AGENDA A meeting of the Governing Body Part I Body... · Ms Anne Hooper Lay Member, LCCG Prof. Simon Mackenzie Secondary Care Doctor, LCCG Mr David Maloney Director of Finance, LCCG

Chair: Dr Faruk Majid Accountable Officer: Andrew Bland Managing Director: Martin Wilkinson

AGENDAA meeting of the Governing Body Part I

Date: 12 September 2019Time: 10.00 am - 12.00 pmVenue: St Laurence Church, CatfordChair: Dr Faruk Majid

Enquiries to: Charles Malcolm-SmithTelephone: 020 7206 3200Email: [email protected]

Voting MembersDr Faruk MajidDr Esther ApplebyMr Andrew BlandMs Alison BrowneMs Debbie BrownDr Charles GostlingMs Anne HooperDr Sebastian KalwijMs Shelagh KirklandProf Simon McKenzieDr Jacky McLeodMr Usman NiaziMr Peter RamraykaDr Angelika RazzaqueDr Ravi SharmaMr Martin Wilkinson

Chair, Lewisham CCG Clinical Director Accountable Officer Registered Nurse Member Clinical Director Senior Clinical Director Lay Member Clinical Director Lay Member Secondary Care Doctor Senior Clinical Director Chief Financial Officer Lay Member Clinical Director Clinical DirectorManaging Director

Non-Voting MembersMr Tom BrownDr Catherine Mbema

Executive Director, Community Services, Lewisham CouncilInterim Public Health Director, Lewisham Council

Dr Simon Parton Local Medical Committee ChairDr Magna AidooMr David Maloney

Healthwatch Lewisham RepresentativeDirector of Finance, Lewisham, Bexley and Greenwich CCGs

QuorumThe Governing Body will be deemed quorate when a minimum of 7 members, 4 of which must be Clinical Directors, one must be either the Chief Officer or Chief Financial Officer and two must be independent members (Lay Members, Secondary Care Doctor or Registered Nurse).

A member who is present at Governing Body meeting and is conflicted by a particular agenda item will not contribute to the quoracy of the meeting for the duration of that agenda item.


Order of BusinessMembers of the public are requested to give any questions to the Governing Body in relation to matters not on the agenda before the meeting in writing to the Board Secretary. These will be responded to, at the discretion of the Chair, at the designated time shown on the agenda

Time Item Papers Presented by

1. 10:00 Welcome and Introductions Chair2. Apologies for absence3. Declarations of Interest 1 - 2 Chair4. 10:05 Minutes of the last meeting

To agree the minutes of the last meeting3 - 14 Chair

5. Matters Arising6. 10:10 CCG Chair's Report 15 - 18 Chair

To receive and note for information

7. 10:15 Managing Director's Report 19 - 24 Martin WilkinsonTo receive and note for information

8. 10:20 Audit Committee Chair's Report 25 - 26 Shelagh Kirkland

To receive and note from the meeting held on 23 July 2019

9. 10:25 Primary Care Commissioning Committee Chair's report

27 - 44 Peter Ramrayka

To receive and note from the meeting held on 6th August 2019

To agree updated Terms of Reference10. 10:30 Public Engagement and Equalities Forum

Chair's Report45 - 48 Anne Hooper

To receive and note from the meeting held on 20th August 2019

11. 10:35 Questions in relation to agenda items from members of the public

FINANCE & GOVERNANCE12. 10:40 Finance Report M3 2019-20 49 - 78 David Maloney

To receive and note for information

Chair: Dr Faruk Majid Accountable Officer: Andrew Bland


13. 10:45 Integrated Governance Committee Chair's Report

79 - 82 Martin Wilkinson

To receive and note for information from the meeting held on 25th July 2019

14. 10:50 South East London Integrated Governance & Performance Committee

83 - 172 Martin Wilkinson

To receive and note for information from the meeting held on 30th August 2019

15. 11:00 Board Assurance Framework 173 - 200

Martin Wilkinson

To receive and agree the recommendations relating to the corporate objectives and BAF for 2019/20

STRATEGY & PLANNING16. 11:10 Strategy & Development Workshop Chair's

Report201 - 202

Charles Gostling

To receive and note from the meeting held on 22nd August 2019

17. 11:15 Commissioning system reform in south east London - CCG Merger proposals and application

203 - 246

Andrew Bland

To agree application for proposed merger of SEL CCGs

18. 11:45 Potential Audit and Risk Management Issues ChairTo identify any issues which the Governing Body consider would benefit further scrutiny by the Audit Committee

19. 11:50 Any Other Business20. 11:55 Questions from Members of the Public

FOR INFORMATION ONLY21. Public Forum Notes for Information (July

2019)247 - 250

22. Approved Committee minutes for information only

251 - 276

Integrated Governance Committee (May

Chair: Dr Faruk Majid Accountable Officer: Andrew Bland


2019)

SEL Integrated Governance & Performance Committee (July 2019)

Audit Committee (May 2019)

Strategy and Development Committee (June 2019)

Date of next meeting: Thursday, 14 November 2019, 10.00 am

The Committee to agree that, if required, the public should be excluded from the meeting while the remaining business is under consideration, as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted.


Managing Conflicts of Interest: Governing Body, committees, sub-committees and working groups

1. The chair of the Governing Body and chairs of committees, subcommittees and working groups will ensure that the relevant register of interest is reviewed at the beginning of every meeting, and updated as necessary.

2. The chair of the meeting has responsibility for deciding whether there is a conflict of interest and the appropriate course of corresponding action. In making such decisions, the chair may wish to consult the member of the governing body who has responsibility for issues relating to governance.

3. All decisions, and details of how any conflict of interest issue has been managed, should be recorded in the minutes of the meeting and published in the registers.

4. Where certain members of a decision-making body (be it the governing body, its committees or sub-committees, or a committee or sub-committee of the CCG) have a material interest, they should either be excluded from relevant parts of meetings, or join in the discussion but not participate in the decision-making itself (i.e., not have a vote).

5. In any meeting where an individual is aware of an interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, the individual concerned will bring this to the attention of the chair, together with details of arrangements which have been confirmed by the governing body for the management of the conflict of interests or potential conflict of interests. Where no arrangements have been confirmed, the chair may require the individual to withdraw from the meeting or part of it. The new declaration should be made at the beginning of the meeting when the Register of Interests is reviewed and again at the beginning of the agenda item.

6. Where the chair of any meeting of the CCG, including committees, sub-committees, or the governing body, has a personal interest, previously declared or otherwise, in relation to the scheduled or likely business of the meeting, they must make a declaration and the deputy chair will act as chair for the relevant part of the meeting. Where arrangements have been confirmed with the governing body for the management of the conflict of interests or potential conflicts of interests in relation to the chair, the meeting must ensure these are followed. Where no arrangements have been confirmed, the deputy chair may require the chair to withdraw from the meeting or part of it. Where there is no deputy chair, the members of the meeting will select one.

7. Where significant numbers of members of the governing body, committees, sub committees and working groups are required to withdraw from a meeting or part of it, owing to the arrangements agreed by the Governing Body for the management of conflicts of interest or potential conflicts of interest, the remaining chair will determine whether or not the discussion can proceed.

8. In making this decision the chair will consider whether the meeting is quorate, in accordance with the number and balance of membership set out in the CCG’s standing orders or the relevant terms of reference. Where the meeting is not quorate, owing to the absence of certain members, the discussion will be deferred until such time as a quorum can be convened. Where a quorum cannot be convened from the membership of the governing body, committees, sub committees and working groups owing to the arrangements for managing conflicts of interest or potential conflicts of interest, the chair may invite on a temporary basis one or more of the following to make up the quorum so that the CCG can progress the item of business:

a) an individual GP or a non-GP partner from a member practice who is not conflictedb) a member of the Lewisham Health and Wellbeing Board;c) If quorum cannot be achieved by a) or b) (above) a member of a governing body of another clinical

commissioning group.

9. These arrangements will be recorded in the minutes.

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Fin

anci

al In

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Pro

fess

ion

al In

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No

n-F

inan

cial

Pe

rso

nal

Inte

rest

Ind

ire

ct In

tere

st

From To

Martin Wilkinson Governing Body Member n/a n/a n/a n/a n/a n/a n/a n/a n/a

Andrew Bland Governing Body Member n/a Yes Yes Yes Direct & Indirect 1. Accountable Officer:

Bexley CCG

Bromley CCG

Greenwich CCG

Southwark CCG

2. Greenwich Charitable Funds Trustee

3. Partner is a Primary Care Contract

Manager (NHS England employee) in NW

London

1.

05/02/18

01/04/18

01/10/17

11/09/13

2. 01/10/17

3. 01/11/12

1. Ongoing

2. Ongoing

3. Ongoing

CCG conflict of interest policy and

procedures will be followed to ensure

interests do not influence CCG's

commissioning/procurement

decisions

Alison Browne Governing Body Member n/a n/a n/a Yes Indirect Close friend CEO RHN Putney 2018 2019 No direct commissioning

involvement

Angelika Razzaque Clinical Director n/a Yes n/a n/a Direct 1. Salaried GP

2. Speciality doctor in dermatology

3. Chair PCDS

1. 01/01/19

2. 01/12/18

3. 01/07/18

1. Ongoing

2. Ongoing

3. Ongoing

Leave meeting if required

Anne Hooper Lay Member n/a n/a Yes n/a Direct Non Exec Director The Mulberry Centre 2014 Ongoing Leaving meeting if required

Charles Gostling Clinical Director Yes Yes n/a Yes Direct & Indirect 1. Shareholder One Health Lewisham

2. Partner The Lewisham Care

Partnership/Morden Hill Site

3. Shareholder SELDOC

4. Professional Member Diabetes UK

5. Stakeholder Governor - SLaM Trust,

assigned role as CCG clinical director

6. Spouse member of NHS Bromley CCG

Governing Body

7. Spouse Children and Families

Programme Lead Healthy London

Partnership

1. 2016

2. 1993

3. 2017

4. 1994

5. 2017

6. 2012

7. 2013

1. Ongoing

2. Ongoing

3. Ongoing

4. Ongoing

5. Ongoing

6. Ongoing

To declare if relevant to

meeting and leave meeting if deemed

necessary

Debbie Brown Clinical Director Yes Yes n/a n/a Direct 1. Working as an ACP in general practice.

Employee not partner

2. Clinical Director Lewisham CEPN

1. 2007

2. 2016

1. Ongoing

2. Ongoing

1. Declare any conflict at beginning of

meetings/leave meeting if requested

by chair

2. Not to attend any meeting or read

any papers that could benefit CEPN

financially. State all conflicts when

invited to meetings, also state

conflicts at the beginning of any

meetings

Esther Appleby Clinical Director Yes n/a n/a n/a Direct Salaried GP St Johns Medical Centre -

moving to partner of SJMC on 01/04/18

01/04/18 Ongoing Withdraw from decisions affecting

these entities

Faruk Majid Chair Yes n/a n/a n/a Direct 1. Director of Light Mine Ltd - runs

appraisal preparation courses for GPs

2. GP Principal at Hilly Fields Medical

Centre and Brockley Road Surgery

3. Member of SELDOC Out of Hours

Service

1. 01.01.18

2. >2000

3. >2000

1. Ongoing

2. Ongoing

3. Ongoing

1. To step out of discussion re

provision of appraisal education

2. Follow CCG COI guidance

3. Follow COI guidance

Jacqueline McLeod Clinical Director Yes Yes n/a Yes Direct & Indirect 1.Salaried GP employed by Dr J Israel, The

Vale Medical Centre

2. GP Appraiser, NHS England

1. 1996

2. 2010

1. Ongoing

2. Ongoing

Appropriate Exclusions

Magna Aidoo Governing Body Member n/a n/a n/a n/a n/a n/a n/a n/a n/a

Peter Ramrayka Lay Member Yes Yes Yes n/a Direct 1. Managinf Director/Owner/Freelance

Healthcare Management Consultant

intermittently providing service to NHS

bodies and major construction firms

involved in DHSC framework contracts

2. Council Trustee/member of the Welfare

Committee membership organisation and

registered charity providing welfare

support to the RAF family

3. Trustee/member of Civilian Committee

4. Companion/Fellow professional

organisation for healthcare managers in

the NHS/Private sector and military

5. Fellow - independent multi-disciplinary

charity dedicated to the improvement of

the public's health and well being

6. Fellow - The UK largest specialist

Institue for the Healthcare Estates Sector

devoted to developing careers, provision

of education and registering enginneers

7. Chairman/Trustee - providing voluntary

support to Guyana health services as and

when required

8. Chairman/Trustee - Cultural group to

relieve need or poverty, to provide or

assist in the provision of facilities

9. Registered patient of Morden Hill

Surgery

1. 2011

2. 2018

3. 2016

4. 1977 - F -

1988, C - 2005

5. 1985

6. 2005

7. 2005

8. 2002

9. Ongoing

1. No

assignments at

present

2. Ongoing

3. Ongoing

4. Ongoing

5. Ongoing

6. Ongoing

7. Ongoing

8. Ongoing

9. Ongoing

Declare any conflict at beginning

of meeting/leave meeting if requested

by chair

Ravi Sharma Clinical Director Yes Yes n/a n/a Direct 1. GP partner in The Lewisham Care

Partnership (June 2017). This includes GP

Practices: St John's Medical Centre, Hilly

Fields Medical Centre, Brockley Road

Surgery, Morden Hill Surgery, Belmont Hill

Surgery, Honor Oak Surgery. These

practices are stakeholder in One Health

Lewisham (a provider company) SELDOC

and one access

2. Member of IFR panel South east London

3. Member of prescribing and medicine

optimization group

4. Director of Prime23 Limited. This is a

private limited company involved in

running GP appraiser course

5. Clinical Director Lewisham CCG

6. GP Appraiser

7. GP trainer

8. Working for Healthclic as private GP for

home visits in London

1. April 2014

2. Dec 2016

3. Feb 2017

4. Sept 2017

5. Sept 2018

6. Nov 2016

7. Aug 2014

8. Feb 2017

1. Ongoing

2. Ongoing

3. Ongoing

4. Ongoing

5. Ongoing

6. Ongoing

7. Ongoing

8. Ongoing

1. Conflict declared as and when

participating in meetings with CCG

2. I am excluded from the discussions

pertaining to applications from my

practice

3. Declaration of conflict of interest as

and when such matters discussed

Sebastian Kalwij Clinical Director Yes n/a n/a n/a Direct 1. Partner Amersham Vale Practice

offering community based primary care in

the Waldron Health Centre

2. Director in Dr iSeb Ltd. Offering medical

services in Lewisham and around London

and involvement in 2 art projects

1. 01/04/18

2. 01/04/18

1. Ongoing

2. Ongoing

1. As d/w CCG GB in the past.

Declare interest when item occurs

2. Not active at present

Shelagh Kirkland Governing Body Member n/a n/a Yes n/a Direct 1. Treasurer and Trustee of Pure Leapfrog

(Co No 05534395)

2. Non-Executive Director of Leapfrog

Finance Ltd (Co No 07038343)

3. Non-Executive Director of Leapfrog

Bridge Finance Ltd (Co No 09726408)

4. Volunteer - Royal Society for Blind

Children (formerly the Royal London

Society for the Blind)

5. Independent Member of the Audit and

Risk Committee of the General

Chiropractic Council

1. 30/12/14

2. 04/03/15

3. 11/08/18

4. Feb 14

5. 12/07/19

1. Ongoing

2. Ongoing

3. Ongoing

4. Ongoing

5. Ongoing

If a conflict is identified at a

meeting, I will not take part in the

discussion and/or decision as

necessary

Simon Mackenzie Governing Body Member n/a Yes n/a n/a Direct 1. Senior Medical Adviser NHS

Improvement

2. Chair NICE Atrial Fibrillation Guideline

Committee

3. Tribunal member Medical Practitioner

Tribunal Service

1. 01/07/17

2. 29/03/18

3. 01/01/12

1. Ongoing

2. Ongoing

3. Ongoing

Not affected by CCG decisions

Catherine Mbema Governing Body Member n/a n/a n/a Yes Indirect Husband is a GP doing locum work

at Woodlands Health Centre

08/05/18 Ongoing n/a

Simon Parton Governing Body Member n/a Yes Yes n/a Direct 1. LMC Chair - represents GPs in Lewisham

as providers

2. Member of Board of Governors

Blackheath Prep School

1. Ongoing

2. Ongoing

1. Recognise and report COI if

necessary

2. Not applicable

Action taken to mitigate riskName

Current position held in the

CCG i.e. Governing Body Member;

Committee Member, Member

Practice; CCG employee or other

Type of Interest

Is the interest

direct or indirect?

Nature of

Interest

Date of Interest

Page 1

Item Number 3


Governing Body Meeting

Minutes of the meeting of the NHS Lewisham Clinical Commissioning Group (LCCG) Governing Body held on Thursday 11 July 2019 at Civic Suite, Catford Road, London

SE6 4RU

Present

Dr Faruk Majid Chair, LCCG (Chair) Dr Esther Appleby Clinical Director, LCCG Dr Magna Aidoo Representative, Healthwatch Lewisham Mr Andrew Bland Accountable Officer, LCCG Ms Debbie Brown Clinical Director, LCCG Ms Alison Browne Registered Nurse, LCCG Dr Charles Gostling Senior Clinical Director, LCCG Ms Anne Hooper Lay Member, LCCG Prof. Simon Mackenzie Secondary Care Doctor, LCCG Mr David Maloney Director of Finance, LCCG Mr Usman Niazi Chief Financial OfficerMr Peter Ramrayka Lay Member, LCCG Dr Ravi Sharma Clinical Director, LCCG Mr Martin Wilkinson Managing Director, LCCGDr Sebastian Kalwij Clinical Director, LCCGDr Catherine Mbema Interim Director of Public Health

AttendanceFrom Lewisham CCG and PartnersMs Lesley Aitken Interim Board Secretary, LCCG (minutes)Ms Caroline Hirst Service Manager - Children’s Joint Commissioning Team LBLMr Charles Malcolm-Smith Deputy Director (Strategy & Organisational Development)Mr Stephen James Communications Manager, NELCSU Ms Fiona Mitchell Nurse Consultant Adult Safeguarding Designate, LCCGMs Gemma Oliver Guys & St Thomas’s NHS Foundation TrustMs Hannah Reeves Business Manager, LCCGMr Ray Warburton Independent Chair, SEL Integrated Governance and

Performance Committee

There were 4 members of the public present for the meeting

Apologies

Mr Tom Brown Executive Director, Community Services, LB Lewisham Ms Shelagh Kirkland Lay Member, LCCG Dr Jacqueline McLeod Senior Clinical Director, LCCG Dr Simon Parton LMC Chair Dr Angelika Razzaque Clinical Director, LCCG

LEW 19/66 Welcome and Introductions

Page 3

Item Number 4

Introductions were made. Dr Majid welcomed all to the meeting and in particular Mr Ray Warburton who was the independent Chair of the SEL Integrated Governance and Performance (IG&P) Committee, Ms Gemma Oliver and Mr Stephen James, Communications Manager.

Ms Kirkland who was unable to attend the meeting had sent questions on agenda items to Dr Majid to be raised at the appropriate time.

LEW 19/67 Declaration of Interest

There were no new declarations of interest or conflicts identified in relation to agenda items.

LEW 19/68 Previous Minutes

The minutes of the meeting held on 9 May 2019 were taken as an accurate record subject to the amending the reference to Ms Cooper to Ms Hooper.

LEW 19/69 Matters Arising and Action Log

The actions on the log had been cleared at the previous meeting.

There were no matters arising at this stage of the meeting.

LEW 19/70 Chair’s Report

Dr Majid presented the Chair’s report and welcomed the Clinical Directors comments on the values and behaviours. Dr Majid asked the Clinical Directors to expand on their notes in the report.

Dr Kalwij reported that in relation to WRES there were plans to hold a seminar with the main providers in November to share good practice.

Dr Appleby added that the Lewisham and Greenwich NHS Trust (LGT) DNA rate should improve because of Referral Assessment Service (RAS), there would now be triage by consultants to allocate patients to the appropriate clinic which would improve the service to patients. GPs could challenge the decisions made by the consultants if felt necessary. The aim was to make the service more efficient for patients and clinicians.

Ms Brown, referring to the community dermatology service, reported that the opening of the clinic was on trajectory to open. There were two hubs in Lewisham, in the Waldron and Sydenham, with progress being continually tracked. The aim for the respiratory service was to have the right diagnosis and right treatment at the right time and to promote self-care.

In response to a question from Ms Hooper, Dr Majid would check if all Lewisham practices were now signed up to the Doctors of the World Safe Surgeries Scheme.

Dr Appleby explained that the aim of End of Life educational events being held for practice staff were to educate primary care teams on the breadth of services provided by hospices.

Mr Ramrayka found the Clinical Directors’ updates useful. He highlighted that there was a raft of policy initiatives to address the areas of equality and queried how these could be integrated into the commissioning contractual process in a timely and effective manner. Dr Majid added that this should include working with the council, an equality agenda for different parts of the borough, inequalities within public health, how the CCG develops

Page 4

policies including the EDS, and how to respond to the public on crime reduction, access to good housing, mental health issues and prevention and response to illness.

Mr Wilkinson added that the main priority would be to refresh the Health and Wellbeing Board strategy linked to integration and population health, for which it is known that the data doesn’t cover all the protected characteristics. Need to improve how information was captured on the local population in order to act on the differences on the services offered and provided across Lewisham.

The workforce should reflect the local population and learn from good practice.

The Governing Body NOTED the report

LEW 19/71 Managing Directors report

Mr Wilkinson presented his report and requested comments.

Responding to a question from Ms Kirkland on digital services, Mr Wilkinson said that the main issue was connectivity across London and SE London and making sure that systems can talk to each other and information shared. For Lewisham the main priority was around population health, all practices have signed up for data sharing agreement with 13 services actively sharing information now. Registries were being developed.

Regarding issues around recruitment to CHC service, Mr Wilkinson reported that there are still gaps but progress had been made with some recruitment of staff, a fuller update would be available next week.

In response to a question from Ms Kirkland on the CQC inspection report in relation to the Princess Royal University Hospital (PRUH) and whether there were any new actions being taken to address issues particularly in relation to Emergency Department (ED), Mr Bland reminded the Governing Body that the inspection held in early February raised a number of issues for immediate action which had been addressed and there was a full action plan in place to address the issues in the finalisation report. There is an independently chaired oversight group for the ED actions in the CQC report for the PRUH issues.

Ms Hooper referring to the ICS and how to progress, commented that what we as an organisation and the system thinks is important and what is important to Lewisham patients and public may be different and gave a plea that there should be ongoing engagement. On the public health approach to violence, do we have any initial idea on what success might look like in 18 months’ time to give people in Lewisham the confidence that this approach was going to be working for them and their communities. Dr Mbema responded that there would be a performance framework with indicators which would be tracked and closely monitored, but that 18 months was too short a time frame. Ms Browne added that there was also data linked to violence towards front line staff at LGT which could be incorporated in the framework and measured.

Mr Bland commented that the ICS would be an enabler for the outcomes wanted for residents which would require collective leadership and accountability and responsibility across providers and commissioners to plan health and care services neighbourhood and borough wide and across SE London.

Dr Gostling reported that he had given a presentation on long-term conditions and ICS to the Public Reference Group (PRG) and the feedback was positive with support on the way forward.

Page 5

In response to Mr Ramrayka on employment of specialist support how might that apply in Lewisham and the with the personalised care plan how would the 42% gap be closed and how will this be monitored? Mr Wilkinson responded that there was funding received from national transformational monies to establish a new service which supported those with severe mental health back into work. Some of our boroughs have been covered by that arrangement already but it was a new service to Lewisham which will be tracked through the STP and through the local maternity system, LMS, where all the STP standards are tracked and measured, both by individual organisations and across LMS in a peer challenging way. Transformational monies expected will be used to recruit staff to support delivery across services to improve maternity care.

Dr Aidoo asked whether Lewisham was applying for any available resources and if so what they would be used for. Mr Wilkinson explained that our PCNs are eligible for the national contract, the resources and staff will be in place within the next year. There will be new staff groups working together, including social prescribing and link workers, building on existing arrangements. Mr Wilkinson agreed with Dr Aidoo that there had been some positive progress in child mental health services across SE London and Lewisham. In SE London there had been a data exercise has just been completed which shows access for those with a diagnosable mental health condition to services of 31.5% across SE London with Lewisham about 27.5% against a 32% target. Lewisham only achieved 21% last year. Waiting times are jointly being monitored with the council and the 52 week long waits had been cleared. More resources have been agreed with South London and Maudsley Foundation NHS Trust (SLaM) to bring those treatment waiting lists down for CAMHS, this was being regularly monitored. The Trailblazer bid was submitted by the joint commissioners with the result expected result soon. The submissions were overly subscribed, it was known that other SE London CCGs have also made a submission.

Mr Wilkinson confirmed that what Healthwatch were being asked to do in relation to engagement on the LTP differed from what Kaleidoscope has been commissioned to undertake but complimentary. Kaleidoscope would be running the larger events with support from Healthwatch and partners. Healthwatch are doing outreach work with community groups.


LEW 19/72 Audit Chairs report

In Ms Kirkland’s absence Mr Maloney gave the report from the Audit Committee held on 21 May 2019. The key focus of the meeting was to discuss the CCG’s Annual Report and Accounts and the year end reports from the Internal and External Auditors. He was pleased to report that the CCG achieved all its financial duties for 2018/19 and that for the financial control total the surplus of £331k was achieved, this was £31k better than the required control total. In the annual accounts there were no changes requested from draft accounts in April and final accounts in May. The feedback from External Audit on the annual report and the annual accounts was good with high standard documents. Mr Maloney passed on his thanks to all the staff in the CCG who had contributed to the report and accounts, Mr Niazi echoed the praise. Prof Mackenzie also especially thanked Mr Malcolm-Smith for the annual report.


LEW 19/73 Primary Care Commissioning Committee Chairs report

Page 6

Mr Ramrayka gave the report from the Primary Care Commissioning Committee (PCCC) held on 18 June 2019. Mr Ramrayka thanked the general practitioners for the information which had gone towards the Primary Care Network (PCN) applications which had been endorsed by the Lewisham Health and Care Partners Executive Board and the OHSEL Board.

Congratulations were given to those involved in the ASK NHS GP APP which was shortlisted for an HSJ award in the Primary Care Initiative of the Year category. Unfortunately, the initiative did not win but the local work being undertaken was recognised.

The areas of contractual non-compliance, highlighted in the CQC rating of inadequate for Dr Batra’s and Queen Road’s practices, have now been resolved.

The Committee had approved the contractual merger of the New Cross Health Centre and Dr Batra’s Practice.


LEW 19/74 Public Engagement and Equalities Forum Chairs report

Ms Hooper gave the report from the Public Engagement and Equalities Forum (PEEF) held on 4 June 2019. The draft workplan had been discussed with outlined public engagement activities and priorities during 2019/20. The objectives of the plan reflect the CCG’s corporate objectives. The plan was expected to be approved by the end of July 2019.

Ms Hooper was pleased to announce that the results of the Improvement and Assessment Framework review has improved from a ‘Requires Improvement’ last year to a ‘Good’ this year. Praise was given to Mr Cartwright, Head of Communications and Engagement, and Ms Rodrigues, Engagement Officer, to Mr Wilkinson and Mr Malcolm-Smith for their leadership and all those from the CCG involved in community and engagement activities.


LEW 19/75 Public questions

Q. Refer to CBC statement about PCNs and the £4.5b I understand it to be for available across the country for extra money for CBC for this financial year and a related issue is workforce and the problems facing CCGs in terms of recruitment of GPs. How many GPs are there in Lewisham compared with when the CCG was formed?

A. Mr Bland responded that £4.5b is a national figure and total investment over the time of the planning period, there were issues on the operating framework for the long-term plan which shaped the detail of the investment of £4.5b. We were not able to describe yet how that will work for Lewisham. Regarding the number of GPs in Lewisham we have to distinguish the whole time equivalent, as there are diverse arrangements including part time working. GP recruitment is an ongoing commitment, there is more of a problem of recruitment and retention of GPs in inner London.

Ms Brown added that there has been an improvement in the number of general practice nurses and nurse practitioners in Lewisham, we are only London borough to have four nurse associates, who are healthcare assistants who have gone on to do a level 4 programme. We are looking at what other members are needed within teams including paramedics and physiotherapies. We need to know what our population health needs are before determining the workforce required.

Page 7

Dr Appleby added that training was also key in retaining staff and broadening the workforce.

Dr Kalwij added that his practice retains trainees and acknowledges that GP ways of working have changed, there was now more of a need for practices to be proactive and dynamic.

Dr Majid was unsure of the figures but thought that the reduction in GP numbers was about 8% over the past 10 years whilst the hospital consultant sector has increased by about 70%. Aiming to improve health services in the community included looking at alternative workforce patterns including the use of pharmacists and nurses. There is digital technology but people still want to see GPs. It is essential that patients and public should get engaged in the way health care services are delivered in the future.

The nurse practitioner service was praised.

Mr Bland added that the discussion regarding PCNs was entirely reliant on GP practices working together with multi-disciplinary teams. There needs to be discussion with LGT regarding community services and how do you blend that resource in order retain our GP and nurses to improve joint recruitment across practices and community services.

Q. Regarding children mental health services and the government’s commitment to the 4 week wait to access CAMHS. There is a hidden waiting list of those waiting for treatment, a comment was made that the CCG would start to look at the secondary wait from assessment to the delivery of treatment. Have you started to monitor that waiting time to treatment following the first assessment?

A. Mr Wilkinson responded that through the joint commissioners the treatment waits are being looked at, a note will be sent to Governing Body members and Dr O’Sullivan on the current position. The Trust have brought the long waits of over a year down but the issue is now of sustainability. There is a deep dive on CAMHS on the BAF agenda item.

LEW 19/76 Finance and Investment Chair’s Report

Prof Mackenzie gave the report from the Financial and Investment Committee (FIC) held on 27 June 2019. It was explained that the actual financial data at this time of year was limited. The key financial risks were around continuing healthcare (CHC) budgets and the GP at Hand Service which was hosted by North West London CCGs.

The current areas of risk in the QIPP plan related to schemes focused on dermatology, respiratory and continuing healthcare. There was an emerging risk around unplanned care.

The FIC endorsed the development of the third floor of the Waldron Health Centre for which the funding was held by the council under a section 106. It was explained that a S106 relates to new development monies which sit with the council and to which CCGs give support to release.


LEW 19/77 Integrated Governance Committee Chair’s report

Mr Wilkinson explained that this section has been redesigned now with two approaches to integrated governance, one is to the local committee, Integrated Governance Committee (IGC) which has the remit for non-acute local indicators, quality, activity and budgets and the SE London Integrated Governance & Performance Committee (SEL IG&P) has the remit of acute, transforming care partnership and A&E which was independently chaired by Mr Warburton on behalf of all six CCGs. Mr Warburton was observing the Governing Body

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meeting. The BAF has been split between local and SE London to reflect the line from committees to Governing Body. The reports in total will give the position for performance and delivery against the operating plan for the CCG.

At the IGC meeting on 23 May 2019, referring to quality, Mr Wilkinson highlighted that there had been improvement around the use of rapid tranquilisation but was more volatile around the incidents of violence and aggression. Dr Gostling, who chairs the CQRG for SLaM on behalf of the four boroughs, reported that SLaM had put in measures in the form of safety with trends indicating the increase of the use of restraint in many sectors. There was concern over the increased level of restraint in the CAMHS PICU in the Bethlem Hospital driven mainly by one patient who has now been transferred to a more suitable placement which has resulted in a significant reduction in the levels of violence and aggression there. Dr Gostling will bring back a fuller report to the next meeting.

Mr Wilkinson confirmed that Lewisham CAMHS access to service standard for Lewisham was 27.5%, not 21.4% as stated in the report.

There was a concern for those with mental health needs being treated in the wrong setting. A workshop had been held with the national team looking at the high level of out of area placements for those who require acute care across Lambeth, Southwark, Lewisham and Croydon and there was a trajectory to reduce that by 50% over this year with an action plan to support this aim. The revised plan was to be submitted this week. Further information would come back to the IGC and was on the SDP agenda across SE London. Mr Wilkinson was pleased about the outcome of the Patient Engagement Indicator, this was one of a number of indicators which get mashed up together to consider the overall rating for the CCG, the overall rating has not yet been received.

Dr Gostling referring to the out of area placements for mental health added that another aspect was housing and discharge, was there any other actions that could be done at SE London level and was there opportunity for influence in this area? Mr Wilkinson responded that Lewisham locally were undertaking work on supported housing, looking at what is required for those sitting in long term in-patient beds. Multi agency discharge events have been held across boroughs and were looking at themes for those with complex needs in SE and SW London.

LEW 19/78 South East London Integrated Governance & Performance Committee

The principle remit of the committee was to look at what was not in the scope of the IGC, looking at the overall SE London control total and where collective action may be required across SE London, constitutional standards in relation to acute hospital setting and the national programme of transformational care linked to learning disabilities and people that may be in inappropriate settings, to see if they can be stepped down, and safety and quality issues.

A deep dive had been held at the meeting on 21 June 2019 on acute activity and finance understanding how the contracts had been set up across SE London including risk and performance. The BAF in the paper used June information and it was recognised that since publication some of the headline indicators had deteriorated further and the risk ratings for some areas would be reviewed before the next meeting as they may be set too low.

On the IG&P Committee for Lewisham were Prof Mackenzie, Dr McLeod and Mr Wilkinson.

Prof Mackenzie highlighted that the acute performance across unscheduled care, 18 weeks and cancer was a concern. Mr Wilkinson responded that improvement plans were being developed and other approaches to the concerns looked at.

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Ms Hooper added that the current performance positions indicated that there were adequate sets of remedial actions but that there were significant risks relating to delivery by the Trust. Our expectations of where we might be at year end may not improve and could potentially get worse. Mr Wilkinson agreed and responded that detailed performance meeting had been held with the Trust as well as with services such as the Cancer Alliance on how to strength the ability to deliver. Mr Bland added the A&E performance was a challenge but that there were improvement plans in place to meet the constitutional standard to which the providers were struggling to meet. It was noted that a departure from the operating plan had not been agreed against any of the standards. The concerns differ on sites, for instance with a considerable 52 week wait at Kings in some specialities, in comparison in Lewisham there was a very low occurrence of 52 week waiters. There was no analysis to say the plans in place were wrong but there needed to be a culture shift and buy in to the plans from all. The ability to recruit staff was also a concern, clinical and administration.

Mr Warburton informed the Governing Body that the aligned incentive contracts and other elements of the start plan put in place put the organisation in a good place but there are considerable risks, the acute providers have to share the vision but CCGs should be more aware in realising what acute services are facing before making referrals. Prof Mackenzie had suggested to the Committee to use a performance data tool called Statistical Progress Control which enables a look at longer trends. Mr Warburton recommended its use.

Referring to the Finance Report Mr Maloney said that there was nothing to add above that reported by Prof Mackenzie earlier in the meeting.

The Governing Body NOTED the Integrated Governance Report and the South East London Integrated Governance & Performance Committee Report LEW 19/79 Board Assurance Framework (BAF)

Mr Wilkinson reported that the BAF refers back to the IGC pulling together the local summary table and the SEL IG&P summary table to produce a heat map which showed all the risks together. The detail for the local area was in this report. There were some high risks in terms of CHC and Mr Wilkinson confirmed that a update note on the position would be sent to members following a meeting with the CHC lead next week.

The deep dive discussion at this meeting would be on CAMHS with Ms Caroline Hirst joining the meeting for the item.

Ms Hirst explained that the National CAMHS Access Target was for two new contacts for any young people which Lewisham were measured against by NHSE. Even though there had been improvement there was concern that Lewisham would not meet the 34% target this year. There were difficulties with applying the definition from NHSE; capturing the flow of the data and the flow of data through the NHS digital system. It was noted that progress has been made, in October 2018 Lewisham was at 22.6%, for 2018/19 was at 27.5% and by the end of March SE London had achieved 31.6% against the 32% target. The target had raised to 34% for 2019/20.

Ms Hirst detailed the actions taken:

A twice-yearly refresh of the CAMHS transformation plan which included eight priorities including the access target

Additional work on the data capture for providers and NHS

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Closely working with SLaM and Oxleas across the six boroughs looking at sharing good practice.

Two reviews were held last year; a council led review on council breaches and a review on NHS Improvement. The recommendations from these had formed an improvement plan.

Four borough meetings are held which look at pathways and dashboards Work has been undertaken in the recruitment and retention of staff with training being

undertaken to progress ban d 4 staff There was increased capacity in the Early Years Alliance An Expression of Interest had been made to the Department of Education for funding

for the Parent School work. Ms Hirst added that the waiting list issue was a key concern especially in generic areas. Positively the long term waiters of 52 weeks have decreased to zero which would need to be sustained. The 32 week wait had also decreased. The referral to access target was a priority recognising the problems for the providers on staff recruitment and retention.

Dr Majid would forward an email from Ms Kirkland on services other areas in the country, including Oxfordshire and the John Radcliffe, that were shown as exemplars in addressing the issues of access to mental health services, though Ms Kirkland in her email acknowledged that Lewisham were using many of the same methods listed.

Ms Hirst added that SLaM’s CAMHS service were recruiting four transformation managers one who would be allocated to Lewisham. SLaM was also looking to recruit more clinic staff.

In response to Dr Aidoo on young people in the past sharing experiences including the stigma of attending signposted mental health units, Ms Hirst explained that there was group work being undertaken, including the Alchemy project which delivered co-produced interventions to marginalised children and young people. To address the stigma and image issue on line services were being developed and that most CAMHS services were delivered at Kaleidoscope which was a multi-function building. Ms Hirst stressed that views from young people and families was intricate to the quality and delivery of service.

In response to Prof Mackenzie’s query on the risk ID99 on the CHC assessment in non-acute settings which had gone from a moderate to a high risk, Mr Wilkinson explained that this related to problems with staffing which meant the service was currently non-compliant. This was a risk which had been rolled over from last year.

The Governing Body NOTED the progress made against the Corporate Objectives, AGREED that the appropriate risks have been identified against the achievement of the draft Corporate Objectives; AGREED the current risk scores and the target risk scores for the risks contained in the BAF; AGREED that there are adequate controls in place to mitigate the risks to the Corporate Objectives and where existing controls have not reduced the current risk score to the target risk score there are credible actions plans, noting that further work is required to ensure they capture the breadth of work on each risk adequately

LEW 19/80 Safeguarding Annual Report 2018/19

Ms Browne introduced the report which described the Safeguarding Adult work achieved during 2018-19, the risks and what was to be progressed to meet statutory requirements. The following positive points were highlighted:

The development of a joint training programme for adult safeguarding and children’s safeguarding

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The work on violence against women and young girls Engagement work with private providers

Ms Mitchell, Nurse Consultant Adult Safeguarding Designate, author of the report highlighted the work on engagement with Primary Care staff with face to face training as good practice, this is now seen as a conduit for advice.

The key risks included:

The Mental Capacity Act has been under judicial review and the system in relation to Deprivation of Liberty for client’s systems and processes. There was now a legal requirement for the responsible person for CHC clients to have a Best Interest Assessor qualification which the current staff do not have. It is acknowledged that this is a national problem and one that would need to be scoped SE London.

SLaM do not have a nominated lead for adult safeguarding therefore are not providing necessary assurance to meet statutory requirements.

In response to Mr Ramrayka on how to quantify the number of people using the safeguarding service, Ms Mitchell said that this was hard to answer as the data is held by the council as the legal body for safeguarding. The CCG were involved in the clinical input.

The Governing Body APPROVED the CCG Safeguarding Adults Annual Report 2018-19 for assurance that effective safeguarding systems and processes were in place for Lewisham to meet its statutory requirements

LEW 19/81 Strategy and Development Workshop Chair’s report

Mr Gostling gave the report from the meeting held on 6 June 2019. The following areas were discussed:

SEL CCG System Reform – a presentation was received to consider questions around functions, influence, decision making and governance. Assurance was given that public engagement and equalities would lie with the Governing Body. It was stressed that quality and equalities were integral to a joined up system. There had been further discussion around the balance between clinical and non clinical members on the Governing Body acknowledging that having two clinical members from each CCG would make the meeting unwieldly.

Population Health Platform – this looked at service delivery and the sections of the population whose needs are not currently being served. It was agreed that there would be a focus on the four clinical priority pathways of diabetes, respiratory, frailty and mental health.

CCG Stakeholder Survey - the CCG’s response rate had increased to 73% with 96% of respondents rated the effectiveness of their working relationship with the CCG as good or fairly good. There were particularly good responses for questions relating to public engagement.


LEW 19/82 Commissioning System Reform in South East London

Mr Bland presented the update report. The Governing Body were reminded that the proposal was for the merger of the six SE London CCGs to establish a single south east London CCG from 1 April 2020 and that there would be a formation of local system boards within each borough that would oversee planning and commissioning of local services across health and social care. The place faced board would consist of commissioning entities sitting alongside

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Local Care Partnerships in each borough. The Programme Plan for the merger would come to the September Governing Body for approval then submitted to the regulators on either 30 September or (by exception) 31 October. The application has resulted from engagement with Governing Bodies, member practices, staff, providers and local government.

The Governing Body would receive recommendations from the System Oversight Group which included an Independent Chair, Mr Warburton, and six CCG Chairs and the two SE London Accountable Officers.

Mr Bland continued that the most significant feature of engagement has been the focus on ways of working, recognising that staff and organisations operate in different partnerships and with different relationships between them.

There have been three potential models for the six Place Based Boards put forward:

1. Greater involvement – separate plans, separate budgets2. Aligned commissioning – aligned plans, separate budgets3. Collaborative commissioning – aligned plans, aligned budgets

Broadly the CCG teams will work in one of three ways:

Single teams undertaking responsibilities once for SE London Teams with a single leadership and point of co-ordination, with resources working on

behalf of each borough Borough based teams

We are currently in the further development of approach and engagement ahead of finalising the application stage of the process.

Ms Hooper queried the level of lay member representation in future plans in order to provide independence taking into account the potential conflict for clinical directors. Mr Bland responded that the Place Based Board would be responsible for primary care but it was recognised that there could be a conflict when dealing with issues of contacts so this would bre the responsibility of a SEL Primary Care Commissioning Committee with delegation from NHSE and with lay members in its membership. The Governing Body NOTED the report and confirmed their continuing support for the actions being pursued through the system reform programme

LEW 19/83 Potential Audit and Risk Management Issues

No audit or risk management issues were raised.

LEW 19/84 Any other business

Mr Wilkinson informed the Governing Body that the Annual CCG Assurance Ratings had been published and was delighted to report that Lewisham CCG had gone from an ‘Requires Improvement’ last year to ‘Good’ rating for 2018/19. Greenwich CCG had also improved to a Good rating.

Dr Majid added that at a recent PLT clinicians had listed many positive achievements by the CCG and that clinician voices were being heard by management. Staff were thanked for all the work undertaken to improve areas and thereby effecting positive change.

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LEW 19/85 Questions from Members of the Public

Q. Regarding the structural change of PCNs. I understand that there will be six PCNs in Lewisham which had been discussed and agreed at a private meeting of the PCCC. As there are currently four neighbourhoods how does that fit together?

A. Mr Wilkinson responded that Central Lewisham will have two PCNs with the other four across North, SE and SW Lewisham working in alignment. The PCNs would operate differently from the neighbourhoods.

Follow up comment – there is a variety of number of PCNs across SE London.

Mr Wilkinson responded that there has been full discussion with GPs including ways of working and how to fit services with the wider system. He recognises the fast pace of progress. Dr Kalwij added that there will be same quality of care in the PCNs as in the neighbourhoods. Dr Majid added that there would be improved care with practices working together. Mr Bland explained that the agreement for PCNs had come from the BMA and regulators.

LEW 19/86 Public Forum Notes

There were no notes from the May Governing Body meeting as there was no members of the public present at the meeting.

LEW 19/87 Approved Committee minutes

The approved minutes of the Audit Committee, Integrated Governance Committee, SEL Integrated Governance and Performance Committee and Strategy and Development Workshop meetings were taken for information.

LEW 19/88 Date of the next meeting

12 September 2019; Governing Body meeting room 1, Civic Suite, Lewisham Town Hall, London SE6 4RU

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CCG Chair’s Report

Governing Body meeting – 12 September 2019

CCG System Reform

Many of you will know that over the last few weeks, CCG senior staff have been occupied in engagement meetings describing the steps necessary for delivery of the NHS long term plan. In order to achieve significant and sustainable improvements in care for the major areas of long term illnesses, our view is that it is necessary to focus on population health, improve service efficiency, reduce duplication of processes, unproductive extra steps and other barriers for patients. An efficient system of community based care requires us to work jointly with our Local Authority partners.

The main agenda item today is to seek agreement on our proposal to merge the six SE London CCGs which will allow us to work to develop services in a more efficient and effective way across borough boundaries for all our populations. However in doing so, I firmly believe in continuing the intensity of attention paid to the particular needs of our Lewisham population as Lewisham CCG has done in the past years and so we have sought to embed safeguards in a new constitution for this to happen. The views of the CCG membership have been very important in developing the proposals for a new CCG for south east London. We have discussed these developments at Neighbourhood and Membership Forums over a number of months, as well as holding two additional engagement sessions during August. Working with my counterparts in the other CCGs we have ensured GP representation and decision-making in the new body has been addressed, and have been able to reach agreement with the chairs of our Local Medical Committees (LMCs) on these points. The decision that we make jointly today will affect the efficiency and opportunity to improve health care for years to come.

Report from Clinical Directors

Dr Jacqueline McLeod

I participated in the Lewisham Whole System Homeless Summit, which was attended by a wide range of stakeholders. We did a stocktake of progress against the joint CCG and local authority commitments made in 2017, reviewing current services, with a focus on the impact of the Rough Sleepers Pilot in the North of the Borough. Stakeholders shared their perspectives on persisting challenges facing our

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Item Number 6

homeless population with commitments made to mitigate them. We also sought to develop a whole system response to recent guidance and policy changes with attention to identified gaps in service provision.Lewisham’s joint work has been recognised at a strategic level as a good example of developing integrated health, housing and social care for people who are homeless.

Each month I attend SEL IG&P Committee and as we have consistently identified staffing challenges as factors affecting acute provider performance this month we undertook a deep dive into workforce. I was able to provide a positive update for Lewisham highlighting the progress made on A&E and urgent care actions through investment in admission avoidance services and importantly daily conference calls linking providers, the CCG and local authority, which have had a significant impact on reducing the number of long waiters.

Dr Charles Gostling

I am continuing to help shape and develop the mental health provider alliance. The proposed model of care and potential pilot of this new service was discussed the primary care network forum and was well received. There is conditional agreement that the pilot should commence in the neighbourhood 1 primary care network and should include both the piloting of both the model of care and the use of EMIS web within the primary care mental health service. The use of EMIS web in community services is a huge leap forward and will allow seamless exchange of information between primary care and primary care based mental health services.

A series of workshops have been set up to consider future development of diabetes services in Lewisham. The workshops have involved Lewisham and Greenwich Trust, the Public Reference Group as well as stakeholders across primary care, including Primary Care Networks, One Health Lewisham and core primary care representatives. It is pleasing to see the level of convergence of ideas and positive engagement for the future. The new Diabetes Model of Care is being developed across Bexley, Greenwich and Lewisham and is in line with Long Term Plan priorities. A business case is nearing completion for presentation to finance and investment committees.

Dr Esther Appleby

Prostate Cancer Pilot underway, currently data gathering and setting up template, and linking with Urology Tumor Group at GSTT to feed into discussion about stratified follow up.

I have been working with colleagues from Greenwich, Bexley and LGT to provide comprehensive Lymphoedema service. There is currently inequality and under provision in the locality that we are trying to address.

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Two educational events on End of Life Care for GPs and Practice teams are being held in Lewisham this month. These are designed to support Quality Improvement work and also demonstrate the services offered by St Christopher’s. A case for Rapid Response Service for overnight palliative care service is being developed.

Learning Disability Ambassador Scheme has been launched with Lewisham Speaking Up. Safety netting pilot underway.

Ms Debbie Brown

Respiratory: Two Integrated hubs in place. I am working with counterparts in Bexley and Greenwich to share good practice and build collaborative working working across BGL. Meet with GSST community team who have shared their success with virtual clinics An ultrasound pilot has been completed and a report on this will follow soon. Group consultation is also being implemented.

Care Homes, weekly meetings with social services, safe guarding lead nurse, commissioners and project managers. We are carrying out a deep dive in to 3 care home conveyances to A&E, triangulating data from London Ambulance, A&E and GP practices. A report will follow.

Dr Sebastian Kalwij

Pathology: various changes to arrangements have been , introduced over the summer that have been very well received by clinicians. These have covered urea test, statin monitoring, and other testing for vitamin D and other proteins. Some changes have been very slow to implement mainly due to IT technicalities.

WRES: A seminar is planned for the 7th of November and all members of the GB are cordially invited. A GP survey has been sent out to GPs and this will be evaluation in due course and presented at the seminar. Some high profile local and national speakers have been confirmed.

Dr Angelika Razzaque

Children and Young People Mental Health:In line with the SEL Children and Young People’s Mental Health Transformation agenda, our providers are moving closer together in the aim to develop a provider alliance. Pathways are currently being reviewed and the future will see a move towards a single point of access. Transition is featuring highly in the proposed working together and links with adult services and the existing alliance are crucial to this. I am chairing the delivery group which meets alternate months and reports into the Mental Health and Emotional Wellbeing Board. A stakeholder meeting with facilitation from iThrive is being planned for mid October to develop a common

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language and adopt the framework for CYP MH. A JSNA on self harm amongst CYP from PH is anticipated shortly and should inform much of the work already in place further.

Children and Young People general:We are proposing a pilot of in reach clinics led by LGT paediatricians in GP practices across Lewisham and Greenwich. We have had one practice in Lewisham volunteering to be part of the pilot, two further practices will be selected according to referral rates. With regards to a community paediatric dietetic service, the trust is currently working up a business case. Parallel, further work is being undertaken on the allergy pathway, particularly concerning prescribing and referral pathways.

Dr F Majid 03.09.2019

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Managing Director’s Report

Governing Body meeting – 12 September 2019

1. Commissioning Intentions 2020/21

In line with the approach initiated last year, the Integrated Contract Delivery Team (ICDT) in the South East London Commissioning Alliance will lead the development of commissioning intentions for our acute providers to ensure a consistent approach and ask of Guy’s and St Thomas NHS Foundation Trust, King’s College Hospital NHS Foundation Trust and Lewisham and Greenwich NHS Trust, as well as coordinate with local CCG commissioners for our main mental health providers of Oxleas and South London and Maudsley NHS Foundation Trusts on behalf of all 6 CCGs in SE London.

In overall terms, the Commissioning Intentions are a build on those introduced in 2019/20, with a heavy focus on areas for acute providers such as referral optimisation (planned care), ambulatory care (urgent and emergency care) and early detection and prevention (cancer). For mental health, the priorities of crisis and acute care, range of services for children and young people continue, along with the local development of our provider alliance. The commissioning intentions will be refreshed to ensure that they are in line with the requirements of the Long-Term Plan, noting that our intentions were broadly in line with national priorities, and will be communicated to NHS providers by the end of September.

2. CCG Changes

The proposed CCG changes that are covered elsewhere in this meeting will have an impact on the roles and employment of all the staff of the CCG. We have held a number of briefing sessions, circulated regular bulletins and covered developments in our bi-weekly ‘staff huddle’ catch-ups to ensure that everyone is kept as up to date as possible. During July and August staff also had the opportunity to attend workshops to look at how various functions might work in a new south east London CCG.

A consultation on changes to the finance team’s structures and roles has recently concluded, and those staff will be supported as the proposals are implemented. As changes affect other staff groups we will be following our policy on organisational change and ensuring there is further staff engagement and support as we go through those processes.

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Item Number 7

3. Our Healthier South East London

During July and August the Our Healthier South East London (OHSEL) team carried out a series of engagement events across the six boroughs. As well as an event for each of our boroughs that discussed a number of areas of care, there were a further six events that each focused on a single topic. The topics talked about included children and young people mental health, access to services, and social isolation. The topic event in Lewisham looked at ‘getting the best start for children and young people’. The outcomes of these events will inform the OHSEL response to the Long Term Plan for the NHS.

Workforce

OHSEL is continuing its ground breaking work to develop the roles of the non-clinical workforce. The non-clinical workforce is an untapped resource at a time when supporting an ageing population with increasingly complex care needs is overwhelming clinical capacity. We have developed and tested two roles through the development of a unique four tier Competency Framework and a training package - Primary Care Navigator and Medical Assistant (now General Practice Assistant - GPA). In each case, evaluation has confirmed the positive impact for learners, practices and patients.

Planned Care: Orthopaedics

In January we updated that all south east London hip/ knee joint replacement patients would be strongly encouraged to attend outpatient group pre-operative education classes prior to receiving surgical treatment. Our nurses, occupational and physiotherapists, supported by patients and consultant surgeons have agreed a common lesson plan made up of patient and carer aims and learning objectives which are now delivered consistently across our south east London hospitals.

This class, delivered 4-6 weeks prior to a patient’s surgery, supports patients and close family members/ carers to understand:

Their roles and responsibilities leading up to their date of surgery The process for admission for surgery and what to bring What to expect following surgery and a patient’s recovery in hospital Advice for making the best recovery and rehabilitation at home

Through improved communication of what to expect, who will be supporting you, and what you can do to make get the most from your surgery, we anticipate that these classes will improve patient experience of care and long-term outcomes.

Children and Young People

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On June 26th a range of leaders from south east London’s children and young people’s services attended the Healthy London Partnership ‘Strategic Leaders Transformation Forum Pan-London Event’. It was an inspiring event with opportunities to network, connect with system leaders across London, explore the challenges and learn from each other. The event aimed to develop a networked approach to leading change at a local system level. We were pleased to have participated and gained ideas and support from the wider network to address improving outcomes for children and young people in our community. We hosted a session at the event, sharing progress on our Children and Young People’s Programme of work including our ambitions, approaches to developing our priority programmes and achievements to date including:

In February 2019 we launched a digital mental health support service for children and young people called Kooth following a successful pilot in Lewisham. Kooth is freely available to children and young people in SEL and includes the provision of online self-care tools.

In May 2019 we held the first South East London Paediatric Asthma Network meeting with the aim of developing a network that can transform the care of children and young people with asthma. The event was very well attended and innovation and best practice from across the area was shared. The Network will meet regularly from autumn 2019 chaired by Richard Illes, consultant in children’s respiratory medicine at Evelina Children's Hospital.

In May 2019 we hosted a leadership workshop for learning disability and autism services across SEL focused on developing our vision for children and young people, ensuring a clear understanding of local unmet need, gaps in care and local health inequalities.

Giving every child the best start in life is a key priority and we are now setting up a Children and Young People’s Transformation Board for South East London which will provide system wide local leadership and oversee local implementation of NHS Long Term Plan ambitions. Our aim is to improve outcomes and reduce health inequalities for all those aged 0-25 through system change and leadership.

MaternityThe delivery of the South East London (SEL) Local Maternity System (LMS) Better Birth’s implementation plan continues. This month we can report welcome developments with the submission of our future funding plans to NHS England, which will support maternity services with the plan. A range of projects have been agreed to secure National 2019/2020 funds and to target key areas where we need to make progress, for example continued support for the introduction of continuity of carer pathways that will enable those women who need it most to receive continuity

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https://www.healthylondon.org/

https://www.kooth.com/

from a small team of midwives throughout the antenatal, labour/birth and postnatal period, and a well-received singing programme for women who are experiencing low to moderate mental health concerns after having a baby.

Our funding plan will also be used as an exemplar for the region, so we are very pleased the LMS has received this recognition. It is a credit to our colleagues across the system who are working hard to deliver our Better Births plan.

South East London Cancer Alliance The south east London (SEL) Cancer Alliance is the cancer programme of the SEL aspirant Integrated Care System. Previously, hosting of the SEL Cancer Alliance Programme Team has been shared between Southwark CCG and Guy’s and St Thomas’ NHS Foundation Trust (GSTT). From July 2019 the programme team will be based fully at GSTT, and we will continue to work with partners across the system to support improvement and transformation across the whole cancer pathway. Our programme team also supports the SEL Accountable Cancer Network, which is the provider network within the SEL Cancer Alliance.

In early July we held an SEL cancer screening workshop, bringing together CCGs, primary and secondary care providers, charities, public health partners and NHS England colleagues to hear about work going on across London and within SEL to improve screening uptake, and to discuss priorities for the future. We hope to build on this initial event by creating a virtual network to share good practice and resources, which we hope will lead to a collaborative system approach to improving screening uptake.

We are also continuing to work closely with Trusts in the sector on improving access and cancer waiting times, with our team members directly supporting operational and clinical colleagues across the system. During June we held three communities of practice events to support development of staff across the system which focused on three areas: patient involvement (including both staff and patients); rehabilitation and personalised care; and operational teams working in cancer.Our delivery plan for 2019/20 includes a range of projects to improve operational performance, early diagnosis and personalised care, working with partners across the ICS.

4. Lewisham Business Intelligence Move

The NEL Commissioning Support Unit’s (NELCSU) Business Intelligence (BI) Team who work on behalf of the CCG are looking to move the NEL BI Data to a public cloud platform. Currently, the NEL BI Data is held on a private cloud, and although secure, this is not the most efficient means of providing the service. This new platform will allow the BI team to take advantage of public cloud service offerings,

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which will provide benefits to Lewisham CCG in both the short term and the long term.

The NEL BI team have worked through the Information Governance implications of this move, and have documented the risks and appropriate mitigating actions to be implemented, and have sought approval from Lewisham’s Senior Information Risk Owner. There is an existing Data Sharing Contract and Agreement for Lewisham CCG which enables the CCG to receive data for commissioning purposes. NEL will be making an amendment to add Microsoft as a sub data processor on behalf of Lewisham CCG as part of this work.

Martin WilkinsonSeptember 2019

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1

Governing Body meeting on 12 September 2019

Report from the Chair of the Audit CommitteeDate of Meeting reported: 23 July 2019

Author: Shelagh Kirkland, Chair of the Audit Committee

Main issues discussed

Report from RSM our Internal Auditors o Review of report on Local Authority Integration and Better Care Fund ( Reasonable

Assurance )o Update of controls catalogue

Issue of the Annual Audit Letter from our External Auditors KMPG following completion of the year-end audit

Report from TIAA our Counter Fraud and Security Management Service Providers

Key points discussed

Reports from RSM

RSM have completed their first deep dive report for the year 2019/20 on Local Authority Integration and Better Care Fund and gave a Reasonable Assurance opinion. They identified two areas for improvement. These related to the information being reviewed at the risk sharing meetings between the Council and CCG on the Better Care Fund and more explicit discussions on the performance of the Better Care Fund at Health and Wellbeing Board meetings.

The Audit Committee reviewed the updated controls catalogue, which now includes items from outsourced providers (Capita – Primary Care; NHS North East London Commissioning Support Unit (NEL CSU) – Finance and Payroll; NHS Shared Business Services (SBS) – Finance and Accounting; NHS digital – GP payments to providers of General Practice Services). It was noted that there were a number of control exceptions relating to Capita but it was also acknowledged that the number had fallen from the previous year. The Committee also recognised that the CCG has no direct contractual relationship with Capita. However, in reply to a letter that was sent to NHS England (NHSE) who hold the relationship, the Chair had received a letter from NHSE stating that they were addressing performance issues with Capita.

Reports from KPMG

The Committee noted the Annual Audit letter issued by KPMG following the submission of the Annual Report and Accounts that summarised the audit findings for 2018/19. The Committee noted there were no changes from the draft letter that they had previously reviewed and that the finalised letter needed to be published on the CCG’s website.

Reports from TIAA

The Committee reviewed the progress reports and concluded that there were no material issues to report.

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Item Number 8

2

Key challenges addressed

No new specific challenges were raised or needed to be addressed at the meeting.

New potential risks

There were no new potential risks identified by the Committee.

How did the meeting help address inequalities and fairness?

There were no specific equalities issues for the Committee to consider.

Note on the Committee and the CCG’s assurance providers

The Audit Committee comprises the CCG’s three Lay Members, the Secondary Care Doctor and the Senior Clinical Director leading on quality. Attending its meetings are the CCG’s three assurance providers: RSM, the Internal Auditors; KPMG, the External Auditors; and TIAA who provide local Counter Fraud and Security Management Services. Senior managers are requested to attend all meetings.

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Governing Body meeting on Thursday 12th September 2019Primary Care Commissioning Committee (PCCC): Chairs Report

Report from: Peter Ramrayka, CCG Lay Member and Chair of the PCCCPCCC date: Urgent planned meeting held on Tuesday 6th August 2019Managerial Lead: Diana Braithwaite, Director of Commissioning & Primary CareAuthor: Ashley O’Shaughnessy, Deputy Director of Primary Care

1. Wells Park Practice - CQC requires improvement1.1 The committee approved that Wells Park Practice be issued with a remedial notice in

respect of those areas of contractual non-compliance which have not yet fully been resolved following their latest CQC inspection, including the specific GP contractual requirement for the contractor to have a practice leaflet in place.

2. Amersham Vale Practice – Estate Expansion2.1 The committee approved the use of 5 additional, currently vacant, clinical rooms and the

staff toilet/kitchenette area in suite 4 at the Waldron HC for the Amersham Vale Practice.

3 Date of next meeting3.1 The next scheduled meeting of the Primary Care Commissioning Committee held in

public is at 9.45am on Tuesday 15th October 2019 at the Civic Suite, Lewisham Town Hall, Catford, London SE6 4RU.

4 Further information4.1 Full meeting papers for the urgent planned Primary Care Commissioning Committee

held on Tuesday 6th August 2019 will shortly be available at: https://www.lewishamccg.nhs.uk/about-us/how-we-work/Pages/Primary-Care-Commissioning-Committee-.aspx as part of the papers for the 15th October 2019 Primary Care Commissioning Committee meeting.

4.2 The Primary Care Commissioning Committee scheduled for the 20th August 2019 was cancelled as there was no immediate business to consider.

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Item Number 9

https://www.lewishamccg.nhs.uk/about-us/how-we-work/Pages/Primary-Care-Commissioning-Committee-.aspx

https://www.lewishamccg.nhs.uk/about-us/how-we-work/Pages/Primary-Care-Commissioning-Committee-.aspx


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A meeting of the Governing Body12th September 2019

Amended Primary Care Commissioning Committee (PCCC) Terms of Reference (ToR)

Clinical LEAD: Jacky McLeodManagerial Lead: Diana Braithwaite

Post: Clinical Director and Primary Care LeadPost: Director of Commissioning & Primary Care

Author: Chima Olugh Post: Primary Care Commissioning Manager

RECOMMENDATIONS: The Governing Body is asked to:

Approve the amended Terms of Reference of the Primary Care Commissioning Committee.

SUMMARY:Following an internal audit carried out by RSM Risk Assurance Services LLP in February 2019, Lewisham CCG was advised to amend the Terms of Reference of its Primary Care Commissioning Committee. The amendment to the Terms of Reference will ensure it is up to date, reflects the membership and meeting arrangements of the Committee and is fit for purpose. Reference to NHS England as a member of the PCCC has been removed from the Terms of Reference to reflect the CCG’s responsibilities under delegated commissioning and the fact that the SE London Primary Care Team are now employed by Southwark CCG, in its host STP capacity. The exception to this amendment is where references to NHS England are made in the Introduction, Statutory Framework and Role of the Committee sections where references to NHS England are given as context to describe the fact that NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.The updated ToR is attached at Appendix 1 which shows the changes that have been made.

KEY ISSUES: Following an internal audit carried out by RSM Risk Assurance Services LLP in February

2019, Lewisham CCG was advised to amend the Terms of Reference of its Primary Care Commissioning Committee.

On 1 April 2019, the NHS England South East London Primary Care Team was transferred to the South East London CCGs as part of the Sustainability and Transformation Plans (STPs). The effect of this means that NHS England is no longer represented on the PCCC.

In order to reflect this change, reference to NHS England as in attendance at the PCCC has been removed from the Terms of Reference of the Primary Care Commissioning Committee.

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Page 2 of 2

CORPORATE AND STRATEGIC OBJECTIVES:The Primary Care Commissioning Committee provides assurance to the Governing Body that there is diligent oversight, robust systems and processes in place for monitoring and verifying the quality and safety of primary care medical services in Lewisham.

CONSULTATION HISTORY:Not Applicable

PUBLIC ENGAGEMENT: There are no direct implications for Public and Patient Engagement arising from the details of this paper.

HEALTH INEQUALITY DUTY:No specific adverse impacts identified.PUBLIC SECTOR EQUALITY DUTY:No specific impacts have been identified

RESPONSIBLE MANAGERIAL LEAD CONTACT:Diana Braithwaite, Director of Commissioning & Primary Care, [email protected]

AUTHOR CONTACT:Chima Olugh, Primary Care Commissioning Manager, [email protected]

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mailto:[email protected]


NHS Lewisham CCG Primary Care Commissioning Committee Terms of Reference

August 2019Version 1.2

Appendix 1

Page 31

Terms of ReferenceMarch 2017

Author/s: NHS England and Lewisham CCG (localised)

Effective Date: 1st April 2017

Review Date: 31st March 2018

Document owner/CCG Contact/s: Diana Braithwaite, Director of Commissioning & Primary Care

Lewisham CCG Consultation: Lewisham CCG Primary Care Programme Board Workshop – 15th February 2017

Ray Warburton OBE, Lay Member, Audit Chair and CoI Champion – 22nd February 2017

Ratified: Governing Body

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Terms of reference – NHS Lewisham CCG Primary Care Commissioning Committee

Introduction 1. Simon Stevens, the Chief Executive of NHS England, announced on 1 May 2014 that

NHS England was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHS England would delegate the exercise of certain specified primary care commissioning functions to a CCG.

2. In accordance with its statutory powers under section 13Z of the National Health Service Act 2006 (as amended), NHS England has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference to NHS Lewisham CCG. The delegation is set out in Schedule 1.

3. The CCG has established the NHS Lewisham CCG Primary Care Commissioning Committee (“Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers as set out in NHS Lewisham CCG’s Constitution and Scheme of Delegation.

4. It is a committee comprising representatives of the following organisations: NHS Lewisham CCG; In attendance:

o Lewisham Council representative of the Health and Wellbeing Board;o Lewisham Local Medical Committee;o Lewisham Healthwatch;o Officers as required to undertake business of the committee, including South

East London CCGs Primary Care Team.

Statutory Framework 5. NHS England has delegated to the CCG authority to exercise the primary care

commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.

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6. Arrangements made under section 13Z may be on such terms and conditions (including terms as to payment) as may be agreed between the NHS England Board and the CCG.

7. Arrangements made under section 13Z do not affect the liability of NHS England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O);b) Duty to promote the NHS Constitution (section 14P);c) Duty to exercise its functions effectively, efficiently and economically (section 14Q);d) Duty as to improvement in quality of services (section 14R);e) Duty in relation to quality of primary medical services (section 14S);f) Duties as to reducing inequalities (section 14T);g) Duty to promote the involvement of each patient (section 14U);h) Duty as to patient choice (section 14V);i) Duty as to promoting integration (section 14Z1);j) Public involvement and consultation (section 14Z2).

8. The CCG will also need to specifically, in respect of the delegated functions from NHS England, exercise those in accordance with the relevant provisions of section 13 of the NHS Act;

a. Duty to have regard to impact on services in certain areas (section 13O);b. Duty as respects variation in provision of health services (section 13P).

9. The Committee is established as a committee of the CCG Governing Body in accordance with Schedule 1A of the “NHS Act”.

10. The members acknowledge that the Committee is subject to any directions made by NHS England or by the Secretary of State.

Role of the Committee 11. The Committee has been established in accordance with the above statutory provisions

to enable the membership of the committee to make collective decisions on the review, planning and procurement of primary care services in Lewisham, under delegated authority from NHS England.

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12. In performing its role the Committee will exercise its management of the functions in accordance with the agreement entered into between NHS England and NHS Lewisham CCG, which will sit alongside the delegation and terms of reference.

13. The functions of the Committee are undertaken in the context of a desire to promote primary care co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

14. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.

15. The Committee has an operational remit under the strategic direction approved by the Governing Body in relation to primary care, which includes;

a. GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing breech/remedial notices and removing a contract);

b. Newly designed enhanced services;c. Design of local incentives schemes as an alternative to Quality Outcomes Framework

(QOF);d. decisions in relation to the establishment of new GP practices (including branch

surgeries) and closure of GP practices; e. Approving practice mergers;f. Making decisions on ‘discretionary’ payments (e.g. returner/retainer schemes);g. Decisions about commissioning urgent care (including home visits as required) for out

of area registered patients;h. Planning primary medical care services in the Lewisham including carrying out needs

assessments;i. Undertaking reviews of primary medical care services in the Lewisham; j. Decisions in relation to the management of GP practice performance and including

(and without limitation); decisions and liaison with the Clinical Quality Commission (CQC), where there is reported non-compliance with standards (excluding any decisions in relation to the performers list);

k. Management of the delegated funds in the Lewisham; l. Premises Costs Directions functions; m. Co-ordinating a common approach to the commissioning of primary care services with

other commissioners in the area where appropriate; and

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n. Such other ancillary activities as are necessary in order to exercise the Delegated Functions.

16. The CCG will also carry out other activities as detailed in Schedule 1 of the Delegation Agreement between NHS Lewisham CCG and NHS England.

17. In particular the Committee will support the Governing Body in fulfilling the following functions and duties to:

a. Meet the public sector equality duty;

b. Act effectively, efficiently and economically;

c. Act with a view to securing continuous improvement to the quality of services;

d. Have regard to the need to reduce inequalities;

e. Promote the involvement of patients, their carers and representatives in decisions

about their healthcare;

f. Act with a view to enabling patients to make choices;

g. Promote innovation; and

h. Act with a view to promoting integration of both health services with other health

services and health services with health-related and social care services where

the CCG considers that this would improve the quality of services or reduce

inequalities.

Geographical Coverage 18. The Committee will make decisions in respect of primary care in the London Borough of

Lewisham population including GP registered population.

Membership19. The Committee shall consist of: 19.1Members with voting rightsa. 3 x Lay Members

o Chair: Lay Member for Primary Careo Vice Chair: Lay Member responsible for Patient Public Engagemento Lay Member: Chair of the Audit Committee and Conflicts of Interest Guardian

b. CCG Chairc. 2 Governing Body GP Members

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d. Registered Nurse or Secondary Care Specialist (single member)e. CCG Managing Director(or nominated deputy)f. CCG Chief Financial Officer (or nominated deputy)g.h. Director of Commissioning & Primary Care19.2 Non-Voting Membersa. Local Medical Committee Representativeb. Healthwatch Representativec. Local Authority Representative of the Health and Wellbeing Board (Elected Member or

Mandated Officer)d. Officers as required to undertake business of the committeee. South East London Primary Care TeamRepresentative

20. The Chair of the Committee shall be a Lay Member of NHS Lewisham CCG. This will not be the Lay Member responsible for Audit.

21. The Vice Chair of the Committee shall be a Lay Member of NHS Lewisham CCG. This will not be the Lay Member responsible for Audit.

Meetings and Voting 22. As a committee of the Governing Body, the Committee will operate in accordance with

the CCG’s Standing Orders (in line with NHS England Standard Operating Procedures). This includes the capacity to manage urgent matters outside the normal arrangements.

23. The aim of the Committee will be to achieve consensus decision-making wherever possible. In the event that a vote is required, each member of the Committee shall have one vote. The Committee shall reach decisions by a simple majority of members present, but with the Chair having a second and deciding vote, if necessary.

Quorum24. The quorum shall be a minimum of 4 members, of which 2 must be Lay Members.

25. Where a quorum cannot be convened from the membership, owing to arrangements for the management of conflicts of interest or potential conflicts of interest; the Chair of the meeting will comply with the conflicts of interest policy.

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26. This may result in;a. The meeting being deferredb. A discussion being undertaken but the decision deferred until the next meetingc. Discussion being undertaken being deferred to the Governing Body

Frequency of meetings 27. The Committee will meet regularly 6 times per year. After 12 months the frequency will

be reviewed.

28. Meetings of the Committee shall: a. be held in public, subject to the application of 28(b);b. the Committee may resolve to exclude the public from a meeting that is open to the

public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time;

c. the closed confidential part of the meeting (as provided for at 28(b) above) shall be referred to as Part 2 of the meeting and shall have a separate agenda and minutes;

d. the Committee may invite the representatives of the local authority (Health and Wellbeing Board), Local Medical Committees and Healthwatch to Part 2 of any meeting where it considers it is appropriate for such representatives to attend all or part of Part 2 of the meeting.

29. The committee may meet in common with other CCGs in south east London (NHS CCG Bexley, NHS CCG Bromley, NHS CCG Greenwich, NHS CCG Lewisham and NHS CCG Southwark – or any combination of these CCGs) when there is common business to transact.

30. Members of the Committee have a collective responsibility for the operation of the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

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31. The Committee may delegate tasks to such individuals, sub-committees or individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

32. The Committee may call additional experts to attend meetings on an ad hoc basis to inform discussions.

33. Members of the Committee shall respect confidentiality in attending and undertaking the business of the committee.

34. The Committee will present an executive summary report and its minutes to the governing body of NHS Lewisham CCG and London region following each meeting for information, including the minutes of any sub-committees to which responsibilities are delegated under paragraph Error! Reference source not found. above.

35. The CCG will also comply with any reporting requirements set out in its Constitution.

36. Terms of Reference will be reviewed on an annual basis.

Accountability of the Committee 37. The Committee will be accountable for the expenditure of the primary care budget

delegated from NHS England to the Governing Body of Lewisham CCG. Responsibility for authorising expenditure against this budget may be further delegated only as set out in the Scheme of Reservation and Delegation ratified by the Governing Body.

38. For the avoidance of doubt, in the event of any conflict between the terms of the CCG’s Operational Scheme of Delegation, the Committee’s Terms of Reference and the CCG’s Prime Financial Policies, the Operational Scheme of Delegation will prevail.

39. The Committee may be required where appropriate to provide reports and information to other Committees of the CCG.

Decisions 40. The Committee will make decisions within the bounds of its remit as set out in clause 22.

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41. The Committee will ensure that any conflicts of interest are dealt with in accordance with the CCG’s Constitution and Standards of Business Conduct Policies which for the avoidance of doubt may include members (voting or otherwise) being excluded from a decision and/or the discussions leading thereto.

42. The decisions of the Committee shall be binding on NHS Lewisham CCG .

43. All attendees are required to declare their interests as a standing agenda item for every committee before the item is discussed, in line with the Lewisham CCG policy on Conflicts of Interest https://www.lewishamccg.nhs.uk/news-publications/Policies/Documents/Lewisham%20CCG%20Conflicts%20of%20Interest%20Policy%20June%2017.pdf .

44. The chair of the meeting of has ultimate responsibility for deciding whether there is a conflict of interest and for taking the appropriate course of action in order to manage the conflict of interest.

45. In the event that the chair of a meeting has a conflict of interest, the vice chair is responsible for deciding the appropriate course of action in order to manage the conflict of interest. If the vice chair is also conflicted then the remaining non- conflicted voting members of the meeting should agree between themselves how to manage the conflict(s).

46. In making such decisions, the chair (or vice chair or remaining non-conflicted members as above) may wish to consult with the Conflicts of Interest Guardian or another member of the governing body.

47. The chair should ask at the beginning of each meeting if anyone has any conflicts of interest to declare in relation to the business to be transacted at the meeting. Each member of the group should declare any interests which are relevant to the business of the meeting whether or not those interests have previously been declared. Any new interests which are declared at a meeting must be included on the CCG’s relevant register of interests to ensure it is up- to-date.

Reporting

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https://www.lewishamccg.nhs.uk/news-publications/Policies/Documents/Lewisham%20CCG%20Conflicts%20of%20Interest%20Policy%20June%2017.pdf



48. The CCG will ensure a person shall act as Secretary to the Committee and will:

a. Circulate the minutes and actions to all members of the Committee within 7 working days of any meeting of the Committee;

b. Report the proceedings of each meeting of the Committee to the next Governing Body;

c. Produce an executive summary report which sets out any decisions made by the Committee to be presented at the next meeting of the Governing Body;

d. The Chair shall draw to the attention of the Governing Body any issues that require disclosure to the full Governing Body or require executive action.

[Signature provisions]

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Version Control

Version Date Amendment By0.1 09/03/2017 Draft to Governing

BodyV Medhurst

0.2 27/03/2017 Amendments sent to GB members following discussion at GB

V Medhurst

0.3 30/03/2017 Addition of 3rd Lay Member title following comments from R Warburton

V Medhurst

1.0 25/04/2017 FINAL via Chairs action and reported at PCCC on 25/04 – subject to amendment of 28a and 28c from 25b to 28b

1.1 25/01/2018 Addition of ‘or nominated deputy’ to CCG Chief Officer and CCG Chief Finance Officer

V Medhurst

1.215/08/2019 NHS Lewisham CCG

Primary Care Commissioning Committee terms of reference were revised following a recommendation by RSM Risk Assurance Services LLP following an internal audit.

References to NHS England have been removed to properly reflect the CCGs responsibilities under delegated commissioning. The exception to this is

C Olugh

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where references to NHS England are made in the Introduction, Statutory Framework and Role of the Committee sections where references to NHS England are given as context to describe the fact that NHS England has delegated to the CCG authority to exercise the primary care commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.

Inclusion of the link to the updated Lewisham CCG policy on Conflicts of Interest.

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Governing Body Meeting 12 September 2019

Report from the Chair of the Public Engagement and Equalities Forum (PEEF)

Date of meeting reported: 20 August 2019 (workshop with CCG Senior Management Team and Governing Body

members)

Author: Anne Hooper, Lay Member

Main issues discussed

At the PEEF workshop in August we analysed our Improvement and Assessment Framework (IAF) results for 2018/19 and discussed public engagement and involvement activities following the proposed changes to the south east London CCGs.

This report also highlights feedback from Lewisham residents on public engagement events held to gain views on the local implementation of the NHS Long Term Plan and the proposed creation of one CCG covering the whole of south east London.

Improvement Assessment Framework (IAF) rating for 2018/19

The IAF assessment is part of NHS England’s Improvement Assessment Framework for CCGs. We are rated on patient and public participation in commissioning health and care. NHSE assess our performance by looking at evidence of our engagement which is published on our website under 5 domains.

Our overall rating for 18/19 was ‘good’ and workshop participants were pleased to note the significant improvement from 17/18 when we were rated ‘requires improvement’. We narrowly missed out on a rating of ‘outstanding’ with an overall score of 13 out of 15 (one short of ‘outstanding’). The improvement was due to a combination of adopting new initiatives in response to the previous assessment and better evidencing of our work. I am pleased that the CCG’s improvements and the hard work of the communications and engagement team and their commissioning colleagues has been recognised with this assessment.

The graph below shows the results for each of the five domains and shows the improvement from the 2017-18 rating. At the workshop we analysed detailed feedback from NHS England for each domain to ensure that we learn from this year’s performance and identify areas to improve. The main areas to improve are listed following the graph.

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Item Number 10

https://www.lewishamccg.nhs.uk/about-us/Pages/Changes-to-the-south-east-London-CCGs.aspx


0 1 2 3

E - Equalities and health inequalities

D - Feedback and evaluation

C - Day to day practice

B - Annual Reporting

A - Governance

18-19 17-18

IAF Rating by domain

Domain A – Governance: rating ‘good’

Areas to improve:

o Increase evidence in relation to how the Governing Body is assured about the difference Public Engagement has made

o More evidence to describe the approach the CCG takes to reviewing involvement across providers and taking action in response. This is an area that most CCGs struggled with nationally. It was noted that the proposed south east London CCG would bring an opportunity to get a better handle on this as many providers work across more than one borough.

Domain B – Annual reporting: rating ‘outstanding’

Areas to improve:

o Demonstrate better how networks have influenced the work of the CCG.

Domain C – Day to day practice: rating ‘outstanding’

Areas to improve:

o Add information outlining that a range of options for receiving information in different formats is available and how people can access it – to be linked from the CCG ‘Get involved’ section.

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Domain D – Feedback and evaluation: rating ‘good’

This was a domain that many CCGs struggled with nationally. We agreed that this should be our main focus to improve and that we will seek to learn from CCGs who were assessed as outstanding for this domain.

Areas to improve:

o The ‘You said, we did…and are doing’ section to be improved by including dates so it is clear what is current/recent.

o Workplan and Progress report don't provide enough information about how effective engagement has been. This would benefit from a more comprehensive account of how the CCG reviews and evaluates the spectrum of engagement activity and takes action in response.

o Example improvement on interpreting and translating review: use diverse and creative methods to feedback, for example videos in different languages and / or signed as per local need, podcasts, infographics, you said we did and feedback via patient partner who took part.

Domain E – Equalities and health inequalities: rating ‘outstanding’

Areas to improve:

o The CCG would benefit from providing more robust evidence of embedding of EDS2 (Equality Delivery System) as part of overall engagement strategy, plan or approach.

Public engagement and involvement activities following the proposed changes to the south east London CCGs

The Forum then discussed what types of public engagement and involvement activities will be required following the proposed creation of one CCG covering all of south east London.

Participants stressed the important role that local knowledge, networks and contacts will need to play to ensure that Lewisham residents’ continue to have a strong voice.

We discussed the continuing need for meaningful engagement and involvement on the impact that decisions made at a strategic level would have on local people and services. We also acknowledged that changes in the design and delivery of local Lewisham services would also require a robust engagement and involvement framework.

We discussed different types of activities occurring at different levels (eg Primary Care Networks, Lewisham, Bexley/Greenwich/Lewisham, and across south east

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London) and the likely resources required. We also discussed governance and assurance and we are developing the rationale for a Lewisham sub-group of the Borough Based Board to ensure Lewisham residents’ views feed into the Place Based Board and are reported to the south east London CCG.

We also noted that all boroughs in south east London have received a ‘good’ or ‘outstanding’ rating for public engagement. This shows that the new organisation will have excellent foundations to build on and that different approaches taken in each CCG have enabled them to meet the needs of their local populations.

The recommendations from the workshop will be fed in to the CCG Change programme with proposals for governance and assurance to come to a future CCG Governing Body.

Lewisham residents’ thoughts on how the NHS Long Term Plan should be implemented locally

Since the last Governing Body we worked with the Our Healthier South East London team to hold two public engagement events in Lewisham to hear what local people think about how the NHS Long Plan should be implement locally. The reports from these events will be published on our website when they are available.

We also supported a number of discussions with seldom heard groups in Lewisham (12 July - BME Mental Health Carers Forum; 19 July – Lewisham Asian Group; 25 July – Lewisham BME Network; and 30 July – Lewisham Mental Health Carers Forum).

In addition Healthwatch Lewisham have published a report into the Long Term Plan engagement they carried out in the borough.

Our Healthier South East London will be publishing the strategy for the implementation of the Long Term Plan in November 2019 and in forthcoming PEEF meetings we will continue to analyse the findings from all of these activities and seeking assurance as to how they will be considered in the ongoing development and delivery of future south east London plans.

Lewisham residents’ thoughts on the proposed creation of one CCG covering all of south east London

Since the last Governing Body we have also been engaging with local residents about the proposed changes to the south east London CCGs. We hosted a discussion on 18 July and following that we attended additional meetings on request, including a Pensioners Forum event on 24 July, Save Lewisham Hospital campaigners on 13 August, and Healthwatch Lewisham’s Planning Committee on 4 September. The findings from these engagement activities informed the papers that the Governing Body are considering today. Reports from the activities will be published in the get involved section of our website.

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https://www.lewishamccg.nhs.uk/news-publications/Pages/helpshapethefuture.aspx

https://www.healthwatchlewisham.co.uk/wp-content/uploads/2019/08/Lewisham-NHS-Long-Term-Plan-Engagement-Report.pdf

https://www.healthwatchlewisham.co.uk/wp-content/uploads/2019/08/Lewisham-NHS-Long-Term-Plan-Engagement-Report.pdf


https://www.lewishamccg.nhs.uk/get-involved/Pages/default.aspx

Governing Body Meeting12th September 2019

Finance Report M3 2019-20

RESPONSIBLE LEAD: David Maloney, Director of Finance

AUTHOR: Michael Cunningham, Head of Finance

RECOMMENDATIONS: The Governing Body is asked to note the Finance Report for Month 3 2019/20, which has previously been scrutinised by the Finance & Investment Committee (FIC) on 25th July 2019.

SUMMARY:The Finance report for Month 3 2019-20 is attached in this report. The headlines are:

At the FIC meeting in July, the Committee reviewed the financial and QIPP position for month 3. A discussion took place in particular on the continuing healthcare budget position, and it was agreed this will be a focus of future discussions.

The CCG has profiled a planned ‘technical’ surplus of £632k YTD at month 3. This reflects that although the plan for the year is to breakeven, NHSE guidance requires the 0.5% (£2,526k) contingency to be profiled in month 12, and as a consequence a ‘technical’ surplus has been profiled in earlier months, in order to show a breakeven plan for the whole year. This profiling is consistent with the operating plan submission. The CCG is reporting achievement of this ‘technical’ surplus YTD at month 3, and as such is reporting an ‘on plan’ financial position.

The CCG is forecasting to meet the annual breakeven target against its control total. The data received from providers at month 3 was of variable quality, and overall not

considered robust enough to support reporting an ‘actual’ position. A decision was therefore taken to report an ‘on plan’ position across SEL relating to acute contracts. However at month 4 an ‘actual’ position has been used and month 4 reports will be on this basis. Since for 2019/20 aligned incentive contracts are in place with the CCGs three main providers, it will be crucially important during the year to retain sight of the underlying contract position, in order to manage activity and inform future years planning.

Commitments information pertaining to Continuing Healthcare is showing emerging cost pressures which are consistent with the operating plan which highlighted this as a high risk area with £1,143k of risk identified. This has been increased by £500k to £1,643k at month 3, and the Continuing Healthcare service has been targeted to identify £500k of mitigations to offset the increase in risk. At month 3 a forecast outturn over spend of £293k is being reported in relation to adults commissioning, and further analysis is being conducted in relation to children’s commissioning expenditure. Month 3 budget review meetings have taken place with the service during July in order to address this concerning financial position. Running cost budgets are showing a

Page 49

Item Number 12

forecast under spend of £687k, and this indicates that the running cost reduction target of £685k is expected to be achieved. There is a small forecast underspend of £12k relating to corporate programme costs.

Other reserves and financing shows a forecast over spend of £406k. This comprises two elements. Firstly a running cost reduction QIPP target of £685k held in reserves, for which achievement is forecasted to be delivered through an underspend of £687k against corporate running costs. The second element is an unbudgeted credit of £279k held in reserves pertaining to balance sheet flexibilities carried forward from the previous financial year.

As referenced above the 0.5% contingency is profiled into month 12 and cannot be used to offset any overspends without CFO approval. As a consequence the forecast overspend on adults commissioning is being offset by use of balance sheet flexibilities held in other reserves of £279k, a small forecast under spend on corporate programme costs of £12k, and a forecast over achievement on the running cost reduction target of £2k. The CCG is not holding any known uncommitted reserves apart from the 0.5% contingency which is held and the use of which is subject to CFO approval, and is the only reserve potentially available to mitigate financial risks.

The CCG is forecasting a net risk position of £2,022k. This is consistent with a common approach agreed for the 6 SEL CCGs, and is the same in total and composition as the risk submitted in the operating plan, with the exception of additional primary care risks, and an increase in risk relating to Continuing Healthcare of £500k offset by additional mitigations of £500k which the Continuing Healthcare service has been targeted to achieve.

The CCG is continuing to work with other SEL CCGs to collectively manage the financial risks across the SEL Alliance.

Due to the timing of committees, the month 4 financial position has not yet been reported, but has been prepared in line with the monthly reporting timetable, and there are no material changes to report.

CONSULTATION HISTORY:Finance & Investment Committee 25th July 2019.

PUBLIC ENGAGEMENT A report setting out the financial position of the CCG is a standing item for Governing Body meetings.

HEALTH INEQUALITY DUTY & PUBLIC SECTOR EQUALITY DUTIES:The CCG’s financial position supports the delivery of strategic and operational commissioning plans and objectives which include delivering the health inequality and the public sector general equality duties.RESPONSIBLE LEAD CONTACT:Name: David MaloneyE-Mail: [email protected]/S CONTACT:Name: Michael CunninghamEmail: [email protected]

Page 50

Page 51


CCG Finance Report 2019/20 Month 03 (Period to end of June 2019)

Governing Body

12th September 2019

Page 53

1. Executive Summary

At a glance position at M03

At Month 3 the CCGs are reporting in line with plan on a YTD and FOT basis. The reported position for M03 for non acute areas are based on actual spend. For Month 3 the

acute position is assumed at breakeven due to the limited data available. At M03 the CCG is currently reporting a full year net risk position of £15.9m as set out in section

10. The CCG will continue to identify mitigations and (non)recurrent measures that can be taken to mitigate this position.

At month 3, CCGs are forecasting full year QIPP delivery of 95.5% or £94.5m against a plan of £98.9m. Bexley and Greenwich CCG are continuing to work on reducing their

unidentified value and anticipate an improvement against the unidentified values at M04.

The main risk outside of QIPP delivery to the CCG’s position relates to primary care. A £2.6m cost pressure has been identified following the changes to Delegated Funding

in March 2019, this particularly impacts Lambeth CCG (£2.2m). We are currently exploring group wide mitigations that could be used to support impacted CCGs in 2019-20

and will provide an update ahead of M06.

There is a forecast full year risk to the CHC budgets of £0.5m based on the Month 3 position, the main pressure being in Greenwich, Lambeth and Lewisham. This pressure

reflects the continuation of pressure on this budget as complexity of the cohort increases. Work is ongoing at a South East London level to ensure we maximise the

potential saving opportunities available.

The CCGs’ acute position is predominantly blocked in 2019/20; however, the CCGs’ need deliver a recurrent underlying position in line or below contract in order to ensure

financial sustainability in 2020-21. For Month 3, CCGs have agreed to report in line with contract, however an updated risk assessment puts the position at £5.6m

overspent (although the CCGs hold of £1.7m reserves to be released against this position); with the underlying position showing a full year risk of £12.9m. Further work is

on-going to better understand these positions and to identify appropriate recurrent mitigations.

Page 54

2. Current Identified material Risks\Issues

•The below table sets out all of the issues that have arisen in Month, what actions or mitigations need to be taken, the Lead, the SRO, the deadline for resolving and escalation points.

Issue/Risk Summary of Issue/Risk SRO Mitigation Month

Identified Expected Date for Completion

£m’s BAF Rating

Likelihood Severity Score

Continuing Healthcare Spend

Continuing Healthcare budgets in 2019-20 were set assuming a 5% growth rate (net of QIPP) as opposed to historical growth of 8%. The financial value is made up on FoT overspend of £0.5m and £5.8m additional risk.

Managing Directors (MDs) (For each

Borough)

Review of application of eligibility criteria Working at scale to identify opportunities Increased use of AQP Review of Clinical Processes Review of Business Processes

May Quarter 2 £6.2m 3 3 9

Primary Care QIPP

The 2019-20 plan requires the delivery of £2.7m of QIPP against both central and local primary care budgets. This requires the development of a plan and approach at South East London Level though delivered locally.

Christina Windle + MDs

Plan is currently being developed to identify the range of actions that can be taken to deliver the saving.


Delegated Primary Care

Changes to the CCGs allocation within the planning round have added a further £2.6m pressure to the primary care contract position. This represents a risk to Lambeth and Southwark Budgets

SEL response and mitigation being developed. May Quarter 2 £2.6m 5 3 15

Non Recurrent Savings

Non Recurrent Savings; The South East London Planning identified the need to deliver 0.2% non recurrently in year. Whilst processes are in place to deliver this saving, the opportunity will only be identified in year.

Usman Niazi

An initial view of financial positions will be undertaken at the end of quarter 1 to assess 1819 balance sheet provisions and 1920 underspends and allocations. The QIPP ask will be reduced in-year as non-recurrent financial benefits are realised.


QIPP

The CCGs still have a £3.5m unidentified QIPP gap, this represents an improvement in the position of £5.4m reported at Month 2; further work is on-going with the a review of the positions as part of the Month 3 QIPP assurance process.

Managing Directors (For each Borough)

Each CCG to draw up an “High Risk” list for discussion and review at the Month 3 QIPP and Finance meeting.

May July £3.5m 3 3 9

Non Block Acute

Whilst the majority of the acute contracts are within a block, the increased expenditure seen in 2018/19 in BMI represents a concern to Bromley CCG, with the size of the D&G Contract being a particular risk to Bexley CCG.

MD’s with ICDT support

Each CCG to work on demand management schemes to reduce unnecessary activity within non local providers.


Acute Underlying Position

CCGs have the majority of their acute spend within a block for 2019/20. If activity was to over-perform materially then the is a risk contracts could be reopened or that an unaffordable starting point will need to be funded in 2020/21

Managing Directors (For each Borough)

Each CCG to ensure they identify and deliver the key milestones in their QIPP programme.

May Quarter 3 n/a 3 5 15

Page 55

Note: a red bracket indicates budget overspend

3

Financial Performance Duties

Duty YTD Target YTD

Performance RAG

Annual

Target

Forecast

Performance RAG

Achieve planned surplus (Expenditure not to

exceed income) £632k £632k £0k £0k

Capital resource does not exceed the

allowance £0k £0k £0k £0k

Revenue resource does not exceed the

allowance £121,993k £121,361k £506,912k £506,912k

Capital Resource use on specified matters

does not exceed the allowance N/A N/A N/A N/A

Revenue resource use on specified matters

does not exceed the allowance N/A N/A N/A N/A

Revenue administration resource use does not

exceed the allowance £1,674k £1,450k £6,696k £6,009k

Page 56

Summary of Financial Position at Month 03

• The CCG has profiled a planned ‘technical’ surplus of £632k YTD at month 3. This reflects that although the plan for the year is to breakeven, NHSE guidance requires the 0.5% (£2,526k) contingency to be profiled in month 12, and as a consequence a ‘technical’ surplus has been profiled in earlier months, in order to show a breakeven plan for the whole year. This profiling is consistent with the operating plan submission. The CCG is reporting achievement of this ‘technical’ surplus YTD at month 3, and as such is reporting an ‘on plan’ financial position.

• The CCG is forecasting to meet the annual breakeven target against its control total. • The data received from providers at month 3 was of variable quality, and overall not considered robust enough to support reporting an ‘actual’

position. A decision was therefore taken to report an ‘on plan’ position across SEL relating to acute contracts. It is however intended to report an ‘actual’ position at month 4. Since for 2019/20 aligned incentive contracts are in place with the CCGs three main providers, it will be crucially important during the year to retain sight of the underlying contract position, in order to manage activity and inform future years planning.

• Commitments information pertaining to Continuing Healthcare is showing emerging cost pressures which are consistent with the operating plan which

highlighted this as a high risk area with £1,143k of risk identified. This has been increased by £500k to £1,643k at month 3, and the Continuing Healthcare service has been targeted to identify £500k of mitigations to offset the increase in risk. At month 3 a forecast outturn over spend of £293k is being reported in relation to adults commissioning, and further analysis is being conducted in relation to children’s commissioning expenditure. Month 3 budget review meetings with the service have been arranged to occur before the end of July in order to address this concerning financial position. Running cost budgets are showing a forecast under spend of £687k, and this indicates that the running cost reduction target of £685k is expected to be achieved. There is a small forecast underspend of £12k relating to corporate programme costs..

• Other reserves and financing shows a forecast over spend of £406k. This comprises two elements. Firstly a running cost reduction QIPP target of

£685k held in reserves, for which achievement is forecasted to be delivered through an underspend of £687k against corporate running costs. The second element is an unbudgeted credit of £279k held in reserves pertaining to balance sheet flexibilities carried forward from the previous financial year.

• As referenced above the 0.5% contingency is profiled into month 12 and cannot be used to offset any overspends without CFO approval. As a

consequence the forecast overspend on adults commissioning is being offset by use of balance sheet flexibilities held in other reserves of £279k, a small forecast under spend on corporate programme costs of £12k, and a forecast over achievement on the running cost reduction target of £2k. The CCG is not holding any known uncommitted reserves apart from the 0.5% contingency which is held and the use of which is subject to CFO approval, and is the only reserve potentially available to mitigate financial risks.

• The CCG is forecasting a net risk position of £2,022k. This is consistent with a common approach agreed for the 6 SEL CCGs, and is the same in total

and composition as the risk submitted in the operating plan, with the exception of additional primary care risks, and an increase in risk relating to Continuing Healthcare of £500k offset by additional mitigations of £500k which the Continuing Healthcare service has been targeted to achieve.

• The CCG is continuing to work with other SEL CCGs to collectively manage the financial risks across the SEL Alliance.

•4

Page 57

Programme Budget

Annual

Budget

(£000s)

Variance to

Month 03

(£000s)

Forecast

Variance

(£000s)

End of Year

Risk

Assessment

Variance

(£000s)

Slides

Acute Contracts 261,948 0 0 (1,004) 7-8

Community Services 35,831 0 0 0 11-12

Joint Commissioning Adults 89,643 (81) (293) (865) 9-10

Joint Commissioning Children 3,799 0 0 (571) 9-10

Primary Care Budgets 82,233 0 0 (1,458) 13-14

Corporate Budgets - Running Cost 6,696 224 687 516 6, 17

Corporate Budgets - Programme Costs 1,829 8 12 12 18

Other, Reserves and Financing 24,932 (151) (406) 1,348 15-16

Total Expenditure 506,912 0 0 (2,022)

Planned Surplus 0 0 0

Revenue Resource Allocation 506,912 0 0 0

CCG Budget Summary 2019/20 - Month 03


5

Page 58

Running Costs

Annual

Budget

(£000s)

Variance to

Month 03

(£000s)

Forecast

Variance

(£000s)

End of Year

Risk

Assessment

Variance

(£000s)

Running costs 6,696 224 687 516

Month 02 (for comparison) 6,696 116 687 516

Notes: 1. The running costs allocation is separate from the Programme budget and should be monitored separately.

2. The CCG has a running cost reduction target of £685k, and the table above shows this target is forecast to be achieved.

3. Further breakdown is provided on slide 17.

CCG Running Costs Summary 2019/20 – Month 03


6

Page 59

Acute Financial Position 2019/20

7 Note: a red bracket indicates budget overspend

Acute Contract Annual Budget

(£000s)

Variance to

Month 03

(£000s)

Forecast

Variance

(£000s)

End of Year

Risk Assessment

Variance (£000s)

Lewisham and Greenwich NHS Trust

(excluding Community contract) 150,239 0 0 0

King's College Hospital NHS Foundation

Trust 38,010 0 0 0

Guy’s and St Thomas’ NHS Foundation

Trust (excluding Community contract) 45,514 0 0 0

Other contracts and non-contracted

activity 28,186 0 0 (1,004)

Acute Managed by CCG 0 0 0 0

Total Acute 261,948 0 0 (1,004)

Month 02 (for comparison) 262,443 0 0 (1,004)

Page 60

Notes on Acute Budgets

• The data received from providers at month 3 was of variable quality, and overall not considered robust enough to support reporting an ‘actual’ position. A decision was therefore taken to report an ‘on plan’ position across SEL relating to acute contracts. It is however intended to report an ‘actual’ position at month 4. Since for 2019/20 aligned incentive contracts are in place with the CCGs three main providers, it will be crucially important during the year to retain sight of the underlying contract position, in order to manage activity and inform future years planning.

• The current risk assessment on acute contracts is forecast at £1,004k consistent with the operating plan submission. This is shown against other contracts in recognition that contracts with the three main providers have been agreed on an aligned incentives basis, thus reducing the in year risks in respect of these contracts.

•8

Page 61

Client Group Financial Position 2019/20

•9 Note: a red bracket indicates budget overspend

Programme Budget Annual Budget

(£000s)

Variance to

Month 03

(£000s)

Forecast Variance

(£000s)

End of Year

Risk Assessment

Variance

(£000s)

Mental Health Contracts 58,393 0 0 0

Mental Heath - NCAs 3,481 0 0 0

Mental Heath - Dementia 1,461 0 0 0

IAPT 3,702 0 0 0

Learning Disabilities 1,368 0 0 0

Continuing Care - Learning Disabilities 2,855 0 0 0

Continuing Care - Mental Health 475 0 0 0

Continuing Care - YPD 5,966 (81) (293) (865)

Continuing Care - Older Adults 4,089 0 0 0

Continuing Care – Palliative Care 1,097 0 0 0

Continuing Care - FNC 2,074 0 0 0

Other Adult Client Groups 4,682 0 0 0

Children Services 3,799 0 0 (571)

Total Client Groups 93,442 (81) (293) (1,436)

Month 02 (for comparison) 93,442 (49) (293) (1,436)

Page 62

Notes on Client Groups Budgets

• The Month 3 position has been based on the latest available data in terms of invoices received and the present patient databases held by the services. The majority of budgets are in line with plan but there is a FOT over spend relating to adults joint commissioning of £293k. There are also pressures within childrens joint commissioning with regard to packages of care which are being worked through to understand the financial impact.

• The end of year risk assessment is currently a FOT overspend of £1,436k, but this assumes that the targeted mitigations of £500k relating to Continuing Healthcare are achieved. Meetings have commenced with the services to ascertain mitigations, and further meetings have been arranged to take place before the end of July to address this financial position.

•10

Page 63

Community 2019-20


(£000s)

Variance to

Month 03

(£000s)

Forecast

Variance

(£000s)

End of Year

Risk

Assessment

Variance

(£000s)

Community Contract 27,470 0 0 0

111/Out of Hours 2,014 0 0 0

Primary Care Transformation

Investment 490 0 0 0

Other Community 5,857 0 0 0

Total 35,831 0 0 0

Month 02 (for comparison) 35,357 0 0 0

•11 Note: a red bracket sign indicates budget overspend

Page 64

Notes on Community 2019-20


• The Month 3 position has been based on the latest available data in terms of activity and invoices received and other information held by the services. Overall the month 3 YTD and FOT position shows breakeven against these budgets.

Page 65

Primary Care Health Services 2019-20


(£000s)

Variance to

Month 03

(£000s)

Forecast

Variance

(£000s)

End of Year

Risk

Assessment

Variance

(£000s)

Prescribing 35,342 0 0 (500)

Other Primary Care 1,825 0 0 0

Delegated Commissioning 45,066 0 0 (958)

Total 82,233 0 0 (1,458)

Month 02 (for comparison) 82,233 0 0 (1,458)


Page 66

Notes on Primary Care Health Services 2019-20


• The primary care position is reported as breakeven YTD and FOT at month 3.

• There is considerable risk attached to this area totalling £1,458k, of which £500k relates to prescribing, other primary care pressures £374k, GMS contract settlement not being cost neutral £345k, and £239k associated with delivery of the delegated commissioning QIPP programme.

Page 67


Other Reserves and Financing 2019/20 (1 of 2)

•15


(£000s)

Variance to

Month 03

(£000s)

Forecast Variance

(£000s)

Other Reserve 0 (151) (406)

Contingency (0.5%) 2,526 0 0

Total Uncommitted Reserves 2,526 (151) (406)

Committed Reserves 22,406 0 0

Total All Reserves 24,932 (151) (406)

Month 02 (for comparison) 23,290 (68) (406)

Page 68

Other Reserves and Financing 2019/20 (2 of 2)

•16

• As referenced on slide 4 in the Summary of the Financial Position, Other Reserves and financing shows a forecast over spend of £406k. This comprises a running cost reduction QIPP target of £685k held in reserves but which is reported as forecast to be delivered through an underspend of £687k against corporate running costs, and an unbudgeted credit of £279k held in reserves pertaining to balance sheet flexibilities carried forward from the previous financial year.

• The 0.5% contingency is profiled into month 12 and cannot be used to offset any overspends without CFO approval. As a consequence the forecast overspend on adults commissioning is being offset by use of balance sheet flexibilities held in other reserves of £279k, a small forecast under spend on corporate programme costs of £12k, and a forecast over achievement on the running cost reduction target of £2k. The CCG is not holding any known uncommitted reserves apart from the 0.5% contingency which is held and the use of which is subject to CFO approval, and is the only reserve potentially available to mitigate financial risks.

• Committed Reserves of £22,406k are understood to be committed and there is no expected favourable variance against these reserves to support programme budgets. The main element of these Committed Reserves relates to the Better Care Fund (BCT) allocations, and a number of other central budget reserves which have not been devolved to programme budgets, or yet utilised to support other CCGs through the SEL risk share arrangements. This is reviewed in detail on a monthly basis.

• Work is continuing as planned to de-risk QIPP and to continue to exert tight budgetary control , in order to restore available mitigations to financial risks.

Page 69

Corporate Running Costs 2019/20 (Separate Allocation)

• The YTD & FOT position at Month 3 shows under spends of £224k and £687k. The main drivers of these under spends are unfilled staff vacancies, and a number of other uncommitted corporate budgets.

Budgets Annual Budget

(£000s)

Variance to

Month 03

(£000s)

Forecast Variance

(£000s)

Staff Costs 3,989 86 258

CSU Recharge 1,444 2 18

Other 1,264 136 411

Total 6,696 224 687

Month 02 (for comparison) 6,696 116 687


Page 70

Corporate Programme Costs 2019/20

• The YTD position at Month 03 shows an underspend of £8k which is forecast to be an underspend of £12k for the full year.

Budgets Annual Budget

(£000s)

Variance to

Month 03

(£000s)

Forecast Variance

(£000s)

Staff Costs 1,478 8 12

CSU Recharge 0 0 0

Other 351 0 0

Total 1,829 8 12

Month 02 (for comparison) 1,829 1 12


Page 71

Financial Risks & Mitigations

As outlined on slide 4, the CCG is reporting a net risk assessed overspend of £2,022k after applying contingency of £2,526k, and further mitigations of £500k required from the Continuing Healthcare service. This position is consistent with the risk reported in the operating plan submission with the exception of other primary care risks £374k, and an increase in Continuing Healthcare risk of £500k. The gross risk position before applying 0.5% contingency, and the additional Continuing Healthcare mitigation, is £5,048k and this is driven by the following key risks;

• Acute Contract Performance: Whilst the CCG has agreed aligned incentive contracts with its three main providers,

there remains risk assessed as £1,004k in relation to other acute contract activity.

• Prescribing, Other Primary care, and Delegated Commissioning: The prescribing budget has regularly met its savings requirements each year and the CCG’s plan assumes this will continue for 2019/20. However there is a general prescribing risk identified of £500k. Other delegated commissioning risks total £958k including to reflect that the reduction in allocation pertaining to the GMS contract settlement may not be cost neutral £345k, and also £239k attached to the delegated commissioning QIPP target.

• Continuing Healthcare is also identified as a key risk area with risk assessed as £1,643k (an increase of £500k since month 2).

• Other programme risks relate to achievement of the CCG QIPP target 0.3% of 2018/19 outturn split across all budget areas £505k, other programme risk £267k, and the risk of not achieving the running cost reduction target £171k.

• The risk assessed position will be reviewed each month. The CCG continues to play a full part in the work to understand and de-risk the overall SEL position.

• The CCG will continue to apply tight budgetary control in order to de-risk the overall financial position.

19

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•20

Cash Position 2019/20

The Maximum Cash Drawdown (after payments made on behalf of NHS Lewisham CCG by NHS Business Services Authority – PPA & HOT) is £506,159k. The actual and forecast drawdown of cash is shown in the table below.

• The cash KPI was again achieved in Month 3, showing continued successful management of the cash position to achieve the target cash balance.

Cash drawdownMonthly

Drawdown £000s

Cumulative

Drawdown

£000s

Proportion of

Annual Cash

Resource Limit %

KPI - 1.25% of

cash balance

as drawdown

£000s

Month end cash

Bank Balance

£000s

NHSE Cash

Target

ACTUAL

Apr-19 35,200 35,200 6.95% 440 119 Pass

May-19 41,600 76,800 15.17% 520 310 Pass

Jun-19 39,000 115,800 22.88% 488 392 Pass

Jul-19 36,500 152,300 30.09% 456

Aug-19 45,143 197,443 39.01% 564

Sep-19 43,686 241,129 47.64% 546

Oct-19 45,143 286,271 56.56% 564

Nov-19 43,686 329,958 65.19% 546

Dec-19 45,143 375,100 74.11% 564

Jan-20 45,143 420,243 83.03% 564

Feb-20 40,774 461,017 91.08% 510

Forecast

Mar-20 45,143 506,159 100.00% 564

Annual Total £506,159

Page 73

•21

Better Payments Practice Code (BPPC) 2019/20

• Under the Better Payments Practice Code (BPPC), CCGs are expected to pay 95% of all creditors within 30 days of the receipt of invoices. This is measured both in terms of the total value of invoices and the number of invoices by count. The CCG continues to show high performance against target.

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•22

Aged Debtors (Receivables) 2019/20

• The value of the non-NHS 181+ relates mainly to invoices outstanding from Lewisham Council. The value of the NHS 181+ invoices relates to a number of NHS organisations totalling £61,740.51. These outstanding balances are being progressed to secure payment, and are not considered at risk.

Page 75

•23

Revenue Resource Limit

Admin

(£000s)

Co-Comm

(£000s)

Programme

(£000s)

Total

(£000s)

Initial CCG Programme Allocation 2019/20 0 46,499 452,095 498,594

Running Costs Allowance 2019/20 6,696 0 0 6,696

2019/20 Opening Allocations 6,696 46,499 452,095 505,290

In year Allocations (Non Recurrent):

Excess Treatment Costs 0 0 (20) (20)

QTR1 LTBI allocations 0 0 33 33

IPS Wave 2 Transformation funding (Q1 & Q2) 0 0 109 109

DWP Employment Advisors in IAPT 0 0 125 125

GPFV International Recruitment - Programme Funding 0 0 28 28

MT funding 19/20. Tranche 1 &2 South East London LMS 0 0 1,261 1,261

Liaison and Diversion /CYP Co-commissioning Network allocation 0 0 86 86

Total Confirmed In Year Allocation 6,696 46,499 453,717 506,912

Brought forward surplus from 2018/19 0 0 10,691 10,691

Total Confirmed Cumulative Allocation 6,696 46,499 464,408 517,603

Page 76

Recommendations

1. To note the financial position against budgets for the ‘Programme Budgets’ and the ‘Running Costs’ as at end of June 2019.

2. To note in particular the forecast over spend in relation to continuing care services of £293k and the need to utilise balance sheet flexibilities in order to forecast an overall on plan position for the year.

3. To note specifically the net risk assessed forecast over spend for the CCG’s overall financial position of £2,022k, and that this is after applying utilisation of the 0.5% contingency, and a further £500k of mitigations to be identified by the CHC service. The CCG does not hold any other uncommitted reserves to mitigate this remaining risk.

4. To note the drivers to the risk assessment mentioned above.

5. To note the reported position reflects a need to continue to apply robust budgetary control and fully deliver QIPP.

6. To note the collaborative approach being implemented across SEL CCGs to applying budgetary control and de-risking the financial position.

David Maloney

Director of Finance

NHS Lewisham CCG

12 September 2019

•24

Page 77


Governing Body meeting on 12th September 2019

Report from the Chair of the Integrated Governance Committee (IGC)Date of Meeting Reported: 25th July 2019

Author: Martin Wilkinson, Chair

1. Quality

The Integrated Governance Committee in July was asked to note quality reports that provided assurance in services including:

Children and Young People’s Community Health Services Adult Community Services – (Lewisham & Greenwich NHS Trust) London Borough of Lewisham commissioned local services including nursing

and care homes and other adult social care services

The Committee also received a report of the Learning Disabilities Mortality Review Programme (LeDeR) Lewisham 2017 – 2019 which provided assurance that the CCG was making progress in this area of work. An unexpected finding of the programme in Lewisham so far was that people with Learning Disabilities are not always well supported by smoking cessation or alcohol addiction services.

Quality exceptions discussed by the IGC included: One Care Home is causing concern as there has been a sustained

deterioration in a number of quality markers. The Home is receiving support from the CCG and the Council to make improvements.

Waiting times for Acute Foot Health Services have increased to concerning levels and commissioners are working to improve accessibility.

There has been an increase in workforce vacancies in the community diabetes service that is causing concern. Recruitment plans are in place.

A small number of Looked After Children’s health reviews were not carried out within the appropriate timescale.

2. CCG Improvement and Assurance Framework

The Committee was pleased to note that the CCG had moved to be rated as Good in 18-19 compared to Requires Improvement in 17-18. Both Leadership and Financial Performance moved to Green in 18-19 (both Amber in 17-18)

The Committee was keen that the challenges for indicators in the Framework were still being focused on during 19-20.

Page 79

Item Number 13

3. NHS Constitutional Standards and Plan Requirements for Non Acute Areas

The key exceptions are

Children and Young People Mental Health TransformationChildren and Young People’s Mental Health Transformation standard has been provided by NHS Digital Data based on the Mental Health Minimum Data Set and a one off collection for providers (largely focused on early intervention, including online), which have not reported to Lewisham CCG. For 18-19 MHSDS only reporting resulted in 21.8% of likely prevalence and with the special data collection this was 25.,7% Both of these are a long way short of the 32% standard (rises to 34%. South East London delivered 31.3% for 18-19.

Personal Health Budgets, although increasing, have not met the plan set. This has been identified as an Issue for 19-20 for the CCG. Q1 and Q2 plans for 19-20 have been set close to the Q4 outturn. A post across South East London CCGs has been recruited to identify further cohorts of patients to increase Personal Health Budgets to the Quarter 4 requirement of three times the current level. Q1 19-20 just submitted is still under the Q1 plan. The CCG is looking to increase Children’s and Mental Health cohorts.

Continuing HealthcareIn Quarter 1 19-20 the proportion of Assessments in Acute Settings increased to 33% which above the less than 15% requirement. Furthermore, the timeliness of assessments (percentage of assessments in 28 days). The acute settings relates to the closure of Sapphire ward. The timeliness issue relates to vacancies in the team. The vacancies will be covered by September/October 19 along with prioritised working, so recovery should be in Q3 19-20.

Children and Young People Eating Disorders ServicesThe CCG is not meeting the Urgent 1 week standard as it had a breach in Q3 which will take 6 more months to drop out of the figures as they are all rolling year. Over that year the CCG had only 3 people referred to the service urgently. Routine performance at 4 weeks is being achieved.

Indicators with more positive assurance are:

Improving Access to Psychological Therapies Indicators are all being met with official data confirming that the quarterly access rate will meet the 4.75% access rate required in Quarter 4 18-19. There has been a slight fall to 4.7% in the quarter to April 19, but local data confirms that this will on track for the Quarter to May 19.

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Similarly, the level of dementia diagnosis for over 65s has met the required rate in every month of 18-19 and in Q1 19-20.

For Mental Health, Out of Area Placements for Lewisham people have already halved from the December baseline to 410 for the quarter finishing in April 19. South East London is below its Q1 19-20 plan.

The CCG dashboard has been supplemented with the 19-20 Primary Care Requirements

The CCG is meeting both the number of practices signed up to the online appointment system and the plan for percentage of extended access appointments booked by patients. This stands at 75 in May 19, which delivers the 75% standard against the standard.

There is more work to get all 6 tests to be completed for those people on Serious Mental Illness Registers. The CCG is at 35% for 18-19 against a plan for 19-20 of 60% (50% from primary care and 10% from acute care).

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Governing Body meeting on Thursday 12th September 2019Summary report from the latest meeting of the SEL Integrated Governance &

Performance Committee

Report from: Ray Warburton, Independent chair of SEL IG&PMeeting date: 30th August 2019Author: Kieran Swann, SEL Assurance Team

1. Principal role of the committee

SEL CCGs agreed that a pan-SEL Committee should be established to monitor the delivery of provider organisations’ statutory and delivery responsibilities to ensure agreed actions / mitigations are followed through; to discuss and agree appropriate remediation; and to pro-actively identify and address declining performance indicators, ensuring deterioration is managed rapidly. The current scope of the SEL Committee includes oversight of and coordination of the SEL CCGs’ response to:

The delivery of the SEL CCG control total and as such the individual annual CCG control totals and both individual and collective mitigations where this is off plan.

The sustainable delivery of all acute NHS Constitution standards and Transforming Care performance.

Matters of clinical quality and safety related to the areas of business within the SEL Committee’s scope.

The committee will additionally act to identify and pro-actively manage key strategic and operational risks relating to the areas deemed as in-scope. The committee approves the SEL BAF for all areas within its scope.

2. Recommendations to the Governing Body for decision / approval / action

The Governing Body should formally note the recommendation made by the committee and undertake the proposed action(s):

2.1South East London BAF; Assurance and Finance Reports

CCGs should use this month’s SEL BAF; performance assurance and finance reports for September Governing Body meetings. These were shared with CCG governance leads on 23 August 2019. July versions of these reports are appended to this report and should be circulated to CCG GBs for reference.

CCGs should ensure there was no duplication of acute or SEL-wide financial risks on local CCG BAFs.

3. Action taken under delegation: Governing Body to note for assurance

The Governing Body should note the below items, where a prime committee undertook an action under the authority delegated to it by the CCG Governing Body:

Page 83

Item Number 14

3.1Deep dive: acute activity and finance

Julie Lowe, Programme Director OHSEL and Angela Bhan, MD Bromley CCG presented a paper that focused on the STP’s approach to current workforce issues and the workforce priorities in the NHS Long Term Plan.

The committee heard that the STP programme which focuses primarily on exploring and implementing initiatives that benefit from a whole systems approach. A key role of the programme is to link and bring together providers and key stakeholders to explore opportunities for improvement and development.

Performance position across south east London on the 62-day cancer waiting time standard. This standard is the highest-risk area of cancer performance in the STP at present and has been at a level below the national standard for a considerable time.

The committee was presented with a summary of the detailed targets that are used to assess the performance along the 62-day pathway target. These include 38-day inter-trust transfers (ITT) and 28-day diagnostic standards.

The committee received a briefing on the key challenges to the sustained delivery of the 62-day standard which they discussed in some detail. These include high staff turnover; staff vacancies in data teams; demand pressures, periodic capacity gaps; resistance to pathway changes and a high proportion of ITTs. The committee discussed the governance of the improvement programme in cancer; looked at action plans by site and tumour group; and discussed specific provider risks related to these.

The committee noted the report and registered its assurance that cancer performance was being comprehensively managed.

3.2SEL CCG Performance Assurance Report

The committee received the monthly report and focused assurance discussions on the current position on RTT (18 and 52 weeks); cancer pathways and waiting times: A&E, diagnostic waiting times and transforming care performance.

The committee noted that RTT performance at GSTT had deteriorated and was marginally behind trajectory on 18 weeks; ahead of plan on PLT reduction; and operating with significant risks of achieving 52-week standards – particularly at KCH and GSTT. Diagnostic performance at LGT was noted to have improved since the previous update, though there remain significant issues at KCH, which are being worked through by a dedicated SEL group. A&E performance was reported as falling behind trajectory at SEL trusts.

Page 84

It was agreed that CCG managing directors should ensure that actions proposed for CCGs in the report were implemented over the course of the month with MDs providing a verbal update on progress to the next committee meeting

The committee noted the current performance position and further noted the key issues associated with this. The committee registered its assurance that an adequate set of remedial actions had been identified and agreed with providers.

The committee noted the significant risks relating to the capacity for trusts and the wider system to deliver all actions and that agreed actions would, if delivered, make the necessary impact to achieve agreed trajectories.

3.3SEL CCGs Finance Update – M3 19/20

The committee noted that SEL CCGs are currently forecasting delivery of plans across the board.

Risks relating to continuing healthcare expenditure, Bexley MSK; non-local contracts, and primary care were noted. A forecast of £35m SEL risk was noted as not reported in the position but the committee was assured this was a manageable level of risk.

The committee noted the current financial position and registered its assurance that an adequate approach to remediation is in place to mitigate identified risks. It was agreed that planned mitigations may reasonably be expected to deliver the necessary improvement to deliver year-end financial targets.

3.4South East London IG&P Board Assurance Framework – July 2019

The committee endorsed the BAF for August 2019 and accepted the proposed risk scores for each risk included

Annexes

Annex 1 South East London Board Assurance Framework – August 2019

Annex 2 South East London Performance Assurance Report – August 2019

Annex 3 South East London Finance Report – August 2019

Final approved minutes of the SEL IG&P Committee July 2019 are contained in the items for information.

Page 85


South East London CCGs Integrated Governance & Performance Committee Board Assurance Framework 30 August 2019

Page 87

Introduction and recommendations to the committee

2

• This SEL Integrated Governance & Performance Committee Board Assurance Framework is designed to support the SEL IG&P

committee to provide oversight of the strategic risks that relate to all areas deemed to be within the committee’s scope as defined in

the terms of reference endorsed by CCG governing bodies in November 2018 and revised in May 2019.

• The over-arching purpose of the BAF is to enable the SEL IG&P committee, CCG governing bodies and any delegated local

committees to be kept suitably informed of significant risks or issues and their associated mitigation plans.

• The SEL IG&P should use this document to ensure that all risks and issues related to in-scope areas are included in the BAF; that the

risk-score is accurate for each; that mitigation actions are robust and achievable; that gaps are clearly identified and that assurances

are noted for the purpose of verification.

• In undertaking these activities, the committee should follow the South East London CCGs Integrated Governance & Performance

Committee Risk Management Framework, which sets out in detail the agreed approach to the management of risk.

• This BAF will be made available to CCGs on a monthly basis and it is proposed that this document is made available together with

the CCG BAF as part of CCG Governing Body papers.

The SEL IG&P Committee is asked to undertake the following:

1. Agree that each risk / issue is accurately described.

2. Review and agree the risk / issue score for each risk included in the BAF.

3. Review the mitigations in place and confirm that these represent a comprehensive approach to taking action to reduce both the

likelihood and potential impact of each risk. Note any gaps in risk mitigations.

4. Note any additional oversight arrangements to be set-up to provide additional levels of assurance for particular risks / issues.

Page 88

Summary of SEL IG&P Committee BAF risks

3

Risk / issue

reference Risk / issue description

Current

rating

SEL-01 STP for the 62 day referral-to-treatment cancer standard 12

SEL-02 STP trusts are not able to achieve their trajectories for timely access to emergency services as measured by the 4 hour A&E target 12

SEL-03 STP acute trusts do not meet their monthly improvement trajectories to clear long waiters by the end of Q3 12

SEL-04 STP acute trusts are not able to achieve their trajectories for the number of patients on elective waiting lists 12

SEL-05 STP acute trusts are not able to achieve their improvement trajectories for the access to planned care as measured by the 18 week standard 9

SEL-06 STP acute trusts do not achieve the monthly improvement trajectories for the access to timely diagnostics as measured by the standard for diagnostic access 16

SEL-07 Financial risk around LAS contract for 2019/20 16

SEL-08 The TCP will not achieve the BRS target by March 2020. 9

SEL-10 Ability to reduce running costs to target by 31 March 2020. 8

SEL-11 Activity related expenditure is greater than budget leading to inability to deliver the SEL and CCG control totals and financial duties. 15

The below table presents a summary of the risks related to all SEL IG&P in-scope areas. The current risk rating the is headline risk-rating post mitigations being applied.

Full details of the status of each risk are provided on the following pages.

Note: risk SEL-09 was closed at the SEL IG&P Committee in May 2019

Page 89

Risk 1: Cancer 62-day pathways

4

Ref Description and

key drivers Likelihood Impact

Initial

Risk

Score

On-going controls (pan-SEL) and frequency Residual

Score Assurances

SEL-

01

The risk that the STP

acute trusts do not

achieve the monthly

improvement trajectory for

the access to cancer

treatment as measured by

the standard for 62 days

from GP referral to

treatment.

4

4

16

• Trusts have developed actions plans to deliver their 62

day trajectory including a SEL Recovery Plan specifically

focusing on shared pathway actions and performance.

• Monthly performance meetings with acute trusts – focus

on internal trust performance and actions relating to them.

This covers areas not picked up by the 62 day Leadership

Group (see below)

• Monthly System Leadership Group – 62 day leadership

meeting with a focus on the shared pathway actions and

performance

• The SCCD (Shared Care Cancer Delivery Team) the

operational arm of the ACN – virtual team including

commissioners to progress actions on a day to day basis.

Monthly ACN Steering group.

• Monthly Members Board – a trust CEO, COO board which

will facilitate trust level escalation where plans are not

being progressed.

• Performance has been under trajectory year to date with

the majority of breaches in Prostate cancer pathways.

Because of this the system is changing the 62 day

leadership group format to have a continued deep dive on

Prostate as well as Lung cancer pathways to help mitigate

the risk.

3 x 4

= 12

• The SEL recovery plan with SMART actions and senior

level action owners, KPIs to measure delivery of the

actions, and a risk and issues log, all of which will be

updated monthly.

• Trust performance reports for performance meetings;

monthly performance against trajectory by trust and

CCG; minutes of performance meetings.

• Trust performance report to 62 day leadership group

showing progress updates for actions by trust and

tumour type; minutes and action log from 62 day

leadership meeting.

• SEL sector dashboards showing information such as

median wait to first outpatient, diagnostic turnaround

time.

• Project summary highlight reports with RAG ratings.

• Papers and minutes of the monthly Members Board

.

• Deep dive template for urology, lung and gynaecology

which monitors performance against the timed

pathways.

Further comments

and additional

planned mitigations to

be enacted:

• Employment of additional staff to create a specialist cancer management sector workforce, including senior operational management, junior operational management and patient

navigator roles for relevant trusts sites. The aim of this recruitment is to deliver sector commitments in relation to improving performance and delivering timed pathways, and also

provide support and buddying/mentoring for trust staff in more general roles involving cancer. £1.2million of transformation funding has been assigned to this new team.

• 360 degree review of ACN Members Board to assure that the governance is fit for purpose.

Forward-view on this risk / issue:

Note: risk relates to period April 2019 to March 2020 unless otherwise stated

Baseline risk scores: April 2019 Initial risk score 3 x 4 = 12; Residual risk score 3 x 4 = 12 Current risk scores: August 2019 Initial risk score 4 x 4 = 16; Residual risk score 3 x 4 = 12

Change in risk scores The initial risk score increased in July because performance was below trajectory for all three providers

Page 90

Risk 2: A&E 4-hour target

5

Ref Description and


Initial

Risk

Score


Score Assurances

SEL-

02

The risk that the STP acute

trusts are not able to

achieve their trajectories

for timely access to

emergency services as

measured by the 4 hour

target.

In 2019/20, trust

trajectories are to deliver

improvements in the

timeliness of access rather

than achieve the national

standard of 95%, which is

reflective of the challenges

faced by all acute

providers in SEL.

4

4

16

• Trusts have developed action plans to deliver their trajectory for

improving performance against the 4 hour standard. These plans

are linked to the SEL strategy for improvement in non-elective

services and have been updated to reflect plans to reduce

ambulance handover delays.

• Monthly performance meeting with acute trusts reviews progress

against the trust specific trajectories.

• ICDT team members attend internal trust meetings relating to A&E

performance delivery.

• Monthly A&E delivery boards at both local and SEL-level provide

oversight on system delivery for non-elective services.

• UEC System meeting with each site and respective CCG,

community and primary care colleagues to assess current

performance against plan and establish if any further system-wide

support or external support is required to ensure delivery of the

trajectory.

• A key theme arising from the UEC system meetings, was the ability

to affect cultural and therefore operational changes in limited

timescales

4 x 3

= 12

• The individual trusts recovery plans with

SMART actions and senior level action

owners; KPIs to measure delivery of the

actions; risk and issues log – all of which

will be updated monthly.

• Trust performance reports for

performance meetings; monthly

performance against trajectory by trust;

monthly reports against KPIs and risk and

issues; minutes of performance meetings.

• Trust reports to their internal A&E delivery

meetings.

• Monthly reports, papers and minutes of

A&E delivery boards.

Further comments

and additional


be enacted:

• Discussions are planned at the ABC Board and SEL UEC Board about actions that can be taken to address cultural change.

• LGT are now part of the national escalation programme and are developing short term immediate recovery actions as part of this process. (KCH are already part of the national

escalation process).



Change in risk scores The initial risk score increased in July because performance was below trajectory for all three providers

Page 91

Risk 3: 52-week waiters

6

Ref Risk description and


Initial

Risk

Score

On-going risk controls (pan-SEL) and frequency

Residual

Risk

Score

Assurances

SEL-

03

The risk that the STP acute trusts

do not meet their monthly

improvement trajectories to clear

long waiters by the end of Q3.

Long waiters are defined as any

patient referred by a GP who has

been waiting more than 52 weeks

and is still waiting at month end.

The count of long waiters is a

monthly census.

4

4

16

• Trusts have developed actions plans to deliver their

reduction trajectory for long waiters.

• Monthly performance meeting with acute trusts will review

progress against the trust specific trajectories.

• ICDT team members attend additional internal RTT

meetings at GSTT and KCH.

• A Star Chamber process has been implemented at GSTT

for the GMS directorate which has an emerging and

increasing number of long waiters over the last few months.

Feedback on this process is shared through the monthly

performance meeting.

3 x 4

= 12

• GSTT and KCH recovery plans with SMART

actions and senior level action owners; KPIs

to measure delivery of the actions; and a risk

and issues log, all of which will be updated

monthly.

• Trust performance reports for performance

meetings; monthly performance against

trajectory by trust; monthly reports against

KPIs and risk and issues; minutes of

performance meetings.

• Detailed monthly report on current and

prospective long waiters at KCH.

• Clinical Harm Reviews are undertaken for

long waiting patients and updates are given

at the relevant CQRG meetings.

• Daily reporting on long waiters has been

introduced at GSTT, and is already in place

for KCH, to be able to provide a real time

assessment of performance,

Further comments and

additional planned

mitigations to be enacted:

• In light of unsuccessful outsourcing attempts, KCH are reviewing options to expand the offer of choice to patients waiting more than 26 weeks for orthopaedic cases



Change in risk scores The initial risk score increased in July because performance at two providers was below trajectory

Page 92

Risk 4: RTT waiting list (PTL) size

7



Initial

Risk

Score

On-going risk controls (pan-SEL) and frequency

Residual

Risk

Score

Assurances

SEL-

04


are not able to achieve their

trajectories for the number of

patients on the waiting list

(patient tracking list or ‘PTL’

size).

3

4

12

• Trusts have developed actions plans to deliver their trajectory

for managing their RTT performance and RTT 18 week

performance.



3 x 4

= 12

• The individual trusts recovery plans with

SMART actions and senior level action

owners, KPIs to measure delivery of the

actions, and a risk and issues log, all of

which will be updated monthly. However,

the ICDT have requested LGT and KCH to

further develop their performance

improvement plans, to ensure that key

challenges are fully addressed.

• Trust performance reports for performance

meetings; monthly performance against

trajectory by trust; monthly reports against

KPIs and risks and issues; minutes of


• Further refinement for the KCH and LGT

performance improvement plans


additional planned


No further comments or planned mitigations



Change in risk scores No change since April 2019

Page 93

Risk 5: Achievement of 18-week RTT standard

8

Ref Description and


Initial

Score On-going controls (pan-SEL) and frequency

Residual

Score Assurances

SEL-

05


are not able to achieve their

improvement trajectories for the

access to planned care as

measured by the 18 week

standard for patients being

referred by a GP for treatment.

3

3

9

• Trusts have developed actions plans to deliver their trajectory

for managing their RTT performance.



• ICDT team members attend additional internal RTT meetings

at GSTT and KCH.

3 x 3

= 9

• The individual trusts recovery plans

with SMART actions and senior level

action owners, KPIs to measure

delivery of the actions, and a risk

and issues log, all of which will be

updated monthly.



performance against trajectory by

trust; monthly reports against KPIs

and risk and issues; minutes of


• Further refinement for the KCH and

LGT performance improvement

plans


additional planned






Page 94

Risk 6: Access to diagnostics

9

Ref Description and


Initial

Score On-going controls (pan-SEL) and frequency

Residual

Score Assurances

SEL-

06


do not achieve the monthly

improvement trajectories for the

access to timely diagnostics as

measured by the standard for

diagnostic access.

The diagnostic standard

assesses a basket of diagnostic

tests against the requirement

that collectively no more than 1%

of patients should be waiting

more than 6 weeks at the end of

each month.

4

4

16

• Trusts have developed actions plans to deliver their diagnostic

trajectory.



• Additional meetings are being held with PRUH site lead to

oversee the delivery of the PRUH trajectory.

• A Star Chamber process has been implemented at GSTT for

the GMS directorate which has an emerging and increasing

number of long waiters in endoscopy over the last few

months. Feedback on this process is shared through the

monthly performance meeting.

4 x 4

= 16

• The individual trusts recovery plans

with SMART actions and senior

level action owners, KPIs to

measure delivery of the actions, and

a risk and issues log, all of which

will be updated monthly.



performance against trajectory by

trust; monthly reports against KPIs

and risk and issues; minutes of


• ICDT now takes part in the weekly

endoscopy oversight meetings at

KCH and are meeting with KCH to

review demand and capacity model.


additional planned


• GSTT have identified additional clinical and physical capacity for endoscopy, however there remains a capacity gap. The trust are reviewing options for outsourcing to

bridge this gap.

• KCH are undergoing a thorough retrospective and prospective clinical harm review process for patients awaiting endoscopy, or those have received a cancer diagnosis in

the last 12 months. To note that KCH delivered and continue to deliver the 2ww target for endoscopy referrals, and their non compliant diagnostic position is driven by non-

2ww referrals.




Page 95

Risk 7: Financial risk around LAS contract for 19/20

10

Ref Description and


Initial

Risk

Score


Score Assurances

SEL-

07

The contract for 2019/20 was agreed in principle

between the NWL LAS commissioning team and

LAS in June 2019.

However, the contract is still not signed due to

disagreement around the level of Hear & Treat

activity that LAS will undertake during 2019/20

which will lower the activity baseline for London.

There is a risk that LAS will not agree to make

significant reductions resulting in more

ambulance conveyances for 2019/20.

Preliminary Q1 activity figures released by

LAS shows SEL activity is 4.2% above

planned levels resulting in significant cost

pressures for SEL. Pan London the LAS is

reporting 4.1% over performance.

Indicatively, this would equate to a cost

pressure of £320k at Q1. To note this

assessment may change following the outcome

of the baseline discussions set out above.

4

4

16

• Interim arrangements are being negotiated

between the NWL LAS commissioning team

and LAS around the Hear & Treat activity

figures; as well as the referral pathways that

need to be set up by each STP. SEL

commissioners are involved in the discussions

to help devise a reasonable plan.

• Ongoing communication from the NWL LAS

commission team to all STPs to inform

ongoing discussions.

4 x 4

= 16

SEL Exec has been kept appraised of the current

status of the contract by the SEL ICDT.

Updates have also been provided via the SEL

Finance Planning and Delivery Committee; as

well as the SEL LAS Demand Management

Group.

Updates also provided to CFOs and Heads of

Finance via the monthly financial reporting

process and associated meetings.

Further comments

and additional


be enacted:

* To be specified following the signature of the contract.



Change in risk scores Both the initial and residual risk scores have increased in August 2019 because Q1 activity figures have confirmed an increase in activity in 2019/20 and a subsequent

estimated cost pressure of £320k.

Page 96

11



Initial Risk

Score On-going risk controls (pan-SEL) and frequency

Residual

Risk

Score

Risk

Assurances

SEL-

08

The TCP will not achieve the

Building the Right Support (BRS)

target by March 2020.

4

4

16

Weekly Programme meeting with SROs (Neil Kennett-Brown and

Fiona Connolly) for risk and issues escalations.

TCP PMO fortnightly risk and issue review.

Monthly inpatient surgery to review case management and ensuring

that patients can return to the community as soon as clinically

appropriate

Monthly TCP Operational and Strategy board meetings with health

and social care stakeholders.

CCG governing bodies, SEL Executives and DASS to be updated

regularly throughout 2019-20.

3x3

= 9

Monthly assurance meetings

with NHS England.

Monthly reporting to SEL IG&P

Risk 8: SEL Transforming Care BRS target 2019/20


additional planned


• Established additional programme management and case management resource with a focus on actions to improve discharge processes, admissions management and

building capacity in the community to reduce of length of stay.

• Building capacity in the community by the establishment of Autism Support Services across South East London and new intensive community support for Lewisham,

Bexley, Bromley and Greenwich and expansion of Lambeth Without Walls services to ensure that more people are cared for in the community.

• Mobilising additional positive behavioural support training offered to family carers of people with learning disabilities and autism who exhibit behaviours that challenge to

prevent admissions.

• Established enhanced data analysis to inform decision making, with regard to patient care and required targeted support to understand the current service provision locally

for the transforming care cohort.

• Development of accommodation models for the cohort in collaboration with DASS, to support complex cases.



Change in risk scores In August the team reviewed and revised the current likelihood and impact of this risk

Page 97

12



Initial Risk


Residual

Risk

Score

Risk

Assurances

SEL-

10

Risk that CCGs will not achieve

the running costs reduction

target by 31 March 2020.

Actions include the review of

CCG functions, structures,

governance and future model.

3

4

12

• Budgets have been set net of the required running cost reduction

and all CCGs are in the process of finalising plans to deliver this

saving in 2019-20.

• CCG financial governance in place and overseen by governing

bodies and delegated committees (where relevant), SELCA

Executive and SEL IG&P.

• Recruitment controls are in place across SEL CCGs panel made

up of AO, CFO and Director of System Reform

2 x 4

= 8


CCG governing bodies to be

updated by CFO / SELCA

finance team / DoFs in April

and regularly throughout 2019-

20.

Risk 10: Delivery of CCG running cost reduction

Further CCG-specific actions

• All CCGs at M04 are reporting spend in line with agreed cost envelopes and all are forecasting year end spend within the agreed budgets which are net of the running cost savings targets.

Further CCG-specific risk controls in place:


additional planned





Change in risk scores The likelihood in the initial risk score was revised up in May 2019

Page 98

13



Initial Risk


Residual

Risk

Score

Risk

Assurances

SEL-

11

Risk that expenditure in 19/20 is

greater than plan/budget leading

to:

1. inability to deliver the SEL

CCG collective and/or

individual CCG control totals

in 2019/20.

2. inability to deliver Individual

CCG CTs and financial

duties

3

5

15

• CCG financial governance in place and overseen by governing

bodies and committees, SELCA Executive and SEL IG&P.

• SEL risk-share arrangement currently being reviewed and

refreshed for 2019-20 and taken through required CCG

governance in early Autumn.

• CFO/AO led CCG specific and SEL-wide monthly finance & QIPP

assurance meetings in place for improved scrutiny assurance.

• Please see Finance Report for more detailed information on

risks.

3 x 5

= 15

Monthly financial review

meetings with NHS England


CCG governing bodies updated

by CFO / SELCA finance team /

DoFs in April and regularly

throughout 2019-20.

Block contract agreed for SEL

providers

0.5% general contingency in

CCG plans

Risk 11: Delivery of SEL and individual CCG control totals in 2019/20

Further CCG-led actions

Bexley: The CCG continues to be the highest risk CCG within SEL due to the £1.8m of unidentified savings. This is an improvement of £0.5m compared to M03 and following assurance meetings during

August the CCG is developing plans to reduce the level of Unidentified savings and will provide an update through the M05 Finance reporting.

Further CCG-specific risk controls in place:


additional planned


• At this point in the year we are still forecasting to achieve the control total positions across SEL CCGs. However the finance report sets out in more detail a gross financial

risk of £25.3m to the control total across SEL, the CCGs are working together to fully validate the level of gross risk and the options for mitigation and will provide an

update on the FOT risk as part of M06 reporting.




Page 99


SEL CCGs Finance Report

Month 4 2019/20

V4.07112018

Page 101

Contents


2. Identified material Risks/ Issues

3. Financial Position

4. QIPP Position

5. Management Costs

6. Acute Start Year Risk Assessment

7. Budget Overview

8. Underlying Position (From M04 Onwards)

9. Risks

10.Debtors

11.Revenue Resource Limit (In Year)

Page 102


At a glance position at M04

At Month 4 the CCGs are reporting a year to date (YTD) overspend of £1.1m across five CCGs with Bexley reporting on plan. The full year forecast outturn (FOT) for all CCGs remains

unchanged and assumes delivery of the full year control totals. As a result of the YTD overspend and other in year cost pressures described in this report the FOT position assumes the use

of £6.3m of contingency funding which represents 44% of the total contingency. At M04 the CCG is reporting a full year gross risk position of £25.4m as set out in section 9 of this report

and a net risk position of £17m after using the balance of the contingency. The CCGs continue to identify actions that can be taken to mitigate this position.

At month 4, CCGs are forecasting full year QIPP delivery of 96.3% or £95.3m against a plan of £98.9m. During M04 Greenwich CCG have closed their unidentified QIPP gap to zero by

identifying £0.6m of schemes. Bexley CCG have reduced their unidentified value by £0.5m during M04 and continue to look for additional opportunities to close the balance.

The YTD position has a number of cost pressures which are set out in section 3 and 7. However the primary driver of the YTD overspend of £1.1m is due to the impact of unplanned cost

pressures on the primary care budgets (except Bexley CCG). Five CCGs have accounted for a £3.5m in year allocation reduction related to primary care services, a third of this charge is

reflected in the YTD position. The YTD overspend will continue into M05 but work is underway to identify mitigations that could be used to support CCG positions in 2019-20 which will be

reflected in the M06 Reports.

Acute - For Month 4, CCGs have used Month 2 SLAM data to report acute positions on its non South East London Contracts. This indicates a forecast overspend of £3.7m with particular

pressures within Southwark (Moorfields) and Bromley (BMI and Dartford). Further work is on-going to validate the recurrent impact of these positions.

Prescribing - CCGs have received 2 months of Prescribing data, this indicates that prescribing costs and activity have increased above expectation in year and the CCGs are presently

forecasting a £1.5m overspend. This represents the non delivery of the 1% outturn reduction assumed in the South East London Financial Planning. The information is still very limited and

the Medicine Management teams across SEL are working together to understand its impact. There is a further risk of c£0.5m per CCG relating to the Cat M issue across England, this

position is expected to be confirmed in Quarter 3 of this year.

Page 103

2. Summary of Key Risks

The below table sets out all of the issues that have arisen in Month, what actions or mitigations need to be taken, the Lead, the SRO, the deadline for resolving and escalation points.

Issue/Risk Summary of Issue/Risk SRO Mitigation Month

Identified Expected Date for Completion

£m’s BAF Rating

Likelihood Severity Score

Continuing Healthcare Spend

Continuing Healthcare budgets in 2019-20 were set assuming a 5% growth rate (net of QIPP) as opposed to historical growth of 8%. The financial value is made up on FoT overspend of £1.5m and £5.3m additional risk.

Managing Directors (MDs) (For each

Borough)

Review of application of eligibility criteria Working at scale to identify opportunities Increased use of AQP Review of Clinical Processes Review of Business Processes


Primary Care QIPP

The 2019-20 plan requires the delivery of £2.7m of QIPP against both central and local primary care budgets. This requires the development of a plan and approach at South East London Level though delivered locally.

CW + MDs Plan is currently being developed to identify the range of actions that can be taken to deliver the saving.


QIPP

Bexley CCG still has a £1.8m unidentified QIPP gap, this represents an improvement in the position of £5.4m reported at Month across 4 CCGs. Further work is on-going with the a review of the Bexley position as part of the Month 5 QIPP assurance process.

MD + DoF (Bexley)

CCG continuing to review all areas for additional mitigations to reduce this value and SEL wide team reviewing potential SEL wide options .

May September £1.8m 3 3 9

Non Block Acute Whilst the majority of the acute contracts are within a block, the available M02 data indicates a £3.7m risk on non block contracts particularly in Southwark & Bromley.

MD’s with ICDT support

Each CCG to work on demand management schemes to reduce unnecessary activity within non local providers.


Acute Underlying Position

CCGs have the majority of their acute spend within a block for 2019/20. If activity was to over-perform materially then the is a risk contracts could be reopened or that an unaffordable starting point will need to be funded in 2020/21

SC + MDs Each CCG to ensure they identify and deliver the key milestones in their QIPP programme.

May Quarter 3 n/a 3 4 12

Prescribing Position

CCGs have been notified of potential changes to the Cat M drugs costs which may amount to a £3m pressure across the 6 CCGs. This is in addition to a £1.5m activity/ price risk seen on present drug usage.

MDs SEL CCGs are working collaboratively across the patch to identify the cost drivers and to deliver mitigations where appropriate

July Quarter 3 £4.5m 3 3 15

Page 104

3. Overall Financial Position

Overview:

• South East London CCGs are required to deliver a £3.2m deficit control total in year. This is a £0.75m improvement on Month 3 following the receipt of £0.75m Commissioner Support Funding in Bexley.

• At Month 4, all CCGs except Bexley are showing a deficit YTD due to the impact of primary care pressures (£1.1m). This is an adjustment to the CCGs allocations reflecting the NHSE identified impact of changes in patient flows the FY impact of this is £3.5m. The forecast outturn position assumes that this pressure will be mitigated by year end through the use of contingencies and other actions.

• The YTD position also has cost pressures within non local Acute Budgets, prescribing and CHC services. These cost pressures have been offset by underspends across a range of budget areas within the CCGs (see section 7).

• The CCGs have validated the Month 2 acute data for its non local contracts and based on this a forecast overspend of £3.7m is predicted. This is reflective of the acute blocks delivered on the main acute providers for 2019/20.

• The main non acute pressures sit within Primary Care as a result of NHSE changes in allocations, in particular within Lambeth and Southwark.

• The other pressures sit within the prescribing, where initial month 2 data indicates a potential emerging risk within some CCGs; and within the Continuing Healthcare Position.

SEL CCGs M04 Financial Position Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Year to Date Expenditure Position

YTD Total Budget 124,796 173,593 147,883 190,480 165,485 163,831 966,068

YTD Total Expenditure 124,796 173,633 148,014 190,816 165,685 164,179 967,123

- -

YTD Total Surplus/ (Deficit) (1,750) (40) 1,069 (336) (200) (348) (1,605)

YTD Planned In Year Surplus (1,750) - 1,200 - - - (550)

YTD Variance againstControl Total - (40) (131) (336) (200) (348) (1,055)

YTD Variance against Control Total % 0.0% 0.0% -0.1% -0.2% -0.1% -0.2% -0.1%

Forecast Year End Expenditure Position

FOT Total Budget 371,336 520,783 446,317 571,443 506,546 498,013 2,914,438

FOT Total Expenditure 371,336 520,783 446,317 571,419 506,546 498,013 2,914,414

FOT Planned In Year Surplus/ (Deficit) (6,750) - 3,600 - - - (3,150)

FOT Total Surplus/ (Deficit) (6,750) - 3,600 24 - - (3,126)

FOT Variance against Control Total - - - 24 - - 24

FOT Variance against Control Total % 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Page 105

4. QIPP Position Overview:

• Following the 2019/20 planning round, a QIPP gap of £98.9m, was identified across South East London. At month 4, CCGs are forecasting 96.3% delivery against schemes, £95.3m. In delivering its 2018/19 position, CCGs delivered 85.8% of their QIPP in year.

• The reported position includes the assumption that the £1.8m unidentified QIPP within Bexley is delivered in full in 2019-20. The level of unidentified QIPP at M04 has improved compared to M03 reducing by £1.1m made up of £0.5m improvement in Bexley CCG and £0.6m in Greenwich CCG which now has zero unidentified QIPP. The overall position represents a significant improvement compared to the same time 2018-19.

• One of the key challenges across South East London is the delivery of the £2.7m Primary Care Delegated QIPP. This position faces increased pressure following the national changes in PC allocation. A working group was mobilised in July to create a detailed plan to deliver this QIPP however delivery of the full value is considered high risk.

• Given the YTD and FOT pressures on the CHC and Prescribing budgets the delivery of the QIPPs in these areas will be a significant challenge.

QIPP Financial Performance at M04 2019-20 Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL

CCGs

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Year to Date QIPP Performance

YTD Planned QIPP Savings 3,508 8,371 4,247 6,503 4,822 4,504 31,955

YTD Actual QIPP Savings 3,216 8,180 3,897 6,437 4,555 4,488 30,773

YTD QIPP Savings (Under)/ Overdelivery (292) (191) (350) (66) (267) (16) (1,182)YTD QIPP Savings Delivery % 91.7% 97.7% 91.8% 99.0% 94.5% 99.6% 96.3%

Forecast Year End QIPP Performance

FOT Planned QIPP Savings 12,264 25,112 12,750 18,671 14,467 15,661 98,925

FOT Actual QIPP Savings 11,718 24,539 11,691 17,947 13,702 15,712 95,309

FOT QIPP Savings (Under)/ Overdelivery (546) (573) (1,059) (724) (765) 51 (3,616)

FOT QIPP Savings Delivery % 95.5% 97.7% 91.7% 96.1% 94.7% 100.3% 96.3%

M03 FOT QIPP Savings (Under)/ Overdelivery (577) (577) (954) (838) (1,300) (219) (4,465)

Page 106

5. Management Costs Overview:

• As part of the 2019/20 planning process all CCGs were tasked with finding a 10% savings against their management costs allocation. This represented a significant step towards the savings expected in 2020/21, and contributed in excess of the initial savings target of £3.78m toward the QIPP savings target.

• At Month 4, CCGs have agreed their management cost envelopes, and have plans in place to deliver them in full.

• At month 4, all CCGs are forecasting to deliver their target following a detailed review of posts and budgets in Month 1.

Management Cost Reduction

Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Year to Date Management Costs

YTD Actual 2,491 3,018 2,518 2,675 2,628 2,424 15,754

In Month Spend 668 750 676 645 729 606 4,074

Straight-Line Forecast 7,473 9,054 7,554 8,025 7,884 7,272 47,262

Straight-Line In Month Position 7,835 9,018 7,926 7,835 8,460 7,272 48,346

Forecast Outturn 7,472 9,056 7,520 8,009 7,827 7,218 47,102

Management Cost Allocation (Programme/ Running Cost) 7,380 9,255 7,560 8,038 7,840 7,258 47,331

Forecast Variance (92) 199 40 29 13 40 229

Total Savings (Initial Savings Target plus Variance) 250 934 659 767 698 701 4,009

Page 107

6. Acute In Year Position

Overview:

At Month 4, the CCGs have received Month 3 SLAM data, however to ensure a robust position can be used for reporting non local contracts, Month 2 SLAM information has been used in producing the non locals position. This position is higher than anticipated, particularly at Moorfields and Croydon; further details of the position by contract are provided on the following slide.

One key risk to highlight is the London Ambulance positon, where significant activity increases plus additional contractual risks means that the reported position could materially worsen in year.

Risk Assessment/ Underlying Position: Due to the limitations of the data, the acute budgets have been reported in line with plan for Month 3; however an updated risk assessment puts the CCGs risk at £3.7m above the present reported position. This position is under-review and further details will be available at Month 5, when the CCGs should have a complete quarter’s activity.

Page 108

6. Acute In Year Position (Non Locals)

Overview:

In reporting the Month 4 position, Month 2 SLAMs have been scaled up to Month 3 “SLAM Month” in the above, then scaled again for Finance Month 4. The main areas of concern are as follows;

Croydon A&E and Emergency increases, particularly for Bromley and Lambeth

Moorfields Known that low contract value was set, coupled with increased growth trend since month 6 last year, and higher referral increase. Moorfields have opened satellite units in SWL, meaning services are more easily accessible

Other Trusts Imperial is hit by one-off Critical Care case for Lambeth. C&W increases across all POD areas, particularly Planned Care areas

Further work will be undertaken which focuses on data and reporting assurance, investigate high trend data to identify the nature of its cost to allow the pressures to be mitigate appropriately.

BY PROVIDER YEAR TO DATE - SLAM MONTH FORECAST YEAR TO DATE - SLAM MONTH

UNDERLYING POSITION - VARIANCE AGAINST PLAN

UNDER/(OVER)Plan Actual

Forecast

Variance

Better/

(Worse) vs

Last Month

Bexley Bromley Greenwich Lambeth Lewisham Southwark Total

£'000s £'000s £'000s %age £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

Barts Health NHS Trust 2,540 2,612 -72 -2.9% -447 -280 -49 -11 45 22 -7 -71 -72

BMI Healthcare 2,484 2,446 39 1.6% 11 761 0 -80 20 45 50 3 39

Chelsea and Westminster NHS Foundation Trust 1,569 1,685 -117 -7.4% -547 -278 -5 -36 2 -10 -30 -37 -117

Croydon Health Services NHS Trust 2,671 3,054 -382 -14.3% -1,183 -869 0 -264 0 -121 20 -18 -382

Epsom and St. Helier University Hospital NHS Trust 405 404 1 0.4% 16 16 0 -9 0 3 0 8 1

Great Ormond Street Hospital For Children NHS Trust 160 131 28 17.6% 107 107 2 15 1 7 -9 13 28

Homerton University Hospital NHS Foundation Trust 224 197 26 11.8% 94 116 0 0 17 28 0 -18 26

Imperial College Healthcare NHS Trust 1,244 1,356 -111 -8.9% -278 -243 16 23 -12 -116 -5 -18 -111

Kingston Hospital NHS Foundation Trust 142 155 -12 -8.7% -18 9 0 0 0 23 0 -35 -12

London North West Healthcare NHS Trust 312 355 -43 -13.8% -149 -133 -14 -20 -3 -18 0 12 -43

Maidstone and Tunbridge Wells NHS Trust 269 324 -55 -20.3% -238 -140 -27 -27 0 0 0 0 -55

Medway NHS Foundation Trust 386 349 37 9.6% 127 127 57 1 -21 0 0 0 37

Moorfield's Eye Hospital NHS Foundation Trust 2,790 3,090 -300 -10.8% -1,387 -846 -108 -13 7 -42 -101 -43 -300

Queen Victoria Hospital NHS Foundation Trust 290 287 3 1.1% -4 57 10 -6 0 0 0 0 3

Royal Brompton and Harefield NHS Foundation Trust 276 332 -57 -20.6% -109 -109 0 63 0 -76 0 -44 -57

Royal Free NHS Foundation Trust 563 463 99 17.7% 369 415 0 15 14 55 4 11 99

The Royal Marsden NHS Foundation Trust 384 420 -36 -9.4% -266 -196 -95 13 -6 42 -16 26 -36

Royal National Orthopaedic Hospital NHS Trust 385 339 45 11.7% 160 178 0 -35 0 26 44 11 45

University College London Hospital NHS Foundation Trust 3,366 3,387 -21 -0.6% -84 169 -4 -3 2 -10 1 -7 -21

Whittington Hospital NHS Trust 112 92 20 17.6% 72 72 0 0 0 21 0 -2 20

Underlying: Contracts 20,571 21,479 -908 -4.4% -3,753 -1,066 -219 -375 66 -123 -50 -207 -908

FOT Underlying: Contracts 82,294 86,047 -3,753 -4.6% -3,753 -1,066 -953 -1,311 135 -361 -335 -928 -3,753

Variance

Under / (Over) Plan

Page 109

7. Budget Overview

Overview:

• The finance figures in this table are reported in line with national NHSE reporting classifications. There will be some differences to local reports which are reflective of local reporting hierarchies. Reporting hierarchies are currently being reviewed with a view to standardisation across SEL CCGs and will be reflected as part of Q3 reporting.

• In order to deliver the agreed control totals at year end, CCGs are proposing to utilise £6.3m of contingency. This will be required to offset the reduction in primary care allocations that CCGs have been notified about.

• The acute contract positions are currently being reviewed following receipt of early M03 data the current FoT. The M05 position will use validated Q1 information to inform the projected FoT.

• The main reported pressure relates to Primary Care due to changes in the allocations pressures are seen within both Lambeth and Southwark.

• Within continuing care, four CCGs are forecasting material overspends, due to the increased number and complexity of patients needing to be actively managed. Work is on-going at a South East London level to identify targeted resources to respond to this challenge.

• In month 4, following the publication of Month 2 PPA data, CCGs are seeing emerging pressures within prescribing. This position is being reviewed by the SEL Medicines Management team but indicates a non delivery of the 1% outturn adjustment assumed within CCG QIPP plans.

Budget Area Position Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL

CCGs

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Year to Date (Over)/ Underspend

Acute Services (including Local Acute Services) 71 (431) 286 61 (37) (282) (332)

Mental Health Services (86) (63) (449) (34) 1 366 (265)

Community Health Services (32) 53 (497) 226 (137) - (387)

Continuing Care Services 190 168 246 (109) (190) (95) 210

Primary Care Services exc Prescribing 153 (11) (130) (449) - (340) (777)

Prescribing (200) (142) (256) (98) (100) (796)

Other Programme Services (48) 322 718 67 (44) 93 1,108

Total Programme Services 48 (104) (82) (336) (407) (358) (1,239)

Running Costs (subset of Management cost) (48) 64 (49) - 207 10 184

Contingency (Requires CFO Agreement) - - -

Total (Over)/ Underspend - (40) (131) (336) (200) (348) (1,055)

Budget Area Position Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL

CCGs

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

FOT (Over)/ Underspend

Acute Services (including Local Acute Services) (500) (1,142) 91 (19) (103) (928) (2,601)

Mental Health Services (186) (123) 163 366 220

Community Health Services (63) 159 (150) 892 - 838

Continuing Care Services 215 504 (586) (429) (595) (700) (1,591)

Primary Care Services exc Prescribing (146) (35) (255) (1,232) (586) (1,100) (3,354)

Prescribing (425) (586) (504) - (1,515)

Other Programme Services 24 (109) 209 (9) 61 715 891

Total Programme Services (470) (1,234) (1,400) (1,138) (1,223) (1,647) (7,112)

Running Costs (subset of Management cost) (110) 192 11 24 687 20 824

Contingency (Requires CFO Agreement) 580 1,042 1,389 1,138 536 1,627 6,312

Total (Over)/ Underspend 0 0 0 24 0 0 24

Page 110

9. Risks (Not in the Position)

At M04 SEL CCGs’ have identified risks of £25.4m. At this point in the year the CCGs are expecting to mitigate this risk through development of in year mitigating actions and as a backstop by use of contingency if required. The CCGs presently hold a remaining contingency of £8.0m. Further detail by CCG is provided on the next slide, however the main risks can be seen as follows:

Acute Contract Performance: As outlined in section 6, the CCGs face a material risk to their acute contract performance if a standard 2% overperformance is assumed, £5.6m. Based on 18/19 performance this could increase by a further £0.6m based on contract performance; and there is a further £1m risk relating to MSK activity within Bexley. The ICDT in collaboration with the CCGs are actively looking to mitigate this position, and further work will be undertaken as robust in year activity comes through. Primary Care Contract: Following the completion of the CCGs planning round, Primary Care funding was reduced across the board adding a financial pressure to SEL, and in particular Lambeth and Southwark. In reporting the position the CCGs have assumed that a SEL mitigation can be identified for this pressure. Continuing Healthcare: One of the CCGs’ key focuses in delivering its 19/20 position is containing the impact of increased complexity and demand within its Continuing Care Budget. The CHC spend has risen year on year, and SEL CCGs are working collaboratively to find mitigations to the pressures that this presents. Drug Pressures: In 19/20 planning CCGs prescribing budgets were reduced by 1%. Whilst QIPP plans are in place to deliver this, there is limited scope within the prescribing budgets to meet any unforeseen pressures such as short stock drugs in year. The CCGs have been notified of a potential £0.5m per CCG pressure on Category M drugs costs which is expected to start to come through in October. QIPP Delivery: In closing its planning gap for 19/20 CCGs identified QIPP targets totalling £98.9m, in reporting its Month 4 position a 96.3% delivery has been assumed, however there is a further £3.6m delivery risk (outside of acute). CCGs are working to mitigate this position and ensure a robust delivery process is in place to ensure in year delivery.

Page 111

9. Risks (not in the position)

CCG Risk (not in the position)

Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL CCGs

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Acute Services Risk

- QIPP Delivery (500) (500)

- ICDT/ CSU View (Assume includes QIPP non delivery) (1,700) (336) (750) (1,296) (458) (573) (5,113)

- Additional Risk (704) (546) 573 (677)

- MSK Performance (1,000) (1,000)

Total Acute Services Risk (2,700) (836) (750) (2,000) (1,004) - (7,290)

Mental Health Services Risk

- Contract Impact (200) (300) (1,000) (1,500)

- Placements Risk (500) (500)

Total Mental Health Services Risk - (200) (500) (300) - (1,000) (2,000)

Community Health Services Risk

- Activity Risk (500) (200) (700)

Total Community Health Services Risk (500) (200) - - - - (700)

Continuing Care Services Risk

- QIPP Delivery (500) (253) (143) (896)

- Activity Risk (750) (250) (750) (595) (1,500) (500) (4,345)

Total Continuing Care Services Risk (750) (250) (1,250) (848) (1,643) (500) (5,241)

Primary Care Services exc Prescribing Risk


Total Primary Care Services exc Prescribing Risk - - - (242) - - (242)

Prescribing Risk


- Drugs Pressures (500) (550) (500) (500) (75) (2,125)

- Cat M (500) - (500) (1,000)

Total Prescribing Risk (500) (771) (1,000) - (1,000) (75) (3,346)

Primary Care Co-Commissioning Risk

- QIPP Delivery - (239) (239)

- Contract Revision (477) (400) - (345) (436) (1,658)

Total Primary Care Co-Commissioning Risk (477) (400) - - (584) (436) (1,897)

Other Programme Services Risk

- QIPP Delivery (2,077) (337) (550) (482) (772) (250) (4,468)

Total Other Programme Services Risk (2,077) (337) (550) (482) (772) (250) (4,468)

Running Costs Risk


Total Running Costs Risk - - - - (171) - (171)

Total Risks (7,004) (2,994) (4,050) (3,872) (5,174) (2,261) (25,355)

Page 112

11. Debtors

Overview:

• During Month 4 the CCGs debtor position has increased from £20.2m to £21.3m This position is driven by an increase in “new” debtors of £4.3m i.e. the aged debt positon has improved by £3.2m.

The main changes in month relate to;

• £870k invoice issue by Bexley for Quarter 2 MH, CAMHS and Community

• £1.5m invoice paid by Bromley Council

• Lambeth received payment from Hillingdon, Haringey and Camden on Levies (£450k each)

• Southwark issued Quarter 1 invoice to Southwark for PH Section 75 & £800k invoices relating to STP recharges.

Work is on-going at a South East London level which aims to materially improve this position in time for Month 6 reporting.

Page 113

12. Revenue Resource Limit (In Year)

Overview:

• In month 4, the CCGs received allocations for

• Transforming Care Partnership Funding Transfer Arrangement (Greenwich), c£0.7m

• Commissioner Support Fund (Bexley), £0.75m

• Healthy London Partnerships (Lambeth), £2.3m

These contribute to a £3.9m increase in allocation in month, and which match expenditure commitments across the CCGs, or as in the case of Bexley a reduction in their in year planned deficit.

Revenue Resource Limit

Bexley Bromley Greenwich Lambeth Lewisham Southwark Total SEL CCGs

£'000s £'000s £'000s £'000s £'000s £'000s £'000s

Revenue Resource Limit (RRL)

Total Month 3 358,537 513,822 443,077 561,426 500,216 490,624 2,867,779

Total Movement in Month 750 (379) 720 2,314 (366) 857 3,896

Total Month 4 359,287 513,443 443,797 563,740 499,850 491,481 2,871,598

Running Cost Allowance (RCA)

Total Month 3 5,299 7,340 6,120 7,703 6,696 6,537 39,695

Total Movement in Month - -

Total Month 4 5,299 7,340 6,120 7,703 6,696 6,537 39,695

Total RRL and RCA

Total Month 3 363,836 521,162 449,197 569,129 506,912 497,161 2,907,397

Total Movement in Month 750 (379) 720 2,314 (366) 857 3,896

Total Month 4 364,586 520,783 449,917 571,443 506,546 498,018 2,911,293

Page 114

South East London CCGs Integrated Governance & Performance Committee Performance assurance recommendations made to CCGs at the previous month’s SEL IG&P committee meeting August 2019

Page 115

Recommendations to CCGs made at the last SEL IG&P Committee (1/2)

2

RTT PTL

1. CCGs will need to full engage in the planned care transformation agenda to ensure referrals to secondary care are optimised and the improvements experienced in 18/19 are

sustained into 19/20.

2. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, particularly at KCH and that at the point of referral this is taken into account. To continue

to be highlighted in GP newsletters and on practice visits.

RTT 52 week wait

1. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, and that at the point of referral this is taken into account, To continue to be highlighted in

GP newsletters and on practice visits.

RTT 18 week

1. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, and at the point of referral this is taken into account, To continue to be highlighted in GP

newsletters and on practice visits.

A&E and urgent care

1. CCGs should be fully engaged in the development and delivery of system wide urgent and emergency care plans, including:

• Equitable access to out of hospital services, including for patients not in the host hospital site

• Provision of admission prevention services

• Support for timely discharge

July 2019 recommendations to CCGs for action. CCG Managing Directors to update verbally on progress at August 2019 committee meeting

Page 116

3

LAS performance

1. Note the delays to an agreed pan-London contract for 2019/20.

111 performance

1. To note the improved performance of the SEL 111 IUC service and that a final Checkpoint meeting will be held with NHS England on the 31st of July for final sign off of the

mobilisation.

Cancer waiting times – 62 day

1. CCGs should be leading cancer locality meetings (with support from the SEL Cancer Alliance), with particular focus on:

• stratified follow-up – to facilitate appropriate patients being managed in a non acute setting,

• ensuring 2ww referrals are in line with agreed process e.g. full patient workup, appropriate documentation with referral, patients aware they are on a 2ww pathway etc,

• working with providers to ensure that eRS is fit for purpose and support their referrals.

• Improving uptake and roll out of FIT

• Improve uptake of cancer screening

Diagnostic waiting times

1. CCGs to be aware of the prolonged waits for endoscopy services at the PRUH.

2. CCGs should highlight to GPs that referrals to endoscopy services should be flagged as urgent only when appropriate to do so. This recommendation applies to referrals for

specialties where endoscopy is a standard part of the pathway.

July 2019 recommendations to CCGs for action. CCG Managing Directors to update verbally on progress at August 2019 committee meeting

Recommendations to CCGs made at the last SEL IG&P Committee (1/2)

Page 117


South East London CCGs Integrated Governance & Performance Committee Performance Assurance Report August 2019

Page 119

2

Contents

This pack summarises the south east London performance position for all areas agreed as in-scope

for the SEL Integrated Governance and Performance Committee:

• Summary of recommendations to CCGs Page 3

• Referral-to-treatment waiting time standard (PTL; 52 and 18 week waits) Page 5

• A&E 4 hour standard Page 12

• London Ambulance Service performance Page 15

• NHS 111 performance Page 17

• Cancer waiting time standards Page 21

• Diagnostic waiting time standard Page 24

• Transforming Care Programme Page 27

Please note: the RAG rating of monthly performance positions are against the

national standard rather than local recovery planned trajectories.

Page 120

Summary of recommendations to CCGs: August 2019 (1 of 2)

3

RTT PTL

1. [Updated action for August 2019] CCGs will need to fully engage in the planned care transformation agenda, including use of RAS, Advice & Guidance and Consultant

Connect to ensure referrals to secondary care are optimised and the improvements experienced in 18/19 are sustained into 19/20.

2. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, particularly at KCH. To continue to be highlighted in GP newsletters and on practice

visits.

RTT 52 week wait

1. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, and that at the point of referral this is taken into account, To continue to be highlighted in

GP newsletters and on practice visits.

RTT 18 week

1. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, and at the point of referral this is taken into account, To continue to be highlighted in GP

newsletters and on practice visits.

2. [Updated action for August 2019] CCGs will need to fully engage in the planned care transformation agenda, including use of RAS, Advice & Guidance and Consultant

Connect, to ensure referrals to secondary care are optimised and the improvements experienced in 18/19 are sustained into 19/20.

A&E and urgent care

1. [Updated action for August 2019] CCGs should be fully engaged in the development and delivery of system wide urgent and emergency care plans, including:


• Provision of admission prevention services / appropriate referrals to ED


CCG Managing Directors to update verbally on progress against the below at the next SEL IG&P Committee meeting: September 2019

Page 121

4

111 performance

1. To note the improved performance of the SEL 111 IUC service and that a final Checkpoint meeting will be held with NHS England on the 31st of July for final sign off of the

mobilisation.

Cancer waiting times – 62 day

1. CCGs should be leading cancer locality meetings (with support from the SEL Cancer Alliance), with particular focus on:






Diagnostic waiting times


2. CCGs should highlight to GPs that referrals to endoscopy services should be flagged as urgent only when appropriate to do so. This recommendation applies to referrals for

specialties where endoscopy is a standard part of the pathway.

3. [New action for August 2019] CCGs should be aware of a Serious Incident Committee meeting on 5th September to review serious incidents relating to delays to endoscopy

procedures.

Summary of recommendations to CCGs: August 2019 (2 of 2)

Page 122

5

RTT: performance headlines and month-on-month trend

Bexley Bromley Greenwich Lambeth Lewisham Southwark SEL CCGs GSTT KCH LGT SEL Acute

18 weeks RTT Incomplete pathway - % of patients waiting for 18 weeks or less (92%) – June 2019

Planned

trajectory 85.0 82.0 85.4 84.9 84.7 84.2 - 87.3 77.9 85.1 -

Current

month 82.9 82.2 85.1 84.7 84.4 82.6 83.7 85.1 78.6 85.4 82.78

SPC position

since Apr 17 Within limits Within limits Within limits Within limits Within limits Within limits -

Below lower

limits Within limits

Below lower

limits -

Number of patients on waiting list (PTL) over 18 weeks - June 2019

Planned

trajectory 2,911 5,616 3,343 4,333 4,589 3,996 24,788 10,628 16,230 5,900 32,758

Current

month 3,414 5,475 3,515 4,334 4,595 4,351 25,684 11,614 16,413 5,772 33,799

Number of patients on waiting list (PTL) over 52 weeks - June 2019

Planned

trajectory 23 19 8 22 10 34 116 35 118 5 158

Current

month 45 18 18 40 18 48 187 89 171 4 264

Key

Performance position

Not achieving national standard

Achieving national standard Best performer

Worst performer

Current month SPC position

(compared to performance since April 2017)

Outside of SPC process limit (good performance)

Outside of SPC process limit (poor performance)

Within SPC limits (within expected levels of variation)

Page 123

RTT PTL: summary of current position

6

Summary of current south east London performance position Main drivers of current performance position High impact actions currently in place to address

performance variance

• KCH & LGT trajectories forecast reductions in PTL size in

2019/20. Both Trusts are below trajectory in June.

• The GSTT trajectory is for an increase in overall PTL size (all

patients including those waiting less than 18 weeks). However

for June their PTL was lower than planned and the trust

therefore performed better than their trajectory.

• The extent to which trusts are able to achieve their PTL

trajectory is linked to the success of CCGs in optimising

referrals and implementing the planned care strategies for

19/20.

• GSTT: the trust is focussed on delivering the 18 week

performance trajectory rather than reduction in overall PTL

size.

• For both KCH and LGT a reduction in their PTL size is

forecast with a small improvement in performance against the

92% standard.

• All Trusts performance improvement plans have been agreed

between commissioners and providers, with SMART actions

and senior level action owners, KPIs to measure delivery of

the actions, and a risk and issues log, all of which will be

updated monthly.

• Monthly performance meetings are in place with acute trusts

to review progress against the trust specific trajectories.

• LGT and KCH plans both include a significant element

relating to strengthening governance and processes,

supporting RTT delivery.

• GSTT implementation of the acute trust aspects of the

planned care strategy, including promoting Advice and

Guidance, implementing Rapid Assessment Services and

enhanced clinical triage; transformation of outpatient

processes and increasing theatre capacity both off and on

site.

Impact or potential impact of the current performance position on the quality of care and mitigation actions in place

• If the Trust PTLs increase it can become harder to manage from an operational perspective. The ICDT are attending GSTT Trust internal RTT meetings and intend to do the same for KCH and LGT to gain

assurance of operation grip.

Page 124

RTT PTL: monthly update

7

What has changed since last month? New actions taken in the last month Proposed actions in the next quarter SEL BAF risk

• GSTT and LGT saw an increase in PTL size between

May and June. KCH had a reduction in PTL size .

• All three Trusts achieved June trajectory.

• ICDT continued to work with trusts in monitoring PTL

size and in refining KPIs to measure delivery of key

actions.

• ICDT have met with newly appointed Director of

Improvement for Elective Care.

• ICDT has commenced monthly meetings with KCH to

review RTT Performance Improvement Plans in detail

prior to the monthly performance meeting.

• ICDT to attend LGT internal PTL meeting.

• As part of their strengthened governance process LGT

are carrying out a significant piece of work on data

quality on their PTL and ICDT are working with them to

understand any issues arising from this work.

SEL BAF

Reference:

• SEL-04

Current risk rating:

• 3 x 4 = 12

(medium risk)

What are your recommendations to the SEL IG&P Committee?

1. CCGs will need to fully engage in the planned care transformation agenda, including use of RAS, Advice & Guidance and Consultant Connect to ensure referrals to secondary care are optimised and

the improvements experienced in 18/19 are sustained into 19/20.

2. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, particularly at KCH. To continue to be highlighted in GP newsletters and on practice visits.

Page 125

RTT 52 week wait: summary of current position

8



• There are more long waiters than expected across the sector.

Only LGT met their June trajectory.

• At KCH the main specialties with long waiters are trauma &

orthopaedics and general surgery, although general surgery

has improved. KCH long waiter specialities are likely to have a

wide spread impact on SEL CCGs, with data for 18/19

showing Lambeth, Bexley, Southwark and Bromley CCGs

having more long waiting patients, and Lewisham and

Greenwich CCGs still having long waiters at the trust but in

slightly lower numbers.

• Although GSTT has a number of specialities with long waiters,

the main specialties have changed with Upper GI & Colorectal

the main drivers.

• LGT long waiters were limited to a single specialty with low

numbers. The number of patients from any one SEL CCG is

expected to be low. The Trust have also seen a low number

of pop on (additions) to the list in trauma & orthopaedics.

• All performance improvement plans agreed between

commissioners and providers with SMART actions and senior

level action owners, KPIs to measure delivery of the actions,

and a risk and issues log, all of which will be updated monthly:

• Monthly performance meetings are in place with acute trusts

to review progress against the trust specific trajectories and

ICDT team members attend additional internal RTT meetings

at GSTT.

• KCH to work in identifying capacity for orthopaedics.

• GSTT to work with other London providers supported by

NHSE/I to identify additional capacity to operate on cleft

patients within the required timescales.


• Clinical Harm Reviews are undertaken for long waiting patients and updates are given at the relevant CQRG meetings.

Page 126

RTT 52 week wait: monthly update

9


• The pre-validated position for July shows an improved

position at KCH but still above trajectory.

• July pre-validated performance for GSTT reporting a

similar number of long waiters to June which is more

than their trajectory.

• LGT are expecting to have two/three long waiters in

July and will not be within trajectory which is zero.

• ICDT are exploring piloting choice at 26 weeks with

KCH using the current outsourcing arrangements with

SWLEOC (Trauma & Orthopaedics).

• ICDT has commenced monthly meetings with KCH to

review RTT Performance Improvement Plans in detail

prior to the monthly performance meeting.

• ICDT working with regional office to ensure any

external support is fully utilised.

SEL BAF

Reference:

• SEL-03


• 3 x 4 = 12

(medium risk)


1. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, and that at the point of referral this is taken into account, To continue to be highlighted in GP newsletters and

on practice visits.

Page 127

RTT 18 week: summary of current position

10

Summary of current south east London

performance position Main drivers of current performance position

High impact actions currently in place to address performance

variance

• GSTT and KCH are below their June trajectories

and have deteriorated since last month’s

performance.

• LGT delivered their June trajectory but performance

was lower than last month.

• The extent to which trusts are able to achieve their PTL

trajectory is linked to the success of CCGs in optimising

referrals and implementing the planned care strategies for

19/20.

• GSTT: Focus of trust is on delivering the 18 week performance

trajectory rather than reduction in PTL size.

• For both KCH and LGT a reduction in their PTL size is forecast

with a small improvement in performance against the 92%

standard.

• All Trusts have recovery plans with SMART actions and senior level

action owners, KPIs to measure delivery of the actions, and a risk and

issues log, all of which will be updated monthly:

• Monthly performance meeting with acute trusts are in place to review

progress against the trust specific trajectories and ICDT team members

attend additional internal RTT meetings at GSTT and KCH.

• LGT and KCH plans both include a significant element relating to

strengthening governance and processes, supporting RTT delivery.

• GSTT implementation of the acute trust aspects of the planned care

strategy, including promoting Advice and Guidance, implementing Rapid

Assessment Services and enhanced clinical triage; transformation of

outpatient processes and increasing theatre capacity both off and on

site.


• Patients are potentially experiencing longer waits for routine treatment than would be expected, provider Trusts have identified actions to address challenged specialties within their RTT performance

improvement plans. The plans will be monitored via the monthly performance meetings.

Page 128

RTT 18 week: monthly update

11


• Performance at all three Trusts has deteriorated slightly

compared to May with LGT the only Trust to achieve

their June trajectory.

None • ICDT working with NHSE/I to ensure any external

support is fully utilised.

• ICDT working with NHSE/I on implementation plan for

managing choice at 26 weeks.

SEL BAF

Reference:

• SEL-05


• 3 x 3 = 9

(medium risk)


1. CCGs should ensure that referrers are aware of the challenged specialties at local trusts, and at the point of referral this is taken into account, To continue to be highlighted in GP newsletters and on

practice visits.

2. CCGs will need to fully engage in the planned care transformation agenda, including use of RAS’s, Advice & Guidance and Consultant Connect, to ensure referrals to secondary care are optimised and

the improvements experienced in 18/19 are sustained into 19/20.

Page 129

12

GSTT KCH LGT SEL Acute

A&E 4 hour waits - 95% of patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department – July 2019

Planned trajectory 90.0 82.3 90.9 -

Current month 83.1 73.6 78.3 81.5

SPC position since Apr 17 Within limits Within limits Below lower limits -

A&E and urgent care: performance headlines and month-on-month trend

Key




Worst performer






Page 130

A&E and urgent care: summary of current position

13



• GSTT, KCH and LGT’s trajectories show slight improvement

during 19/20 but does not meet the national standard.

• Performance at each Trust has been below trajectory for

each month this year.

A mismatch between demand and capacity in both physical and

staffing resource:

• Increases in acuity leading to increased rates of admission

• Continuing pressure from patients presenting in ED with

serious mental health issues

• Challenges with patient flow, within the EDs, from EDs to

ward areas and in timely discharge from hospital

• The variability in SEL of available appropriate alternative

pathways e.g. to support streaming at the front door,

admission avoidance or in and out of hospital services.

All trusts have developed performance improvement plans to

deliver their trajectory for improving performance against the 4

hour standard and link to the SEL strategy for improvement in

non-elective services:

• KCH have established performance improvement work

streams on both sites which are focused on improving flow in

the emergency department and acute assessment, improving

site management and improving length of stay and discharge

processes on wards.

• The LGT performance improvement plan focus on the end to

end pathway and includes developing a new clinical model

and site reconfiguration to drive improved flow and

performance.

• GSTT actions are focused on addressing three elements -

LAS Handover and RAT, throughput, and discharge and

transfer. In addition, there are projects related to the Urgent

Care Centre, looking at assessment, capacity and the

environment. The final focus is staffing demand, with both a

clinical and administrative focus.

Monthly performance meetings with acute trusts are in place to

review progress against the trust specific trajectories and ICDT

Team members attend internal trust meetings relating to A&E

performance delivery as well as multi agency A&E Delivery Board

meeting.


• Quality implications relating to sub optimal ED performance is a scheduled discussion at the three Trust CQRG meetings. Specific concerns/cases will be raised directly with the Trusts via the quality alert

systems.

Page 131

A&E and urgent care: monthly update

14


• GSTT, KCH and LGT did not meet the A&E trajectory

in July.

• Performance in July deteriorated when compared to

June for GSTT and LGT but there was improvement

for KCH.

• The London-wide Mental Health compact was

launched on 1st July, aimed at improving the ability to

manage the risk that people in mental health crisis

pose as they move through the urgent care system.

• LGT have been moved into enhanced National

Escalation Process which includes regular meetings

with National Lead for UEC.

• LGT submitted immediate recovery plans for both sites,

the development of which will be supported by ICDT

and other system partners.

• ICDT will be reviewing gaps in existing plans with a

view to allocating or optimising external / internal

support.

SEL BAF

Reference:

• SEL-02


• 3 x 4 = 12

(medium risk)


1. CCGs should be fully engaged in the development and delivery of system wide urgent and emergency care plans, including:


• Provision of admission prevention services / appropriate referrals to ED


Page 132

15

LAS: activity and performance headlines

Bexley Bromley Greenwich Lambeth Lewisham Southwark SEL CCGs

CCG delivery against ambulance response indicators– M1 - 4 (YTD)

Category 1 Mean

Target: 00:07:00 00:06:57 00:06:30 00:06:09 00:06:15 00:06:18 00:06:05 00:06:20

Category 1 90th centile

Target: 00:15:00 00:11:08 00:10:54 00:10:23 00:10:04 00:10:27 00:09:47 00:10:27

Category 2 Mean

Target: 00:18:00 00:22:54 00:20:49 00:19:09 00:16:11 00:19:33 00:14:55 00:18:36


Target: 00:40:00 00:46:39 00:42:39 00:39:49 00:33:02 00:40:23 00:30:26 00:38:24

Category 3 Mean

Target:01:00:00 00:54:44 00:55:05 00:50:47 00:50:39 00:57:03 00:45:30 00:51:53


Target: 02:00:00 02:06:56 02:12:43 02:01:01 01:56:54 02:15:36 01:46:52 02:02:00


Target: 03:00:00 03:09:16 03:16:33 02:56:28 03:00:35 03:08:25 03:12:33 03:08:36

Definitions

Category 1 Life Threatening: A time critical life threatening event requiring immediate intervention or resuscitation.

Category 2 Emergency: Potentially serious conditions that may require rapid assessment and urgent on-scene intervention and/or urgent transport.

Category 3 An urgent problem (not immediately life threatening) that needs treatment to relieve suffering and transport or assessment and management at the scene with referral where

needed within a clinically appropriate timeframe.

Category 4 Problems that are less urgent but require assessment and possibly transport within a clinically appropriate timeframe.

LAS activity (actual vs plan) – 2019/20

Total Activity (Plan)

Total Activity (Actual)

Total activity - Variance

Total activity – Variance (%)

Data unavailable until Pan London contract is

agreed and signed

Page 133

LAS performance: summary of current position

16



• 2019 activity figures are not available until the Pan London

contract is agreed for 2019/20. This was anticipated to be

agreed at the end of July 2019 however negotiations are yet

to be completed and the contract remains unsigned.

• YTD 2019 (M1-4) performance targets show LAS met only

Category 1 and 3 ambulance response times and has not

achieved Category 2 and 4. Performance has continued to

deteriorate from M1.

• LAS missed Category 2 performance by 36 seconds,

Category 3 by 2 minutes and Category 4 by 8 minutes and 36

seconds for SEL.

• Across the 6 CCGs, LAS continues to struggle in maintaining

targets mainly in Bexley, Bromley & Lewisham.

• LAS report that activity is up across London since April 2019

affecting response times; however this data has yet to be

shared with commissioners.

• LAS ambulance response times in Bexley can be attributed to

the distance ambulances need to travel to reach patients as

there are no acute hospital sites in the Bexley area.

• LAS report an increase in acuity of patients, as seen

elsewhere in the urgent care system.

See following slide for planned actions.


A representative for SEL CCGs attends the LAS CQRG meetings which oversee the delivery of high quality care, including review of Serious Incidents. The current report does not highlight any significant

quality concerns relating to LAS delivery of performance standards.

Page 134

LAS performance: monthly update

17


The NWL LAS Commissioning team continue to

negotiate Hear & Treat activity that LAS will undertake

during 2019/20 which will set the activity baseline for

London. SEL commissioners are included in the on-going

discussions. The contract was anticipated to be signed

by the end of July 2019, however negotiations continue.

SEL commissioners have confirmed the LAS Clinical Hub

is able to refer directly into a number of existing ACPs

including Oxleas Rapid Response Teams and SLaM CAT

Service. These pathways have been developed and are

in the process of sign off. Access to services from the

Clinical Hub will support the CCG contract obligations

which detail that SEL needs to deliver access to 1,162

referrals for 2019/20.

The Clinical Assessment Service in NHS 111 IUC

continues to revalidate Category 3 and 4 ambulances

before they are sent to 999 for dispatch.

Across SEL, commissioners and providers have agreed

new referral pathways for the LAS Clinical Hub which

includes the @Home service, Greenwich’s JET service

and Bromley Rapid Response team.

Pan-London commissioners agreed a core set of codes

to be used by LAS which will improve reporting and

support commissioners to understand their local activity.

The codes will be launched on 31st August.

SEL CCGs have developed plans to reduce demand by

decreasing call outs and a reduction in conveyances in

their areas.

The CCGs will also explore a joint approach where it

makes sense including communications / patient

messaging and the usage of CMC in all care settings.

SEL commissioners will continue to deliver the additional

referral pathways for the LAS Clinical Hub with the aim to

have all ACPs available to the Hub by October 2019.

Additional ACP referral pathways will be developed to

support lower demand on Emergency Departments.

Lewisham have identified 2 new ACPs to help reduce

ambulance conveyances.

SEL commissioners will support a once for SEL approach

to communications and consider other demand

management schemes where it makes sense to do so.

CCGs will continue the programme of work to review and

update the Directory of Services to ensure that crews and

the LAS Clinical Hub have quick access to services in

order to avoid a call out or conveyance to hospital.

SEL BAF

Reference:

• SEL-07


• 4 x 4 = 16 (High

risk)


• No recommendations at present.

Page 135

18

111 performance: headlines and month-on-month trend

January February March April May June July

Call volume 36,275 34,782 40,278 37,967 38,642 36,455 38,542

Calls answered in

60 seconds (target) 95% 95% 95% 95% 95% 95% 95%

Calls answered in

60 seconds

(performance)

76.3% 76.2% 74.2% 85.1% 92.7% 88.9% 76.7%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19

% o

f ca

lls

Month-Year

Urgent and Emergency Care Referrals from SEL 111 IUC

111 calls resulting in ambulance dispatch 111 calls resulting in referral to ED/UTC

Page 136

111 performance: summary of current position

19



• July 2019 call volumes were 5.28% above forecast. At

present, the 111 IUC service is 4.79% above forecast

cumulatively for the year. This has impacted on ‘calls

answered within 60 seconds’ performance which has reduced

to 76.7% from a high of 92.7% in May.

• The proportion of calls abandoned after more than 30

seconds in July 2019 was 4.8%, just below the national target

of 5%.

• The proportion of Category 3 and 4 ambulance dispositions

revalidated by a clinician before sending to 999 was 78.1%,

above the national KPI target of 50%.

• The proportion of Emergency Treatment Centre dispositions

revalidated by a clinician was 39.0%, below the national KPI

target of 50%.

• The proportion of 111 calls resulting in ambulance dispatch or

referral to a ED/UTC has remained low since December 2018.

• The 111 IUC service upgraded their telephony platform on the

10th of July which resulted in a number of technology issues

which contributed to poor performance over the course of two

weeks as problems were resolved.

• There was a national Adastra outage on the 27th of July

affecting the 111 IUC service and many of SEL out of hours

providers resulting in poor performance over the course of two

days. This has been declared an SI and being investigated

nationally.

• Workforce shortage across all skill sets; particularly call

handlers and Advanced Nurse Practitioners (ANPs)

continues. The call handler shortage has contributed to

difficulties achieving the ‘calls answered in 60 seconds’

performance target.

• A Recovery Action Plan around the ‘calls answered in 60

seconds’ performance target has been agreed with LAS and

is monitored via monthly contract management meetings.


• A SEL 111 IUC Quality and Safety Committee meets bi-monthly to oversee the quality and safety of care within the 111 IUC service. This is supplemented by a smaller sub group meeting on alternate

months.

• A benefits realisation plan has been agreed between LAS and SEL commissioners, consisting of a series of reviews that will take place over the course of the year to ensure all aspects of the service

specification are appropriately implemented and are delivering the expected outcomes for patients.

• HLP are leading on a Pan London 111 IUC workforce review, looking at rates of pay across the skill sets by provider, with the aim of agreeing consistent pay London-wide in order to mitigate the

recruitment and retention issues that all 111 IUC providers are currently experiencing.

• There is a pan-London CAS development group, overseeing the development and safety of the Clinical Assessment Services within 111 IUC services.

Page 137

111 performance: monthly update

20


• The SEL 111 IUC Alliance Memorandum of

Understanding (MoU) – which has been in

development for approximately two years – has been

signed by 6 of the 19 organisations involved in the

111 IUC service as of July 2019.

• SEL and NEL commissioners have collaborated

together to develop the new 111 IUC call log data

specification for the Adastra call log extracts that will

feed into the CSU’s 111 data warehouse on a daily

basis. This will allow commissioners access to data

describing the full patient journey within the 111 IUC

service.

• LAS have received internal approval to fund a new

workforce rota tool that will allow more sophisticated

modelling of their clinical workforce requirements.

• LAS have worked with GPOOH providers to review

the urgency of the home visit requests and are

following up training needs identified as a result of

this review with their clinical workforce.

• A new clinical profile has been developed for

adoption by all the GP hubs. This will standardise the

offer across the 12 SEL GP hubs and increase

available appointments for the 111 IUC service.

• The Directory of Services team and SEL

commissioners have completed the review of the

profiles of all stand-alone UTCs to make sure their

profiles are correct for 111 IUC service referrals.

• LAS have completed a review of walk in referrals to

UTCs and found that these are largely appropriate.

• The SEL 111 IUC team has started attended

sessions with CCGs and practice managers around

the new GP Connect functionality which will allow the

111 IUC service to directly book appointments into

GP practices across SEL.

• Collect signatures on the SEL 111 IUC Alliance MoU

from the remaining 13 participants.

• LAS to create a data call log extract script based on

the call log data specification agreed by SEL and

NEL Commissioners. CSU to commence work on the

development of the 111 IUC data warehouse.

• Commissioners to work with their GP hub providers to

ensure they adopt the new clinical profile, expand the

opening hours listed for their services on the

Directory of Services and increase the number of

appointments available to 111.

• Work will continue with providers to review 111 IUC

referral pathways to make sure that 111 has the

correct and appropriate access. Priority will be around

rapid response teams across SEL.

• SEL will launch the new programme of work around

direct booking into primary care practices across SEL

using GP Connect.

SEL BAF

Reference:

No risks at this time.

Not included on SEL

BAF.


• No recommendations at present.

Page 138

21


Cancer 62 day waits - % of patients waiting 62 days or less from urgent GP referral (85%) – June 2019

Planned

trajectory 82.0 85.4 78.6 81.8 79.2 80.4 - 78.5 84.5 78.0 -

Current

month 72.9 60.6 66.7 87.3 72.4 80.0 73.6 72.0 70.2 72.5 73.5

SPC position

since Apr 17 Within limits

Below lower

limits Within limits Within limits Within limits Within limits - Within limits Within limits Within limits -

Cancer 31 day waits - % of patients waiting 31 days or less between definitive diagnosis and first treatment (96%) – June 2019

Current

month 97.8 97.7 96.7 99.1 98.9 100.0 98.3 98.5 95.9 95.6 97.5

SPC position

since Apr 17 Within limits Within limits Within limits Within limits Within limits Within limits - Within limits Within limits Within limits -

Cancer 2 week waits - % of patients waiting two week or less between urgent GP referral and first appointment with a specialist (93%) – June 2019

Current

month 95.3 95.3 94.7 90.3 91.8 90.0 92.8 89.3 94.1 94.4 91.9

SPC position

since Apr 17 Within limits Within limits Within limits

Below lower

limits Within limits Within limits -

Below lower

limits Within limits Within limits -

Tables on the following two pages set out the current performance position of each SEL CCG and provider against national standards. The position

against the standard is RAG-rated and the position against the previous month’s performance is indicated by the arrow as per the below key.

Cancer waiting times: performance headlines and month-on-month trend

Key




Worst performer






Page 139

Cancer waiting times – 62 day: summary of current position

22

Summary of current south east London

performance position Main drivers of current performance position High impact actions currently in place to address performance variance

• SEL trusts/CCGs did not met the 62 day

performance in 18/19, and despite improvements

at KCH over the course of 18/19, there has been a

deterioration in performance at LGT, which results

in the overall SEL remaining static.

• Due to the drivers behind performance against the

62 Day standard, there is differential impact by

CCGs. Lambeth and Southwark CCGs will tend to

be closer to delivering the 62 day standard

because a higher proportion of their patients will

start and finish their cancer pathway either within

GSTT or KCH - Denmark Hill.

• However, for Lewisham, Greenwich, Bexley and

Bromley CCGs, patients will start their pathway at

a local trust/site e.g. Princess Royal University

Hospital (PRUH), University Hospital Lewisham,

and for some treatment pathways will be

transferred to GSTT or KCH - Denmark Hill for

treatment. These patients are therefore more

likely to have issues with meeting the required

standards as the timeliness of transfers is one of

the key drivers.

At the start of the financial year, there are three key

areas driving the current risk:

• The overall performance at LGT and the timeliness

of Inter Provider Transfers performance (IPT) for

patients transferring from LGT to GSTT.

• The timeliness of IPT performance for patients

transferring from KCH to GSTT.

• The ability for the treatment trust to treat the

patients within the standard if the patient arrives

late or not at a diagnostic stage that would support

the start of treatment.

Within the above there are tumour pathways which are

more challenged than others, e.g. urology and lung.

• Trusts have developed action plans to deliver their 62 day trajectory including a SEL

recovery plan specifically focusing on shared pathway actions and performance.

• Monthly performance meeting are in place with acute trusts – focus on internal trust

performance and actions relating to them are in place. A monthly system leadership

group – 62 day leadership meeting is in place, with a focus on the shared pathway

actions and performance

• The SEL recovery plan has been agreed between commissioners and trusts with

SMART actions and senior level action owners, KPIs to measure delivery of the

actions, and a risk and issues log, all of which will be updated monthly:

• Full utilisation of TP biopsy in outpatients.

• Recruitment to 28 day faster diagnosis project lead for SEL.

• Continue SEL cancer diagnostic fund for CT and MRI.

• 1.2 million of transformation money has been assigned to a specialist SEL cancer

management sector workforce to be recruited and based at individual Trust Sites. By

Q2

• Full utilisation of One Stop and Straight to Test pathways for key tumour sites: lung

by Q2, gynaecology by Q1, breast by Q1, upper GI by Q2.

• Endobronchial ultrasound (EBUS) services to begin at Woolwich and PRUH. By Q2

• Additional lung and lower GI oncologists recruited at GSTT and oncology workforce

review conducted by the ACN. By Q2

• Implement a model to expedite abnormal CXRs to CT in the lung pathway within 48

hours. By Q2

• Recruitment to joint urology workforce roles at the PRUH with Denmark Hill by Q3

• Fully roll out telephone assessment clinic model for 100% of appropriate lower GI

patients. By Q4.


• Individual trusts complete Root Cause Analysis of all patients that are treated beyond 62 days, for IPT patients this is a joint exercise between relevant Trusts. Findings are shared at the relevant SEL

tumour group (clinically led meetings), and summary findings are shared at the 62 day group, to ensure that current actions match the emerging issues.

Page 140

Cancer waiting times – 62 day: monthly update

23


• All three trusts and SEL as a sector missed the

performance trajectory in June.

• Performance has been challenged at the start of

2019/20. A number of issues have impacted the

prostate and lung pathways which are the biggest

contributors to breaches in the sector. Whilst some

issues for prostate have now been resolved it will take

a few months before performance reflects this

improvement whilst backlogs are worked through the

system. There are still further actions required to

address issues in both pathways.

• SEL cancer performance improvement plans (PIPs)

reviewed and updated.

• SEL IGP 62 day cancer deep-dive presented

• 62 day Leadership group – Provider level deep dives

into Urology and Lung – updated pathway templates

completed by the group with additional next steps for

improvement.

• New 6 month outsourcing contract agreed for Sector

CT and MRI.

• Recruitment day for specialist cancer management

sector workforce band 4 roles to be held in August.

held. 50% of band 8C and 7 posts offered.

• Rapid Assessment Diagnostic Clinic (RADC) national

workshop attended. Meetings held with clinical leads to

discuss potential for expansion. Transformation funding

available.

• Continued employment of remaining staff for specialist

cancer management sector workforce.

• 62 Day group to review Lung and Urology deep dive

actions for progress. Additional deep dive pathway

report to be produced and completed for Gynaecology

to highlight clear next steps.

• Additional bilateral meeting to be held with new KCH

senior management team.

• Invoices for sector diagnostic fund to be completed

taking £1.8 million for sector diagnostics. £450k from

each organisation.

• 360 degree ACN members board review to ensure

sufficient governance in system.

• Cancer section of the long term plan to be completed.

• Support package for Cancer MDT Leadership and

Team Development to be procured

• Additional management support expected from NHSE/I

to be based at LGT site.

SEL BAF

Reference:

• SEL-01


• 3 x 4 = 12

(medium risk)


CCGs should be leading cancer locality meetings (with support from the SEL Cancer Alliance), with particular focus on:






Page 141

24

Diagnostic waiting times: performance headlines and month-on-month trend


6 weeks Diagnostics - % of patients waiting for 6 weeks of less (99%) – June 2019

Planned

trajectory 2.9 10.5 2.4 6.1 2.8 7.1 - 4.0 12.1 1.0 -

Current

month 3.4 6.5 4.2 6.2 3.5 7.1 5.3 10.5 6.3 1.0 6.4

SPC position

since Apr 17 Within limits Within limits

Below lower

limit

Below lower

limit

Below lower

limit

Below lower

limit -

Below lower

limit Within limits Within limits -

Key




Worst performer






Page 142

Diagnostic waiting times: summary of current position

25



• At the start of the year GSTT had a trajectory that shows

compliance with the national standard from January 2020.

Performance for June was above the trajectory with more long

waiters than planned.

• KCH have a trajectory that moves towards compliance in

19/20 and shows a compliant position from March 2020.

Performance for June is below planned trajectory but is not

compliant with the national standard.

• LGT have a trajectory that is compliant with the national

standard throughout 19/20, performance for June is compliant

with the national standard.

• At GSTT Endoscopy, Echocardiology and Non Obstetric

Ultrasound are the primary drivers of poor performance.

• At KCH Endoscopy on the PRUH site is the primary driver of

poor performance.

• At LGT sleep studies have the highest number of breaches

but overall Trust performance is compliant.

• All trusts performance improvement plans agreed between

commissioners and providers with SMART actions and senior

level action owners, KPIs to measure delivery of the actions,

and a risk and issues log, all of which will be updated monthly.

• Monthly performance meeting are in place with acute trusts

which will review progress against the trust specific

trajectories.

• The KCH plan focuses on echocardiography for Denmark Hill,

and endoscopy for PRUH, including expanding capacity by

utilising available in and outsourcing options.


• Serious Incidents are under investigation at KCH (PRUH) relating to delayed non 2WW diagnostics which resulted in a cancer diagnosis. A weekly endoscopy briefing is produced by the Trust which gives

a detailed update on clinical harm review process which is being undertaken.

Page 143

Diagnostic waiting times: monthly update

26


• GSTT identified additional physical and clinical capacity

for endoscopies however, there is still a gap in

capacity. The Trust are expecting a further

deterioration in Endoscopy performance in July.

• KCH performance for June shows an improved position

compared to May and is below planned trajectory.

• LGT achieved the standard and trajectory in June and

are forecasting compliance in July.

None • ICDT will be working with the regional team who are

seeking solutions to pan-London capacity issues such

as endoscopy.

• ICDT to meet KCH to review IST demand and capacity

model for both sites.

SEL BAF

Reference:

• SEL-06


• 4 x 4 = 16

(high risk)



2. CCGs should highlight to GPs that referrals to endoscopy services should be flagged as urgent only when appropriate to do so. This recommendation applies to referrals for specialties where

endoscopy is a standard part of the pathway.

3. CCGs should be aware of a Serious Incident Committee meeting on 5th September to review serious incidents relating to delays to endoscopy procedures.

Page 144

Transforming Care: inpatient count position and trend (1 of 4)

27

There are currently 71 adults inpatients*, 16 above the BRS target position of 55 by end Aug 2019.

• The TCP is forecasting an end March 2020 position of 64 adult inpatients, 14 above the BRS target of 50, position which was approved by NHSE/I national team.

• The target was built on an analysis of the current cohort as well as a modelling based on review of the historical data and expected positive impact that new services will have in the

trajectory.

*Position at 21/08/2019.

DATA SOURCE: SEL TCP inpatient tracker 20190821 version 2

Page 145


28

There are currently 78 inpatients (71x adult, 7 x children)*



Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

85 89 91 84 81 80 81 78 - - - - - - -

38 41 41 39 36 36 36 35 - - - - - - -

39 40 39 38 39 36 36 36 - - - - - - -

8 8 7 7 6 8 9 7 - - - - - - -

63 66 65 62 61 59 59 58 - - - - - - -

- - - - - - 79 78 76 74 72 70 68 66 64

61 60 58 58 57 56 55 55 54 53 53 52 51 51 50

61 60 58 84 83 80 79 78 76 74 72 70 68 66 64

2 3 3 -9 -3 2 -1 -4 -11

11 10 8 4 7 8 9 3

In Q2: ~8 admissions

expected, with 8

remaining at end of Q2

19/20

9 7 5 13 10 6 10 7 11

FY 17/18 Q4

Inp

ati

en

ts

Net

Ch

an

ge

in

mo

nth

Admissions

Discharges

Tra

jecto

rie

s

Ad

ult

s

Total

CCG

Spec Comm Adults

Spec Comm Children

TCP Forecast ***

BRS Trajectory

Recovery Trajectory

Adult inpatients per

million pop'n (IAF)

FY 19/20 Q1 FY 19/20 Q2 FY 19/20 Q3 FY 19/20 Q4

-13

In Q3: ~22admissions expected, with 17

remaining at end of Q3 19/20

18

-3

In Q4: ~20 admissions expected, with 16

remaining at March 20

7

Page 146

Of 78 inpatients, 36 are estimated to be suitable for discharge by the end of March 2020.*

• 38 inpatients are not expected to be discharged before March 2020 (Black RAG rated), 25 of whom are Specialised Commissioning adults.

• The RAG rating for ‘TBC’ patients will be agreed at upcoming CTRs and the next TCP surgery on 02/09/2019..


29

RAG Bexley Bromley Greenwich Lambeth Lewisham Southwark Spec Comm Total

Amber 2 0 1 2 0 1 5 11

Red 1 0 2 4 3 3 5 18

Purple 0 0 0 1 0 0 6 7

Black 0 2 3 3 2 3 25 38

TBC 0 1 0 0 0 1 2 4

3 3 6 10 5 8 43 78

To be confirmed

After March 2020

October - December 2019

July - September 2019

Estimated Discharge Date

January - March 2020



Page 147

There are currently 78 inpatients (71x adult, 7 x children)*

• ~33% (24) of current adult inpatients were admitted to hospital with a diagnosis other than ASD/LD. Out of those patients:

• 7 patients had ASD as a primary diagnosis, and 4 patients had ASD as secondary.

• 8 patients had LD as a primary diagnosis, and 6 patients had LD as a secondary.

• 1 patient had LD/ASD as a secondary diagnosis.

• ~ 28% (2) of current CYP inpatients were admitted to hospital with a diagnosis other than ASD/LD.

• 1 patients had ASD as a primary diagnosis.

• 1 patients had ASD/LD as a primary diagnosis.


30



Page 148

• Progress has been made with current inpatient CTR completion but challenges remain with regard to completion of pre and post-admission CTRs

• The TCP PMO team has been tracking issues beyond TCP control which have resulted in CTR non-compliance. These issues have been escalated to the Strategic Case Manger and

NHSE regional team via monthly assurance meetings.

Transforming Care: Care Treatment Plan position and trend (1 of 3)

31

Metric Target Apr

2019

May

2019

Jun

2019

Jul

2019

Aug*

2019

Ad

ult

s

Post Admission • % admissions in rolling quarter

with post-admission CTR within

28 days of admission.

>75% 100% 67% 25% 100% 83%

Non-Secure

Adults in Hospital

• % current inpatients with CTR

in last 6 months. >75% 84% 82% 82% 88% 91%

Secure Adults in

Hospital

• % current inpatients with CTR

in last 12 months. >75% 95% 92% 92% 97% 89%

CY

P (

<1

8 y

ea

rs)

Post Admission • % admissions in rolling quarter

with post-admission CTR within

14 days of admission

>90% 0% 0% 0% 0% 50%

In Hospital • % current inpatients with CTR

in last 3 months. >75%

86% 100% 100% 100% 100%



Page 149

Transforming Care: Care Treatment Plan position and trend (3 of 3)

32

*CTR Breaches for metrics 1 and 4:

Spec Comm

• 1x Adult - Diagnosis post admission.

• 1x Child - Diagnosis post admission

• *CTR Breaches for metrics 2, 3 and 5:

CCG

• 2x Adult - patient has refused consent. Review of consent once patient mental state improves.

• 1x Adult best interest, patient due to be transferred to another provider site

Spec Comm

• 2x Adult - patient has refused consent.

• 1x Adult – reason TBC.

• 1x Adult- best interest, patient due to be transferred to another provider site.



Page 150

Transforming Care Programme: summary of current position

33



• The south east London Transforming Care Partnership has

been set a target of reducing transforming care inpatients

from 71 to 58 by March 2019, in line with national Building the

Right Support (BRS) bed reduction plans.

• This did not however allow for local demographic

considerations and a significant increase in existing cohort

numbers, as identified within the first year of the programme.

• Whilst the end of year inpatient position was 26 patients

above the BRS trajectory, targeted interventions are in place,

aimed at rapidly improving the performance position.

• The TCP is maintaining a consistently high discharge rate,

facilitated by increased case management and programme

management support, however continuing pressure from

admissions continues to impact net change.

• SEL TCP was set a target of reducing TC adult inpatients

from 84 to 50 by March 2020, in line with national Building the

Right Support (BRS) bed reduction plans. However, this did

not allow for local demographic considerations and a

significant increase in existing cohort numbers, as identified

within the first year of the programme.

• The Operational target agreed with NHS England for SEL

TCP adult inpatients is 64, 14 above the BRS target. The non-

compliant target was built on analysis of the current cohort as

well as modelling based on analysis of the historical data and

expected positive impact that new services will have in the

trajectory.

• The SEL inpatient cohort is complex which results in

challenging discharge pathways. 54% of the current cohort is

amenable to change and 46% is not (Black RAG rated) due to

complex care needs and/ or MoJ restrictions. These two

distinct groups require different approaches to improve care

and facilitate return to the community.

• There are a lack of local specialised support services for

people living in the community with learning disabilities and/ or

autism and their families.

• CCGs, Local Authorities and providers do not always

effectively share information regarding patients at risk of

admission. This limits the ability of the TCP to put in place

support to manage escalating crises in the community.

• Care and Treatment Review (CTR) compliance is challenged

for the pre/post admission KPIs. This is being driven by NHS

England central co-ordination challenges, TCP capacity

challenges and community risk information sharing issues.

Discharge improvement:

• Dedicated case managers in post.

• Regular case management rhythm established.

• Monthly inpatient surgeries.

• Escalation channels open to SEL AO and NHSE national.

Admission prevention:

• Introduction of compulsory root cause analysis.

• PBS training to family carers and professional workforce.

• Autism awareness training to professional workforce.

• Borough level review of risk register processes, supported by

central NHSE resource.

Capacity building:

• Mobilisation of SLaM & Oxleas autism support services.

• Mobilisation of new BBG intensive community support service.

• Expansion of Lambeth Without Walls service.

• Commissioning of Lewisham Intensive Community Support

service.

• New accommodation models under development.

Page 151

High Impact Action Expected completion date and status Key risks to delivery of the action SEL BAF risk

Discharge improvement:

• Regular case management rhythm established including

monthly surgery meetings chaired by Deputy SRO, supported

by weekly case manager/TCP PMO update and escalation

calls.

• Escalation channels open to SEL AO and NHSE national team.

• Ongoing case management and

monitoring.

• Ongoing case management and

monitoring.

• Fixed term contacts for PMO and Case Management

team. In case of significant turnover in the PMO and Case

Management teams there is a risk that specialist

knowledge will be lost, causing the programme to lose

momentum/ effectiveness.

SEL BAF

Reference:

• SEL-08


• 2 x 5 = 10

(medium risk)

Admission prevention:

• Enhanced process for the Dynamic Risk register under review.

• Introduction of compulsory root cause analysis for all

admissions and monthly CTR breaching reporting.

• PBS training provided to family carers delivered in Q4 2018/20.

• PBS training and Autism awareness training confirmed,

delivered in Q1 and Q2 2019/20.

• Q4 2019/20

• Implemented.

• Delivered.

• Delivered.

• There is a shortage of suitable community support

services which can lead to unnecessary admissions/ re-

admissions and can cause delays to discharges.

Capacity building:

• Evaluation SLaM & Oxleas autism support services pilots.

• Mobilising p BBG intensive community support service pilot.

• Evaluation of Lambeth “Without Walls” service expansion.

• Kick-off mobilisation of the Lewisham CCG proposal for

community support services pilot.

• Ongoing.

• Q3 2019/20

• Ongoing.

• TBC.

• There is a lack of clarity regarding NHSE and Spec

Comm programme funding beyond 2019/20 This may

impact the ability of the TCP to retain key programme

team resources.

• There is a lack of skilled LD/ ASD workforce in SEL,

including specialisms such as psychology, mental health/

LD nursing and community carer. This is impacting the

quality of care available and limiting the ability of NHS and

independent providers to mobilise new services at pace.

34

Transforming Care Programme: monthly update

Page 152

SEL Assurance Report Appendix 1: SPC analysis of performance standards August 2019

Page 153

2

Contents

Introduction and overview of SPC approach PAGE 3

SPC charts by constitution standard:

• RTT performance – CCGs PAGE 4

• RTT performance – Providers PAGE 6

• Cancer 2 week waits performance – CCGs PAGE 7

• Cancer 2 week waits performance – Providers PAGE 9

• Cancer 31 days performance – CCGs PAGE 10

• Cancer 31 days performance – Providers PAGE 12

• Cancer 62 days performance – CCGs PAGE 13

• Cancer 62 days performance – Providers PAGE 15

• Diagnostics performance – CCGs PAGE 16

• Diagnostics performance – Providers PAGE 18

• A&E performance – Providers PAGE 19

Page 154

3

Overview of approach

Statistical Process Control (SPC) is a tool used to support statistical interpretation of measures across a time series and identify if variation is due to

‘special’ or ‘common’ cause variation.

• An SPC chart includes a mean (average) line and two control lines above and below it. This helps inform a statistical interpretation of the data series.

• The main use of an SPC chart is to show the bounds of expected variation for a data series. The charts indicate ‘common cause variation’ (i.e. data

points that sit within the expected range of variation) and ‘special cause variation’ (i.e. data points that sit outside the expected range of variation or form

a particular pattern which was unlikely to arise without cause).

• Where a data point (or points) sits above the upper SPC limit this ‘special variation’ shows an improvement in performance beyond that which would be

explainable by the expected month-to-month variation in performance.

• Where a data point (or points) sits below the lower SPC limit this ‘special variation’ shows a deterioration in performance beyond that which would be

explainable by the expected month-to-month variation in performance.

• As well as data points outside the SPC limits, particular patterns of data can represent a ‘special cause variation’ (i.e. the pattern observed would not be

expected to arise organically). The graphs on the following slides use the same methodology as NHS England / NHS Improvement to highlight special

cause variation in the following instances:

• Any single point outside the control limits

• A trend of six data points in a row above or below the mean

• A run of six data points in ascending/descending order

• In essence, ‘special variation’ data is likely to have a cause linked to something exceptional changing in the system.

• In the charts on the following pages, the data series is the monthly performance position going back to April 2017.

Key:

Common cause variation

Special cause variation - concern

Special cause variation - improvement

Upper / lower control process limit

Average (mean)

Target

Page 155

4

RTT 18 weeks - CCGs

Page 156

5

RTT 18 weeks - CCGs

Page 157

6

RTT 18 weeks - Providers

Page 158

7

Cancer 2 Week Waits - CCGs

Page 159

8

Cancer 2 Week Waits - CCGs

Page 160

9

Cancer 2 Week Waits - Providers

Page 161

10

Cancer 31 Day - CCGs

Page 162

11


Page 163

12

Cancer 31 Day - Providers

Page 164

13


Page 165

14


Page 166

15

Cancer 62 Day - Providers

Page 167

16

Diagnostics - CCGs

Page 168

17

Diagnostics - CCGs

Page 169

18

Diagnostics - Providers

Page 170

19

A&E

Page 171


A meeting of the Governing Body12 September 2019

Board Assurance Framework

LEAD: Martin WilkinsonMANAGERIAL LEAD: Charles Malcolm-Smith

Post: Managing DirectorPost: Deputy Director (Strategy & Organisational Development)

AUTHOR(s): Katie Hitchen Post Corporate Services Officer

The Governing Body is asked: To agree that the appropriate risks have been identified against the achievement

of the Corporate Objectives To agree the current risk scores and the target risk scores for the risks

contained within the Board Assurance Framework To agree that there are adequate controls in place to mitigate the risks to the

Corporate Objectives and where existing controls have not reduced the current risk score to the target risk score there are credible action plans, noting that further work is required to ensure they capture the breadth of work on each risk adequately.

Background

The CCG’s Corporate Objectives sets out key priority areas and actions which the CCG will undertake during 2019/20 to deliver the CCG’s Operating Plan. The Corporate Objectives for 2019/20 cover:

Four clinical priority areas:o Respiratoryo Diabeteso Mental healtho Frailty

The focus on these areas is to support the CCG’s goal of making community based care something that can be relied on. Each area has identified initial health and care outcomes to be achieved, key initiatives and expected financial impact.

Primary Care Support and DevelopmentThis includes development of primary care networks, the procurement approach for GP Extended Access Hub for 2020/21, patient engagement in GP Practices, confirmation of the approach translation and Interpreting services across Lambeth, Southwark and Lewisham, and review of primary care services for the homeless

System development – South East London CCG and place-based arrangementsThis objective area covers changing arrangements for Safeguarding Adults across south east London, and for care homes, the partnership children’s safeguarding working in Lewisham and tri-borough Child Death Overview Panel. It will also include quality reporting mechanism

Page 173

Item Number 15

for local providers, and the CCG role in south east London Integrated Care System Development and the developing and implementing the model for Lewisham place-based integrated commissioning

Delivering Quality and Financial PlansThis objective area covers delivery of statutory financial duties and financial control total targets, QIPP programme planning and delivery, Enhanced Health in Care Homes (EHCH) model, and emergency optimisation and discharge to assessThroughout the year, work is undertaken to identify and understand the specific risks the CCG may face which may impact the achievement of the CCG’s objectives and strategic aims.The Board Assurance Framework describes those risks to achieving the agreed Corporate Objectives which have a current score of either “very high” or “high”.

Board Assurance Framework (BAF)

The delivery of the Corporate Objectives involves the CCG exposing itself to a wide range of different types and levels of risks to achieve the benefits that are planned to be achieved during 2019/20. These risks, however, should be identified and managed in a controlled manner.

Throughout the course of the year, Lewisham CCG follows a stepped approach to the management of risk, which follows a process of identifying, analysing, examining and monitoring risks to the achievement of the Corporate Objectives.

The Management Team oversees the development of the Corporate Risk Register at the start of each financial year, which is then reviewed on a bi-monthly basis to monitor identified risk and ascertain any new risks.

The Senior Management Team (SMT), at their meeting on 3 September, have reviewed the risks associated with the achievement of the Corporate Objectives.

Following this assessment, there are currently 5 local risks on the CCG Risk Register that meet the criteria for inclusion on the BAF. The Summary Risk Table shows the risks rated with 12 or above (ie “High” or “Very High”) Current Score.

Page 174

Figure 1: Summary of the Local BAF

ID Risk Title Risk Owner Rating Score Impact L/hood Rating Score Impact L/hood Rating Score Impact L/hoodRisk Movement

99

The NHSE target for CHC Assessments completed in non-acute settings is not delivered and the CCG is not assured by NHSE

Hughes, Heather

6 Moderate Risk 2 3 20 Very High Risk 4 5 2 Low Risk 1 2 None

101 Financial Targets 2019/20Maloney, David

15 Very High Risk 5 3 15 Very High Risk 5 3 10 High Risk 5 2 None

100

No integrated care arrangements in place to deliver proactive, holistic and coordinated health and care

Wilkinson, Martin

12 High Risk 4 3 12 High Risk 4 3 9 High Risk 3 3 None

83BGL QIPP Programme delivery for 2019/20 and planning for 2020/21

Wilkinson, Martin

16 Very High Risk 4 4 12 High Risk 4 3 8 High Risk 4 2 None

93

Lewisham CCG is unable to meet the 34% CAMHS access target by end April 2019

Hirst, Caroline

4 Moderate Risk 4 1 12 High Risk 4 3 4 Moderate Risk 4 1 Increased

Original Current Target

There are currently 6 SEL risks that meet the criteria for inclusion on the SEL BAF. The SEL summary risk table shows the risks rated with 12 or above (ie “High” or “Very High”) Current Score. Further detail on the SEL BAF and management of those risks is contained in the report on the South East London Integrated Governance & Performance Committee.

Page 175

Figure 2: Summary of SEL BAF

SEL BAF Risks - August 2019

ID Risk TitleRisk Owner Rating Score Impact L/hood Rating Score Impact L/hood

SEL-01

STP for the 62 day referral-to-treatment cancer standard High Risk 12 4 3 Very High Risk 12 4 3

SEL-02

STP trusts are not able to achieve their trajectories for timely access to emergency services measured by the 4 hour A&E target High Risk 12 3 4 High Risk 12 3 4

SEL-03

STP acute trusts do not meettheir monthly improvement trajectories to clear long wiaters by the end of Q3 High Risk 12 4 3 High Risk 12 4 3

SEL-04

STP acute trusts are not able to achieve their trajectries for the number of patients on elective waiting lists High Risk 12 4 3 High Risk 12 4 3

SEL-06

STP acute trusts do not achieve the monthly improvement trajectories for the access to timely diagnosis as measured by the standard for diagnostic access

Very High Risk 16 4 4


SEL-07

Financial risk around LAS contract for 2019/20 High Risk 12 3 4


Original Current

The below heatmap table (figure 3) shows the distribution of all CCG and SEL risks identified through the Corporate Risk Register, by their current risk score.

Page 176

Figure 3: Heatmap of Corporate and SEL Risk Register September 2019

Heat Map -July 2019 Current RatingsAlmost Certain

5

No of Local Risks = 1

Risk ID: L99

Likely4


No of SEL Risks = 1

Risk ID: SEL02

No of Local Risks = 0No of SEL Risks = 1Risk ID:

SEL06, SEL07

Possible3


Risk ID: L21


No of SEL Risks = 1

Risk ID: L25, L30, L102, L104,

SEL05, SEL08

No of Local Risks = 3No of SEL Risks = 3

Risk ID: L83, L93, L100

SEL01, SEL03, SEL04


Risk ID: L101

Unlikely2


Risk ID: L59


Risk ID: L22, L38, L41, L63

No of Local Risks = 2No of SEL Risks = 1

Risk ID: L13, L90, SEL10

Rare1


Risk ID: L39

Risk MatrixNegligible

1Minor

2Moderate

3Major

4Catastrophic

5

Total Number of Local Risks (L..) = 18Total Number of SEL Risks (SEL..) = 9

Likelihood

Impact

The BAF attached as Appendix A provides full details of the risks set out in figure 1.

The Governing Body are asked to agree: that the appropriate risks have been identified against the achievement of the

draft Corporate Objectives the current risk scores and the target risk scores for the risks contained within

the Board Assurance Framework that there are adequate controls in place to mitigate the risks to the Corporate

Objectives and where existing controls have not reduced the current risk score

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to the target risk score there are credible action plans, noting that further work is required to ensure they capture the breadth of work on each risk adequately.

AppendicesAppendix A – Local Board Assurance FrameworkAppendix B – Risk Appetite MatrixAppendix C – Glossary of TermsCORPORATE AND STRATEGIC OBJECTIVESThe report provides an outline of the corporate objectives for the CCG for 2019/20, and identifies key risks to the achievement of those objectivesCONSULTATION HISTORY:Senior Management Team Meeting (3 September 2019) – High level risks discussedCorporate Objectives and Risk Management Group (11 June 2019) IGC (23 May 2019) – Agreement of Corporate Objectives subject to further development of the success measuresIGC Workshop (25 April 2019) - discussed the development of Corporate Objectives and high level Risks.Corporate Objectives and Risk Management Group (9 April 2019) – Defined the high level risks to the achievement of the Corporate Objectives.PUBLIC ENGAGEMENT The Public Engagement Risk has defined the risks to Public Engagement. HEALTH INEQUALITY DUTY & PUBLIC SECTOR EQUALITY DUTYThere is a specific risk with regards to Equalities considerations being effectively included in the CCG plans and activities (Risk Identifier 38). These are monitored through the Corporate Objectives and through the management Equality and Diversity Group. RESPONSIBLE MANAGERIAL LEAD CONTACT:Name: Charles Malcolm-SmithE-Mail: [email protected] AUTHOR CONTACT:Name: Katie HitchenE-Mail: [email protected]

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Appendix A – Local BAF September 2019

Corporate Objective:

Financial Delivery 2019/20 & Financial Planning 2020/21

Risk BGL QIPP Programme delivery for 2019/20 and planning for 2020/21(Risk ID 83)

Risk Description:(What is the risk?)

If Bexley, Greenwich & Lewisham (BGL) CCGs do not deliver a credible two-year QIPP Programme this will jeopardise delivery of the financial control total for the current year and 2020/21

It has been caused by: Failure to deliver the 2019/20 commissioner/provider/local

authority-led commissioning interventions and demand management programmes to reduce both acute and non-acute activity

Lack of identified resources and expertise to develop early programmes for 2020/21

It could lead to: An increase in the acute activity run-rate Failing to meet planning expectations of IAF for 2019/20 Re-opening of block contract agreements with providers Contract mediation and/or arbitration Inability to deliver balanced budget in line with plans Inability to commit to new investments Loss of reputation

Risk Owner: Martin Wilkison Risk Manager: Annie NortonDirectorate: Not applicable

Risk Appetite: Low Risk Response: Mitigate

Original Score: Current Score: Target Score: Risk Movement:

Very High Risk High Risk High RiskImpact 4 x Likelihood 4

Impact 4 x Likelihood 3

Impact 4 xLikelihood 2

None

Controls: (What are we doing to mitigate the risk?)

Integrated Contract Delivery Team (ICDT) has secured a large proportion of acute QIPP in the contracts with the main providers for BGL

BGL commissioners have made significant investments in community provider(s) to implement services that will reduce avoidable acute activity

Programme Management Office (PMO) for BGL CCGs has

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been fully in place since the end of May 2019 and leads on providing independent and robust assurance of processes to ensure delivery and implementation progress against plans

Assurance Sources:

The monthly BGL governance and performance management process, which consists of:(i) Monthly Highlight Report updates from Commissioning

Programme Leads reviewed with the PMO(ii) Monthly input from the BGL Business Intelligence (acute

acitivity and financial data) for schemes. This is supplemented with financial performance assessments from the ICDT for contractualised acute schemes and ledger-driven data from Finance for non-acute schemes

(iii) Monthly Planned and Unplanned Care QIPP Assurance Meetings led by the Senior Responsible Officer (SRO) with Programme Leads, PMO and Finance to: Review, understand, challenge and assure the

position, including discussion of mitigation or further escalation, as necessary with regard to key issues and risks

(iv) Monthly BGL Executive QIPP Assurance Meetings with BGL Managing Directors, Chief Finance Offier, SROs and the PMO covering the entirety of QIPP Programme

Monthly SEL Finance Assurance Meetings with the Director of Finance for the SEL Clinical Commissioning Alliance, Chief Finance Officer and BGL Managing Directors

Monthly SEL Delivery Group led by the ICDT with Chief Finance Officers and Directors of Commissioning from across the SEL Clinical Commissioning Alliance

Risk Assurances: (What evidence do we have that the controls are working?)

Highlight Reports and monthly QIPP Assurance Report demonstrating progress and flagging key issues with mitigation details, as per the process outlined above

QIPP Assurance Report submitted to respective CCGs’ Finance & Investment Committee / Integrated Governance & Performance Committee / Governing Body

ICDT Integrated Report and contract management meetings with acute providers

Submissions to NHS England including adhoc returns and review of the NHSE Menu of Opportunities and RightCare data

Assurance Type: ManagementAssurance level: LimitedGaps in Risk Remaining under-delivery of QIPP (Bexley CCG) for 2019/20

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Controls:Actions: Development of the joint BGL QIPP resources/expertise

package for endorsement by the BGL Managing Directors (August/September – BGL SROs).

Agreement for temporary resources regarding Lewisham (July) and Bexley (August) CHC schemes (BGL MDs).

Recovery planning fortnightly meetings implemented from July 2019 for Unplanned Care to support focus on reducing inherent risk for 2019/20 schemes, led by the BGL SROs supported by the PMO.

Weekly meetings implemented from August 2019 for Bexley CCG to support focus on reducing 2019/20 unidentified gap and under delivery (currently £1.8m at Month 4), which includes development of 2020/21 schemes led by the Bexley SRO, Business Intelligence, Finance and PMO – supported by a temporary increase in commissioning resources to support (July).

BGL CCG 2019/20 QIPP & Financial Management Internal Audit.

SEL will set out the 2020/21 QIPP requirements and the process as a consequence of; the Long-term financial plan, the 2020/21 Commissioning acute round and the associated Commissioning Intentions Refresh (September 2019)

Last updated: Last updated: Annie Norton 21/8/19Last reviewed: Diana Braithwaite 04/09/19

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Corporate Objective: Mental Health

Risk Lewisham CCG is unable to meet the 34% CAMHS access target by end April 2019(Risk ID 93)

Risk Description: (What is the risk?)

Accurate data is not routinely flowed or captured through the Mental Health Service Data Set (MHSDS) via the NHS Digital Portal, to demonstrate increased access to evidence based mental health provision for children and young people

It is caused by:• Variability across providers regarding the 'mental health access' definition• The vast range of databases used to capture data, which are not compatible with NHS digital• Difficulties for non-NHS providers when flowing data through the SDCS• Missed opportunities, by providers, to validate data and ensure accurate reporting • Misinterpretations of the access definition

This could lead to:• Inconsistencies in reporting across different service areas (NHS and non-NHS providers)• Under-reporting • Difficulties when meeting the national access target • More children presenting in a mental health crisis at hospital due to lack of access into treatment/support

Risk Owner: Hirst, Caroline Risk Manager: Newell, EmilyDirectorate: Other



Moderate Risk High Risk Moderate RiskImpact 4 x Likelihood 1



Increased


• Through performance management arrangements commissioners continue to work with providers to ensure relevant data is captured to support the CAMHS access targets.• Ongoing development of the new services which will support access targets.• Working senior managers in Kooth to review national access definition.

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• Implementing the NHSI recommendation to ensure that providers strengthen governance and sign off processes related to reported data• Commissioners and providers across the SEL STP are committed to the national agenda and have been working together to understand the current issues in relation to access. Various steps have been taken to respond to this, including regular SEL STP meetings with commissioners and providers, a technical group was established, alongside development of provider guidance notes.• The NHS Lewisham CAMHS Transformation Plan was refreshed in October 2018 and ‘improvement against the CAMHS access target’ has been incorporated as one of eight key priorities.• The Alchemy project has been funded to deliver co-produced interventions to marginalised CYP during 19/20. Included in the menu of support are evidence-based waiting list workshops, intended to facilitate better waiting list management and increased access.

Assurance Sources:

• NHSE Assurance meeting have been replaced with an internal SEL STP assurance process• Commissioner-led project plan linked into SEL STP recovery plan, overseen by STP Mental Health Steering Group• SLaM Core Contract Meetings• Lewisham CAMHS Contract Meetings• 4 borough data meetings with SLaM have been established and should result in the implementation of a monthly performance dashboard in October 2019• Contract monitoring processes for SLaM, and non-NHS providers Compass (including Kooth), Core Assets and EYA• CYP Mental Health and Emotional Wellbeing Programme Board• Joint Commissioning Group• SEL STP CAMHS Steering Group


• Commissioner-led improvement plan linked into SEL STP recovery plan, overseen by STP Mental Health Steering Group• Contracts with SLaM and non NHS organisations• Performance reports to Core Contract Meetings and overall governance for the CYP mental health performance dashboard sits with the MH and EWB board.• Oversight of SEL performance against the access target sits with the SEL Assurance Team

Assurance Type: ManagementAssurance level: LimitedGaps in Risk None

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Controls:

Actions: • Increased capacity within the CWP programme which includes additional permanent and trainee posts. Recruitment has commenced (August 2019)• Development of a provider alliance between SLaM and non NHS provider/s to respond to current gap in relation to self-harm and challenging behaviour (December 2019)• Increased capacity within the Early Years Alliance (previously PSLA) to deliver evidence based provision for conduct and behaviour (July 2019)• Following the NHSI review, the CAMHS improvement programme involves implementation of a conceptual framework to support pathway development, which will have an eventual impact on demand and capacity (Ongoing). The recommendations will also lead to newly established KPIs alongside demand and capacity mapping, which should help focus SLaM’s efforts to meet the target.• Additional work to be undertaken with NHSE and providers to ensure data is captured accurately through manual and MHSDS/SCDS submissions (Ongoing)• Bid submitted to NHSE for the mental health in schools pilot (CCGs to be notified in July)• Lewisham has been successful in securing funding to implement two Mental Health Support Teams (MHSTs) as set out in the Transforming Children and Young People’s Mental Health Green Paper, 2017. MHSTs have been designed to deliver evidence based interventions to children and young people in primary and secondary schools, with mild to moderate needs, with a focus on behaviour, anxiety, depression to support during primary to secondary school transition. This activity should increase access.

Last updated: Last updated: Jessica Juon 13/08/19Last reviewed: Caroline Hirst 13/08/19

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Corporate Objective: Urgent and Emergency Care

Risk The NHSE target for CHC Assessments completed in non-acute settings is not delivered and the CCG is not assured by NHSE(Risk ID 99)


Failure to deliver the DH ‘must dos’• <15% of CHC assessments to be undertaken in acute hospitals by March 2018 and to be maintained across all 4 quarters of any year• all assessments to be completed within 28 days from checklist to DST• conversion of all CHC packages of care to PHBs• maintaining schedule of reviews for long term CHC packages, Fast Track and FNC eligibility

Non delivery of 2019/20 QIPP Failure to competently manage Appeals/

complaints which is detrimanetla to the reputation and finncial posiiton of the CCG

Increased risk of safeguarding issues not being properly investigated and resolved

This is caused by: • Not being able to discharge people quickly from acute wards to community settings• Ongoing changes in and growth to NHSE quality measures and increased assurance• Increasing demand for CHC assessments as part of the discharge pathway• Insufficient resource in the CHC team to manage this and other priorities relating to reviews due to turnover in the team allied with staff sickness• Impact of changes to contracting of Brymore and Sapphire beds

It could lead to:• Unsafe discharges to get people home• Increased pressure on A&E/inpatient beds through readmissions• General capacity issues for CHC Team to manage assessments in dispersed community settings, including out of borough residential and nursing homes• Increase in referral to decision breaches (>28days)• Increased delays in discharges• Increased risk of future PUPOC• Increased risk to complex patients in the

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community• Increase in complaints and litigation• Non delivery of QIPP savings• There is insufficient detailed knowledge of the application of the NHS Framework and lack of continuity within the team to best manage the eligibility assessment process and complex case management

Risk Owner: Hughes, Heather Risk Manager: Carlin, DeeDirectorate: Joint Commissioning



Moderate Risk Very High Risk Low RiskImpact 2 x Likelihood 3



None


• x1 B6 posts interviewed now clearing the final recruitment process and x1 out to advert• x2 B6 vacancies agreed locum cover in interim• x1 B7 vacancy agreed 3 months locum cover and short term contract pending CHC review• x1 B8b locum for 4 months starting 2 September 2019 has been sourced with long standing understanding of CHC processes and structures

Additional (to establishment x1 B7 post agreed for 6 months (locum/ short term contract)

• Implemented interim/without prejudice Responsible Commissioner agreement• Continued funding by LBL of additional CHC Nurse based at the hospital• Maintaining brokerage team focus on nursing and residential placements• Maintaining Monday morning RfD review meetings with a renewed focus on location of assessment• Ensuring that enhanced checklists from hospital are signed off by social work to ensure robustness of recommendation for placements• Prioritising CHC Team activity to support enhanced number of community assessments• Working with CCG commissioners for Sapphire to manage impact of LGT actions around Sapphire beds• LBL have taken urgent action to identify 5 NEF beds in the community and are seeking to identify Nursing Dementia beds for step down

Assurance • Current position information is reported monthly to the

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Sources: A&E Delivery Board• Weekly review of the location of assessments (acute vs community) at the RfD meeting• Maintenance of a real time assessment location list by CHC Team• Monthly reporting of the location of assessments to CHC Exec and the SEL STP CHC meetings• Quarterly reporting to NHS Digital and separately to NHSE (London) CHC Team through AIMS


LCCG's CQIN performance dipped at the end of Q3, was signposted then as expected to maintain Q4 and evidence is that this performance dip has maintained into Q1 of 19/20 and we have not achieved the revised trajectory.

Assurance Type: ManagementAssurance level: SignificantGaps in Risk Controls:

• Turnover and therefore discontinuity in the team continues even with locum cover• A B6 post holder remains on LT sickness absence and this post is not being covered• Impact of the reduction in Sapphire beds on the discharge pathway, despite sourcing NEF community beds, remains acute for being able to step down patients, and current specific need is for Nursing Dementia

Actions: Whole sytstem workshop with commissioners, local authority and providers to consider long-term solutions for providing step-up and step down care in the community (Sept 19)

Seeking to secure Nursing Dementia beds in a local care home with CCG funding (Oct 19)

Significant 'managing down' by Joint Commissioners into the management of the team both in operational terms and for complaint and appeals management. In addition providing support to a high level of immediate access for B7 Team Leader Interim to mitigate against unsafe decision making (Ongoing)

Clear workplan with priorities for the B8b (Sep 19)

Last updated: Reviewed by: Heather Hughes 22/08/19Updated by: Heather Hughes 22/08/19Reviewed by: Diana Braithwaite 04/09/19

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Corporate Objective: CCG Development 2019/20

Risk No integrated care arrangements in place to deliver proactive, holistic and coordinated health and care(Risk ID 100)


An Integrated Care System for Lewisham is not established by 2020 as Lewisham's Health and Care Partners do not take the necessary action to establish effective integrated care arrangements for Lewisham, including a place based board/integrated care partnership and associated provider alliances.

It is caused by:• A lack of leadership across the system to drive forward and deliver the necessary changes at pace and scale • Lack of understanding, engagement and buy in from stakeholders across the system, including staff, public, patients, service users and carers• A lack of clarity on the relationship between local integrated arrangements and the wider SEL ICS• Decisions taken across system continue to support individual organisational benefit, and do not address risks or establish value to system as a whole• Inability to reach agreement on new or redesigned models of care, pathways or services• Limited capacity and capability to deliver agreed programmes and projects within agreed timescales• A lack of strategic direction, associated plans and capability to progress work on key enablers - workforce (both commissioners and providers), IT and estates – which therefore impedes the delivery of an integrated care system• Inability to share key service and activity data to shape the redesign of integrated services and a lack of leadership, ownership and engagement locally to utilise the population health system to identify transformation opportunities• Operational pressures limit the ability of those involved to fully engage with transformation activity

It could lead to:• Failure to target resources to meet local need and address inequalities effectively• Further fragmentation of services across the system• Failure to deliver co-ordinated and holistic care• Continued pressure on emergency and urgent

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care• Lack of development in community based care• Lack of clarity on decision making, responsibility and accountability between local and SEL system• Risks and gains are not shared appropriately across the system• Duplication not addressed and no improvement in VFM is achieved• Reduced ability to meet NHS constitutional standards or agreed partnership objectives• Lack of shared financial and activity data leading to inability to model proposed changes effectively or agree shared benefits and risks• Financial sustainability not achieved• Planning and development of enablers do not align with development of integrated delivery models• Staff continue to work in silos• Poor patient / service user experience• No improvement in key health and care outcomes

Risk Owner: Wilkinson, Martin Risk Manager: Wainer, SarahDirectorate: Corporate Directorate

Risk Appetite: High Risk Response: Mitigate


High Risk High Risk High RiskImpact 4 x Likelihood 3



None


• Commitment to national coverage of Integrated Care Systems (ICSs) by April 2021 set out in NHS Long Term Plan• Demonstrable commitment by Lewisham Health and Care partners and Health and Wellbeing Board to stronger and more collaborative working within existing governance and partnership arrangements • Oversight of provider alliance development provided by specific leadership and operational groups for Mental Health (working age adults) and Care at Home• Full business cases and detailed risk registers in place for both MH and Care at Home provider alliance development• Joint Integrated Commissioning Group for Children and Adults established• Refreshed integrated commissioning intentions to be agreed across adults and CYP by September 2019• Development of place-based integrated commissioning functions and governance overseen by SEL CCG System Reform Group

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• Local partnership vision for community based care agreed • Regular update reports presented to LHCP, the Health and Wellbeing Board and to GB's of each sovereign organisation• Population Health and Care System Programme Board in place to oversee provision of shared analytical platform, common health and care record, and registries of information on specific conditions or population groups. Work includes reviewing the levels of engagement and utilisation across the system • LHCP Estates Group established to identify joint opportunities to share estates between health and care• SEL CCG System Reform Group monitoring engagement and providing key messages across all stakeholders for SEL ICS development and place-based local care partnerships• • Six primary care networks established, in line with national guidance, as a key component of Integrated Care Systems Regular discussions with LBL on future placed based joint commissioning arrangements• Partnership approach to Frailty agreed with Bexley and Greenwich

Assurance Sources:

• Confirmation from NHS England and NHS Improvement that SEL is first area of London to be part of the next wave of Integrated Care Systems (ICS) in England• Reports on progress and planned actions submitted to Health and Wellbeing Board, LHCP Executive Board, the Provider Alliance Development Board and to specific leadership and operational groups for Mental Health (working age adults) and Care at Home and minuted accordingly• Reports on progress and planned actions submitted to sovereign governing bodies for approval - including CCG Governing Body and Strategy and Development • Discussion and actions recorded at Core Contract meetings• No decisions affecting sovereign bodies agreed without being taken through appropriate governance and approval routes within each body• Development of integrated arrangements follows guidance on best practice and information from NHSE, including high impact care models and better care fund examples• All formal changes fall within existing legal frameworks• Training undertaken in the use of Experience Based Co-Design by front line staff• Better Care Fund Plan 2017-19 which supports integrated working approved in October 2017. Policy framework for BCF for 19/20 received.

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• HWB and CCG Governing Body supported and endorsed the plans to develop integrated community based care on 6 and 11 July 2017 respectively.• Care at Home Provider Alliance progressing joint training and further opportunities for joint working• Positive evaluation of NCT pilots and Local Care Networks• Approval on investment in population health and care system by CCG and other partners• Successful application to One Public Estate Programme and s106 monies to support neighbourhood hub development• Membership from across system on Provider Alliance Leadership and Operational Groups for Care at Home and Shadow Adult Mental Health Alliance• Provider Alliance Business Cases and Plans approved - Care at Home approved by Lewisham CCG Governing Body and LBL Mayor and Cabinet in November 2018 and by Lewisham and Greenwich NHS Trust in February 2019• Application of learning from Canterbury NZ and South Tyneside relating to ICS development - 3 May 2019• 35 GP practices currently sharing data on the population health platform as well as hospital and community services data• A small pilot group of professional volunteers are starting to use the new tools and information and feeding back to the programme team before the programme is widened further. The tools include four cohort registries for people with Diabetes and Respirator related needs.

Assurance Type: ManagementAssurance level: LimitedGaps in Risk Controls:

• Overarching strategic framework for health and care needs updating• LCCG is dependent on other local providers and commissioners to mirror CCG's commitment to the development of an integrated care system • A ICS system is being developed across SEL and local activity needs to align • LCCG can ensure workforce development within its own organisation but is reliant on other local providers and commissioners to implement cultural and behavioural change to support the delivery of integrated and personalised care• LCCG is dependent on LBL supporting the development of integrated strategic commissioning and progressing work at a similar pace•LCCG is dependent on commitment, capacity and resources of providers to progress Provider Alliance work at pace and scale

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Actions: • Testing of draft outcomes framework, once measures have been identified (DC - March 2020)• LHCP Executive Board to meet in Sept 2019• Care at Home Provider Alliance Leadership Group planned for Sept/Oct 2019• Partnership Agreement for Care at Home to be finalised by LGT and LBL by April 2020.• Shadow PA for Care at Home in place by October 2019. • Merger of PAs for MH and Care at Home by 2021 - timetable subject to approval by PADB• MH Provider Alliance workstreams to be finalised to initiate first stage of community service transformation - August 2019• CBC vision to inform the development of estates across the system, in particular the development of the Waldron as a neighbourhood hub (ongoing)

Last updated: Last updated: SW/KG/CL 15/08/19Last reviewed: Sarah Wainer 15/08/19

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Corporate Objective: All Corporate Objectives

Risk Financial Targets 2019/20(Risk ID 101)


The CCG fails to meet its statutory financial duties and fails to deliver NHS England's targeted breakeven to control total

It is caused by: • The CCG does not have effective arrangements to control expenditure• The CCG does not have effective cash management arrangements• The CCG does not have adequate management and reporting arrangements• The CCG does not fully deliver its QIPP savings plan• Unplanned and unavoidable cost pressures

It could lead to:• Failure to manage Revenue Resource limit• Failure to manage within combined resource limit• Failure to manage to within draw down limit• Failure to manage within running cost allowance• Failure to deliver targeted breakeven to control

Risk Owner: Maloney, David Risk Manager: Maloney, DavidDirectorate: Finance Directorate



Very High Risk Very High Risk High RiskImpact 5 x Likelihood 3



None


• Expenditure controls• Standing Financial Instructions and Financial Policies• Reservations of Powers and Scheme of Delegation• Schedule of Matters Delegated to Officers• Detailed budget setting procedures - including detailed review of budgets• Detailed budgets 19/20 agreed with budget holders• Budget approved by Finance & Investment Committee• Budgets delegated to authorised budget managers• Audit Committee• Finance and Investment Committee investment controls• Integrated Governance Committee scrutiny - both SEL and Lewisham CCG

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• Contracts based on planned activity and expenditure • Aligned incentive (block) contracts with LGT, KCH, GSTT and a block contract with SLAM• Financial plan compliant with NHSE business rules• Contingency • SBS authorised user controls• Co-ordinated/collaborative PMO approach to deliver QIPP across Bexley, Greenwich and Lewisham CCGs. Head of BGL PMO role now appointed to.• Review of uncommitted CCG budgets• De-risking the 2019/20 QIPP Plan• Budget changes reported to Governing Body • RRL controls and IAT processes• Contract management processes • Cash controls• Maximum cash drawdown• Detailed cash flow forecasts• Maintenance of minimal cash balances at end of each month• Bank mandates and signatory controls• Monthly financial performance reporting• The CCG has established in year financial performance monitoring at the Integrated Governance Committee and escalation to the Governing Body• Financial performance is monitored at provider level at contract monitoring meetings• Annual financial control environment self assessment• Escalation of QIPP recovery plans to Managing Director• SEL risk share agreement

Assurance Sources:

• Prime Financial Policies and schemes of delegation approved by GB• Final Budget approved by Finance & Investment Committee under delegated authority from the Governing Body and noted by the Governing Body• Financial reporting to Lewisham CCG IG & FIC Committee and Governing Body, and SEL IG Committee• Audit committee scrutiny• Finance and Investment Committee scrutiny• Internal Audits• External Audits• Service auditor report on CSU controls• Monthly performance report to IG Committee• Bank and control account reconciliations • Deputy CFO review meetings with FASS team• Audit Committee and IA review of financial control environment self assessment • Finance update at the CD/SMT Meeting• 0.5% general contingency in CCG plan

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• SEL financial assurance meetings with NHS England


• Internal Audit report on financial management (significant assurance)• Operating plan meets NHSE business rules

Assurance Type: ManagementAssurance level: AdequateGaps in Risk Controls:

• Insufficient reserves to meet all identified financial risks

Actions: • Maximise the collaborative QIPP for SE London and across Bexley, Greenwich and Lewisham CCGs • Quarterly financial deep dive meetings with all CCG budget holders and at regular intervals focussing on uncommitted budgets (DM; Ongoing)• Ongoing review of financial position during the year and implementation of mitigating actions as needed (DM; ongoing)• Focus on referral/demand management with support from CD's (DB; ongoing)• Focus on delivery of 19/20 QIPP plan (DB: now to end March 2020)• SEL wide monthly Finance & QIPP Assurance meetings in place for improved scrutiny assurance • Quarter 1 deep dive budget meetings have taken place in July and as a minimum will be held quarterly thereafter. For budgets that carry a material financial risk, these meetings will take place on a monthly basis.

Last updated: Last updated: David Maloney 14/08/19Last reviewed: David Maloney 14/08/19

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Appendix B – Glossary of Terms

(Source: Risk Management Framework (ver 3.0) ratified on 22nd September 2015)

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Appendix D – Glossary of Terms

Glossary of terms: RiskRisk Definition“The combination of the probability of an event and its consequence. Consequences can range from positive to negative.” (Institute of Risk Management)

“A probability or threat of damage, injury, liability, loss, or any other negative occurrence that is caused by external or internal vulnerabilities, and that may be avoided through pre-emptive action.” (Business Dictionary)

AAction RequiredWork that is required to close assurance gaps

Action Target DateThe date that the actions are due to be completed

Assurance Gaps Where the CCG has no evidence of whether or not its controls are effective

Assurance GivenThe evidence that controls are effective or not

Assurance Level The strength of the evidence; None, Limited, Adequate, Significant

Assurance SourceWhere the CCG finds evidence that its controls are effective

Assurance TypeWhether the evidence was generated and collated by management (Internal Assurance shown as IA+ for positive assurance and IA- in red text for negative assurance) or by an independent body (External Assurance shown as EA+ for positive assurance and EA- in red text for negative assurance)

CControlsWhat the CCG has put in place to lessen the impact of the risk should it occur and reduce the likelihood of it occurring

Current ScoreThe Current (‘residual’) risk score which is the most recent risk assessment

OOriginal Score

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The score that has been assessed at the beginning of the financial year

RResponseWhat the CCG has decided to do about the risk: mitigate, accept, transfer or close.

Risk Appetite ‘The amount and type of risk that an organisation is willing to take in order to meet their strategic objectives.” (Institute of Risk Management)

Risk appetite is normally smaller or less than risk tolerance.

“The amount and type of risk than an organisation is prepared to seek, accept or tolerate.” (BS 31100:2008)

“The amount of risk, on a broad level, that an organisation is willing to take on in pursuit of value.” (KPMG)

Risk ScoresRisk Scoring Matrix

Almost certain5

Moderate High Very High Very High Very High

Likely4

Moderate High High Very High Very High

Possible3

Low Moderate High High Very High

Unlikely2

Low Moderate Moderate High High

Rare1

Low Low Low Moderate Moderate

Negligible1

Minor2 Moderate

Major 4

Catastrophic5

ImpactRisk Matrix

Likel

ihoo

d

NHS Lewisham CCG uses the standard NHS 5*5 risk scoring matrix shown above. The impact or consequence of the risk should it occur is measured on the x axis and the likelihood of the risk occurring is measured on the y axis.

Risks are evaluated using the matrix x * y, shown as I * L (Impact * Likelihood), and scored as:• 1 - 3 (green) Low Risk • 4 - 6 (yellow) Moderate Risk• 9 - 12 (amber) High Risk• 15 - 25 (red) Very High Risk.

Risk Tolerance

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“While risk appetite is about the pursuit of risk, risk tolerance is about what an organisation can deal with.” (Institute of Risk Management)

The organisation’s readiness to bear the risk after risk treatments in order to achieve its objectives. (BS 31100:2008)

“Risk thresholds, or risk tolerances, are the typical measures of risk used to monitor exposure compared with the stated risk appetite.”

The following pages have been copied from Institute of Risk Management (2011), “Risk Appetite and Tolerance. Executive Summary.” Institute of Risk Management, London.

TTarget Score All risks on the CCG Risk Register specify the target risk score (i.e. a desired level of risk that the organisation believes is optimal to meet its objectives by the end of the financial year (unless otherwise stated)). The acceptability of the target risk score is subject to review by senior management and relevant Committee as part of the normal review process for the Risk Register.

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Page 1 of 1

Governing Body12th September 2019

Report from the Chair of the Strategy & Development WorkshopDate of Meeting(s) reported: 22nd August 2019Author: Dr Charles Gostling

Main Issues discussed

The meeting covered items on the south east London response to the Long Term Plan for the NHS and SEL CCG system reform.

Response to the NHS Long Term Plan

Julie Lowe (Programme Director, Our Healthier South East London (OHSEL)) presented an update on the South East London response to the NHS Long Term Plan. There has been a round of public engagement in the six boroughs that has also included topic-based events. There will be further development and system engagement on the response during September and October for final submission in November. The overview that was presented also included the relationship with the vision for health and care at a London level, the actions that are being put in place in the south east London System Improvement Plan around performance and finance, and the commitments to enhance Integrated Care System (ICS) maturity and system ways of working. In order to deliver the aims and visions set out in our five year plan, the South East London system will need to achieve long term financial sustainability and the challenges to achieving this were highlighted.

The discussion included the need to address health inequalities needs at both borough and south east London level; interventions will need to be targeted at the appropriate level, such as London wide, across south east London, in borough as well as through primary care networks (PCNs). Other areas included workforce and equality of opportunity, the wider determinants of health, digital transformation, and governance of the SEL ICS.

SEL CCG System Reform

The meeting received an update from Andrew Bland (Accountable Officer for the CCG) on the developments for the proposed south east London CCG merger, covering options for the Governing Body composition for the new CCG, for a SEL Council of Members, and on Borough Based Boards. Arrangements would be put in place for membership voting on the new constitution. The meeting also reviewed the proposed operating framework for the new CCG, including outline roles within the executive structure. The update included the merger application document requirements and timetable.

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Item Number 16


A meeting of the Governing Body12 September 2019

Commissioning system reform in south east London

Merger proposals and application - September 2019

CLINICAL LEAD: Faruk MajidMANAGERIAL LEAD: Andrew BlandMartin Wilkinson

CCG Chair

Accountable Officer Managing Director

RECOMMENDATIONS: The Governing Body is asked to approve an application to NHS England and Improvement (NHSE&I) to merge the six CCGs in south east London (SEL - Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark) from 1 April 2020, establishing a single SEL CCG; and the dissolution of the existing six CCGs from that point.

SUMMARY:1.1. The same proposals are being received by each of the six CCG Governing Bodies at

their meetings in public over September 2019. Applications for merger have to be made to NHSE&I by 30 September 2019.

1.2. This paper outlines the:

Context for the merger proposals

Case for change for merger agreed by Governing Bodies in May 2019

Process followed to date in support of this application

Key features of the proposed new CCG

Operating model and governance of the proposed new CCG

Process through which the capacity and capability of the new CCG will be secured

Arrangements for the ongoing assessment of risks, mitigations and benefits

1.3. When considering the proposals Governing Bodies will need to have assured themselves that:

The views of key stakeholders and partners have been sought through an engagement process and have been adequately and appropriately taken into

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Item Number 17

account in the proposals

The proposals have the support of member practices

1.6 This paper provides Governing Bodies with further details and assurance on each of these points. In this context the Governing Body is asked to:

Approve an application for merger and its submission to NHSE&I on 30 September 2019

Note that in addition to Governing Body approval the CCG’s membership will also need to approve the proposed new CCG Constitution and endorse the merger application

Approve the proposed senior executive team structure for the new CCG (found at section 5.18 of this paper).

Note the process and principles by which the management structure of the new CCG will be derived and implemented (see section six and supporting documentation.

Note that an application for this merger application will only be progressed if the approvals sought above are agreed in all six CCGs according to the same process.

KEY ISSUES: 2. Context

The NHS Long Term Plan

2.1. Our proposals for merger form part of SEL’s response to the Long Term Plan for the NHS in England published in January 2019. The Long Term Plan clearly outlined the importance of orientating commissioning and provider working around populations at a Neighbourhood (circa 50k), Place (circa 150 to 450k) and systems (over 1m) and this mirrors the arrangements outlined by the SEL ICS for a ‘system of systems’ approach where neighbourhoods are understood to be organised and coterminous within the boroughs in which they sit, where our natural ‘Places’ are our six boroughs and our system is, on a long standing and well evidenced basis, SEL.

2.2. The Long Term Plan goes on to outline the future of CCGs in England and states, in the context of ICS development, which the plan mandates:

“Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area. CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation.” (pg. 29 LTP Chapter 1)

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2.3. The creation of a SEL CCG allows for the simultaneous and coordinated commissioning of all three population scales which is critical due to the interdependence of our system (given patient flows) in terms of quality, performance and financial sustainability. It also supports the changes to the commissioning function outlined by the Long Term plan, noting that in SEL we had already, as part of the CCG Alliance and STP work as an Aspirant ICS, recognised the need to make changes to our system in advance of that.

2.4. CCGs of whatever size will remain sovereign commissioning bodies in their own right and their statutory duties to their residents remain unchanged by merger.

2.5. A CCG for SEL will be coterminous with the footprint of the SEL ICS and the six local authorities in SEL.

CCG Management Cost Allowance

2.6. In November 2018 all CCG Accountable Officers (AOs) were asked to make plans, with their Governing Bodies, to secure a 20% reduction in management costs by 1 April 2020. The funding associated with that reduction (£4.7m for SEL) would then be transferred to commissioning of front-line services.

2.7. It is important to note that SEL have taken steps to minimise their management costs in the past and as such do not currently spend the full management cost allowance. As a result, the challenge reduced in financial terms but is increased in implementation terms because many efficiencies have already been achieved.

2.8. SEL CCGs plan to achieve this reduction to time and at the required level but a significant element of it will be reliant upon our ability to reduce any waste and duplication and make efficiency gains through the merger of our organisation. A failure to realise these opportunities through merger will of necessity, result in a straightforward reduction in management capacity.

2.9. As both a collective of CCGs, STP partners and now ICS partners we have outlined the requirement for a ‘system of systems’ approach to the future commissioning and delivery of services in SEL, and supporting improved sustainability and health outcomes. That ‘system of systems’ map is provided in figure 1.

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Figure 1: South east London ‘system of systems’ map

2.10. It is critical that the merger proposals for the CCG do more than aggregate a statutory body across a bigger footprint. The coterminousity of the new CCG and the ICS is important in overall terms, but critically so in terms of our ability to differentiate the scale of commissioning activity, including deepening the local focus of health and care commissioning at borough level with local authorities, whilst enhancing our ability to join up decision making when care pathways extend beyond that borough.

3. Case for change

3.1. Our application for merger is made in support of our ambition to secure more integrated, high quality and sustainable services for SEL’s residents and in response to the NHS Long Term Plan (January 2019). It was agreed by Governing Bodies in May 2019.

3.2. It responds to the policy context in which we operate, in addition to the very immediate challenges faced by SEL in terms of quality and variation of outcomes, performance and finance.

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Objectives

3.3. Through the creation of a single SEL CCG we are seeking to create a commissioning system that:

Locates and coordinates decision making for the populations we serve and the services we commission at the scale at which they are best planned and delivered

Brings about a greater integration of health and social care commissioning around the wider needs and wellbeing of our population and the whole person

Fundamentally shifts the interaction between providers and between commissioners and providers towards collaboration and collective responsibility for patient outcomes, service delivery and living within available resources

3.4. We will be changing our commissioning arrangements alongside the establishment of provider and commissioner alliances in each borough (Local Care Partnerships) and at SEL level as the platform for our developing Integrated Care System (ICS).

Case for change

3.5. In May 2019, the CCG Governing Bodies concluded a process of testing a case for change that has underpinned our subsequent work to describe and make arrangements for a new commissioning body. The case for change was based upon creating a new commissioning approach that would derive:

Responsive population-based commissioning at very local (neighbourhood), borough, and system (SEL) place levels that those diverse communities require - simultaneously through the redesign of commissioning functions and planning and co-ordination of a single commissioning authority.

A different approach to commissioning - that gives greater focus to system strategy, planning and oversight; greater integration of health and social care commissioning; and enables alliances of providers to take ‘traditional commissioning roles’ in service design, responding to populations of similar geography or need.

The ability to derive solutions at the required scale and pace, to the quality, performance and financial challenges that cannot be resolved by our current organisations working in isolation.

The requisite capacity and different capability required to commission services for our populations going forward within a reduced management cost envelope and in line with the above objectives.

3.6. In addition, we recognised the clear need to take control and secure the very local design of our new commissioning system at the earliest opportunity, recognising the need to:

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Go beyond a simple aggregation of our organisations and design a CCG that empowers commissioning focus at every tier of our multi-layered system.

Take urgent action in recognition that the quality, performance and financial challenges we face are long standing and we know now require a more coherent commissioning response beyond the collaborative actions of separate commissioning organisations currently in place.

Ensure that the required reduction of management costs in SEL is underpinned by a planned redesign of our approach to ensure their achievement retains the requisite capacity and capability, rather than a simple reduction in resource.

4. Process

Delivery

4.1. In SEL the CCGs have set up a ‘CCG System Reform’ process to take forward the merger proposals, including the establishment of a governance structure to deliver both ‘pre’ and ‘post’ application activities.

4.2. The System Oversight Group (SOG) is comprised of the Chairs and Accountable Officers (AOs) of the six CCGs and oversees the programme, making recommendations to all six CCG Governing Bodies, as well as providing them with the necessary advice and documentation to support their decision making.

4.3. The SOG is supported by a System Reform and Delivery Group (SRDG) that is independently chaired, bringing together subject matter experts (SMEs) and executive directors from across the CCGs to focus upon the delivery of programme activities. The SRDG also benefits from clinical and local authority input as members.

4.4. The overall programme is further supported by an Executive Director seconded and dedicated to this programme of work and a small Programme Management Office (consisting of project leadership and support, HR and communications expertise and resource).

4.5. The entirety of this infrastructure will be maintained until April 2020 for the purposes of implementation and potentially beyond that. It will be reviewed in quarter three 2019/20 to ensure it has the capacity to support the restructuring of the management teams of the CCG and wider CCG reform programme implementation ahead of and during 2020/21.

4.6. The summary process for the reform programme is provided in figure 2.

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Figure 2: Summary Process

4.7. At the outset the SOG agreed a set of principles, endorsed by Governing Bodies, by which the programme would abide and they are provided at Appendix one.

Pre-application and application

4.8. The vast majority of reform programme work between March and August 2019 has been focused upon engagement to shape a new CCG design, taking due account of views expressed.

4.9. Following initial engagement with stakeholders and consideration of the NHS Long Term Plan in February and March, the CCG Governing Bodies agreed to submit an expression of interest for merger to the Regional Director for NHSE&I in April 2019.

4.10. In May 2019, Governing Bodies agreed a case for change for the merger of the CCGs in SEL (summarised in section 3.5 and 3.6) and approved the continuation of development and engagement on proposals to merger and on the specific design of that new body and how it would work.

4.11. Our proposed application will be considered by all CCG Governing Bodies between 4 and 18 September 2019 and later in September the membership of each SEL CCG will consider a new constitution for that body and the dissolution of their current CCG from 1 April 2019.

4.12. This two-part approval process will culminate in a final application being made to NHSE&I on 30 September 2019, which will then be subject to an assurance process by our regulator over October and either an approval, conditional approval or rejection in early November 2019.

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Post-application

4.13. Should our merger application be successful then the SRDG and SOG will give focus to implementation processes including possible shadow running where appropriate. Major programmes of work will relate to:

Structure design, engagement and consultation with staff, followed by implementation (as outlined below)

Population of the shadow Governing Body membership so that the leadership group can begin to oversee transition more directly

Full preparation of organisational ‘handover and closure’ including staff transfer to the new body where that will relate to TUPE, employment liabilities, policies and procedures, ledgers etc.

Establishment of Borough Based Boards with agreement upon both the level of formality of joint arrangements to be established at ‘Place’ from 1 April 2020 in each borough, recognising that these arrangements will develop over time.

Ongoing communication and engagement with stakeholders upon the implementation of these changes.

Engagement

4.14. The proposals outlined are the product of an extensive period of engagement with the full range of stakeholders and partners across SEL. Our communications and engagement plan outlined our approach in detail and we have implemented it in full with over 120 meetings alongside other communications conducted with residents/ population, member practices, NHS providers, Local Medical Committees, Healthwatch, local government leadership, Health and Wellbeing boards, Overview and Scrutiny Committees, the wider Integrated Care System (ICS) partnership, other London Sustainability and Transformation Partnerships (STPs) and NHS regulators.

4.15. The purpose of this engagement was to shape our proposals, to ensure a full awareness of them and their implications, and to ensure we have demonstrably taken account of views expressed.

4.16. Our approach to engagement has been shaped by the following:

The need to engage across six boroughs and so we have ensured that we have undertaken this process both in individual boroughs but also by bringing the six boroughs together to have shared discussions in some instances.

The wide range and number of stakeholders and partners to engage with, which has required us to utilise small and large scale face to face meetings, attend existing meetings (e.g. Health and Wellbeing Boards), and produce written briefings

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and updates

The fact that the act of merger does not involve any changes to services

5. A single CCG - key features

5.1. The proposed CCG remains coterminous with the six boroughs. In response to the case for change above and taking account of views expressed in our engagement processes, we have designed and agreed a merger proposal that formalises arrangements for SEL commissioning at scale, whilst establishing ‘Place’ or Borough Based Boards that will take delegated authority for planning and delivering more localised change (see Appendix Two – Outline Governance Arrangements separate document).

5.2. The main features of our merged CCG proposal:

Coherence - A single and coherent approach to commissioning for the entirety of our population organised through a single commissioning authority that is clinically led by our Governing Body, connected to and led by our membership through a Council of Members.

Clinically led - A clinical leadership approach that retains the best features of a clinically led organisation as a CCG but recognises the broader clinical leadership offered by developments such as Primary Care Networks (PCNs), our ICS clinical programmes and our Local Care Partnership (LCP) leadership teams.

Responsive - Prime committees that secure both the safe and effective commissioning of services in line with our statutory duties right across SEL, and place delegated authority to enable decision making at the most appropriate scale, through Borough Based Boards in the case of the commissioning of community based care with a greater integration of health and social care commissioning.

ICS ready - A clear interaction and shift towards collaboration between commissioners and providers, and between providers by organising commissioning arrangements alongside emergent commissioner and provider Alliances at SEL and borough level, referred to as Local Care Partnerships (LCPs) at the borough level.

Affordable - An operating model that will reorganise our management resource to support our delivery whilst living within our management cost allowance through the removal of duplication, inefficiencies, and the concentration of expertise.

Operating model

Decision making

5.3. The merger proposal establishes a commissioning operating model that is reflective of our ‘system of systems’ and the need for a multi-layered response at each tier of the

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system. Planning and commissioning (for all areas) would be led and coordinated at SEL level by the Governing Body supported by its local (borough) and SEL committees. Annual commissioning plans will include engagement with and be recommended for support by the Council of members. Figure 3 outlines the commissioning process within the new CCG:

Figure 3: Commissioning processes within the new SEL CCG

5.4. Borough teams will have an interest in and influence upon all SEL commissioning including generation of local priorities with local member practices and clinicians to feed into SEL wide plans. This will either be organised and developed through Borough Based Boards or through the coming together, with equal representation, of clinicians and managers in SEL fora.

5.5. Within the model:

The Specialised / Acute planning and commissioning function will be undertaken once across SEL with associated responsibility, authority and budget

The responsibility, authority and budget related to Primary/ community / out of hospital services will be delegated to Borough Based arrangements (including a Borough Based Director and a Borough Based Board) who sit on the Governing

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Body

In all cases, budget and other financial information will be transparently shared across SEL and boroughs

Primary Care strategy development, planning and commissioning intention creation will be undertaken at borough level

Should boroughs wish to undertake further delegated responsibilities, a set of criteria has been agreed (and can be found in the ‘Outline Governance Arrangements’ document – Appendix two) and against which such proposals would be considered by the SEL CCG Governing Body.

Borough Based Boards

5.6. A key feature of this model is the ability to commission local and in particular community-based care services at borough level. Our proposals create the opportunity and expectation that that will be undertaken in the best interest of residents if it is increasingly a joint or integrated commissioning board across health and care in partnership between the SEL CCG and the Local Authority for that borough.

5.7. To that end the proposal makes clear that each local authority has the opportunity to agree with the CCG both the level of formality, with which they would like to operate a shared arrangement, drawing upon one of the three models outlined in figure four. This application formalises that opportunity only and between 30 September 2019 and 1 April 2020 there will be opportunity to make further agreements within each borough as to the local start point and the trajectory for change.

Figure 4: Three models for shared commissioning arrangements

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5.8. In addition to these arrangements it is the clear expectation that in each borough the LCP will directly interact with commissioners on the Borough Based Board (and for many of the commissioners, they will already be a part of the those Commissioner / Provider relationships).

5.9. It is envisaged that this will be conducted via formal meetings, likely in two parts, - the Borough Based Board and then together with the LCP Board.

Governance

5.10. The Outline Governance Arrangements document (Appendix two) in support of this application provides full details of SEL’s proposals. These establish a Council of Members allowing the membership a clear forum for engagement but also importantly to participate in the decision making of the CCG within its mandate as well as hold the Governing Body to account for delivery against it; a Governing Body that is both compliant with statutory requirements and contains equal representation from each of the six boroughs; and a series of prime committees including Audit, Remuneration, Integrated Governance and Performance, Commissioning Strategy, Primary Care Commissioning Committees, and the six Borough Based Boards (also prime committees).

5.11. The Terms of Reference for the Audit, Remuneration and Primary Care Commissioning committees will be contained within the draft Constitution document. In the case of Borough Based Boards it is important to note that their final composition will be reflective of the formality of joint arrangements and leadership in each borough. However, in order to ensure safe and effective governance arrangements it will be the case that minimum voting membership of the Borough Based Board will be established, and this is detailed in Appendix Two.

Constitution

5.12. The draft constitution prepared for the new organisation will require the approval of the CCGs’ membership, according to the requirements of their current constitutions for those decisions reserved to them accordingly. It is important to note that the document is draft and that some elements of the constitution are not yet fully agreed. The Governing Body is advised that those areas that remain outstanding do not relate to the proposed decision-making or governance of the CCG, as it relates to commissioning patient care, but rather to mechanisms for voting in future upon matters reserved to the membership, where a consensus cannot be reached. NHSE&I guidance requires provision of a plan for the constitution as part of the merger application.

Clinical leadership

5.13. The new CCG will continue to be a clinically led membership organisation. It will

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however operate in a new operating environment where clinical and professional leadership will change.

5.14. The current proposals establish a Council of Members for the CCG providing a vehicle through which practices can participate in decision-making appropriately and hold their Governing Body to account. That Council of Members will have borough-based divisions for the purposes of local clinical engagement (each chaired by an independent (of the Governing Body and borough-based boards) local GP. In addition, we have ensured that clinical leaders are included from all boroughs, equally, on SEL decision making groups, including the Governing Body. We intend to perpetuate our clinical associate type arrangements albeit they will change over time.

5.15. Our CCG arrangements are set in a context of change as we move toward ICS ways of working and so our merged CCG will also sit in the context of a changing landscape including PCN and LCP development right across SEL, offering new and different forms of clinical leadership and input. As such we will need to develop further proposals for this area post application and ahead of April 2020, acknowledging that changes will also continue to be made after that date.

Management resources

5.16. The section that follows provides details upon the process by which the new CCG’s management structures will be populated, noting our clear assessment that current Alliance management structures provide a firm platform from which to build a single CCG’s management support, with the changes outlined below, but that it does require change in order to improve or optimise our approach whilst ensuring it is affordable.

5.17. In May 2019, the Governing Bodies approved the overall Operating Model for management structures and that is provided within the Outline Governance Arrangements document. It sets an expectation that the SEL CCG and all its parts will work as ‘one team’ and will need excellent interfaces, underpinned by significant organisational development (for which a final outline organisational development strategy will be prepared as part of the final application). It is also aimed at and designed to ensure that proposals stay within the management cost envelope, which is significantly less than received currently. This, alongside improved effectiveness, is achieved in part through a number of functions being performed by teams that are either single SEL teams working with and on behalf of each borough or SEL teams with ‘embedded’ resource, physically working in each borough. The model then includes functions that will work as fully borough-based teams.

Executive leadership

5.18. Whilst section six outlines the steps the CCGs will undertake to optimise delivery arrangements and ensure they are affordable, the SOG has now recommended the following Executive team structure for the CCG (for which the portfolios and

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responsibilities are outlined in the Outline Governance Arrangements document – Appendix two):

An Accountable Officer – the single CCG will require a single AO and from the 1 October 2019 all six CCGs will share the same AO. This will be a CCG Governing Body voting member.

A Chief Financial Officer – the single CCG will require a single CFO and pending the outcome of consultation and implementation of current proposals, the six CCGs will share a single CFO, and this will be confirmed in advance of application and be enacted in November 2019. This will be a CCG Governing Body voting member

Six ‘Place’ Based Directors – the operating model for the CCG describes leadership positions for each borough. At this point we can confirm that as a minimum there will be one appointed Place Based Director with dual accountability to the CCG AO and Local Authority CEO (Lambeth) and five Directors with borough leadership responsibility for aspects of NHS commissioning and working as part of agreed joint arrangements with the respective Local Authorities. All six will work with and through a Borough Based Board. It is anticipated that ‘Lambeth’ type arrangements might be adopted in other boroughs either in advance of 1 April 2020 or post-merger. They will be voting members of the CCG Governing Body.

A Chief Nurse – This new executive director role will be created upon the recommendation of SOG and will have responsibility for Nursing, Quality, Safeguarding and other related requirements that should be exercised by an Executive Director, once for the CCG, in line with statutory requirements.

A Chief Operating Officer – This post will be responsible for overall leadership of corporate, governance, assurance, communications and engagement, and business support functions. The post will ensure the effective leadership and co-ordination of the CCG across it’s multi-layered SEL and borough structures.

An Executive Director of Commissioning and Planning – providing leadership and coordination of the CCG’s commissioning strategy and planning process (working with SEL wide and borough-based teams plus ICS partners) and leadership of specialised/ acute commissioning and wider contracting functions.

5.19. The team above represents a near equivalent ‘head-count’ of executive directors as offered by current Alliance arrangements, with the addition of the Chief Nurse post. When taken together this team satisfies the requirements of the CCG as a statutory body, abides by and is well placed to lead the proposed CCG Operating model.

6. Securing capacity and capability

6.1. Over the next six months the System Reform programme will lead, on behalf of the CCGs, a process for design, consultation and implementation of full CCG structures for April 2020.

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6.2. To date, the SEL Alliance executive team and the SRDG has been giving thought to potential structures for SEL wide and borough structures, and an initial phase of staff engagement, on a number of functions has been conducted which included discussions with over 200 staff. In July 2019, the SRDG and SOG met together to agree a final approach to this area as outlined below.

6.3. This approach excludes finance structures, the primary care contracting team that will be a ‘lift and shift’ from current SEL wide arrangements; primary care support teams in each borough (that will be maintained as part of wider borough transformation teams in most cases); or Medicines Optimisation Teams in each borough. The latter two areas represent clear commitments made to member practices during the engagement phase. Finally, it will not relate to the current Our Healthier South East London (or ICS) team, the consideration of which will be taken forward as an ICS wide engagement aligned to our Wave three ICS development programme.

6.4. For all other functions the following process will apply:

Action: Complete by:

1 Initial draft structure proposals across all functions to be outlined following work to date with baseline and indicative future costs to provide a realistic basis from which to engage more widely

13 Sep 19

2 Complete a design and engagement period involving staff, governing bodies and stakeholders to shape structures from initial draft proposals from 16 September 2019

11 Oct 19

3 Produce final structures and test with SRDG and SOG in order to move to a consultation

18 Oct 19

4 On 21 October 2019 launch a nine-week consultation with all staff

20 Dec 19

5 On 20 January 2020 provide a management response to consultation and implementation on new structures

27 Mar 20

6.5. The process above will be undertaken with due account of all management of change policies that have been harmonised across the CCGs.

6.6. Importantly, the timeline ensures that proposals for change only reach the point of consultation post successful application submission and with the certainty of membership support for changes.

6.7. In addition to a clear requirement to abide by the agreed Operating Model the SOG

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have also proposed a set of bespoke principles against which these CCG structures should be designed, agreed and implemented and they are included in the Outline Governance Arrangements document (Appendix two).

7. Responding to engagement

7.1. These proposals have taken due account of the programme of engagement activities, the issues raised and the changes to our proposals made as a result.

7.2. In general terms the proposal for merger has received a high level of support from stakeholders and partners. This is particularly true of the arrangements that allow a single commissioning authority to appropriately address the full pathway of care received by residents through commissioning more effectively across SEL, whilst ensuring a more integrated health and care approach to commissioning in each borough.

7.3. In terms of support, all 17 ICS partners are signatories of the SEL Wave Three ICS application in May 2019, which proposed merger. In addition, each of the NHS Providers and the ICS have provided written letters of support for the proposal to merge.

7.4. Each local authority in SEL has welcomed these proposals and is actively engaging in preparations for the implementation of Borough Based Boards.

7.5. Engagement with local residents and patient groups has been positive, noting some express a concern as to whether the new CCG would lose local borough connectivity, responsiveness and the ability to take account of the views of local people. The establishment of Borough Based Boards and arrangements we have established or committed to locally (in boroughs), in terms of maintaining local partnerships and engagement, alongside further explanation of the statutory requirements of a CCG, irrespective of size, have sought to address those concerns.

7.6. The Healthwatch organisations across SEL have expressed their support and have agreed the recruitment of additional resource with the CCGs to allow them to operate effectively at borough and SEL levels.

7.7. Finally, in the case of member practices, it seems clear that support has been expressed for merger. Concerns have, however, been shared around the governance arrangements within the constitution (in relation to Governing Body composition, voting and the Council of Members arrangements) and the availability of resources in local CCG support teams to general practice. Our proposals have taken clear steps to address those areas.

7.8. Our widespread engagement has provided invaluable feedback. As a result, we have been able to make concrete proposals that demonstrably respond to potential issues

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and concerns raised by stakeholders.

8. Understanding impact, risks and benefits

8.1. Importantly, the act of merger does not involve or require changes to service provision for residents. Instead our merger proposals create a safe and effective commissioning system capable of discharging its statutory duties.

8.2. In the London context we have been careful to recognise the clear need to remain locally responsive and connected to residents in the very diverse communities we serve and ensure that relationship is not negatively impacted upon; so we have:

Ensured an equal voice on our Governing Body and committees for each borough in our SEL arrangements

Developed Borough Based Boards with delegated authority to secure this focus. We have ensured that we will perpetuate all local CCG interactions with borough partnership and related arrangements (Health and Wellbeing Boards, Safeguarding, Overview and Scrutiny arrangements) to ensure effective CCG input to these wider processes and arrangements

Retained local commissioning and leadership teams and enhanced their ability to interact with local authority commissioners and other local partnerships

Maintained borough based clinical engagement with members and the wider system and resources to allow for full engagement of local people

8.3. Clearly, the act of merger may have significant impact upon our staff and as such we have undertaken work to ensure we take the requisite steps to mitigate any risks.

8.4. Going forward it will be important that we have an approach to track the benefits of the changes we are making and the benefits realisation approach is outlined below and will be followed by the new CCG:

Economic benefit – financial improvement, releasing cash, increased income and better use of funds

Effectiveness benefit – Doing things better or to a higher standard

Efficiency benefit – Doing more for the same or the same for less

People benefit – A benefit that although it has an economic, efficiency or effectiveness reason has a direct benefit to our people

System benefit – A benefit that although it has an economic, efficiency or effectiveness reason has a direct benefit on our systems

8.5. Whilst merger, in and of itself, does not have an impact in terms of service change, and because we have taken steps to ensure both local responsiveness and future ICS

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alignment, we clearly expect to realise the opportunities and benefits highlighted by our case for change over time.

Risks and mitigations

8.6. Risk and impact assessment upon proposals for merger have been understood in two ways – those risks to successful implementation of merger and the risks / impact of establishing a merged and single CCG for SEL, alongside mitigation plans and they will be continued to be monitored over time.

9. Recommendations and next steps:

9.1. The Governing Body is asked to: Approve an application for merger and its submission to NHSE&I on 30 September

2019 Note that in addition to Governing Body approval the CCG’s membership will also

need to approve the proposed new CCG Constitution and endorse the merger application

Approve the proposed senior executive team structure for the new CCG (found at section 5.18 of this paper and in the Merger Application document).

Note the process and principles by which the management structure of the new CCG will be derived and implemented (see section six and supporting documentation).

Note that an application for this merger application will only be progressed if the approvals sought above are agreed in all six CCGs according to the same process.

9.2. Our final application document and proposed constitution will reflect the details outlined above and the assurances received by Governing Bodies more generally. They will be:

Considered by the membership over the coming days and in NHS Lewisham CCG member practices will be asked to agree the draft constitution for the new CCG.

Submitted to NHSE&I on 30 September 2019

CORPORATE AND STRATEGIC OBJECTIVESThe organisation changes will support stronger performance financial planning, implementation and monitoring to meet statutory duties and constitutional standards.CONSULTATION HISTORY:

Strategy & Development Workshops February, April, June, August 2019 Membership Forum April, June, August 2019 Neighbourhood Meetings May, July, September 2019

PUBLIC ENGAGEMENT Public Reference Group June 2019 Stakeholder event July 2019

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HEALTH INEQUALITY DUTY & PUBLIC SECTOR EQUALITY DUTYThe strengthened commissioning system and working at scale will support greater impact and effectiveness in meeting the health inequality and public sector equality duties.Any organisational change impacting on staff will follow best practice and include an equality impact assessment.

RESPONSIBLE MANAGERIAL LEAD CONTACT:Name: Martin Wilkinson E-Mail: [email protected]

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1

Appendix One

CCG System reform - SOG agreed set of principles

• Evidence enhanced effectiveness and enable our ICS development in response to the Long Term Plan

• Seek to drive best value out of all corporate investment; we will aim to minimise impact on staff by maximising efficiencies from estates, corporate costs and other non-pay costs

• Ensure capacity and capability at each scale; the necessary cost savings will need to be delivered but there must be assurance that the CCG and place based systems are able to undertake the CCG’s required functions effectively

• Encourage integration with other partners; particularly at the borough level it is expected that there could be increased blended teams with Local Authorities and other partners, and that some place based functions could be delivered with or by these partners

• Initially include all functions; however some may be moved out of scope by the Delivery Group or Oversight Board

• Speak to immediate and future operating environments; this programme should actively move us towards our ‘system of system’ ICS vision and therefore consider our resource requirements for the future as well as the immediate term

• Support our staff through this change; we will aim to communicate regularly, engage as much as possible, and offer options for our staff to minimise the concerns and impact related to these changes

Please see separate document for Appendix Two

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The purpose of this document is to outline the proposed governance

arrangements of NHS South East London CCG and includes:

• Influence & Decision Making arrangements

• Joint Commissioning Arrangements with the Local Authorities

• Functional analysis included the agreed operating model and executive leadership

team

• Governance

NHS South East London CCG

Outline Governance Arrangements

Appendix Two

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There are three interdependent elements of the design which need to be considered in parallel:

2

Three Interdependent Elements of Design

2. Functions

3. Governance

1. Influence & Decision

Making

What are the functions and teams required at each level to shape and

deliver the outlined responsibilities?

What governance is required to appropriately deliver and oversee

responsibilities?

Where will responsibility, decision making and budgets sit and critically how will every part of the new SEL CCG influence that?

This pack aims to summarise the key proposals in each of the areas for implementation for the new NHS South East London CCG

There is an overarching need to ensure that our future approaches support strong engagement with other partners, and move us positively towards our ICS

ambitions

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3

1. Responsibilities, Influence and Decision Making across our commissioning system

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1. ‘Where’ things happen in this commissioning operating model should be reflective of our ‘System of systems’ and the need for a multi-layered response (see next slide for the model supported to date)

2. Planning and commissioning (for all areas) would be led and coordinated at SEL level by the Governing Body supported by its local (borough) and SEL committees

3. Annual commissioning plans will include engagement with, and be recommended for support to the council of members. The council of members would have representation from all six boroughs

4. Borough teams will have an interest in and influence all south east London commissioning including generation of local priorities with local members and clinicians to feed into SEL wide plans.

5. Specialised / Acute planning and commissioning will be undertaken once across SEL with associated responsibility, authority and budget

6. The responsibility, authority and budget related to Primary/ community / out of hospital services will be delegated to boroughs from the Governing Body

7. In all cases, budget and other financial information will be transparently communicated to SEL and boroughs

8. Primary Care strategy development, planning and commissioning intention creation will be undertaken at borough level.

9. Should boroughs wish to undertake further delegated responsibilities, a set of criteria has been agreed (see App 1) and applications can be considered by the SEL Governing Body once appointed

10. The level and formality of joint arrangements in Borough Based Boards will be a matter for (existing) CCG and Local Authority decision before April 2020

4

1. Responsibilities, Influence and Decision Making across our commissioning system - Key messages

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5

Summary of Proposed Model - Responsibilities, Influence and Decision Making

The below is a high level summary of the proposed approach for a collaborative strategy and planning process, and associated decision making in the new SEL CCG

To note there have been discussions about where boroughs want to undertake further delegation (see Appendix 1)

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6

Joint Commissioning Arrangements with the Local Authority

Our case for change has emphasised the importance of joint commissioning across health and social care and consequently three models have been proposed, and agreed:

To note it is not proposed there is a prescriptive model for this joint working; every borough/ current CCG has been asked to agree their approach as of 1st April 2020 with their Local Authority

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7

2. Functional Analysis

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1. Need for a robust structure to deliver upon the arrangements being proposed for responsibilities, influence and decision-making (including delegation to place based boards)

2. Expectation that SEL CCG and all its parts will work as ‘one team’ and will need excellent interfaces, underpinned by significant organisational development

3. Need to ensure that proposals stay within the management cost envelope, which is significantly less than received currently, and enables us to invest in the skills and capabilities we need to achieve ICS

4. Functions in ‘blue’ (on the next slide) in the proposed model will be performed by teams that are either single SEL teams working with and on behalf of each borough or SEL teams with ‘embedded’ resource – physically working in each borough

5. Functions in ‘Salmon’ (on the next slide) in the proposed model will work as fully borough based teams

6. Boroughs are working with local partners on integration and joint transformation priorities and how this will work from 1st April 2020 and this will be developed alongside this programme

7. Primary Care Support, Medicines Optimisation practice support and GP IT, if right for the borough, will remain available to local practices as they are now

8. Many aspects of commissioning and contracting are already provided by single SEL teams today (e.g. Primary Care Contracting) and this will not change. Greenwich, Bexley and Bromley community services are the only main providers not already contracted for by a single team.

8

2. Functional Analysis - Key messages

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2. Summary of Proposed Model - Functions

9

Commissioning Strategy & Planning

Contracting (except

client groups)

Finance - Financial

Strategy &

Planning

Comms

/engagement -

delivery & support

Quality Oversight to

commissioning, Sis/QAs,

surveillance

Acute (Mental

/Physical)

commissioning

Corporate

support*

Finance (embedded)

Quality (coordination)

Assurance of delivery

& Performance

Comms/

engagement

(embedded)

Corporate

support

(coord/

embedded)

Single SEL CCG (once for SEL functions)

*Includes: Governance, FOI, IG, Complaints, E&D, Data Warehousing, Procurement, OD, HR & payroll, GP and Corp IT (excepting Bexley and Bromley) /// **Non acute elements (maternity included in acute) .

SEL embedded Resource; Either coordinating on

behalf of or fully embedded in place

Bexley

Bromley Greenwich Lambeth

Lewisham

Southwark

Primary Care Commissioning

Community (MH & physical)

Commissioning

Client Groups: CYP**, learning disabilities, physical disabilities, non-acute mental

health

Medicines Optimisation Safeguarding

SEND

Assurance (coordination)

SEL-wide Transformation (system owned)

Enablers Workforce Digital Estates System wide pathway changes

Local transformation team






Borough based teams may work together as/ when required

SEL Functions (at scale/ embedded)

Borough functions (where possible with partners eg LA)

Transformation teams (owned by commissioners and providers)

Note all boroughs are represented on SEL GB

Commissioning will require an interaction at all levels

To note: Further discussion required on Quality, BI, CHC & Medicines Management

QI & OD



Commissioning

Client Groups: CYP**, learning disabilities, , physical disabilities, non-acute mental

health


SEND



Commissioning

Client Groups: CYP**, learning disabilities, physical disabilities, non-acute mental

health


SEND



Commissioning


health


SEND



Commissioning


health


SEND



Commissioning


health


SEND

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The agreed Executive leadership team is as follows:

10

2. Executive Leadership Team

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• Better outcomes and experience for patients - a prevailing priority; however, it is important when considering the allocation of capacity over a multi-layered organisation. Allocative decisions must keep the population at its heart as often resource deployed at SEL level will achieve better outcomes for residents than if it were deployed at borough level (and the reverse), equally there may be considerations around different ‘places’ in SEL that are not homogenous.

• Statutory requirements of a CCG are fulfilled effectively - As a single statutory body, there will have to

be sufficient centralised resource to undertake that safely and effectively and it must be adequately resourced. A CCG is not an ICS. Until such time as those self-regulatory and collective accountability features outlined by the ICS maturity matrix are achieved and recognised as such by regulators, the Improvement Assessment Framework requirements and its successors must be adhered to.

• Value for money and efficiency - that structures should take all possible opportunities to remove

waste, minimise non-value adding processes and avoid duplication. This should apply to non-pay as much as it does to pay and should take full advantage of any procurement opportunities to drive efficiency from commissioning support services.

• Clinical Leadership - As a clinically led organisation resources should be made available to support

effective clinical leadership. This investment should pay due regard to the national establishment of Primary Care Networks and our ICS’s development of Local Care Partnerships and provider alliances that could and should provide different opportunities for clinical leadership and the resourcing of it. The NHS Long Term Plan is clear on the future of CCGs as smaller, strategic bodies and points to the movement of system and clinical leadership to ICS partners. This is in part the rationale for CCG management cost reduction and its reinvestment in the ‘Provider side’.

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2. Structure Design – Guiding Principles (1 of 2)

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• Transition to an ICS - any new structure will need to reflect our ambitions to become an ICS. Whilst regulation has not changed, there is a very clear and stated direction of travel which means we should be moving away from transacting for activity and towards shared responsibility for the cost and the care provided to the population of SEL. This is unlikely to have resulted in a meaningful change to requirements on 1 April 2020 but must certainly feature in longer range thinking.

• The balance of capability and capacity across the new CCG - to perform effectively the new SEL CCG

must not lose the capability to support effective commissioning and transformation at local level and must significantly build its capability and capacity to do so at SEL level, for which it currently devotes less than 25% of its resources dependent on definition. CCGs will be key enablers of change and must be co-investors in transformation activities. However, co-investment must be a principle alongside other ICS partners as experience has shown a significant correlation between ‘ownership’ and ‘funding’ of such teams and functions.

• Affordability - The CCG will need to demonstrate the 20% reduction in expenditure as per the national

requirement upon it. It will also be unable to deploy programme costs for any given year beyond that which is available to it when taking into account expenditure of patient care.

12

2. Structure Design – Guiding Principles (2 of 2)

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13

3. What governance will we need to support this?

..At a South East London and Place Based level

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14

3. The single Governing Body composition - Key Messages

1. 26 voting members with a GP majority

2. Voting membership includes 13 GPs ( 12 borough GPs and 1 chair with a casting vote), 1 registered nurse, 1 secondary care doctor (15 clinicians in total), 3 lay members and 8 Executive members

3. These clinical representatives form part of the Governing Body making decisions for south east London, and would also work closely with the membership and other clinical leaders in each borough (including those on the LCP board, PCN Clinical Directors, and OHSEL clinical leads)

4. The GP majority would be secured by the casting vote of the chair

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15

3. The single governing body composition

The proposed Governing Body membership is:

Board Type Member Voting Total per type

Governing Body

Clinical

SEL Chair X 1 Yes + Casting

13 GP votes + casting vote (provides GP majority)

15 Clinical votes

GP Lead X 12 Yes

Secondary Care Dr X 1 Yes

Registered Nurse X 1 Yes

Lay Lay Member X 3 Yes 3

Exec

Accountable Officer X 1 Yes

8 Chief Financial Officer X 1 Yes

Place Based Directors X 6 Yes

Total voting 26

Note that in addition to the above the Chief Nurse would be in attendance as would other South East London CCG executives as required

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16

3. South east London Prime Committees - Key messages

1. Prime and sub-committees are provided on the following slide

2. All south east London committees will have equal representation from each of the six boroughs

3. The Primary Care Commissioning Committee will receive recommendations from borough based boards and focus on appropriate contractual actions required to undertake strategies agreed through Borough based boards

4. A core CCG membership for Borough based boards has been agreed which includes a lay member (see slide 16). However, the exact composition will be determined by the (current) CCG and the Local Authority depending upon the level of joint arrangements that they decide upon - reflecting collaborative working on social care, public health etc

5. The Borough based board must be chaired by a voting member of the SEL Governing Body, preferably one of the two borough GPs, (determined by that borough) and membership must contain the GB voting members from that borough

6. It is proposed that Healthwatch and the LMC are also ‘in attendance’ at these boards in every borough

7. Boroughs also each have a Local Care Partnership board which has further clinical and professional representation from across the local system. They will meet alongside the Borough based board (with a part 1 / 2 as appropriate)

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17

3. Summary of Proposed Model – SEL CCG Prime Committees

Proposed prime and subcommittee structure:

The prime committees above would comply with all nationally mandated requirements and provide the appropriate governance to effectively run the SEL CCG

Borough (place) based boards are a critical part of our new system and will represent prime committees of the SEL CCG governing body. They will bring together the CCG in the borough and the local authority. It is increasingly considered that Borough based boards will be a part two of local care partnership boards that will also include providers, including primary care network leads

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18

3. Borough (place) Based Boards - Key messages

• It is proposed that these prime committees should be referred to as Borough Based Boards (BBB) with the following core membership:

• Borough Based Director • The two GPs from the SEL Governing Body • One lay member • Director of Public Health (non-voting for CCG matters) • Healthwatch (non-voting) • LMC (non-voting)

NB: the Executive membership of the board is potentially dependant on staff in boroughs

• The Local Authority membership will be determined in line with the level of formality of arrangement and afforded status and decision-making rights (on LA budgets or any formal joint agreements) commensurate with those arrangements

• Officers (CCG or LA, embedded or local) will be agreed between the local leadership and the CCG Accountable Officer to ensure the effective running of the BBB

• Clinical leadership will also be present in the provider focussed Local Care Partnership Boards that will sit alongside these BBBs.

• It is proposed that a GP voting member of the SEL CCG GB must chair or co-chair (with the local authority if that reflects the formality of joint arrangements). Co-chairing would not be expected where there is no similar delegation of LA funds to the BBB.

• It is proposed that the (CCG) Chair of the Borough Based Board will have a casting vote

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3. Council of Members (CoM) - Key messages

• A single Council of Members will be established, across south eat London, from 1 April 2020 that will allow for:

o Members to hold the single SEL CCG Governing Body to account and take decisions on matters reserved to

the membership as outlined in the scheme of reservation and delegation

o Members to be held to account for ensuring their contribution to the commissioning development of the CCG

• Each borough will establish a Membership Division of the Council of Members which will each have an independent

chair

• Each member practice will appoint a practice representative (and a deputy)

• The practice representatives will represent their member practice’s views, act on behalf of their member practice in

matters relating to the CCG and vote on the Council of Members on matters relating to the CCG, reserved in the

constitution to the members

• Engagement with membership will continue to take place locally in boroughs, as it does now, and all matters related to

votes will be discussed at these fora

• There will be a single Council of Members meeting that takes place at least annually and more likely bi-annually with

all SEL practice representatives (i.e. an all member conference)

• At least 50% of all south east London practice representatives will be required to be present / vote (electronically) in

order for the Council of Members to be deemed as quorate

• Voting will take place once across south east London

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20

Appendix 1 – Further detail on delegation

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21

1. Proposed initial delegation to place (1/2)

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22

1. Proposed initial delegation to place (2/2)

Some boroughs expressed a desire to secure a greater level of delegation over and above the proposed core delegated responsibility for the planning and commissioning of out of hospital services and arrangements to secure an interest in and influence over acute / specialised planning and commissioning and SEL wide planning and commissioning. Below is a high level proposed criteria by which further delegation would be considered and assessed post application NB: no further delegation would be considered until the SEL governing body has been appointed.

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LEWISHAM CCG

GOVERNING BODY PUBLIC PRE-MEETING

11 July 2019, 9.30-10.00am

From the Governing Body: Dr Faruk Majid, CCG ChairMr Martin Wilkinson, Lewisham CCG Managing DirectorMs Anne Hooper, Lay MemberDr Charles Gostling, Senior Clinical DirectorDr Sebastian Kalwij, Clinical DirectorDr Magna Aidoo, Lewisham Healthwatch

From the CCG:Mr Steve James, Communications ManagerMr Charles Malcolm-Smith, Deputy Director (Strategy & OD)Ms Teresa Rodriguez, Engagement Officer

6 members of the public attended

Question 1

What is being covered on south east London re-organisation at engagement events on 16th July?

CCG Response

We are hosting engagement events on 16th July that will inform the south east London response to the Long Term Plan. Events are being held in each borough and covering different topics. There are a range of developments that will be covered, including changes to the CCG, primary care networks, a place based board and implementing the Long Term Plan. The engagement event will be a good opportunity to learn about the context of changes and contribute to these developments.

Question 2 (also submitted in advance by email)

Migrant charges - Lewisham CCG is aware of the growing horror at the divisive and damaging impact of government policy introduced in 2017 to enforce NHS trusts to seek out and charge those deemed to be ineligible for free NHS care at the point of need. In 2018 LGT invoiced 541 women for maternity care, and this charging process currently includes women who have miscarried or suffered the trauma of a stillbirth.

Lewisham CCG reimburses LGT 50% of the invoiced charge provided LGT can document the patient details and unpaid invoice. That data is shared with the Home

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Item Number 21

Office. This financial incentive to identify more and more people deemed ineligible. Many who are able to appeal are subsequently found to be entitled in the first place. This policy ends the principle of the NHS for universal access to free NHS care at the point of need.

The Association of Medical Royal Colleges, including the RCGP and RCPCH, and the Royal College of Midwives have called for the suspension of the policy and the BMA calls for its scrapping altogether.

Will Lewisham CCG make a public statement calling for the end to this current policy - a policy disguised as charges for 'holidaymakers' and 'health tourists' but in fact hitting vulnerable and undocumented migrants and citizens of the UK unable to provide documentation?

CCG Response

This reflects national guidance and is not an issue that applies only to Lewisham CCG. We will ask commissioning leads to review the process to ensure that the process is being correctly applied locally. We are clear that we do not want to see people who are entitled to free care not to receive it. We will come back with the outcome of the review, and will ensure that people who are eligible are not unfairly treated or disadvantaged.

Follow-up

The Save Lewisham Hospital Campaign has been in discussion with Lewisham & Greenwich Trust and will share the work we have done with them.

CCG Response

We recognise the value of working with the trust on data and in the context of the relevant legal and statutory framework.

Question 3 (also submitted in advance by email)

SE London Pathology network contract and LGT - The introduction of the huge SE London pathology network contract has occurred without public consultation. The motivation put forward by Lord Carter of Coles is financial. There is scant evidence of significant savings. There are significant clinical questions about the risk that such a huge contract, destined to go to a private company, will undermine established relationships in clinical pathways between NHS clinicians and clinical pathologists and will impact on patients.

No risk or health equalities impact assessment has been publicised

There are serious conflicts of interest:

Just one of these is that Lord Carter is chair of one of the three shortlisted bids, applying for a network which is his policy and overseen by NHSI for whom he sits on their board.

LGT currently provides pathology services for many of Lewisham's GPs and is not part of the above contract.

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Will Lewisham CCG agree to call for a public consultation, and ask for a full risk assessment and health equalities and impact assessments to be completed and made public, to look at the impact on patients, clinicians currently using services and local NHS trusts?

CCG Response

This is not a service that requires public consultation as there will not be a direct impact on patients. However, there should be public engagement in the processes, which we would support. A decision has not yet been taken, and for Lewisham it will be taken alongside Bexley and Greenwich.

Question 4

For the engagement events on the Long Term Plan that are taking place, the questions do not match the concerns that people have about services, and how does this relate to the work that Healthwatch was commissioned to undertake to engage and produce a report?

CCG Response

Healthwatch are carrying out work that is additional to thism other public engagement activity.

We encourage people to attend all the events to contribute and share their views and concerns.

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Integrated Governance CommitteeMinutes of Meeting held on Thursday 23rd May 2019

Present Martin Wilkinson (MW) Managing Director (Chair) Alison Browne (AB) Nursing and Quality DirectorShelagh Kirkland (SKi) Lay MemberProf. Simon Mackenzie (SM) Secondary Care DoctorDavid Maloney (DM) Director of FinanceDr Faruk Majid (FM) LCCG ChairPeter Ramrayka (PR) Lay MemberDr Charles Gostling (CG) Senior Clinical DirectorDr Jacky McLeod (JM) Senior Clinical Director Dr Ravi Sharma (RS) Clinical Director

Attending Charles Malcolm-Smith (CMS) Deputy Director (Strategy & OD) (notes)Corinne Moocarme (CM) Joint Commissioning LeadMike HellierGraham HewettGwenda Scott

Apologies Debbie Brown Clinical DirectorDee Carlin (DC) Head of Joint CommissioningDr Esther Appleby (EA) Clinical DirectorDiana Braithwaite (DB) Director of Commissioning & Primary CareDr Sebastian Kalwij (SK) Clinical DirectorDr Angelika Razzaque (AR) Clinical Director

IGC 19/39 Welcome and Introductions

Chair welcomed all to the meeting.

IGC 19/40 Apologies for Absence

Apologies were taken and noted.

IGC 19/41 Declaration of Interests (DoI)

There were no new interests declared.

IGC 19/42 Minutes of Previous Meeting

The Committee agreed the minutes as an accurate record.

IGC 19/43 Review of Actions & Matters Arising

CQRG Meeting – Workforce Update

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Item Number 22

JM provided an update on outstanding action to review a workforce update from LGT. This had been covered at the CQRG meeting held on 16th May.CQRG were advised that a recruitment drive by the trust in the Philippines had led to the recruitment of 100 nurses who would be starting over sporadic dates.

The CQRG also received a report on the results of the staff survey and WRES outcomes for the trust. The CQRG noted:

The gap between the Percentage of white and BME staff believing that the Trust provides equal opportunities for career progression or promotion is 23%.

Percentage of staff experiencing harassment, bullying or abuse for staff in the last 12 months. Almost 3% more BME staff reported experiencing this.

A high disparity in the experience of the following groups: Disabled, BME, Male and 21-30 years old.

A lack of progression for BME staff from Band 7 to Band 8a and above in both clinical and non-clinical roles

There is under-representation of BME groups at Board level, particularly in respect of voting members

There were no clear plans in place to address these inequalities There was no clear plan in place to support disabled staff to enable them

carry out their work.

The division with the highest sickness and absence rate is Surgery and bullying was reported in surgery and cancer divisions

The CQRG noted that EDI characteristics of the Trust Guardians was not reflective of the staff or population demographics.

The CQRG noted the number of voluntary leavers in the first year remains high.

The CQRG was not assured of the actions presented by the Trust in response to highlighted issues. The Trust also did not provide the CQRG with an update on the workforce related CQC action plan

The committee noted the need to link with SEL IGP committee as many areas relate to acute matters. The CQRG chair’s summary would be presented to the Contract Management Board. The committee needs to maintain sight of these issues as they relate to community divisions. The absence of robust workforce plans is a concern as it suggests there may also not be appropriate plans in place for other improvement areas.

There could be implications for morale in the amongst the LGT nursing workforce if recruiting abroad for nurses above band 7 as it implies there may be limited opportunity for internal promotion.

FM has also raised workforce concerns with other SEL CCG chairs and will pursue further and update the committee in due course.

Mental Health Complex Care MoU

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MW provided an update on the MoU that had been agreed at the previous meeting of the committee. It had been approved by 6 CCG committees and will be updated for comments received. MW is chairing a steering group and will email members of the committee with the MoU when finalised.

Action: MW to email finalised MoU

IGC 19/44 Committee Terms of Reference

CMS introduced proposed changes to the terms of reference for the committee, reflecting changes arising from the establishment of the SEL IGP committee.

The committee suggested changes under the ‘areas of focus’ section to provide more clarity and distinction between the IGC and IGP, for instance in non-financial benefits realisation. The focus on the four clinical priority areas should also be reflected in the workplan for the committee.

For ‘escalation’, the link with the IGP should be added where there is an interface between community and acute areas.

It was also confirmed that there would be a September meeting of the committee, although this date was omitted from the meeting schedule shown in the cover report for this item.

The committee AGREED the terms of reference subject to changes and would be presented to the Governing Body for approval.

IGC 19/45 Quality Exception Report

CG presented the report that focussed on mental health and highlighted the following.

Violence and aggression – incidents had steadily increased. The SLaM view was that this reflected increased reporting, not necessarily more incidents. Of particular concern are the increased levels in CAMHS PICU and Snowfields units.

Use of restraints also has an overall increase, driven by an increase in CAMHS PICU. Lambeth had improved outcomes in use of prone restraints and the practices used there would be spread trust-wide.

There was reported reduction in rapid tranquilisation use.

Other areas: friends and family test outcomes remain stable. Collaborative care plans improvement has not been sustained. It is not clear what the measure is for whether a care plan has been done collaboratively.

The committee discussed whether there was a link between the decrease in rapid tranquilisation and restraint. This was not clear. The duration of restraint was also a factor; inappropriate and hasty restraint may lead to the need for rapid tranquilisation.

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Use of restraint would be stable if CAMHS were removed from the figures. The increase in use with young people was concerning. There was also a disparity between ethnic groups, used disproportionately with BAME patients, and is known to apply in MH services across the NHS not just SLaM. A further break down in data is being reported to the CQRG on 24th May.

The committee also queried whether there was a timeline for adopting across SLaM the 4 steps that had been applied in Lambeth, and whether the outcomes after use of prone restraint were known

The increasing serious incidents in the self-harm category was noted. GH advised that this was related to attempted suicides and also reflected a general increase in number of suicides amongst the population. The committee asked for more information on the process for ‘lessons learnt’ from incidents, whether SLaM could demonstrate learning and impact, and how the level of risk is assessed. The SI figures are shown for Lewisham based services and it was requested that there is a comparison with other boroughs.

Action: GH to add comparative data with other boroughs

GH also reported that the way SIs are being managed is changing. It would become a provider-led initiative, managed internally and reported to commissioners for monitoring.

IGC 19/46 Performance Report

MH introduced the report, now covering non-acute services only. He highlighted the following:

Children and Young People’s Mental Health TransformationCCG is unlikely to meet 32% standard. MW advised that with special data collection might reach 30%.

Personal health budgetsNeed to treble PHBs by using other cohorts. CYP and MH are looking at potential cohorts. The new SEL post has not started. There is a risk to meeting the year end target. The committee also identified the need to ensure quality and standardised definitions for PHB across SEL so that the needs of patients are being met.

CHCTeam has secured fixed term resource but gaps remain and there is a backlog to address.

Children and Young People Eating DisordersThere is one breach showing from Q3 that will remain as the figures are produced on a rolling year basis.

Out of area placements

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Remain high, and SLaM is an outlier. A workshop is being held between commissioners and providers and this will be subject to further discussion at the committee’s July meeting.

Action: for forward planner deep dive on mental health out of area placements for IGC July meeting.

The winter plan secured 10 extra beds that have now been mainstreamed. While demand does fluctuate, sufficiency of community services is a consideration; other initiatives such as through LAS are being introduced. Other considerations are the length of stay of out of area placements and the distance (London or elsewhere), and assuring quality and safeguarding issues.

Elsewhere is SEL, Oxleas do not have female for PICU so BBG this will always be out of area. This can happen for Lewisham if PICU full but not as great an issue.

Primary CareMore work is required to be completed for those people on SMI registers

IAFThe CCG is the only CCG in South East London with a majority of indicators in the top quartile compared to being in the bottom quartile of all CCGs.Dementia it may be Outstanding as both indicators are in the top quartile of all CCGs.Anticipated that two indicators currently Amber should turn Green in Quarter 4. Financial Sustainability should meet all standards including being above the 85% QIPP threshold. Quality of Leadership should move to Green on the basis of Directions being lifted. Mental Health there is a new score for the Quality of Data submitted by the Mental Health Providers and all CCGs in South East London are in the bottom quartile as a result of the scores by South London and Maudsley and Oxleas. There is a CQUIN to improve this in 19-20.The CCG overall scoring (e.g. Requires Improvement, Good etc.) for 18-19 should be published in June or July 2019 linked to the next iteration of data.

ObesityAs requested at a previous presentation on the Improvement and Assurance Framework on childhood obesity and overweight percentage for 10-11 year olds, GS attended the meeting to provide the dashboard and key actions for obesity. Lewisham was part of 2016 national pilot for whole system approach to childhood obesity. The changes have led to promising results but levels are still high.

There have been improvements for children at reception stage; difficult to pinpoint one factor, but UNICEF Baby Friendly accreditation may have contributed positively. Year 6 obesity rates are stable: 38% of children are overweight or obese. Nationally the levels are rising so keeping stable is an achievement.

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Prevalence of severely obese children is 5%, equivalent to 150-190 children per year.Family intervention is needed. Those children who are obese are likely to be at risk of developing co-morbidities such as diabetes. Severely obese children in reception are likely to be severely obese in year 6. This has not yet been tracked in Lewisham but is likely based on national figures.Results of reception and year 6 weight assessments are fed back to parents with a phone call to follow-up and signposting to attend support programmes, though take-up is not high. GPs are not advised on the results of the assessments. The reasons for the low-take up may be because the way they view their children is not consistent with media representation of obesity, and they may look normal compared to others at school.The committee identified the benefits of GPs being informed where a child is shown to be obese at reception or year 6, and to have information about the services available. As PCNs make more social prescribing referrals it is important that there sufficient services in place.GS also advised, in response to queries from committee members, that nationally it has been shown that interventions that have been tracked for 2 years have been sustained when completed. Figures for drop outs before the end of the programme are not available.Other interventions in Lewisham include the daily mile, sugar smart and the baby friendly accreditation. Schools are involved through the daily mile (whole school approach to reach all children not just currently active), recruiting to roles to work with schools to become healthier, and Ofsted is introducing changes to bring more emphasis on physical activity and PE. Out of school, the borough has a planning policy to restrict new fast food outlets. A bid is being submitted to replicate the TfL restriction on fast food advertising.

Maternal obesity programme – just under half of women at their booking appointment are overwerweight or obese. Midwives can refer to Weightwatchers and Slimming World after pregnancy.

Other aspects: there is an equalities issue and Black Afro Caribbean population are at higher risk, and this is highest proportion of school age population. Completion of borough’s exercise referral scheme is low. GP practices are being encouraged to become ‘Parkrun Practices’. Health partners can contribute through vending machines and inpatient nutrition.

SK is part of obesity project board and further discussion should take place at CD/SMT and PCOG.

Action: GS &SK to take forward to CD/SMT meeting discussion about service options.

Other areas of the performance reportThe committee noted other areas contained within the IAF report:

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- Primary care workforce would be discussed further at PCOG- Quality of life for carers to be brought back to next IGC meeting

Action: MH to liaise with Ashley O’Shaughnessy to schedule primary workforce at PCOG

Action: CMS to include Quality of life for carers in IGC forward plan

IGC 19/47 Corporate Objectives

CMS introduced the draft corporate objectives for the CCG for 2019/20.The following comments were made:

- CG to be shown as clinical director lead for the objectives concerning financial balance and financial control total

- Quantified, detailed and realistic success measures to be included for all objectives

- CDs and SMT to check and confirm leads for all objectives

The committee AGREED the corporate objectives areas, subject to further development and additions discussed

IGC 19/48 Any other business

None

IGC 19/49 The next meeting of the IGC will be held on 25th July 2019.

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South East London Integrated Governance & Performance Committee

Minutes

26 July 2019

PresentRay Warburton (RW) Independent Lay Member & Meeting ChairAndrew Eyres (AE) Accountable Officer, Lambeth CCGMartin Wilkinson (MW) Managing Director, Lewisham CCGChristina Windle (CW) Director of Commissioning Operations, SELCASarah Cottingham (SC) Director ICDT, SELCARoss Graves (RGr) Managing Director, Southwark CCGKeith Wood (KW) Lay Member, Bexley CCGJacqueline McLeod (JM) Clinical Lead, Lewisham CCGSue Gallagher (SG) Lay Member, Lambeth CCGMalcolm Hines (MH) Director of Finance, Southwark, Bromley & Bexley CCGsSimon MacKenzie (SM) Secondary Care Doctor, Lewisham CCGRichard Gibbs (RG) Lay Member, Southwark CCG Harvey Guntrip (HG) Lay Member, Bromley CCGEmir Faisal (EF) Lay Member, Lambeth CCGRobert Davidson (RD) Clinical Lead, Southwark CCGValerie Shanks Pepper (VSP) Director of Integrated Commissioning, Bexley CCG & CouncilOmar Al-Ramadhani (OAR) Assurance Manager, SELCACarl Glenister (CG) Cancer lead ICDT, SELCA

ApologiesUsman Niazi (UN) Chief Financial Officer, SEL Commissioning Alliance (SELCA) 1

Christine Caton (CC) Chief Financial Officer, Lambeth CCGDavid Maloney (DM) Chief Financial Officer, Greenwich & Lewisham CCGsSiddharth Deshmukh (SD) Chair, Bexley CCGAndrew Bland (AB) Accountable Officer, SEL Commissioning Alliance (SELCA) 1Tony Read (TR) Director of Financial Strategy, SELCAAndrew Parson (AP) Chair, Bromley CCGKrishna Subbarayan (KS) Chair, Greenwich CCGYvonneke Roe (YR) Clinical Lead, Southwark CCGAdrian McLachlan (AM) Chair, Lambeth CCGKieran Swann (KSw) SEL Assurance Team, SELCANeil Kennett-Brown (NKB) Managing Director, Greenwich CCGRobert Park (RP) Lay Member, Southwark CCG Amana Humayun (AH) Lay Member, Greenwich CCGAngela Bhan (ABh) Managing Director, Bromley CCG

1 (Bromley, Bexley, Lewisham, Greenwich and Southwark CCGs)

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1. Introductions, apologies and declarations of interest

RW welcomed members to the meeting. Apologies were noted as above.

The chair welcomed Valerie Shanks Pepper (VSP), Robert Davidson (RD) and Emir Faisal (EF) to the meeting.

RW noted the meeting was not quorate but it was agreed to proceed. Managing Directors (MD) will be contacted before future meetings to confirm attendance of members/deputies to ensure meetings are quorate – Action OAR/KS.

The committee was notified that the running order of the agenda had changed to accommodate the availability of presenters.

No interests conflicting with the business of the meeting or changes to existing interests were declared.

2. Minutes of the last meeting – 21 June 2019

The minutes were approved as an accurate record.

RW highlighted follow-up discussion had occurred via email on Transforming Care and this exchange and an update will be shared at the next meeting – Action NKB

MH updated the committee on the aged debtors position. At the end of June 2019, the overall south east London (SEL) debt was just over £20m which was considerably lower than 2018/19 year-end. He acknowledged there had been concerns around the Southwark position relating to debt owed by the council, however assurance was provided that the position had improved significantly. Some issues have been resolved and the debt had dropped from £2m to around £500k and it was anticipated the debt would soon drop by another £400k. MH detailed the governance process to write off debt and assured the committee the majority of debts are recovered.

It was noted that committee summary reports were presented at the last CCG governing body meetings and governance leads will be contacted to review the process and content of the reports – Action KS.

SC reported that setting up direct access to neuro-imaging at KCH had not progressed because modifying pathways mid-year would not be wise in light of recent performance challenges. Direct access to neuro-imaging will be considered as part of 2020/21 commissioning intentions – a further update will be provided in the upcoming diagnostics deep dive - Action SC.

MH clarified risk share transfers in 2018/19 have not been returned to originators but he would be working with UN to progress repayment over the coming months – a further update will be provided in September 2019 – Action UN.

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The committee noted the finance risks in the finance report would not be incorporated into the wider SEL board assurance framework (BAF) given they are primarily operational risks that contribute to the assessed position on risk 11.

All other actions were noted to have been completed.

The committee reviewed the action log and noted all actions due for July 2019 as being complete.

3. SEL CCGs Finance Update – M3 19/20

MH presented the M3 report and noted although it was early in the year, year-end QIPP delivery was forecast at 95%. He confirmed the overall financial position was good and all CCGs are expecting to achieve their control totals. There remain risks around non-local contracts, primary care and continuing health care, however the SEL position compares favourably with other parts of London which have higher levels of risk. The committee noted the risk around GP at Hand which was around £2-3m. Payment had not been made to north west London and at present Southwark and Lambeth are potentially most exposed.

The committee noted a forecast of £35m SEL risk which was not being reported in the position but assurance was provided this was a manageable level of risk. RG asked if sufficient reserves are available to mitigate the risk and if the reserve position could be included in future reports. SM asked if next year’s risk levels are being reviewed and if plans are being developed. MH confirmed reserves are around £20-25m and other mitigations are in place. He added the levels of reserves would be made available in the next report and SC suggested the underlying positions could also be added – Action UN/SC.

SC provided an update on the local acute position. She noted SEL is performing broadly in-line with plan and is forecasting to achieve the planned position by year end. She highlighted a key risk around Bexley MSK services and noted a shortfall in the budget to support underlying run rate and backlog clearance. Work has been done with all four SEL providers to manage flow and run rate, but the budget will not fund enough activity to reduce the backlog which will result in a significant backlog next year.

On the long-term plan, SC highlighted a submission is due in September and explained the planning assumptions and approach that was being taken - further details will be reported back to the committee in September – Action SC.

SG cautioned that triage systems being introduced on eRS at GSTT could increase the risk of referrals being missed or lost. She also highlighted advanced care plans were not being clearly flagged on hospital patient administration systems resulting in instructions being missed and a loss of potential cost savings. In response, JM explained the SEL planned care board will oversee implementation of eRS referral assessment services (RAS) and they are aware of the potential risks. She advised the committee that the RAS is being rolled out in a phased way, with attention to patient pathways and admin processes to identify any gaps and ensure reliability. SC added some patients are currently being referred to the wrong clinics which negatively impacts on patient experience and reduces efficiency. However RASs will help to ensure patients are referred to the right clinics first time.

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JM highlighted the advanced care plans can be accessed through the Coordinate My Care tool.

The committee noted the current financial position and registered its assurance that an adequate approach to remediation is in place to mitigate identified risks. It was agreed that planned mitigations may reasonably be expected to deliver the necessary improvement to deliver year-end financial targets.

4. SEL CCG Performance Assurance Report

SC updated colleagues on acute performance. On RTT 18 weeks she confirmed providers were marginally behind their trajectories and there were signs of improvement. The PTL size is better than planned and performance is encouraging compared to previous years. She highlighted significant issues around the 52 weeks position with KCH having the highest number and GSTT falling behind trajectory. Local June data indicates a further deterioration in performance; however, a number of mitigating actions are in place and each provider has a productivity efficiency programme in place.

On demand management, SC confirmed referral levels were above plan which will adversely impact on waiting times and adherence to performance trajectories. Discussions are taking place with the London NHS England team to develop a London-wide solution for cleft surgery which represents a number of GSTT’s 52 week waiters. In the interim further referral restrictions for cleft surgery at GSTT will be considered at the next system oversight meeting on 2 August. It was noted that KCH has been outsourcing activity to 18 Week Support but the provider has not delivered the expected level of activity which is driving under performance at the trust.

On A&E four-hour performance, SC noted performance was below plan for all providers and KCH are particularly challenged, however provisional data for June and July shows some improvement. She added SEL is the most significant under performer against plan in London and regulators are now scrutinising improvement plans. She noted significant challenges to performance including capacity, workforce challenges (managers and clinical staff), operational grip and overcoming resistance to pathway change. The committee noted KCH and LGT are now subject to national escalation.

Diagnostics performance was discussed and there is performance variance at all three SEL acute providers, however LGT had returned to compliance based on the latest provisional data. Endoscopy performance at KCH remains a significant issue and a SEL group is working to agree improvement plans, one of which will focus on training more endoscopists.

Referring to the LGT RTT SPC graph, RW highlighted the sustained drop in performance since May 2018 and asked what the drivers were. SC highlighted LGT was consistently compliant with the standard before May 2018 and performance had recently dropped due to emergency pressures and a shift in focus on reducing the PTL size instead of waiting times. SC assured the committee the trust is being asked to focus on reducing waiting times particularly as referral rates to the trust have dropped.

To support the on-going demand management work with practices, JM asked if practices could be enabled to refer patients to community services in neighbouring boroughs. SC agreed this could be considered as an interim solution if sufficient capacity is available, but she emphasised in the long term a core consistent community services offer is required across SEL

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which will be a key focus of next year’s commissioning intentions – Action SC to explore potential for GP referrals to community services in neighbouring CCGs. In response to a query on procedures of limited clinical effectiveness, SC confirmed these were no longer commissioned in current contracts.

Referring to the A&E performance recommendation in the report, SM noted he was not fully assured that sufficient progress will be made on improving A&E performance. SC agreed that in the interim it will be challenging for KCH to meet planned performance levels and the priority now is to ensure there is some improvement in performance and the quality and safety of services is maintained.

Regarding the use of community services, RG queried what was being done to reduce the significant variation in uptake across practices. SC highlighted central triage functions are being setup on eRS which will help reduce variation in access to services.

In response to a query from SG, SC confirmed the system does have sight of potential process inefficiencies in areas like diagnostics, however addressing these is challenging due to staffing issues and immediate operational pressures. SG suggested the utilisation of patient navigators to relieve pressure on staff and SC agreed this was a good idea and confirmed 8 band 4s had already been recruited to support cancer pathways.

RD asked if the recent consultant pension tax changes were impacting on consultant capacity. SC confirmed it was making it more difficult for providers to run extra sessions which was impacting on routine waiting times. She added GSTT are particularly keen to raise the issue with regulators.

In drawing the discussion to a close, RW pointed the committee to the recommendations in the assurance report and asked if the committee i) accept the recommendations and ii) would commit to taking them back to their CCGs for action. All delegates endorsed these two requests and agreed that MDs would be responsible for following up and providing an update back to the committee on implementation.

RW registered his disappointment that no one was present from Greenwich CCG to comment on the recommendations – Action OAR/KS to circulate the recommendations to all CCGs. RW also expressed disappointment that we did not have the wherewithal to have a discussion of Transforming Care at today’s committee. We should ensure that this does not happen again – Action NKB.

The committee agreed it needed to consider layers of assurance and these would be guided by specific questions that the committee could consider – Action OAR/KS circulate the questions.

The committee noted the current performance position and further noted the key issues associated with this. The committee registered its assurance that an adequate set of remedial actions had been identified and agreed with the provider.The committee noted the significant risks relating to the capacity for trusts and the wider system to deliver all actions and that agreed actions would, if delivered, make the necessary impact to achieve agreed trajectories.

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5. Cancer deep-dive

SC introduced Carl Glenister, SEL cancer lead, to the meeting.

SC presented the deep dive which focused primarily on 62 day performance which is the main area of performance pressure. She highlighted meeting the 62 day standard relied heavily on achieving specific milestones in the pathway like completing inter trust transfers (ITT) by 38 days and treating patients within 24 days at the receiving trust. She added the shadow reporting of the new 28 day diagnosis standard had exposed pathway gaps including longer than expected waiting times for diagnostics and first outpatient appointments.

SC identified high staff turnover as a major challenge and vacancies in data teams were inhibiting the providers’ ability to track and manage patient pathways. She also highlighted demand pressures, insufficient capacity, resistance to pathway changes and a high proportion of ITTs as other challenges.

SC took the committee through the rest of the deep dive and touched on the system’s key commitments, action plans by site and tumour group and provider risks. She highlighted lung and neurology tumour groups were receiving particular focus but conceded the system needed to ensure waiting times did not increase for other tumour groups.

SG asked if newly developed immunotherapy drugs for lung cancer are being offered by local providers. A response will be provided by the next meeting – Action SC.

SG noted the large number of pathways in the system and queried if this made the system too complex. AE explained the system was complex because of a deliberate policy of consolidating services which produces better clinical outcomes. Despite this, he acknowledged the system was looking to simplify pathways.

SG also asked what was driving the high staff turnover rate and if providers are addressing the source of the problems. RW asked that this is addressed in the upcoming deep dive on workforce.

Although efforts are being made to reduce waiting times, AE emphasised the importance of making progress in improving diagnosis, early intervention, prevention and the support offered to patients recovering from cancer.

Referring back to the Performance Assurance Report, the committee agreed the recommendations on cancer performance and MDs will report progress back to the committee – Action MDs.

For future deep dives, RW asked committee members to provide specific questions and topics to help ensure the deep dives are focused on the key areas of interest – Action OAR/KS to ask for feedback.

The committee noted the report and its assurance that cancer performance was being comprehensively managed.

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South East London IG&P Board Assurance Framework – July 2019

Before going through the BAF, RW reminded the committee to consider if the risks are accurately described, the risk scores are correct, the appropriate mitigations are in place and if additional oversight is required.

RW and CW highlighted initial risk scores had increased from 12 to 16 to reflect the current performance position. The scores changed for 62 days cancer, A&E 4 hour waits and 52 week waits. The residual risk scores were unchanged because confidence remained in the mitigations in place. A summary of the risk score changes will be included in future reports, and the initial risk scores, agreed at the start of the year, will be included – Action OAR/KS.

In response to a query from RW, the committee agreed the risk scores of 9 for RTT 18 weeks and 15 for achievement of control totals. It was highlighted that the initial risk score for Transforming Care did not correspond to the impact and likelihood score – action KS/CW to clarify the correct score.

In response to a query from KW, SC explained the process of moderating the risk owners’ assessment of the risk scores. She explained risk scores were based on the professional judgement of those who work closest to the areas of risk which are then tested by the assurance team and agreed by the committee.

To give the BAF sufficient attention, SM suggested the committee is asked to focus on two to three risks per month - Action KS. While there could be merit in placing the BAF earlier in the agenda, there is merit in coming to it last, as the committee can review risks based on the discussions of performance and finance throughout the meeting.

HG highlighted workforce as a challenge in all performance areas and suggested it should be reviewed by the committee as a stand-alone risk. CW clarified that workforce was not within the agreed scope of the committee and is covered by the OHSEL and individual CCG boards. The committee endorsed the BAF for July 2019 and accepted the proposed risk scores for each risk.

7. Any other business

No items were raised.

8. Date of next meeting: Friday 30 August 2019, 3.00 - 5.00pm.

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AUDIT COMMITTEE

Minutes of the meeting held 21 May 2019Room 4 Civic Suite, Catford

PRESENT

Shelagh Kirkland (SK) Chair, Lay Member for Audit, LCCG Anne Hooper (AH) Lay Member, LCCGProf. Simon MacKenzie (SM) Secondary Care Doctor, LCCGDr Jacky McLeod (JM) Senior Clinical Director, LCCGPeter Ramrayka (PR) Lay Member, LCCG

IN ATTENDANCE

Michael Cunningham (MC) Head of Finance, LCCGJanice Friis (JF) Senior Financial Control Manager, NEL CSURichard Hewes (RH) External Audit Director, KPMGKatie Hitchen (KH) Corporate Service Officer (minutes), LCCGDavid Maloney (DM) Director of Finance, Lewisham, Bexley & Greenwich CCGsCharles Malcolm-Smith (CMS) Deputy Director, Strategy & Organisational DevelopmentTaryn Retief (TR) External Audit Manager, KPMGSartaj Virdi (SV) Internal Audit, RSMMartin Wilkinson (MW) Managing Director, CCG

APOLOGIES

There were no apologies.

AC19/37 Welcome and introductions

SK welcomed all to the meeting.

AC19/38 Declarations of Interest

There were no other new interests declared by members which would knowingly affect the business of the meeting.

AC19/39 Minutes of the last meeting

The minutes of the meeting held on 24 April 2019 were approved as an accurate record.

AC19/40 Matters arising

There were no matters arising.

04.1 Action Log

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The action log was updated.

04.2 Any matters not covered on the action log

There were no further matters discussed.

AC19/41 Annual Report 2018/19

The Committee raised a small number of presentational points regarding the annual report which CMS agreed to update.

The Committee thanked everyone for all their hard work with producing the annual report.

The Committee APPROVED the 2018/19 Annual Report subject to the presentational changes discussed

AC19/42 Annual Accounts 2018/19

DM confirmed that the CCG had met all its financial duties for 2018/19. DM explained that aside from a small number of presentational changes the final annual accounts were unchanged from the draft accounts the Committee had reviewed at its previous meeting. DM explained that the external audit had largely been completed and that the final annual accounts would be submitted as per the national deadline of 29 May 2019.

DM thanked MC, the finance teams in both the CCG and the CSU together with the external auditors for their hard work in ensuring that the year-end had gone so smoothly.

SK raised a presentational issue regarding some of the notes to the annual accounts. It was agreed that this would be discussed and resolved following the Committee meeting.

The Committee APPROVED the 2018/19 Annual Accounts

Post meeting – the presentational issue raised by SK was resolved satisfactorily.

AC 19/43 NEL CSU Service Auditor Report

JF presented the report.

The Committee noted the report and cover letter containing the management disclosures for 2018/19 and had no additional concerns above those in the report.

AC 19/44 Internal Audit

SV presented the report which summarised the work RSM had completed during the year. It was confirmed that the review of the data security and protection toolkit was complete and the 2 minor issues noted in the report had since been resolved.

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SV explained that the final version of the Head of Internal Audit Opinion included with the Annual Report was consistent with the draft document presented previously to the Committee.

MC thanked Internal Audit colleagues for all of their work undertaken during the year.

The Committee NOTED the Internal Audit Annual Progress Report and the final Head of Internal Audit Opinion

AC 19/45 External Audit

RH presented the Annual External Audit Report, discussing the main headlines and reasons for the clean audit opinion. RH explained that the external audit was largely complete and had gone well. RH complimented the CCG on the good quality of the draft annual accounts and supporting papers that they had received.

RH explained that although the CCG’s Legal Directions had now been lifted, they were in place for the majority of the 2018/19 financial year which meant that ‘an except for’ qualified opinion had been issued for Value for Money. Wording had been agreed with the CCG which was reflected in the audit opinion.

The Committee reviewed and approved the Annual External Audit report and opinions gave their approval for the Management Representation letter to be signed.

AC 19/46 To receive and note rolling logs

Due to a change in staffing, the rolling logs would be brought to the next Audit Committee meeting.

ACTION: KH to locate rolling logs

AC19/ 47 Any other business

There was no other business discussed at this point of the meeting.

AC19/48 Date of next meeting

Tuesday 23 July 2019, 9.30am

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Minutes of the meeting of the Strategy & Development Committee held on Thursday 6th June 2019

Lewisham Town Hall Chambers, CatfordMembersDr Charles Gostling (CG) Senior Clinical Director, ChairDr Esther Appleby (EA) Clinical DirectorDiana Braithwaite (DB) Director of Commissioning and Primary CareDebbie Brown (DBr) Clinical DirectorAlison Browne (AB) Registered Nurse MemberDee Carlin (DC) Head of Joint CommissioningShelagh Kirkland (SKi) Lay MemberProf Simon MacKenzie (SMa) Secondary Care DoctorDr Faruk Majid (FM) CCG Chair Charles Malcolm-Smith (CMS)Deputy Director OD and Strategy (notes)Dr Jacqueline McLeod (JM) Senior Clinical DirectorPeter Ramrayka (PR) Lay MemberDr Angelika Razzaque (AR) Clinical DirectorDr Ravi Sharma (RS) Clinical DirectorSarah Wainer (SW) Programme Lead, Whole System Model of CareMartin Wilkinson (MW) Chief Officer

In AttendanceLivia Royle (LR) PH Consultant, Lewisham Public Health

For item SD 19/17Christina Windle (CW) Director of Commissioning Operations, SELCA

For item SD 19/18Dean Holliday (DH) Population Health and Care Programme Director Miren Shah (MS) Cerner Corporation

ApologiesAndrew Bland (ABl) Accountable Officer Anne Hooper (AH) Lay MemberDr Sebastian Kalwij (SK) Clinical DirectorDavid Maloney (DM) Director of FinanceCatherine Mbema (CM) Acting Director of Public HealthDr Simon Parton (SP) LMC Representative

SD19/14 Introduction and welcome

The Chair welcomed all to the meeting.

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SD19/15 Declarations of Interest

There were no new Declarations of Interest.

SD19/16 Summary notes of the workshop on 4th April 2019

The Group agreed the minutes as an accurate reflection of the meeting.

There were two actions recorded:

An initial meeting had taken place with the council and lay members and there would be a follow-up in July

Public health had attended CD/SMT meeting to follow-up on the JSNA discussion and feed into the topic assessments for 2019.

SD 19/17 SEL CCG Reform

MW and CW provided a presentation on the CCG system reform programme, including key questions for consideration.

MW introduced the context for the proposed changes as a core part of the integrated care system (ICS) development, and that a Wave 3 ICS application had been submitted to NHS England.

The proposed operating model for the SEL CCG was reviewed, based on responsibilities for strategy and planning, commissioning, contracting, and delivery. This would involve at-scale strategy & planning, at-scale commissioning (acute services (physical and mental health) and borough-based commissioning teams (primary care, community services, out of hospital services), at-scale single contracting function, with delivery at all levels.

The points raised included whether the split of commissioning responsibilities was consistent with the aim of closing gaps between secondary care, community and primary care. There would be a particular challenge with mental health as commissioning and contracting arrangements as well as pathways do not differentiate between acute and community services, and are borough-based.

The planned care work that had been undertaken across BGL was cited as an example of system working that could be applied in unplanned care work, and that ways of working need to reflect the whole system. Delegation to one borough would have an impact across the system and so would need agreement of others.

As an example of how services could be tailored to local needs, the current arrangements for primary care were discussed, where there is at-scale contracting but local commissioning.

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MW moved on to the considerations for responsibilities, influence and decision-making, including the ways of working and the different levels of joint commissioning between health and social care.

The summary of functions to be carried out within different parts of the system was reviewed, as single SEL CCG (once for SEL functions, SEL embedded Resource in place), local transformation teams (that may work together as/ when required), SEL-wide transformation.

The discussion looked at issues around the assurance of quality of services. Current proposals are to establish a new leadership role across SEL but to leave local teams in place. The need for local intelligence was identified, for instance where there may be concerns regarding local, small providers, and that reporting would be more difficult if there are additional layers in place. Safeguarding also needs to be place-based focused. Consistent quality assurance processes across the SEL CCG will be required so that the governing body can be adequately assured, and the Director of Quality will need to rely on an appropriate quality presence in each borough.

The committee AGREED with the proposal to prioritise the system planning and commissioning, finance, assurance and performance, communications and corporate governance areas first, enabling a longer design period for the others

The committee AGREED for a South East London Director of Quality to oversee quality across the area and lead the design of these functions over a longer period.

Members queried the impact on capacity and resources in the new structures to achieve the required management cost reductions. It was clarified that the intention was to minimise the impact on staff, for instance through adopting single processes and reducing duplication, establishing a single governing body, and developing skills and new ways of working.

It was clarified that the CCG reform programme governance includes review of risk register and progress by the oversight group that would escalate to governing bodies if required.

The proposed prime committees of the CCG were reviewed. These would include audit, remuneration, commissioning strategy, integrated governance and performance, primary care commissioning committee, and 6 place-based boards. It was emphasised that local PCCCs cannot be established as there is no provision for ‘double delegation’, however, local influence can be made through place-based boards, with reporting to and decisions ratified by the PCCC.

It was highlighted by members of the committee that public engagement and equalities are not included in the proposed committee structures. Assurance on these statutory responsibilities would lie with the governing body.

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Equalities considerations during the change process were also discussed. It was raised that there is a need for more diversity at senior levels, and diversity can be lost during periods of change. There was reassurance that the change process was being overseen by an HR advisor and would follow required policies including an equalities impact assessment. HR processes would be applied for those affected.

It was also highlighted that there should also be equity of senior positions held by inner and outer SEL. This would be reflected in the governance arrangements and membership of the governing body.

It was clarified that under the proposed governing body membership in the slide pack, the lay members would be voting members.

In considering the membership of the Governing Body, there was discussion about the clinical and non-clinical balance and that the current proposed configuration would see clinicians in the minority, there would also be pressure on the capacity of the GPs to deliver their roles. But it was also raised that increasing the number of GP representatives would make the overall membership of the Governing Body larger and therefore possibly less effective as a group.

The option of having the place-based directors as non-voting members was raised as a way of giving a majority to clinical members without increasing the overall numbers on the Governing Body, though it was also considered that these post holders would provide a voice and responsibility for their ‘place’ and so it would be appropriate for them to be voting members.

The proposed transfer of the current six CCG chairs into the GP representative positions was recognised as providing benefits of continuity during transition, and that one of these should become the new chair. There would be a need to establish an election process so that the appointment reflected the membership. As members of the Governing Body the existing chairs would be bringing a local perspective while having south east London responsibility.

In considering the possible membership of the place-based board, it was highlighted that representatives from a council of members would provide a direct link with the membership. Areas delegated to the place-based board might cover primary care commissioning, community services, and other non-hospital services. Further consideration of how this would apply to mental health services patient pathways would be needed, though there is a distinction between contracting and commissioning of these services which might be reflected in resourcing of function.

There would be further discussion of the composition of the place-based board particularly with the local authority.

The committee AGREED that there should be 3 lay members of the Governing Body and that there should be further consideration of the numbers of practice/GP

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representation on the Governing Body to take into account the need for clinical input and representation along with the group’s effectiveness.

SD 19/18 Population Health Platform

DH outlined that the Cerner platform provides the tools and capabilities to bring information from across the Lewisham Health and Care Partnership to support transformation. It can provide the systems intelligence about priorities, with live and integrated data from which to make decisions.

DH summarised the opportunities arising from the implementation of the platform, including to identify and track cohorts of people and their care, a more joined up provider and commissioner system, care management and co-ordination, see whole populations and cohorts in one place, see across someone's entire care record and multiple long term conditions / care needs, measure improvement in key areas, spots gaps, high risk areas and opportunities quickly and respond, focus on early intervention commissioning and provision.

DH explained some of the findings from the data, for instance the number of bed days arising from admissions for new diabetics without diagnosis and for those at risk of diabetes. The discussion that followed highlighted that the data may not reflect information from records that is included in free text (e.g.diabetes advice and support) or how read codes are used.

In order to ensure that the benefits of the system can be achieved there is the need to develop the system around care pathways, to cleanse and improve the data, and this will involve engaging with clinicians so the system is working better. The more complete the data, the more reliable and more useful the system is.

DH and MS are working with 6 GP practices, and developing closer working with clinical directors, clinical reference groups and leaders in LGT.

The analytics workstream will focus on a few areas, such as diabetes, and use analytics to drive improvement. There can be a link with education and development needs, for instance reasons for admissions.

The committee AGREED that the development of the population health platform should be through focus on the four clinical priority pathways.

SD 19/19 Stakeholder Survey Report

CMS introduced the report on the outcomes of the annual stakeholder survey. The outcomes are generally positive for the CCG in comparison to similar CCGs. The CCG’s response rate had increased from 59% to 73%. 96% of respondents rated the effectiveness of their working relationship with the CCG as good or fairly good and other particularly positive responses were for the questions relating to public

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engagement. There are improvement areas for system working, delivering value for money and improving quality.

SD 19/20 Any Other Business

There were no further items of business.

The next meeting of the Strategy and Development Committee will be 1st August 2019.

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