 of 40

219219

Liverpool CCG requires all employees to complete, and keep up to date with their

statutory and mandatory training. This is delivered via e-learning and its content and

frequency is aligned to the requirements of the UK Core Skills Training Framework.

This framework, developed by the Skills for Health for the health sector, helps to

ensure the quality of the training defines the expected learning outcomes and

proposes refresher periods.

Liverpool CCG continuously aims to ensure that through the provision of statutory

and mandatory training and continuous personal development, its employees are

provided with the knowledge, skills and competence to undertake their roles

proficiently.

Page 36 of 40

220220

SECTION 4: FUTURE CHALLENGES

The CGG has maintained its strong and effective working relationships with providers, NHS England, Liverpool City Council

and external organisations including the Care Quality Commission, Monitor and the NHS Trust Development Authority

(NTDA). Continued partnership working with these stakeholders will greatly enhance our surveillance capabilities and

influence further positive work with our main providers to drive continuous improvements in the quality of healthcare services

for the people of Liverpool.

The Action Plan below is an indication of some of the work that will be taken forward in the next few years by Liverpool CCG

to respond to this challenging agenda in order to maintain quality.

Area of Work Key Stakeholders Led by Deliverables Date completed

Development of Cheshire &

Merseyside agreement on

sanctions

Merseyside &

Cheshire CCGs

Providers

Patients

Alison

Picton

Consistent, clear and auditable trail of

decision making on sanctions

On - going

NHS England Implementation

Plan for GP Primary Care

Commissioning to transfer to

the CCG

NHS England Local

Medical Committee

Public Health

England

Liverpool City

Council,

Scott

Aldridge

Memorandum of Understanding

between the CCGen NHS England

and Liverpool CCG

Governance arrangements

functioning including Primary Care

Commissioning Committee and

May 2015

September 2015

Page 37 of 40

221221

Primary Care

Support Services,

CCG Member

practices.

Primary Care Quality Group

Exercise delegated authority for the

management of GPs core contract

compliance, Directed Enhanced

Services, complaints and premises.

Annual assurance provided to NHS

England, as legally responsible for

GP core contracts

May 2016 and

On-going

Care Homes Integrated

Dashboard

Liverpool City

Council

Patients & Families

CCG

Providers

Jonny

Keville

Hosting and publication of data and

information

Autumn 2015

Serious Incident Management

Process Improvement

Patients and their

families

Providers

Commissioners

NHS England

CCG Quality Team

CCG Safeguarding

Denise

Roberts

Improved performance report

Improved management of provider

improvement action plans

Improved learning shared through

NHS England Quality Forum

On-going

Page 38 of 40

222222

Team

Increased reach of workforce

training

All CCG workforce Zafi Bisti E-learning system September 2015

Acting on Mersey Internal Audit

Agency recommendations

CCG Officers

Governing Body

Ian Davies CCG SMT meetings review of

performance data reported at this

level

December 2015

Patient Experience Project

established

Patients

Providers

NHS England

Healthwatch

CCG

commissioners

Carole Hill Project Plan

Partners engaged

Resources identified

On - going

Integration of services/patient

led services

Patients

Providers

Contracts

Quality Team

Jane Lunt Learning from trailblazer work e.g.

diabetes

Identification of Lead Providers

Collaboration between providers

Integration of contract quality

processes between providers

On-going

Transfer of NWCSU quality

support services

NHS England

CCG

Care Homes, CHC

and Complex Care

Derek

Rothwell

Commissioning intentions agreed

Specification for CHC and IFR

May 15

June 15

Page 39 of 40

223223

Commissioners

Providers

Patients

Contract Awarded

Staff TUPE

September 15

Nurse Re-validation NHS Trusts

CCG

Primary Care

Care Homes

Kerry

Lloyd

Support to CCG, primary care and

nursing home workforce in transition

to new system for revalidation

01/04/16

Implement Sign up to Safety

Pledges to strengthen patient

safety

Community

NHS Trusts

Denise

Roberts

Develop a 3 year Safety Improvement

Plan

Identify the patient safety

improvement areas the CCG will

focus on within the safety plans.

Engage our local community, patients

and staff to ensure that the focus of

our plan reflects what is important to

our community

Publish, report on and update plan

regularly

Page 40 of 40

224224


QUALITY SAFETY & OUTCOMES COMMITTEE Minutes of meeting held on Tuesday 2nd June 2015 at 3pm

Room 2 4th Floor Arthouse Square

Present Dave Antrobus (DA) Chair/Lay Member Jane Lunt (JL) Head of Quality/Chief Nurse & Vice

Chair Shamim Rose (SR) GP Governing Body Member Fiona Lemmens (FL) GP Governing Body Member Rosie Kaur (RK) GP Governing Body Member Donal O’Donoghue (D’OD) Secondary Care Consultant In attendance Mavis Morgan (MM) Healthwatch Volunteer Helen Smith (HS) Head of Safeguarding Adults –

Safeguarding Service Esther Golby (EG) Deputy Designated Nurse Safeguarding

Children – Safeguarding Service Cheryl Mould (CM) Head of Primary Care Quality &

Improvement Margaret Goddard (MG) Named GP for Safeguarding Julia Stoddart (JS) Programme Delivery Manager, Children

and Maternity Kellie Connor (KC) Clinical Quality & Performance Manager Kerry Lloyd (KL) Deputy Chief Nurse Jackie Johnson (JJ) Senior Information Analyst (Item 5 only) Paula Jones PA/Minute taker Apologies Denise Roberts (DR) Clinical Quality & Safety Manager Paula Parvulescu (PP) Consultant in Public Health Medicine Katherine Sheerin (KS) Chief Officer Tony Woods (TW) Head of Strategy & Outcomes 1. WELCOME & INTRODUCTIONS

The Chair welcomed everyone to the meeting.

Page 1 of 10

225225

2. DECLARATIONS OF INTEREST

None

3. MINUTES AND ACTIONS FROM 21ST APRIL 2015

The minutes from the meeting held on 21st April 2015 were approved as an accurate record of the discussions which had taken place subject to the correction to be made on page 3rd bullet to refer to Serious Incidents rather than Serious Untoward Incidents and the correction of a typographical error on page 9 3rd bullet.

Matters Arising and Action Points not already on the agenda. 3.1 DA asked whether the review of the mapping process of provider

resource to ensure reporting done to the Child Death Overview Panel (item 3.4) had been done. He was informed that this was ongoing.

3.2 KL noted that the NHS England half day event re national

frameworks on Serious Incidents and Never Events had taken place and that she had attended. The framework had been reviewed. Steis – there had been a number of additional resources for providers – the process was ongoing and there would be another meeting at the end of June re the management of Steis and commissioner information.

3.3 It was noted that a report on Hospital Based Discharge

Standards would be brought to the August 2015 meeting and had been removed from the June 2015 agenda. Given the need for this to be presented to the Governing Body as well Quality Safety & Outcomes Committee was not the only route.

3.4 Action Point Three – JL noted that she had checked with the

Primary Care Team on the monitoring of patients on Lithium Therapy on below toxic levels rather than therapeutic range.

3.5 Action Point Four – JL noted that the Care Act Update including

transition for young people with complex needs was not ready and would be brought to a future meeting.

Page 2 of 10

226226

3.6 Action Points Five, Six and Seven – it was noted that the Risk Register and Early Warning Dashboard amendments had been made.

3.7 Action Point Eight – it was noted that work was ongoing on

adding the 2015 Working Together to the statutory guidance and contract variations being required for the key performance indicators around Female Genital Mutilation.

4. RISK REGISTER – REPORT NO: QSOC 14-15

JL presented the Risk Register to the Quality Safety & Outcomes Committee. DA commented on items which did not change and JL noted that there needed to be clarity around risks which did not change and how to manage this. The Quality Team met regularly to discuss the Risk Register and static Trusts should have the non moving risks raised at the Clinical Quality and Performance Groups. KL was to look at the Corporate Risk Register with Stephen Hendry to marry up the processes of the two register and presentation, perhaps future presentations of the Risk Register at the Quality Safety & Outcomes Committee could take the format of a paper with more narrative. FL commented that the Clinical Quality and Performance Groups should report regularly to the Quality Safety & Outcomes Committee, perhaps along the lines of the committees reporting to the Governing Body. KL agreed to look at the best way of doing this and bring comments back to the next meeting. DA asked how other CCGs managed this and in response it was noted that most other CCGs were only the co-ordinating commissioner for one trust unlike Liverpool. CM noted that Primary Care Care Quality Commission issues should be included on the Risk Register as two practices were now in special measures. FL referred to the Alder Hey Safeguarding Key Performance Indicators risk and queried if this should now be green. DA noted that the likelihood was still 20. KC responded that the Trust had demonstrated improvement.

Page 3 of 10

227227

RK referred to the Alder Hey recruitment risk – JL noted that this was a national issue and that many disciplines were experiencing staff shortages which had led to foreign recruitment. FL noted that the Royal infection control risk was showing a residual rating of 8 current risk 16 but progress was still flat and wondered if the trajectory was wrong. The Quality Safety & Outcomes Committee: Noted the content of the risk register and on-going actions

against medium and high risk areas. Added any additional risks identified at the meeting.

5. TRUST CONTRACT QUALITY – EARLY WARNING DASHBOARD - REPORT NO: QSOC 15-15 KC presented the Early Warning Dashboard to the Quality Safety & Outcomes Committee. The Quality Safety & Outcomes Committee commented as follows:

• DA commented on the presentation and the difficulties in

understanding if % increases were good or bad. JJ responded that green and red coding was used to assist i.e. green was an improvement, red was bad. KC noted that there had been a previous request for comparison with the previous year’s data. JJ noted that they would try to build this in for next year.

• KC noted that Regional Advancing Quality targets Royal

Liverpool Hospital had struggled over several months but was doing a lot better than other providers.

• KC referred to the national Dementia CQUIN and that Liverpool

Heart & Chest Hospital and Liverpool Women’s Hospital were performing better due to their population size.

• JJ noted that this was a standard report produced for all CCGs

but it would be possible to produce something more bespoke if required.

• FL noted the First Episode measure on the Advancing Quality

CQUIN and that the target for Mersey Care was low compared Page 4 of 10

228228

to 5 Borough Partnership and there had been an improvement only over the last four months. KC suggested that the national physical health CQUIN had a consequential influence over other services. JL noted that Mersey Care were due to receive a Care Quality Commission visit the following week.

• FL referred to heart failure at the Royal Liverpool Hospital

where the target had been set higher than for other providers but performance significantly poorer than the national average – this would be picked up at the Clinical Quality and Performance Group and mitigating factors considered. KC noted that the discharge information fail would also be looked at.

• FL noted Stroke performance at Southport where Liverpool

CCG was not the co-ordinating commissioner but an associate to the contracts and asked for the CCG to ask for an update. KC agreed to do this.

• FL raised the issue of whether the dashboard for North West

Ambulance Service should exclude Stroke and TIA and which was to be checked.

The Quality Safety & Outcomes Committee: Noted the performance of the CCG in delivery of key

national performance indicators and the recovery actions taken to improve performance.

6. SAFEGUARDING REVIEWS – UPDATE AND REVEW OF ASSOCIATED ACTION PLANS – REPORT NO: QSOC 16-15

JL presented a paper to the Quality Safety & Outcomes Committee to give an update with regard to progress in implementing the recommendations from the Reviews undertaken in 2014. The paper contained an overview report and two action plans one for the Mersey Internal Audit Agency Safeguarding Review and the other for the Peer Review of Safeguarding Adults, Safeguarding Children and Looked After Children. The five outstanding recommendations from the Mersey Internal Audit Agency Review would be completed by the end of 2015. The Edge Hill Peer Review had been longer and there were a total of 19

Page 5 of 10

229229

recommendations, currently five were amber and fourteen were green. The Safeguarding Steering Group met regularly chaired by Fiona Clark at South Sefton CCG. It had signed off the Memorandum of Understanding and the Service Specification. The Key Performance Indicators were monitored via this group. Following the Peer Review there were new posts recruited to in the Safeguarding Service with and a Looked After Children Nurse recruited a Designated Nurse for Looked After Children who had started the previous week. Another Designated Nurse for Children had been recruited and would start the middle of July 2015. A review of the capacity of the Adult Safeguarding Team had resulted in two new members recruited to start in August 2015. It was hoped that Quarter three would show significant improvement. It was noted that the Quality Safety & Outcomes Committee was the vehicle for alerting/notifying the Governing Body about Safeguarding. RK wondered if there was a need for a Designated Nurse in Primary Care. MG noted that there was now a network of Named GPs for the Cheshire & Merseyside CCGs (MG for Liverpool CCG) – she agreed to bring back to the next meeting a flow chart of the Safeguarding capacity for the next meeting with contacts and level of risk. JL referred to Primary Care Safeguarding which previously would have been under NHS England but with the development of co-commissioning should now become simpler and provided opportunity. JL noted in response to query from DA that now that MG was in place as the Named GP items 4.2, 4.3 and 4.4 in the Peer Review Action Plan (Appendix 2) were now green. MM commented on the soft intelligence that GPs were able to glean re potential safeguarding. MG added that this demonstrated the need for multi-agency working to have a joined up approach.

The Quality Safety & Outcomes Committee: Noted the work to date in terms of implementation of

recommendations. Noted the work to complete outstanding recommendations

and the associated timescales. Noted the proposal that the Safeguarding Annual Report

was the vehicle for ensuring improvement to safeguarding systems and processes for LCCG.

Page 6 of 10

230230

7. SAFEGUARDING SERVICE REPORT - REPORT NO: QSOC 17-15

The Safeguarding Service Report was presented to the Quality Safety & Outcomes Committee: Adult Safeguarding – HS:

• Mental Capacity Act/Deprivation of Liberty Safeguards Coroners Process – death of a person under Deprivation of Liberty now to be informed to the Coroner.

• Serious Case Reviews/Domestic Homicide Reviews updates

were contained in the report.

• Care Homes – four remained suspended from admitting new residents. DA expressed concern about relatives/patients being made aware of the suspension. JL noted that any Continuing Healthcare patients would be assessed. HS added that a suspension was not advertised but neither was it concealed. Legal advice was being sought. MM was concerned about patients who had no family but was assured by SR that each patient in this situation would have representation allocated.

Children’s Safeguarding – EG:

• Provider compliance information for Quarter four would be provided in the next report.

• Serious Case Review Child N – this would be published in the

next couple of days and would probably attract significant media attention. A detailed report would be provided next quarter.

SR asked about possible training for Counter-Terrorism and Security Act re prevention of terrorism. HS responded that this was Home Office funded and there would be statutory training.

The Quality Safety & Outcomes Committee: Noted and approved the content of the document.

8. QUALITY STRATEGY– REPORT NO: QSOC 18-15 Page 7 of 10

231231

KL introduced the first draft of the Liverpool CCG Quality Strategy to the Quality Safety & Outcomes Committee. The purpose of having a specific strategy was to ensure that quality was embedded in the organisation. Page 2 of the Strategy contained a list of the people who had inputted into its drafting. Section 9 of the Strategy was about embedding quality in Liverpool via the governance structure, Governing Body, Quality Safety & Outcomes Committee, Risk Management, Audit Risk & Scrutiny Committee, Corporate Risk Register, Quality Surveillance Groups, Member Practices, Healthwatch, Safeguarding, Complaints, Equality, Serious Incidents and Never Events along with patient engagement and representation. There were different governance arrangements across all the different commissioning scenarios. Quality in Primary Care Services needed was to be added to the Risk Register. DA felt that this was a comprehensive document, however he felt that there was not enough on patient engagement and this was an excellent opportunity to give it a higher profile within the CCG. DOD commented:

• Efficiency was part of quality. • How did this link to NICE quality standards? • How did we know were aligned to the Quality Accounts

produced by our providers on an annual basis.

KC responded that the Quality Accounts were evaluated against a national toolkit and then priorities developed, this was not a health economy engagement session. CM added that member practices were engaged with via specific engagement sessions and that a Primary Care Strategy was being developed – this could be the appropriate place to link in to the Quality Strategy. JL agreed with this as the document was a CCG document, not specifically belonging to the Quality Team. FL highlighted potential boundary issues within the document as it used the Merseyrail plan but excluded areas in the city such as Kirkdale and Walton in the north of the city. She also asked who the audience was for the document. JL clarified that this was an internal document for the CCG to simplify how we worked together. FL felt that it needed to be shorter/simpler and reference Healthy Liverpool which underpinned everything. KL offered to prepare and Executive Summary to go at the end of the document. Further comments/feedback post meeting were welcomed.

Page 8 of 10

232232

The Quality Safety & Outcomes Committee: Noted the proposed draft content to date. Made recommendations on content. Considered consultation process for the strategy. Provided timeline on publication.

9. NURSING REVALIDATION AND REVISED CODE

(PROFESSIONAL STANDARDS AND BEHAVIOUR FOR NURSES AND MIDWIVES)– REPORT NO: QSOC 19-15

KL presented a paper to the Quality Safety & Outcomes Committee on the planned changes to the nursing revalidation process and the revised code of practice. A paper would be prepared for the next meeting of the Care Home Project Group with Liverpool City Council from KL. MG suggested learning from the GP revalidation process. JL noted that GPs were independent practitioners and Trust employed nurses had the benefit of a Human Resources Department, Practice Nurses however were in a different situation and this responsibility lay with the GP Practice as the employer. The Quality Team was liaising with Liverpool CCG Human Resources to plan and prepare internal staff for the changes. Work was led by Moira Cain, the Governing Body Practice Nurse member to ensure Primary Care had infrastructure in place to support this. There was concern that nurses coming up to retirement might look to retire earlier rather than go through the revalidation process.

The Quality Safety & Outcomes Committee: Noted the contents of the report. Requested updates as required.

10. SIGN UP TO SAFETY CAMPAIGN –REPORT NO: QSOC 20-15

Page 9 of 10

233233

KL presented a paper to the Quality Safety & Outcomes Committee on the proposal for Liverpool CCG to sign up to the national safety campaign ‘Sign Up to Safety’. The Quality Safety & Outcomes approved this approach to demonstrate a commitment to ensure that patient safety was integral to the commissioning process.

The Quality Safety & Outcomes Committee: Noted the attached pledge proposals (Appendix 1). Commented on the attached pledge proposals. Contributed further additions to the pledge proposals.

11. ANY OTHER BUSINESS

.

12. DATE AND TIME OF NEXT MEETING Tuesday 18th August 2015 – 3pm to 5pm

Page 10 of 10

234234

FINANCE PROCUREMENT AND CONTRACTING COMMITTEE TUESDAY 4 AUGUST 2015 1:30PM – 2:30PM

ROOM 2 ARTHOUSE SQUARE FINAL MINUTES

MEMBERS Nadim Fazlani (NF) Chair Tom Jackson (TJ) Chief Finance Officer Maureen Williams (MW) Lay Member – GB Member Dave Antrobus (DA) Lay Member – GB Member Maurice Smith (MS) GP – Governing Body Member In Attendance Kim McNaught (KM) Deputy Chief Finance Officer Tony Woods (TW) Programme Director – Community Services

and Digital Care Ian Davies (ID) Programme Director – Hospitals & Urgent

Care Phil Saha (PS) Head of Programme Finance Tim Caine (TC) Principal Analyst Lynne Hill (LH) PA/Minute Taker Apologies Katherine Sheerin (KS) Chief Officer Derek Rothwell (DR) Head of Contracts and Procurement Cheryl Mould (CM) Head of Primary Care Quality and

Improvement Jane Lunt (JL) Chief Nurse/Head of Quality Alison Ormrod (AO) Interim Head of Finance Tina Atkins (TA) Practice Manager-Governing Body member 1 Welcome and Introductions Introductions were made and all welcomed to the Committee. 2 Declarations of Interest There were no declarations of interest.

1

235235

3a Minutes from the previous meeting held on 23 June 2015 The minutes were agreed as a correct and accurate record of

the meeting held on 23 June 2015. 3b Action Notes of the previous meeting held on 23 June 2015 It was noted that actions for August have to be completed in time for presenting to the next Finance, Procurement and Contracting Committee on Tuesday 25 August 2015 10am – 12:30pm. 3b1 Contract Update St Helens and Knowsley TCl to be asked to present the data at the 25 August 2015 FPCC. 3b2 Neighbourhood Development Fund KM to check with PJ/JL if the TOR/JDs have been actioned. Action: KM to follow up with PJ/JL

3b3 Procurement Waivers ID/DR to present a paper to the FPCC on 25 August 2015. 3b4 Publishing Data A paper to be presented to the FPCC in December 2015. Action ID/DR/SH

3b5 Anti Coagulation Tariff Monitoring KM to follow up with TCl to confirm if the Contract Variation has been actioned. Action: KM to follow up with TCl and check if Contract

variation has been actioned. 3b6 Advice of Prescription Procurement It was noted that additional information was received via email by the FPCC members following the FPCC In June 2015.

2

236236

3b7 Termination of Pregnancy Services (TOPS) ID stated that this will take some time to resolve. It was agreed that there will be a requirement to discuss outside of the meeting and bring any suggestions to a future FPCC. Action: ID to discuss issues of TOPS with appropriate staff.

3b8 Finance and Contract Performance Update Month 02 DA queried the grant payment delays. KM had asked the team to review the reason for delays and the majority relate to lack of information provided by the organisations receiving the grants. Regular meetings have been established between the Finance Team and the Grants Team. Finance are taking ownership of a wider remit around the payments and this includes the monitoring of invoice submission with the individual organisations to minimise delays. DA mentioned the Register for Tradeship and if invoices can be processed via this. KM was not aware of this and agreed to investigate further. Action: KM to identify any potential use of Register of

Tradeship. 3b9 New HQ Building Update ID stated that the CCG has negotiated with NHS Property Services that LCCG can remain in Arthouse until end of November 2015. ID reported that NHS Property Services still taking issue on the dilapidation of the building. The work within the new building has commenced. The Escrow Account will be discussed at the Governing Body meeting. MW thought that there was an issue with the payment. Monies/costs will be invoiced against Hill Dickinson and LCCG will need to be recharged for the payments. KM raised concerns about the correct accounting treatment of these payments. It was agreed that a process will need to be developed to enable payments to be actioned in accordance with auditable financial processes. Action ID/KM to discuss outside of meeting to action.

3

237237

All other actions have been dealt with or are for future meetings.

4 Finance & Contract Performance Update (FPCC44-15) KM updated the Committee on the Finance and Contract Performance report and stated that as this is month 3 the data is limited however some useful information available for the Committee. The following was highlighted:

• On target to meet annual spending forecast • Underspent in a number of areas including contracts, however as it

is the first quarter there is no cause for concern or forecast issues. A review of the agreed investment programme is ongoing to identify phasing of expected spend. This work will be finished at the end of the month and will contribute to the future financial plan. DA queried the overspend of £50k on Child and Adolescent Mental Health Services (CAMHS). KM agreed that she will follow this up as it appears it could be an anomaly with the coding of expenditure and phasing of budget. Action: KM to check on the figures on CAMHS.

The Committee noted the Finance & Contract Performance

Update. 5 June 2015 KPI report (FPCC45-15) KM stated that the KPIs were continuing to demonstrate achievement of targets and highlighted that we are achieving all aspects of the Better Payment Practice Code (BPPC) targets. This supports the CCG’s intention to pay suppliers promptly and contributes to the social value strategy. DA queried if block contracts are paid in equal twelfths over the year. KM confirmed this unless there were in year contract variations.

4

238238

NF asked whether the Committee found the report useful. A discussion followed and it was agreed that if the KPIs are indicating a trend that is concerning then this should be reported and routine compliance should not be reported in detail. KM agreed to revise the report with a focus on exception reporting. Action: KM to action and feedback to the team on the

suggested changes to the KPI report. The Committee noted the KPI Report.

6 Contract Update Month 03 (FPCC 46-15) KM stated that the report is based on the first two months’ data and as such cannot be relied upon to indicate trends or forecasts. There are some areas of underperformance at this point but the indication is that the activity will be undertaken later in the year. The concerns over the over performance at St Helens & Knowsley Trust (StH&K) will be reported in detail at the next Committee. TC added that the month 3 activity figures had been received today and that the activity is reducing at StH&K. Action: Detailed StH&K activity trends and variance will be

presented to the next meeting. KM to discuss with DR. 7 Mental Health Clustering Issue (verbal update) TJ updated the Committee on the Mental Health Clustering issues. This is a national exercise that CCGs are working to resolve with Merseycare and involves a request for a different payment approach next year. It has thrown out a number of issues and currently teasing out cross subsidisation with Secure Commissioning and CCGs. In addition, there are disparities between the cost of services provided to Liverpool and South Sefton CCGs. South Sefton have stated that they want to operate differential unit pricing between the Liverpool and South Sefton contracts. Further discussions are ongoing with South Sefton and Mersey Care. This approach may lead to further issues with the contract negotiations for the next financial year.

5

239239

TW asked what approach has been adopted in other areas and Trusts. TJ stated that this is being considered as part of the contract discussions. TJ stated that the update is brought to the Committee so they are aware of the issues and discussions. TJ will to write to South Sefton CCG to formalise the concerns and intentions of LCCG. Action: TJ to write to South Sefton CCG regarding the Mersey

Care contract. The verbal update was noted by the Committee.

8 Information Governance Update Report (FPCC47-15) TW updated the Committee on the previous submission to the FPCC of the final Information Governance submission document in March 2015. The individual policies were not included in that submission, but are now presented here for completeness. TW highlighted the following:

• Our final declaration was a ‘satisfactory’ rating of 72% compliance, with attainment of at least level 2 compliance against all 28 requirements, with level 3 compliance declared against 5 of the requirements.

• The declaration represented an improvement on the 2013/14

declaration of 66%, with level 2 compliance declared across all requirements but no level 3 compliance. MIAA reviewed 8 key requirements and gave ‘significant’ assurance against level 2 attainment.

• TW was the Senior Information Risk Owner (SIRO) but this role will be passed to TJ following the appropriate handover. The Caldicott Guardian remains as Dr Simon Bowers.

• Policies and Procedures will need to be updated to show the new

SIRO and will require the governance team to review them in full to give a corporate view.

6

240240

Action: TJ/ID/ to progress the review of the policies with

the governance team.

• An information Sharing Agreement was signed at the ILinks Development Conference. LCCG have pushed the boundaries and are the only organisation to have undertaken this.

• MIAA have a contract arrangement to provide the IG support to the

CCG. This arrangement continues to be monitored and it is recommended that it is maintained.

• A further report will be provided to the FPCC in November 2015. This will include the current year’s toolkit. Action: TJ/TW to present IG Report and toolkit in

November 2015 MW acknowledged the significant amount of work involved in the preparation and maintenance of the IG Toolkit and expressed thanks to TW and teams involved. MW highlighted her concern that the FPCC are reviewing and adopting the policies but do not have the remit to sign off, as this will be the Governing Body. MW asked if they will have to go through the normal procedure which is HR Committee and/or Governing Body. ID stated that they are not specific HR policies and are general/technical policies and therefore are not required to go to HR Committee. MW reported that Staff Side may have an issue if they have not been consulted. ID suggested that the policies go through to Staff Side as a matter of courtesy to share, however they will be going to the October 2015 Governing Body for final approval. That Liverpool CCG Finance, Procurement and Contracting Committee:

• Noted the final declaration on CCG adherence to Information Governance Toolkit Standards

7

241241

• Noted the MIAA Information Governance Assurance Review Report and outcome of significant assurance

• Noted confirmation from the Health and Social Care Information Centre (HSCIC) of agreement of the CCG declaration

• Noted the key changes to management arrangements for 2015/16 and the ongoing improvement programme

• Recommend the Governing Body approve the Policies and Procedures Action: TW Information Governance Policies and

Procurement to be presented to the October 2015 Governing Body for ratification.

9 Any Other Business Professional Services Review MW stated that some time ago NHSE had issued guidance around the re-procurement of CCG external auditors who have to be in place by 2017 so the process should start next year. The guidance specified the establishment of a Recruitment Panel and specified various matters around conflicts of interest and independence. The guidance assumes most of the panel will be Audit Committee members although the Final Panel has to formally be approved by the Governing Body. MW suggested that this would be a useful opportunity, and good practice, to review all CCG Professional services since many have not been reviewed since PCT days. Such a review could include External Audit, Internal Audit, Legal Services, Pay Roll and any other services deemed appropriate to include. MW suggested that it should be the new independent panel who looks at all professional service providers and decides on how we progress to procurement. (Post minutes note – this Panel is essentially a task and finish group and will have no permanent existence MW). TJ supported reviewing all the professional services however he reminded the committee that the Panel will need to take into consideration any current contractual arrangements. ID stated that the current NHS Procurement Framework approach was used in respect of Legal Services and had been taken historically from

8

242242

Primary Care Trusts (PCT). Our current legal professional services are taken from that framework and that contracts do not exist for the professional legal services we currently have in place. The Committee agreed to the review and delegated it to the Audit Risk and Scrutiny Committee to process and return back to FPCC with its recommendations when completed. The Panel to be established would need to review the following professional services using the same panel (with the relevant officers involved where appropriate).

• Audit - Internal /External • Legal services • Payroll • Other areas to be considered within the work plan

Action: Review of current professional services/

contracts and provision of detail and commitments to Audit Committee Date to be confirmed(DR/ID/MW)

Action: Set up Audit selection / recruitment panel in accordance with NHSE Guidance and time for selection/recruitment of professional services before 2017 for Liverpool CCG (MW/TJ/DR)

Date and time of next meeting Tuesday, 25 August 2015 10am – 12:30pm – Room 2, Arthouse Square.

9

243243

244244

HEALTHY LIVERPOOL PROGRAMME

HOSPITAL BASED SERVICES

COMMITTEE(S) IN COMMON

KNOWSLEY, LIVERPOOL AND SOUTH SEFTON CCGS AND NHSE

WEDNESDAY 5 AUGUST 2015

PRESENT:

Nadim Fazlani Chair NHS Liverpool CCG Katherine Sheerin Chief Officer NHS Liverpool CCG Fiona Clark Chief Officer NHS Sefton CCG Tom Jackson Chief Finance Officer NHS Liverpool CCG Graham Morris Governing Body Member NHS Sefton CCG Donal O’Donoghue Secondary Care Doctor / Governing Body Member NHS Liverpool CCG Samih Kalakeche Director of Adult Services and Health Liverpool City Council Paul Brickwood Chief Finance Officer NHS Knowsley CCG Ian Davies Head of Operations & Corporate Performance NHS Liverpool CCG Carol Hughes PA / Minutes NHS Liverpool CCG

APOLOGIES:

Andy Pryce GP / Chair NHS Knowsley CCG Dianne Johnson Chief Officer NHS Knowsley CCG Ian Moncur Councillor Sefton Council

245245

1.0 1.1

Welcome, Introductions and apologies Chair welcomed all and introductions were made. Apologies were received as above.

2.0 2.1

3.0

3.1

Minutes & Actions of the Meeting held on the 6 May 2015 The minutes of the previous meeting were agreed as a true and accurate record subject to the following amendments:

• To include Ian Davies in attendee list • 6.1 to amend Technical Innovation to Digital Health 7.8 Mayor’s Health Summit: SK updated that the Mayor’s Health Summit scheduled for September had been moved and will now be held in November 2015. 8.0 RLBUHT Foundation Trust application KS advised that the FT application would now be submitted to Monitor in September 2015. Healthy Liverpool Programme Overview A presentation was provided by T Jackson who noted that the Healthy Liverpool Programme remains a whole system transformation programme with 5 main transformation workstreams and 6 commissioning based service improvement programmes which would contribute to transformation generally. The Clinical Directors for each programme area were confirmed:

• Community: Dr Janet Bliss • Urgent Care: Dr Fiona Lemmens • Digital : Dr Simon Bowers • RHBC : Dr Donal O’Donoghue • Living Well: Dr Maurice Smith T Jackson highlighted the Living Well key milestones:

• Business Case approved by Governing Body on the 14 July 2015 • Physical and Sport Executive Board established in May and meet every 6 – 8

weeks • All 5 sub-groups to be established by September • Engagement and insight work to commence in October • Promotion of family activities through Change for Life summer campaign launched

in partnership with PHE • Community Grants Scheme launched • Physical Activity to be included in the GP Spec for 2016/17. • Recruitment of new post to commence August. •

246246

T Jackson highlighted the strands and themes of both the Digital Care and Innovation and Community Workstreams and following discussion S Kalakeche requested that Children and Families should be included in the community services model. Dates of HLP engagement were provided with events being run to test principals and key themes with the public. It was noted that staff side engagement was a challenge about how to address staff within Liverpool. Staff side had attended the programme advisory board and further work is required for more involvement with staff. HLP is moving through the NHSE assurance process and they are comfortable with the pace and timelines. Next Steps: • September 2015 - Royal FT Outcome • September 2015 - Alder Hey opening • October 2015 - Outcome of appraisal for future form of LCH • November 2015 - Mayoral Summit • Nov 15 March 16 - Pre-consultation engagement programme • May 2016 - Mayoral election • June 2016 on - Formal public consultation on first phase S Kalakeche noted that Mayoral elections would be held in May and asked for other CCGs to consider building in Purdah. With regards to commitment it was highlighted that K Sheerin and N Fazlani would present to Trust Provider Boards during September and October 2015. A series of clinical assemblies will be arranged and a Provider Board established which would also include Trusts from Wirral, St Helens and Southport. S Kalakeche advised that there was a consensus to work together and move away from organisational structures to do something different and that the Local Authority should be included in the provider forum. In response, K Sheerin asked whether consideration should be given across the 3 CCGs about differences in community services e.g. for changes to hospital services what is dependent upon changes in the community which will interlink and how to make sure this adds up. Discussion took place which identified the difference across the 3 CCGs and LAs in relation to discharge planning and for the need to review community models across the 3 areas to understand variation, to agree an acceptable variation, to identify where consistency is required and to agree a consistent process.

247247

4.0 4.1

The impact in the changes to community services and hospital activity across the 3 areas should also be taken into account. Hospital Programme with feedback from the Clinical Assembly Dr O’Donoghue highlighted the following areas:

• An intention to build on the excellent learning events and clinical summit • Strong view of building system based uniformity and reliable standards with close

correlation of outcomes, locally where possible and centrally where it adds value. • Other areas discussed related to major trauma centre, cancer and relocation of

Clatterbridge and opportunities that brings, cardiology, LWH issues in terms of obstetrics, gynaecology and neonatal.

• Focus on delivery of best possible outcomes for patients Dr O’Donoghue noted that the above were all extremely positive to take to the mayoral summit and to continue to make progress and start engagement in terms of secondary care and primary community care and to build a clinical assembly event around that. I Davies noted that the key output on the day was a whole vision and strategy for hospital services and single service delivery, potentially with collaborative cardiology service for the whole of the city, areas of duplication and variation in outcomes were highlighted, all with different pressures. All providers highlighted problems with workforce and training. Recognition on the day was that this is a journey that requires some pace and that everything cannot be done at the same time, so consideration is needed about what needs to be done at pace in the short and medium term, with the timescale of 20 years for hospital transformation as opposed to the 5 years originally identified. Following much discussion K Sheerin asked whether we were at the point to commission work jointly with Knowsley and Sefton CCG. In response F Clarke noted that there is an assumption that because in hospital care is being provided by LCCG and is the same in other areas there is a danger in repetition of some work. Dr Fazlani commented that joint work could be done but discussion was required about what could be done jointly to avoid duplication of work and what can be jointly commissioned. Agreed that a paper would be produced jointly by K Sheerin, F Clarke and D Johnson about why we should more formally commission together, what should be commissioned and how.

248248

5.0 6.0 7.0 8.0

Update from NHS England (Specialised Commissioning) None given. Key Next Steps: Dr Fazlani highlighted the key points: to consider: 1. What footprint is chosen and work to be done together, e.g. 3 CCGs

commissioning from Liverpool providers and to agree how that could be done and the impact on providers. However, this doesn’t necessarily mean that we commission the same as long as threshold and standardisation remain the same.

2. What can be commissioned together from Liverpool providers and what that

means.

Action: to consider how to commission from Liverpool and accept broader problems for Knowsley.

K Sheerin advised that a paper will be presented to Trust Boards in September giving an outline of the Strategic Business Case. It was suggested that this should also be presented to Part 2 of CCG Governing Bodies. This was agreed. Action: K Sheerin/Dr Fazlani to also present to CCG Boards.

TJ to provide draft Outline agreement to be discussed at the September CIC meeting.

Any other business None discussed. Date of next meeting: 2 September 2015 – Same venue as CCG network.

249249

250250

TH SEPTEMBER 2015 AT 1PM BOARDROOM ARTHOUSE SQUARE …€¦ · Clare Duggan 2.5 Public Health...

Documents

Transcript of TH SEPTEMBER 2015 AT 1PM BOARDROOM ARTHOUSE SQUARE …€¦ · Clare Duggan 2.5 Public Health...