Voting Members - enfieldccg.nhs.ukBarnet, Camden, Enfield, Haringey and Islington CCGs Mr Andrew...
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NCL Joint Commissioning Committee 1 st February 2018 3-5pm Holbrook Committee Room, Enfield CCG, 116 Cockfosters Rd, Barnet EN4 0DR Voting Members Ms Karen Trew (Chair) Governing Body Vice Chair and Lay Member, Enfield CCG Dr Mo Abedi Governing Body Chair, Enfield CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG Dr Peter Christian Governing Body Chair, Haringey CCG Dr Matthew Clark Ms Bernadette Conroy Secondary Care Clinician, Camden CCG Governing Body Lay Member, Barnet CCG Ms Angela Dempsey Ms Kathy Elliott Nurse Representative Enfield CCG Governing Body Lay Member, Camden CCG Dr Debbie Frost Governing Body Chair, Barnet CCG Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Ms Catherine Herman Governing Body Non-Clinical Vice Chair and Lay Member, Haringey CCG Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden, Enfield, Haringey and Islington CCGs Dr Jo Sauvage Governing Body Chair, Islington CCG Ms Sharon Seber Nurse Representative Haringey CCG Non-Voting Members Cllr Jason Arthur Councillor, Haringey London Borough Council Cllr Janet Burgess Councillor, Islington London Borough Council Cllr Alev Cazimoglu Councillor, Enfield London Borough Council Dr Jeanelle De Gruchy Director of Public Health, Public Health Haringey Cllr Pat Callaghan Councillor, Camden London Borough Council Cllr Hugh Rayner Ms Sharon Grant Ms Parin Bahl Councillor, Barnet London Borough Council Healthwatch Haringey Healthwatch Enfield Attendees Professor Fares Haddad Clinical Lead for Adult Elective Orthopaedic Services, University College London Hospitals NHS Foundation Trust Mr Rob Hurd Chief Executive, Royal National Orthopaedic Hospital NHS Trust Mr Paul Sinden NCL Director of Performance and Acute Commissioning, Barnet, Camden, Enfield, Haringey and Islington CCGs Mr Andrew Spicer NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington CCGs Mr David Stout Senior Programme Director, NCL STP Apologies Minutes Ms Brenda Thomas Board Secretary, Enfield CCG AGENDA Lead Action Paper Time Page 1. Introduction 1.1 Welcome and Apologies for Absence Chair Note Verbal 15.00 1.2 Declaration of Interests Chair Note 1.2 15.02 4-7 1.3 Gifts and Hospitality Chair Note Verbal 15.05 1
Transcript of Voting Members - enfieldccg.nhs.ukBarnet, Camden, Enfield, Haringey and Islington CCGs Mr Andrew...
NCL Joint Commissioning Committee 1st February 2018 3-5pm Holbrook Committee Room, Enfield CCG, 116 Cockfosters Rd, Barnet EN4 0DR
Voting Members
Ms Karen Trew (Chair) Governing Body Vice Chair and Lay Member, Enfield CCG Dr Mo Abedi Governing Body Chair, Enfield CCG Ms Sorrel Brookes Governing Body Lay Member, Islington CCG Dr Peter Christian Governing Body Chair, Haringey CCG Dr Matthew Clark Ms Bernadette Conroy
Secondary Care Clinician, Camden CCG Governing Body Lay Member, Barnet CCG
Ms Angela Dempsey Ms Kathy Elliott
Nurse Representative Enfield CCG Governing Body Lay Member, Camden CCG
Dr Debbie Frost Governing Body Chair, Barnet CCG Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield,
Haringey and Islington CCGs Ms Catherine Herman Governing Body Non-Clinical Vice Chair and Lay Member,
Haringey CCG Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden, Enfield,
Haringey and Islington CCGs Dr Jo Sauvage Governing Body Chair, Islington CCG Ms Sharon Seber Nurse Representative Haringey CCG Non-Voting Members Cllr Jason Arthur Councillor, Haringey London Borough Council Cllr Janet Burgess Councillor, Islington London Borough Council Cllr Alev Cazimoglu Councillor, Enfield London Borough Council Dr Jeanelle De Gruchy Director of Public Health, Public Health Haringey Cllr Pat Callaghan Councillor, Camden London Borough Council Cllr Hugh Rayner Ms Sharon Grant Ms Parin Bahl
Councillor, Barnet London Borough Council Healthwatch Haringey Healthwatch Enfield
Attendees Professor Fares Haddad Clinical Lead for Adult Elective Orthopaedic Services,
University College London Hospitals NHS Foundation Trust Mr Rob Hurd Chief Executive, Royal National Orthopaedic Hospital NHS
Trust Mr Paul Sinden NCL Director of Performance and Acute Commissioning,
Barnet, Camden, Enfield, Haringey and Islington CCGs Mr Andrew Spicer NCL Head of Governance and Risk, Barnet, Camden,
Enfield, Haringey and Islington CCGs Mr David Stout Senior Programme Director, NCL STP Apologies Minutes Ms Brenda Thomas Board Secretary, Enfield CCG
AGENDA
Lead Action Paper Time Page
1. Introduction
1.1 Welcome and Apologies for Absence Chair Note Verbal 15.00 1.2 Declaration of Interests Chair Note 1.2 15.02 4-7 1.3 Gifts and Hospitality Chair Note Verbal 15.05
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1.4 Minutes of Committee Meeting on 7th December 2018
Chair Approve 1.4 15.06 8-16
1.5 Action Log Chair Note 1.5 15.10 17 1.6 Questions from Public
Chair Note Verbal 15.15
2. Governance
2.1 Chairing of the NCL Joint Commissioning Committee and Terms of Reference
Chair Approve 2.1 15.20 18-20
3. Activity and Performance
3.1 Acute Commissioning Report Paul Sinden Note 3.1
15.25 21-67
3.2
Transforming Care Programme Update
Kath McClinton
Note
3.2
15.50
68-90
4. Commissioning
4.1 Planning for 2018-19 Paul Sinden Note 4.1 (Paper to Follow)
16.00
4.2 Adult Elective Orthopaedic Services: Achieving the Best Value for Patients
Fares Haddad/Rob Hurd
Approve 4.2 16.10 91-101
5. Risk
5.1 NCL Joint Commissioning Committee Risk Register
Paul Sinden Discuss 5.1 16.15 102-112
6. Questions from Public
6.1 Question and Answer Session
Chair Discuss Verbal 16.20
7. Any Other Business
7.1 Forward Planner 2017/18
Chair Discuss 6.1 16.25 113
7.2 Deadline for submission of reports for the next meeting- Monday 26th March 2018
Chair Note Verbal 16.30
8. Dates of Next and Future Meetings:
Thursday 5th April 2018;
Thursday 7th June 2018;
Thursday 2nd August 2018;
Thursday 4th October 2018;
Thursday 6th December 2018;
Thursday 7th February 2019.
9. Part 2 Meeting
9.1 To resolve that as publicity on items contained in Part 2 of the agenda would be prejudicial to public interest by reason of their confidential nature, representatives of the press and members of the public should be excluded from the remainder of the meeting. Section 1 (2) Public Bodies (Admission to meetings) Act 1960.
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NOTES
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Voting Members
NAME TITLE NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED
East Enfield Medical Practice - GP Practice GP Principal 27/06/2017 27/06/2017
Evergreen Surgery Limited - GP Practice Director and Shareholder 27/06/2017 27/06/2017
Brick Lane Surgery GP Principal
Wife also a GP Principal
27/06/2017 27/06/2017
Medicare Medical services LLP - Runs walk in centre at Evergreen
and South East Locality access hub
Director and Shareholder 27/06/2017 27/06/2017
DM786 Limited Property management
Company
Director, Wife is a Director, Mother and children are shareholders 27/06/2017 27/06/2017
DM786 Health Ltd Health Consultancy (not actively trading) Director, Wife is a Director, Mother and children are shareholders 27/06/2017 27/06/2017
Prime Point Limited Primary care medical services provider (not
actively trading)
Director/Shareholder 27/06/2017 27/06/2017
Enfield Health Partnership Limited, Provider of community
gynaecology service
Shareholder 27/06/2017 27/06/2017
Enfield Healthcare Alliance Limited –runs Chalfont Road and
Boundary Court GP Practices
Shareholder 27/06/2017 27/06/2017
Southbury GP Surgery Wife is a salaried GP 27/06/2017 27/06/2017
South East Locality access hub Wife is a locum GP 27/06/2017 27/06/2017
Carlton House Surgery GP Partner 27/06/2017 27/06/2017
Help On Your Doorstep Trustee 07/07/2017 07/07/2017
East London Music Group Trustee 07/07/2017 07/07/2017
Lewisham and Greenwich NHS Trust Paediatric Registrar
05/10/2017 26/10/2017
Welbodi Partnership - registered UK Charity Board Member05/10/2017 26/10/2017
Kings College London
Wife is a research fellow which is funded by the NHS National
Institute of Health Research and Tommy's Charitable Trust
05/10/2017 26/10/2017
University of Cambridge Idependent Chair of the Building and Estates Committee 27/06/2017 27/06/2017
North London NHS Estates Partnership Non-executive director 27/06/2017 27/06/2017
Community Health Partnership Non-executive director 27/06/2017 27/06/2017
Bancrofts School Governor 27/06/2017 27/06/2017
St Paul’s Way Trust School Trustee 27/06/2017 27/06/2017
Network Homes Chair 27/06/2017 27/06/2017
Hadley Wood Association Trustee 27/06/2017 27/06/2017
Royal Free London NHS Foundation Trust Hospital Husband is consultant anaesthetist and Clinical Director 27/06/2017 27/06/2017
Agenda Item: 1.2
Lay Member, Barnet CCG Governing BodyMs Bernadette Conroy
Chair, Enfield Clinical Commissioning GroupDr Mo Adebi
BARNET, CAMDEN, ENFIELD, HARINGEY AND ISLINGTON CLINICAL COMMISSIONING GROUPS:
NCL JOINT COMMISSIONING COMMITTEE REGISTER OF INTERESTS
Secondary Care Doctor, Camden CCG
Governing Body
Dr Matthew Clark
Ms Sorrel Brookes Lay Member, Islington CCG Governing Body
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Muswell Hill Practice GP Partner 27/06/2017 27/06/2017
Federated4Health, the pan-Haringey GP federation Muswell Hill Practice is a member and Practice Manager at Muswell
Hill Practice is Chair
27/06/2017 27/06/2017
WISH- urgent care provider at Whittington Hospital Muswell Hill Practice is a member 27/06/2017 27/06/2017
Muswell Hill Practice Practice provides anticoagulant care to Haringey residents under a
contract with Haringey CCG.
27/06/2017 27/06/2017
The Hospital Saturday Fund - a charity which gives money to health
related issues.
Member and wife is a Patron 27/06/2017 27/06/2017
The Lost Chord Charity - organises interactive musical sessions for
people with dementia in residential homes.
Wife is a patron 27/06/2017 27/06/2017
Haringey Health Connected, the federation of west Haringey GP
practices
The Practice Manager at Muswell Hill Practice is the Finance Director 27/06/2017 27/06/2017
Salmons Brook residents Edmonton Non-Executive Director 05/10/2017 26/10/2017
RSM UK Consulting- RSM are the internal auditors for Barnet,
Camden, Enfield, Haringey and Islington CCGs
Associate Director 05/10/2017 26/10/2017
Lyndsey Lee Foundation Trustee 05/10/2017 26/10/2017
Camden Patient and Public Engagement Group Member 27/06/2017 27/06/2017
Caversham Group Practice- Patient Participation Group Member 27/06/2017 27/06/2017
Kaeconsulting - independent consultancy Owner/Director 27/06/2017 27/06/2017
UK Public Health Register (UKPHR) Assessor and Chair of the Registration Panel 27/06/2017 27/06/2017
Faculty of Public Health Member 27/06/2017 27/06/2017
PHAST - public health consultancy Associate 27/06/2017 27/06/2017
Millway Practice GP Partner 27/06/2017 27/06/2017
Barndoc Healthcare Ltd GP Partner colleague at Millway Practice is the Chair of Barndoc
Healthcare Ltd
27/06/2017 27/06/2017
GP Partner is a member of the Pan Barnet Federated GPs Network
Board.
GP Partner colleague at Millway Practice is a member of the Pan
Barnet Federated GPs Network Board
27/06/2017 27/06/2017
Mid-West GP Federation Member 27/06/2017 27/06/2017
KPMG Son is a graduate trainee with the KPMG Banking Sector 27/06/2017 27/06/2017
Chief Financial Officer for the 5 CCGs in North Central London
(Barnet, Enfield, Haringey, Islington and Camden)
Chief Finance Officer for the five CCGs 14/06/2017 03/08/2017
East London NHS Foundation Trust Wife is a senior manager 14/06/2017 03/08/2017
Dr Neel Gupta Chair, Camden Clinical Commissioning
Group
The Keats Group Practice Salaried GP, no other interests declared. 27/06/2017 27/06/2017
Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden,
Enfield, Haringey and Islington Clinical
Commissioning Groups
No interests declared No interests declared No interests declared 27/06/2017
Bloomsbury Surgery GP Partner 13/06/2017 13/06/2017
Haverstock Healthcare Limited GP Practice is a shareholder 13/06/2017 13/06/2017
Central Health Evolution Limited GP practice is a member 13/06/2017 13/06/2017
Camden Clinical Assessment Service ('CCAS') Assessor Provde 2-4 sessions per month 13/06/2017 13/06/2017
City Road Medical Centre GP Partner 27/06/2017 27/06/2017
Islington GP Federation City Road Medical Centre is a member practice 27/06/2017 27/06/2017
Health Education North Central and East London Non-executive Board Member 27/06/2017 27/06/2017
Ms Kathy Elliott Lay Member, Camden CCG Governing Body
Dr Peter Christian Chair, Haringey Clinical Commissioning
Group
Nurse Member, Enfield CCG Governing BodyMs Angela Dempsey
Dr Debbie Frost Chair, Barnet Clinical Commissioning Group
Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden,
Enfield, Haringey and Islington Clinical
Commissioning Groups
Dr Josephine Sauvage Chair, Islington Clinical Commissioning
Group
Clincial Vice Chair, Camden CCG Governing
Body
Dr Kevin Ritchie
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South Islington GP Alliance ('SIGPAL') City Road Medical Centre purchased shares to support the
development of SIGPAL. The shares are held as a joint asset by the
practice and not by individual partners
27/06/2017 27/06/2017
Ms Sharon Seber Primary Care Health Professional Member,
South East, Haringey CCG Governing Body
JS Medical Practice Employee- Advanced Nurse Practitioner 05/10/2017 26/10/2017
Ravenscroft Medical Centre GP Partner 28/07/2017 28/07/2017
South Locality Barnet Practices Network Limited Director 28/07/2017 28/07/2017
Royal Free London NHS Foundation Trust Hospital Wife is a specialist in haemophilia at Royal Free Hospital. 28/07/2017 28/07/2017
NHSE Performer List Decision Panel (outside of North Central
London)
Chair of Panels 27/06/2017 27/06/2017
Broxbourne School Hertfordshire Chair of the Governing Body 27/06/2017 27/06/2017
Wormley C of E Primary School, Hertfordshire Chair of the Governing Body 27/06/2017 27/06/2017
North East London ('NEL') CCGs 111 Procurement Chair and non-scoring panel member (providing assurance to NEL
CCGs on process)
27/06/2017 27/06/2017
Lloyds Pharmacy Clinical Homecare Son employed in operational role 27/06/2017 27/06/2017
Non Voting Members
NAME NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED
Step Up To Serve Health and Social Care Campaign Manager 26/10/2017 26/10/2017
Royal College of Obstetricians and Gynaecologists
Spouse is Methodologist/Audit Lead - National Maternity and
Perinatal Audit 26/10/2017 26/10/2017
Fabian Society Member
Unison Member
Haringey Council Cabinet Member for Finance and Health 26/10/2017 26/10/2017
Islington Council Executive Member for Health & Social Care & Deputy Leader of the
Council
26/10/2017 26/10/2017
The Advisory Group For The Friendship Network, Manor Garden
Welfare Trust
Member 26/10/2017 26/10/2017
Unite Member 26/10/2017 26/10/2017
Whittington Park Community Centre Trustee 26/10/2017 26/10/2017
Cabinet member for Tackling Health Inequality and Promoting
Independence
Councillor, Camden Borough Council
05/10/2017 26/10/2017
St Michael's Primary School Governor of St Michael's Primary School 05/10/2017 26/10/2017
Unison Union Member 05/10/2017 26/10/2017
Enfield Council Cabinet Member for Health & Social Care 26/10/2017 26/10/2017
Office of Joan Ryan MP Case Worker (Part time) 26/10/2017 26/10/2017
Imaginist Co LTD Director 26/10/2017 26/10/2017
Barnet Council Deputy Mayor 26/10/2017 26/10/2017
Mill Hill Preservation Society Member 26/10/2017 26/10/2017
Conservative Councillors Association Member 26/10/2017 26/10/2017
Mill Hill Neighbourhood Forum Committee Member 26/10/2017 26/10/2017
Friends of Mill Hill Park Committee Member 26/10/2017 26/10/2017
Copthall Community Sports Group Committee Member 26/10/2017 26/10/2017
Hale Association Member 26/10/2017 26/10/2017
Bernie Grant Arts Centre Partnership Limited Director 12/07/2017 12/07/2017
Bernie Grant Trust Trustee 12/07/2017 12/07/2017
Public Voice Community Interest Company Chair 12/07/2017 12/07/2017
Haringey Citizen's Advice Bureau Member 12/07/2017 12/07/2017
Foods Standards Agency- Food Hygeine Regulation Scheme sub-
committee
Member 12/07/2017 12/07/2017
Metropolitan Police independent advisory committee Haringey Member 12/07/2017 12/07/2017
Unite Trade Union Member 12/07/2017 12/07/2017
Ms Karen Trew
Clincial Vice Chair, Barnet CCG Governing
Body
Dr Barry Subel
Dr Josephine Sauvage Chair, Islington Clinical Commissioning
Group
Lay Member and Vice Chair, Enfield CCG
Governing Body
Councillor Jason Arthur Councillor, Haringey Council
Councillor Patricia Callaghan Councillor, Camden Council
Councillor Val Duschinsky Councillor, Barnet Council
Chair, Healthwatch HaringeyMs Sharon Grant OBE
Councillor Alev Cazimoglu Councillor, Enfield Council
Councillor, Islington CouncilCouncillor Janet Burgess MBE
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Occasional research, unremunerated, on NHS Wales & other patient
voice issues for a Labour MP Researcher
12/07/2017 12/07/2017
Dr Jeanelle De Gruchy Director of Public Health, London Borough of
Haringey
National Association of Directors of Public Health Vice President 27/06/2017 27/06/2017
S H Housing Ltd Director 26/10/2017 26/10/2017
Homehurst Residents Co Ltd Director 26/10/2017 26/10/2017
Atkinsons Alms House Trustee 26/10/2017 26/10/2017
Fairway School Governor 26/10/2017 26/10/2017
Deansbrook Infant School Council Representative 26/10/2017 26/10/2017
Reserve and Cadets Association to greater London Council Representative 26/10/2017 26/10/2017
Samuel Atkinson's Trust Trustee 26/10/2017 26/10/2017
Mill Hill Preservation Society Member 26/10/2017 26/10/2017
Civilian Committee of 1374 sqn ATC Chairman 26/10/2017 26/10/2017
RAFA Hendon and District President 26/10/2017 26/10/2017
Attendees
NAME NAME OF ORGANISATION AND NATURE OF ITS BUSINESS POSITION HELD / NATURE OF INTEREST DATE DECLARED DATE UPDATED
Mr Will Huxter NCL Director of Strategy No interests declared No interests declared 31/07/2017 01/09/2017
Mr Ian Porter Director of Corporate Services, Camden CCG No interests declared No interests declared 27/06/2017 27/06/2017
Mr Paul Sinden NCL Director of Performance and Acute
Commissioning, Barnet, Camden, Enfield,
Haringey and Islington Clinical
Commissioning Groups
No interests declared No interests declared 27/06/2017 27/06/2017
Mr Andrew Spicer NCL Head of Governance and Risk, Barnet,
Camden, Enfield, Haringey and Islington
Clinical Commissioning Groups
WEL CCGs Brother is Director of Commissioning (Transformation) 27/06/2017 27/06/2017
Councillor Hugh Rayner Councillor, Barnet Council
Chair, Healthwatch HaringeyMs Sharon Grant OBE
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NORTH CENTRAL LONDON (‘NCL’) JOINT COMMISSIONING COMMITEE Minutes of the meeting held in public on Thursday 7 December 2017, 15:00-17:00
Somers Town Living Centre, 2 Ossulston St, Kings Cross, London NW1 1DF. Present: Voting Members
Ms Karen Trew (Chair) Governing Body Vice Chair and Lay Member, Enfield CCG
Dr Mo Abedi Governing Body Chair, Enfield CCG (until Item 4.4)
Ms Sorrel Brookes Governing Body Lay Member, Islington CCG
Dr Peter Christian Governing Body Chair, Haringey CCG
Dr Matthew Clark Secondary Care Clinician, Camden CCG Ms Bernadette Conroy Governing Body Lay Member, Barnet CCG
Ms Angela Dempsey Nurse Representative, Enfield CCG
Ms Kathy Elliott Governing Body Vice Chair and Lay Member, Camden CCG
Dr Debbie Frost Governing Body Chair, Barnet CCG
Dr Neel Gupta Governing Body Chair, Camden CCG Ms Catherine Herman Governing Body Non-Clinical Vice Chair and Lay Member,
Haringey CCG
Dr Jo Sauvage Governing Body Chair, Islington CCG
Ms Sharon Seber Practice Nurse Member, Haringey CCG
Non-Voting Members
Ms Parin Bahl Chair, Healthwatch Enfield
Ms Sharon Grant Chair, Healthwatch Haringey
Dr Jeanelle De Gruchy Director of Public Health, Haringey London Borough Council
Cllr Hugh Rayner Councillor, Barnet London Borough Council
In attendance
Mr Will Huxter Director of Strategy, North Central London CCGs Mr Paul Sinden NCL Director of Performance and Acute Commissioning,
Barnet, Camden, Enfield, Haringey and Islington CCGs
Mr Andrew Spicer NCL Head of Governance and Risk, Barnet, Camden, Enfield, Haringey and Islington CCGs
Observers: Mr John Wardell Chief Operating Officer, Enfield CCG Ms Helen Boswell Assistant Director Performance Management, NELCSU Apologies:
Cllr Jason Arthur Councillor, Haringey London Borough Council
Cllr Janet Burgess Councillor, Islington London Borough Council
Cllr Pat Callahan Councillor, Camden London Borough Council Cllr Alev Cazimoglu Councillor, Enfield London Borough Council Mr Simon Goodwin NCL Chief Finance Officer, Barnet, Camden, Enfield,
Haringey and Islington CCGs
Ms Helen Pettersen NCL Accountable Officer, Barnet, Camden, Enfield,
Haringey and Islington CCGs
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Minutes: Ms Carolyn Cullen Interim Board Secretary, Camden CCG
1 Introduction
1.1 Apologies for Absence
1.1.1 Apologies had been received from Councillors Jason Arthur, Janet Burgess, Pat Callaghan and Alev Cazimoglu. Apologies were also received from Simon Goodwin and Helen Petersen with Will Huxter, Director of Strategy North Central London CCGs, deputising for the latter.
1.2 Declarations of Interest
1.2.1 Attendees were asked to review the declarations of interest register ahead of Committee meetings and to declare if they believed they were conflicted for any items on the agenda. There were no additional interests declared.
1.3 Gifts and Hospitality Register
1.3.1 Kathy Elliott declared she had been hosted on the UCLH table at the Health Service Journal Awards; the value was estimated at under £25. There were no other declarations of gifts and hospitality.
1.4 Opening Remarks
1.4.1 The Chair welcomed everyone to the meeting; and introductions were made.
1.5 Questions from the public 1.5.1 There were no questions from the public.
2 Governance
2.1 Minutes of the Committee meeting on 5 October 2017 2.1.1 The minutes were approved as an accurate record. 2.2 Notes from the Seminar held on 2 November 2017 2.2.1 The notes of the seminar were approved as an accurate record. 2.3 Action log 2.3.1 It was agreed to close all completed actions: The following updates on open actions
were given: Item 8: Acute Commissioning Report format – further comments to be given when considering this item on the agenda.
3 Activity and Performance
3.1 Acute Commissioning Report 3.1.1
An executive summary for the acute commissioning report was provided for the December 2017 Committee setting out:
The performance challenges in delivering the NHS Constitution targets for A&E, Cancer 62-day waits, and referral-to-treatment. All Trusts, with the exception of
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Whittington Health were falling behind improvement trajectories to deliver the A&E four hour wait target. In September 2017 78.5% compliance with the 62-day cancer wait was achieved across NCL, an improvement from August but below the 85% standard with the deficit against the standard primarily accruing from waiting list backlogs at UCLH and Royal Free London. Royal Free London and UCLH did not meet the RTT standard in September; overall NCL RTT performance continued to deteriorate;
Activity trends from 2016/17 to 2017/18 across NCL showed growth of less than 1% for the year-to-date. The trend was within the 3% growth assumption built into provider contracts for 2017/18 before the impact of Sustainability and Transformation Plan (STP) interventions;
Cost increases on acute contracts were in excess of activity trends reflecting a combination of increasing case-mix complexity, providers catching up on under-recording of activity from prior years particularly at Royal Free London, and the inflationary pressure from payment-by-results based contracts through counting and coding changes;
From the above, the need to realign system incentives to support delivery of the Sustainability and Transformation Plan (STP) priorities and focus on cost reduction was required.
3.1.2
Responses from the Committee to the Executive Summary were:
Matthew Clark indicated that further evidence was required to support acute provider assertions that acuity levels and complexity of case mix had risen. Jo Sauvage informed the meeting that the Kings Fund was currently analysing acuity levels and if NCL went ahead with a clinical audit then Kings Fund acuity classifications could be used. Acuity measures would subsequently be discussed at the North Central London (NCL) Sustainability and Transformation Plan (STP) Health and Care Cabinet;
Debbie Frost asked for further evidence of under recording of activity in prior years at Royal Free London. Paul Sinden stated that this was being determined through the contract reconciliation process;
Debbie Frost asked if the referral-to-treatment (RTT) patient numbers shown for the Royal Free London on page 25 were accurate; Paul Sinden stated clarity would be provided in the next report to the Committee;
Angela Dempsey stated that the frequency of outpatient follow-ups was lengthening; and asked how the outcomes from clinics are assessed; Paul Sinden replied that this is being reviewed by the STP Finance Group and through Contract Quality Review Groups;
Debbie Frost stated that patient transport at the Royal Free London was free to patients and paid for by the CCG; and asked if this is a consistent position across NCL. Paul Sinden indicated that it was and that patient transport will be addressed in 2018/19 commissioning.
3.1.3 3.1.4 3.1.5
Paul Sinden gave an update on the main quality and performance issues, and mitigating actions being undertaken, in acute contracts. Cancer 62 day standard: Recovery plans from Royal Free London and UCLH anticipated recovery of the waiting time standard in November 2017 and March 2018 respectively. Reductions in waiting list backlogs at both Trusts were consistent with respective recovery plans. This meant that recovery of the standard in NCL had fallen behind the original assumption of September 2017. The report included metrics on inter-provider transfers, as requested by the Committee on October 2017, to show whether waiting time breaches accrued from internal pathways and/or inter-provider transfers. A&E: All Trusts, with the exception of Whittington Health were failing to achieve their Sustainability and Transformation Fund (STF) A&E improvement trajectories. The
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3.1.6
impact on patient experience continued to be monitored, with particular focus on mental health pathways. Emergency Departments with the most fragile performance were North Middlesex University Hospital, Royal Free Hampstead and Barnet Hospital and all were subject to system escalation meetings with NHS England and NHS Improvement, as well as additional assurance for winter plans including contingency plans for peaks in pressure. All A&E Delivery Boards had been asked to submit additional winter plans with potential for additional funds to be received for schemes prioritised by NHS England and NHS Improvement. Referral to Treatment (RTT): Referral-to-treatment (RTT) performance continued to deteriorate, with both Royal Free London and UCLH not meeting the standard in September 2017. Both providers had submitted recovery plans with UCLH indicating recovery of the standard by February 2018 and Royal Free London by August 2018 (the latter trajectory had not been accepted by commissioners and was subject to further review). CCGs continued to work with providers to consider patients with the longest waits, with CCGs seeking to confirm from Trusts treatment dates or plans for patients on pathways waiting for 45 weeks and over, and receive from Trusts Clinical Harm Reviews for all those who breach 52 weeks.
3.1.7 Responses from the Committee focussed on the North Middlesex University Hospital (NMUH) recovery plan for A&E and in particular responses to a stocktake exercise in September 2017 for system leaders to discuss quality and safety issues, following which a letter of concern was issued by NHS England and NHS Improvement and the senior team at the Trust strengthened through the appointment of a new Chief Executive and Medical Director. Following the results of a recent survey of Junior Doctors, the new Medical Director at NMUH had undertaken an immediate review of supervision in A&E and remedial actions had been put in place to address the concerns of the Junior Doctors.
Mo Adebe welcomed the appointment of the new Medical Director and the focus on addressing the concerns on supervision raised by the Junior Doctors;
Sharon Grant asked if the NMUH recovery plan adequately addressed the issue of staff shortages, and how the system was alert to this;
Parin Bahl asked for clarification as to how patients, Healthwatch and commissioners would be kept informed on whether the action plan was delivering the required improvement;
Jo Sauvage stated that there had been multiple interventions at NMUH and what was needed now was a review of the workforce, its skills and capacity, which could be done by an independent agency for example Health Education England;
It was agreed that there would be a further update on progress with deliver the NMUH recovery plan at the February meeting.
3.1.8 3.1.9 3.1.10
Action: Paul Sinden to update the Committee in February 2018 on progress with implementing the recovery plan by North Middlesex University Hospital (NMUH). The Committee received an overview of new national Ambulance Response Programme (ARP) introduced in October 2017 after being piloted in the north of England. The new programme focussed on identifying the sickest patients to enable them to receive the fastest response and giving control room staff more time to assess incidents. Initial performance data indicated that London Ambulance Service (LAS) was meeting the new performance standards. Ambulance handover times to local emergency departments remained longer than the 15-minute target, with only 25% of ambulance arrivals dealt with at Royal Free Hampstead within 15 minutes. Action plans to improve handover were being monitored by A&E Delivery Boards. The Vehicle Tethering pilot run by London Ambulance Service had now concluded,
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with the intention that the programme would reduce incidences of ambulance moving across boundaries. Early reports indicated tethering worked well to reduce response times whilst hospital flow was good, but when flow became challenged by lengthy waits at hospitals and increased demand, then tethering could become counter-productive to response times.
3.1.11 Patient Experience. Friends and Family Test (FFT) responses received a low
positive response rate at North Middlesex University Hospital for outpatient appointments, maternity and A&E attendances relative to other providers in North Central London and across London.
3.1.12 3.1.13 3.1.14
The Committee made the following questions and comments on the updates for London Ambulance Service and patient experience:
Parin Bahl drew attention to the poor patient experience at NMUH outpatient department and asked whether the action plan to improve outpatient experience was delivering improvements;
Parin Bahl asked whether the revised response time categories in the new Ambulance Response Programme (ARP) had been communicated to the public. The Chair stated that this should be communicated in a consistent way across NCL and London and this would be picked up at the LAS Strategic Commissioning Board by Paul Sinden;
Following the Committee discussion the Chair asked Paul Sinden to allocate more time for the acute commissioning report at future meetings and that the report is further developed to have a greater quality as well as performance focus.
Contract performance – The Committee was asked to note the finance and activity position for acute contracts as at month 7. NCL CCGs had reported overall year-to-date acute over performance of £13.4m and a forecast outturn over performance of £17.4m. The forecast for the year-end took into account individual CCG adjustments for the impact of STP interventions later in the year and the impact of marginal rates, with the impact of the latter being a £7.4m reduction in forecast outturn. The underlying year-end over performance in acute providers on a full payment-by-results tariff would therefore be £24.8m at month seven. Quarter One reconciliation process. Quarterly reconciliations were carried out to align commissioner and provider assumptions on performance against contracts. Quarter one reconciliations were agreed with North Middlesex University Hospital, UCLH and Whittington Health in mid-October 2017. The reconciliation with Royal Free London has been more complex to resolve, resolution on the final items (patient transport service cost pressures, the application of productivity metrics to the contract, and counting and coding changes was reached in late November as indicated in the papers. Subsequently the Trust has indicated an additional £2m pressure on patient transport services for 2017/18. Commissioners have not recognised this increase in the reported cost pressure (month 7 reports are not consistent with the reported £2m increase in pressure).
3.1.15 The Committee noted the report
3.2 Learning Disabilities – Transforming Care Programme 3.2.1
Paul Sinden gave an overview of the programme that aimed to reduce the number of hospital beds commissioned for patients from North Central London with a learning disability and/or autism by the end of March 2019 to 48 from a baseline of 81. To do this patients were being transferred from both CCG and specialist commissioning funded placements into community care packages funded by CCGs and local authorities. Paul Sinden drew attention to the significant financial risk that this programme represents.
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3.2.2 3.2.3 3.2.4 3.2.5
The report to the December 2017 Committee provided an update on financial modelling to assess the local impact for both the NHS and Social Care on the repatriation of care from inpatient settings into the community. The modelling had been developed to incorporate an assessment of new individuals entering the programme (previous costings were based solely on people in the current cohort). The paper made recommendations on the cohort of patients that would attract a funding transfer from CCGs to Local Authorities for CCG funded placements on discharge with effect from 1 April 2017. This followed on from the Committee agreeing in principle in October 2017 that monies released from CCG funded placements, as individuals were moved into the community, would be recycled to cover the costs of packages of care across the CCGs and Social Care. The funding transfer agreement from NHS England to cover the costs of community packages of care for people transferred from specialist commissioning placements had yet to be resolved. In October 2017 the Committee agreed that a letter be sent on its behalf to NHS England requiring resolution of the funding transfer, following this NHS England subsequently made a proposal for a limited transfer of funds, but this had been collectively rejected by all the Transforming Care Programmes in London. The cost pressure based on the funding transfer proposal from NHS England results in a £3.3m cost pressure to NCL. This increased by £1.7m to £5.1m when taking into account new patients entering the Transforming Care cohort.
3.2.6 The Committee then responded to the update:
Sharon Seber asked why the transfer to the community from hospital beds was not significantly reducing unit costs; Paul Sinden stated that the transfers into the community related to the most complex patients, and this was exacerbated in the short-term by stranded fixed costs in inpatient settings. Community provision was expected to deliver better experience for the individuals;
Kathy Elliot asked that the implications for each CCG be provided. Paul Sinden agreed to provide this information in the next update report;
Hugh Raynor asked for clarity that local services had already absorbed £1.4m from transfers of care in 2016/17. Paul Sinden confirmed this was the case but representation to NHS England for the supporting funding transfer continued to be made;
Angela Dempsey informed the Committee that the Chief Nurse of England had congratulated Enfield on the quality of services provided to this client group.
3.2.7 The Committee approved the principles set out in the report in relation to funding transfers from CCGs to local authorities for transfers of care from CCG funded placements into the community.
Action:
Paul Sinden to provide an update on progress on reducing the number of inpatient beds by Borough/CCG, and progress on the funding transfer agreement between NHS England and the CCGs to support transfers of care.
4 Commissioning
4.1 Planning for 2018/19 4.1.1 Paul Sinden provided an overview of the local planning process for 2018/19
developed for North Central London in lieu of formal guidance from NHS England/NHS Improvement for the coming year. Progress to date included:
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Systems intentions for 2018/19 shared with providers on 29 September 2017;
Resolution of the quarter one position for 2017/18 with providers by mid-October with the exception of the Royal Free London;
Opening contract baselines for 2018/19 issued to providers by 31 October 2017 with the exception of the Royal Free London which was deferred until resolution of the quarter one position for 2017/18;
Work was underway to agree planning principles for growth and STP/local QIPP interventions that would be applied to contract baselines. Contract baselines for 2017/18 factored in 3% growth offset by 3% deductions for STP / local QIPP interventions built into 2017. Baselines for 2018/19 would be influenced by activity trends in 2017/18 indicating that growth was within 1% compared to the previous year, and the impact of interventions would be a minimum reduction of 3% on hospital activity;
Contract baselines for 2018/19 were originally targeted for completion by 20 December 2017, but this had been deferred to the end of January 2018 to allow further time to agree planning principles (see above);
Baselines, once agreed, would be incorporated into the two-year contracts signed in December 2016 through a contract variation. There would be an opportunity for a further contract variation in March 2018, if end of year outturn for 2017/18 materially differed from the forecast made in December 2017 replicating the process used for agreeing 2017/18 contract baselines.
4.1.2 The following questions and comments were made by the Committee in response:
Kathy Elliot asked how the growth assumptions had been determined. Paul Sinden indicated that the 3% assumption for 2017/18 had been agreed with providers through STP finance meetings, and the 1% for 2018/19 was based on emerging activity trends;
Neel Gupta indicated that given growth trends in 2017/18 and the development of STP and local QIPP plans for 2018/19 that the ambition for acute hospital contracts should be a minimum of a 2% reduction from forecast outturn in 2017/18;
Matthew Clarke asked whether it was agreed with providers to move away from payment-by-results (PbR) contract form in 2019/20. Paul Sinden responded that work was underway on alternative contract forms with providers with the aim to shadow run in 2018/19, but with no guarantee of adoption in 2019/20;
Paul Sinden agreed to provide a further update to the February 2018 Committee in particular for any planning guidance published by NHS England and NHS Improvement.
4.1.3 The Committee noted the progress on the planning process for 2018/19.
4.2 Update on Procedures of Limited Clinical Effectiveness (PoLCE) 4.2.1 Jo Sauvage updated the Committee on progress against the four workstreams:
Work stream 1: consistent application of the Current NCL PoLCE Policy The revised contract process for PoLCE related claims had now been agreed with the three acute providers on the 50% marginal rate contract in 2017/18 (Royal Free London, North Middlesex University Hospital and the Whittington). Work stream 2: Adopting the previously agreed changes to the NCL PoLCE policy Non-contentious procedural updates that fell within the remit of the existing policy would be circulated to the NCL Sustainability and Transformation Plan (STP) Health & Care Cabinet (HCC) members for consideration. If no substantial comments and/or changes proposed were received from the Cabinet, then adoption of the updates would come to the Joint Commissioning Committee for approval.
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Work stream 3: Rollout of the Enfield Changes At the November 2017 meeting the North Central London Joint Health Overview
Scrutiny Committee (JHOSC) indicated that they might agree with initial legal advice provided to Enfield CCG that the residual changes do not require public consultation and that they may simply require local clinical engagement. Whether or not the ultimate decision from the JHOSC was to consult the CCGs would work with Healthwatch on the resulting engagement programme. If JHOSC did ultimately decide that public consultation was required this would commence in January 2018. Work stream 4: Expanding the NCL Procedures of Limited Effectiveness (PoLCE) policy This work would be undertaken across London, but the advice from NHS England continued to be that there would be local rather than London-wide consultation on any expansion of policies. To gauge the comparative position, work had been undertaken to look at the London extended PoLCE list and the PoLCE list from CCGs outside London. A refined list of procedures was now being considered; with a clinical group to consider proposals for each group of procedures established. Further updates would be given to the Committee in the future.
4.2.2 Comments from the Committee focused on equity of access:
Sharon Seber stated that there was a strong case for national consultation;
Parin Bahl commented on the risk of the postcode lottery to patients; and it would be important to get the national and local messages to align.
4.2.3 The Committee agreed that the final advice on consultation requirements from the
Joint Health and Overview Scrutiny Committee should be followed. If formal consultation was required it would commence in January 2018.
4.3 Planning for winter 2017-18 4.3.1 4.3.2
Paul Sinden stated that winter plans for each A&E delivery board, to maximise hospital and community capacity at peak times of demand, were now in place. Each A&E Delivery Board had developed escalation processes supported by mutual aid structures to respond to surges in demand and operational pressures. To help meet winter pressures CCGs and Social Care were working to support acute trusts by:
Increasing use of primary care hubs and redirection initiatives to divert patients from A&E where clinically appropriate to do so;
Reducing the number of delayed transfers of care in hospital beds to support patient flow’ with North Central London on track to meet targeted reductions;
Reducing the number of continuing healthcare assessments carried out in hospital; with a target of 85% being undertaken in the community by January 2018.
4.3.3 Each A&E delivery board had prepared and submitted supplementary costed resilience plans to NHS England. These plans were to provide capacity over and above initial winter plans, with the prospect of additional funding from NHS England once schemes were approved.
4.3.4 The Committee then focused on the need to align national and local communications on the use of urgent and emergency care services over the winter. National communications regarding the Christmas/New Year period would be published by NHS England in the next few days, and it was important that the narrative in GP surgeries/Hubs and in A&E was consistent with this. Will Huxter stated that the wording of the communications would be discussed at the NCL Sustainability and Transformation Plan (STP) Health and Care Cabinet to ensure consistency.
4.3.5 The Committee noted the report and the submission of supplementary winter plans to
15
NHS England to provide additional system resilience over the winter. 4.4 Dermatology Service at North Middlesex University Hospital 4.4.1 4.4.2
The Committee received an update on future provision of dermatology services at North Middlesex University Hospital (NMUH) following the Trust serving notice on delivery of the service to Haringey CCG on 25 August 2017. Haringey and Enfield CCGs had been working with the Trust to commission a dermatology service from an alternative provider to ensure service continuity. The re-commissioning exercise was now complete and Concordia Heath would provide a service at the NMUH site between 8 January 2018 and 31 March 2018 as an interim measure, with the Royal Free London providing a longer term service from 1 April 2018.
4.4.3 Concordia were to provide the service as a sub-contract to the main CCG contract
with NMUH, so that the Trust continued to be responsible for the delivery of the service, including compliance with NHS constitution targets, clinical quality and safety until 31 March 2018. The CCG commissioning relationship therefore remained with North Middlesex University Hospital during this period.
4.4.4 Debbie Frost requested further assurance from Royal Free London on their capacity
to take on another service, and as part of this that a longer interim solution through Concordia Health be considered.
4.4.5 The Committee noted the report and the plans for future provision of dermatology
services at North Middlesex University Hospital. Action:
Royal Free London to be asked to provide assurance on their readiness to provide the dermatology service (transferring from North Middlesex University Hospital) on 1 April 2018 to the February Committee.
5 Risk
5.1 NCL Joint Commissioning Committee Risk Register 5.1.1 Paul Sinden asked the Committee to note the main updates to the risk register.
Overall, the highest risks related to managing winter pressures, supporting recovery of NHS Constitution waiting time standards and that North Central London was a system in deficit. The addition of a risk for delivery of the 18-week referral to treatment standard at UCLH and Royal Free London was highlighted. The Chair thanked Andrew Spicer for his thorough report.
5.1.2 The Committee noted the report.
6 Questions from public
6.1 There were no questions.
7 Any other business
7.1 Forward Planner 2017-18 7.1.1 The Committee noted the forward planner.
8 Date of next meetings
8.1 Thursday 1 February 2018 Holbrook Committee Room, Enfield CCG, 116 Cockfosters Road, Barnet EN4 0DR.
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Agenda Item: 1.5
NORTH CENTRAL LONDON JOINT COMMISSIONING COMMITTEE
ACTION LOG – FEBRUARY 2018
Action No
Meeting Date Action Lead Deadline Update
1. 3rd August 2017
Acute Commissioning Report To develop the performance report to enable the Committee to see trends going forward.
Paul Sinden
5th October
2017
Following the December meeting the report has been developed to provide a greater quality as well as performance focus.
2. 7th December 2017
Learning Disabilities – Transforming Care Paul Sinden to provide an update on progress on reducing the number of inpatient beds by Borough/CCG, and progress on the funding transfer agreement between NHS England and the CCGs to support transfers of care.
Paul Sinden
1st February
2018
Report to the February Committee provides an update on Borough based impact of the Transforming Care Programme, including the impact of the revised Funding Transfer Agreement from NHS England.
3. 7th December 2017
Planning for 2018/19 The Committee to receive a summary of Planning Guidance for 2018/19 from NHS England and NHS Improvement.
Paul Sinden
1st February
2018
Planning guidance not published at the time papers to the Committee published. An update will be provided on publication.
4. 7th December 2017
Procedures of limited clinical effectiveness The Committee to receive an update on Joint Health Overview Scrutiny Committee (JHOSC) advice on any need for public consultation for workstream three (the roll-out of changes approved by Enfield CCG to the rest of North Central London).
Paul Sinden
1st February
2018
The NCL policy for procedures of limited clinical effectiveness will next be considered by the Joint Health Overview Scrutiny Committee (JHOSC) on 6 February 2018
5. 7th December 2017
North Middlesex University Hospital Dermatology Service
Royal Free London to be asked to provide assurance on their readiness to provide the dermatology service (transferring from North Middlesex University Hospital) on 1 April 2018 to the February Committee.
Paul Sinden
1st February
2018
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NCL Joint Commissioning Committee Meeting on Thursday 1st February 2018
Report title Chairing of NCL Joint Commissioning and Committee Terms of Reference
Agenda item 2.1
Date 26th January
2018
Lead director Paul Sinden Director of Performance and Acute Commissioning
Tel/Email [email protected] Tel 020 3688 2906
Report author Andy Spicer NCL Head of Governance and Risk
Tel/Email [email protected] Tel 020 3688 2032
Sponsor(s) (where
applicable) Tel/Email
Report summary Introduction This report provides an update on the appointment to the Chair of the NCL Joint Commissioning Committee. Independent Chair Interviews for the Independent Chair for the Committee took place in August 2017 but an appointment was not made. From the recruitment it was clear that it would be difficult to appoint an Independent Chair of the right calibre who would also be able to restrict themselves to the role of Chair of the Committee. At the CCG Seminar held on 7 September 2017 it was therefore agreed that a Lay Member representative from the Committee undertake the role of Chair for six months, after which the appointment of an Independent Chair would be further considered. At the seminar it was agreed that Karen Trew, the lay representative from Enfield CCG, would Chair the Committee during this time. The appointment was effective for 2017/18 with further consideration therefore required for April 2018 onwards. Terms of reference Section eight of the terms of reference refer to appointment of the Committee Chair and Vice Chair, and was used to appoint a Chair from CCG lay members in the absence of an Independent Chair: The Chair of the Committee shall be independent and shall ordinarily not be an officer, employee or office holder of any of the NCL CCGs except to the extent necessary to hold a contract for the role of independent Chair. Where the Chair is unable to participate in a meeting or vote due to absence or a conflict of interest the Vice Chair may chair the meeting. The Vice Chair of the Committee shall be a lay member from an NCL CCG.
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The terms of reference were used to appoint Karen Trew, lay member representative for Enfield CCG, as Chair of the Committee after an independent chair was not appointed following interviews in August 2017. Should the Committee opt to source the Committee Chair form CCG lay member representatives the terms of reference can be amended as follows: The Chair of the Committee shall be appointed from CCG lay member representatives on the Committee. The Vice Chair of the Committee will also be sourced from CCG lay member representatives on the Committee. Where the Chair is unable to participate in a meeting or vote due to absence or a conflict of interest the Vice Chair may chair the meeting. The Vice Chair of the Committee shall be a lay member from an NCL CCG. The Terms of Reference for the Committee will be reviewed on an annual basis in the final quarter of each financial year. Review will include consideration of appointment of the Committee Chair including the option of appointing an Independent Chair. It is important to note that voting arrangements for the Committee will remain the same: The Committee shall comprise of the following voting members:
The Chair of Barnet CCG;
The Chair of Camden CCG;
The Chair of Enfield CCG;
The Chair of Haringey CCG;
The Chair of Islington CCG;
A lay representative from Barnet CCG
A lay representative from Camden CCG;
A lay representative from Enfield CCG;
A lay representative from Haringey CCG;
A lay representative from Islington CCG;
The NCL Accountable Officer;
The NCL Chief Financial Officer;
Three independent clinical advisors. One of whom must be a Secondary Care clinician and one of who must be a nurse.
Options for 2018/19 and onwards Options that the Committee are asked to consider are:
Continue to source the Committee Chair from CCG lay member representatives of the Committee;
Appoint an Independent Chair. Recommendation
The Committee is asked to recommend that the Committee Chair continues to be sourced form CCG Lay Member;
That Karen Trew, lay member representative for Enfield CCG, continues as Chair of the Committee for 2018/19;
A further review of Chair arrangements for the Committee be undertaken in the final quarter of 2018/19;
A Vice Chair for the Committee is appointed from the other CCG lay member representatives;
The terms of reference are amended to reflect the appointment of a CCG lay member representative as the preferred option for recruiting the Committee
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Chair;
Updated terms of reference are sent to Governing Bodies in March 2018, with the revised terms of reference effective from April 2018.
Purpose (tick one
only)
Information Approval
To note
Decision
Recommendation The NCL Joint Commissioning Committee is asked to:
Note the report;
Recommend that the Committee Chair continues to be sourced form CCG Lay Member;
That Karen Trew, lay member representative for Enfield CCG, continues as Chair of the Committee for 2018/19;
A further review of Chair arrangements for the Committee be undertaken in the final quarter of 2018/19;
A Vice Chair for the Committee is appointed from the other CCG lay member representatives;
The terms of reference are amended to reflect the appointment of a CCG lay member representative as the preferred option for recruiting the Committee Chair;
Updated terms of reference are sent to Governing Bodies in March 2018, with the revised terms of reference effective from April 2018.
Conflicts of Interest
Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy.
Strategic Direction The report supports the following strategic objectives:
Commission the delivery of NHS constitutional rights and pledges;
Improve health outcomes, address inequalities and achieve parity of
Esteem;
Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for- money services.
Identified risks and risk management actions
This report helps to maximise the opportunities and benefits of the five NCL CCGs working together to commission services for the benefits of patients.
Resource implications
Costs for the Committee Chair will be met from within existing resources across the five North Central London Clinical Commissioning Groups.
Engagement
The report is presented to the NCL Joint Commissioning Committee which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough.
Equality impact analysis
This report was written in accordance with the provisions of the Equality Act 2010.
Report history None
Next steps For Governing Bodies to consider the proposed changes set out in this paper.
Appendices None
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NCL Joint Commissioning Committee Meeting on Thursday 1st February 2018
Report title Acute Commissioning Report
Agenda item 3.1
Date 26th January
2018
Lead director Paul Sinden, NCL Director of Performance and Acute Commissioning
Tel/Email [email protected] Tel 020 3688 2906
Report author Sarah Rothenberg NCL CSU POD Director of Finance NEL Commissioning Support Unit Eileen Fiori NCL POD Director NEL Commissioning Support Unit
Tel/Email [email protected] Tel 020 3688 1658 [email protected] Tel 020 3688 1983
Sponsor(s) (where
applicable) Tel/Email
Report summary This report provides an overview of the key issues in performance, quality, contracting and finance across North Central London (NCL) acute hospital provider contracts. Further detail is contained within the Acute Commissioning report for the Joint Commissioning Committee. From a performance and quality aspect the most significant risks in NCL at present are under achievement of the A&E, Referral to Treatment (RTT) and cancer standards. Performance Accident and Emergency Performance across the sector is challenging. Accident and Emergency delivery systems have seen some improvements, but this is not on a sustained basis. There is an expectation from NHS England and NHS Improvement that during the winter, Accident and Emergency systems should deliver services to at least a 90% standard in the final quarter of 2017/18. The NCL aggregate performance was 85.5% against an aggregate trajectory of 91.3% and the 90% minimum standard for winter 2017/18. There is increased external scrutiny for North Middlesex and Royal Free Hospitals’ performance against the 4 hour standard:
North Middlesex University Hospital had been improving from 80.27% in August 2017 to 87.24% in October 2017, but there has been a subsequent deterioration since then with a performance of 72.47% in December 2017 and continued reduced performance indicated in the provisional data for January 2017.Workforce and compliance to internal processes raised as ongoing issues impacting on performance. There is continued supportive measures
21
put in place by commissioners directly working at the trust to support patient flow through the hospital;
Royal Free London Hospitals had a deteriorating position in Accident and Emergency performance. Local data indicates that following an improvement in November 2018 there has been a dip in performance at the Barnet Hospital site from 88.7% in November 2017 to 82.8% in December 2017. A Recovery Action Plan is being developed for improving performance. The initial draft identifies the leads and actions in the demand management, hospital patient flow, discharge management and workforce work streams. Further work is required on considering the impact of each the work stream actions on the overall trajectory.
University College London Hospital has refreshed their Accident and Emergency Remedial Action Plan to improve performance and avoid being closer scrutiny. Further assurance is required from commissioners on the expected impact of actions and timescales. CCGs are working with the Trust to secure this information. Additional winter funding has been made available to the system for the winter of 2017/18 to support performance. The funding has been allocated in two tranches. Acute trusts have been allocated funds on a ‘fair shares’ basis to reflect the cost of emergency and urgent elective activity across winter that is already in operational plans and is being incurred by providers. The second tranche has been directed at service developments prioritised by A&E Delivery Boards to improve winter resilience. Referral to Treatment The number of patients waiting for more than 18 weeks for treatment has reduced from 15,607 in October 2017 to 14,944 in November 2017. There has been a reduction across all of the major NCL providers.
There were a total of 52 NCL CCG patients on the referral to treatment pathways in November 2017 that had not been treated within 52 weeks of being referred. 14 of the 52 week waiters were at Imperial and 37 at Royal Free London. CCGs are undertaking clinical harm reviews with providers for these patients through Clinical Quality Review Groups. On 2 January 2018 the National Emergency Pressures Panel made a series of recommendations to help hospitals manage the sustained winter pressure. Although the impact has not yet been established, it is predicted that this will have resulted in increasing numbers of patients on waiting lists during December 2017 and January 2018, and in the short and longer term will have an impact on referral to treatment performance. Performance continues to be monitored at each of the Trust contract meetings. There is further information awaited from NHS England regarding additional funding to manage this cancellation of planned care activity Royal Free London has not achieved the Referral To Treatment 18 week target since August 2017. Commissioners received an initial Recovery Action Plan on 4 December 2017. This has been discussed with commissioners and colleagues from NHS England and NHS Improvement. Further work is required on validation of the trust’s data currently showing patients waiting on an 18 week pathway. University College London Hospital has developed and is implementing a Remedial Action Plan with trajectories for improvement for each specialty. There have been difficulties with delivering this because of increasing demand in Ear Nose and Throat services and the new date for achievement is March 2018.
22
North Middlesex University Hospital, Whittington Health and the other NCL providers met the referral to treatment standard in November 2017. Cancer Four of the five NCL NHS Trusts achieved the Two Week Wait All Cancer Standard in November 2017 with an aggregate performance of 94.1% against the standard of 93%. North Middlesex University Hospital was the only outlier and failed to achieve the two week wait standard with a performance of 90.5%. NCL Trusts failed to achieve the aggregate 62 Day Urgent referral Standard in November 2017 with performance of 79.6% against the 85% threshold and below performance in October 2017 (80.5%). There has been an improvement across three out of five NCL trusts, although only Royal National Orthopaedic Hospital achieved the standard this month. NCL STP are ranked fourth out of the five London STPs for this standard in November 2017. In order to improve this performance, NCL providers continue to work to the NCL Cancer STP five-point action plan which is a key driver to support sustainable recovery of the 62 Day Standard. An external clinically led review of cancer management at University College London Hospital is complete and final outputs awaited. The review is looking at the governance and management arrangements within University College London Hospital to ensure that the cancer services and the delivery of cancer standards are appropriately supported and met. Royal Free London Hospital secured Rapid Improvement Funding through the Recovery Fund monies in December 2017. £44,000 will be invested to extend the straight to test pilot for Lower Gastro Intestinal pathway which is due to start from January 2018 and £49,000 to improve Dermatology compliance by recruiting an additional consultant who is due to start in January 2018. North Middlesex University Hospital have made further progress with the implementation of actions contained within their cancer improvement plan with the start of the straight to test Lower Gastro Intestinal pilot and the ‘optimal lung’ pathway pilot in January 2018. In addition, North Central and East London sector’ have an over-arching 62 day pathway cancer action plan. Within this there is a requirement to improve the timeliness of NCL patients that are referred on to a Tertiary trust. This needs to be within 38 days of referral. The North Central and East London sector is aiming for sustainable compliance of the Inter Trust Transfer standards in quarter one 2018/19 Diagnostics
All five NCL providers achieved the diagnostic target of 99% in November 2017 and Royal Free London Hospital returned to a compliant position after failing the standard for the previous three months.
Quality Never Events in NCL Since the beginning of the financial year North Middlesex University Hospital and the Royal Free London Hospitals Trust have reported an increased number of Never Events. The Royal Free Hospitals Trust has reported initially nine Never Events to date of which one was de-escalated. North Middlesex University have reported five Never Events to date. Barnet CCG have requested for the Royal Free Hospitals Trust to present a thematic and trend analysis at the 31 January 2018 quality review meeting (CQRG), have commissioned NEL CSU safety team to undertake an in-depth
23
Thematic Review to be completed by March 2018 and have organised an assurance visit on Never Events for 30 January 2018. Haringey CCG are undertaking a thematic analysis of the learning following previous Never Events of the same type and are planning an assurance visit with a focus on root causes and action plans for February 2018. Contracts NCL CCGs have reported overall year-to-date acute over performance of £15.7m and a forecast outturn over performance of £22.8m. For the four main acute providers, NCL CCGs have reported year-to-date over performance of £19.1m and forecast outturn over performance of £21.7m. The forecast for the year-end takes into account individual CCG adjustments for the impact of STP interventions later in the year and the impact of marginal rates, with the impact of the latter being a £13.5m reduction in forecast outturn. The forecast outturn has increased by £4.9m at month nine compared to month eight, driven by increases in Trust reported activity in the four main NCL acute trusts. Over 60% of this increase is at the Royal Free in Non-Elective £1.8m, Drugs £0.3m and Outpatients £0.4m. An initial review of the increase in Non-Elective shows two areas of increase. The first is a switch in coding to Best Practice tariff by the Trust, where activity stays the same whilst cost on average has increased £130 for each spell, an overall cost of £0.2m. The second area of increase is in Non-Elective admissions. Delivery of STP interventions has also reduced to 61% of plan from 63% in the previous month, reducing the impact of interventions by £0.6m Quarterly contract reconciliations have progressed slower with Royal Free London than other providers. Agreement with the Trust has now been reached for 2017/18 on the three main disputed items (patient transport, productivity metrics and counting and coding), with this in place the final impact of the application of marginal rate to the contract can now can be agreed with the Trust. Discussions continue with the Royal Free London about a full and final year-end settlement. Activity comparison to 2016/17 Across NCL, activity levels from 2016/17 to 2017/18 are broadly stable and have therefore not increased in line with growth assumptions included in planning assumptions for 2017/18 and contracts (3%). The current calculations are anticipating growth to be 0.7% across all NCL providers for the NCL CCGs. In more detail there has been:
An increase in Accident and Emergency activity since 2016-17. (The increases are at Whittington Health which is currently up by 4% compared to this time last year, North Middlesex University Hospital up by 2% and Royal Free London up 1%. University College London Hospital are 1% below their previous year’s activity):
A decrease in daycase activity since 2016-17 for the Royal Free London, North Middlesex University Hospital and Whittington Health Hospital;
A decrease in Elective activity since 2016-17 for The Royal Free London, North Middlesex University Hospital and University College London Hospital;
A slight decrease in Outpatient First Appointments activity since 2016-17;
A slight increase in Outpatient Follow-Up Appointments activity since 2016-17.
All of the above highlights the importance of maintaining close performance management both financial and for the delivery of the constitutional standards. The success on the delivery of Sustainability and Transformation Plan (STP) interventions and the locally identified savings plans is key in providing
24
assurance and confidence that transformation can and is happening across the system, within and outside the acute provider settings.
Purpose (tick one
only)
[See Note 6]
Information Approval To note
Decision
Recommendation The NCL Joint Commissioning Committee is asked to:
NOTE and COMMENT ON the report;
COMMENT ON the report format.
Conflicts of Interest
Conflicts of Interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy.
Strategic Direction The acute commissioning report supports delivery of the following strategic objectives:
Commissioning the delivery of NHS constitutional rights and pledges;
Improving the quality and safety of commissioned services;
Improving health outcomes, address inequalities and achieve parity of esteem;
Maintaining financial stability and ensure sustainability through robust planning and commissioning of value-for- money services.
Identified risks and
risk management
actions
The main risks to note are included in the opening risk register for the NCL Joint Commissioning Committee and include:
Performance risks to delivery of NHS Constitution Standards for Accident and Emergency and Cancer 62-days Referral to Treatment;
The delivery of the STP interventions and local CCG saving plans;
The agreement of remaining Royal Free issues outside the three escalated issues that have been resolved;
The increasing number of Never Events at Royal Free and North Middlesex Hospitals.
Resource
implications
For CCG finances, the report focuses on the performance of contracts falling within the remit of the JCC rather than overall CCG positions.
Engagement
The report is presented to the NCL Joint Commissioning Committee which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough.
Equality impact
analysis
This report was written in accordance with the provision of the Equality Act 2010.
Report history and
key decisions
The report has been developed with reference to contract reports provided to individual CCGs in 2016/17 and 2017/18.
Next steps The Acute Commissioning Report will now be used at individual CCG Committee meetings to provide an overview of contract performance. The report will be developed in response to feedback from the JCC and CCG Committees.
Appendices Acute Commissioning Report
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Acute Commissioning Report Introduction This report sets out an overview of provider contracts for which management was delegated to the Joint Commissioning Committee by the five Clinical Commissioning Groups (CCGs) in North Central London (NCL) in November 2016. The report therefore incorporates:
Acute hospital contracts;
Integrated Urgent Care service (NHS 111 and GP out-of-hours) provided by London Central and West Unscheduled Care Collaborative;
London Ambulance Service. Content In line with the functions listed above the NCL Joint Commissioning Committee will consider all aspects of provider performance to ensure there is a comprehensive oversight of contract management. This will include the following four sections:
1. Quality and Performance The quality and performance section of the report provides a summary of nationally and locally reported data, describes the overall quality of the acute services in NCL and the actions being taken to deliver sustainable improvement. The report shows published Accident and Emergency performance data for December 2017, other performance data for November 2017 for the other standards and more recent un-validated information where available.
2. Contracts The report focuses on the performance of contracts falling within the remit of the Joint Commissioning Committee and will therefore not fully reflect the overall CCG positions. The position shown uses month nine information (December 2017), which is reported as month eight plus one in line with reporting arrangements to show a projected month nine position. The report provides details of:
North Central London (NCL)-wide acute contract overview;
Claims and challenges;
Quarter one and quarter two reconciliations;
Main risks and mitigations to contracts.
3. Financial Performance The report will provide details of:
Run-rate of expenditure to support trend analysis;
Performance by Trust;
Performance by CCG;
Narrative to support the figures. 4. Activity Performance
The report provides details of:
NCL-wide acute activity overview;
Comparison between 2016/17 and 2017/18. Report details
1. Quality and Performance
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The Committee is asked to note the CCG and provider CCG performance as summarised in the dashboards overleaf. This section explains the issues underlying the performance and the actions being taken by providers and commissioners to improve the delivery of the standards. This section also includes the quality and performance information for the London Ambulance Service and the Integrated Urgent Care service provided by London Central West Unscheduled Care Collaborative. Patient experience as measured by the Friends and Family Test can provide a proxy for patient reported satisfaction with treatment outcomes. This has been included as part of the provider performance, where relevant. NCL CCG Performance Figure 1
Data Source: Unify2 and Open Exeter NCL Provider Performance Figure 2
Data Source: Unify2 and Open Exeter 1.1 Accident and Emergency 1.1.1 Performance Performance across the sector is challenging. Accident and Emergency delivery systems have seen some improvements, but this is not on a sustained basis. There is an expectation from NHS England and NHS Improvement that during the winter, Accident and Emergency systems should deliver services to at least a 90% standard. Whittington Health managed to meet this level and the agreed trajectory in November 2017 with a performance of 91.29%. Performance deteriorated in December 2017 and all NCL
Measure
Date of
Current Data
Four-hour max wait in A&E Dec-17 88.15% 87.47% ¯ 84.92% ¯ 86.34% ¯ 89.97% ¯
RTT: 90% admitted performance Nov-17 81.13% ¯ 82.48% ¯ 77.47% 79.45% ¯ 84.93%
RTT: 95% non-admitted Nov-17 90.10% ¯ 92.18% ¯ 87.64% ¯ 90.41% ¯ 91.15% ¯
RTT: 92% incomplete Nov-17 88.46% 91.55% 87.04% 92.40% 92.65%
Cancer waits: 2 week All Cancers Nov-17 92.90% 95.81% ¯ 91.75% ¯ 94.66% 96.05%
Cancer waits: 2 week breast symptomatic Nov-17 97.45% ¯ 93.26% 94.51% ¯ 99.32% ¯ 98.18%
Cancer waits: 31 days diagnosis to treatment Nov-17 97.71% ¯ 97.96% ¯ 97.67% ¯ 98.75% ¯ 97.26% ¯
Cancer waits: 31 days diagnosis to treatment subsequent drug treatment Nov-17 100.00% ® 100.00% ® 100.00% ® 100.00% ® 100.00% ®
Cancer waits: 31 days diagnosis to treatment subsequent surgery Nov-17 100.00% ® 83.33% ¯ 100.00% 93.33% ¯ 100.00% ®
Cancer waits: 31 days treatment subsequent radiotherapy Nov-17 97.50% ¯ 86.96% ¯ 100.00% 100.00% ® 100.00% ®Cancer waits: 62 days referral to treatment Nov-17 85.19% 72.41% ¯ 78.13% ¯ 78.38% ¯ 80.65% ¯
Cancer waits: 62 days referral to treatment -referral from screening Nov-17 100.00% 100.00% ® 77.78% ¯ 100.00% ® 81.82% ¯
Cancer waits 62 days upgrade Nov-17 94.74% 50.00% ¯ 92.31% 89.47% ¯ 88.89%
Diagnostic waits > 6 wks Nov-17 99.13% 98.89% 99.52% 99.48% 99.40%
IslingtonHaringeyEnfieldBarnet Camden
Measure
Date of
Current Data
Four-hour max wait in A&E Dec-17 98.98% 72.58% ¯ 83.66% ¯ 86.60% ¯ 86.53% ¯
RTT: 90% admitted performance Nov-17 75.15% ¯ 80.03% 74.53% 79.99% ¯ 85.09% ¯ 77.15%
RTT: 95% non-admitted Nov-17 95.46% ¯ 93.49% ¯ 87.90% 90.25% ¯ 90.25% ¯ 87.78% ¯
RTT: 92% incomplete Nov-17 94.67% ¯ 94.68% 92.35% 87.46% 91.14% 92.21%
Cancer waits: 2 week All Cancers Nov-17 93.75% ¯ 90.45% ¯ 95.90% ¯ 94.02% 94.80% 96.08%
Cancer waits: 2 week breast symptomatic Nov-17 100.00% 95.48% ¯ 93.00% ¯ 100.00%
Cancer waits: 31 days 1st Definitive Treatment Nov-17 100.00% ® 100.00% ® 91.67% ¯ 97.87% ¯ 96.55% ¯ 100.00% ®
Cancer waits: 31 days diagnosis to treatment subsequent drug treatment Nov-17 100.00% ® 100.00% ® 100.00% ® 100.00% ®
Cancer waits: 31 days diagnosis to treatment subsequent surgery Nov-17 100.00% ® 100.00% ® 94.44% ® 100.00% 95.89% 100.00% ®
Cancer waits: 31 days treatment subsequent radiotherapy Nov-17 100.00% ® 100.00% ® 98.00% ¯
Cancer waits: 62 days referral to treatment Nov-17 100.00% 69.05% ¯ 85.71% 84.24% 74.58% 83.08% ¯
Cancer waits: 62 days referral to treatment -referral from screening Nov-17 55.56% ¯ 94.23% 88.89%
Cancer waits 62 days upgrade Nov-17 87.30% ¯ 85.71% ¯ 92.77% 84.91% 80.00% ¯
Diagnostic waits > 6 wks Nov-17 100.00% ® 99.75% 99.82% 98.48% 99.13% ¯ 99.24%
WhittingtonMoorfields NMUH RNOH Royal Free UCLH
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Accident and Emergency systems were below both local trajectories and the national standard (95%). The NCL aggregate performance was 85.5% against an aggregate trajectory of 91.3% and the national floor performance for the winter of 90%. Following a new national requirement by NHS Improvement, Accident and Emergency safety checklists are being implemented in all Accident and Emergency departments across NCL. An Accident and Emergency safety checklist is a time based framework of tasks, which is completed for every patient in Accident and Emergency, other than those with minor complaints. It is prescriptive and contains all basic elements of care for that patient’s condition and when used correctly ensures that fundamental care is delivered safely and efficiently. North Middlesex University Hospital Accident and Emergency performance at North Middlesex University Hospital had been improving from 80.27% in August 2017 to 87.24% in October 2017, but there has been a subsequent deterioration since then with a performance of 72.47% in December 2017 and continued reduced performance indicated in the provisional data for January 2017. Figure 3
Data Source: Unify2 and local provide data From a workforce perspective an interim Clinical Director is providing leadership to the Accident and Emergency Department whilst interviews for a permanent Clinical Director are due to take place imminently. There are also a number of vacancies at consultant and middle grade level. In order to attract staff, North Middlesex University Hospital, in conjunction with the Royal College of Emergency Medicine, is amending job descriptions before going out to advert for consultant posts and ongoing advertising for the middle grades vacancies is in place to address the vacancies. This report has previously reported on concerns raised by the General Medical Council, Health Education England and the Care Quality Commission regarding the learning environment of trainee doctors in the North Middlesex University Hospital Emergency Department. Weekly support calls with these stakeholders continue to ensure progress of an agreed action plan. Following the recent poor performance there has been a focus on ensuring that all staff are familiar with and use the agreed internal escalation processes that will enable a hospital and system wide response at times of extreme pressure. There are a number of actions that are being taken to support the North Middlesex University Hospital Accident and Emergency system. These include:
Increasing the use of the Discharge to Assess pathways to support people to have their social care and continuing healthcare needs assessed in the community, rather than in hospital. The multi-agency service is provided through Haringey social services single point of access. Haringey supports both the North Middlesex University Hospital and Whittington Health to manage 30 patient referrals a week;
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Securing an additional £606k of funding for partners within the Haringey and Enfield Accident and Emergency Care Delivery Board to provide additional staff to the short stay ward at the North Middlesex. This provides an additional therapist capacity to support Discharge to Assess, extra patient streaming and redirection support in the Accident and Emergency Department, and enhanced mental health support for patients in a crisis who present at North Middlesex University Hospital Emergency Department;
Strengthening escalation processes relating to Delayed Transfers of Care, so that senior leaders get involved when there are unacceptable delays to getting patient’s home or to community settings;
Holding a Multi-Agency Discharge Event, that took place on 28 December 2017, so that health and care organisations can focus on better joint working during one of the most challenging times of the year;
Providing approximately 2,600 additional primary care appointments a month through primary care hubs and opening a new hub at the North Middlesex’s Emergency Department;
Implementing daily CCG Director to North Middlesex University Hospital Director calls with the Trust so issues and challenges can be problem solved quickly.
Royal Free London Royal Free London Hospitals had a deteriorating position in Accident and Emergency performance from 87.79% in November 2017 to 83.66% in December 2017. This was against an agreed trajectory of 91.3%. Local data indicates that following an improvement in November 2018 there has been reduced performance at the Barnet Hospital site from 88.7% in November 2017 to 82.8% in December 2017. (Some of the improvement in November 2018 at the Barnet Site was due to improved ambulance handover processes). The Royal Free site has shown a deteriorating position at the Royal Free site from 86.69% in October 2017 to 79.4% in December 2017. The Emergency Care Improvement Programme Team reviewed the ambulance handover process at Barnet Hospital during November 2017. London Ambulance Service data showed marked improvement in the ambulance handover time with a reduction in both the 30 and 60 minutes handover standard. Prior to the review, 40% of patients were waiting more than 30 minutes to have their care handed over from the ambulance service to the emergency department. This has reduced to 10% waiting more than 30 minutes. Prior to the review, 15% were waiting more than 60 minutes, which has reduced to 5%. The Emergency Care Improvement Team are placing a similar focus on ambulance handover processes at the Royal Free site. A Recovery Action Plan is being developed for improving performance at the Royal Free site. The initial draft identifies the leads and actions in the demand management, hospital patient flow, discharge management and workforce work streams. Further work is required on considering the impact of each the work stream actions on the overall trajectory. The learning and consequent changes following the Multi Agency Discharge Event and the Perfect Week held at the Barnet Hospital site in October 2017 were used for a follow-up Multi Agency Discharge Event held in December 2017 at both the Royal Free and Barnet sites. Lessons learnt in these events will be incorporated in the Accident and Emergency recovery plans. A SAFER week event commenced on 2 January 2018, these events will promote early discharges and improve flow in patient pathways. The SAFER patient flow bundle blends five elements of best practice
S – Senior review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions.
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A – All patients will have an expected discharge date and clinical criteria for discharge. This is set assuming ideal recovery and assuming no unnecessary waiting.
F – Flow of patients will commence at the earliest opportunity from assessment units to inpatient wards. Wards that routinely receive patients from assessment units will ensure the first patient arrives on the ward by 10 am.
E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday.
R – Review. A systematic multi-disciplinary team review of patients with extended lengths of stay (>7 days – ‘stranded patients’) with a clear ‘home first’ mindset.
University College London Hospital University College London Hospital has refreshed the Accident and Emergency Remedial Action Plan to improve performance. Further assurance is required by commissioners on the expected impact of actions and timescales. CCGs are working with the Trust to secure this information. The University College London Hospital / Camden Accident and Emergency system has:
Completed a review of floor space occupied by its Emergency Department Unit and Clinical Decision Unit;
Now implemented front door streaming;
Reviewed Emergency Department leadership roles;
Implemented a revised operational policy that will improve communication about Accident and Emergency pressures across the trust.
As part of the recovery plan there are a number of actions that have a critical impact on delivering the Accident and Emergency improvement trajectory. These include:
Step Down Beds: Camden CCG commissioned Evergreen Ward Step down beds at St. Pancras. These beds continue to be utilised and regular updates provided monthly to the Accident and Emergency Delivery Board;
Specialty Response: Reducing specialty delays in Emergency Department and improving response times by implementing Emergency Department avoidance schemes for example hot clinics and speciality pathways that are Emergency Department led;
Specialty level demand & capacity and flow: Strengthening operational resilience and capacity management across the clinical areas in the tower through 24-48 hour demand and capacity management, improving bed cleaning turnaround times, introduction of operational manager of the day and ward liaison roles and consistent board round processes across the hospital;
Urgent Treatment Centre Delivery: Efficiency improvements and throughput in the urgent treatment centre by embedding a reconfigured staffing and leadership model.
In addition, the completion of the Emergency Department capital project in March 2018 will create additional space in clinical areas that will support the flow of patients through the department. 1.1.2 Supporting actions 1.1.2.1 Accident and Emergency Delivery Boards In order to support an improvement in patient flow, Accident and Emergency Delivery Boards are focussed upon delivering:
Ambulance Handover;
Urgent care streaming;
Enhanced ambulatory care;
A reduced number of Delayed Transfers of Care and stranded patients (waiting discharge for more than six days);
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Increasing numbers on patients on Discharge to Assess pathways. 1.1.2.2 Ambulance Handover Accident and Emergency Delivery Boards have carried out an assessment against a number of actions that support improvements in ambulance handover and reflect the recommendations in the recent guidance on improving ambulance handover times. These actions include analysis of patient flows for those conveyed by ambulance, investigating the operational steps for handover of patients and what escalation triggers for delays are in place. 1.1.2.3 Discharges The simplified discharge work stream has supported the implementation of work to reduce delays in transfer of care, to increase the number of patients on discharge to assess pathways and reduce the number of patients having Continuing Health Care assessments in acute hospital services. The improved position for NCL delayed bed days per day reported for September 2017 has not been sustained in October and November 2017. Whilst still meeting the trajectory of less than 60 patients delayed in acute beds per day; the number increased from 48.33 in September 2017 to 56.72 in November 2017. CCGs are at different stages with implementing Discharge to Assess pathways and this forms part of the Urgent and Emergency Care work stream performance indicators. NHS England are placing more emphasis upon delivering and enhancing these targets in their engagement with the Accident and Emergency Delivery Board systems. 1.1.3 Additional Winter Resilience funding Funding has been made available to the system for the winter of 2017/18 to support performance. The funding has been allocated in two tranches. Acute trusts have been allocated funds on a ‘fair shares’ basis to reflect the cost of emergency and urgent elective activity across winter that is already in operational plans and is being incurred by providers. A second tranche of funding is additional winter funding for new initiatives to improve Accident and Emergency performance over winter. There is a clear expectation that Accident and Emergency systems will need to deliver the improvements in forecast outturn positions and Accident and Emergency performance, and in particular meet the 90% floor for performance for winter 2017/18. Arrangements have been put in place to monitor the implementation and impact of these plans on A&E performance within Accident and Emergency Delivery Boards and contract management meetings and will be reviewed in fortnightly teleconferences with regulators. 1.1.3.1 North Middlesex University Hospital / Haringey and Enfield The North Middlesex University Hospital / Haringey and Enfield system has successfully bid for winter money (£606,000) to support:
An additional Primary Care Hub at North Middlesex University Hospital;
An Enhanced Enfield Crisis and Mental Health Support and Redirection Team;
Community Multi-Disciplinary Team in-reach and a focus on short stay;
Further clinical support to maximise streaming and redirection. It is expected that the system will deliver at least 90% performance over quarter four. 1.1.3.2 University College London Hospital / Camden The University College London Hospital / Camden system has successfully bid for winter money (£500,000) to:
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Enhance the RAPID service to support further admission avoidance and Discharge to Assess pathways 2 and 3;
Support an electronic coordination centre to maximise patient flow over a seven day period;
Enhance the staffing in a surge area in the Emergency Department. It is expected that the system will deliver at least 90% performance over quarter four. 1.1.3.3 Whittington Health / Islington The Whittington Health / Islington Accident and Emergency system has secured winter money (£818,000) to:
Provide an additional 3 beds to support timely discharge of patients;
Increase capacity in the Urgent Care Centre;
Provide additional administrative support to clinical staff to maximise patient flow and support appropriate discharge;
Extend the Mental Health front door presence at Whittington Health Accident and Emergency;
Extend the Mental Health Crisis Team capacity in Islington;
Additional Mental Health beds to support patients at Whittington Health. It is expected that the system will maintain the current year to date performance of 91.4% over quarter four. 1.1.3.4 Royal Free London / Barnet The Royal Free London / Barnet Accident and Emergency system has successfully bid for winter money (£2,201,000) to:
Increase acute bed capacity at the Royal Free and Barnet Hospital sites;
Support Discharge to Assess pathways;
Provide enhanced nursing home care;
Provide GP services at the front end of hospitals;
Provide additional community nursing capacity.
It is expected that the system will deliver at least 90% performance over quarter four. 1.1.3.5 Barnet, Enfield and Haringey Mental Health Trust Barnet, Enfield and Haringey Mental Health Trust has received £724,000 mental health winter funding to provide additional resources in the Crisis Resolution and Home Treatment Team. 1.1.3.6 Camden and Islington Foundation Trust Camden and Islington Foundation Trust has received £126,000 for a Bed Management Hub and Assertive Discharge Team. 1.2 Referral to Treatment Royal Free London and University College London Hospital did not meet the standard in November 2017 with a respective performance of 87.46% and 91.14% against a target of 92%. As a consequence Barnet, Camden and Enfield CCGs failed to meet the Referral To Treatment standard. NCL CCGs as an aggregate only achieved 88.46% in November 2017. Provider updates are provided in section 1.2.2.
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1.2.1 Overall Referral To Treatment Waiting List Size The NCL waiting list for patients waiting for treatment at November 2017 is shown below. Figure 4
The number of patients waiting for more than 18 weeks for treatment has reduced from 15,607 in October 2017 to 14,944 in November 2017. There has been a reduction across all of the major NCL providers.
There were a total of 52 NCL CCG patients on the referral to treatment pathways in November 2017 that had not been treated within 52 weeks of being referred. 14 of the 52 week waiters were at Imperial and 37 at Royal Free London. The number of 52 week waiters for NCL providers has increased from 45 in October 2017 to 62. 60 of these are patients waiting at Royal Free London.
Figure 5
Data Source: Unify2 On 2 January 2018 the National Emergency Pressures Panel made a series of recommendations to help hospitals manage the sustained winter pressure. These included:
Extending the deferral of all non-urgent inpatient elective care to free up capacity for the sickest patients to January 31st. The panel reiterated that cancer operations and time-critical procedures should go ahead as planned;
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Day-case procedures and routine outpatient appointments should also be deferred where this will release clinical time for non-elective care.
Clinical time released from the above actions should be re-prioritised to:
Implement consultant triage at the front-door so patients are seen by a senior decision maker on arrival at the Emergency Department;
Ensure consultant availability for phone advice for GPs;
Maximise the usage of ambulatory care and hot clinic appointments as an alternative to Emergency Department attendance and/or hospital admissions;
Increase support from Allied Health Professionals, for example physios and therapists, for rehabilitation and discharge;
Staff additional inpatient beds;
Ensure twice daily review of all patients to facilitate discharge. Although the impact has not yet been established, it is predicted that this will have resulted in increasing numbers of patients on waiting lists during the winter and in the short and longer term will have an impact on referral to treatment performance. In addition providers may experience an increasing number of patient complaints. It is expected that providers will have taken due consideration to patient safety when cancelling appointments or procedures. Impact will be monitored through the Quality and Contract Review meetings. There is further information awaited from NHSE regarding additional funding to manage this cancellation of planned care activity. 1.2.2 Referral To Treatment Provider update 1.2.2.1 Royal Free London Royal Free London has not achieved the Referral To Treatment 18 week target since August 2017. This is primarily because of the implementation of a new reporting logic in August 2017. This resulted in an overall reduction of the waiting list as the duplicated pathways were removed, but at the same time resulted in a disproportionate increase in patients whose pathways breached the 18 week standard. This affected the overall Referral To Treatment performance. There were 60 patients waiting for more than 52 weeks at Royal Free London in November 2017. Royal Free London has established a clinical harm process. Monthly reports showing progress and the learning from the reviews will be considered by the Royal Free London Clinical Quality Review Group. Commissioners received an initial Recovery Action Plan from the Trust on 4 December 2017. This has been discussed with commissioners and colleagues from NHS England and NHS Improvement. Further work is required on validation of the trust’s data currently showing patients waiting on an 18 week pathway. Additional staff have been recruited to support this. It is anticipated that all of the initial validation work will be completed by the end of March 2018. There are 2,000 outstanding cases to review. The ‘business as usual’ validation process continues as planned. The Intensive Support Team from NHS Improvement are making sure that the logic rules that are being used are appropriate and helping the Royal Free London team to make sure that patients are treated in chronological order where clinically possible. Work is underway to further develop the speciality based action plans and trajectories.
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The Director of Commissioning at Barnet CCG and Director of Performance for NCL CCGs will be representing CCGs at the Royal Free London Referral to Treatment Steering Group that oversees the recovery plan. Barnet CCG are including information about the Royal Free London position on referral to treatment in the regular GP Bulletin and are working with Royal Free London to ensure that all key stakeholders are aware of the current position and the actions being taken to deliver improvement. 1.2.2.2 University College London Hospital University College London Hospital has developed and is implementing a Remedial Action Plan with trajectories for improvement for each specialty. There have been difficulties with delivering this because of increasing demand in Ear Nose and Throat services and the new date for achievement is March 2018. Camden CCG are closely monitoring the progress and impact of the plans and are monitoring the weekly patient tracking list. If the March 2018 deadline is not met Camden CCG will issue a Contract Performance Notice. A process is in place for University College London Hospital clinical harm reviews to be undertaken for all patients on pathways that have breached the 52 week standard and harms reviews are reported at the monthly Clinical Quality Reference Group. The September 2017 report included reviews of 45 patient pathways and found no evidence of clinical harm. 1.2.2.3 Other North Central London Trusts North Middlesex University Hospital, Whittington Health and the other NCL providers met the referral to treatment standard in November 2017. Close attention will be paid to the December 2017 and January 2018 patient tracking lists to assess the impact of the winter plan. 1.3 Cancer 1.3.1 Two Week Wait Standard Four of the five NCL NHS Trusts achieved the Two Week Wait All Cancer Standard in November 2017 with an aggregate performance of 94.1% against the standard of 93%. North Middlesex University Hospital was the only outlier and failed to achieve the two week wait standard with a performance of 90.5%. NCL Trusts achieved the two week wait cancer standard in October 2017 with an aggregate performance of 93.0%. When looking at CCG performance for NCL this was a mixed picture. The aggregated CCG performance was 94% for its patients accessing cancer treatment at all providers. However Barnet and Enfield CCGs did not meet the standard with performances of 92.9% and 91.7% respectively. Figure 6
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Data Source: Open Exeter 1.3.2 Cancer 62 day standard NCL Trusts failed to achieve the aggregate 62 Day Urgent referral Standard in November 2017 with a performance of 79.6% against the 85% threshold. This represents a dip in performance when compared to October 2017 Performance of 80.5%. There has been an improvement across three out of five NCL trusts, although only Royal National Orthopaedic Hospital achieved the standard this month. Figure 7
Data Source: Open Exeter Patient breaches can occur at the hospital that they were referred to and treated at or at a hospital that required their treatment to be referred on as part of their cancer pathway. Breaches that occur when referred onto another provider are captured as ‘shared breaches’ and will be recorded as 0.5. There were a total of 66.5 breaches from 325.5 patient pathways. A reduction of 18.5 breaches in November 2017 would have returned NCL Trusts to a compliant position. 32% of NCL breaches in November 2017 month were attributed to the Urology tumour site. Only Barnet CCG achieved the 62 Day Urgent GP Referral standard in November 2017 against the standard of 85%. The aggregate CCG performance in November 2017 was 80.2% with a total of 48 breaches from 242 Patient Pathways. For the CCGs where pathways were non-compliant against the standard the breaches were as follows: Camden CCG – 8 breaches from 29 Patient Pathways resulting in a performance of 72.4% Enfield CCG – 14 breaches from 64 Patient Pathways resulting in a performance of 78.1% Haringey CCG – 8 breaches from 37 Patient Pathways resulting in a performance of 78.4% Islington CCG – 6 breaches from 31 Patient Pathways resulting in a performance of 80.6% NCL STP are ranked fourth out of the five London STPs for this standard in November 2017. In order to improve this performance, NCL providers continue to work to the NCL Cancer STP five-point action plan which is a key driver to support sustainable recovery of the 62 Day Standard. This includes:
Reducing median waits for first event to seven days;
Full implementation of the optimal Prostate and Lung pathway;
Straight to test for lower Gastro-Intestinal;
Patient Tracking List management and tracking of backlog;
Root cause analyses for 62 day breaches.
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Providers across NCL are also required to report Clinical Harm Reviews on all breach patients and those over 104+ days and are expected to be discussed at the quality review meetings. NEL Commissioning Support Unit have completed a stocktake of the current arrangements across NCL for completing and reviewing root cause analyses for cancer breaches and reporting learning about clinical harm and pathway improvement. It was found that there is an inconsistent approach within Trusts and CCGs with:
The quality and robustness of the root cause analyses;
Identifying opportunities to improve the pathways;
Identifying, reporting and utilising the learning from clinical harm reviews. A workshop on Inter Trust Transfer root cause analysis with NCL Trusts identified a number of actions to improve robustness and consistency of processes. A standard operational procedure is being developed for use across NCL. All NCL Trusts will be using common breach report documentation and common processes. They have agreed to submit the root cause analyses in a timely manner and a standard operational procedure setting out the arrangements will be finalised in February 2018. 1.3.3 Inter Trust Transfer North Central and East London sector’ have an over-arching 62 day pathway cancer action plan. Within this there is a requirement to improve the timeliness of NCL patients that are referred on to a Tertiary trust. This needs to be within 38 days of referral. The North Central and East London sector is aiming for sustainable compliance of the Inter Trust Transfer standards in quarter one 2018/19. NCL Trust trajectories are based on a performance threshold of 85% for patients being transferred within 38 days. Figure 8
Data Source: NCL Providers 1.3.4 Provider update University College London Hospital University College London Hospital achieved six out of the eight cancer waiting times standards in November 2017. The non-compliant cancer waiting time standards in November 2017 were for the 62 day Urgent GP referral and the 62 day Screening standard. The overall 62 Day Urgent GP referral standard performance improved this month to 74.6% albeit below agreed trajectory of 82.6%. This performance is influenced by the number of breaches caused by late referrals from other trusts but University College London Hospital
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only managed to meet the standard for 83% for the patients that were referred to their services by GPs directly. There were a total of 22.5 breaches from 88.5 patient pathways in November 2017 and these were spread across a number of tumour sites with the majority (10.5) in the Urology speciality. All 62 day breaches, including all those over 100 day breaches undergo a breach analysis and these are analysed and reported at the Clinical Quality Review Group. University College London Hospital continue to work with referring trusts and with the NCL, North East London and West Essex sectors to streamline pathways. Weekly operational phone calls are in place to manage improvement at a patient level and the sector monitoring tool is updated on a weekly basis. An external clinically led review of cancer management at University College London Hospital is complete and final outputs awaited. The review is looking at the governance and management arrangements within University College London Hospital to ensure that the cancer services and the delivery of cancer standards are appropriately supported and met. Royal Free London Royal Free London has achieved seven out of the eight cancer waiting times standards in November 2017. The 62 Day GP referral standard was almost compliant with a performance of 84.2% against the Recovery Fund target of 85.8% and the national standard of 85%. The majority of breaches for patients who are waiting more than 62 days on the cancer pathway were from skin, Urology and Lower Gastro Intestinal pathways. The Renal pathway continues to be challenging due to late Inter Trust Transfers whilst treatment within 24 days on the timed pathway standards needs to improve further. 57% of the Inter Trust Transfer referrals were sent within 38 days of the 62 day pathway against the agreed trajectory of 60% in November 2017. Royal Free London Hospital secured Rapid Improvement Funding through the Recovery Fund monies in December 2017. £44,000 will be invested to extend the straight to test pilot for Lower Gastro Intestinal pathway which is due to start from January 2018 and £49,000 to improve Dermatology compliance by recruiting an additional consultant who is due to start in January 2018. A meeting is being planned in January 2018 between Barking, Havering and Redbridge University Trust and Barts Health in an effort to reduce the tertiary Inter Trust Transfer delays in Renal pathway received by Royal Free London. North Middlesex University Hospital North Middlesex University Hospital did not achieve the standard in November 2017 with a performance of 69.05%, below the national standard of 85%. This was a decrease in performance compared to October 2017 performance of 88.24%. There were forty two 62-day treated cases in November 2017 with 13 breaches. Majority of the breaches were in Lower Gastro Intestinal (4) and Urology (5.5) cancer pathways. North Middlesex University Hospital have made further progress with the implementation of actions contained within their cancer improvement plan with the start of the straight to test Lower Gastro Intestinal pilot and the ‘optimal lung’ pathway pilot in January 2018. Diagnostics
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All five NCL providers achieved the diagnostic target of 99% in November 2017 and Royal Free London Hospital returned to a compliant position after failing the standard for the previous three months. The Royal Free London improvement has been linked to the new Computer Tomography scanner which is operational from November 2017. However, Echocardiography, Gastroscopy, Colonoscopy and Flexi-Cystoscopy modalities remains non-compliant and waiting list initiatives are ongoing to improve access.
As a result of the Provider performance, all of the NCL CCGs except Camden CCG achieved the diagnostics standard in November 2017. Aggregate Diagnostics Performance across NCL CCGs improved from 99.15% in October 2017 to 99.46% in November 2017. Camden CCG has not achieved the standard for four consecutive months with a performance of 98.92% in November 2017 Non-compliant modalities for Camden CCG in November 2017 were Computer Tomography (1.1%), Peripheral Neurophysiology (1.2%), Urodynamics (14.3%), Colonoscopy (4.8%), Flexi Sigmoidoscopy (1.1%), Cystoscopy (25.3%) and Gastroscopy (1.2%). The main driver of Camden CCG non-compliance was the performance at Royal Free London who contributed approximately 65.3% of the 49 breaches in November 2017. 1.5 London Ambulance Service With the introduction of the new Ambulance Response Programme, the method for performance reporting is being reviewed by the London Ambulance Service and commissioners. Formal contract reports are not yet available but the London Ambulance Service has provided a weekly tripartite report that includes some monthly performance data. November 2017. This provides a summary of performance against the new standards for the whole of London. Figure 9
The four new patient categories are: Category 1 – Life Threatening (8% of calls) Category 2 – Emergencies (48% of calls) Category 3 – Urgent (34% of calls) Category 4 – Less Urgent (10% of calls).
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The London Ambulance Service are below the national standard for many of the new categories in December 2017. The context and actions to improve performance will be considered at the contract performance meeting in January 2018, and reported to the next NCL Joint Commissioning Committee. 1.6 Integrated Urgent Care Service London Central West Unscheduled Care Collaborative provides the integrated urgent care service that covers both the NHS 111 service and GP out-of-hours. London Central West Unscheduled Care Collaborative are meeting all of the agreed national and local Key Performance Indicators apart from call waiting time. The call waiting time remains a challenge because of staffing levels. A recruitment plan has been implemented. Callers waiting for more three minutes on a call receive messages about the availability of NHS 111 online and GP Hub appointment services and should be more aware of how to access some of the other support and advice available to them. Figure 10
Data Source: London Central West Unscheduled Care Collaborative Contract and Performance Report Although London Central West Unscheduled Care Collaborative is not meeting the national Key Performance Indicator (95%), it has been agreed as part of the contract monitoring that the Key Performance Indicator is locally set 85%, whilst recruitment continues. They are not yet meeting the target, however, they are reporting an improvement of 4% from the previous month. This continues to be impacted by rostering issues and a shortfall in overall staff, however their workforce plan is progressing to achieve this trajectory. Performance of the integrated urgent care service has held up well over the winter to date compared to peer services nationally. A Serious Incident occurred at London Central West Unscheduled Care Collaborative in April 2017. NHS England requested a commissioner initiated external review in addition to the Provider Serious Incident root cause analysis investigation. The external review was led by Professor David Colin Thome. An extraordinary Clinical Quality Review Group has been scheduled for 16th February 2018 to review the independent investigation report, which will be followed by a steering group meeting with NHS England. Enfield CCG is the Lead Commissioner for the NCL Integrated Urgent Care Contract, John Wardell, Accountable Officer, has taken overall lead on the contract management. Deborah McBeal, as the Senior Responsible Officer for Integrated Urgent Care, has responsibility for delivery of an agreed set of performance and financial recovery actions, known as The Roadmap.
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Weekly progress meetings are held with representatives from the Provider, Commissioners and CSU, to progress the initiates in the Roadmap alongside an action and decision log, capturing outstanding actions and noting decisions made for each initiative. The Roadmap is monitored through the Integrated Urgent Care Contract Management Group on a monthly basis and any issues would be escalated to that group. The Roadmap consists of 23 cost improvement initiatives. A number of items have been approved and have either been, or are in the process of being implemented:
Reduce level of winter uplift requirements (i.e. staffing should be maintained at a safe level in accordance with your own capacity and demand modelling);
KPI reduction to 85% and transition to “average answer time”;
Implementation of new face to face service response metric;
Integrated Urgent Care Triage – change in response times;
Amend safe exit to include under 1 year only (this will change from including 1-5 year olds and over 75 year olds, which will now be managed through regular pathways);
Introduction of ANP for home visiting where safe to do so;
Redeployment of triage nurses. Current areas of focus also include soft launch of the Primary Care Centre bases at weekends and the deployment of the interface to allow appointments to be booked directly into GP Extended Access Hubs. Financial support for the provider, LCW, has been agreed for 2017/18 to support this process (£1m). Each CCG has also appointed a GP representative to oversee the road map process and provide clinical assurance of any changes to the service specification made. London Central West Unscheduled Care Collaborative are working with the NCL senior management team to agree service delivery going forward within an agreed financial envelope for 2018/19 onwards. 1.7 Quality issues 1.7.1 Never Events Never Events are Serious Incidents events that are wholly preventable because national guidance or safety recommendations have been put in place that provide strong protective barriers. They require special investigation and the learning from the investigations should prevent future occurrences. One of the key changes that have been made nationally is the removal of the option to impose financial sanctions associated with Never Events. It was concluded that commissioners imposing financial sanctions following Never Events reinforced the perception of a ‘blame culture’. The removal of financial sanctions should not be interpreted as a weakening of effort to prevent Never Events but is about emphasising the importance of learning from their occurrence, not blaming. Since the beginning of the financial year North Middlesex University Hospital and the Royal Free London Hospitals Trust have reported an increased number of Never Events. The Royal Free Hospitals Trust had reported nine Never Events to date of which one was de-escalated. They were three cases of wrong site surgery, three of retained foreign objects, one of wrong implant and one of an overdose of insulin due to appreciation or incorrect device. This is set against a background of an increased incidence of Never Events in the calendar year of 2016 and the Royal Free Hospitals Trust having undertaken an intense programme of addressing the occurrence of Never Events.
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Barnet CCG have organised an assurance visit on Never Events for 30 January 2018, have requested for the Trust to present a thematic and trend analysis at the 31 January 2018 CQRG and have commissioned NEL CSU safety team to undertake an in-depth Thematic Review to be completed by March 2018. North Middlesex University have reported five Never Events to date. Of these, three cases were wrong site surgeries / procedures and two cases of retained foreign objects. This is an increase of reported Never Events from 2016/17 when three Never Events had been reported. Haringey CCG are undertaking a thematic analysis of the learning following previous Never Events of the same type and are planning an assurance visit with a focus on root causes and action plans for February 2018. 1.7.2 Patient Experience (by exception) The scores of the Friends and Family Test in the Emergency Department at North Middlesex Hospitals has required continuous oversight from commissioners. In previous months, patient feedback on A&E services broadly mirrored the performance of the 4 hour access target and had seen an improvement in positive patient responses from 46.3% in July to 65.6% by November 2017. However there is concern that this rating by patients will deteriorate over the winter months. North Middlesex University Hospital recognises the need to increase awareness and use of the Friends and Family Test by its clinicians and has been identified as priority action for the Trust. A number of workshops have been set up to improve the collection and management of feedback. Two workshops have taken place in December 2018 and more are planned in January 2018. 2. Contracts 2.1 Background Contract performance in 2017/18 is based on signed two year contracts for 2017/18 and 2018/19. The details are described below:
Contracts were agreed with Marginal Rates of 50% for Royal Free London, North Middlesex University Hospital and Whittington Health and 75% for University College London Hospital for 2017/18. Marginal rates will apply both above and below agreed financial thresholds. This Marginal Rate agreement helps to mitigate the risk of over performance to commissioners, and offers protection to Providers if activity falls below plan;
As part of the overall contract settlement, there was also an agreement to reduce the transactional burden of the claims and challenges process for both commissioners and providers in order to free up capacity for more transformational projects and support delivery of the Sustainability and Transformation Plan (STP). Providers and commissioners have agreed a common process across NCL for this;
Ambitious STP activity reductions have been included in acute provider contracts, which equate to £36m across all providers for NCL Commissioners;
The individual contract plans have been re-costed to reflect the new nationally required HRG4+ level detail (Healthcare Resource Group: the currency in which activity is measured and paid for);
Growth of 3% has been agreed in all contracts, with the offsetting STP reductions at a similar level. The key risk is that STP reductions are largely phased to quarters three and four of 2017/18.
The financial forecast projections reported by CCGs assume STP delivery, if these schemes do not deliver the position of the CCGs will deteriorate.
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2.2 Claims and Challenges As part of the 2017/19 NHS Standard Contract, CCGs and those providers using the 50% marginal rate – Royal Free London, North Middlesex University Hospital and Whittington Health all committed to reducing the volume of claims and challenges and associated management infrastructure servicing these. This approach recognised that risk would be managed in a different way. The principle of the agreement was that “we will put it right together” rather than “we will follow a rigid adversarial process”. Following dialogue between commissioners and providers the revised claims and challenges process was signed off on 21 July 2017 by the NCL Contract Delivery Group and STP finance group with providers with the exception of University College London Hospital whose contract states they are subject to full contractual challenges. The revised Claims Process at the Royal Free London is not reducing the transactional discussions because of the large number of data capture changes that the Trust has made and data issues compared to last year. Each month the review of the Royal Free London data reveals more changes that indicate a cost implication for CCGs. In addition, the Trust is not responding to the monthly queries raised by the Commissioning Support Unit. All challenges are being discussed as part of the escalation process. A summary of claims raised to date for NCL CCGs for all trusts is presented in the table below. Of the £60.7m raised to date, £12.9m has been accepted (21%) by Trusts. Claims by CCG The value of accepted claims in the table below may increase because the impact of the quarter one Royal Free London figures are not yet included Figure 11
The table below indicates the level of claims submitted at each of the four main acute trusts (from April to November 2017) with the level of claims currently accepted. . Claims and Challenges by Trust Figure 12
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Analysis by Trust shows that the Royal Free London contract has the highest value and volume of outstanding claims and challenges for the remainder of the year, however, most of these issues will be resolved once the quarter one claims position is finalised. The figures above show claims raised between April to November 2017. The North Middlesex University Hospital acceptance of claims is higher than other providers. Two claims relating to Accident and Emergency coding changes and Paediatric Blood Tests that have been agreed as part of quarter one reconciliation and will apply going forward. Last year the percentage of accepted claims at North Middlesex University Hospital was 24%. 2.3 Quarter One Reconciliation Process Quarter one reconciliation positions have been agreed with all providers. 2.3.1.Royal Free London Quarter One Agreement For Royal Free London, whilst there is agreement on the three main disputed items of patient transport, productivity metrics and counting and coding, the final impact of the application of Marginal Rate has to be agreed with the Trust. This is wrapped up in the ongoing discussions about a full and final year-end settlement or a settlement agreed based on year end activity levels. 2.3.1.1 Settlement for 2017/18 Figure 13 below sets out the settlement on the areas of dispute listed above, and compares the settlement to the original positions of the CCGs and Trust as at Quarter One. Figure 13
The settlement included:
Fixed 2017/18 positions for patient transport services, productivity metrics, and the counting and coding challenges;
A view to the treatment of these items in 2018/19 – patient transport moving to a cost and volume basis after a gateway process for effective control of contracts; the alignment of productivity metrics to service lines to better target improvements rather than show a single line discount not attached to activity, and further technical review of all claims and challenges by a third party to agree a technical baseline.
Whilst an agreement has been reached on the items escalated through the quarterly reconciliation process commissioners will still seek to arrive at an overall year-end settlement
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for 2017/18 with the Trust. The year-end settlement would encompass areas still open to variation with the Trust following settlement of the disputed items:
Third party resolution of counting and coding challenges for 2018/19 contract baselines;
The impact of Sustainability and Transformation Plan and local interventions to reduce activity;
Application of marginal rates to the contract;
Resolution of prior-year issues including CQUIN;
Agreement on services provided by the Trust to CCGs that sit outside of the contract. CCGs have therefore made a proposal for a full and final settlement for 2017/18 and 2016/17 to the Trust as set out below:
£11m payment over and above plan for 2017/18. £9.5m in CCG positions with further £7m in downside risk assessments;
Recognition of £0.8 claim for CQUIN for 2016/17 if all other legacy items for the year are removed – invoices for patient transport services /winter planning etc. Recognising CQUIN would help the Trust with payment from non-NCL CCGs.
2.4 Quarter Two Reconciliation Process NEL Commissioning Support Unit, on behalf of commissioners, have shared quarter two reconciliation templates with NCL Providers, with the exception of Royal Free London Hospital and will agree these with Providers in January 2018. The reconciliation process with Royal Free London Hospital will be based on the agreement for disputed items set out above. 2.5 Main Risks and Mitigations The Committee is asked to note the main risks on acute contracts, and the mitigating actions being taken to address those risks: 2.5.1 Risks
The increasing dependence on delivery of STP interventions in the second half of 2017/18 to prevent further over performance on contracts;
The cost pressure to CCGs accruing from the introduction of the new tariff, with costs being £7m over the funding adjustment received from NHSE by the five CCGs;
Potential for Elective activity growth following a pause in planned care activity at all providers to provide support for winter pressures on emergency pathways in December 2017 and January 2018.
2.5.2 Actions
The application of the marginal rates are in place to mitigate over performance. The current benefit is £13.5m;
A ‘Deep dive’ has been initiated at University College London Hospital to understand the over performance in Non-Elective activity, and the impact on Referral To Treat performance - whether cancellations of elective procedures are taking place due to the growth in emergency admissions;
Coding and counting deep dive initiated at Royal Free London, which is contributing to wider discussions regarding the closedown of the quarter one and two positions;
Contract challenges issued in line with national guidance;
Undertaking growth comparison for the past two years of Payment by Results and Non Payment by Results activity.
A summary of financial performance by Trust by Point of Delivery and Trust by CCG follows. The appendix contains more detailed information and can be made available on request. 3 Financial Performance
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3.1 Performance Against Contract Baselines The Committee is asked to note the following when considering the CCG finance and activity position for acute contracts as at month nine:
Data provided by providers was of sufficient quality to enable reporting of financial performance;
NCL CCGs have reported overall year-to-date acute over performance of £15.7m and a forecast outturn over performance of £22.8m (see table below);
For the four main acute providers, NCL CCGs have reported year-to-date over performance of £19.1m and forecast outturn over performance of £21.7m (see table overleaf);
The forecast for the year-end takes into account individual CCG adjustments for the impact of STP interventions later in the year and the impact of marginal rates, with the impact of the latter being a £13.5m reduction in forecast outturn;
The forecast outturn has increased by £4.9m at month nine, driven by increases in Trust reported activity in the four main NCL acute trusts. Over 60% of this increase is at the Royal Free in Non-Elective £1.8m, Drugs £0.3m and Outpatients £0.4m. An initial review of the increase in Non-Elective shows two areas of increase. The first is a switch in coding to Best Practice tariff by the Trust, where activity stays the same whilst cost on average has increased £130 for each spell, an overall cost of £0.2m. The second area of increase is in Non-Elective admissions. Delivery of STP interventions has also reduced to 61% of plan from 63% in the previous month, reducing the impact of interventions by £0.6m
The table below reports the financial performance by CCG and by Provider. Figure 14
For information, ‘Other Acute’ contains:
Non Contract Activity;
Service level agreement exclusions;
Out of sector contracts including Bart’s Health and Imperial College Healthcare;
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Recovery Plan at Haringey CCG only. Increases on Other Acute at month nine are driven by activity changes in the Out of sector contracts at all the CCGs. 3.2 Financial Mitigations The Committee is further asked to note CCGs have included the following mitigations in their year-end forecasts for acute contracts, and they are summarised in the table below. Figure 15
All CCGs
Critical Care forecast outturn variance
Adjusted for long stay patients
STP In-Contract Interventions
Applied using CCG work stream monitoring submissions
Marginal Rate application Applied NEL Commissioning Support Unit estimate
The adjustments for Critical Care and STP interventions have been applied to the forecast outturn only. Marginal rates have been applied to both year-to-date and forecast outturn positions. The rationale for these adjustments for each CCG is described in more detail below. 3.3 STP interventions The planned impact of STP activity reductions in 2017/18 reduces acute contract baselines by £36m across all NCL providers. STP Interventions are heavily weighted to delivery later in 2017/18 with £27m of the £36m impact phased into quarters three and four as indicated in the graph below. The phasing of STP interventions, and risks to delivery, need to be factored into the risks of over performance on acute contracts by the year-end. Figure 16
The table below summarises year-end delivery assumptions by each CCG against the £33.4m planned impact of STP interventions on the four main acute contract baselines in 2017/18.
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Figure 17
The month nine forecast outturn includes an assumption of £12.9m slippage against the targeted delivery of STP interventions. The forecast achievement against plan (61%) has dropped 2% from last month’s 63% achievement. Barnet has maintained forecast achievement at last month’s levels. Haringey, Islington and Camden have reduced achievement by 13%, 2% and 4% respectively. This is offset by Enfield which has increased its achievement again by 4% to 77%. 3.4 Application of Marginal Rates The table below summarises the application of marginal rates by CCG at month nine. Figure 18
The forecast outturn of £22.9m over performance across acute contracts for the five CCGs is after the application of marginal rates allowed for in contracts. At month nine marginal rates are forecast to yield £13.5m benefit to the CCGs in 2017/18. The underlying year-end over performance in acute providers on a full payment-by-results tariff would therefore be £36.3m at month nine. 3.5 Financial Run Rates Run-rates provide a high-level view of expenditure on acute contracts. In line with the phasing of STP interventions above, the run-rate of expenditure on acute contracts was expected to reduce the run-rate in the second half of the year. This has not materialised as the STP intervention achievement is 61% of plan. Together with increases in Non-Electives the run-rate has increased over 16/17 levels at month nine (figure 19). Figure 19
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The run-rate analysis for month nine shows an increase at the Royal Free London 8%, and North Middlesex University Hospital 6%, while the run rate decreased at The Whittington 7% and University College London Hospital 1%. The financial year-to-date run-rate comparison to this time last year shows that Royal Free London is 6% higher, University College London Hospital 4% higher, North Middlesex University Hospital 4% higher and Whittington Health 1% higher for the following reasons:
Royal Free London relates to an increase primarily in Outpatients, Non-Elective Admissions, Drugs and Devices, Diagnostic Imaging and Accident and Emergency. In contrast, Elective activity is 7.5% lower indicating a capacity shift to emergency activity and may explain the slippage on Referral To Treat performance;
University College London Hospital overall financial run-rate has remained stable between 2016/17 and 2018/19. Within this Non-Elective spend has increased during the latter part of 2016/17 and quarter one 2017/18, which has been offset by reduced spend on elective and day case work. In the nine months of 2017/18 the monthly run-rate has been £17.5m, against a planned position of £16.7m. The run rate would need to reduce to £15.3m in the last three months of 2017/18 in order for NCL to hit the contract plan. The introduction of QIPP schemes impacting on last quarter of the financial period will assist with this;
The North Middlesex University Hospital rise primarily relates to Accident and Emergency cost increases and Non-Elective increases when compared to last year. The former was successfully challenged during the quarter one reconciliation process with a credit returning to the CCGs, increase in Non-Elective is being investigated;
Whittington Health increase primarily relates to Accident and Emergency cost increases, in part due to increased tariffs for 2017/18 and also due to coding changes which were challenged and resolved as part of the quarter one reconciliation process. Maternity has also seen an increase from last year due to tariff uplifts;
Comparisons between years can be misleading due to Identification Rules year on year changes that have switched commissioner responsibility, and associated cost, between specialised commissioning and CCGs.
A projected run rate for the future months has been estimated, as requested by the Committee in October 2017, and is shown as dotted lines on the graph above overleaf. Projected run-rates are consistent with the month nine reported forecast outturn on each contract. As the QIPP schemes in the latter part of the year increase the yield of delivery the overall run rates should decrease. Consideration of the trend for the rest of the year needs to take into account the materiality of QIPP (£36m) compared to acute contract baselines for the year (£1.2b) making the decrease in run-rate not particularly discernible in the graph above. Months 11 and 12 are expected to show relatively higher run rates due to the extra working days which translate into additional planned care activity.
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The financial run rate movement month on month will continue to be reviewed alongside performance against plan, as a useful indicator of underlying contract performance in 2017/18 that will be the start point for contract baselines in 2018/19. 3.6. Individual Trust performance Updates This section summarises performance against plan for each Trust by CCG. A detailed report, available on request, provides a more granular analysis of Trust performance against plan. 3.6.1 Whittington Health Figure 20
Figure 21
At month nine the year-end position is £0.5m over performance against plan for NCL CCGs. This is an adverse movement of £0.2m from the month eight position, driven by an increase in activity and cost within Outpatients and Non-Electives. Camden and Enfield CCGs are under performing against plan whilst Barnet and Haringey are over performing and Islington CCG is reporting to plan. The forecast outturn position includes adjustments for accelerated delivery of the STP, which will come into effect in the later part of the year.
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The table below shows the split between acute and community reporting for the Trust with community activity forming part of a block contract. Figure 22
Key points of delivery causing this variance are: Accident and Emergency The forecast over performance within A&E at month nine is £1m. The year-to-date over performance of £0.6m is driven by increases in activity and also in part by a coding change notified in 2016/17 by the Trust. A £0.2m reduction to account for this coding change has been agreed across NCL CCGs as part of the quarter one reconciliation and has been adjusted for in this position. Non Elective The forecast over performance within Non Elective at month nine is £0.8m. The year-to-date over performance of £0.4m is driven by over performance seen in Accident and Emergency, Geriatric Medicine and General Medicine. Outpatients The forecast over performance within Outpatients at month nine is £0.8m. Year-to-date over performance seen across a number of specialties, but in particular Trauma and Orthopaedics where there is a large STP impact phased for achievement in quarter four. Critical Care The forecast under performance within Critical Care at month nine is £2.9m. Critical Care is under performing across all CCGs, with a year-to-date under performance of £2.1m. However in the main, this is driven by under performance against plan for Haringey CCG. This under performance is offset by over performance in Critical Care on the University College London Hospital contract for Haringey CCG. Maternity The forecast under performance within Maternity at month nine is £1.4m. Under performance is seen in both births and maternity pathways with a year-to-date under performance of £1.1m. Further action on the contract for future reports will include:
An agreed variation that will change CCGs’ contract values to take into account the application of changes to Identification Rules between CCGs and specialised commissioning. Funding has now transferred from NHS England and it is therefore expected that this variation will be in place for month ten reporting.
3.6.2 Royal Free London Figure 23
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Figure 24
The position reported at month nine for Royal Free London shows a £14.4m forecast over performance against the contract plan for NCL CCGs at the year-end. Overall, there has been an unfavourable movement in forecast outturn of £2.5m from month eight to month nine. The unfavourable movement is driven by a Best Tariff Cost that was not reported in the past few months along with the changes described below. The areas causing variance to the plan are: Outpatients The forecast over performance within Outpatients at month nine is £5.3m. The variance to plan causing the CCGs over performance is within the specialties listed below:
Trauma & Orthopaedics;
Cardiology;
Ophthalmology;
Nephrology. Within Cardiology the Trust has advised that they undercharged activity in 2016/17 and this is now being coded in line with guidance. Agreement has been reached on the value of all counting and coding changes to be applied for quarter one and this has been adjusted within the ‘Other’ category. The over performance in Trauma and Orthopaedics is predominantly impacting Barnet CCG which is £1.2m forecast above plan and is within both First and Follow Up Outpatient attendances. The Ophthalmology over performance is predominantly at Enfield CCG which is £0.79m forecast above plan where there is a negative plan due to the value of the planned service transfer. Overall, the application of STP has resulted in some specialties and specific activity reporting against negative plans which is the result of the Sustainability and Transformation Plans removing more activity than was historically sent to Royal Free London Hospital. As a
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result of the changes Royal Free London Hospital are making actual activity has changed considerably from previous years. The over performance in Nephrology is due to a misattribution of specialised commissioned activity and this has been closed down within the overall challenges process as part of the quarter one reconciliation and an adjustment has been made within the ‘Other’ category. Non-Electives (Unplanned Care) The forecast over performance within Non-Electives at month nine is £3.4m. Camden CCG is over performing by £3.1m and Barnet CCG is over performing by £1.7m. The total overspend is offset by underperformance at Islington CCG of £0.7m, Haringey CCG of £0.5m and Enfield CCG of £0.3m. Non- Elective over performance by specialty is within General Medicine and Accident & Emergency of £3m. Non Elective has experienced a significant in month cost pressure to all CCGs from month eight to month nine of £1.7m. This is predominantly in the Barnet CCG and Camden CCG positions. Best Practice Tariff recording is the main reason for the over performance. Non–Elective inpatients; Non Elective same day and short stay are the principal drivers of the cost increase. The NCL conversion ratio from Accident and Emergency to Non-Elective for month eight is 16.08%. This is higher than the preceding 2017/18 average or the same period in 2016/17 with a particularly sharp upward movement in month. When compared to the prevailing conversion ratio in Months one to seven of 14.46% this equates to approximately 287 additional patients admitted in the month. Figure 25
The month eight submissions also has Non-Elective activity which is charged at Best Practice Tariffs which has increased in month by £0.7m. Best Practice Tariff activity attracts additional top up payments above the normal tariff that are designed to incentivise high quality and cost-effective care. The aim is to reduce unexplained variation in clinical quality and to encourage best practice: Figure 26
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Figure 27
There is also an average shift of 11% each month between the initial (‘Flex’) submission and the final (‘Freeze’) position. As such it is expected that the rise in month eight Best Practice Tariff activity may be an underestimate of the actual activity attracting the higher tariff: Figure 28
Accident and Emergency The forecast over performance within Accident and Emergency at month nine is £1.6m. At specific activity level, this can be attributed to:
Emergency Medicine, Category 1 Investigation with Category 1-2 treatment £1.1m;
Emergency Medicine, Category 2 Investigation with Category 1 Treatment £0.85m.
Analysis has shown a shift to more complex activity, with the resulting increase in costs which has been challenged as a counting and coding change at the Barnet site. Following the quarter one agreement there is an adjustment within the ‘Other’ category. Diagnostic Imaging The forecast over performance within Diagnostic Imaging at month nine is £1.4m. Diagnostic Imaging performance is driven by high levels of activity in GP Direct Access tests and a small number of Direct Access high volume/low cost activities. NEL Commissioning Support Unit challenged this as a counting and coding change. Agreement has been reached on the value
Activity
Apr May Jun Jul Aug Sep Oct Nov Grand Total
BPT 804 903 1,328 953 699 636 804 966 7,093
Other 4,149 4,619 4,316 3,992 3,835 3,861 4,035 4,217 33,024
Grand Total 4,953 5,522 5,644 4,945 4,534 4,497 4,839 5,183 40,117
-
200
400
600
800
1,000
1,200
1,400
Apr May Jun Jul Aug Sep Oct Nov
NCL Non Elective BPT Activity
Freeze
BPT Activity Apr May Jun Jul Aug Sep Oct Nov Grand Total
Freeze 804 903 1,328 953 699 636 804 966 7,093
Flex 746 858 698 909 736 624 752 966 6,289
Movement 58 45 630 44 37- 12 52 - 804
% 7.2% 5.0% 47.4% 4.6% -5.3% 1.9% 6.5% 0.0% 11.3%
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of all counting and coding changes to be applied for quarter one and this has been adjusted within the ‘Other’ category. Electives (Planned Care) The forecast over performance within Electives at month nine is £1.2m. Enfield CCG is forecast to be £3.6m over plan. The total over performance against plan is partially offset by under performance in the forecast of the Barnet CCG position of £2.2m. The over performance is in the specialities of Ophthalmology and Trauma & Orthopaedics. Over performance for Enfield CCG in Ophthalmology is because of the service transfer by the CCG. As with Outpatients, there is a negative plan for Ophthalmology for Enfield CCG due to the value of the service transfer and the application of STP. Trauma and Orthopaedics over performance is mainly at Enfield CCG with a £1.04m forecast overspend compared to plan. There is an overspend for Enfield CCG within Inpatient admissions of forecast £1m and is driven by specific activity covering major hip or knee procedures. Other The forecast over performance within ‘Other’ at month nine is £1m. Over performance in this category is driven by adjustments and settlement of issues arising from the quarter one reconciliation, including:
The £4.9m forecast deduction by Barnet CCG for local QIPP that is not included in contract agreed with Royal Free London;
The £3.0m cost to CCGs on productivity metrics due to agreement that 50% of the agreed contract reduction of £6m will be included in 2017/18. The Metrics for 2018/19 are to be negotiated as part of a review of all of the activity plans;
The £2.4m cost to CCGs on the Claims and Challenges against the plan levels. Agreement has been reached on the value of these to be applied for quarter one and this has been adjusted within the ‘Other’ category and therefore not applied to the activity at point of delivery or specialty level. Agreement on the treatment of these changes for the remainder of the year has not been reached. CCGs have included adjustments of £3.7m in anticipation of claims being resolved in their favour.
CCGs are benefitting by £3.9m on adjustments made for the marginal rate activity. Regular Attenders The forecast over performance within Electives at month nine is £0.7m. Within Regular Attenders there was a step change in Medical Oncology activity in December 2016 for all CCGs. Royal Free London responded to the query raised on this change that they undercharged activity in 2016/17 and this has now been updated and is being coded correctly. This is part of the ongoing escalation discussions for resolution. Following the quarter one agreement on the value of all counting and coding changes there is an adjustment within the ‘Other’ Category. 3.6.3 University College London Hospital Figure 29
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Figure 30
The University College London Hospital position at month nine shows a £3.9m over performance against the contract plan for NCL CCGs. The forecast outturn for month nine deteriorated by £0.8m compared to month eight. The movement is a result of deterioration in the Islington, Haringey and Barnet CCG positions. Islington CCG had the largest in month deterioration of £0.5m in the forecast outturn of the NCL CCGs driven by Non-Elective casemix increase £0.2m, Outpatients £0.2m which had been accrued for in previous months and Critical Care £0.1m. The areas causing variance to the plan are: Non-Elective (Unplanned Care) The forecast over performance within Non-Elective at month nine is £4.5m. For NCL the year-to-date position is seeing significant over performance in Non-Elective emergency admissions of £4.0m. The casemix reported by University College London Hospital in month eight data was significantly higher in unit cost when compared to previous months. This issue has been challenged in the latest claims and challenges letter. The areas causing variance to the plan are:
Activity growth: Overall, for the first eight months of 2017/18, Non-Elective activity is 8% higher than in the same period in 2016/17 (around 140 admissions per month). This is having an impact on all specialties and is reflective of an underlying growth in emergency activity at University College London Hospital over the past 12 months;
Non-delivery of STP: The current forecasted position for STP at University College London Hospital is 50%, which translates to an under delivery of £1.4m against planned impact of around £2.8m;
Accident and Emergency Casemix: The overall volume of accident and emergency attendances at University College London Hospital has been lower year to date in 2017/18
Commissioner YTD+1 Plan YTD+1 ActualYTD+1
Variance Annual Plan Annual Actual
Annual
Variance
Movement
from last
month
NHS Barnet CCG 19,555,613 19,107,047 (448,566) 25,908,435 25,541,562 (366,873) 385,534
NHS Camden CCG 49,949,820 50,890,730 940,910 66,451,428 67,353,616 902,188 (58,062)
NHS Enfield CCG 12,730,995 12,407,398 (323,597) 16,974,665 16,561,923 (412,742) (181,193)
NHS Haringey CCG 15,537,701 16,998,995 1,461,294 20,654,819 21,779,677 1,124,858 111,931
NHS Islington CCG 52,430,913 54,512,417 2,081,504 69,907,878 72,527,816 2,619,938 502,970
Grand Total 150,205,042 153,916,588 3,711,546 199,897,225 203,764,595 3,867,370 761,180
POD Analysis YTD+1 Plan YTD+1 ActualYTD+1
Variance Annual Plan Annual Actual
Annual
Variance
Movement
from last
month
Accident and Emergency 9,405,183 9,064,428 (340,755) 12,344,644 11,975,237 (369,407) 124,766
CQUIN 3,808,779 3,651,082 (157,697) 4,993,328 4,858,462 (134,866) 1,432
Critical Care 5,615,576 6,213,797 598,220 7,543,715 7,430,376 (113,339) 27,588
Diagnostic Imaging 6,948,397 6,231,632 (716,765) 9,378,882 8,316,045 (1,062,836) (405)
Drugs and Devices 5,669,381 6,264,638 595,257 7,413,428 8,352,850 939,423 165,538
Elective 29,675,249 29,088,028 (587,221) 38,961,185 38,664,351 (296,834) 51,838
Maternity 20,587,104 19,750,036 (837,068) 27,029,170 26,279,010 (750,159) (42,427)
Non-Elective 29,273,964 33,064,394 3,790,431 39,149,525 43,644,972 4,495,447 135,867
Other 3,239,148 3,191,403 (47,745) 5,755,620 4,829,356 (926,264) (158,852)
Outpatients 34,126,304 35,543,048 1,416,743 44,853,123 46,941,800 2,088,677 455,838
PTS 1,855,955 1,854,101 (1,854) 2,474,607 2,472,134 (2,472) 0
Grand Total 150,205,042 153,916,588 3,711,546 199,897,225 203,764,595 3,867,370 761,180
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compared to the previous year, whist the clinical acuity of those presenting has increased. This results in more patients needing admission to an emergency bed at the Trust;
Emergency activity is over performing against contract plan across the NCL acute provider contracts, and is responsible for over 50% of acute contract over performance. Previous analysis showed that there may have been market share shifts between providers which has driven some of the over performance at University College London Hospital.
Critical Care The forecast under performance within Critical Care at month nine is £0.1m. Year-to-date over performance is due to high volumes of bed days for lower complexity patients, alongside some high cost patients discharged for Islington and Haringey CCGs. The Haringey CCG forecast for one exceptionally high cost patient mitigates the year-end forecast position to reduce back down to being in line with planned costs. At an NCL level the monthly volume and value of Critical Care bed days billed by University College London Hospital is in line with the 2016/17 averages. This confirms year-to-date over performance relates to monthly phasing of the plan and high cost patients. Outpatients The forecast over performance within Outpatients at month nine is £2.1m. This is a direct extrapolation of the year-to-date over performance reported in the position. The forecast position deteriorated by £0.5m in month nine. The movement in activity and cost in month nine reporting is partially offset by the outpatient seasonality accrual adjustment made by NCL CCGs in month eight. Activity levels are in line with the overall planned volume of attendances and procedures overall. This is supported by the fact that GP referrals to University College London Hospital across NCL is lower than in 2016/17. The Outpatient position reported is due to higher than planned follow-up and procedure activity and is a result of the impact of HRG4+ pricing model, which generates more procedures compared to the previous model, and potential specialty level charging issues under investigation with University College London Hospital and Camden CCG. The main driver of Outpatient Procedures over performance is Neuropsychology tests. The issue is these tests should potentially be charged to NHS England and have been challenged as such. The query forms part of the quarter two reconciliation. The remaining over performance within outpatients sits primarily within under delivery of STP interventions in the forecast outturn, where an original plan of £2.4m of activity was due to be removed from University College London Hospital whilst the latest reporting shows only £1.3m under delivery. 3.6.4 North Middlesex University Hospital Figure 31
Figure 32
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The North Middlesex University Hospital position at month nine is a £3.1m over performance against the contract plan for NCL CCGs. The areas causing variance to the plan are: Outpatients The forecast over performance within Outpatients at month nine is £4.8m. The combined CCG year-to-date Outpatients position is over performing by £3.7m. This is made up of a forecast over performance to plan of £1.4m within Outpatient Follow-ups. The over performance is in a range of specialities; Ophthalmology, Cardiology, Medical Ophthalmology and Respiratory Medicine and is primarily due to the failure of the STP interventions to deliver reductions in all specialities. The forecast over performance within Outpatient First appointments for all CCGs is £0.7m. This is mainly driven by Anaesthetics which is being queried with the Trust as a pathway change relating to pain patient referrals. In addition the specialities of Ophthalmology, Trauma & Orthopaedics and Gynaecology are all over performing against plan. All of these areas have STP schemes which should be delivering a reduction in referrals. Non-Elective (Unplanned Care) The forecast over performance within Non-Elective at month nine is £4.3m. The combined year-to-date Non-Elective position is over performing by £3.4m. This is made up of Non-Elective £3.9m, Non-Elective Non-Emergency £0.9m and Non-Elective Same Day £0.6m. This is offset by underspend in Non-Elective Excess Bed Days £0.9m and Non-Elective Short Stay £1.1m.
Non-Elective £3.9m: Geriatric Medicine is over spent at £1.3m mainly due to the national coding change relating to Sepsis which is causing a forecast of £0.5m of the reported variance to plan. Activity that the Trust has not previously undertaken, or has a zero plan is contributing a further £0.5m variance to the plan.
Non-Elective Non-Emergency forecast over performance of £0.9m. This is mainly due to a forecast variance to plan within Stroke Medicine of £0.3m and Cardiology £0.2m.
Non-Elective Same Day forecast over performance £0.6m. This is mainly due to a forecast variance to plan within Accident and Emergency of £0.4m and General Surgery £0.09m.
Accident and Emergency The forecast over performance within Accident and Emergency at month nine is £0.9m. The year-to-date over performance within the Accident and Emergency department is £0.8m.
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Accident and Emergency has a forecast overspend, but is offset by underspend in the Urgent Care Centre. NEL Commissioning Support Unit has been successful in Accident and Emergency change in coding. As part of the quarter one reconciliation process 67% of overspend across two areas of over performance has been credited. Keeping in line with the agreement, a similar adjustment has been made to the forecast position. Drugs and Devices The forecast over performance within Drugs and Devices at month nine is £0.6m. The overspend is mainly in Ophthalmology which is subject to a query related to Enfield CCG Any Qualified Provider pathway of care transfer. Other The forecast under performance within Other at month nine is £4.8m. The unmitigated position submitted by North Middlesex University Hospital Provider Submitted is an over spent at £0.8m, mainly due to Ambulatory Care Unit forecast overspend of £1.5m. This overspend is offset by adjustments of £3.6m giving a net year-to-date position of £2.8m underspend. The CCG made adjustments to take into account the quarter one reconciliation, STP achievement and Marginal Rate. Maternity The forecast under performance within Maternity at month nine is £2.1m. The Maternity Unit is under performing year-to-date by £1.6m. This is driven by a forecast underspend within Obstetrics of £1.2m and Midwife Episodes of £0.4m. Critical Care The forecast under performance within Critical Care at month nine is £0.8m. The underspend is mainly driven by reduction in Adult Critical Care 1 and 2 organ supported care. 3.6.5 Other Providers by Exception Barts Health The Trust has maintained the 95% coding level for the third month in a row, so the early risk of low levels of coding has now been removed. At month nine the forecast outturn remained relatively unchanged with a £0.2m increase across the five NCL CCGs. 3.7 Individual Commentary from CCGs 3.7.1 Barnet CCG* The total budget expenditure on Acute Contracts is £269.0m*, which is net of £10.9m QIPP (£7m is in acute contracts) – gross of any re-investment. At month nine the forecast outturn is £279.6m*, which is an over performance against plan of £10.5m. The forecast outturn has increased by £2.8m* since month eight due to activity levels increasing at the majority of providers (particularly at the Royal Free) partially offset by marginal rate impact. November activity was above trend in all points of delivery except Accident and Emergency (and above October) and may not be reflective of the performance in the remainder of the year. The forecast outturn includes expected QIPP slippage and impact of marginal rate. Royal Free London The largest contract is Royal Free London (£181.9m*). At month nine (excluding QIPP) the underlying position has worsened to around £2.6m over performance from broadly on plan, after amending for Barnet CCG’s share of the adjustments described above in the Contracts and Royal Free London section of this report. There are some variance by Point of Delivery
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with over performance in Accident and Emergency, non-elective, Outpatients and those items such as claims and challenges include in ‘Other’; partially offset by under performance in elective. Other in sector University College London Hospital forecast outturn is an under performance of £0.4m. This is mainly due to Maternity and Critical Care. The forecast outturn for other acute trusts in sector is an over performance of £0.8m (£1.0m net of QIPP slippage and marginal rate).
Other acute spend Forecast outturn for Out of Sector Acute Trusts is an over performance of £2.1m, spread across a number of organisations with relatively small over performance against each. *Note the analysis excludes local QIPP and winter resilience which is included in the summary tables earlier in this report
3.7.2 Camden CCG As at month nine the acute contracts are forecasting a year-end over performance of £3.4m year-to-date and forecast outturn of £4.7m. This indicates a negative cumulative movement against the month eight position of £0.1m. The main drivers continue to be forecast over performance at the Royal Free £2.9m, University College London Hospital £0.9m and Imperial College £0.9m. Forecast is after the application of STP QIPP and marginal rate adjustments. University College London Hospital As at month nine University College London Hospital is forecast to over perform by £0.9m. This is mainly driven by forecast over performance in Non-Elective (£2.5m), offset by forecast underspends in Electives (£0.8m), Critical Care (£0.4m), Accident & Emergency (£0.2m) and Diagnostic Imaging (£0.2m). There has been minimal movement in the overall forecast outturn and individual Point of Delivery level forecasts against prior month. The year-to-date and forecast outturn positions broadly align at month nine. This is due to the phasing of QIPP schemes, which are scheduled to be delivered in the latter part of the financial year. Royal Free London At month nine the Royal Free London is forecast to over perform by £2.9m for the full year, an increase of £0.1m against prior month forecast. Over performance is mainly driven by Non Elective (£3.1m), Accident and Emergency (£0.5m) and Diagnostic Imaging (£1.9m) activities, which have been offset by forecast underspends in Critical Care (£0.4m), Maternity (£0.5m) and accepted challenges to activity (£1m). Imperial At month nine Imperial College over performance is £0.9m, consistent with prior month. This is mainly driven by over performance within Non Electives (£0.9m) and Critical Care (£0.2m), which are primarily offset by forecast under performances within Maternity (£0.2m) and Drugs & Devices (£0.2m). 3.7.3 Enfield CCG At month nine there is a forecast overspend against plan of £7.02m. However this is based on a number of adjustments and contains further risks.
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The current assessment of QIPP estimates slippage of £7.5m in total split between £2.5m within Acute Contracts and £5m outside of Acute contracts. This slippage has been absorbed in the overall financial position through a number of non-recurrent mitigations which remain high risk. (The CCG continues to hold £6.0m of identified QIPP not built into contracts or budgets). North Middlesex University Hospital The contract with North Middlesex University Hospital is over performing year to date by £3.1 m and forecast to overspend by £2.9m at year-end. The key over performing Points of Delivery are forecast to be Non-elective (5.3m), Outpatients (£3.3m) and Accident and Emergency (£0.9m). This is partially offset by a forecast underspend in Maternity (£0.8m). Included in the position are adjustments for; STP achievement at 75%, and the impact of the marginal rate at 50%. The position also reflects the forecast adjustment based on the quarter one reconciliation. Royal Free London The contract with Royal Free London is overspent by £3.6m year to date and forecast to over-spend by £3.8m at year end. The key over performing Point of Delivery are forecast to be Elective (£1.8m), Outpatients (£1.7m) and Maternity (£0.6m). There is significant under performance in emergency admissions (£0.2m) Included in the position are adjustments for; STP achievement at 75%, and the impact of the marginal rate at 50%. No other challenges are included in the position. University College London Hospital The contract with University College London Hospital is under-spent by £0.3m year to date and forecast to under-spend by £0.4m at year end. The key underperforming Points of Delivery are forecast to be Elective (0.4m) and Non-Elective non-emergency (£0.1m). This is partially offset by a forecast over-spend in Non-Elective (£0.2m). Included in the position are adjustments for; STP achievement at 75%, and the impact of the marginal rate at 25%. No other challenges are included in the position. 3.7.4 Haringey CCG At month nine the forecast outturn on acute contracts is £226.5m*, which is an overspend against plan of £3.5m. However this is based on a number of adjustments and contains further risks, in particular additional in-year acute over performance and under-delivery of STP interventions. The position currently forecasts QIPP slippage of around £1.8m, largely relating to STP planned care. The overspends within the local acute contracts accrue from Whittington Health (£0.4m) University College London Hospital (£1.1m) and Royal Free London (£0.9m). The out of sector providers are also reporting overspends of £1.5m for Homerton (£0.5m), Guys (£0.4m), Imperial (£0.4m) and Royal Brompton (£0.3m). The out of sector contracts do not benefit from marginal rate protection. *Note that this figure does not cover all acute spend, for example, it excludes winter pressures, ambulance and private providers, and so will not align with figures shown in Figure 15.
Whittington The contract is reporting an overspend of £0.3m at month nine and forecast to overspend by £0.4m at year end. Over performance is being reported in Accident and Emergency, Drugs and Devices and Outpatient activity. This is offset by underspends in Critical Care, Diagnostic Imaging and Maternity.
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Included in the position are adjustments for seasonality, high cost Critical Care patients, STP achievement and the impact of the marginal rate at 50%.
North Middlesex The contract is performing to plan at month nine and forecast to plan at year end. Over performance is being reported in outpatients, Accident and Emergency and Non-Elective activity. This is offset by underspends in Elective, Maternity, Diagnostic Imaging, and Critical Care.
Included in the position are adjustments for seasonality, STP achievement, non-recurring Orthopaedic trauma activity and the impact of the marginal rate at 50%. Other in sector The University College London Hospital forecast outturn over performance of £1.1m is being reported in drugs and devices, maternity and outpatients. Royal Free London over performance of £0.9m is largely driven by Critical Care activity. 3.7.5 Islington CCG At month nine, the overall acute position is reporting a pressure of £3.3m for forecast outturn that represents the largest financial risk to the CCG. This is an adverse movement of £1m from the prior month and is mostly due to increase in month activity changes at UCLH (£0.5m); The Royal Free (£0.1m); Barts (£0.1m) and Guys and St Thomas (£0.1m). The main in-sector pressures accrue from UCLH (£2.6m), however this is predominantly offset by an underspend at Royal Free London (£1.1m). Out of sector contracts, which do not benefit from marginal rate protection, currently contributes £1.6m to the overall adverse forecast outturn. The main pressures are reported in Barts (£0.9m), Homerton (£0.4m), and Guys & St Thomas (£0.5m) which have been partially offset by an underspend in Chelsea & Westminster (£0.2m). University College Hospital Year-to-date there is £2.1m over performance (Non Elective, Outpatients, Critical Care and Drugs and Devices). At forecast outturn there is a reported £2.6m over performance (Non Elective, Outpatients, Critical Care, Elective, Drugs and Devices and offset by Diagnostic Imaging, Maternity and A&E). This position includes QIPP and the impact of marginal rate. The majority of the pressure continues to be reflected in Non Elective £1.9m forecast outturn, specifically within the specialities of Accident & Emergency, Clinical Pharmacology, Gastroenterology, Geriatric Medicine and Neurology. The year-to-date position has seen a pressure in Critical Care due to a long stay patient discharged however these costs have been adjusted for the forecast to mitigate a potential upward trend. The forecast outturn also includes additional seasonality activity within Elective admissions and Outpatient appointments. Whittington Health The final position has been reported as break-even which includes an adjustment for QIPP and the impact of marginal rate. The forecast over performance on this contract is reported within Outpatients (£0.3m) and A&E (£0.2m). Outpatients over performance is driven by Trauma and Orthopaedic (£0.3m) and Ophthalmology costs (£0.1m). The Whittington’s A&E pressure is driven in the main by Emergency Medicine Category 2 (Investigation with Category 1- 2 and 2-4 Treatments). 4 Activity Performance
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This section summarises the activity performance of the four main providers at an NCL level, the main focus being a comparison of activity level between the two financial years 2016 and 2017. The appendix to this report shows further, more detailed information, and can be made available on request. Accident and Emergency In NCL we have seen an increase in Accident and Emergency activity since 2016-17. The increases are at Whittington Health which is currently up by 4% compared to this time last year, North Middlesex University Hospital up by 2% and Royal Free London up 1%. University College London Hospital are 1% below their previous year’s activity. Figure 33
A&E Activity Actuals : 2016/17 vs 2017/18
Daycases In NCL there has been a decrease in daycase activity since 2016-17 for the Royal Free London, North Middlesex University Hospital and Whittington Health hospitals. Royal Free activity is below 16/17 actuals by 31%. This drop has been caused by reduced activity in:
Colorectal Surgery – reduction in Colonoscopies and Flexible Sigmoidoscopies
Dermatology – reduction in Minor Skin procedures
Urology – reduction in Flexible Cystoscopies
North Middlesex activity below 16/17 actuals by 2%; Whittington Health is below 16/17 actuals by 12%. This drop has been caused by reduced activity in:
Urology – reduction in Flexible Cystoscopies
Colorectal Surgery – reduction in Colonoscopies
General Surgery - reduction in Minor Skin procedures University College Hospital are an outlier as daycase activity is above 16/17 actuals by 6%. This increase has been caused by increased activity in:
Urology – Therapeutic substance into bladder
Gastroenterology – therapeutic colonoscopy
Pain management – Infusion of therapeutic substance.
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It is anticipated that these reductions are as a direct result of successful QIPP schemes. It is also anticipated that the cancellation of non-urgent planned care to support winter pressures will also reduce the number of referrals into diagnostic settings. Figure 34
Daycase Activity Actuals : 2016/17 vs 2017/18
Electives In NCL there has been a decrease in Elective activity since 2016-17 for The Royal Free, North Middlesex University Hospital and University College London Hospital.
Royal Free activity is below 16/17 actuals by 9.5%.
North Middlesex University Hospital activity is below 16/17 actuals by 1.7%.
University College London Hospital are below 16/17 actuals by 13.5%. Whittington Health’s Elective activity is above 16/17 actuals by 3.8%. Figure 35
Nationally there is a 4.04% decrease in Elective Care. It is anticipated that the cancellation of non-urgent planned care activity to support winter pressures will also continue to reduce the number of referrals into planned care settings. Figure 36
Elective Activity Actuals : 2016/17 vs 2017/18
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Non-Elective admissions In NCL, we have seen an increase in Non-Elective activity since 2016-17 for all our Acute providers:
Royal Free London activity is above 16/17 actuals by 3.9%;
North Middlesex University Hospital activity is above 16/17 actuals by 5.6%;
University College London Hospital are above 16/17 actuals by 1.8%;
Whittington Health activity is above 16/17 actuals by 1.7%. Figure 37
One of the drivers is the change in rules that now records activity previously captured by NHSE and is now recorded by CCGs in 2017-18. This contributes to 2% increase in activity across NCL. Nationally there is a 3.28% increase in Non-Elective Care (source: National MAR return). Figure 38
Non Elective Activity Actuals : 2016/17 vs 2017/18
Outpatient First Attendances In NCL we have seen a slight decrease in Outpatient First Appointments activity since 2016-17.
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Royal Free activity is below 16/17 actuals 3.2%. This has been as a result of activity within Maxillo–Facial that is now recorded by NHSE;
Whittington Health activity is below 16/17 actuals by 5.6%. This is due to a reduction in appointments in Dermatology and General Surgery
University College London Hospital are below 16/17 actuals by 3.5%. This has been as a result of activity within Maxillo–Facial that is now recorded by NHSE.
North Middlesex University Hospital are an outlier as Outpatient First Appointment activity is above 16/17 actuals by 6.5%. This increase has been caused by increased activity in Trauma and Orthopaedics, Gynaecology, Cardiology and Anaesthetics. Figure 39
Outpatients First Activity Actuals : 2016/17 vs 2017/18
Outpatient Follow Up In NCL we have seen a slight increase in Outpatient Follow Up Appointments activity since 2016-17. This is largely being driven by:
The Royal Free with a 10% increase - this is due to an increase in Anticoagulant Service and Dermatology;
North Middlesex with a 9.5% Increase - this is due to an increase in Colorectal Surgery, Breast Surgery, Respiratory Medicine, Urology and Ophthalmology.
Whittington Health and University College London Hospital have seen a slight decrease in activity against 2016-17:
University College London Hospital are below 16/17 actuals by 7.7% - this is due to a decrease in Anticoagulant Service, Maxillo-Facial Surgery, Diabetic Medicine and ENT;
Whittington Health activity is also below at 5% - this is due to a decrease in Anticoagulant Service and General Surgery.
Figure 40
Outpatients Follow Ups Activity Actuals : 2016/17 vs 2017/18
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Report Development The acute commissioning report provided to the NCL Joint Commissioning Committee has been updated with changes following feedback received from previous reports. The intention is that this report is also used by CCGs to inform their respective Governing Bodies and supporting Committees of acute contract performance. The Committee is therefore asked to make recommendations for further development of the report to ensure that the Joint Commissioning Committee and CCGs receive a comprehensive and rounded assessment of provider performance.
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1
NCL Joint Commissioning Committee Meeting on Thursday 1st February 2018
Report title Transforming Care Programme Update
Agenda item 3.2
Date
25th January
2018
Lead director Paul Sinden Director of Performance and Acute commissioning NCL
Tel/Email [email protected] 020 3688 2906
Report author Kath McClinton Assistant Director Special Projects Islington CCG and Senior Responsible Officer (SRO) Transforming Care Programme
Tel/Email [email protected] 020 3688 2921
Sponsor(s) (where
applicable)
Tel/Email
Report summary Transforming Care is a national programme aimed at supporting people with learning disabilities to live rewarding and fulfilling lives in the community and prevent the need for long term hospital care. As part of this we are required to reduce the number of hospital beds commissioned for patients with a learning disability and/or autism by the end of March 2019, when the Programme ends. This report updates the Committee on North Central London’s performance against our overall bed reduction trajectory, along with progress against a sub-target relating to patients with an inpatient stay of 5 years or more. It also provides an update on an improved Funding Transfer Agreement offer from NHS England for patients funded by Specialist Commissioning as well as a break down, by CCG area, of the local transfer costs to Local Authorities for those CCG funded patients with a hospital admission of 12 months or more prior to community discharge. The likely funding transfer from Specialist Commissioning for long stay patients 2016/17 and 2017/18 is in the region of £1m, assuming planned discharges are achieved. The full year cost of the local funding transfer from CCGs to the Local Authorities for patients discharged over the same period of time is a similar amount.
Purpose (tick one
only)
Information Approval To note
Decision
Recommendation Note the current North Central London performance against the bed
Appendix:
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2
reduction trajectory and measures in place to support sustained progress;
Note the improved Funding Transfer Agreement from NHS England;
Approve the funding transfer from individual North Central London CCGs to the respective Local Authorities for those CCG funded patients with an inpatient stay of 12 months or more on discharge, effective from 1 April 2016;
Receive a further update at the April Committee.
rev
Conflicts of Interest
Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy.
Strategic Direction Delivery of the Transforming Care Programme supports:
Commissioning the delivery of NHS constitutional rights and pledges;
Improving the quality and safety of commissioned services;
Improving health outcomes, addressing inequalities, and achieving parity of esteem;
Integrating and enabling local services to deliver the right care in the right setting at the right time;
Achieving the aims of the Care Closer to Home workstream in the North Central London Sustainability and Transformation Plan.
Identified risks and
risk management
actions
The main risks identified in the Transforming Care Programme update are:
The pace of change required to meet the challenging bed reduction target by March 2019;
Financial risk arising from discharge of patients from Specialist Commissioning into locally funded care packages who are non-dowry eligible;
£1m transfer from the CCGs to the respective Local Authorities for long stay patients on discharge.
Resource
implications
Resource implications are identified as follows:
£0.1m increase to the pressure from NHS England as stated in December Committee paper, now £5.2m;
£1.1m transfer from the CCGs to the respective Local Authorities for long stay patients on discharge.
Engagement
The Transforming Care Board oversees implementation of the programme, with membership of the Board including CCG and Local Authority representatives from across the five boroughs, NHS England, Mental Health Trusts, Healthwatch, and Family Carers.
Equality impact
analysis
This report was written in accordance with the provisions of the Equality Act 2010.
Report history This is a follow up report to the North Central London Joint Commissioning Committee, following the funding transfer update presented to the December 2017 meeting. Local implementation is overseen by the Transforming Care Board, supported by an Implementation Group and a series of task and finish groups
Next steps Next steps for the Transforming Care Programme are to:
Continue with monthly patient surgeries to support North Central London performance against trajectory;
Continue with patient discharges as planned to meet NCL’s trajectory;
Complete NHS England Funding Transfer Applications for eligible patients discharged in 2016/17 and 2017/18.
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3
Appendices Sample performance summary December 2017
NHS England Funding Transfer Agreement
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1. Introduction Transforming Care is a national programme aimed at supporting people with learning disabilities to live rewarding and fulfilling lives in the community and prevent the need for long term hospital care.
The three-year programme, established by NHS England in the wake of the abuse scandal at Winterbourne View Hospital, is due to end in March 2019. By the end of the Programme Transforming Care Partnerships (TCPs) will be expected to have met their targets for hospital bed reduction as set out by NHS England.
NCL partnership has 81 patients defined as being in the Transforming Care cohort and we are required to achieve a net reduction of 33 beds to arrive at a total of 48 inpatient beds or less by 31 March 2019. Patients in scope fall into two separate cohorts; one group is funded by the CCGs and the second group by NHS England through Specialist Commissioning.
This report updates the Joint Commissioning Committee on North Central London’s performance against the bed reduction trajectory; the current position on the proposed funding transfer from Specialist Commissioning to CCGs and sets out the financial position for each CCG/Local Authority area for CCG funded patients discharged from 1 April 2016 with an admission of 12 months or more.
2. Performance As at 31 December 2017, the NCL Transforming Care Programme is currently performing ahead of the overall trajectory, illustrated in the table below. Performance is determined by the net inpatient figure and new admissions continue to impact on performance, despite a number of discharges taking place in the last few months.
In addition to the overall trajectory, performance is also measured against those patients identified as ‘long-stay’ i.e. those who have been in impatient settings for at least five years. NCL’s performance against this sub-trajectory currently requires improvement, as demonstrated below. This is a similar picture across London and nationally as these are often the most complex patients to discharge. However, it should be noted that of the 31 patients within this cohort, only 21 are deemed as eligible for discharge:
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Performance has historically been reviewed on an NCL basis rather than setting individual CCG and Local Authority targets. This approach has masked some of the variation in performance across the patch, which has become more apparent as more people are discharged over time. In particular, Haringey are behind plan and are now responsible approximately for 40% of the total cohort. The Programme office recently developed a monthly borough based performance report which is distributed to Chief Officers and Directors of Commissioning on the CCG side and to Directors of Adult and Children’s services, plus their deputies on the Local Authority side. The December report is appended to this report. There are a number of challenges affecting the rate at which patients are being discharged from hospital, including:
Identifying and securing community support packages of sufficient quality to meet the complexity of need demonstrated by people within the Transforming Care cohort;
Identifying suitable accommodation, particularly within inner-city NCL boroughs;
Discharge planning practice across North Central London. Whilst there are some areas with robust and efficient joint working and discharge planning processes, this is not the case across the patch.
Support is provided by both the NCL Transforming Care Programme Management Office and NHS England to address these challenges, including:
Monthly assurance calls to discuss ‘long-stay patients’ chaired by NHS England and attended by the NCL Senior Responsible Officer and Programme Manager, commissioners and operational colleagues. Cases are discussed individually, with a view to identifying any barriers to discharge and to escalate or address these where possible in order to ensure continued progress against the discharge plan;
For all other patients, funded by CCG or Specialist Commissioning, the NCL Programme Management established monthly ‘Surgeries’ which are chaired by the Programme Senior Responsible Officer, and work in a similar vein to NHS England assurance calls;
The NCL Programme has funded additional Care Coordinator resources (known as the TCP Hub) to support local operational teams for 12 months. Currently, these resources are primarily focussed in Haringey and Islington, who hold responsibility for 16 out of the 21 long-stay patients deemed eligible for discharge. There is an additional post in Camden covering Adult and children’s services and recruitment is underway for a further two posts to support Barnet and Enfield;
These staff provide additional capacity support to local teams in developing discharge planning activity, for example through the sharing of good practice, identifying where there are local systemic barriers to discharge and developing pathway improvements
81 80 7885 82
70 67 65 62 60 57 5548
81 79 7680
71 6864 64
31 29 29 27 27 25 25 22
31 31 31
0
10
20
30
40
50
60
70
80
90
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Year 0 Year 1 (2016/17) Year 2 (2017/18) Year 3 (2018/19)
Long-Stay Patients - Performance 31 December 2017
All Patients - Targets All Patients - Actual
Long stay patients - Targets Long stay patients - Actual
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NHS England has recruited a Housing lead to work with local boroughs to support commissioners with identifying premises and providers that can meet the needs of patients awaiting discharge. Commissioners are also being supported to work across borough boundaries to commission bespoke packages for multiple patients who could successfully live in a shared setting. The NCL Programme is also in the process of recruiting a Housing officer to work with Local Authorities across NCL to identify and develop relationships with private landlords who may have suitable properties.
We recently completed procurement for a Positive Behaviour Support resource across NCL, building on the expertise already held locally. This project is due to start in February 2018 and will run for 12 months. It is anticipated this work will enhance expertise and capacity across the patch to improve the management of challenging behaviour and prevent unnecessary hospital admission
An offer from the Institute of Public Care (Oxford Brookes University) and Local Government Association to deliver an NCL focussed piece of work on Market Engagement. An initial workshop took place on 17 January, with 60 attendees including commissioners across adults and children’s services, operational teams, experts by experience, providers local to NCL and other London-based providers. The workshop focussed on exploring a partnership approach to engaging and developing the local provider market to better meet the needs of people within the Transforming Care (and wider Learning Disabilities) cohort. Feedback from those who attended the workshop was positive, and further work will take place over the next few months to progress the actions.
3. Specialist Commissioning funded patients Following push back from Transforming Care Partnerships, NHS England has revised their offer to CCGs for patients discharged from Specialist Commissioning. The latest Funding Transfer Agreement guidance received on 17 January is appended to this report, and includes the following key changes:
Funding for dowry eligible patients (in hospital 5 years or more, as at 1 April 2016) discharged in 2016/17. Previous guidance was 2017/18 onwards. The full cost of the Specialist Commissioning placement will be transferred;
Net inpatient reduction, excluding dowry eligible patients - where funds are transferred to Transforming Care Partnerships based on the net discharges (total discharges minus total admissions). This is expected to be in the region of £180,000 per net discharge;
A quarterly reconciliation of net position;
Funds will be paid to the lead CCG who will administer the funds on behalf of the Transforming Care Partnership;
Funds will transfer back to Specialist Commissioning for re-admissions; to be picked up through the reconciliation process.
The Funding Transfer Agreement is due for discussion and approval at the London Transforming Care Board 24 January. In the meantime, NHS England has asked London Transforming Care Partnerships to complete the Funding Transfer Agreement (FTA) paperwork for dowry eligible patients, discharged since April 2017. North Central London has three patients who meet these criteria in 2017/18, broken down as follows: Table 1
Borough Adult/Child Discharge Quarter Approximate Funding Transfer
from NHSE (per annum) (£'000)
Camden CCG Adult Q1 17/18 144
Islington CCG Adult Q2 17/18 165
Barnet CCG Adult Q2 17/18 161
Total 470
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In addition, to the above, based on current discharge plans, there is a possibility that an additional two dowry-eligible patients (Haringey and Islington) will be discharged before the end of Q4, 2017/18, with £330k funding attached. Similarly, in 2018/19, it is anticipated that a further two dowry-eligible patients could be discharged (Haringey and Enfield). This would generate approximately £309k in funding transfers from NHS England. A breakdown of anticipated future dowry-eligible discharges to the end of the programme is provided below: Table 2
Borough Adult/Child Discharge Quarter (expected future
discharges)
Approximate Funding Transfer from NHSE (per annum)
(£'000)
Islington CCG Adult Q4 17/18 165
Haringey CCG Adult Q4 17/18 165
Haringey CCG Adult Q3 18/19 144
Enfield CCG Adult Q3 18/19 165
Total 639
Our records show one dowry eligible patient was discharged in 2016/17 although this data will need validating with NHS England: Table 3
Borough Adult/Child Discharge Quarter Approximate Funding Transfer
from NHSE (per annum) (£'000)
Haringey Adult Q3 16/17 165
Total 165
In total, approximately £1.3m will be received from Specialist Commissioning, covering discharges across the life of the programme including the discharge made in 2016/17. This is the amount that was expected and reported to committee in December 2017. A funding transfer in the region of £180k per net reduction of specialist commissioning beds is proposed in the latest guidance, this currently has no impact. Dowry eligible patients are excluded with funding already expected to flow, and it is not expected there will be a net reduction when including current admission levels. Table 4
Current Commissioner - NHS England Discharges Full Year Effect of Transfer to Area
(£m)
Total Discharges in 2016/17 18 1.4
Current year and Future Discharges of current inpatients 24 3.5
Pressure arising on Discharges to local area 4.9
Funding Transfer Agreement eligible 8 (1.3)
Pressure to be absorbed after FTA 3.6
Potential further Admissions 18 2.7
Over-achievement on trajectory target before new admissions (7) (1.0)
Total Expected Pressure to TCP area 5.2
*further admissions based on 11 in the 9 months to 31 December 2017
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8
Based on the current level of admissions the total potential recurrent pressure is £5.2m across North Central London. .
4. CCG funded patients The December Committee considered and agreed the following funding principles in relation to three sub-groups of CCG funded patients.
Long-stay patients defined as being in hospital 12 months or more. It is proposed a local North Central London funding transfer agreement (NCL FTA) from CCGs to the Local Authority applies to this cohort of patients. If the patient is re-admitted then the FTA should cease at a patient level unless the process is managed on a net basis;
Short-stay patients already known to services and funded in the community prior to hospital admission. A Funding Transfer Agreement is not necessarily required and consideration should be given to their funding history. This cohort may also need to be managed through existing processes between CCGs and Social Care, on a case by case basis;
New admissions, not previously known to services or funded in the community. A joint approach is proposed for this cohort of patients with costs negotiated between the CCG and Local Authority as now, on a case by case basis and percentage funding split apportioned and agreed according to need.
2016/17 Table 1 below reflects the full year costs, by CCG area, relating to the long-stay patients eligible for the NCL funding transfer from CCGs to Local Authorities for patients discharged during 2016/17. Table 5
The flow required to Local Authorities to fund the 6 discharges that occurred in 2016/17 at full year effect is £499k. 2017/18 Table 5 reflects the full year costs of patients discharged to date in 2017/18 Table 6
The flow required to Local Authorities to fund the 5 discharges that occurred in 2017/18 at full year effect is £598k Total 2016/17 and 2017/18
Grand Total 11 1,555 1,776 1,098 678 1,098
CCG Area Discharges
Inpatient Cost
(Prior to Discharge)
(£'000)
Total Community
Cost
(£'000)
Cost to LA
(£'000)
Cost to CCG
(£'000)
Funding Flow
required from CCG to
LA
(£'000)
Enfield 3 385 409 245 164 245
Islington 2 281 406 353 53 353
Grand Total 5 666 815 598 217 598
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It is proposed the North Central London Funding Transfer Agreement from the CCGs to Local Authorities reflects the offer from NHS England to include discharges from 1 April 2016. The full year effect of this transfer is £1.1m. From the information held by the NCL Programme Office, there appear to be stranded costs of £281k associated with the two Islington patients discharged in 2017/18, although these have become available for use. Future costs Table 3 reflects the projected future costs for patients with a discharge date within the life of the Programme who have a hospital admission of 12 months or more. Table 7
When looking only until the programme end there is nearly enough money in the system if funding can flow. Community costs are expected to be £279k less than current inpatient costs; however there are £363k of stranded costs. This results in an £84k pressure, although a block bed would become available. It should be noted that the future costs are estimated, using the individual patient banding work completed as part of the financial modelling exercise. This was based on the patient’s most likely expected care setting on discharge, with costs banded on the level of need. Looking beyond the programme end date there are currently only a further 3 Camden discharges that are expected in 2019/20. While these look affordable if funding flows with the patient, the community costs are significantly less than the inpatient costs. This raises a question about the banding information for these patients. This will be explored further. There is a possibility that up to eight additional patients, who are not yet ready for discharge, may be discharged after the life of the programme – by the end of 2020/21. Due to the complexity of needs experienced by these patients, the cost of providing appropriate support in the community could be substantial, and where possible, it is advisable that funding should flow for these patients. S117 and NHS Continuing Health Care Section 117 of the Mental Health Act 1983 places a joint duty on local NHS and adult social services commissioners to provide free aftercare services for people that have previously been sectioned under the treatment sections of the Mental Health Act, i.e. Sections 3, 37, 45A, 47 and 48. The duty to provide aftercare services begins at the point that someone leaves hospital and
Year of
Discharge
CCG Area
(£'000)
Discharges
Expected
(£'000)
Inpatient Cost
(£'000)
Expected Community
Cost
(£'000)
Cost above/(below)
Inpatient Cost
(£'000)
Possible
Stranded
Costs
(£'000)
2017/18 Haringey 6 1,577 1,512 (65) 0
Islington 1 149 130 (19) 0
2017/18 Total 7 1,726 1,642 (84) 0
2018/19 Camden 1 201 78 (123) 0
Haringey 4 767 808 41 0
Islington 2 385 141 (244) 182
2018/19 Total 7 1,353 1,027 (326) 182
TBC Enfield 1 182 313 131 182
TBC Total 1 182 313 131 182
Total to
programme
end incl. TBC
15 3,261 2,982 (279) 363
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lasts for as long as the person requires the services. A number of patients, with mental health related conditions, who fall within the Transforming Care Programme will be subject to Section 117. It is recognised that for some patients who have been in hospital for 12 months or more, the local Funding Transfer Agreement may result in a CCG contribution to community costs over and above the level expected in relation to Section 117 responsibilities. The purpose of the Funding Transfer Agreement is to support the effective management of long-term costs across the local health and care system; this is in recognition of the fact that the complexity of needs experienced by people within the Transforming Care cohort can result in high-cost community care arrangements which would otherwise be unsustainable, increasing the risk of re-admission to hospital, which would be funded by CCGs. The Funding Transfer Agreement should not lead to a reduction in local governance when agreeing packages of care; local funding panels would still be expected to determine the weighting against health and social care, whilst recognising that, where applicable, CCG funding will be used to support both.
5. Conclusion Transforming Care is a complex programme. With 15 months remaining of the formal NHS England programme, North Central London is ahead of trajectory although we still require an overall net bed reduction of 16 before the end of March 2019. There are a range of measures in place to support sustained improvement and the Transforming Care programme office will continue to have oversight of performance and escalate issues locally where needed. The improved offer from NHS England is welcome and further work will take place to validate 2016/17 activity. Current information indicates that £1m should transfer from Specialist Commissioning, assuming all discharges are achieved, which off-sets the local funding transfer to Local Authorities for long stay patients discharged from 1 April 2016.
6. Recommendations It is recommended that the Committee:
Note North Central London performance against the bed reduction trajectory and measures in place to support sustained progress;
Note the improved Funding Transfer Agreement offer from NHS England;
Approve the funding transfer from the individual North Central London CCGs to the respective Local Authorities for those patients with an inpatient stay of 12 months or more on discharge;
Receive a further update at the April Committee.
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Transforming Care Partnership
North Central London
North Central London Transforming Care Programme
Monthly Local Performance Summary
December 2017
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Transforming Care Partnership
North Central London
Transforming Care Partnership
North Central London
Overview
• This report highlights NCL and borough-level performance against Transforming Care Programme (TCP) objectives. Data is taken from the monthly patient tracker submitted to the NCL TCP Programme Management Office by each local area and Specialised Commissioning.
• Whilst NCL are performance managed as a Transforming Care Partnership, the individual performance of boroughs increasingly has an impact on the overall performance of the Partnership.
• To meet trajectory for the reduction in inpatient beds by the end of the Programme (March 2019), the total number of NCL inpatients who are within the TCP cohort is expected to be 48 or below by March 2019.
• The total number of inpatients (CCG and NHSE) at 31 December 2017 is 64. Islington successfully discharged 3 patients in December. These were offset by 3 admissions across NCL.
• Performance is split between patients funded by CCGs (e.g. in acute inpatient settings) and NHSE Specialised Commissioning (i.e. secure settings, CAMHS Tier 4 settings). Within the overall target there is a sub-target for patients who have been in hospital for 5 years or more (“Long-stay”).
• New admissions have negated the discharges achieved in December, and alongside delayed discharges, this continues to affect progress towards the trajectory.
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NCL Performance – December 2017
Trajectory Breakdown38
32 2937 39 41 39
33 34 34 35 34 3329 26 27 28 29
41 39 37 4047
39 38 38 37 37 37 35 35 36 38 39 36 35
7971
66
77
8680 77
71 71 71 72 69 68 65 64 66 64 64
0
10
20
30
40
50
60
70
80
90
100
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun July Aug Sep Oct Nov Dec
2016/17 2017/18
Number of inpatients - to 31 Dec 2017
NHSE CCG NCL Total
81 80 7885 82
70 67 65 62 60 57 5548
81 79 7680
71 6864 64
31 29 29 27 27 25 25 22
31 31 31
0
10
20
30
40
50
60
70
80
90
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Year 0 Year 1 (2016/17) Year 2 (2017/18) Year 3 (2018/19)
Progress against Trajectory – December 2017
All Patients - Targets All Patients - Actual Long stay patients - Targets Long stay patients - Actual80
Transforming Care Partnership
North Central London
Local Performance – All patients (December 2017)
Barnet Camden Enfield Haringey Islington Total
SC CCG SC CCG SC CCG SC CCG SC CCG
Number of inpatients at 31 Dec 2017 3 8 3(inc. 1 child)
5 3 1 10*(inc. 2
children– TBC)
15 10(inc. 3
children)
6 64
Number of inpatients clinically ready for discharge
0 0 0 0 1 0 2 9 3 4 19
Total number of discharges this month 1 0 0 0 0 0 0 0 0 3 4
Total number of missed discharges this month
0 0 0 0 0 0 0 0 1 0 1
Number of admissions during this month 0 0 0 0 0 0 0 2 1 0 3
Number of planned discharges for next month
0 0 0 0 0 0 2 1 2 1 6
SC = Specialised Commissioning
Actions for next month (January):
• Islington to discharge 3 patients (including 2 Specialised Commissioning)• Haringey to discharge 3 patients ((including 2 Specialised Commissioning)
* Includes an additional patient newly diagnosed with ASD, not previously within TCP cohort
81
Transforming Care Partnership
North Central London
Local Performance – Long-stay patients (5-years+)
Current number of long-stay inpatients may increase in future months as additional patient’s length of stay reaches 5-year threshold
Chart showing 5yr+ progress against target (for specific borough)
Barnet Camden Enfield Haringey Islington Total
SC CCG SC CCG SC CCG SC CCG SC CCG
Current number of inpatients (31 Dec 2017)
1 8 1 2 2 0 5 7 3 2 31
Current number of inpatients excluding those at Harperbury SRS*
1 0 1 1 2 0 5 7 3 1 21
Number of inpatients clinically ready for discharge
0 0 0 0 1 0 2 7 2 1 13
Expected number of discharges this month
0 0 0 0 0 0 0 0 0 0 0
Total number of discharges this month
0 0 0 0 0 0 0 0 0 0 0
Total number of missed/delayed discharges this month
0 0 0 0 0 0 0 0 0 0 0
Number of planneddischarges for next month
0 0 0 0 0 0 1 1 1 0 3
* Patients currently at Harperbury Secure Residential Services are currently ineligible for discharge due to legal ruling. Patients are CCG-funded.
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Transforming Care Partnership
North Central London
Local Performance – Q3 Summary
Barnet Camden Enfield Haringey Islington Total
SC CCG SC CCG SC CCG SC CCG SC CCG
Total Admissions Q3 1 0 0 0 0 0 0 3 1 0 5
Total Discharges Q3 2 0 0 0 0 3 0 0 0 3 8
Total missed discharges Q3* 0 0 0 0 0 1 0 3 1 2 7
Total 5Yr + Discharges Q3 0 0 0 0 0 0 0 0 0 0 0
Number of remaining inpatients clinically ready for discharge as at 31 Dec 2017
0 0 0 0 1 0 2 9 3 4 19
* Missed discharges may have been achieved at a later date during the Quarter
• 8 patients were discharged in Q3, however, this was offset by 5 admissions, and up to 7 expected discharges which were not achieved.
• Considering the number of remaining patients who are clinically ready for discharge, Haringey and Islington face the biggest challenge to progress a number of discharges in Q4.
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London Transforming
Care –Funding Transfer Agreement (FTA)
Paper
1
16 January 2018
v1.2
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2
FTA Funding – Core PrinciplesUnder the Transforming Care programme, Specialised Commissioning funding for inpatients’ care will be redistributed to TCPs when patients are discharged. The London proposal is that funds are transferred from Spec Comm to TCPs as outlined below:
1) Dowry patients (inpatients of 5 yrs + at 1 April 2016)If a dowry patient is discharged (or transferred), Specialised Commissioning will release the cost of the inpatient’s care. This will follow the patient to the community, in line with national guidelines. Dowry patients must have the first right to their funding allocation, including if their needs fluctuate over time.
This amount would be transferred to the TCP via a nominated CCG. The TCP would need to complete an FTA form for each dowry patient after they have been discharged to access the funds.
2) Net inpatient reduction (net patient discharges)It is expected that Specialised Commissioning will also discharge non-dowry patients, in line with the Transforming Care trajectory. However, Spec Comm also receives new admissions that it will need to fund. Therefore, a net inpatient reduction model is being followed – where funds are transferred to TCPs based on the net discharges (total discharges minus total admissions). This process excludes dowry patients who will already have received funds as outlined above.
At the end of every quarter, Specialised Commissioning will carry out a reconciliation process to determine the net inpatient reduction amount for that period based on admissions and discharge data and the associated actual costs of inpatient care. For transparency, TCPs will have visibility of this. TCPs may be required to complete a form to confirm the net inpatient reduction. Please see slide 5 for the process for FY17/18.
Specialised Commissioning will then transfer an amount equal to the total monies released by the net inpatient reduction to the TCPs via the nominated CCG, based on quarterly payments in arrears. 85
3
Key points• Funds released – The amount of funds released to the TCPs will be the actual cost to Spec Comm of the
dowry patients (the cost of the inpatients’ care) and an additional amount based on funding released due to the net inpatient reduction approach (expected to be in the region of £180,000 per net discharge). For transparency, Spec Comm will share full details of inpatients’ associated costs with TCPs.
• Net inpatient reduction vs beds closed – The model is based on a net inpatient reduction approach i.e. the number of net patient discharges – regardless of whether there is confirmation of bed closures. However, if a patient is discharged from a block contract bed, funds will be released after a transitional period of approximately three months.
• New Admissions – Funds are intended for patient discharges. There is no additional funding for new admissions, hence the net inpatient reduction approach. If a TCP has net admissions over a time period, no funds will be released for that period.
• Readmissions – Funds should be transferred back to Spec Comm from TCPs if patients are readmitted. This will happen through the reconciliation process.
• 16/17 dowry patient discharges – Spec Comm will transfer funds for 16/17 dowry patient discharges from FY17/18 onwards on a non-recurrent recurrent basis.
• FTA forms – Specialised Commissioning is revising the FTA forms to ensure they are easier to complete and are consistent with the FTA process. Revised FTA forms and guidance will be shared with TCPs in the coming weeks. In the meantime, please use the existing FTA form.
• National guidance and standardising the FTA process – The National Team is having discussions to standardise the FTA process nationally relating to dowry patients and savings to be transferred. The national team has seen our commitment to dowry patients and to transfer the actual monies saved. Any future national policy changes and impact on London policies would be subject to further engagement with TCPs.
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1. TCPs and CCGs must ring fence funds received from Spec Comm for Transforming Care
• All funds transferred from Spec Comm to TCPs must be ring fenced for Transforming Care purposes only. This will allow TCPs to redirect savings from cheaper community care packages to more expensive packages and make other TC-related investments.
• If any excess money from Spec Comm is not used for Transforming Care and TCPs are not able to demonstrate this in an annual audit report, those funds will need to be returned to Spec Comm.
2. Spec Comm funds will be transferred to a TCP via a nominated CCG• TCPs will need to nominate a CCG to receive funds from Spec Comm, to work towards
‘pooled budgets’. TCPs must have the appropriate governance in place to manage the funds received by a nominated CCG and must be able to demonstrate the appropriate governance. If there is any dispute in the way funds are distributed from the TCP’s nominated CCG to other CCGs, this must be escalated to the Accountable Officer who will make a decision.
3. CCGs must agree a mechanism to transfer funds to Local Authorities• CCGs will need to agree a joint funding mechanism for any funding to be transferred to the
Local Authorities (Section 75 or Section 256 (BCF)) or other agreed arrangements.
4
Role of TCPs and CCGs
87
5
Next steps: Guide for TCPs
• 16/17 dowry patient discharges: Specialised Commissioning will share information on 16/17 dowry patient discharges and their associated costs. TCPs will need to check this matches their records and submit an FTA form for each patient to Specialised Commissioning via the central mailbox to access the funds. Funding will commence from 17/18 on a non-recurrent recurrent basis.
• Q1-Q3 17/18 funds transfer: Specialised Commissioning will share data on the funds it expects to transfer to TCPs for Q1-Q3 17/18 based on dowry patient discharges and the net inpatient reduction approach in the coming weeks. TCPs will need to confirm this matches their records and complete the relevant forms (forms and guidance will be provided) to access the funds. The FTA Panel will then review the forms and authorise funding transfer before the end of the financial year.
• Q4 17/18 funds transfer: The same approach outlined for Q1-Q3 will be followed after the end of Q4 17/18.
• 17/18 dowry patients: TCPs can submit FTA forms for dowry patient discharges at any point in the year, provided the patient has already been discharged.
• Funds associated with patients: In the spirit of transparency, Specialised Commissioning will share with TCPs information on the remaining Transforming Care inpatients (dowry and non-dowry) and their associated funding in the coming weeks.
January MarchFebruary April onwardsFY 17/18 FY 18/19
Spec Comm to share Q1-Q3 17/18 fund transfer details
Spec Comm FTA panel to review and approve FTA forms for Q1-Q3 17/18
Funds transferred to TCPs for Q1-Q3 17/18
Spec Comm to share Q4 17/18 fund transfer details
TCPs submit FTA forms for Q1-Q3 17/18
88
6
Spec Comm internal FTA process
An escalation process needs to be determined.
TCP send to SC mailbox
Business Support, led by
ProgrammeOfficer
Spec Commfinance FTA Panel Programme
Officer
Spec Commreceives a completed FTA form for dowry patients once they are discharged and/or the net inpatient reduction form every quarter through a centralisedmailbox.
Business Support, led by ProgrammeOfficer, checks and validates the forms (checks admission and discharge dates and destinations). The Programme Officer communicates with the TCP if patients are not eligible or to ask for additional information if the form is incomplete. The validated forms are then sent to Spec Comm Finance.
Spec CommFinance, Information and Clinical (Case Managers) check the forms and make a recommendation to the FTA Panel on whether funds should be released and the amount.
The FTA Panel, members of which are decided by SMG, meets to make a decision on whether the funds should be released and to agree the amount. - There is a monthly panel which considers dowry patients. - Every quarter these panels will be longer to discuss the net inpatient reduction.
The ProgrammeOfficer owns the
comms to TCP on the decision and
process for release of funds.
Receive a complete FTA form for dowry
patients
Check and validate forms
Review form and make
recommend-ation
Panel decision on FTA request
Communication to TCP
Act
ivity
Con
tent
Who
?
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7
Timeline of process to sign-off
04/12 11/12 01/0118/12 25/01 15/0108/01 22/01
2017 2018
Spec Comm presented high level FTA process to TCPs at LGA / ADASS workshop06/12
14/12TCPs asked to provide feedback on high level FTA
14/12Spec Comm Finance session agree detail of FTA model
15/12Working session with Spec Comm and NHS England Finance to address TCP feedback
13/12NHS England Regional and National discuss TCP Financial plan
18/12FTA process raised at Spec Comm SMG
16/01FTA final sign off with TC SRO and Regional Exec
24/01
Present agreed FTA process to TC Board
TCPs have opportunity to ask questions
Develop comms on FTA process for TCPs
10/01
21/01
Determine amount to transfer to TCPs for Q1-Q3 1718 and FTA panel to sign off
16/01Communicate final process with Spec Comm SMG
Communicate FTA process with TCPs17/01
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NCL Joint Commissioning Committee Meeting on Thursday 1st February 2018
Report Title Adult Elective Orthopaedic Services: Achieving the Best Value for Patients
Agenda Item 4.2
Date 25th January 2018
Lead Director Will Huxter, Director of Strategy
Tel/Email [email protected] 020 3816 3942
Report Author David Stout, Senior Programme Director Report presented by: Professor Fares Haddad, UCLH Rob Hurd, Royal National Orthopaedic Hospital
Tel/Email [email protected] [email protected] [email protected]
GB Sponsor(s) (where applicable)
Tel/Email
Report Summary This paper sets out a proposal to establish a review of adult elective orthopaedic services across North Central London (NCL). This review will seek to identify opportunities to:
improve outcomes for patients
improve quality of services by reducing unwarranted variation
improve value for money
It is proposed that this review will be clinically led and undertaken as part of the North Central London Sustainability and Transformation Partnership (NCL STP), with final decisions on any proposed changes to be taken by the Joint Commissioning Committee of the NCL Clinical Commissioning Groups. It is anticipated that this phase of the review will be completed by March 2019.
Purpose (tick one
only)
Information Approval
To note
Decision
Recommendation The NLC Joint Commissioning Committee is asked to approve the establishment of the Adult Elective Orthopaedic Services Review Group as set out in this paper.
Strategic
Objectives Links
The proposed project will support delivery of:
The North Central London Sustainability and Transformation Plan;
Local CCG priorities on quality improvement
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There may also be a benefit to the financial sustainability of services.
Identified Risks
and Risk
Management
Actions
A full risk assessment will be undertaken as part of the project plan. High level risks include:
Delays in delivery of the project due to constraints in management and clinical capacity to engage
Concerns from staff, patients and/or the public about the project These risks are mitigated by ensuring appropriate project funding and effective communications.
Conflicts of Interest
None
Resource
Implications
Project support will be jointly funded through national funding from the Get It Right First Time (GIRFT) programme and the STP programme budget. Recruitment to programme support posts will proceed following approval of the project at the Joint Commissioning Committee.
Engagement
Section 6 of the papers sets out the proposed approach to engagement.
Equality Impact
Analysis
An equality impact assessment will be carried out as part of the development of the outline business case.
Report History A first draft of the paper was discussed at the NCL Joint Commissioning Committee seminar on 2nd November 2017
Next Steps Subject to approval of the paper, the Adult Orthopaedic Service Review Group will be established in February 2018 to initiate the review.
Appendices Appendix One: Activity analysis
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Adult Elective Orthopaedic Services: Achieving the best value for patients
1. INTRODUCTION
This paper sets out a proposal to establish a review of adult elective orthopaedic services across North Central London (NCL).
This review will seek to identify opportunities to:
improve outcomes for patients
improve quality of services by reducing unwarranted variation
improve value for money
It is proposed that this review will be clinically led and undertaken as part of the North Central London Sustainability and Transformation Partnership (NCL STP), with final decisions on any proposed changes to be taken by the Joint Commissioning Committee of the NCL Clinical Commissioning Groups.
It is anticipated that this phase of the review will be completed by March 2019.
2. BACKGROUND
Realising the opportunities for improving Musculoskeletal (MSK) patient care pathways is an agreed priority of the North Central London Sustainability and Transformation Partnership (NCL STP). Under the STP planned care workstream we have established an STP MSK Design Group to bring together the projects already established in local CCGs to promote prevention and appropriate best pathways for patients with MSK conditions. These existing projects include work on the primary care elements of the pathways.
There are already many areas of good practice in elective orthopaedics in North Central London – local engagement in prevention and improving MSK pathways, the length of stay in hospital has been falling, complications and revision rates are well within expected levels and the local population benefits from having local access to regional specialised services. The sector has also made progress in reducing the costs to the NHS of expensive implants. There is also good work taking place to increase focus on improving orthopaedic clinical pathways so that patients access the appropriate clinical expertise that they need and that wasted time for patients and clinicians is avoided – for example the Camden Integrated Musculoskeletal Service (CIMS) model has UCLH as the lead provider for Camden CCG and Barnet and Enfield CCGs have in parallel identified the Royal Free London as the proposed lead provider. Other providers work in partnership with these lead provider models of care. Haringey and Islington have identified community outpatient MSK as a priority area as part of their Wellbeing Partnership working in partnership with Whittington Health.
However, it is also recognised that the current system is not fully realising the opportunities available to deliver the best possible care for patients. We have used two nationally available analyses to identify opportunities for improvement:
NHS RightCare - a national NHS England supported programme committed to delivering the best care to patients, making the NHS’s money go as far as possible and improving patient outcomes; and
93
NHS Improvement’s Getting It Right First Time (GIRFT) Programme – which aims to help to improve the quality of care within the NHS by reducing unwarranted variations, bringing efficiencies and improving patient
The analysis of historic and current activity and patient outcomes from these programmes has identified significant opportunity for reducing unwarranted variation and improved patient outcomes in relation to the delivery of elective secondary care orthopaedic services. Realising these opportunities for patients also comes with potential for significant corresponding financial benefits to the local NHS, supporting a more sustainable financial landscape for the future. It is recognised these financial benefits fall across commissioner and provider plans and that this project is an enabler to catalyse these quality and financial benefits to the North Central London population.
We currently deliver secondary care orthopaedic interventions for NHS patients from NCL from twelve separate NHS and independent sector sites within NCL (plus other NHS and independent sector sites outside of NCL):
Royal National Orthopaedic Hospital
UCLH - University College Hospital
UCLH - National Hospital for Neurology and Neurosciences, Queens Square
Whittington Hospital
North Middlesex University Hospital
Royal Free London – Royal Free Hospital
Royal Free London - Barnet Hospital
Royal Free London - Chase Farm Hospital
Royal Free London - Hadley Wood
Highgate Private Hospital (Aspen)
The Cavell Hospital (BMI Healthcare)
The Kings Oak Hospital (BMI Healthcare)
Volumes of adult surgical procedures by NHS provider and procedures undertaken at each site are set out in appendix one.
Clinical leaders in orthopaedics both locally and nationally believe there is evidence that the best clinical outcomes for patients, patient care quality and efficiency benefits are optimised through ring-fenced orthopaedic elective care consolidated in critical mass and co-located with appropriate clinical support services and infrastructure. This allows replication of standardised best practice pathways of care responsive to individual patient needs. It also promotes the best workforce training and research and learning environment for recruitment and retention of staff.
The NCL STP Health & Care Cabinet, which includes clinical leaders from all providers and CCGs in NCL, have therefore concluded that there may be opportunities to achieve quality of care improvements for patients by reducing the fragmentation of secondary care that currently exists for the North Central London population
This paper therefore proposes the formal establishment of project to review how to deliver the best outcomes for patients and best value in the secondary and tertiary planned adult elective orthopaedic care setting - an important component of the overall patient care pathway. This project is a sub set of the wider MSK care pathway work in the STP (including primary care).
3. PROPOSED ADULT ELECTIVE ORTHOPAEDICS SERVICES REVIEW
The purpose of this project is to realise positive patient outcome and improvement opportunities in areas recognised to be detrimental to quality and productivity in orthopaedics. The case for change will build on the opportunities for patients that are considered to be available across the following areas:
94
Reducing cancellations, reducing complications and ensuring the best patient outcomes for orthopaedic interventions;
Reducing unnecessary time spent in hospital before and after orthopaedic surgical interventions;
Ensuring all care is based on the best evidence with compliance with CCG policies on procedures of limited clinical effectiveness;
Ensuring services are best placed to have the best workforce and an environment which promotes training and the recruitment and retention of staff;
Promoting research to ensure a culture of learning and promoting best practice and excellence in patient care;
Getting best value services through the optimum use of facilities dedicated to expert care in orthopaedics – staff, equipment and facilities geared up to provide the best care.
The objectives will also include the promotion of further engagement of secondary care in supporting prevention and best practice MSK patient care pathways and helping to ensure that the NHS recruits and retains the staff that are needed to provide the highest possible standards of care.
Other important factors which will need to be considered in the review are patient travel time will and financial efficiency.
It is also important that the improvement opportunities in elective orthopaedics are not realised at the expense of unintended consequences on other services. Therefore the project will also consider important interdependencies with other services – such as trauma services; such services are outside of the scope of this project but obviously any impact of recommendations from this project need to evaluate the impact on services outside of the scope of the project.
4. GOVERNANCE
It is proposed the project is undertaken as part of the NCL STP, and that it is led by a new Adult Elective Orthopaedic Services Review Group with Rob Hurd (CEO at RNOH) as Project Sponsor and Professor Fares Haddad (UCLH and Chair of the NCL STP MSK Design Group) as Clinical Lead. The review will make recommendations to the CCG’s Joint Commissioning Committee, which will make final decisions on whether to proceed to consult on any proposals for change.
The proposed governance structure for this review is set out below:
The respective roles of the groups would be as follows:
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Adult Orthopaedic Elective Services Review Group – to plan and oversee the review
including the development the case for change; demand and capacity modelling,
communications and engagement; workforce modelling; and the development and
evaluation of options (see proposed mandate below). The review group will make
recommendations to the NCL Joint Commissioning Committee for decision-making.
STP MSK Design Group – to share progress and ensure alignment with the wider STP MSK
pathway review programmes
STP Health & Care Cabinet – to provide system clinical oversight and scrutiny and final
endorsement of the emerging clinical models to the STP Programme Delivery Board. To help
source independent clinical advice if required. To support the members of the review group
in leading the amplification and ‘buy-in’ of clinical decisions within their respective
organisations.
STP Programme Delivery Board – to review progress of the adult elective orthopaedics review
as part of the wider planned care workstream and ensure alignment with other STP
programmes
Joint Commissioning Committee – to agree to the establishment of the review, receive
recommendations for the Review Group and make final decisions on any service configuration
options. The Joint Commissioning Committee has delegated commissioning decision-making
powers on acute services on behalf of the five CCGs in NCL
Any impact on Specialised Services commissioned by NHS England Specialised Commissioning will require their separate approval. However, this project is complementary to NHS England’s review of specialised services and moves to place based leadership of specialised service planning.
5. INITIAL PROJECT MANDATE
The proposal is for an initial project mandate covering the following responsibilities:
1) Establish the Adult Orthopaedic Services Review Group
In order to be effective all Trusts and CCGs must recognise and agree that the Adult Elective Orthopaedic Services Review Group is the official forum through which all new plans for secondary care orthopaedic services must be developed after which they will be submitted for approval by the NCL Joint Commissioning Committee. Having appropriate representation on the proposed review group will be very important. Therefore membership of the review group will be drawn from each of the main provider organisations together with CCG and specialist commissioning representation. The role of the members on the review group will include responsibility for ensuring effective communication and engagement with the wider staff group within their organisation. Ensuring effective input from social care will be discussed with Directors of Adult Services. The appropriate mechanism to ensure patient and public input to the review group to help co-produce from the outset of the programme will be discussed with local HealthWatch leaders and the Joint Overview & Scrutiny Committee. Proposed membership of the review group will include:
96
Clinical chair – Professor Fares Haddad, UCLH
Project sponsor – Rob Hurd, Chief Executive, Royal National Orthopaedic Hospital)
A clinical representative from each provider site (with more than 5% of overall activity)
Clinical representatives of the CCGs
A representative of specialised commissioning
A representative of NHS England
Patient & Public input (as agreed with HealthWatch)
2) Define the vision and case for change based on clear, detailed evidence including issues/gaps identified from: a) Clinical outcomes indicators b) External review and analysis of activity, demand and capacity c) Financial data and information from both Trusts and Commissioners d) Patient experience data and information e) Local context (e.g. forthcoming opportunities and developments)
This element is a key to success – the system needs to develop a clear and shared vision of what needs to change and why, including a clear understanding of how it can capitalise on current opportunities and overcome constraints.
3) Develop, evaluate and shortlist options for improving services i.e. the range of credible interventions (evidence based) that could be implemented in order to address the issues/gaps in current service arrangements to deliver improvements in quality, outcomes and value for money.
4) Develop Pre-Consultation Business Case (if options for change are recommended from phase 3) a) Case for Change b) Options Appraisal (Quality, Outcomes, Patient Experience, Finance, Capacity etc.) c) Recommendations on preferred option.
Any proposals for change of service configuration which evolve from this project would need to meet the four tests of service reconfiguration as set out by NHS England in the document "Planning, assuring and delivering Service Change for Patients". There must be clear and early confidence that a proposal satisfies the four tests and is affordable in capital and revenue terms.
The government’s four tests of service reconfiguration are:
• Strong public and patient engagement. • Consistency with current and prospective need for patient choice. • Clear, clinical evidence base. • Support for proposals from commissioners.
Commissioners would also need to consider when to engage with NHSE for the Strategic Sense Check which takes place once Commissioners conclude they have a sufficiently robust case for change and a set of emerging options, or earlier if the potential implications are far reaching. The Sense Check will:
• Explore the case for change and the level of consensus for change. • Ensure a full range of options are being considered, that potential risks are
identified and mitigated; and that options are feasible. • Ensure high level capital cost and revenue affordability implications are being properly
considered. • Show impact on neighbouring commissioners and populations has been considered. • Ensure assessment against the ‘four tests’ is ongoing and other best practice checks
are being applied proportionally.
6. ENSURING APPROPRIATE ENGAGEMENT
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It is recognised that ensuring appropriate engagement with patients and the public, clinicians and other staff is a key factor for success.
Clinical engagement will be through the clinical leads assigned to the project. Any key decision points will be taken through the STP Health & Care Cabinet and/or using independent clinical review. We will also use the existing STP MSK design group as a key means of engagement to ensure alignment with wider MSK pathway redesign and to bring together joint working on the different local CCG work on MSK pathways as well as the secondary care aspects being covered by this project.
Patient and public involvement is very important to the success of the process and early engagement is helpful in ensuring the right direction through co-production from the outset of the programme. A key point is to ensure that at an early stage, the process involves listening to patients to establish what they think is important about their services and what needs to improve before developing options about what to change. Where possible we will use existing patient and public engagement mechanisms which have been put in place as part of the wider local MSK redesign work.
We will discuss the appropriate approach to patient & public involvement with both leaders of the local HealthWatch organisations and the Joint Health Overview & Scrutiny Committee.
7. PROJECT TIMESCALES & PROJECT CAPACITY
Should the project come up with any proposals to change the current pattern of service delivery, based on the engagement exercise and evaluation of ways to improve services, and then the project would need to take into account the formal process that must be followed for any potential service change of this nature. The project would be divided into a number of phases, which are outlined in the diagram below:
This is a complex project with a number of parallel strands. This project proposal covers at high level, those actions required to reach development of a pre-consultation business case. It is anticipated that this will take around 12 months (i.e. by March 2019 if agreement is reached to proceed as recommended by this paper). More detailed timescales and deliverables will be formally agreed specified as the full project plan is worked up, assuming the project is approved.
Project support will be jointly funded through national funding from the Get It Right First Time (GIRFT) programme and the STP programme budget. Recruitment to programme support posts will proceed following approval of the project at the Joint Commissioning Committee.
Individual Trust contributions will be in the form of analytics, clinical input and capital planning around options. Therefore elements of this will be from within existing resources available within Trusts and so contributions from individual organisations will be dependent on their in-house capacity to support these aspects of the project.
98
Depending on the outcome of this phase of the project, if there is a proposal for change agreed by the Joint Commissioning Committee there will be a further stage of work. This would include final business case development once the preferred option is selected, full public consultation and if approved an implementation plan. This next phase would require agreement of additional resource which is not covered in this proposal.
8. RECOMMENDATIONS
The Joint Commissioning Committee is asked to approve the establishment of the Adult Elective Orthopaedic Services Review Group as set out in this paper.
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APPENDIX ONE
Table One - Activity Numbers: Adult Surgical Procedures (all commissioners)
Trust Carpal tunnel release
Wrist arthrodesis (fusion)
Dupuytren’s fasciotomy
Primary ankle replacement
Ankle arthrodesis (fusion) Spinal Other All
North Middlesex 152 <5 18 <5 <5 119 1987 2923
Royal National Orthopaedic Hospital 35 <5 <5 21 45 1562 1444 10270
The Royal Free 62 <5 126 <5 <5 1010 1606 6254
University College London Hospitals 196 <5 41 <5 <5 1500~ 1650 3592
Whittington 156 <5 24 <5 <5 276 1843 2091
Activity by NHS Trust Source and year: HES 2015-16 Note: Royal Free activity includes Royal Free Hospital, Barnet Hospital and Chase Farm Hospital UCLH includes University College Hospital and National Hospital for Neurology and Neurosciences
Table Two - Activity Numbers: Total day Case and elective admissions 2016/17 (NCL CCGs
only)
Royal Free London NHS Foundation Trust 3390
North Middlesex University Hospital NHS Trust 2523
The Whittington Health NHS Trust 1971
University College London Hospitals NHS Foundation Trust 1878
Royal National Orthopaedic Hospital NHS Trust 1024
Highgate Hospital (Aspen) 290
The Cavell Hospital (BMI Healthcare) 259
The Kings Oak Hospital (BMI Healthcare) 223
Other NHS Providers (outside of NCL) 766
Other independent sector providers (outside of NCL) 214
Total 12538 Source: NELCSU Note: Royal Free activity includes Royal Free Hospital, Barnet Hospital and Chase Farm Hospital Note: UCLH includes University College Hospital and National Hospital for Neurology and Neurosciences
Trust Primary hip replacement
Revisional hip replacement
Repair of fractured neck of femur
Primary knee replacement
Revisional knee replacement
Primary shoulder replacement
Shoulder sub-acromial decompression
Primary elbow replacement
North Middlesex 110 7 230 188 8 17 80 <5
Royal National Orthopaedic Hospital 348 173 <5 438 102 80 59 16
The Royal Free 180 8 199 199 12 11 58 <5
University College London Hospitals 284 29 154 263 35 19 131 <5
Whittington 158 19 132 136 7 9 92 <5
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Table Three- Orthopaedic services by site (NHS Providers only)
Site Orthopaedic Surgical
Sub Specialty Other MSK Services
Barnet Hospital (part of Royal Free
London)
Lower Limb Arthroplasty
Upper Limb
Hand (carpel tunnel
release)
Foot & Ankle
Pain management &
rehabilitation
Chase Farm Hospital (part of Royal
Free London
Lower Limb Arthroplasty
Upper Limb
Hand (carpel tunnel
release)
Foot & Ankle
Pain management &
rehabilitation
North Middlesex University Hospital Lower Limb Arthroplasty
Upper Limb
Hand (carpel tunnel)
Foot & Ankle
Spinal (Injections)
Pain management &
rehabilitation
Royal National Orthopaedic Hospital Lower Limb Arthroplasty
Upper Limb
Hand
Foot & Ankle
Spinal (Surgery &
Injections)
Peripheral Nerve Injury
Sarcoma (soft tissue and
bone tumour)
London Spinal Cord
Injury Centre
National Specialist
Rehabilitation
Programmes
Specialist Pain
Management
programmes
Royal Free Hospital (part of Royal
Free London)
Lower Limb Arthroplasty
Upper Limb
Hand
Foot & Ankle
Spinal (Injections)
Pain management &
rehabilitation
UCLH Including National Hospital for Neurology and Neurosciences
Lower Limb Arthroplasty
Upper Limb
Hand
Foot & Ankle
Spinal (Surgery &
Injections)
Pain management &
rehabilitation
Specialist sports
surgery
Whittington Health Lower Limb Arthroplasty
Upper Limb
Hand
Foot & Ankle
Spinal (Surgery &
Injections)
Pain management &
rehabilitation
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NCL Joint Commissioning Committee Meeting on Thursday 1 February 2018
`
Report title NCL Joint Commissioning Committee Risk Register
Agenda item 5.1
Date 1st
December
2017
Lead director Paul Sinden Director of Performance and Acute Commissioning
Tel/Email [email protected] Tel 020 3688 2906
Report author Andy Spicer NCL Head of Governance and Risk
Tel/Email [email protected] Tel 020 3688 2032
Sponsor(s) (where
applicable) Tel/Email
Report summary North Central London Joint Commissioning Committee Risk Register This paper provides an overview of the updated risk register for the North Central London CCG Joint Commissioning Committee. The risk register covers areas of commissioning delegated to the Committee by the five North Central London CCGs in November 2016. There are 21 risks on the NCL Joint Commissioning Committee risk register with one new risk being JCC21. The main updates to the risk register are summarised below:
JCC1: Cancer 62-days – revised recovery plan received from Royal Free London, and backlog being reduced in line with recovery of the standard by the end of November 2017. The revised recovery plan for UCLH has now been received with the waiting time standard being recovered by June 2018 and by April 2018 for internal pathways. This is later than the anticipated March 2018 recovery;
JCC2: A&E 4-hour waits / JCC13: Winter Pressures – additional winter schemes approved and funded in December 2017 by NHS England and NHS Improvement are being implemented. Providers have enacted mutual aid plans for January 2018 freeing up clinical time from elective pathways to support emergency patient flows;
JCC3: Transforming Care – In December 2017 the Joint Commissioning Committee agreed the cohort of patients for whom the cost of CCG funded inpatient placements would be recycled to cover the costs of community packages of care across the NHS and Social Care. NHS England have published a revised Funding Transfer Agreement for packages of care transferred into the community from specialist commissioning funded inpatient placements, and this is reflected in the Transforming Care update to the Committee in February 2018;
JCC5: Contract provisions for marginal rate and claims and challenges. Claims and challenges process agreed, including that for procedures of limited clinical effectiveness (PoLCE), with North Middlesex
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University Hospital, Royal Free London, and Whittington Health;
JCC8: Member attendance at the Joint Commissioning Committee - Ensuring Local Authority representation could be supported by Officers deputising for Councillors when the latter cannot attend;
JCC9: Effective delivery of contracts with providers / JCC11: Management of acute contracts within baselines– Quarter one reconciliations completed with all main acute providers for 2017/18 as a pre-cursor to establishing opening contract baselines for 2018/19. Approach to disputed items with Royal Free London in 2017/18 (productivity metrics, patient transport, counting and coding challenges) agreed;
JCC12: Assuring the quality of community care packages for transforming Care cohort. Contract award for Positive Behaviour Support Programme in January 2018. Use of “surgeries” to consider packages of care for individuals transferring back into the community;
JCC15: Mobilising the Sustainability and Transformation Plan – CCG Governing Bodies are considering the case to in-house the NELCSU multi-disciplinary contracting team in January 2018 with the rationale including creating greater capacity for STP intervention delivery;
JCC17: Streamlining assurance processes with NHS England. - CCGs have agreed a unified approach to delivering and monitoring the CCG Improvement and Assessment Framework that forms part of the CCG assurance process with NHS England;
JCC20: Referral-to-Treatment – New risk added to the register in December 2017. The waiting time standard is being missed by UCLH and Royal Free London with the recovery plan received from UCLH which indicates that the waiting time standard will be recovered by February 2018. The recovery plan from Royal Free London was received on 4 December 2017, but with the waiting time standard not achieved until August 2018. The pace of recovery has been challenged by CCGs. Recovery plans spanning financial years will need to be cognisant of marginal rates;
JCC21: Integrated Urgent Care service – a road map has been agreed with the provider to ensure that the service specification is commensurate with the financial resources available after NHS England requested additional functionality that sat outside of the contract specification and contract payment from CCGs.
The Committee is asked to note that the risk register for the Joint Commissioning Committee has been linked to individual CCG registers, with risk with a rating of twelve or above on the JCC register being added to CCG registers. There are no requests to remove risks from the register.
Purpose (tick one
only)
Information Approval To note
Decision
Recommendation The NCL Joint Commissioning Committee is asked to:
Note the report;
Provide feedback on the risks included;
Advise on further development of strategic risks falling within the remit of the Committee.
Conflicts of Interest
Conflicts of interest are managed robustly and in accordance with the NCL Conflicts of Interest Policy.
Strategic Direction The risk register focuses on risks relating to delivery of the strategic objectives of the five CCGs in North Central London delegated to the Joint Commissioning Committee:
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Commission the delivery of NHS constitutional rights and pledges;
Improve the quality and safety of commissioned services;
Improve health outcomes, address inequalities and achieve parity of
Esteem;
Maintain financial stability and ensure sustainability through robust planning and commissioning of value-for- money services.
Identified risks and risk management actions
The initial risk register for the NCL Joint Commissioning Committee is appended to this report. The risk register will be a standing item for each meeting of The Committee.
Resource implications
Updating the risk register is the responsibility of each risk owner and respective teams. Governance leads will support this by providing monitoring, guidance and advice.
Engagement
The report is presented to the NCL Joint Commissioning Committee which includes elected GP representatives, lay members, Healthwatch, Public Health and representatives from each NCL London borough.
Equality impact analysis
This report was written in accordance with the provisions of the Equality Act 2010.
Report history The initial risk register for the Joint Commissioning Committee has been developed with reference to existing risk registers from individual CCGs.
Next steps To continue to identify and manage risks falling within the remit of the Joint Commissioning Committee in a robust way.
Appendices Appendices are:
Risk Register;
Risk Tracker;
Risk Scoring Key.
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North Central London CCG Risk Register as at February 2018
ID Director Objective Risk Controls in place Evidence of Controls
Overall
Strength of
Controls in
Place
Consequence (C
urre
nt)
Lik
elih
ood (C
urre
nt)
Ratin
g (C
urre
nt)
Ris
k le
vel (C
urre
nt)
Controls Needed Evidence of Controls Needed Actions Update on Actions Action Completion Date
Consequence (T
arg
et)
Lik
elih
ood (T
arg
et)
Ratin
g (T
arg
et)
Ris
k le
vel (T
arg
et)
JCC 1 Paul Sinden
62 Days Waiting
Time Standard is
Met
Delivery of Cancer 62-day waiting time standard (Threat)
Cause: There may be insufficient capacity within the system, and
inefficiencies along pathways in particular for inter-provider transfers.
Effect: There is a risk that the system may be unable to cope with the
level of demand and has limited resilience to unexpected events.
Impact: This may result in people not receiving treatment within 62
days with potential adverse impact on their health outcome.
C1. North Central London ('NCL') cancer governance arrangements
established to cover both performance and transformation.
C2. Improvement trajectory agreed with NHS England and NHS
Improvement.
C3. Remedial Action Plans in place with providers that are not meeting
the 62 day standard. Updated plan received from Royal Free London.
C4. 38 day transfer protocol in place for inter-provider transfers from
district general hospitals to tertiary services with the 38 day standard
compatible with treatment commencing within 62 days.
C5. Trajectory agreed with providers to meet the 38-day standard for
transfers of care
C6. Recovery plan received from UCLH, with overall compliance by
June 2018 and compliance on internal pathways by April 2018
C1. Meeting papers and notes.
C2. Plans and trajectories in place with providers to allow
NCL to meet the standard overall. Backlog analysis indicates
reduction towards sustainable level. Progress most marked
at Royal Free London in October and November.
C3. Plans.
C4. Transfer protocol document.
C5. Provider trajectories
C6. Provider recovery plan
Weak
4 4 16
Ve
ry H
igh
CN1. Arrangement to be put into place to ensure
all providers are abiding by the inter-provider
transfer protocol.
CN2. Individual providers to resolve internal
pathway issues to ensure they meet the 62 day
target.
CN3. Backlog reduction by providers to level
consistent with delivery of the waiting time
standard.
CN1. Improvements delivered in-line with
agreed trajectories and contained in reports.
CN2. Improvements delivered in-line with
agreed trajectories and contained in reports.
CN3. Analysis agreed with NHS
Improvement indicates maximum backlog
level to deliver the standard
A1. Continue to work with providers on
delivering the trajectories.
A2. Continue to work with providers to
ensure sustainable delivery and
includes work through the cancer
vanguard.
A3. NCL recovery of the 62 day
standard by December 2017.
A4. UCLH recovery of the 62 day
standard by end of March 2018 and is
consistent with system recovery by
December 2017. Updated recovery plan
required from the Trust.
A1. Meeting with providers on a
fortnightly basis and ensuring their
plans are consistent with agreed
trajectories.
A2. Meeting with providers on a
fortnightly basis.
A3. Currently on track for delivery.
A4. UCLH recovery plan received but
defers recovery to June 2018 from
expected recovery by March 2018
required.
A1. 31.07.2017
A2. 31.07.2017
A3. 30.09.2017.
A4. 31.03.2018.
3 4 12
Hig
h
JCC 2 Paul Sinden
A&E 4 Hour Time
Waiting Standard
is Met
Delivery of four-hour waiting time standard for A&E (Threat)
Cause: There may be insufficient capacity across hospital and
community services to meet peaks in emergency care demand.
Effect: There is a risk that people will spend more than four hours
within emergency departments before receiving definitive treatment or
be located in the wrong part of the system due to pressures along the
emergency care pathway.
Impact: This may result in people experiencing delays in treatment,
admission to a hospital bed and/or discharge back into the community.
C1. A&E Delivery Boards established and meet monthly which have
executive level representation from key providers and commissioners in
the system
C2. A&E Delivery Boards are informed by dashboards that monitor key
parts of the system to highlight any issues in terms of capacity and/or
performance.
C3. With key providers, and using resilience funding available A&E
Delivery Boards have agreed which parts of the system would benefit
from increased capacity or efficiency changes.
C4. Continued monitoring of the plan (i.e. initiatives) against agreed
outcome measures by A&E Delivery Boards.
C5. Funding is targeted to support the remedial action plans (RAPs)
agreed with UCLH.
C6. A North Central London (NCL) wide review of how winter went
across NCL took place on 6th April 2017 to share lessons learnt.
C7. All A&E Delivery Boards submitted plans to NHS England for winter
2017/18 based on experiences and pressures in 2016/17
C1. Meeting papers and notes.
C2. Meeting papers and dashboards.
C3. Remedial Action Plans, meeting papers and notes.
C4. Meeting papers, notes and dashboards.
C5. Plans to utilise winter resilience monies.
C6. Report.
C7. Plans
Weak
4 4 16
Ve
ry H
igh
CN1. Improved management of demand for
acute services.
CN2. Secure additional capacity in the
community
CN3. Measures to reduce mental health waits in
emergency departments and/or clinical decision
units
CN4. Implementation of STP initiatives for Care
Closer to Home and Urgent & Emergency Care
to build resilience in community services
CN5. Development of mutual aid plans within and
across A&E Delivery Boards
CN1. Demonstration of A&E attendances
and admissions being within operating plan
assumptions and contained in a report.
CN2. Demonstration of prompt transfer of
packages of care from hospital to
community setting and contained in a report.
CN3. Demonstration of a reduction in
waiting times for mental health patients in
emergency departments before transfer to
mental health services and contained in a
report.
CN4. STP initiatives in place.
CN5. Performance behind recovery
trajectories.
A1 . Develop a demand and capacity
plan for both hospital and community
services.
A2. Implement STP initiatives.
A3. Develop mutual aid plans for
January 2018 to meet peaks in demand.
A1. A&E Delivery Boards are
developing system wide demand and
capacity plans.
A2. STP initiatives are being
implemented in accordance with
individual plans. Progress on
implementation is reviewed in CCGs
and STP work streams monthly.
Additional winter schemes, funded in
December 2017 underway for each
A&E Delivery Board.
A3. Providers implementing plans to
release clinical resource from elective
pathways to support emergency patient
flow through A&E and wards
A1. 30.08.2017
A2. 31.07.2017
A3. 08.12.2017
3 4 12
Hig
h
JCC 3
Paul Sinden C1. Transforming Care Partnership plan agreed for North Central
London CCGs, with resources secured from NHS England in
recognition of agreed plans
C2. New NCL Joint Commissioning Committee established with first
meeting on 6th July 2017.
C3. NCL Joint Commissioning Committee to have oversight of
progress.
C4. Transforming Care Partnership Board and supporting
implementation groups have been established.
C5. Principle of recycling funds from CCG funded placements to cover
the costs of community packages of care across CCGs and Social
Care agreed by JCC on October 2017. Cohort to attract funds from
CCG placements agreed in December 2017.
C1. Meeting papers and minutes from Transforming Care
Partnership Board.
C2. Meeting papers.
C3. Meeting papers and reports.
C4. Meeting papers and notes.
C5. Meeting papers and minutes
.
Average
3 4 12
Hig
h
CN1. Revised trajectory that moves forward
some transfers into the community from
current projections and contained in a
report.
CN2. An agreement with NHS England on
a funding transfer in line with the shift of
packages of care into the community.
A1. 31.07.2017
A2. 30.09.2017
A4. 07.12.2017
3 3 9
Hig
h
JCC 4 Paul Sinden
Provide Robust
Contract
Monitoring
Baselines Against
Which In Year
Performance can
be Assessed
Provision of robust activity and financial information to support
acute provider contract monitoring (Threat)
Cause: If we continue to be unable to resolve the complexity of setting
contract baselines that incorporates the impact of STP and QIPP
interventions in detail
Effect: There is a risk it will reduce the robustness of contract
monitoring.
Impact: This may result in a delay in Remedial Action Plans being
undertaken as trend analysis and variances from pan are less clear
and heightening the risk of contract over performance.
C1. Activity and financial impact of STP interventions agreed and
included in contract baselines at high-level.
C2. Agreement to reflect detailed finance and activity STP and QIPP
plans in month two reports with providers.
C3. Contracts with Acute providers signed with the impact of STP
interventions incorporated.
C1. Acute provider contracts.
C1. Agreed schedule of impact of STP interventions on
2017/18 provider contracts
C2 Action points from Finance and Activity Modelling Group
C3. Signed contracts for 2017/18 and 2018/19.
Average
3 4 12
Hig
h
CN1. Detailed STP interventions at HRG level
and incorporated into contract baselines.
CN2. Revised baseline incorporated into contract
reports and used to monitor in year performance.
CN1. Commissioner and provider sign off
of the detailed contract baseline.
CN2. Revised baseline being used to
monitor in year performance and contained
in reports.
A1. Contract teams to work with
providers to ensure Month 2 reports are
reflective of the detail of STP
interventions.
A1. Contract baselines reflect the
impact of STP and local QIPP
interventions.
A1. 31.07.2017
2 4 8
Hig
h
JCC 5 Paul Sinden
Contract
provisions for
marginal rates
and streamlined
claims and
challenges
process are
operational
Embedding and enacting pivotal contract agreements for marginal
rates and a streamlined transaction process for claims and
challenges into contact monitoring. (Threat)
Cause: If we do not translate the high-level agreement to use marginal
rates and the streamlined claims and challenges process included in
contracts signed in December 2016
Effect: There is a risk that in-year monitoring will not be reflective of full
contract provisions for marginal rates and claims/challenges process
Impact: This may result in underlying performance against contract not
being fully measured in line with contract provisions, and retention of
local resource in transactional processes rather than support delivery of
the STP
C1. Contracts signed in December 2016 with providers included the
use of marginal rates for variances from plan and establishing a
streamlined claims and challenges process, as part of an overall
package of negotiations.
C2. Detailed agreement of the application of marginal rates to contract
baselines specifying areas included and excluded in place with UCLH,
Whittington Health, North Middlesex University Hospital
C3. Claims and challenges process for UCLH contract in 2017/18
agreed
C4. Existing monthly contract management processes in place
including SUS/SLAM activity reconciliations, and process for claims and
challenges.
C5. Claims and challenges process, including that for procedures of
limited clinical effectiveness, agreed with North Middlesex, Royal Free,
and Whittington Health
C1. Acute provider contracts
C2. Contract meeting notes
C3. Contract meeting notes
C4. Contract meeting notes
C5. Contract meeting notes
Average
3 4 12
Hig
h
CN1. Agreement of marginal rate application to
Royal Free Hospitals Contract.
CN2. Agreement of claims and challenges
process with Royal Free Hospitals, Whittington
Health, and North Middlesex University Hospital.
A single agreement will apply to all three trusts as
all are on 50% marginal rate.
CN1. Document containing agreement
between provider and commissioners
CN2. Document containing agreement
between providers and commissioners
A1. Completion of negotiations for
application of marginal rate to Royal
Free Hospitals contract. Four
outstanding items as at 27 June 2018,
A2. Completion of negotiations for
application of claims and challenges
process with providers.
A1. Agreement reached with Royal Free
London on disputed items for 2017/18 -
metrics, patient transport services, and
counting and coding challenges.
Agreement on application of marginal
rate should flow from this.
A2. Claims and challenges approach,
including for procedures of limited
clinical effectiveness agreed with
providers.
A1. 07.07.2017
A2. 07.07.2017. Completed in
November 2017
2 4 8
Hig
h
Transforming Care Partnership for Learning Disabilities -
delivering the transfer of care from inpatient placements to
community packages of care in line with national timelines and
without cost pressures to health and care services (Threat)
Cause: if we are unable to transfer complex cases from inpatients to
the community within the set timelines and resource envelopes for
inpatient care.
Effect: There is a risk that patients may remain in inpatient placements
beyond the expected time of transfer to community packages of care.
Impact: Patients may remain in inpatient placements longer than
anticipated as community care packages are developed. Cost
pressures accruing from establishing the community packages of care
may have to be met from local health and care resources.
CN1. NHS England have requested that the
trajectory for repatriations from inpatient to
community settings be accelerated to provider
greater resilience in meeting national targets for
repatriation. This involves moving some
repatriations from year three to year two of the
programme. Any shift in trajectory needs to be
agreed locally.
CN2. The flow of funding from inpatient
placements to community packages needs to be
agreed. Currently, the increase in community
packages results in cost pressures for both
Councils and CCGs. Funds have yet to transfer
from NHS England from the reduction in inpatient
placements they commission.
Reduce Reliance
on Inpatient
Placements for
the Transforming
Care Cohort
within Learning
Disabilities
A1. Agree funding transfer from NHS
England in line with the repatriation of
people from NHSE funded placements
into locally funded care packages in the
community.
A2. Conclude negotiations with NHS
England on the transfer of funding to
support local care packages.
A4. Operationalise agreement for
funding community packages of care
across CCGs and Social Care from
CCG funded placements
A1. NHS England have issued an
updated proposal for a funding transfer
agreement to CCGs for consideration.
A2. Negotiations with NHS England are
being conducted.
A3. Paper to JCC in December 2017
proposing a way forward on transfer of
funds between CCGs and Social Care
was agreed. Completed
105
ID Director Objective Risk Controls in place Evidence of Controls
Overall
Strength of
Controls in
Place
Consequence (C
urre
nt)
Lik
elih
ood (C
urre
nt)
Ratin
g (C
urre
nt)
Ris
k le
vel (C
urre
nt)
Controls Needed Evidence of Controls Needed Actions Update on Actions Action Completion Date
Consequence (T
arg
et)
Lik
elih
ood (T
arg
et)
Ratin
g (T
arg
et)
Ris
k le
vel (T
arg
et)
JCC 6 Paul Sinden
Effective and
aligned Decision-
making across
new CCG
governance
arrangements
Alignment of Decision Making (Threat)
Cause: if we do not ensure that our pan NCL commissioning is aligned
both at a system wide and local CCG level
Effect: There is a risk that we do not effectively commission for the
entire clinical pathway, unnecessarily delay decision making and not be
aligned.
Impact: This may result in wasted resources, time, delays in service
change and a negative impact on the integration of the health care
system.
C1. NCL Joint Commissioning Committee established with first
meeting on 6th July 2017.
C2. NCL Primary Care Co-Commissioning Committee in Common in
place.
C3. NCL senior management team in place.
C4. NCL Head of Governance and Risk in place.
C5. Organisational Development workshops on the NCL Joint
Commissioning Committee held in May and June 2017.
C6. CCG Governing Body approval of new commissioning
arrangement in November 2016.
C7. Proposed approach to system intentions draft and will be
presented at the NCL Joint Committee on 6th July 2017.
C1. Meeting papers and Terms of Reference.
C2. Meeting papers, minutes and Terms of Reference.
C3. Contracts of employment.
C4. Contract of employment.
C5. Notes from workshops.
C6. Minutes and papers from CCG Governing Bodies held
in November 2016.
C7. Report.
Average
3 3 9
Hig
h
CN1. Develop commissioning cycle to
operationalise the new commissioning
arrangements.
CN2. Agreed system intentions in place.
CN1. Policy document.
CN2. Agreed policy document.
A1. Develop commissioning cycle to
operationalise the new commissioning
arrangements.
A2. Agree approach to system
intentions.
A3. Sign off system intentions for 2018-
19.
A1. To discuss the approach to this at
SMT.
A2. System intentions signed off by
JCC and CCG Governing Bodies prior
to issue to providers.
A3. System intentions for 2018/19
issued to providers in September 2017.
A1. 31.07.2017.
A2. 06.07.2017
A3. 07.07.2017
2 2 4
Mo
de
rate
JCC 7 Paul Sinden
Effective
communication
of the remit of the
Committee to
stakeholders
including public
and local
authorities
Insufficient communication of Joint Commissioning Committee
remit (Threat)
Cause: if we do not ensure that there is sufficient communication of
the Committee remit and role.
Effect: There is a risk that our stakeholders do not understand the role
and purpose of the Committee and in particular how it relates to STP
decision-making leading to stakeholder disengagement.
Impact: This may result in delays to the Committee effectively
discharging its duties in line with delegated authority and in particular
management of acute contracts to support delivery of the Sustainability
and Transformation Plan .
C1. NCL Joint Commissioning Committee Terms of Reference
approved.
C2. Paper on remit of the Joint Commissioning Committee presented
at the meeting held on 6 July 2017.
C3. Organisational Development workshops on the NCL Joint
Commissioning Committee held in May and June 2017
C4. Meeting brief sent to Councillors and Healthwatch that provided a
summary of the papers
.
C1. Meeting papers and Terms of Reference.
C2. Meeting papers
C3. Notes from workshops.
C4. Briefing note
Weak
3 4 12
Hig
h
CN1. Develop comprehensive communication
plan to stakeholders.
CN1. Communications plan A1. Identify communications lead to
develop the plan and identify key
stakeholders and their preferred
communication channels
A2. Action the agreed communications
plan
A1. Agree approach with CCG
Accountable Officer
A2. Generation of action plan once
approach agreed
A1. 03.08.2017
A2. 30.09.2017
2 2 4
Mo
de
rate
JCC 8 Paul Sinden
Ensuring
member
attendance of the
Joint
Commissioning
Committee
Insufficient member attendance at Committee meetings (Threat)
Cause: if we do not ensure that voting and non-voting members of the
Committee attend meetings and have the opportunity to read and
comment on Committee papers
Effect: There is a risk that the Committee will not effectively operate to
the terms of reference signed off by CCG Governing Bodies, and/or
meet quoracy requirements .
Impact: This may result in delays in decision-making that will impact on
managing contracts within resource envelopes and delivering service
improvements.
C1. NCL Joint Commissioning Committee Terms of Reference
approved including membership
C2. Revised forward planner in place for the Committee in 2017/18
C3. Independent clinicians (3) recruited to the JCC
.
C1. Meeting papers and Terms of Reference.
C2. Forward planner
C3. Meeting papers
Average
3 3 9
Hig
h
CN1. Develop corporate calendar to ensure the
Committee meetings and timing fits with CCG and
stakeholder business cycle
CN2. Ensure clarity on the remit of the
Committee (see risk JCC7)
CN3. Ensure Local Authority representation at eh
Joint Commissioning Committee
CN1. Corporate calendar
CN2. Please see controls under risk JCC7
CN3. The need for Councillors to give
apologies for the meetings
A1. Develop corporate calendar
A2. Undertake actions under risk JCC7
A3. Propose Local Authority officers can
deputise for Councillors
A1. Work on corporate calendar to get
underway in August 2017
A2. Please see actions for risk JCC7
A3. Consider Local Authority
representation at JCC
A1. 30.09.2017
A2. 30.09.2017
A3. 01.02.2018
2 2 4
Mo
de
rate
JCC 9 Paul Sinden
Effective delivery
of contracts with
providers
according to
signed contracts
for 2017/18 and
2018/19
Relationships with providers not strong enough to support
contract delivery (Threat)
Cause: if we do not ensure that provider contracts are managed from
within a robust contract framework, supported by strong working
relationships with providers
Effect: There is a risk that provider contacts will not be delivered in a
manner that effectively supports broader system aims and managed
within available resources
Impact: This may result in wasted resources, time, delays in service
change and a negative impact on the integration of the health care
system.
C1. Signed contracts in place for 2017/18 and 2018/19
C2. Contract frameworks in place with each provider
C3. Collaborative arrangements in place through Finance and Activity
Modelling (FAM) Group as part of STP governance framework
C4. Sustainability and Transformation Plan governance and supporting
work streams with commissioner and provider membership in place.
C5. Quarter one reconciliation agreed with providers as a precursor to
establishing the opening contract baseline for 2018/19
C6. Principles and process for setting contract baselines for 2018/19
agreed with providers through STP finance meeting.
C1. Signed contracts
C2. Meeting minutes and papers
C3. Meeting minutes and papers
C4. Meeting minutes and papers
C5. Meeting minutes and papers
C6. Meeting minutes and papers
Average
4 3 12
Hig
h
CN1. Development of system intentions, as
opposed to commissioning intentions, for 2018/19
CN2. Agreed contract baselines in place for
2018/19
CN3. Ensure representation from Councils at the
JCC
CN1. Policy document.
CN2. Agreed baseline sin place for each
provider
CN3. High level of apologies for JCC
meeting from selected Councillors
A1. Develop and sign-off system
intentions for 2018/19.
A2. Develop and agree [planning
timetable for 2018/19
A3. Agree contracts baselines for
2018/19
A4. Consider Local Authority Officers
attending JCC if Councillors cannot
A1. System intentions sent to providers
on 30 September 2017
A2. Planning timetable for 2018/19
including principles for establishing
contract baselines for 2018/19 agreed
A3. Opening baselines for 2018/19 sent
to providers in November 2017
A4. In risk report for February 2018
A1. 03.08.2017.
A2. 03.08.2017
A3. 30.09.2017
A4. 01.20.2018
4 2 8
Hig
h
JCC 10 Paul Sinden
Effective
mobilisation of
Sustainability and
Transformation
(STP) plans and
CCG QIPP plans
to ensure
contracts remain
within resource
envelopes
Mobilisation of STP and QIPP plans (Threat)
Cause: if we do not ensure that STP and QIPP plans are delivered in
accordance with planning assumptions
Effect: There is a risk that contracts will not be delivered within
resource envelopes for 2017/18
Impact: This may result in delays to service changes, higher contract
baselines for 2018/19 than anticipated in financial plans for CCGs, and
a wider system financial gap.
C1. Signed contracts in place for 2017/18 and 2018/19
C2. Contract frameworks in place with each provider including Local
Delivery Teams to support the STP
C3. In-year contract variances subject to marginal rates rather than full
tariff adjustments
C4. Collaborative arrangements in place through Finance and Activity
Modelling (FAM) Group as part of STP governance framework
C5. Sustainability and Transformation Plan governance and supporting
work streams with commissioner and provider membership in place
C6. Development of schemes for 2018/19 underway. Project initiation
documents shared with providers for planned care, care closer to
home, and urgent and emergency care
C1. Signed contracts
C2. Meeting minutes and papers
C3. Signed contracts
C4. Meeting minutes and papers
C5. Meeting papers
C6. Meeting papers and project initiation documents
Average
4 4 16
Ve
ry H
igh
CN1. CCG and CSU redirection of capacity to
support mobilisation of STP interventions
CN2. Collaborative work with providers to realign
system incentives, and contract form, to support
STP delivery
CN1. Realigned CCG and CSU teams for
contract frameworks that release resources
to support the STP
CN2. Proposals for alternative contract
form
A1. Finalise proposals to increase
support for STP work streams
A2. Progress the work of the acute
contract modelling group to consider
alternative contract forms
A1. Potential in-housing of NELCSU to
provide greater support and capacity for
delivery of STP interventions.
A2. To include the ambition to change
system incentives in system intentions
A1. 31.07.2017.
A2. 30.09.2017
4 3 12
Hig
h
106
ID Director Objective Risk Controls in place Evidence of Controls
Overall
Strength of
Controls in
Place
Consequence (C
urre
nt)
Lik
elih
ood (C
urre
nt)
Ratin
g (C
urre
nt)
Ris
k le
vel (C
urre
nt)
Controls Needed Evidence of Controls Needed Actions Update on Actions Action Completion Date
Consequence (T
arg
et)
Lik
elih
ood (T
arg
et)
Ratin
g (T
arg
et)
Ris
k le
vel (T
arg
et)
JCC11 Paul Sinden
Management of
acute contracts
to ensure
contracts are
delivered within
contact baselines
(CCG resource
envelopes)
Managing acute contracts within contract baselines (Threat)
Cause: if expenditure on acute contracts exceeds planned contract
baselines
Effect: There is a risk that CCGs will not meet their financial duties
and/or investment is withheld to support delivery of the Sustainability
and Transformation Plan
Impact: This may result in delays to investing in primary care and
community capacity and perpetuate the risk over performance on acute
hospital contracts
C1. Signed contracts in place for 2017/18 and 2018/19
C2. Contracts include marginal rate payments/deductions for variances
from plan and 3% growth (higher than historic growth trends)
C3. Contract management framework in place with providers
C4. Issue of contract notices in line with contact provisions
C5.. Mobilisation of STP and QIPP plans (see JCC10)
C6. North Central London Finance and Activity Modelling (FAM) Group,
with commissioner and provider membership. that oversees system
financial position
C7. Work on alternative contract forms to support the Sustainability and
Transformation Plan (STP) through the Acute Contract Modelling
Group (with commissioner and provider membership)
C8. Quarter one reconciliation agreed with providers as a precursor to
establishing the opening contract baseline for 2018/19
C9. Agreement of treatment of disputed items with Royal Free London
in 2017/18 reached
C1. Signed contracts
C2. Signed contracts
C3. Meeting minutes and papers
C4. Contract documentation and correspondence including
remedial action plans
C5. See JCC10
C6. Meeting minutes and papers
C7. Meeting minutes and papers
C8. Meeting minutes and papers
Average
4 4 16
Ve
ry h
igh
CN1. Development of system intentions for
2018/19
CN2. Develop proposals to realign system
incentives including new contract forms for
hospital contracts
CN1. CCG system leadership for
commissioning. Contract requirement to
signal major contact/service changes
CN2. Historic year-on-year over
performance on acute contracts caused in
part by the inflationary impact of payment-by-
results
A1. Develop and sign-off system
intentions for 2018/19
A2. Develop, in co-production, with
providers, proposals for alternative
contract forms for hospital providers
A3. Development of planning
assumptions for 2018/19 with providers.
A1. System intentions issued to
providers.
A2. Consideration of models used
elsewhere - Aligned Incentive Contract
in Bolton; Accountable Care models
A3. Scenarios for 2018/19 being
developed through STP finance
meetings
A1. 30.09.2017
A2. 31.10.2017
A3. 31.01.2018
4 3 12
Hig
h
JCC 12 Paul Sinden
Assuring the
quality of
packages of care
transferred into
the community
for the
Transforming
Care Cohort
within Learning
Disabilities
Transforming Care Partnership for Learning Disabilities - ensuring
that care packages established in the community deliver care that
meets the needs of the individual and to the requisite quality and
safety. (Threat)
Cause: if we are unable to transfer complex cases from inpatients to
the community whilst effectively meet the needs of the individual.
Effect: There is a risk that patients may receive sub-optimal care
leading to readmission risk, an increase in safeguarding requirements
locally, and risk of legal challenges to the transfer of care being raised.
Impact: Patients may remain in inpatient placements longer than
anticipated as community care packages are developed.
C1. Transforming Care Partnership plan agreed for North Central
London CCGs, with resources secured from NHS England in
recognition of agreed plans
C2. Transforming Care Partnership Board and supporting
implementation groups have been established.
C3. Scrutiny process of community provider support plans, risk plans,
and crisis plans for individual cases prior to transfer.
C4. Quality checks of community placements, with any quality
conversion routed through local quality alert and/or safeguarding
processes.
C5. Development of "surgery" approach for agreeing transfers of care
for complex individuals
C1. Meeting papers and minutes from Transforming Care
Partnership Board.
C2. Meeting papers and notes.
C3. Provider plans
C4. Notes from provider meetings plus any quality alerts
raised, and supporting action plans from providers
C5. Meeting notes
Average
3 3 9
Hig
h
CN1. Development of reports on individual
placements in line with care plans incorporating
patient outcomes and quality metrics for
consideration by the Transforming Care
Partnership Board
CN2. Mobilisation of service developments for the
Accommodation, Positive Behaviour Support,
and multiagency hub to increase community
capacity.
CN1. Care plans for individuals / outcomes
from provider reviews
CN2. Plans agreed with NHS England to
improve community capacity to support care
packages and prevent admission
A1. Develop reporting proposals
including outcomes
A2. Implement service developments in
line with existing mobilisation plans
A1. Discuss approach to quality at Joint
Commissioning Committee on 3 August
2017.
A2. Progress with mobilisation
monitored through the Transforming
Care Partnership Board.
A1. 30.11.2017
A2. Multi-agency protocol
30.09.2017
A2: Accommodation 31.10.2017
A2. Positive Behaviour Support
contract award made in January
2018
3 2 6
Mo
de
rate
JCC 13 Paul Sinden
Management of
winter pressures
to support
recovery of A&E
waiting time
standard and
protect capacity
for delivery of
cancer and
referral-to-
treatment waiting
time standards
Ensuring that management of winter pressures supports recovery
of waiting time standards for A&E and cancer and protects
capacity for elective pathways (Threat)
Cause: if we are unable to manage non-elective flows within planned
hospital and community capacity to meet winter pressures
Effect: There is a risk that patients may receive sub-optimal care and
long waiting times leading to the local system missing waiting time
standards for A&E and referral-to-treatment. Historically capacity to
meet cancer waiting time standards has been successfully ring-fenced.
Impact: Patients may remain in inpatient placements longer than
anticipated as community care packages are developed.
C1. Establishment of A&E Delivery Boards with representation across
health and care system
C2. Establishment of NCL Urgent and Emergency Care (UEC) Board
C3. STP work streams for urgent and emergency care established for
long-term sustainability.
C4. Winter plans for 2017/18 prepared by each A&E Delivery Board
C5. Recovery plans submitted by each A&E Delivery Board to regain
A&E four-hour waiting time standard
C6. See JCC2 - recovery of A&E four-hour waiting time standard
C7. Supplementary winter plans submitted by each A&E Delivery Board
to NHS England and NHS Improvement in December 2017
C1. Meeting papers and minutes from A&E Delivery Boards
C2. Meeting papers and minutes from UEC Board .
C3. Work streams plans and QIPP monitoring reports
C4. Plans submitted and reports/dashboards monitoring
progress.
C5. Plans submitted and reports/dashboards monitoring
progress.
C6. See JCC2
C7. Funding confirmation for priority supplementary
schemes from NHS England
Average
4 5 20
Ve
ry h
igh
CN1. Development of NCL-wide escalation
process for winter 2017/18
CN2. NCL winter workshop on 27 September to
align plans across A&E Delivery Boards.
CN3. Development of further plans for winter
2017/18 to ensure resilience
CN1. Series of individual escalation
meetings held with NHS England and NHS
Improvement for each A&E Delivery Board
separately
CN2. In winter 2016/17 NCL system support
was needed to support North Middlesex
University Hospital.
CN3. Slippage on existing recovery plans for
all A&E Delivery Boards in NCL and risk of
further escalation with regulators.
A1. Agree escalation process for NCL
with NHS England and NHS
Improvement
A2. Hold winter workshop on 27
September
A3. Identification of further recover plans
through winter workshop and A&E
Delivery Boards
A4. Provider mutual aid plans
developed for January 2018 to free up
clinical time from elective care pathways
to support emergency patient flows
A1. NCL approach to escalation agreed
in principle with NHS England. All A&E
Delivery Boards have agreed escalation
protocols to respond to surges in
pressure and/or demand
A2. Actions from winter workshop will be
actioned through A&E Delivery Boards
A3. Response from regulators to winter
plans will specify further actions to be
taken to alleviate winter pressures
A4. Providers to confirm impact of
mutual aid on elective and emergency
care pathways
A1. 13.10.2017
A2. 30.09.2017 - write up of
actions
A3. 31.10.2017
A4. 28.20.2018
4 4 16
Ve
ry h
igh
JCC 14 Paul Sinden
Mobilising STP
schemes that
shifts activity
away from acute
providers in a
way that allows
those providers to
release capacity
and costs, and
thereby reduce
overall system
costs
STP and local plans target the shift of care from hospital into
community settings, to reduce the overall system financial deficit
this needs to be done in a way that allows hospital providers to
reduce capacity and costs. This risk follows on from the initial risk
of mobilising STP and local plans in JCC10 (Threat)
Cause: if we are unable to shift care from hospital to community
settings that allow providers to make a step-change in capacity
Effect: There is a risk that hospital providers are left with stranded
costs and we do not reduce overall system costs
Impact: STP and local interventions do not help reduce the system
financial deficit in the anticipated way.
C1. Signed contracts for 2017/18 and 2018/19 that include the impact
of STP interventions
C2. System intentions for 2018/19 that seek to align intentions across
CCGS so we commission at scale
C3. Agreement of approach to planning round for 2018/19 with
providers through STP finance meetings. Contract baselines for
2018/19 to include the impact of STP interventions.
C4. Work with providers on alternative contract forms to support STP
delivery, with the work informed by provider cost profiles.
C5. STP Finance meetings with commissioners and providers that has
a common understanding of financial position in NCL system
C6. STP interventions for 2018/19 developed and shared with providers
C1. Contract documentation
C2. NCL Systems Intentions letter
C3. Meeting paper and notes.
C4. Meeting papers and notes.
C5. Meeting papers and notes
C6. Meeting papers and project initiation documents
.
Average
4 4 16
Ve
ry h
igh
CN1. Development of STP work streams
interventions plans for 2018/19
CN2. Agreement of contract baselines for 208/19
CN3. Development of alternative contract models
and incentive systems
CN1. Interventions impacts need to be
planned and agreed for incorporation into
contracts
CN2. Signed contracts for 2017-19 require
the negotiation of contact baselines for
2018/19
CN3. Alternative contract forms need to be
shadow run in 2018/19 to be used in
contracts from 2019/20 onwards
A1. Work streams development of STP
plans for 2018/19.
A2. Agree option for setting contract
baselines for 2018/19.
A3. Negotiation of contract baselines for
2018/19 incorporating 2017/18
plan/outturn, growth and impact of
interventions.
A4. Agree models for alternative
contract forms to be shadow run in
2018/19
A5. Create finance and activity
schedules that support the shadow
running od the alternative contract
forms.
A1. STP work streams notified on
planning timetable and working to
identify interventions.
A2. Options for setting contract
baselines went to STP finance meeting
on 01.09.2017 and will go to meeting on
29.09.2017 for decision.
A3. To follow on from finance STP
decision (see A2)
A4. Acute contract modelling group
established
A5. Open book approach to provider
cost profiles agreed
A1. 30.11.2017
A2. 13.10.2017
A3. 31.12.2017
A4. 31.12.2017
A5. 01.01.2018
3 3 9
Hig
h
JCC 15 Paul Sinden
Creating the
capacity to
deliver
Sustainability and
Transformation
Plan and local
interventions to
planning
timelines
STP and local plans have ambitious plans for delivery with £36m
impact on hospital contracts planned for in 2017/18. The system
needs to create the capacity to implement these initiatives.
(Threat)
Cause: if we are unable to resource the service changes we wish to
make through eh STP and local initiatives
Effect: There is a risk that service changes will be delayed or reduced
in scope
Impact: STP and local interventions do not help reduce the system
financial deficit in the anticipated way.
C1. STP work streams established to co-ordinate planning and
implementation of interventions
C2. Streamlined transaction process for contracts to release resource
to support the STP
C3. Reports established to monitor the impact of interventions on
provider contracts.
C4. CSU teams realigned to provide greater support to the STP
C1. Meeting papers and minutes
C2. Provider contract meeting papers
C2. Contract claims and challenge process for 2017/18
C3. Contract monitoring report and CCG QIPP delivery
reports
C4. Meeting papers and notes from NCL CCG Senior
Management Team.
Average
3 4 12
Hig
h
CN1. Finalisation of claims and challenges
process by agreeing process for procedures of
limited clinical effectiveness (PoLCE)
CN2. Implement streamlined reporting process
across Joint Commissioning Committee and CCG
Committee structures
CN1. Process for PoLCE claims and
challenges the only outstanding item for the
contract transaction process
CN2. Duplication of performance reports
across Joint Commissioning Committee and
CCG Committees
A1. Develop contract reports that
support the requirements of both the
JCC and CCGs
A2. Finalise claims and challenges
process for PoLCE
A3. Proposal to in-house NELCSU multi-
disciplinary contracts team to CCG
Governing Bodies in January 2018 will
provide greater capacity to support
delivery of STP interventions.
A1. Workshop on reports held in
September 2017 to agree report format
A2. PoLCE process agreed with
providers
A3. Letter of intent to NELCSU once
approval from five CCG Governing
Bodies received
A1. 30.09.2017
A2. 31.10.2017
A3. 31.01.2018
3 3 9
Hig
h
107
ID Director Objective Risk Controls in place Evidence of Controls
Overall
Strength of
Controls in
Place
Consequence (C
urre
nt)
Lik
elih
ood (C
urre
nt)
Ratin
g (C
urre
nt)
Ris
k le
vel (C
urre
nt)
Controls Needed Evidence of Controls Needed Actions Update on Actions Action Completion Date
Consequence (T
arg
et)
Lik
elih
ood (T
arg
et)
Ratin
g (T
arg
et)
Ris
k le
vel (T
arg
et)
JCC 16 Paul Sinden
Creating the
workforce to
deliver
Sustainability and
Transformation
Plan and local
interventions
Delivery of many STP and local interventions are dependent on
changes to workforce skill-mix and enhanced capacity in primary
care and community services. (Threat)
Cause: if workforce development and training plans are not aligned to
local delivery plans
Effect: There is a risk that the workforce required to successfully
implement our delivery plans will not be available in the right numbers
or skill-mix.
Impact: The delivery of our local plans will be delayed and/or the
beneficial impact reduced.
C1. Community Education Provider Networks established in NCL
C2. Local Workforce Advisory Board for NCL established
C3. Capital Nurse Programme in London
C4. Health Education England part of NCL STP
C1. Meeting papers and minutes.
C2. Meeting papers and minutes
C3. Meeting papers and minutes
C4. Meeting papers and minutes
.
Average
3 4 12
Hig
h
CN1. Ensure STP service work streams initiatives
consider workforce implications
CN2. Ensure STP workforce requirements are
collated for future years
CN3. Communicate STP workforce requirements
to national education and workforce
CN4. STP recruitment and retention plans
developed
CN1. Care plans for individuals / outcomes
from provider reviews
CN2. Plans agreed with NHS England to
improve community capacity to support care
packages and prevent admission
To be confirmed To be confirmed To be confirmed
3 4 12
Hig
h
JCC 17 Paul Sinden
Streamlining the
assurance
process with
NHS England to
ensure maximum
local capacity to
support delivery
of the
Sustainability and
Transformation
Plan
Assurance processes with regulators are based on overall
performance the five CCGs as statutory bodies, plus themed
assurance reviews for delivery of financial duties and NHS
Constitution targets. (Threat)
Cause: if we are unable to streamline assurance processes with
regulators following the introduction of the new commissioning
arrangements for NCL CCGs in April 2017
Effect: There is a risk that CCG capacity will be increasingly used for
assurance preparation and meetings
Impact: Less CCG capacity, including senior capacity, is available to
support delivery and implementation of local plans
C1. New commissioning arrangements for NCL CCGs in place from
April 2017
C2. Establishment of London Performance and Contracts meeting
between NHS England and CCG STP representatives that includes a
focus on streamlining assurance processes
C3. Mapping of performance functions across NCL CCGs undertaken
to identify opportunities for joint working across CCGs
C4. Unified approach to delivering and monitoring CCG Improvement
and Assessment Framework (IAF) approach agreed by NCL Senior
Management Team
C1. CCG Governing Body papers November 2016
C2. Meeting papers and notes.
C3. Report
C4. Meeting papers and notes
Average
3 4 12
Hig
h
CN1. Development of winter escalation process
for regulators on the STP footprint rather than
through individual A&E Delivery Boards
CN2. Alignment of performance function across
CCGs - what can be done once across the five
CCGs to support the assurance process
CN3. Work with NHSE on proposal for
streamlining CCG assurance meetings
CN1. Experience of winter 2016/17
CN2. Many meetings/calls with the five
CCGs involved, with five reports prepared in
preparation e.g. Operating Plan activity
monitoring.
CN3. Assurance meeting process for CCGs
in 2017/18 - individual meetings with CCGs
plus themed meetings on A&E, cancer,
transforming care and finance
A1. Develop proposal for NCL approach
to CCG assurance with NHS England
A2. Develop proposals for carrying out
the performance functional cross NCL
CCG and CSU
A3. For winter plans and escalation see
JCC14
A1. Ass durance process discussed at
London Contracts and Performance
Group
A2. Monthly performance leads
meetings established to develop
proposals for joint working
A1. 30.11.2017
A2. 30.11.2017
3 3 9
Hig
h
JCC 18 Paul Sinden
Reducing the
system financial
deficit in line with
planning
assumptions
NCL is a system in deficit. One of the aims of our Sustainability
and Transformation Plan is to deliver financial recovery and
maintain and sustainable health and care system. The STP sets
out the challenges to financial recovery from demographic and
demand trends. (Threat)
Cause: if our plans do not deliver financial balance
Effect: There is a risk that additional savings plans will need to be
developed that have a greater impact on service delivery and access
than current plans, and the local system comes under greater scrutiny
from regulators.
Impact: Delivery of our STP developments is slowed down and impact
reduced. Greater local resource is taken up with assurance processes
C1. STP finance meeting established that has a common view of
system deficit
C2. Collaborative approach to contracting round for 2017/18 and
2018/19
C3. Work on alternative contract forms for future years to support cost
reduction
C4. Monthly reporting cycle and monitoring
C5. Working groups established for areas of pressure and with scope
for cost reduction - estates, continuing healthcare, demand
management etc.
C6. Iterative CCG QIPP plans
C1. Meeting papers and minutes from STP finance group
C2. Contract documentation; notes from STP finance
group.
C3. Notes from acute contract modelling group
C4. Reports
C5. Meeting notes
C6. Reports
.
Average
4 5 20
Ve
ry h
igh
CN1. Identify opportunities for year-end
settlements with providers to allow planning
certainty and focus on cost reduction
CN2. Identification of further savings opportunities
for the system
CN3. Ensure mobilisation of STP and local
interventions (see JCC 10)
CN1. Quarter one reconciliation process.
Both CCGs and providers under financial
pressure
CN2. CCG finance reports - risks outweigh
opportunities in 2017/18
CN3. See JCC10
A1. Finalise quarter one reconciliation
process to identify opportunities for year-
end settlements
A2. Continue to identify further savings
opportunities
A3. 2081/19 planning round to set
contract baselines for 2018/19
A4. Greater alignment of CCG QIPP
and provider cost improvement
programmes (CIP) for 2018/19
A1. Quarter one reconciliation process
underway
A2. Opportunities being developed
through STP finance group and locally
by CCGs
A3. Process for planning round agreed
through STP finance group
A4. QIPP/CIP meeting January 2018
A1. 30.10.2017
A2. on-going
A3. 31.12.2017
A4. 31.01.2018
4 4 16
Ve
ry h
igh
JCC 19 Paul Sinden
Aligning local
delivery with the
political
environment
including London
Local Elections in
May 2018.
Delivery of local plans, in particular for the STP, is subject to
support from stakeholders including elected representatives
through Scrutiny Committees. Plans will also need to be cognisant
of the politic cycle including elections. (Threat)
Cause: if we are unable to secure stakeholder support for our plans
Effect: There is a risk that implementation of our plans will be delayed
whilst that support is secured.
Impact: Existing plans to support service changes and financial
recovery are delayed or new plans required to be developed.
C1. Establishment of Health and Wellbeing Boards
C2. Joint commissioning arrangements between CCGs and Councils
including Section 75 Agreements and Better Care Fund
C3. Health Scrutiny Committees
C4. Council engagement in STP leadership and work streams including
the Health and Care Cabinet and Advisory Board
C5. Council membership of CCG Governing Bodies and Joint
Commissioning Committee
C1. Meeting papers and minutes
C2. Meeting papers and minutes; Section 75 agreements.
C3. Meeting paper and minutes
C4. Meeting papers and minutes
C5. Meeting papers and minutes
.
Average
3 4 12
Hig
h
CN1. Identify further opportunities for council
engagement in and benefit from STP initiatives -
e.g. care market resilience
CN2. System intentions for 2018/19 to Health and
Wellbeing Boards
CN1. Work underway to identify areas of
joint work councils could undertake through
the STP
CN2. Health and Wellbeing Boards have
historically received commissioning
intentions
A1. Identify opportunities for further
Council engagement and benefit from
STP
A2. CCGs to take system intentions to
respective Health and Wellbeing Boards
A1. Councils working together to identify
opportunities
A2. CCGs working with Councils on
developing intentions
A1. 31.03.2018
A2. 30.11.2017
3 3 9
Hig
h
JCC 20 Paul Sinden
18-week referral-
to-treatment
waiting time
standard is met
Delivery of referral-to-treatment (RTT) waiting time standard
(Threat)
Cause: There may be insufficient capacity within the system, and
inefficiencies along pathways.
Effect: There is a risk that the system may be unable to cope with the
level of demand and has limited resilience to unexpected events.
Impact: This may result in people not receiving treatment within 18
weeks of referral from their GP with potential adverse impact on their
health outcome.
C1. Contract governance arrangements established to cover
performance.
C2. Remedial action plan agreed with UCLH.
C3. Planned Care work stream considering demand management
schemes to support RTT delivery including Clinical Advice and
Navigation.
C4. Remedial action plan received from Royal Free London but with
recovery of the waiting time standard targeted by August 2018. CCGs
and NHS Improvement are challenging the Trust for a faster recovery.
C1. Meeting papers and notes.
C2. Agreed remedial action plan
C3. STP Project Initiation Documents (PIDs)
C4. Draft remedial action plan
Average
4 4 16
Ve
ry H
igh
CN1. Receipt of Royal Free London remedial
action plan
CN2. Build more effective early warning system
for long waits
CN3. Development of planned care initiatives in
the STP to support delivery of elective pathways
CN4. Agreement of contract terms including tariff
for Clinical Advice and Navigation.
CN5. Ensure payment for waiting list backlog
consistent with marginal rates set in the contract
CN6. Understand impact of winter planning
mutual aid on elective waiting time performance
CN1. Royal Free London missing the
waiting time standard
CN2. Growth in long waits including waits
over 52 weeks (for which clinical harm
reviews are undertaken)
CN3. STP service developments offset
demographic growth
CN4. Clinical Advice and Navigation
requires a different tariff to outpatient
referral
CN5 Under performance in 2017/18 due to
backlog recouped at marginal rate, pay for
backlog clearance at marginal rate if falls
into 2018/19
CN6. Trust plans to free-up clinical capacity
from elective pathways to support winter
pressures
A1. Continue to work with UCLH and
Royal Free London on delivery of
remedial action plans
A2. Continue to work with providers to
ensure sustainable delivery including
work through the STP
A3. Develop activity plans for 2018/19
for sustainable delivery
A4. Develop tariff arrangements for
Clinical Advice and Navigation
A1. Monitor remedial action plans
through contract meetings.
A2. Development of planned care
initiatives for 2018/19 underway.
A3. Development of activity plans for
2018/19 underway
A4. Initial work on potential tariffs has
started
A1. 04.12.2017
A2. 30.11.2017
A3. 20.12.2017
A4. 20.12.2017
3 3 9
Hig
h
108
ID Director Objective Risk Controls in place Evidence of Controls
Overall
Strength of
Controls in
Place
Consequence (C
urre
nt)
Lik
elih
ood (C
urre
nt)
Ratin
g (C
urre
nt)
Ris
k le
vel (C
urre
nt)
Controls Needed Evidence of Controls Needed Actions Update on Actions Action Completion Date
Consequence (T
arg
et)
Lik
elih
ood (T
arg
et)
Ratin
g (T
arg
et)
Ris
k le
vel (T
arg
et)
JCC 21 Paul Sinden
Integrated urgent
care service
continues to
operate as
effective part of
urgent and
emergency care
system
Delivery of integrated urgent care service covering NHS 111 and
GP out-of-hours service (Threat)
Cause: The additional functionality requested by NHS England sits
outside of the contract agreement between the provider (LCW) and
CCGs giving the provider a cost base over and above contract
payments .
Effect: There is a risk that the provider will incur a structural deficit if
they continue to deliver to the enhanced specification .
Impact: This may result in the provider no longer being able to provide
an effective integrated urgent care service placing additional pressure
on the rest of the local urgent and emergency care system.
C1. Contract between CCGs and the provider (LCW)
C2. Road map of service changes to match the service specification to
contract financial baseline.
C3. GP clinical oversight of the impact of the road map on integrated
urgent care service and broader urgent and emergency care system
C4. Weekly meetings between CCGs and provider to oversee progress
with implementing the road map
C1. Signed contract
C2. Agreed remedial action plan
C3. Meeting notes
C4. Meeting notes
Average
4 3 12
Hig
h
CN1. Agreement of contract for 2018/19
CN2. Learning from this contract to prevent
occurrence elsewhere in the future
CN1. Road map may result in changes to
original service specification
CN2. Provider cost pressure accrued from
activity sitting outside of the signed contract
A1. Agree service specification and
contract baseline for 2018/19 in line with
road map conclusions
A2. Review of contract meetings and
governance
A3. Implement national technological
changes via National Digital Programme
to support delivery of the road map
A1. Commissioner and provider group
established to implement road map.
Group meets weekly. CCGs have
identified GP leads for clinical oversight.
A2. Additional senior commissioning
and contracting support added to
contract meetings.
A3. Islington pilot of national IT
developments
A1. 31.03.2018
A2. 28.02.2018
A3. 31.03.2018
4 2 8
Hig
h
109
NCL Joint Commissioning Committee Risk Register Current Risk Score Tracker
Risk ID 6th July 2017
3rd August 2017
5th October 2017
7th December 2017
1st February 2017
JCC 1 16
16 16 16 16
JCC 2 16
16 16 16 16
JCC 3 12
12 12 12 12
JCC 4 12
12 12 12 12
JCC 5 12
12 12 12 12
JCC 6 9
9 9 9 9
JCC 7
12 12 12 12
JCC 8
9 9 9 9
JCC 9
12 12 12 12
JCC 10
16 16 16 16
JCC 11
16 16 16 16
JCC 12
9 9 9 9
JCC 13
20 20 20
JCC 14
16 16 16
JCC 15
12 12 12
JCC 16
12 12 12
JCC 17
12 12 12
JCC 18
20 20 20
JCC 19
12 12 12
JCC 20 16
16
JCC 21
12
110
Risk Scoring Key This document sets out the key scoring methodology for risks and risk management.
1. Overall Strength of Controls in Place There are four levels of effectiveness:
Level Criteria
Zero The controls have no effect on controlling the risk.
Weak The controls have a 1- 60% chance of successfully controlling the risk.
Average The controls have a 61 – 79% chance of successfully controlling the risk
Strong The controls have a 80%+ chance or higher of successfully controlling the risk
2. Risk Scoring
This is separated into Consequence and Likelihood. Consequence Scale:
Level of Impact on the Objective
Descriptor of Level of Impact on the Objective
Consequence for the Objective
Consequence Score
0 - 5% Very low impact Very Low 1
6 - 25% Low impact Low 2
26-50% Moderate impact Medium 3
51 – 75% High impact High 4
76%+ Very high impact Very High 5
Likelihood Scale:
Level of Likelihood the Risk will Occur
Descriptor of Level of Likelihood the Risk will Occur
Likelihood the Risk will Occur
Likelihood Score
0 - 5% Highly unlikely to occur
Very Low 1
6 - 25% Unlikely to occur Low 2
26-50% Fairly likely to occur Medium 3
51 – 75% More likely to occur than not
High 4
76%+ Almost certainly will occur
Very High 5
111
3. Level of Risk and Priority Chart
This chart shows the level of risk a risk represents and sets out the priority which should be
given to each risk:
LIKELIHOOD
CONSEQUENCE
Very Low
(1)
Low (2)
Medium (3)
High (4)
Very High
(5)
Very Low (1)
1 2 3 4 5
Low (2)
2 4 6 8 10
Medium (3)
3 6 9 12 15
High (4)
4 8 12 16 20
Very High (5)
5 10 15 20 25
1-3
Low Priority
4-6
Moderate Priority
8-10
High Priority
15-25
Very High Priority
112
NCL Joint Commissioning Committee Forward Planner 2018-19
2018-2019
Agenda Items
Governing Body
Item (Yes or No)
05/0
4/18
07/0
6/18
02/0
8/18
04/1
0/18
06/1
2/18
07/0
2/19
1. Standing Items
Apologies No √ √ √ √ √ √
Declarations of Interests No √ √ √ √ √ √
Register of Gifts and Hospitality No √ √ √ √ √ √
Minutes of Last Meeting No √ √ √ √ √ √
Action Log No √ √ √ √ √ √
Forward Planner No √ √ √ √ √ √
AOB No √ √ √ √ √ √
2. Governance
Remit of the Committee No √ √
Terms of Reference- Annual Review Yes √
Appointment to Chair of the Committee Yes √
3. Activity and Performance
Acute Contract Report Yes √ √ √ √ √ √
Integrated Urgent Care Report Yes √ √ √ √ √ √
Learning Disabilities- Transforming Care Cohort Yes √ √ √ √ √ √
In-Health Contract Update Yes √ √ √ √ √ √
4. Commissioning
System Intentions 2019-20 Yes √ √
Planning for 2019/20 Yes √ √
Links to specialist commissioning Yes √ √ √
5. Risk
NCL Joint Commissioning Committee Risk Register Yes √ √ √ √ √ √
6. Other ItemsProcedures of limited clinical effectiveness Yes √ √ √ √ √ √
Specialist services not commissioned by Specialist Commissioning - Cancer
/ Maternity No √ √
7. Business Cases - dates to be confirmed
Outline business case for Moorfields Eye Hospital Yes
Outline Business case for St Pancras (Camden & Islington Foundation
Trust) Yes
Outline Business Case for St Ann's (Barnet, Enfield and Haringey Mental
Health Trust) Yes
113
