AGENDA - High Weald Lewes Havens CCG · High Weald Lewes Havens (HWLH) and this has the potential to improve the lives and care of all its dementia sufferers and their carers. The

NHS High Weald Lewes Havens Clinical Commissioning Group

A meeting of the High Weald Lewes Havens Clinical Commissioning Group Governing Body to be held in public on Wednesday, 25 January 2017 at 1.00pm,

Venue : Boardroom, 36-38 Friars Walk, Lewes BN7 2PB

Members Dr Elizabeth Gill Clinical Chair (EG) Alan Beasley Chief Finance Officer (AB) Dr Peter Birtles Clinical Lead for Urgent Care (PB) Wendy Carberry Chief Officer (WC) Peter Douglas Lay Member Governance, and Vice Chair (PD) Karen Ford Lewes Havens Locality Practice Management Lead (KF) Alan Keys Lay Member Patient and Public Involvement (AK) Denise Matthams Registered Nurse Member (DM) Dr Neil Myers Lewes Havens Locality Chair (NM) Frank Powell High Weald Locality Practice Management Lead (FP) Dr Ragu Rajan Planned Care Clinical Programme Lead (RR) Dr Sarah Richards Chief of Clinical Quality and Performance (SR) Dr David Roche High Weald Locality Chair (DR) Dr Michael Rymer Secondary Care Clinician (MR) Martin Smits Lay Member Primary Care Governance In attendance Joanne Bernhaut Consultant in Public Health, East Sussex County Council (JB) Tim Crowhurst Board Services Officer (TC) (minutes) Hugo Luck Associate Director of Operations (HL) Ashley Scarff Director of Strategy (AS) Sally Smith Director of Delivery and Primary Care (SS) Members of the public

AGENDA

Questions from the public will be taken prior to the formal opening of the Governing Body meeting. A record of the discussions will be appended to the formal minutes.

Item No

Item Action Lead Paper Time

01/17 Welcome and apologies for absence Note EG Verbal 13.00 02/17 Declaration of interests Note EG Verbal

03/17 Minutes of the 26 October 2016 Governing Body meeting

Approve EG Yes

04/17 Matters Arising/Action Log Note EG Yes

05/17 Chair’s report Note EG Verbal 13.20

06/17 Chief Officer’s report Note WC Verbal 13.35

Section 1 - Quality, Performance and Delivery

07/17 Quality report

Review and discuss

SR Yes 13.50

08/17 Finance and Contract report (including QIPP)

Review and discuss

AB Yes 14.15


09/17 Performance Report

Patient Transport Service update

Review and discuss

HL/WC Yes 14.35

Section 2 - Public Health and Engagement

10/17 Patient and Public Involvement (PPI) update

Note AK Yes 15.00

11/17

Reporting from sub-committee Chairs and Leads

Note

Verbal 15.15 i) High Weald locality DR

ii) Lewes Havens locality NM

iii) Quality and Performance Committee DM

iv) Clinical Executive Committee SR

Section 3 – Governance

12/17 Assurance Framework Review and

Approve HL Yes 15.30

13/17

Policies review – various Sponsorship & Joint working

Gifts & Hospitality

Conflicts of Interests Policy

Purchasing Card Policy

Whistleblowing Policy

Social Media Policy

Complaints Policy

Risk Management Policy

Risk Management Strategy

Reporting and Managing Incidents and Serious Incidents

Ratification AB/HL Yes 15.45

Section 4 - Items to note - to discuss by request only.

14/17 Public Health updates: November 2016 and December 2016 Director of Public Health Annual Report –

Note JB Yes

15/17 Clinical Executive Committee minutes October, November and December 2016

Note SR Yes

16/17 Quality & Performance Committee minutes September, October and November 2016

Note DM Yes

17/17 Audit and Risk Committee minutes September 2016

Note PD Yes

18/17

East Sussex Clinical Networks minutes

Accident & Emergency Delivery Boards – none for this Governing Body meeting

Note EG Yes

19/17 Health & Wellbeing Board minutes July 2016

Note EG Yes

20/17 Primary Care Commissioning Committee (PCCC) minutes October 2016 and November 2016

Note MS Yes

21/17 Any Other Business To be notified to Chair at least 2 working days in advance.

EG 15.55

Close

16.00


Section 5 – Confidential PART 2. Items to approve or note by consent (only to be discussed upon request)

Dates of future meetings: Wednesday 22 March 2017 – tbc Wednesday 24 May 2017 – Ashdown Room, Uckfield Civic Centre Wednesday 26 July – Main Hall, Peacehaven Community Centre

Freedom of Information Act: Those present at the meeting should be aware that their names and designation will be listed in the minutes of this Meeting which may be released to members

of the public on request.

Conduct of meetings in relation to attendance by members of the public: Members of the public are asked to note that Governing Body meetings are meetings of the Governing Body held in public. They are not ‘public meetings’ where members of the public can speak at any point. The Agenda above identifies when the Chair will receive questions and comments from the public. For all other agenda items speaking rights are reserved to Governing Body members and agreed representatives sitting at the table; members of the public should not speak or intervene in proceedings unless invited to do so. In all matters the Chair’s decision is final. The introduction by the public or press representatives of recording, transmitting, video or similar apparatus into meetings of High Weald Lewes Havens Commissioning Group is not permitted.

Written questions from the public: Members of the public attending Governing Body meetings are welcome to ask questions at the beginning of the meeting. Please submit your questions at least three working days before the meeting to [email protected] ensuring you include a contact name, telephone number or email address. Governing Body papers: Papers are held on the Clinical Commissioning Group website and can be accessed through the following web page link: http://www.highwealdleweshavensccg.nhs.uk/about-us/our-governing-body/meetings-in-

public/?categoryesctl9967092=18153

mailto:[email protected]

http://www.highwealdleweshavensccg.nhs.uk/about-us/our-governing-body/meetings-in-public/?categoryesctl9967092=18153

http://www.highwealdleweshavensccg.nhs.uk/about-us/our-governing-body/meetings-in-public/?categoryesctl9967092=18153

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DRAFT Minutes of the High Weald Lewes Havens Clinical Commissioning Group Governing Body held in public from 1.00pm on Wednesday, 26 October 2016

Members Dr Elizabeth Gill Clinical Chair (EG) Alan Beasley Chief Finance Officer (AB) Dr Peter Birtles Clinical Lead for Urgent Care (PB) Wendy Carberry Chief Officer (WC) Peter Douglas Lay Member Governance, and Vice Chair (PD) Karen Ford Lewes Havens Locality Practice Management Lead (KF) Dorothy Goldman Acting Lay Member Patient and Public Involvement (DG) Alan Keys Lay Member Patient and Public Involvement (AK) Denise Matthams Registered Nurse Member (DM) Dr Neil Myers Lewes Havens Locality Chair (NM) Frank Powell High Weald Locality Practice Management Lead (FP) Dr Ragu Rajan Planned Care Clinical Programme Lead (RR) Dr Sarah Richards Chief of Clinical Quality and Performance (SR) Dr David Roche High Weald Locality Chair (DR) Dr Michael Rymer Secondary Care Clinician (MR) Martin Smits Lay Member Primary Care Governance In attendance Tim Crowhurst Board Services Officer (TC) (minutes) Hugo Luck Associate Director of Operations (HL) Ashley Scarff Director of Strategy (AS) Sally Smith Director of Delivery & Primary Care (SS) Victoria Spencer-Hughes Consultant in Public Health, East Sussex County Council (V S-H) Members of the public: An opportunity for questions from the public was provided prior to the formal opening of the Governing Body meeting. The vice-Chair advised that a number of written questions had been received by the CCG in advance of the meeting in respect of the Patient Transport Service (PTS). As the member of the public who had submitted them was not in attendance, the questions and the CCG’s responses were circulated in writing at the meeting. [Nb. A record of the questions and the CCG’s answers are also appended to the Minutes of this meeting and are posted on the CCG’s website with the papers for October 2017 Governing Body meeting.] There were no other questions raised by members of the public.

Item number Item Action owner

125/16 Welcome and apologies for absence

The vice-Chair welcomed everyone to the meeting. Apologies were received from:

Elizabeth Gill (Chair)

Karen Ford

Dorothy Goldman

Neil Myers

Ragu Rajan

Elizabeth Gill had formally delegated her role as Chair to Peter Douglas (vice-Chair) for this meeting. The Governing Body noted the apologies for the meeting.

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126/16 Declaration of interests

There were no declarations of interest at this meeting.

127/16 Minutes of the 28 September 2016 Governing Body meeting

The Governing Body agreed the minutes of the 28 September 2016 meeting were an accurate record of the meeting. The Governing Body approved the minutes.

128/16 Matters Arising / Action Log

The Governing Body reviewed the Actions Log: 82/16 Quality report: To identify which care homes have frequent repeat visits from South East Coast Ambulance Service (SECAmb) and then cross reference to the local GP surgeries responsible for those homes Sarah Richards advised that SECAmb is still working on the IT which will help provide easy access to this data. In the meantime, a manual search has revealed only one nursing home in the HWLH locality with repeat visits over the last few months. Data will continue to be sent to the CCG on a monthly basis. 108/16 Quality report: To investigate Paediatric service delays to review children following referrals from GPs Sarah Richards advised that any delays are largely arising due to an increase in referrals. The CCG is monitoring this closely and detailed analysis will be brought to Quality & Performance Committee, which reports to Governing Body. The Governing Body noted the other completed action; there were no other matters arising.

129/16 Chair’s report

In the absence of the Chair, the vice-Chair reflected on the key issues addressed since the last Governing Body meeting in public in September 2016. Congratulations were offered to Dr Elizabeth Gill, Dr Emma Costello, Kim Grosvenor and the CCG’s Dementia Golden Ticket Team on winning the National Primary Care Award for Pathway Innovation of the Year in October 2016. The Golden Ticket is a multi service integrated pathway that has been piloted around Buxted Surgery in East Sussex with excellent feedback and results. The CCG is now in the process of rolling out The Golden Ticket across High Weald Lewes Havens (HWLH) and this has the potential to improve the lives and care of all its dementia sufferers and their carers. The Chair encouraged Governing Body members to attend the Council of Members meeting on 2 November 2016 (at the East Sussex National, Uckfield), where Dr James Kingsland OBE (National Clinical Commissioning Network Lead for England) is the key speaker. Finally, the vice-Chair said he was pleased that this Governing Body meeting was being held at the Meridian Centre on this, the 100th anniversary of the founding of Peacehaven. It felt especially appropriate given the town was originally formed for retiring WW1 veterans as it was felt that the setting, sea air and simple lifestyle were thought to have aided good health. The Governing Body noted the vice-Chair’s report.

130/16 Chief Officer’s report

Wendy Carberry reflected on the key issues addressed since the last Governing Body meeting in public. Wendy Carberry advised that she had been part of a Kent, Surrey, Sussex Academic Health Network visit to Healthcare Denmark’s Health Innovation Centre in Odense - which works to identify the specific needs for development through collaboration between the healthcare system and the business world. The visit included a session at the Department of Sports Science and Clinical Biomechanics, and a presentation about a Dementia project in Odense

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“Marguritten” – where a community is going to be built for people with Dementia. It was reported that the Sustainability & Transformation Plan (STP) was submitted to NHS England on 21 October 2016. A Director for the STP has now been appointed. It was advised that HWLH CCG is continuing with its successful Apprentice Scheme. Two apprentices are currently in post with a third apprentice due to start in early November 2016. Finally, it was reported that following a review of Sussex Partnership Foundation NHS Trust (SPFT) following a Serious Incident (SI), support has been provided and will be on-going to staff. It was advised that SPFT’s performance is not out of sync with other mental service trusts. The Governing Body noted the Chief Officer’s Report.

Section 1 - Quality, Performance and Delivery

131/16 Quality report

Sarah Richards presented the October 2016 Quality Report - confirming that this was a high level report, the more detailed of which was discussed in depth at the October 2016 Quality and Performance (Q&P) Committee meeting. The report was taken as read, but there was some discussion in particular about the three HWLH provider trusts in special measures and another requiring improvement. It was noted that as HWLH is not the lead commissioner, it has to rely to an extent on other CCGs to drive improvements. It is hoped however that the Central Sussex and East Surrey Alliance, of which HWLH is a member, will have more collective influence across the providers in terms of performance improvement. More specifically, in response to a question from a member of the Governing Body about Paediatrics waiting times following referral, it was advised that while data was not immediately to hand, waiting times are still longer than would be preferred but there is an improving position as a result of the new pathway. Denise Matthams advised that she was happy to provide details of reviews that are being undertaken, outside of East Sussex, of traditional community paediatric models. In response to a question about Referral to Treatment Time (RTT) compliance, particularly at Brighton & Sussex University Hospitals NHS Trust (BSUH), it was advised that pressures continue in the Digestive Diseases and Neurology specialities in particular; the CCG continues to monitor this closely through the clinical and quality review meetings it attends. The Governing Body noted the quality update.

132/16 Primary Care Safeguarding Assurance Tool

Sarah Richards presented a report about the Primary Care Safeguarding Tool. The Governing Body was being asked to approve the Assurance Tool and provide further direction to the CCG’s designated nurses regarding implementation. It was advised that as outlined in the Children Act 2004, Care Act 2014 and in statutory guidance, providers should meet the safeguarding standards for adults and children. Under delegated arrangements, CCGs are also now responsible for ensuring that the GP services commissioned have effective safeguarding arrangements and are compliant with the Mental Capacity Act (MCA). In addition, both the Safeguarding Adult’s Board (SAB) and Children’s Board (LSCB) have mechanisms for gaining assurance from partner agencies but currently, there are no mechanisms for the Boards to gain assurance from primary care. The Primary Care Assurance Tool has therefore been devised by the designated nurses as a proportionate way of gaining effective safeguarding assurance. It was reported that the proposal is that the Tool is disseminated to practices with clear guidance regarding completion. The Tool will assist practices with identifying any areas of vulnerabilities and will provide clear evidence ahead of any inspections, such as by the Care

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Quality Commission (CQC). It was advised that main health providers are completing a lengthy assurance document and this has been adapted and significantly reduced as a proportionate way of seeking the information that is required to gain assurance from primary care. The Governing Body discussed the Assessment Tool in some detail, including resource implications for individual practices and how the CCG might otherwise ensure that practices are compliant without use of the tool. In conclusion, the Governing Body agreed:

that the CCG and practices do need a ‘statement’ which confirms that practices do take safeguarding seriously as evidence for the CQC;

to accept the Assessment Tool as good voluntary practice; and

to take this issue for further discussion at the December 2016 meeting of the Primary Care Commissioning Committee, including consideration of whether to discuss with the Local Medical Committee (LMC) to obtain its view of how appropriate assurance can be achieved.

133/16 i) Finance & Contracts report ii) Operational Planning update

Alan Beasley presented the Finance & Contracts report for month 6 2016/17 and the Operational Planning update. It was advised that overall, the latest activity data indicates a worsening position from last month in respect of acute over-performance. The CCG is continuing to forecast over-performance at BSUH (of £1.0 million) and MTW (of £1.8 million). However, there is also evidence at month 6 of over-performance materialising at Queen Victoria Hospital NHS Foundation Trust (QVH), forecast to be £0.5 million by the year-end.

In addition to the acute pressures, risks remain in respect of continuing healthcare (CHC); the forecast overspend being £1.1 million. This is in addition to the pressure on Funded Nursing Care (FNC), due to the standard national rate increasing by 40%. That pressure is now forecast to be £0.6 million. It was reported that while these pressures are partially mitigated, it is imperative that the shortfall in the QIPP savings (currently £6.6 million) is addressed if the CCG is to achieve its required surplus. The mitigations do not include 1% non-recurrent reserves held back of £2.2 million because, at this stage, CCGs have been instructed that the reserve cannot be allocated against expenditure and it is sacrosanct. It was advised that the shortfall for 2016/17 not only presents a risk to the CCG achieving its financial target for 2016/17, but it is also a recurring pressure that rolls forward into 2017/18 and future financial years. However, some of the mitigating areas to offset these pressures in 2016/17 are non-recurring and will not be available in future years. It is therefore imperative that the CCG realigns its activities and efforts to areas that will make a material difference in generating the necessary savings the CCG needs to achieve financial balance.

It was reported that the Programme Management Office (PMO) continues to meet weekly with Budget Managers and is exploring further areas for potential savings to address the gap for 2016/17. Individual budget holders will also be called to discuss with the Remedial Action Plan (RAP) Group during November 2016. Although the PMO and the RAP Group are committed to addressing the shortfall, wider engagement and commitment from both staff and stakeholder leads in the HLWH localities is essential to ensure success in reducing the deficit. In continuing to analyse data, from Providers and GP practices, to look for possible savings opportunities, it was advised that a number of interventions are already being undertaken by the CCG, including for example in Medicines Management and the flu prevention programme. Alan Beasley advised however, that this was first time that he had come to the Governing Body with this level of unmitigated risk and he is looking for proposals and actions from the Governing Body which will reduce the pressures. In response to a question from a member of

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the Governing Body, it was advised that the QIPP schemes have not delivered this year as originally anticipated, either because of over confidence on estimations or other underlying issues. Finance issues and concerns are starting to get in the way of the CCG’s day-to-day business and while difficult decisions are starting to be taken by the CCG in order to reduce the deficit, it was agreed it may be necessary to work up trajectories for progress if matters do not improve quickly enough. A member of the Governing Body suggested that given the overspend on elective care, the CCG might consider what can be brought back to primary care from this area. Another member suggested that the CCG needs to consider large, economies of scale programmes that help to deliver significant rates of return on investment. There was also discussion about whether decisions about how to reduce the deficit might involve the Communities of Practice, but it was acknowledged that this might simply generate a divergence of views. In conclusion, the Governing Body gave its support to the Executive to take decisions they regard as necessary and appropriate in order the help reduce the deficit. The Governing Body noted the Finance report for month and Operational Plan update.

134/16 Performance Report, including Patient Transport Service update

Hugo Luck presented the Performance report for October 2016 and advised that the data behind the figures is discussed in more detail at the Quality and Performance Committee meetings. The following issues were highlighted in particular: It was advised that Referral to Treatment Times (RTT) for August 2016 have seen a small improvement on the previous month, increasing to 83.9% across the three CCG providers. In particular, BSUH is above trajectory and steadily improving, with significant reductions in the 18 week backlog over the last two months. Particular pressures include the A&E 4-hour standard, which at BSUH is currently at 84% against a target of 95%; in that respect, surge and escalation plans are being refreshed. It was also reported that there has been little improvement in meeting Cancer Waits targets; and a paper is currently being prepared which is likely to be considered at a future meeting of the Clinical Executive Committee. Finally, it was advised that the CCG is leading on a new discharge policy, Choice, which will help patients avoid long stays in hospitals and normalise timely and effective discharge. An engagement and communications plan is currently being activated. In response to a question from a member of the Governing Body about GP Practice expenditure performance, it was advised that the CCG is working with individual practices to address over-performance. It was agreed that given the current financial outlook (see agenda item 133/16 above) it might be helpful to accentuate those discussions and consider how the approach and support might be better targeted. The Governing Body noted the Performance report for October 2016. Sally Smith provided a brief update about the Patient Transport Service (PTS). It was advised that feedback from provider trusts whose patients use the service, and from patients themselves, remains constant in that the service is improved although not consistent or embedded across Sussex. It was advised that Docklands Medical Services (DMS), a transport subcontractor, is still not providing a service in Sussex and ex SECAmb staff employed by DMS continue to be available for work. The East Sussex CCGs is looking at the potential of proving alternative arrangements for this staff group. The additional capacity sourced by Coperforma to mitigate the loss of DMS is ensuring that service delivery is being maintained. The Sussex CCGs have worked with

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Coperforma and the unions to put in place a mechanism coordinated by the GMB Union to pay DMS staff any outstanding payments via a third party payroll. This has ensured staff have now been paid there standard pay up to September 2016. The CCGs continue to work with Coperforma and the unions to find a solution for DMS staff. It was reported that the CCGs are utilising the powers available within the NHS standard contract and enacting these where Coperforma’s performance falls below what is expected. The work of the Patient Safety Group, led by a GP with representatives from HealthWatch, local authority safeguarding, hospital trusts to oversee patient safety and experience is on-going. Members of the group continue to visit hospitals, speaking to patients and front line staff to get their feedback on the service. It was advised that the Patient Safety Group will be collating their findings into a report. The feedback that the CCGs are receiving from patients and staff identifies that the service level is being maintained with the latest patient user survey shows patient satisfaction at 4.1 out of 5.

Finally, it was reported that the CCG recently visited Coperforma and performed a full quality audit on the policies and processes. The CCGs continue to monitor the PTS situation closely and have further developed a variety of contingency plans based on scenario planning to enact should anything happen that may adversely impact on service delivery.

The Governing Body noted the update in respect of the PTS.

Section 2 – Public Health & Engagement

135/16 Patient & Public Involvement (PPI) update

In Dorothy Goldman’s absence, Hugo Luck presented the PPI update for October 2016. It was reported that PPI continues to be woven into all HWLH activity. It was advised that at its meeting on 8 September 2016, the High Weald Patient Participation Group (PPG) received a presentation from Giles Adams, SECAmb’s Operational Manager, who had been invited to answer questions on performance; held a talk on a newly formed Endometriosis Group; and raised questions about how much money HWLW CCG has and how it decides on what to spend it - which were fielded by Ashley Scarff, the CCG’s Director of Strategy. It was also reported that the three Lewes GP practices held a Summer Fair in the School Hill Surgery garden on 17 September 2016. It was well organised and well publicised but not well attended. Most interest seemed to be generated by the plan and diagrams for the Lewes Health Hub. It was advised that on 2 September 2016, Dorothy Goldman attended the Healthwatch Show Case in Hastings. This was an excellent opportunity to grasp the range of activities that Healthwatch undertakes and to note the number of organisations which work in partnership with it. On 7 September 2016, she also took part in the Havens Health Promotion and Self-management meeting which concentrated on "Environment and Setting". This included, inter alia, oral health, a food plan for the Havens, proposals for an outdoor wellbeing centre and social prescribing. The broad range of participants (PPGs, 3VA, Citizens Advice, practice managers, Wave Leisure) was impressive as was the wealth of local knowledge brought to each subject. Finally, it was advised that engagement on the Choice campaign will be a major activity going forward. The campaign will help patients avoid long stays in hospitals and normalise timely and effective discharge. There will also be engagement activity on HWLH’s Connecting 4 You programme and the CCG is thinking about imaginative ways of contacting different demographic groups of the HWLH population. The Governing Body reflected upon the number of complex issues and layers that the CCG is currently engaging on. The Governing Body noted the PPI update provided.

136/16 Reporting from sub-Committee Chairs and Leads :

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i) High Weald locality ii) Lewes Havens locality iii) Quality and Performance Committee iv) Clinical Executive Committee

High Weald Locality meeting David Roche provided an update about the most recent High Weald locality meeting. It was reported that a well-attended September 2016 meeting had discussed the MSK service, had received a presentation about the new Communities Diabetes service and a presentation about the new Eating Disorder service. The meeting also had its usual feedback from GPs about matters arising. Lewes Havens Locality meeting In the absence of both Neil Myers and Karen Ford, there was no report from the Lewes Havens locality for this Governing Body meeting. Quality and Performance (Q&P) Committee Denise Matthams reported that the October 2016 meeting of the Committee had discussed an ‘Away Day’ or seminar to reflect upon what is and what is not in the CCG’s gift in respect of quality concerns and risk management. It had been agreed that this issue should be discussed with the Governing Body. The Governing Body subsequently agreed that this issue will be addressed at a future Informal Governing Body meeting. Action: To reflect upon what is and what is not in the CCG’s gift in respect of quality concerns and risk management - to be addressed at a future Informal Governing Body meeting. The Committee had also agreed that the CCG’s current financial position should be brought to the attention of the Governing Body at its October 2016 meeting; in order to ensure that i) the Governing Body is fully aware of the pressures arising for the CCG for the remainder of 2016/17 and into 2017/18 and ii) to ensure that there is some pace behind what needs to achieved in respect of further QIPP savings. The Governing Body agreed that this issue had been addressed at agenda item 133/16 (above). Clinical Executive Committee (CEC) Sarah Richards advised that the October 2016 Committee meeting had received an update about Stroke Service reconfiguration; BSUH’s integrated ‘front-of-house’ programme; 111 service re-procurement; the Central Sussex and East Surrey Alliance programme; and had agreed the Information Management and Technology strategy for 2016. The Governing Body noted the sub-committee updates.

HL/ SR

Section 3 – Governance

137/16 Equality & Diversity Objectives update

Hugo Luck presented the Equality & Diversity update. The Governing Body was advised that in March 2016, the CCG published its annual public sector equalities duty report to demonstrate its compliance with the equalities legislation. Throughout 2016, the CCG has continued to use the tools and compliance mechanisms available under the Equality Act 2010 to ensure that the services it commissions promote equality of access and treatment for the local population and for CCG staff. It was reported that the Equality Delivery System (or EDS2) is a performance improvement tool to help NHS organisations improve their equality performance and outcomes through a review of qualitative and quantitative evidence related to the protected characteristics covered under the Equality Act 2010. The EDS2 monitors performance through a grading process with its local partners against four key areas or goals. These are:

Goal 1: Better Health Outcomes

Goal 2: Improved Patient Access and Experience

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Goal 3: A Representative and Supported Workforce

Goal 4: Inclusive Leadership It was advised that the CCG is yet to undertake an assessment of goals 1 & 2 to ensure compliance for 2016/17. The CCG is currently in the planning stages (two commissioning priorities for assessment have been agreed and a stakeholder session scheduled for December 2016) with the aim of completing the EDS2 implementation by the end of the financial year 2016/2017, as required by NHS England. The outcomes of the assessment will be embedded into commissioning operational plans to facilitate service improvement. It was reported that the CCG has however undertaken assessment of goal 3 in partnership with staff at the Health and Wellbeing Working Group meeting in July 2016. The findings of the workshop have been collated and considered in the context of the organisation’s development plan. An improvement plan has been produced and is being taken forward within the CCG by the Head of Corporate Services. HWLH CCG is also currently in the planning stages of the goal 4 assessment, which will take the form of a peer assessment, with Healthwatch as the independent assessor. The Governing Body will be approached for assistance in collating evidence against this Goal and an update will be provided to the Governing Body in March 2017. It was advised that the Workforce Race Equality Standard (WRES) is a benchmarking tool introduced by NHS England to gauge the current state of race equality within NHS organisations. It is designed to drive the progress being made over the years to eliminate wider aspects of discrimination in the treatment of Black and Minority Ethnic (BME) staff. CCGs have two roles in relation to the WRES – as commissioners of NHS services and as employers. Formally, CCGs are not required by the NHS standard contract to fully apply the WRES to themselves. However, at a minimum level, all commissioners of NHS services, including CCGs, are expected to have “due regard” to using the WRES in helping to improve workplace experiences and representation at all levels for their own BME staff. It was advised that HWLH CCG is in the process of taking steps to ensure that their providers are implementing the WRES by:

Gathering a list of providers that are required to implement the WRES

Undertaking a desktop exercise to investigate whether the providers’ WRES reports are published

Implementing provider assurance mechanisms through committees and meetings with providers

Finally, in order to comply with the Public Sector Equality Duty, it was reported that the CCG is required to provide Equality & Diversity training to its staff. Training sessions have been delivered to staff, plus a tailored Equality & Diversity training session for the Governing Body.

The Governing Body noted the report.

Section 4 – Items to approve or note by consent (only to be discussed upon request)

138/16 Public Health update: October 2016

The Governing Body noted the update.

139/16 Clinical Executive Committee minutes: September 2016

The Governing Body noted the minutes.

140/16 Quality and Performance Committee minutes: August 2016

The Governing Body noted the minutes.

141/16 Audit and Risk Committee minutes : April 2016 and May 2016

The Governing Body noted that the minutes.

142/16 Clinical Networks minutes:

Accident & Emergency Delivery Boards

The Governing Body noted that there were no minutes presented to this

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Tabled Question (in advance)

Niamh Murphy:

1) For each reporting period since Coperforma commenced the Patient Transport contract, what is the mean and median waiting time for patients where Coperforma have failed to meet targets for transporting patients to a medical appointment?

April May June July August September

Mean (minutes) 128 93 79 68 47 46

Median (minutes)

72 52 41 33 24 24

2) For each reporting period since Coperforma commenced the Patient Transport contract, what is the mean and median waiting time for patients where Coperforma have failed to meet targets for transporting patients back from a medical appointment?

Governing Body meeting.

143/16 Health & Wellbeing Board Minutes

The Governing Body noted that there were no minutes presented to this Governing Body meeting.

144/16 Primary Care Commissioning Committee minutes: August 2016

The Governing Body noted the minutes of this meeting.

145/16 Any Other Business

There was no other business raised at the meeting, which closed at 3pm. Dates of future meetings: 25 January 2017 at 1.00pm in the Boardroom, 36-38 Friars Walk, Lewes BN7 2PB 22 March 2017 – venue tbc

Section 5 – Confidential PART 2. In order to maintain patient and commercial confidentiality, representatives of the press and other members of the public were excluded from the remainder of the meeting -- having regard to the confidential nature of the business transacted, publicity on which would be prejudicial to the public interest” (Section 1(2) Public Bodies (Admissions to Meetings Act 1960) refers.)

--------------------------------------------------------------------------------------------------------------------------------------- Freedom of Information Act: Those present at the meeting should be aware that their names and designation will be listed in the minutes of this Meeting which may be released to members of the public on request.

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April May June July August September

Mean (minutes) 96 92 75 70 59 57

Median (minutes) 74 69 55 53 45 42

3) For each reporting period since Coperforma commenced the Patient Transport contract, what is the maximum waiting time for patients where Coperforma have failed to meet targets for transporting patients to a medical appointment?

Unfortunately, due to data quality issues this information is not readily available.

4) For each reporting period since Coperforma commenced the Patient Transport contract, what is the maximum waiting time for patients where Coperforma have failed to meet targets for transporting patients back from a medical appointment?

Unfortunately, due to data quality issues this information is not readily available.

5) In situations where patients are transported to Community appointments in non-hospital locations, e.g. GP Surgeries with limited opening times, e.g. closed at lunch time, what is your assessment of risk to such patients in circumstances were the return transport is delayed? Are such patients expected to wait outside a closed building?

Although the vast majority of patients are transported to hospital appointments there are a small number who fall into the situation mentioned above. There would be an expectation that (as with arrangements with hospitals) the care and any associated risk need to be dealt with by the healthcare provided.. There would be no expectation that patients waited outside a closed building if there was any additional risk to the patient.

Date Agenda Item Item Information Initial Action RequiredAction owner Action Due

Action

CompleteFurther Actions/Comments

27/07/2016 82/16 Quality Report

To identify which care homes have

frequent repeat visits from SECAmb

and then cross reference to the local

GP surgeries responsible for those

homes.

Sarah Richards 28/09/2016 Complete

September 2016 update : SR will provide a verbal update at

the meeting. 28 September meeting update: Sarah

Richards advised that SECAmb is still working on this data

and ensuring compliance with its governance systems. A

further update will be provided at the October 2016 Governing

Body meeting. It was suggested the matter might be

escalated to the Head of Operations, if necessary. 26

October 2016 meeting update : Sarah Richards advised that

SECAmb is still working on the IT which will help provide easy

access to this data search. In the meantime, a manual search

had revealed only 1 nursing home in the HWLH locality with

repeat visits over the last few months. Data will continue to be

sent to the CCG on a monthly basis.

28/09/2016 108/16 Quality Report

To investigate Paediatric service

delays to review children following

referrals from GPs, and report back to

Governing Body.Ashley Scarff 26/10/2016 Complete

October 2016 update : An analysis of performance will be

taken to Q&P Committee; the outcome of which will be

recorded in the Q&P minutes and Quality reports to Governing

Body. 26 October 2016 meeting update: Sarah Richards

advised that any delays are largely due to an increase in

referrals. The CCG is monitoring this closely and detailed

analysis will be brought to Quality & Performance Committee

which reports to Governing Body.

26/10/2016 136/16

Reporting from Sub-

Committees: Q&P

Committee

To reflect upon what is and what is

not in the CCG’s gift in respect of

quality concerns and risk

management - to be addressed at a

future Informal Governing Body

meeting.

Hugo Luck /

Sarah Richards25/01/2017 Complete

January 2017 update: Risk Workshop to be undertaken at

February 2017 Informal Governing Body meeting

HWLH CCG Governing Body ACTION LOG

A formal meeting of the Governing Body

Item Number:

Date of meeting: 25 January 2017 5/17

Title of report: Chair’s Report for January 2017 Governing Body meeting

Recommendation: The Governing Body is recommended to note the Chair’s Report.

Summary: The Chair will reflect on the key issues addressed since the last Governing Body meeting in public, update on the key meetings attended, and look forward to the next two months.

Governing Body sponsors: Dr Elizabeth Gill, Chair and Peter Douglas, Lay Member (Governance) and Vice Chair

Author(s): Tim Crowhurst (Board Services Officer) Date of report: 17/01/17

Review by other committees: None

Health impact: None, for information only

Financial implications: None, for information only

Legal or compliance implications: None, for information only

Link to key objective and/or principal risks: None, for information only

Patient and public engagement: N/a

Equality Analysis (EA) completed: Negative Impact Neutral Impact Positive Impact No Impact Not Required

☐ ☐ ☐ ☐ ☒

EA Summary: N/a, report for information only

Privacy Impact Assessment (PIA): No personal data used Data processes sufficient Actions required

☒ ☐ ☐

Actions: N/a, report for information only


Item Number:


Title of report: Chief Officer’s Report – January 2017

Recommendation: The Governing Body is recommended to note the Chief Officer’s Report.

Summary: The Chief Officer will reflect on the key issues that she has needed to address since the last Governing Body meeting in public, update on the key meetings attended, and look forward to the next two months.

Governing Body sponsor: Wendy Carberry, Chief Officer

Author(s): Tim Crowhurst (Board Services Officer) Date of report: 17/01/17


Health impact: None, for information only

Financial implications: None, for information only

Legal or compliance implications: None, for information only

Link to key objective and/or principal risks: None, for information only

Patient and public engagement: None, for information only


☐ ☐ ☐ ☐ ☒

EA Summary: N/a, report for information only


☒ ☐ ☐

Actions: N/a, report for information only


Item Number: 7/17

Date of meeting: 25 January 2017

Title of report Quality Report

Recommendation: The Governing Body is recommended to review the summary report.

Summary: This report provides a brief summary including the actions required or taken to reduce or mitigate the current quality issues / concerns. Following Care Quality Commission (CQC) inspections, one of the main acute hospitals serving High Weald Lewes Havens (HWLH) patients requires improvement; two acute hospitals are currently in ‘special measures’.

Governing Body sponsor: Dr Sarah Richards, Chief of Quality and Performance.

Author: Simon Neale Clinical Quality Manager

Date of report: 10/01/17

Review by other committees: Quality & Performance Committee

Health impact: Underperformance has the potential to impact on quality and health outcomes for residents using those services.

Financial implications: Where residents do not achieve optimal health outcomes and quality from the commissioned services there are inherent additional costs to the health system. These can be related to on-going health needs and / or as a consequence of residents suffering avoidable harm associated with healthcare.

Legal or compliance implications: Potential for commissioned providers to breach CQC registration, legislative and compliance requirements should quality of services be sub-optimal.

Link to key objective and/or principal risks: Risks associated with the duty to provide quality and improve health outcomes for residents within High Weald Lewes Havens geographical area.

Patient and public engagement Individual risks may have potential impact for patient and public engagement.

Equality Impact Assessment (EIA) completed: Negative Impact Neutral Impact Positive Impact No Impact Not Required

☐ ☐ ☐ ☐ ☒

An EIA is not necessary for this report.

Privacy Impact Assessment: No personal data used Data processes sufficient Actions required

☒ ☐ ☐

Actions: Not applicable.

1

Quality Report - Summary of key issues and successes 1. Introduction. 1.1. The Quality Team reviews and scrutinises data from a variety of sources and obtains local intelligence through dialogue and

meetings with provider and Lead Commissioner Quality Leads. This summary report details the most significant quality issues and successes being monitored and addressed by HWLH CCG.

2. Glossary. 2.1. An alphabetical list of abbreviations / acronyms used within the report.

Abbreviation: Meaning:

B&H CCG Brighton and Hove Clinical Commissioning Group

BSUH Brighton and Sussex University Hospitals NHS Trust

CAMHS Children and Adolescent Mental Health Service

CAWS Children and Adult Wheelchair Service

CCG Clinical Commissioning Group

CHC Continuing Healthcare

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

ESHT East Sussex Healthcare Trust

ESCC East Sussex County Council

IC24 Integrated Care 24 - Out of Hours GP service provider

MTW Maidstone and Tunbridge Wells NHS Trust

PRH Princess Royal Hospital

SECAmb South East Coast Ambulance Service

SECAS South Central Ambulance Service NHS Foundation Trust

SPFT Sussex Partnership Foundation Trust

SSNAP Sentinel Stroke National Audit Programme

PTB Patient Transport Bureau

TDA Trust Development Authority

MSK Muscular Skeletal Service

SMSKPE Sussex Muscular-Skeletal Partnership East

2

2.0 Summary The following table details the key issues effecting High Weald Lewes Havens (HWLH) patients and the proposed or actual action taken.

Summary

Domain Quality Concern / Risk Action Taken / Required Action for

Governing Body

1 Preventing people dying prematurely

NHS 999 response times for HWLH continue to be below the national target. Although this appears to be in line with other Ambulance Services in rural locations, further scrutiny and monitoring is required to determine the consequences in a delay and consider ideas for improvement. SECAmb continue to fail meet the target for red 1 and red response within 8 minutes for July 2016 across the whole system. CQC Report- Overall rating- Inadequate IC24 Out of Hours GP service struggling to provide cover across Sussex and limited assurance on internal governance processes.

Remedial action plan established and agreed with SECAmb, however the recovery plan was not met resulting in a financial penalty. In March 2016, on behalf of all CCGs, Kent Surrey Sussex Lead Commissioners sent a formal extended contract performance notice, to encompass a number of quality, safety and performance measures. An assurance visit/clinical shift is being planned by the HWLH Clinical Quality Team to shadow the paramedic teams on a night shift in the locality. CQC report - Special Measures. Sussex wide commissioning team written robust action plan to ensure adequate cover and governance system. On-going monthly monitoring of a remedial action plan progress. On-going monthly reviews taking place between Sussex quality teams and IC24 to improve serious incident reporting process.

To be aware of the concerns raised and actions in place to resolve them

3

Summary


Governing Body

CQC Report - Overall rating (Head office) – Requires improvement

IC24 CQC inspection report published following inspection in July 2016. Individual East Sussex sites (including Woodingdean) rated ‘Good’ - IC24 head office rated as “Requires Improvement”

2 Enhancing the

quality of life for people with long term conditions

Paediatric Community Service delays to review children following referral from GPs. Long waiting list for patients in East Sussex requiring a specialised wheelchair or follow up check due to historic waiting list prior to new provider.

Waiting times have improved through extra activity from another provider and work by ESHT. The number waiting for follow up appointments and treatment is being reviewed and assessed through the contract and performance committee with ESHT. Quality involvement at contract meetings. Current data suggests the activity by the service is now meeting new demand and reducing the historic waiting list. The provider will work on treating those patients waiting the longest through assessing priority and contacting the patient to determine current need. Additional funding provided by CCG. Waiting time data by month now provided and progress will be monitored. There have been in-month improvements and work is continuing on reducing the numbers on the waiting list.

To be aware of the concerns raised and actions in place to resolve them.

4

Summary


Governing Body

3 Helping people to

recover from episodes of ill

health or following injury

Delay to treatment. A number of specialties at BSUH are failing to meet the Referral to Treatment Time (RTT) 18 week compliance with long waiting times.

Patient safety and experience linked to planned care delays is monitored via monthly quality review meetings. This includes monthly monitoring of complaints and other patient feedback mechanisms received both by BSUH and the CCG to gauge and manage patients’ experience of care and treatment linked to long waits. The trust had gone through a validation process of a number of patients with an unknown RTT status, which resulted in an additional 1300 patients added to the waiting list, the predicted timescale for achieving zero 52-week waits remains at March 2017. Patient review processes currently in place: 1. Clinical review panel looking at patients who waited over 52 weeks for their end treatment/procedure - this is a retrospective review of whether the person came to harm as a result of the wait, and implementation of incident reporting and Duty of Candour where indicated. 2.Clinical review of people waiting over 52 weeks and who have not yet received their end treatment/procedure – this is being undertaken in the Digestive Diseases services, where this issue is the most significant.


5

Summary


Governing Body

4 Ensuring that people have a

positive experience of care

BSUH A&E is struggling to meet the high demand on its service and subsequently failing to meet the 4 hour target with some 12 hour breaches reported. This also impacts on SECAmb with Ambulance handover delays at the hospital.

Patient Transport Services meeting the quality agenda and contractual quality measures

Performance against the 4-hour A&E standard was 82.6% in October 2016, against a target of 95%, which is similar to the continuing monthly position in 2016. The Emergency Department refurbishment following CQC recommendations regarding privacy and dignity is now complete. The existing provider (Coperforma) and HWLH CCG have agreed to terminate the contract with effect from 1 April 2107 with the contract passing to South Central Ambulance Service NHS Foundation Trust (SCAS) – a transition team comprising of members of Coperforma, SCAS, TIAA and patient representatives has been instigated to oversee the gradual transition handover merging the work streams of the two providers into the new service whilst supporting existing delivery of patient transport.

To be aware of the concerns raised and actions in place to resolve them. To be aware of the concerns raised and actions in place to resolve them.

5 Treating and caring for people in a safe environment and protecting them from avoidable

harm

CQC compliance at BSUH. Overall rating: ‘Requires Improvement’ and ‘Inadequate’ for urgent care services at the Trust.

Report published and Trust placed in special measures - The Trust CQC action plan in response to the recent report continues to be implemented – a further unannounced CQC visit is to take place prior to February 2017.


6

Summary


Governing Body

CQC compliance at MTW - Overall rating: ‘Requires improvement’ CQC compliance at ESHT - Overall rating: ‘Inadequate’ CQC compliance for SPFT - Overall rating: ‘Requires improvement’ CQC Compliance for IC24 (Head office) – Requires improvement

Trust CQC quality improvement plan actions in response to the recent report continue to be implemented. Trust reports good progress in conjunction with mock ’CQC’ inspections. Report published and Trust placed in special measures. Plan developed and monitored by NHS Improvement and lead CCG, formally re-inspected as a follow-up by the CQC during the w/c 3rd October 2016. No formal feedback has yet been received at the time of writing - update expected early 2017. Following initial 2015 report, a further CQC inspection of SPFT services was undertaken during September 2016 resulting in a further rating of ‘Requires improvement’ for the domains of ‘safe’, ‘effective’ and ‘well-led’ Associated action plans being monitored by the lead commissioning CCG with process in place to monitor progress for East Sussex. Individual East Sussex sites (including Woodingdean) have been rated ‘Good’ - IC24 head office rated as “Requires Improvement” within the “Safe” domain.

7

Summary


Governing Body

Concerns exist over the ability for nursing homes to demonstrate improvements in quality and safety following suspension to admissions by East Sussex County Council.

ESCC and CQC working collaboratively with improvement programmes. A new pilot project to support care homes to take patients of a higher dependency is being established, including funding for staff training and minor building adaptations.

3. Other Quality Team Activity / initiatives

Work continues to progress on the development of an integrated incident reporting system for all GP Practices within HWLH. The system is ready to pilot in 3 participating GP practices and the project is currently ‘on hold’ pending review for a future roll out in 2017.

The quality dashboard has been established for primary care and data collection is underway.

The Quality team is continuing to provide support to GP practices regarding formulation of action plans following CQC inspection; all HWLH CCG GP practices have now been inspected by the CQC.

Full support was provided by the HWLH Quality Team to the new revised PTS service arrangement, including support with clinical governance and incident reporting. A HWLH Quality Manager was contracted to work solely with PTS for 3 months until December 2017 in order to support the quality and patient safety agenda; training was also provided to the PTS senior managers on Serious Incident Management, Root Cause Analysis (RCA) and Adult Safeguarding/PREVENT. A full quality impact assessment is currently underway in regards to the new integrated interim provider South Central Ambulance NHS Foundation Trust

RCA training has also been provided to The Horder Centre.

HWLH have been graded as providing ‘Substantial Assurance’ regarding the management of serious incident following an internal audit by TIAA in July 2016.

Clinical assurance visits and full quality impact assessments have been completed in regards to the Children and Adult Wheelchair Services (CAWS) provided by Millbrook Healthcare, The Horder Centre, Eastbourne Street Triage service and BSUH Neurosurgical ICU as well as participating in a series of infection control focused audits for the community hospital sites within the locality – namely Lewes Victoria hospital, Uckfield community hospital and Crowborough War Memorial hospital.

8

4. Recommendation. 4.1. The Governing Body is required to review the report and consider any further actions for assurance Simon Neale - Clinical Quality Manager Report date: 10 January 2017

Item Number: 08/17 A formal meeting of the Governing Body Date of meeting: 25 January 2017

Title of report:

Finance Report Month 9 2016/17

Recommendation: The Committee is recommended to note the Finance Report.

Summary: At month 9, the pressures against the forecast outturn total £11.8 million. This represents an increase from month 8 of £0.8 million due to increased reported activity at Brighton and Sussex University Hospitals NHS Trust (BSUH) and East Sussex Healthcare NHS Trust (ESHT). Although “one-off” items have been identified to mitigate these risks and enable the CCG to externally report it will meet its statutory duties for 2016/17, the shortfall represents a significant pressure for 2017/18 and beyond. The Executive Team continues to review areas to generate savings and address the shortfall.

Committee sponsor: Alan Beasley

Author(s): Alan Beasley Date of report: 16/01/17

Review by other committees: Reviewed by the CCG’s Quality and Performance (Q&P) Committee.

Health impact: Not applicable.

Financial implications: Contained in the report.

Legal or compliance implications: Actions to be taken to deliver the statutory financial duty.

Link to key objective and/or principal risks: Contained in the report.

Patient and public engagement: Not applicable.

Equality Analysis (EA) completed: Negative Impact Neutral Impact Positive Impact No Impact

☐ ☐ ☐ ☒

EA Summary: Not applicable.


☒ ☐ ☐


Finance Report Month 9

1. Executive Summary

The pressures in respect of over-performance with the CCG’s main acute providers 1.1.have increased by £0.8 million from month 8. Discussions are being held with South, Central and West Commissioning Support Unit (CSU) to identify the reasons for the further acceleration in activity. These will be shared with the CCG once they have been ascertained. In addition, the pressure in respect of continuing healthcare remains.

Total pressures against the forecast outturn at month 9 total £11.8 million. 1.2.Mitigations which offset this pressure currently stand at £5.6 million, leaving an underlying shortfall of £6.3 million. Although there are further one-off mitigations which allow the CCG to report that it will meet its control total for 2016/17, the £6.5 million represents a pressure on 2017/18 and beyond.

The mitigations shown in the table below do not include 1% non-recurrent reserves 1.3.

held back of £2.2 million. CCGs have been instructed that the reserve cannot be allocated against expenditure in 2016/17.

Pressures and Mitigations Month 9

Pressures

£'000

Main Acute Provider overspends (see para. 3.1) (8,511)

Queen Victoria Hospital over-performance (595)

Continuing Health Care - Adults - increase in activity (884)

Continuing Health Care - Children - increase in activity (350)

FundedNursing Care - 40% national increase from 16/17 (1,118)

offset by: Funded Nursing Care - decrease in activity 425

(1,927)

Learning Disabilities (215)

Additional Patient Transport (526)

Total Pressures (11,774)

Mitigations

Contingency 1,137

Better Care Fund Contingency 2,781

MSK Clawbacks 800

Sussex Community Contract Recharge 335

Property Services Underspend 300

Millbrook VAT Recovery 100

Shortfall (6,321)

2. Month 9 2016/17

The table below provides a summary of the CCG’s reported position at month 9 to 2.1.NHS England , showing that the QIPP savings will be achieved and it will meet its financial targets for year:

A Summary Operating Cost Statement at Month 9 is shown below. A detailed 2.2.Operating Cost Statement, including planned expenditure against CCG commissioning areas is shown in appendix 1. The table shows the overspends in the acute sector and continuing care. These overspends are being offset by the contingency and the Better Care Fund (contingency and return of underspends from the local authority).

Statutory Duties

Maximum Performance Achieved? Maximum Performance Achieved?

National

Health Service

Act Section Duty £'000 £'000 £'000 £'000

223H (1) Expenditure not to exceed income 168,290 166,916 227,617 225,556

223I (2)Capital Resource use does not exceed the amount

specified in directions49 50 * 250 250

223I (3)Revenue Resource use does not exceed the

amount specified in directions167,842 166,468 227,020 224,959

223J (3)Revenue Administration Resource use does not

exceed the amount specified in Directions2,757 2,757 3,676 3,676

Key Target met less than 5% below target >5% from target

2016/17 to Month 9 Forecast 2016/17 Year End

* £65k Capital Resource has been phased monthly. Although actual expenditure exceeds plan, the CCG expects to meet its Capital Resource Limit (CRL)

for the year. In addition to the £65k for corporate IT upgrades, £185k capital funding has been secured for IT costs and refurbishment in respect of the

CCG's office move later in the financial year.

SUMMARY OPERATING COST STATEMENT

FOR THE NINE MONTHS ENDED 31 DECEMBER 2016

Full Yr

Commissioning Plan Plan Actual Variance Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000

Acute 107,878 80,909 86,355 (5,446) 115,183 (7,305)

Community 19,621 14,716 14,395 320 19,202 419

Better Care Fund 5,206 3,905 (1,389) 5,293 (2,768) 7,974

Mental Health 15,643 11,732 11,703 29 15,923 (279)

Continuing Healthcare 10,412 7,841 9,333 (1,492) 12,338 (1,926)

Primary Care 51,414 38,150 38,628 (479) 51,414 0

Other Commissioning* 7,797 5,805 4,885 920 7,783 14

Total Commissioning 217,971 163,057 163,911 (854) 219,075 (1,104)

Corporate (Running Costs) 3,676 2,757 2,557 199 3,676 0

Reserves 2,208 0 0 0 2,208 0

Contingency 1,104 655 0 655 0 1,104

Total Non-Commissioning 6,988 3,412 2,557 854 5,884 1,104

Total Operating Costs 224,959 166,468 166,468 0 224,959 (0)

Revenue Resource Limit 227,020 167,842 167,842 0 227,020 0

Surplus / (Deficit) 2,061 1,374 1,374 0 2,061 0* For a breakdown of Other Commissioning Services, see appendix 1

CCG Operating Costs

Year to date Forecast

3. Contracts

The table below shows the movements in the main acute contracts between month 3.1.8 and month 9:

Discussions are on-going with the NHS South, Central and West (SCW) CSU to 3.2.identify the causes for these movements. Brighton and Sussex University Hospitals NHS Trust (BSUH) is showing over-performances in all activity areas with significant variances to plan on A&E, non-elective and outpatient costs.

Maidstone and Tunbridge Wells NHS Trust (MTW) equally shows performance 3.3.above plan in all activity areas. In addition, with the exception of outpatient first and follow-ups, both activity and costs are up from last year in all areas.

The over-performance at East Sussex Healthcare NHS Trust (ESHT) appears to be 3.4.mainly in respect of A&E appointments and elective inpatients. The charts also show significant increases in activity in these areas from last year.

4. QIPP

The Executive Team continue to review QIPP as a standing item and meets weekly. 4.1.There is an acceptance that the QIPP for 2016/17 will not be met in full and efforts are concentrated on identifying savings to address the recurring shortfall detailed in paragraph 1.1. Plans are being developed and members of the executive team are taking ownership for individual actions in each service area.

The Programme Management Office (PMO) continues to meet weekly with Budget 4.2.

Managers and is exploring further areas for potential savings to address the financial shortfall. The QIPP Summary for 2017/18 is shown in appendix 2 and a detailed QIPP report is shown in the attached appendix.

Trust M9 M8 Movement

Brighton and Sussex University Hospitals NHS Trust 43,776 43,568 (208)

Eeast Sussex Healthcare NHS Trust 11,738 11,738 0

Maidstone and Tunbridge Wells NHS Trust 22,960 22,551 (409)

Queen Victoria Hospital NHS Trust 3,778 3,519 (259)

Total Movement (876)

5. Financial Plan 2016/17 and 2017/18

The CCG submitted detailed financial plans to NHS England for 2017/18 and 5.1.2018/19 by the deadline of 23 December 2016. The Plans submitted show that the CCG will meet its financial targets for the two years. However, for this to be achieved, it is essential the CCG meets its QIPP targets for the two years. The CCG must deliver QIPP savings of £11.4 million in 2017/18 and £10 million in 2018/19, which represents a significant challenge. The QIPP targets are approximately 5% of the CCG’s turnover (see attached appendix).

A Summary Plan for 2017/18 and 2018/19 is shown in appendix 3. Funding to 5.2.commission non-GP Primary Care services has increased by 2% in both years. It is expected that the Payments by Results (PbR) tariff will increase by 0.3% in 2017/18 (0.00% in 2018/19) which reflects cost pressures and developments of 2.3% (2.0% in 2018/19) offset by expected provider efficiency of 2.0% (2.0% in 2018/19).

GP Primary Care commissioned services has increased by 5.2% in 2017/18 (4.4% 5.3.in 2018/19). The CCG is committed to investing £3 per head of population over the next two years for practice transformation from its core allocation. Currently, it is planned that £1 per head will be invested non-recurrently in 2017/18 with the balance of £2 per head invested non-recurrently in 2018/19.

The CCG’s running costs allocation for 2017/18 and 2018/19 is the same as 5.4.2016/17 at £3.7 million. Costs associated with nationally negotiated pay awards will be funded from internal efficiencies.

Other acute contracts include Surrey and Sussex Healthcare NHS Trust, Royal Surrey County NHS Foundation Trust and Western Sussex Hospitals NHS Foundation Trust. It also includes private providers including Spire Healthcare Ltd, BMI Healthcare Ltd and Nuffield Health.

Appendix 1 - DETAILED OPERATING COST STATEMENT

FOR THE NINE MONTHS ENDED 31 DECEMBER 2016

Full Yr

Commissioning Plan Plan Actual Variance Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000

Brighton & Sussex Uni Hospitals 40,025 30,019 32,082 (2,063) 43,776 (3,751)

East Sussex Healthcare 10,875 8,156 8,803 (647) 11,738 (863)

Maidstone& Tunbridge Wells 19,336 14,502 16,685 (2,183) 22,960 (3,624)

Queen Victoria Hospital 3,183 2,387 2,833 (446) 3,778 (595)

London Contracts 2,946 2,209 2,578 (369) 2,938 8

Horder Centre 116 87 14 73 27 89Patient Transport 1,140 855 1,376 (521) 966 174

South East Coast Ambulance Service (999&111) 5,985 4,489 4,560 (71) 5,984 1

Non Contract Activity 3,832 2,874 2,898 (25) 4,029 (197)

MSK 18,211 13,658 12,571 1,087 16,762 1,449

Other Acute Contracts * 2,231 1,673 1,954 (281) 2,226 5

Total ACUTE 107,878 80,909 86,355 (5,446) 115,183 (7,305)

East Sussex Healthcare 2,485 1,864 1,863 1 2,485 0

Kent Community Health NHST 1,371 1,029 1,185 (156) 1,580 (209)

Sussex Community Trust 15,378 11,533 10,905 628 14,750 628

Hospices 326 244 336 (92) 326 0

Other Community Services 61 46 106 (60) 61 0

Total COMMUNITY SERVICES 19,621 14,716 14,395 320 19,202 419

BETTER CARE FUND BALANCE 5,206 3,905 (1,389) 5,293 (2,768) 7,974

Sussex Partnership NHS Foundation Trust 13,199 9,900 10,043 (144) 13,199 0

Health in Mind 1,730 1,297 1,316 (19) 1,755 (25)

Dementia 75 56 56 1 75 0Other Mental Health 639 479 288 191 893 (254)

Total MENTAL HEALTH 15,643 11,732 11,703 29 15,923 (279)

Adults Continuing Healthcare 7,179 5,417 6,128 (711) 8,063 (884)

Childrens Continuing Healthcare 437 328 590 (262) 787 (350)

Funded Nursing Care 2,796 2,097 2,615 (519) 3,488 (693)

Total CONTINUING HEALTHCARE 10,412 7,841 9,333 (1,492) 12,338 (1,926)

Winter Pressures 957 675 130 545 957 (0)

Childrens Services 97 73 642 (569) 61 36

Out Of Hours 982 736 766 (30) 1,071 (89)

Collaborative Fees 104 78 68 10 104 0

Programme Projects 964 723 571 152 964 0

Programme Support 801 600 534 66 801 0

Programme Property Charges 591 443 447 (3) 678 (87)

Integrated Community Equipment Store 715 536 339 197 678 37

Wheelchair Service 462 346 (93) 439 462 0

Learning Disabilities 393 295 456 (161) 608 (215)

Continuing Healthcare Assessment & Support 1,275 956 708 249 943 332

Medicines Management - Clinical 456 342 316 26 456 0

Total OTHER COMMISSIONING 7,797 5,805 4,885 920 7,783 14

TOTAL COMMISSIONING 166,557 124,907 125,283 (376) 167,661 (1,104)

Prescribing 27,113 20,335 20,947 (612) 27,113 0

Enhanced Services 2,815 2,111 1,906 205 2,815 0

Practice-based Commissioning Schemes 0 0 64 (64) 0 0

Primary Care Commissioning 21,055 15,380 15,476 (95) 21,055 0

Primary Care IT 431 323 236 87 431 0

Total PRIMARY CARE 51,414 38,150 38,628 (479) 51,414 0

CORPORATE (RUNNING COSTS) 3,676 2,757 2,557 199 3,676 0

Earmarked Reserves 2,208 0 0 0 2,208 0

Contingency 1,104 655 0 655 0 1,104

Total RESERVES AND CONTINGENCY 3,312 655 0 655 2,208 1,104

Total OPERATING COSTS 224,959 166,468 166,468 (0) 224,959 (0)

Revenue Resource Limit 227,020 167,842 167,842 0 227,020 0

Surplus / (Deficit) 2,061 1,374 1,374 0 2,061 0

CCG Operating Costs

Year to date Forecast

Appendix 2

Table 4 QIPP Analysis 2017/18 Scheme Full Value £’000

Risk Adjusted £’000

Full Year Effects

MSK 2,200 2,200

Community 2,030 1,320

Diabetes 100 95

Kinesis 100 95

Tier 3 Weight Management 100 95

Gastroenterology 100 95

Ophthalmology 200 190

Urology 50 50

Dermatology 250 240

Total Full Year effects 5,130 4,380

RightCare

Trauma & Injuries 200 130

CVD/Circulation 200 130

Neurological 250 160

Respiratory 150 100

Other 250 160

Total RightCare 1050 680

Other benchmarking

Better Care Better Value 100 70

QVH Contract – N:F Rates 200 130

Learning Disabilities 500 330

CHC 200 130

LPP List 250 160

Total Other Benchmarking 1250 820

Insight & Intelligence

Havens 150 98

Mental Health - OoAPs 300 200

Golden Ticket 100 70

Prescribing 1500 1430

IT 640 420

Self-Care/Self-Management 400 380

Medically Unexplained Symptoms 200 190

TECS 300 290

Frailty/Geriatrician 300 290

Falls 300 290

Connecting for You 500 330

Practice Performance 1000 950

Validation of NCA’s 200 130

Pipeline Schemes * 1000 450

Total Insight and Intelligence 6890 5518

Total QIPP 14320 11400

Appendix 3

Financial Plan 2017/18 and 2018/19

Revenue Resource Limit

£ 000 2016/17 blank12017/18 2018/19

Recurrent 224,346 228,780 233,243

Non-Recurrent 613 (2,430) (2,469)

Total In-Year allocation 224,959 226,350 230,774

Income and Expenditure

Acute 114,928 112,699 111,441

Mental Health 15,852 16,214 17,226

Community 18,993 20,974 21,643

Continuing Care 12,233 13,145 13,858

Primary Care 29,928 29,059 29,497

Other Programme 8,294 8,048 10,459

Primary Care Co-Commissioning 21,055 21,403 21,820

Total Programme Costs 221,283 221,542 225,944

Running Costs 3,676 3,675 3,674

Contingency 0 1,133 1,156

Total Costs 224,959 226,350 230,774

HLWH CCG: 2017/18 QIPP Overview Page 1 of 17

Appendix 4 - QIPP Paper

Introduction

It is recognised by HWLH CCG that QIPP schemes need to be delivered not only to secure the CCG

business rules on a recurring basis (see Appendix 1) and to fund the 9 ‘must dos’ in the Operating Plan

but also to internally generate investment funding for the transformational change set out in the

Sustainability Transformation Programme (STP), Central and East Sussex Alliance (CSESA) and

Connecting 4 You (C4U) programmes. The level of net QIPP targeted by HWLH CCG is £11.4m in

2017/18 and £10m in 2018/19. This represents c5% of the CCG resource allocation and will be a

significant challenge.

The QIPP requirement for 2017/18 is driven by two main issues:

1. The recognition that QIPP plans for 2016/17 did not sufficiently address significant pressures

on A&E and non-elective activity resulting in a forecast over performance of £8.3m against

plan on acute contracts.

2. Unfunded 2016/17 cost pressures impacting on the 2017/18 position such as Funded Nursing

Care (FNC) and Continuing Health Care (CHC) estimated to be £1.8m per annum and other

pressures totalling £1.3m.

This paper describes in more detail the calculation of the QIPP target, the methodology used to

identify opportunities for QIPP schemes and the delivery method utilised by HWLH CCG to secure

them.

2016/17 Likely Outturn

The CCG is forecasting that it will achieve all its financial targets in 2016/17. However this is being

achieved by applying all available contingencies and non-recurrent underspends.

The total overspend on acute services is forecast to be £6.7m (£8.3m at the CCG’s main acute

providers offset by an under spend on the MSK contract of £1.5m and other acute contracts of £0.1m).

The over-performance at the main acute providers is driven predominantly by more A&E and non-

elective activity than planned being seen in our hospitals.

There was a further £1.8m overspend on continuing healthcare, due to actual activity being above

that historically seen and planned for and a nationally agreed 40% increased “price” of NHS Funded

Nursing Care Costs. The over spend was offset by the CCG applying unutilised non-recurrent and

contingency reserves to ensure the planned surplus was achieved.

Stripping out the impact of contingencies and non-recurrent benefits provides a start point for

2017/18 of an adverse variance against plan of £7.9m

Table 1 below provides further details of this.


Table 1 - Underlying Position 2016/17 Underlying

Position £000s

Acute 119,259

Community 19,593

Mental Health 15,852

Continuing Healthcare 12,413

Primary Care (Prescribing and Locally Commissioned Services) 29,928

Primary Care Commissioning 21,055

Other Programme Costs 13,483

Total Programme Costs 231,583

Running Costs 3,676

Contingency 0

Total Costs 235,259

Revenue Resource Limit 227,268

Surplus/(Deficit) (7,991)

Operating Plan 2017/18

The NHS funding available to HWLH CCG to commission non GP Primary Care services increases by

2.00% in both 2017/18 and 2018/19. It is expected that the Payment by Results (PbR) tariff will

increase by 0.3% in 2017/18 (0.00% in 2018/19) which reflects cost pressures and developments of

2.3% (2.0% in 2018/19) offset by expected provider efficiency of 2.0% (2.0% in 2018/19).

Funding for GP Primary care commissioned services increases by 5.2% in 2017/18 (4.4% in 2018/19).

Details of 2017/18 GMS inflation and other unavoidable pressures are awaited and this will determine

the total level of available funding to strengthen general practice in the short term and support

sustainable transformation. The CCG is committed to investing £3 per head of population over the

next two years in practice transformation from its core allocation. It is currently planned that £1 per

head will be invested non- recurrently in 2017/18 with the balance of £2 per head invested non-

recurrently in 2018/19. The CCG has set aside £5 per head from within its GP primary care baseline

budget to maintain schemes developed in 2015/16 and 21016/17 where there is evidence of a

reduction in hospital based activity or other CCG or national objectives are met. The CCG has

developed plans to invest other amounts identified in the GPFV to improve resilience of and access to

general practice over the next two years.

The CCG’s running cost allocation for 2017/18 and 2018/19 is the same as 2016/17 at £3.7m. Any

costs associated with nationally negotiated pay awards will be funded from internal efficiencies.

Overall growth in NHS funding is higher than other sectors of government. However, given the growth

in demand for acute services experienced within HWLH, the funding settlement still provides a

challenging backdrop against which the CCG intends to deliver a radical restructuring of the local

health system.


Delivering more patient centred community based services closer to people’s home and reducing non

elective admissions to acute hospital settings will have a significant financial impact on both

commissioners and providers. Pump priming investments will continue to be required in community

based services to create the capacity to underpin reduced referrals to hospitals, but hospital capacity

will need to be maintained while the community based services are developed and implemented. The

CCG financial plans assume that recurrent efficiencies totalling £11.4m will be delivered in 2017/18

and £10m in 2018/19 and this provides the internal source of funds for investments to secure the

required transformational change and deliver the CCG business rules:

The operating plan assumes a demographic driven increase in costs of healthcare services totalling

£5.5m. Table 2 below analyses this by sector.

Table 2 Pressure (2017/18) £’000

Growth % (17/18)

Acute (inc ambulance services) 1,985 1.7%

Community 644 3.4%

Mental Health 300 1.9%

Primary Care 464 4.2%

Prescribing 1,422 5.4%

FNC/CHC 707 5.8%

5,522

This together with the £7.991m underlying position detailed in Table 1 underpins the QIPP target set

which is analysed in Table 3.

Table 3 2017/18 £’000

2018/19 £’000

Growth in funding (4,045) (4,047)

Tariff Increases 425 0

Cost pressures and Developments eg FNC 1,507 1,000

Demographic Growth 5,522 5,056

Brought Forward Underlying Position 7,991 7,991

Total 11,400 10,000

QIPP 11,400 10,000

Difference Nil Nil

QIPP Schemes

The methodology used by the CCG to identify and quantify efficiency opportunities are:

1. Reviewing the on-going impact of schemes already implemented such as MSK and the

procurement of community services.

2. NHS RightCare

The October 2016 ‘Commissioning for Value’ Packs highlight areas where the CCG should look

to deliver improvements in both the quality and cost of healthcare, these include:


a. 1 life per year in comparison to the CCGs best performing peer CCGs.

b. Elective Admissions. (Total value opportunity - £3,582k)

i. MSK - £1,046k in comparison to 10 similar CCGs, and a further £777k when

compared to the best performing 5 CCGs. Fixed 5 year MSK Prime Provider

contract officially commenced April 2015. Contract values were based on

moving towards upper quartile programme budgeting spend.

ii. Circulation - £334k in comparison to 10 similar CCGs, and a further £203k

when compared to the best performing 5 CCGs. Analysis indicates that all

Sussex CCGs are outliers in this area indicating a necessity to develop a pan-

Sussex strategy. With regards to HWLH, the RightCare reports highlight

significantly lower Non-Elective Spend, and lower mortality. The CCG has

developed and implemented new services to detect AF, and works with

practices to improve CHD detection rates.

iii. Neurological - £386k in comparison to 10 similar CCGs, and a further £107k

when compared to the best performing 5 CCGs. Approximately three quarters

of this potential saving is attributable to the PBC sub category of ‘Chronic

Pain’. This is also covered by the MSK Prime Provider Contract. A review of

the remaining savings indicates higher local prevalence at specific practices,

and a high proportion of patients being referred to London (at higher MFF

cost).

iv. Respiratory - £215k in comparison to 10 similar CCGs, and a further £142k

when compared to the best performing 5 CCGs. The CCG is working with

practices to increase the detection of COPD, and the new Respiratory service

has commenced as part of the community programme.

v. Trauma & Injuries - £155k in comparison to 10 similar CCGs, and a further

£152k when compared to the best performing 5 CCGs. Further analysis is

being conducted to identify key drivers for the variation.

vi. Endocrine, nutritional & metabolic - £65k in comparison to the 5 best

performing peer CCGs. New service commenced in July 2016 – will improve

the quality of care and deliver savings.

c. Non-Elective Admissions

i. Previous reports had indicated that HWLH had lower non-elective admissions

spend than the average of the 5 best performing similar CCGs.

ii. The October 2016 Commissioning for Value (CFV) report indicates a potential

opportunity of £528k in comparison to the 5 best performing peer CCGs.


iii. Trauma & Injuries -The reported number of Falls has decreased over the

previous 4 years, and likely to reduce further following a review of the Falls

and Fracture Management Services.

iv. Musculoskeletal – HWLH has a low ’Rate of DEXA scan activity’ implying that

our population does not have equivalent access to this diagnostic test.

v. Endocrine, nutritional & metabolic -As above, a new service commenced in

July 2016 and therefore expect relevant indicators to improve.

d. Primary Care Prescribing (Total of £2,108k – mostly in comparison to average of best 5

similar CCGs). Significant savings have been delivered over the past two years with

further savings planned in 2017/18.

3. Other benchmarking activities

a. NHS Benchmarking Club

b. NHS Better Care, Better Value Indicators

c. Dr Foster – Rightcare reporting (New)

d. Public Health England – Public Health Profiles

e. South Central West CSU standard reporting

4. Insight and intelligence from:

a. Commissioners

b. Networking

c. Conferences

d. Better Care Exchange

e. The Health Service Journal (HSJ)

Table 4: 17/18 QIPP Overview for HWLH CCG

Table 4 QIPP Analysis 2017/18 Scheme Full Value £’000

Risk Adjusted £’000

Full Year Effects

MSK 2,200 2,200

Community 2,030 1,320

Diabetes 100 95

Kinesis 100 95

Tier 3 Weight Management 100 95

Gastroenterology 100 95

Ophthalmology 200 190

Urology 50 50

Dermatology 250 240

Total Full Year effects 5,130 4,380

RightCare


Trauma & Injuries 200 130

CVD/Circulation 200 130

Neurological 250 160

Respiratory 150 100

Other 250 160

Total RightCare 1050 680

Other benchmarking

Better Care Better Value 100 70

QVH Contract – N:F Rates 200 130

Learning Disabilities 500 330

CHC 200 130

LPP List 250 160

Total Other Benchmarking 1250 820

Insight & Intelligence

Havens 150 98

Mental Health - OoAPs 300 200

Golden Ticket 100 70

Prescribing 1500 1430

IT 640 420

Self-Care/Self-Management 400 380

Medically Unexplained Symptoms 200 190

TECS 300 290

Frailty/Geriatrician 300 290

Falls 300 290

Connecting for You 500 330

Practice Performance 1000 950

Validation of NCA’s 200 130

Pipeline Schemes * 1000 450

Total Insight and Intelligence 6890 5518

Total QIPP 14320 11400

*Pipeline QIPP Schemes

The Key Line of Enquiry is to further reduce the growth in acute spend particularly A&E attendances

and Unplanned Admissions.

a) Referral Management from Primary Care

a. Identify practices with highest A&E and NEL admission rates, as well as OP,EL, and

prescribing spend.

b. Review data including GP Patient Survey, CQC reports, soft intelligence, NHSE Primary

Care Reports, and QOF (also highlighted by RightCare)

c. Cluster Lead approach enables a quadrupling of frequency of meetings thus ensuring

actions are followed up and improvements delivered.

d. All of the 9 high spending practices to be visited before then end of January 2017.

b) Increase utilisation of alternative emergency pathways:

a. Promoting MIUs

b. Increasing use of Summary Care Record to encourage

i. See & Treat


ii. Hear & Treat

iii. OOHs

iv. Primary Care

c) Frailty Pathway

a. Recruiting additional Community Geriatrician resource in the High Weald locality

b. Reviewing potential recruitment of Frailty Nurses

c. Use of Risk Stratification and Frailty Index to highlight most appropriate patient to

MDT’s

d) Map of Medicine

e) Self-Management

Review, enhance and extend the use of Self-Management services in to the Havens Locality.

f) Technology Enabled Care Services (TECS)

Further Key Lines of Enquiry

a) CHC/FNC

b) LD

c) Prescribing Call Centre

g) Referral Management

a. Promoting the use of Kinesis for con-referrals with MTW

b. Project Manager meeting regularly with practices to promote and encourage.

c. Promoting the use of Kinesis for non-acute services.

d. Regular reviews of comparative referral rates at locality meetings and at practice

review meetings.

Risk Adjusted QIPP - Effect and Impact of Delivery Risk

Individual schemes will have specific delivery risk, therefore a high level assessment is made for each

QIPP scheme by the PMO. These assessments are made in conjunction with Executive Leads for each

scheme using fixed %’s. By applying these %’s the CCG presents a risk adjusted QIPP programme

against which performance is assessed. These have been applied to derive the risk adjusted QIPP

schemes in the table above.

Table 5 - Risk Adjust. Percentage of Full Value QIPP expected

High 10%

Medium 65%

Low 95%

Nil 100%

Planned Point of Delivery impacts

The following table shows the required reductions against 2016/17 forecast out turn activity

projections by Point of Delivery (POD)

Table 5 – POD Impact A&E NEL OP EL/DC

Planned Impact Activity 4800 1500 9520 1560

Planned Impact % -13.50% -11.10% -8.40% -10.50%

Planned Impact Activity (Risk Adjusted) 2420 810 6000 780


Planned Impact % (Risk Adjusted) -6.8% 6.0% 5.3% 5.3%

The activity reductions required are significant and present a challenge both in terms of the CCG’s

ability to deliver these in year and the potential to destabilise the financial position of the provider

organisations which may not be able to right size and therefore release costs immediately.

The contracts agreed with the main providers do not incorporate the level of QIPP required by the

CCG. However the PODs where reductions are expected to be impacted on by QIPP schemes are

subject to PbR and the CCG will only be required to pay for actual activity delivered.

Given the scale of the challenge and activity reductions required, the CCG has an embedded PMO

driven delivery model and robust governance arrangements which are described below. In addition to

this the CCG has identified a number of further non recurrent mitigations which are described at the

end of this paper.

Delivery Model & Governance

The CCG has established a PMO function

Each QIPP scheme is subject to review at Business Case stage to ensure it is consistent with agreed

CCG criteria. This includes a requirement to demonstrate a return on investment (ROI) of 3:1. This

ensures that any optimism bias, interdependencies or overlaps with existing schemes, and investment

underperformance are considered before the project has commenced. Delivery is monitored through

weekly PMO updates against agreed milestones with monthly overarching QIPP highlight reports going

to the Executive Team and the CCGs Quality and Performance Committee and Governing Body.

Finance

Support

Head of

Intelligence

PMO

Manager

Programme

Support

Manager

ricer

Programme

Support

Manager

PMO

Analyst

Programme

Support

Manager

Executive

Team

Quality

Support


Mitigations to offset further delivery risk / Slippage

The current operational finance plan includes some non-recurring opportunities to offset further risk

that crystallises during 2017/18. These total £4,000k analysed as follows:

Table 6 - Mitigation £’000

Contingency held at 0.5% 1,000

50% of NR reserve available to be committed 1,000

Slippage on BCF 2017/18 Schemes 1,500

Quality Premium achieved 250

Estates efficiencies 250

Total 4,000

A Remedial Action Plan (RAP) has been implemented in 2016/17 to reduce the £7.9m underlying

position described in table 1 above. Details of the RAP are included at Appendix 2. Any reduction in

the underlying position going into 2017/18 reduces the overall QIPP requirement,


Appendix 4a

1. CCG Business Rules

• Minimum cumulative / historic underspend - 1% i.e. planned Income & Expense surplus.

• Contingency – minimum 0.5%.

• Non Recurrent spend – 1% of which 0.5% may be committed non-recurrently at the beginning

of each year.

• Admin costs to be limited to notified allocation

• Any quality premium received to be applied to programme spend

• Transparency on the source and application of funds such as Marginal Rate Emergency Tariff

(MRET)

• National policy commitments met. In 2016/17 nine ‘must do’ priorities were set out by NHS

England. These remain the priorities for 2017/18 and 2018/19. These national priorities and

other local priorities need to be delivered within the financial resources available in each year.

2. Finance

• Deliver individual CCG and NHS provider organisational control totals, and achieve local system

financial control totals. At national level, the provider sector needs to be in financial balance in

each of 2017/18 and 2018/19. At national level the CCG sector needs to be in financial balance

in each of 2017/18 and 2018/19.

• Implement local STP plans and achieve local targets to moderate demand growth and increase

provider efficiencies.

• Demand reduction measures include: implementing RightCare; elective care redesign; urgent

and emergency care reform; supporting self-care and prevention; progressing population-health

new care models such as multispecialty community providers (MCPs) and primary and acute

care systems (PACS); medicines optimisation; and improving the management of continuing

healthcare processes.

• Provider efficiency measures include: implementing pathology service and back office

rationalisation; implementing procurement, hospital pharmacy and estates transformation

plans; improving rostering systems and job planning to reduce use of agency staff and increase

clinical productivity; implementing the Getting It Right First Time programme; and

implementing new models of acute service collaboration and more integrated primary and

community services.


Appendix 4b 2016/17 Remedial Action Plan (RAP)

April 2016

At the start of 2016/17 HWLH CCG had a QIPP target of £9.2m. During July 2016 a further cost pressure of £980k was identified relating to Funded Nursing

Care (FNC), resetting the QIPP target of £10.2m.

At the beginning of the financial year £7.9m of QIPP savings had been identified; however, given the significant reduction in Outpatients and Non-Elective &

Electives admissions this represented, only a proportion of the QIPP was fed in to provider contracts.

July 2016

In July 2016 over-performance against the acute contracts was first identified and highlighted the potential non-achievement of forecast savings as part of

the QIPP programme. The following key programmes were reported to SMT and the Governing Body as contributing to the over-performance.

Principle Shortfalls Domain Lead Shortfall (000s)

Primary Reason Mitigation

Medicines Management Meds Mgmt

PW 300 Treatment of FYE from 15/16 (£500k) Partial mitigation through additional projects and accelerating Integrated Pharmacy Pilot

Self-Management (KYOH) Comm HL 150 Lewes practices slow to submit candidates

HSCC Comm HL 634

Tele-Dermatology Planned HL 120 Delays in commencement (PMO 25/7)

Diabetes Planned HL 400 Delays and risk of patients not transferring

Ophthalmology Planned HL 300 Delays

GP-Kinesis Planned HL (PMO) 70 Slow uptake with GPs Has been passed to PMO team to deliver

Technology Enabled Care (TECS) Comm HL 60 Slow to plan and deliver – ESBT ?push ahead separately with SCFT – Significant Opportunity – need Resource

Map of Medicine IM&T AB/NK 450 Lack of use by GPs Options being considered

Roving GP Primary SS 100 Recruitment

Paramedic Practitioner Primary SS 40 Recruitment

Practice Connect Worker Primary SS 100 Sick, and resigned Age UK East Sussex

2,784


Themes

Assessment of the under-performing projects highlights 4 clear themes contributing towards the under-achievement of the above schemes:

Staff capacity to deliver an extensive range of projects, and other unforeseen issues that are commanding considerable time and resource, to the

detriment of Business as Usual.

Recruitment – inability or delays recruiting in to Roving GP, Practice Connect Worker, Paramedic Practitioners, and Geriatricians.

Collaborations – delivering in 2017/18 onwards, but consuming resource now. (TECS, KYOH, HSCC etc….)

Engagement – schemes such as Kinesis, Map of Medicine, and Know Your Own Health have struggled to gain a foothold.

Mitigation/Recovery Plan

To address the forecast overspend, the CCG created the ‘QIPP Remedial Planning Group’ to reduce programme under-performance and identify alternative

mitigating actions. The group is chaired by the Chief Finance Officer. Membership includes members of the executive team and the project management

office. Terms of Reference were agreed in early August, with the first meeting arranged for the 8th September.

Meeting Dates

8th September Held

25th October Held

17th November Not Held

13th December Not Held

12th January

9th February

14th March


In preparation for the inaugural meeting of the QIPP Remedial Action Group, a number of potential mitigating actions were identified

Ideas using existing resources

Review of High Cost CHC & LD individuals (spend shared with EHS & HR) TBA

Practice Peer Reviews - as at month 2, 5 practices will account for £2.4m of forecast expenditure above their cluster average (assuming 50% delivery = £1.2m saving)

£1.2m

RAMU (£388k) – HMSX, B&H and HWLH v BSUH (Counting issue for in contract meetings)

£388k

Lower level dependency nursing care – est. £100k (allow for risk adjustment) £50k

Ensuring HSCC is used and not circumvented, promote referrals from BSUH/MTW, and ensure the appropriate services are in place via the community contract. (seeing a possible reduction in shortfall of £100k)

£100k

Avastin v Lucentis (£200k) £200k

PoLCE (London list)- 17/18 [e.g. Apicoectomy (£1,000); Adenoidectomy for Otitis Media (£2,000); Meatoplasty of External Ear – none in 15/16; Laser treatment for soft palate (snoring); Wisdom Teeth Extraction (£70,000); Anal procedures (£29,000); (allowing for risk adjustment)]

£50k

Review of new ESBT Schemes £0

Paediatric Info Pack £10k

Subtotal: Existing Ideas £2.0m

Planned Care (1 Project Manager 7/8a)

Cardiology ECGs & ECHOs by GPs TBA

Diabetes service promotion £15k

Tele-Dermatology…move quickly from Lewes Pilot £30k

Ophthalmology: (Occular Hypertension; Glaucoma Refinement; AMD Triage; Flourocein Angiography; wAMD Monitoring in the community (ESBT))

£50k

GP-Kinesis (dedicated project lead now assigned to ramp up delivery) £20k

Unnecessary Scopes – IY to check with HW – (£100k- conservative estimate) £100k

Reduction of unnecessary/expensive blood tests £10k

Subtotal: Planned Care £225k


Urgent Care (1 Project Manager 7/8a)

MIU Promotion £20k

Self-Management (KYOH) - ?increase the number of patients/?extend £10k

Falls (OTAGO) TBA

Practice Connect Worker – accelerate discussions with AUKES to get them in to all practices and cover Chapel St/Meridian position

£50k

Checking how the £5 per head was spent/used, is it still happening/delivering any results.

£15k

Revisit Rowe Avenue paramedic project £50k

Community resilience TBA

Subtotal: Planned Care £145k

Total known potential towards shortfall £2.37m


Delivery of Action Plan

On 14 November the Executive Team Meeting focused on financial recovery and Executives were charged with developing Action Plans for their respective

remits (as follows).

Remit Executive

Primary Care Sally Smith

Acute Care (inc QVH) Peter Finn/Chris Tait/Steve Clarke

Community Ash Scarff

Social Care Hugo

1. Primary Care - Practice Review

All practices within HWLH CCG have been visited over the past four years in a rolling programme of reviews to identify areas of best practice, and

issues that could be improved. The new structure with ‘Cluster Leads’ enables the CCG to accelerate this successful programme to facilitate more

frequent visits, and ensure agreed actions are followed-up.

A review of practice performance indicates that nine practices have a higher cost per weighted patient compared to the remainder. Priority has been

given over to the extensive analysis and evaluation of practice performance, and accommodating meetings within busy GP and management diaries.

Forecast Variance

Key Issues Meeting Date

Belmont Surgery £217,731 A&E, EL, NEL, OP 18th January

Groombridge & Hartfield £119,312 A&E, EL, OP, Presc 11th January

Rotherfield £41,001 A&E, EL OP, Presc 22nd November

The Meads £340,195 EL, NEL, OP 29th November

Buxted Surgery £333,952 NEL, Presc 11th October

Newick £533,019 A&E, EL, NEL, OP, Presc 6th February

School Hill £106,354 NEL, OP, Presc 20th December

Chapel Street £429,728 A&E, EL, NEL, OP, Presc 21st December

Rowe Avenue £217,110 A&E, NEL, OP 20th January

£2,338,402


2. Acute Care - Provider Review

Analysis of the CCG’s three main provider contracts highlighted significant increases in the total and average level of diagnostic and procedure coding

per episode.

Following the above high level analysis, the CCG requested the CSU to perform more detailed investigations to demonstrate and confirm that the

increase in coding has resulted in higher average cost per spell. This investigation is due to report back to the CCG in early January with regards to

MTW, and following the results of this, will be rolled out to ESHT and BSUH later in the month.

The Estimated Value of the additional coding for MTW and ESHT is:

Provider POD Estimated Value Comment

MTW A&E £100k Led by West Kent CCG

MTW Non-Elective £150k SCWCSU investigating

ESHT Non-Elective £350k SCWCSU investigating

BSUH – to follow

3. BSUH – Rapid Access Medical Unit (RAMU) (Peter Finn)

Analysis had identified that the creation of the RAMU at the Princess Royal Hospital (PRH) had resulted in a counting issue, resulting in increased cost.

This has now been accepted and is incorporated with the challenges relating to the BSUH contract.

4. Lower Level Dependency Nursing Care (Hugo Luck)

This has been initiated and the service is currently recruiting to posts. An update from Andy Cunningham will follow

5. Promoting the use of Health and Social Care Connect (HSCC)

HSCC has now been established as business as usual, and therefore the project which led to its implementation is closed. East Sussex County Council

(ESCC) however state that the HSCC will not deliver savings on its own contrary to clear indications within the business case.

The HSCC should however deliver benefits to the CCG, hence a twin approach is being taken in a meeting between the CCG and ESCC on the 10th

January to:

a. Ensure the highest possible use of the HSCC

b. Review staffing and costs associated with HSCC to ensure it offers VFM


6. Review of London Contracts

7. CHC/FNC and Learning Disabilities review (Chris Tait / Ashley Scarff / Peter Finn)

8. Promoting the use of MIUs and other alternatives for Urgent Care (Hugo Luck)

The Primary Care Team designed and distributed leaflets during early December via a variety of routes such as schools, newspapers, social media. The

leaflets are reported to have been widely received and remind residents of the options available to them, alternative to A@E. The further promotion

of A&E alternatives is also identified as part of the Community Services Delivery Improvement Plan (SDIP).

9. Christmas ward rounds.

These took place over Christmas similarly to the previous year. In addition the CCG has extended the scheme throughout January to further reduce

activity and alleviate pressures in secondary care.

10. Practice Connect Worker (Quayside and Meridian)

This initiative sought to place a member of staff within practices. It was intended that the PCW would receive referrals from GPs and practice staff,

and they would sign-post to community groups, expert benefit advice & housing advice. The pilot post-holder unfortunately resigned after a short

period of sick leave and the pilot ceased. However, the CCG has subsequently contracted an organisation to provide the service from the 4th January

to 31st March. The CCG is also in conversation with Age UK East Sussex regarding a permanent solution.

11. Kinesis

Through a concerted effort by Vicki Langley (Programme Support Manager), the service is slowly starting to deliver savings. This mirrors the progress

made in West Kent CCG with a slow rate of pick-up. A reduced cost has been negotiated for subsequent months.

Savings of £5,163 have been delivered thus far. Further actions have been identified to improve uptake including the use of Kinesis in the Tele-

Dermatology project and Vicki is working with stakeholders to consider how Kinesis might also be used for community and mental health services.

–End.



Item Number:


Title of report: Performance Report – January 2017

Recommendation: The Committee is recommended to note the performance against the National Standard Indicators.

Summary: Referral to Treatment (RTT-Target 92%) - (as at Month End November 2016) The overall rate for 'Incomplete Pathways' is gradually improving, and now stands at 85.5%. This compares to 82.82% in August 2016. Over this period, the number of >52 week waiters has fallen from 44 to 33 (32 of these patients are at Brighton & Sussex University Hospitals NHS Trust (BSUH)). BSUH performance relating to 'Incompletes' has increased to 80.44%. East Sussex Healthcare NHS Trust (ESHT) performance has however deteriorated to 80.83%, having been around 87/88% earlier in the year. Maidstone & Tunbridge Wells (MTW) continues to perform around 90/91%. Diagnostics (Target 99%) Diagnostics performance for October 2016 has improved slightly, but remains at 98%. There were a total of 56 patients waiting over 6 weeks, 27 of whom were at Sussex Community Foundation Trust (SCFT), and 16 at BSUH. Of the 56, 26 were for Non-Obstetric Ultrasound, 9 for Gastroscopies, and 7 for MRI scans. Accident & Emergency (Target 95%) All three providers are struggling to meet the A&E target, and thus far showing little sign of improvement. BSUH and ESHT are both below their A&E trajectories. Cancer Waits As reported in December 2016, the main challenges relate to the 62-day targets, where all three of our main providers are struggling. BSUH and ESHT performance remains unchanged Ambulance Calls South East Coast Ambulance Service (SECAmb) performance overall continues to be significantly below the required national target levels, and HWLH continues to receive the lowest level of performance from SECAmb, and also the lowest in comparison to the 'Lightfoot' reviews achievable performance levels. Mixed Sex Accommodation BSUH declared 137 breaches in September 2016, the highest for over a year. 12 breaches have been declared at MTW. As Pembury consists of single rooms, this is most likely to be Maidstone hospital, and therefore unlikely to be HWLH patients. Mental Health CPA - For the first two quarters in 16/17, Sussex Partnership Foundation Trust (SPFT) is 0.6% below the target of 95%. Historically, performance has fluctuated and SPFT have delivered for the year as a whole. For patients with their first episode of psychosis and starting a package of care within 2 weeks, HWLH and SPFT are safely above the national target. Psychosis - For the first seven months, SPFT are at 70% against the target of 50%.


MRSA No patients have been recorded with MRSA in the year to September 2016 in the CCG’s three main providers. Clostridium Difficile BSUH reported 5 cases in October 2016, and now, similar to ESHT & MTW, are above their year to date ceilings. Eight cases have been attributed to HWLH during October 2016, which if confirmed would place the CCG at risk of exceeding the ceiling for this KPI Never Events ESHT has reported one 'Never Event' in April 2016. This related to medication being administered via an incorrect route. No harm was caused to the patient. MTW have reported an event in August 2016 (wrong sided implant). BSUH are reporting 2 events in September 2016, one for a retained laparoscopic retrieval bag, and another whose feet had been scalded and subsequently transferred to QVH. 52 Week Waiters From a peak of 257 as at the end of August 2016, BSUH has reduced the number of patients waiting over 52 weeks to 161 by Mid-December 2016. The majority of these cases (157) are for Digestive Diseases. Cancelled Operations (EBS2) BSUH and ESHT have improved marginally. Both ESHT and MTW were above the national average in Q1 and Q2. Friends & Family Scores appear to be relatively consistent. GP Practice Performance As at month 7, the two highest spending practices, 2 per cluster are: Groombridge & Hartfield Medical Group, and Belmont Surgery Buxted Surgery, and The Meads Newick Health Centre, and School Hill Medical Practice Chapel Street Surgery, and Rowe Avenue Surgery Meetings with all the above practices have been arranged, and only Mid-Downs (February 2017), Rowe Av (20 January 2017), and Wadhurst (18 January 2017) outstanding.

Committee sponsor: Hugo Luck, Associate Director of Operations

Author(s): Stephen Clarke, Head of Information and QIPP


Review by other committees: Reviewed by the CCG’s Quality and Performance Committee

Health impact: Individual performance risks may have potential health impact.

Financial implications: Individual performance risks may have potential financial impact with respect to penalties applicable and usage of the RTT monies

Legal or compliance implications: Individual performance risks may have potential legal impact.

Link to key objective and/or principal risks: Quality Domains and financial balance

How has patient and public engagement informed this work: Not applicable


Equality Analysis (EA) Process - outcome: Negative Impact Neutral Impact Positive Impact No Impact Not required for report

☐ ☐ ☐ ☐ ☒


☒ ☐ ☐


High Weald Lewes Havens CCG

Quality & Performance Report

18th January, 2017

Page 1 of 23

Page PagePOD Report 3 Urgent Operations 18Current Issues 4 Elective Operations 18Commentary 6 Never Events 19RAG Indicators 8 E-Referral Service 19Referral to Treatment 10 Personal Health Budgets 19Diagnostics 10 Medication Errors 19A&E Waits 11 Anti-microbial resistance 19Cancer Waits 12 Friends & Family Test 20Cat A Ambulance Calls 15 GP Performance 21Mixed Sex Accommodation 16 Access to IAPT 22Mental Health 16 Dementia 22Early Intervention In Psychosis 16 Health Checks 23MRSA 17 Smoking 23C. Diff 17 Falls 23Referral to Treatment 52 weeks 18Ambulance Handover Delays 18

Contents

Page 2 of 23

POD report

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

2012 2013 2014 2015 2016

A&E Cost to Month 7

£0

£2,000,000

£4,000,000

£6,000,000

£8,000,000

£10,000,000

£12,000,000

£14,000,000

£16,000,000

2012 2013 2014 2015 2016

Elective Cost to Month 7

£12,500,000

£13,000,000

£13,500,000

£14,000,000

£14,500,000

£15,000,000

£15,500,000

£16,000,000

£16,500,000

£17,000,000

2012 2013 2014 2015 2016

Non-Elective Cost to Month 7

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,000

£4,000,000

2012 2013 2014 2015 2016

Outpatients First Cost to Month 7

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,000

£4,000,000

£4,500,000

£5,000,000

2012 2013 2014 2015 2016

Outpatient Follow-up Cost to Month 7

£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

2012 2013 2014 2015 2016

Outpatient Procedures Cost to Month 7

Page 3 of 23

NHS RightCare released a new report relating to Long Term Conditions, during December. Below is a selection of bar graphs where the CCG is an outlier.

Current Issues

Current Issues

Page 4 of 23

Current Issues

Referral to Treatment (RTT-Target 92%) - (as at Month End November 2016)

Commentary

Page 5 of 23

Referral to Treatment (RTT-Target 92%) - (as at Month End November 2016) The overall rate for 'Incomplete Pathways' is gradually improving, and now stands at 85.5%. This compares to 82.82% in August. Over this period the number of >52 week waiters has fallen from 44 to 33 (32 of these patients are at BSUH). BSUH performance relating to 'Incompletes' has increased to 80.44%. ESHT performance has however deteriorated to 80.83%, having been around 87/88% earlier in the year. MTW continues to perform around 90/91%. Diagnostics (Target 99%) Diagnostics performance for October has improved slightly, but remains at 98%. There were a total of 56 patients waiting over 6 weeks, 27 of whom were at SCFT, and 16 at BSUH. Of the 56, 26 were for Non-Obstetric Ultrasound, 9 for Gastroscopies, and 7 for MRI scans. Accident & Emergency (Target 95%) All three providers are struggling to meet the A&E target, and thus far showing little sign of improvement. BSUH and ESHT are both below their A&E trajectories. Cancer Waits As reported in December, the main challenges relate to the 62-day targets, where all three of our main providers are struggling. BSUH and ESHT performance remains unchanged Ambulance Calls SECAMB performance overall continues to be significantly below the required national target levels, and HWLH continues to receive the lowest level of performance from SECAMB, and also the lowest in comparison to the 'Lightfoot' reviews achievable performance levels. Mixed Sex Accommodation BSUH declared 137 breaches in September, the highest for over a year. 12 breaches have been declared at MTW. As Pembury consists of single rooms, this is most likely to be Maidstone hospital, and therefore unlikely to be HWLH patients. Mental Health CPA - For the first two quarters in 16/17, SPFT are 0.6% below the target of 95%. Historically, performance has fluctuated and SPFT have delivered for the year as a whole. For patients with their first episode of psychosis and starting a package of care within 2 weeks, HWLH and SPFT are safely above the national target. Psychosis - For the first seven months, SPFT are at 70% against the target of 50%

MRSA No patients have been recorded with MRSA in the year to September in the CCGs three main providers.

Commentary

Page 6 of 23

KPI Themes National Quality Requirements Q3 Q4 Q1 Q2 Q3

84.5% 82.1% 82.5% 83.2% 84.3%

96.0% 97.1% 96.7% 95.8% 98%

87.2% 82.5% 86.2% 83.7%

15/16 16/17

Referral to

Treatment &

Diagnostics

E.B.3 % on incomplete non-emergency pathways (yet to start treatment) waiting no more than 18 weeks from

referralE.B.4 % of patients waiting less than 6 weeks from referral for a diagnostic test

A&E E.B.5 % of attendances (where the patient was admitted, transferred or discharged) within 4 hours of their arrival

Rag Indicator

No patients have been recorded with MRSA in the year to September in the CCGs three main providers. Clostridium Difficile BSUH reported 5 cases in October, and now, similar to ESHT & MTW, are above their year to date ceilings. Eight cases have been attributed to HWLH during October, which if confirmed would place the CCG at risk of exceeding the ceiling for this KPI Never Events ESHT has reported one 'Never Event' in April. This related to medication being administered via an incorrect route. No harm was caused to the patient. MTW have reported an event in August (wrong sided implant). BSUH are reporting 2 events in September, one for a retained laparoscopic retrieval bag, and another whose feet had been scolded and subsequently transferred to QVH. 52 Week Waiters - From a peak of 257 as at the end of August, BSUH has reduced the number of patients waiting over 52 weeks to 161 by Mid-December. The majority of these cases (157) are for Digestive Diseases. Cancelled Operations (EBS2) BSUH and ESHT have improved a little. Both ESHT and MTW were better than the national average in Q1 and Q2. Friends & Family Scores appear to be relatively consistent. GP Practice Performance As at month 7, the two highest spending practices, 2 per cluster are: Groombridge & Hartfield Medical Group, and Belmont Surgery Buxted Surgery, and The Meads Newick Health Centre, and School Hill Medical Practice Chapel Street Surgery, and Rowe Avenue Surgery Meetings with all the above practices have been arranged, and only Mid-Downs (Feb), Rowe Av (20th Jan), and Wadhurst (18th Jan) outstanding.

Page 7 of 23

92% 94.3%

91.2% 92.5%

97.5% 98.8%

93.5% 93.3%

100% 98.6%

97.2% 94.8%

77.1% 73% 80.3% 79.5%

57.1% 53.8% 64.3% 84.2%

75% 67% 50% 100%

58.2% 43.0% 45.2% 43.5% 34.7%

53.3% 38.9% 36.9% 28.6% 26.5%

91.5% 85.3% 84.8% 77.8% 77.9%

3 6 39 28 26

91% 98.6% 93.8% 95.2%

61.3% 83.3% 80%

KPI Themes National Quality Requirements Q3 Q4 Q1 Q2 Q3

1 0 0 0 0

10 6 9 9 8

25 39 54 107 40

4 9 0 2 0

E.B.9 % waiting no more than 31 days for subsequent treatment where the treatment is surgery

E.B.10 % waiting no more than 31 days for subsequent treatment where that treatment in an anti-cancer drug

regimenE.B.11 % waiting no more than 31 days for subsequent treatment where that treatment is a course of

radiotherapy

Cancer Waits E.B.6 % referred urgently with suspected cancer by a GP waiting no more than 2 wks for first OP appointment

E.B.7 % referred urgently with breast symptoms (where cancer not initially suspected) waiting no more than 2

weeks for first appointmentE.B.8 % waiting no more than one month (31 days) from diagnosis to first definitive treatment for all cancers

Ambulance

Targets

E.B.15.i % of Category A Red 1 ambulance calls resulting in an emergency response arriving within 8 minutes

E.B.15.ii % of Category A Red 2 ambulance calls resulting in an emergency response arriving within 8 minutes

E.B.16 % of Category A calls resulting in an ambulance arriving at the scene within 19 minutes

E.B.12 % waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for

cancerE.B.13 % waiting no more than 62 days from referral from an NHS screening service to first definitive treatment

for all cancersE.B.14 % waiting no more than 62 days for first treatment following a consultant's decision to upgrade the

priority of the patient (all cancers)

15/16 16/17

Hospital

Acquired

Infections

E.A.S.4 Rates of MRSA

E.A.S.5 Rates of Clostridium Difficile

Mixed Sex

Accom.

E.B.S.1 Mixed sex sleeping accommodation breaches

Mental Health E.B.S.3 % people under adult mental health illness specialties on CPA who were followed up within 7 days of

discharge from psychiatric in-patient care

52 Weeks E.B.S.4.3 Referral to treatment waits over 52 weeks (incomplete )

A&E Handovers E.B.S.7 Ambulance to A&E handover delays

Mental Health People with first episode of psychosis starting treatment with a NICE-recommended package of care

treated within 2 weeks of referral

Cancelled Ops E.B.S.6 Number of urgent operations cancelled for a second time

Page 8 of 23

E.B.S.2

8 1 1 3

4% 4%

E.A.9

107a1.03 1.04

107b12.1% 11.9%

89% 88% 90% 89% 89%

97% 97% 97% 96% 96%

3.9% 5.5% 4.5% 2.5%

58.3% 63.5%

Referral to treatment waIting times for non-urgent consultant led treatment

Percentage of patients on incomplete non-emergency pathways (yet to start treatment) waiting no more than 18 weeks from referral

Target Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD Var

92% 92.3% 92.4% 91.8% 92.0% 92.1% 91.5% 91.6% 91.8% 91.5% 91.3% 90.9% 90.6% 90.4% 91.1% -0.9%

92% 85.9% 85.0% 82.6% 82.6% 82.2% 81.4% 81.5% 82.8% 83.3% 83.2% 82.8% 83.7% 84.3% 83.1% -8.9%

92% 78.6% 77.0% 73.9% 75.4% 73.8% 73.2% 73.5% 74.8% 75.3% 75.3% 75.1% 76.8% 77.8% 75.5% -16.5%

92% 92.7% 92.8% 92.1% 92.1% 92.2% 90.5% 90.2% 90.7% 89.5% 88.5% 87.5% 86.7% 85.7% 88.3% -3.7%

92% 95.7% 95.2% 93.9% 93.6% 92.0% 90.8% 90.4% 91.0% 91.4% 92.1% 91.0% 90.4% 90.5% 91.0% -1.0%

92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

NHS

e-referrals

105a Utilisation of the NHS e-referral service to enable choice at first routine elective referral

Personal Health

Budgets

105b Number of personal health budgest in place per 100,000 CCG population

Cancelled Ops

% of cancelled operations cancelled on or after the day of admission fo non-clinical reasons that are not

offered another binding date within 28 days

Never Events Number of never events

Medication

ErrorsNumber or reported medication error incidents as % of all reported incidents for that provider

Anti-microbial

resistance

Number of antibiotics prescribed in primary care per STAR-PU

Number of co-amoxiclav, cephalosporins and quinolones as a percentage of the total number of

selected antibiotics prescribed in primary care

Friends &

Family Tests

E.A.6 A&E Friends and Family Score

Inpatient Friends and Family Score

Local Quality

Requirments

IAPT Access to IAPT services: People entering IAPT services as a % of those estimated to have

anxiety/depressionDementia Estimated diagnosis rate for people with dementia

Former Quality

Requirements

Health Checks % of eligible people who receive a health check

% of people offered a health check who received one

Smoking % of people successfully quitting smoking with help from the NHS stop smoking service

Falls Total number of spells of inpatients with diagnosis including fall

2015/16 2016/17

E.B

.3

National

HWLH

BSUH

ESHT

MTW

100%

Operating Standards

Page 9 of 23

Diagnostic test waiting times

Percentage of patients waiting less than 6 weeks from referral for a diagnostic test


99% 98.3% 98.4% 97.8% 97.9% 98.7% 98.3% 98.2% 98.6% 98.5% 98.6% 98.3% 98.5% 98.9% 98.5% -0.5%

99% 95.6% 96.5% 96.0% 96.9% 97.8% 96.7% 96.3% 97.6% 96.3% 95.0% 94.5% 97.9% 98.0% 96.5% -2.5%

99% 91.8% 93.4% 94.6% 95.8% 97.8% 95.0% 93.4% 97.4% 98.4% 97.9% 97.2% 99.0% 98.1% 97.3% -1.7%

99% 98.1% 99.0% 98.0% 96.2% 97.6% 93.3% 97.1% 97.3% 97.4% 97.8% 97.0% 97.5% 99.1% 97.6% -1.4%

99% 99.8% 99.8% 99.7% 99.7% 99.8% 99.6% 99.6% 99.7% 99.8% 99.9% 99.7% 99.7% 99.8% 99.7% 0.7%

99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%

Accident and emergency waits

Percentage of A&E attendances where the patient was admitted, transferred or discharged within 4 hours of their arrival at an A&E department

Target Q3 Q4 Y/E Q1 Q2 Q3 YTD Var

95% 91.5% 88.0% 88.0% 90.3% 90.6% 89.0% 90.2% -4.8%

95% 86.3% 81.9% 81.9% 85.2% 83.0% 82.6% 83.9% -11.1%

95% 89.2% 84.5% 84.5% 83.8% 80.9% 78.0% 81.7% -13.3%

95% 87.7% 82.1% 82.1% 91.0% 88.1% 89.0% 89.5% -5.5%95% 95% 95% 95% 95%

2015/16 2016/17

E.B

.4

National

HWLH

BSUH

ESHT

MTW

From 1 July 2015 NHS England have changed the frequency at which data is published, this will now only be on a monthy basis. From July onwards the BSUH and ESHT weekly data is taken from sitreps that are

provided at a local level and therefore should be treated with caution. The monthly and quarterly tables are based on the NHS England validated and published data

By Quarter 2015/16 2016/17

E.B

.5

NationalBSUHESHTMTW

By Month 2015/16 2016-17

70%75%80%85%90%95%

100%

Q3 Q4 Q1 Q2 Q3

National

BSUH

ESHT

MTW

Target

70%

75%

80%

85%

90%

95%

100%

Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16

National

HWLH

BSUH

ESHT

MTW

Target

85%

90%

95%

100%


National

HWLH

BSUH

ESHT

MTW

Target

Page 10 of 23


95% 92.3% 91.3% 91.0% 88.7% 87.8% 87.3% 90.0% 90.2% 90.5% 90.3% 91.0% 90.6% 89.0% 90.2% -4.8%

95% 82.3% 88.6% 88.0% 82.6% 81.6% 81.0% 84.2% 86.3% 85.1% 84.1% 81.2% 83.7% 82.6% 83.9% -11.1%

95% 91.2% 89.4% 86.7% 85.7% 86.0% 79.0% 82.9% 85.1% 83.2% 82.6% 79.5% 80.5% 78.0% 81.7% -13.3%

95% 90.2% 88.1% 84.9% 80.4% 82.6% 84.5% 91.6% 90.5% 91.0% 87.7% 87.4% 89.4% 89.0% 89.5% -5.5%

Target 06/12 13/12 20/12 27/12 03/01 10/01 17/01 24/01 31/01 07/02 14/02 21/02 28/02 06/03 13/03 20/03 27/03 03/04

95% 84.8% 91.3% 88.4% 91.7% 80.3% 80.5% 84.8% 85.8% 80.7% 81.0% 83.0% 80.7% 81.7% 80.0% 80.1% 82.6% 80.8% 80.8%

95% 86.5% 85.4% 86.4% 88.8% 85.1% 87.0% 85.5% 83.6% 86.6% 90.2% 88.5% 82.5% 84.2% 81.0% 78.1% 78.8% 81.3% 74.3%

Target 10/04 17/04 24/04 01/05 08/05 15/05 22/05 29/05 05/06 12/06 19/06 26/06 03/07 10/07 17/07 24/07 31/07 07/08

95% 81.2% 79.3% 83.9% 94.3% 87.5% 83.1% 84.3% 87.1% 91.6% 80.2% 86.4% 83.8% 86.1% 85.5% 84.7% 83.0% 82.8% 82.2%

95% 83.1% 77.0% 81.5% 92.6% 82.6% 82.6% 90.2% 84.6% 84.4% 79.7% 81.3% 85.2% 85.9% 87.0% 85.8% 76.1% 80.3% 80.7%

Target 14/08 21/08 28/08 04/09 11/09 18/09 25/09 02/10 09/10 16/10 23/10 30/10 06/11 13/11 20/11 27/11 04/12 YTD

95% 80.3% 82.6% 80.0% 82.2% 80.5% 86.7% 82.2% 84.3% 82.0% 84.3% 82.0% 83.4% 81.9% 81.8% 81.6% 82.6% 82.1% 83.6%

95% 82.8% 75.4% 80.0% 81.6% 77.7% 76.6% 82.9% 83.3% 77.0% 81.2% 75.4% 76.6% 82.2% 81.5% 82.3% 83.0% 81.0% 81.7%

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Cancer waits

Percentage of patients referred urgently with suspected cancer by a GP waiting no more than two weeks for first outpatient appointment

% <2 wks All BSUH ESHT MTW Target

92.1% 1299 1411 94.0% 92.4% 93.0% 93%

92.4% 1352 1463 93.3% 88.6% 94.6% 93%

90.2% 1291 1432 91.3% 91.1% 90.6% 93%

89.5% 1408 1573 86.6% 95.0% 92.0% 93%

92.0% 1566 1702 92.6% 96.1% 91.1% 93%

94.3% 1635 1733 94.4% 97.2% 93.0% 93%

93%

93%

93.2% 3201 3435 93.2% 96.4% 91.7% 93%

E.B

.5

NationalBSUHESHTMTW

By Week (rolling year) 2015/16

E.B

.5

BSUH

ESHT

2016/17

BSUH

ESHT

2016/17

BSUH

ESHT

HWLH

E.B

.6

Provider

Q1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

70%

75%

80%

85%

90%

95%

100%

BSUH

ESHT

Target

80%

85%

90%

95%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

Page 11 of 23

0.2% 0.2% 3.4% -1.3%

Percentage of patients referred urgently with breast symptoms (where cancer was not initially suspected) waiting no more than two weeks for first outpatient appointment

% <2 wks All BSUH ESHT MTW Target

97.3% 145 149 98.5% 93.8% 95.7% 93%

93.2% 137 147 96.8% 80.5% 94.4% 93%

91.8% 145 158 98.6% 89.2% 89.3% 93%

92.5% 136 147 96.5% 93.7% 85.6% 93%

91.2% 156 171 97.3% 96.3% 86.1% 93%

92.5% 148 160 97.3% 96.3% 89.6% 93%

93%

93%

91.8% 304 331 97.3% 96.3% 87.1% 93%

-1.2% 4.3% 3.3% -5.9%

Percentage of patients waiting no more than one month (31 days) from diagnosis to first definitive treatment for all cancers

% <31 dys All BSUH ESHT MTW Target

97.0% 227 234 96.7% 97.0% 98.8% 96%

94.8% 200 211 95.8% 96.9% 97.1% 96%

96.7% 234 242 96.8% 98.4% 96.6% 96%

94.4% 253 268 97.7% 98.3% 96.4% 96%

97.5% 234 240 98.9% 98.8% 96.6% 96%

98.8% 254 257 98.4% 98.6% 96.6% 96%

96%

96%

98.2% 488 497 98.7% 98.7% 96.6% 96%

2.2% 2.7% 2.7% 0.6%

Percentage of patients waiting no more than 31 days for subsequent treatment where that treatment is surgery


95.7% 45 47 93.5% 100% 100% 94%

100% 46 48 96.1% 100% 88.6% 94%

94.7% 36 38 91.2% 100% 94.9% 94%

88.6% 31 35 97.9% 100% 91.5% 94%

93.5% 29 31 96.6% 100% 77.2% 94%

93.3% 56 60 96.5% 97.4% 84.6% 94%

94%

94%

93.4% 85 91 96.6% 98.9% 79.7% 94%

-0.6% 2.6% 4.9% -14%

Percentage of patients waiting no more than 31 days for subsequent treatment where that treatment is an anti-cancer drug regimen

E.B

.6E

.B.7

Provider

Q1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

Variation

Variation

HWLH

HWLH

E.B

.8

Provider

Q1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

Variation

HWLH

E.B

.9

Provider

Q1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

Variation

80%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

80%

85%

90%

95%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

80%

85%

90%

95%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

80%

85%

90%

95%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

Page 12 of 23


100% 60 60 100% 100% 99.7% 98%

98.5% 66 67 99.6% 100% 98.8% 98%

100% 68 68 100% 100% 99.4% 98%

100% 72 72 100% 100% 98.1% 98%

100% 86 86 98.3% 100% 96.4% 98%

98.6% 69 70 99.5% 100% 97.1% 98%

98%

98%

99.4% 155 156 98.6% 100% 96.6% 98%

1.4% 0.6% 2.0% -1.4%

Percentage of patients waiting no more than 31 days for subsequent treatment where that treatment is a course of radiotherapy


88.4% 84 95 94.2% 100% 96.8% 94%

97.5% 77 79 98.9% 100% 95.9% 94%

98.8% 79 80 99.2% 95.3% 94%

97.8% 87 89 99.0% 100% 94.6% 94%

97.2% 103 106 97.9% 94.6% 94%

94.8% 92 97 97.3% 94.4% 94%

94%

94%

96.1% 195 203 97.7% 94.5% 94%

2.1% 3.7% 0.5%

Percentage of patients waiting no more than two months (62 days) from urgent GP referral to first definitive treatment for cancer

% <62 dys All BSUH ESHT MTW Target80.0% 92 115 73.6% 74.4% 81.9% 85%74.8% 83 111 76.8% 74.8% 75.3% 85%77.1% 101 131 80.8% 77.3% 76.5% 85%73.0% 100 137 78.6% 74.2% 74.4% 85%80.3% 98 122 79.0% 73.7% 71.5% 85%79.5% 124 156 78.5% 76.1% 75.7% 85%

85%85%

79.9% 222 278 78.8% 74.6% 72.8% 85%-5.1% -6% -10% -12%

Percentage of patients waiting no more than 62 days from referral from an NHS screening service to first definitive treatment for all cancers


88.5% 23 26 85.6% 85.7% 90.7% 90%

E.B

.10

Provider

Q1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

Variation

HWLH

HWLH

E.B

.11

Provider

Q1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

Variation

HWLH

E.B

.12

ProviderQ1 15/16Q2 15/16Q3 15/16

E.B

.13

ProviderQ1 15/16

Q4 15/16Q1 16/17Q2 16/17Q3 16/17Q4 16/17YTDVariation

HWLH

80%

85%

90%

95%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

70%

75%

80%

85%

90%

95%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

90%

100%HWLH

70%

75%

80%

85%

90%

95%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

Page 13 of 23

77.8% 14 18 82.8% 82.5% 89.7% 90%

57.1% 8 14 76.2% 72.7% 84.6% 90%

53.8% 21 39 77.0% 68.4% 73.1% 90%

64.3% 18 28 67.9% 75.0% 81.6% 90%

84.2% 16 19 78.0% 89.2% 84.4% 90%

90%

90%

72.3% 34 47 70.3% 80.6% 82.7% 90%

-18% -20% -9.4% -7.3%

Percentage of patients waiting no more than 62 days for first definitive treatment following a consultant's decision to upgrade the priority of the patient (all cancers)

% <62 dys All BSUH ESHT MTW

0% 0 2 100% 59% 78.3%

0 0 75.0% 87% 91.7%

75.0% 3 4 95.0% 70.2% 73.5%

100% 3 3 89% 90.6% 71.9%

50% 1 2 100% 83.3% 80.0%

100% 5 5 50.0% 77.8% 69.0%

86% 6 7 85.0% 81.0% 75.0%

Category A ambulance calls

Percentage of Category A Red 1 ambulance calls resulting in an emergency response arriving within 8 minutes

Target Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD Var

75% 73.3% 71.9% 72.6% 69.9% 68.0% 66.5% 72.4% 71.3% 70.5% 69.2% 67.6% 70.0% 68.3% 67.3% 69.3% -5.7%

75% 64.3% 53.9% 56.4% 43.6% 46.7% 38.8% 52.0% 41.9% 55.0% 38.8% 48.7% 30.6% 51.3% 34.7% 42.7% -32.3%

75% 73.8% 72.4% 74.5% 72.0% 65.5% 62.2% 71.6% 70.1% 66.4% 59.6% 62.1% 64.6% 62.6% 64.7% 64.3% -10.7%75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%

Percentage of Category A Red 2 ambulance calls resulting in an emergency response arriving within 8 minutes

E.B

.13

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

Q4 16/17

YTD

Variation

Q4 16/17

YTD

Variation

2015/16 2016/17

HWLH

E.B

.14

ProviderQ1 15/16

Q2 15/16

Q3 15/16

Q4 15/16

Q1 16/17

Q2 16/17

Q3 16/17

2016/17

E.B

.15.i

National

HWLH

SECAMB

2015/16

50%

60%

70%

80%

90%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

Target

0%

20%

40%

60%

80%

100%

Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17 Q3 16/17 Q4 16/17

HWLH

BSUH

ESHT

MTW

0%

20%

40%

60%

80%


National

HWLH

SECAMB

Target

Page 14 of 23


75% 68.8% 67.4% 67.2% 63.3% 60.3% 58.0% 67.3% 65.2% 65.0% 62.9% 60.3% 63.9% 62.0% 62.9% 63.3% -11.7%

75% 52.7% 55.8% 51.3% 47.1% 38.9% 30.8% 51.1% 40.1% 37.0% 33.5% 30.3% 29.2% 26.2% 26.5% 31.8% -43.2%

75% 73.4% 71.1% 71.1% 62.8% 57.7% 49.8% 68.8% 60.0% 56.8% 51.5% 49.5% 52.5% 52.8% 54.1% 53.9% -21.1%75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%

Percentage of Category A calls resulting in an ambulance arriving at the scene within 19 minutes


95% 93.0% 92.6% 92.5% 91.1% 89.7% 88.0% 92.5% 92.2% 92.3% 91.1% 89.5% 91.3% 90.6% 90.4% 91.1% -3.9%

95% 91.2% 91.3% 92.0% 90.2% 83.5% 82.2% 90.8% 90.2% 85.5% 78.7% 78.8% 77.3% 77.2% 77.9% 79.9% -15.1%

95% 94.6% 94.3% 95.4% 93.5% 91.3% 87.6% 93.8% 92.0% 91.0% 88.8% 88.0% 89.7% 90.0% 90.0% 89.9% -5.1%95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Mixed Sex Accommodation

Mixed sex sleeping accommodation breaches

Target Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 YTD Var

0 1 1 0 5 1 10 12 12 15 5 14 9 8 18 93 93

0 0 0 0 0 2 14 57 69 76 77 113 80 41 137 650 650

0 16 3 27 29 0 130 0 7 0 0 0 0 0 0 7 7

MTW 0 0 0 6 0 0 6 0 0 0 0 0 0 0 12 12 12

E.B

.15.ii

National

HWLH

SECAMB

2015/16 2016/17

E.B

.S.1 HWLH

BSUH

ESHT

2015/16 2016/17

E.B

.16

National

HWLH

SECAMB

20%30%40%50%60%70%


National

HWLH

SECAMB

Target

70%

80%

90%

100%


National

HWLH

SECAMB

Target

020406080

100120140

Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16

HWLH BSUH

ESHT MTW

Page 15 of 23

Mental Health

Percentage of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care

Target Q3 Q4 Y/E Q1 Q2 YTD Var

National 95% 96.9% 97.2% 97.0% 96.2% 96.8% 96.5% 2%

95% 91.0% 98.6% 96.5% 93.8% 95.2% 94.4% -1%

95% 95% 95% 95% 95%

Q3 15/16Q4 15/16Q1 16/17Q2 16/17

People with first episode of psychosis starting treatment with a NICE-recommended package of care treated within 2 weeks of referral


50% - - 0% - 50% 100% 67% 50% 67% 50% 100% 100% 80% 70% 20%

50% - - 63% 63% 78% 75% 61% 85% 84% 65% 83% 74% 82% 77% 27%

Health Care Acquired Infections

Zero tolerance MRSA

AssignedTarget Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E

HWLH 0 0 0 0 0 0 0 1 0 0 0 0 0 1

BSUH 0 0 0 0 1 0 0 0 0 0 0 0 0 1

ESHT 0 1 1 0 0 2 0 0 0 0 0 0 0 4

MTW 0 0 0 1 0 0 0 0 0 0 0 0 0 1

Target Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD

HWLH 0 0 0 0 0 0 0 0 0

BSUH 0 0 0 0 0 0 0 0 0

ESHT 0 0 0 0 0 0 0 0 0

MTW 0 0 0 0 0 0 0 0 0

HWLH

SPFT

2014/15

E.A

.S.4

2015/16

2015/16 2016/17

E.B

.S.3

HWLH

2015/16 2016/17

National Quality Requirements

90%

92%

94%

96%

98%

100%

Q3 15/16 Q4 15/16 Q1 16/17 Q2 16/17

National

HWLH

Target2016/17 Q1 breaches: Apr - 2 breaches: 1. Not recorded properly, 2. Still under investigation May - 3 breaches: 1 & 2 - Patients with dementia living in nursing homes (nursing home contacted instead) , 3. No more information available at present

Data for this measure is only available from Dec 2015. The target of 50% should be achieved from April 2016.

Page 16 of 23

Rates of Clostridium Difficile

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E

Ceiling 3 3 3 2 3 3 2 3 3 2 3 3 33

Actual 3 3 2 3 6 4 4 3 3 3 2 1 37

Ceiling 4 4 4 4 4 3 4 4 4 4 3 4 46

Actual 3 5 9 4 1 5 7 3 4 2 4 3 50

Ceiling 3 4 3 3 3 3 4 3 4 4 3 4 41

Actual 1 3 5 2 7 6 3 5 2 4 3 6 47

Ceiling 2 2 2 2 2 2 2 2 3 3 2 3 27

Actual 1 1 1 3 3 3 3 2 0 0 0 1 18

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD

Ceiling 3 3 3 3 3 3 3 21

Actual 4 4 1 6 2 1 8 26

Ceiling 4 4 3 4 4 4 4 27

Actual 4 2 2 7 3 9 5 32

Ceiling 3 4 3 3 3 3 4 23

Actual 2 7 7 2 5 3 4 30

Ceiling 2 2 2 2 2 2 3 15

Actual 2 2 4 8 1 2 1 20

RTT: Number of incomplete pathways greater than 52 weeks

Target Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD

0 867 834 755 727 683 865 8810 870 1003 943 1076 1061 1181 1427 7561

HWLH 0 5 8 12 16 9 14 68 22 19 13 27 44 36 40 201

BSUH 0 40 46 81 81 62 81 411 100 84 92 211 226 184 185 1082

ESHT 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

MTW 0 0 0 0 0 0 2 7 0 0 0 0 0 1 0 1

Ambulance to A&E handover delays

Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD

% More than 30 minutes delay

Royal Sussex County Hospital 24.2% 11.9% 6.1% 13.1% 18.1% 24.6% 15.8% 18.6% 14.7% 18.0% 23.7% 24.2% 26.6% 20.1%

Princess Royal Hospital 17.8% 9.0% 6.7% 7.6% 7.9% 8.0% 6.6% 5.4% 9.7% 7.6% 14.0% 16.6% 19.9% 11.4%

Eastbourne DGH 17.3% 20.2% 28.3% 26.2% 24.0% 31.4% 23.7% 24.3% 19.4% 28.1% 32.7% 28.5% 33.0% 27.2%

Maidstone Hospital 2.3% 3.0% 2.8% 2.8% 3.8% 2.7% 2.4% 2.0% 2.8% 4.2% 3.7% 3.2% 3.2% 3.1%

Tunbridge Wells Hospital 3.3% 4.5% 6.2% 8.9% 6.8% 10.5% 5.8% 6.2% 6.1% 8.0% 8.3% 7.5% 8.7% 7.2%

% More than 60 minutes delay

Royal Sussex County Hospital 3.1% 0.6% 0.8% 3.2% 3.8% 5.5% 1.6% 2.4% 1.8% 3.0% 5.0% 3.2% 5.8% 3.2%

BSUH

ESHT

MTW

2015/16 2016/17

E.B

.S.4

.3 National

2014/15E

.A.S

.5

HWLH

BSUH

ESHT

MTW

2015/16

HWLH

2015/16 2016/17

E.B

.S.7

Page 17 of 23

Princess Royal Hospital 1.0% 1.5% 0.8% 2.4% 2.1% 0.4% 0.7% 0.2% 0.8% 1.4% 0.8% 2.0% 1.9% 1.1%

Eastbourne DGH 1.2% 1.8% 6.5% 4.8% 3.8% 7.7% 3.9% 6.0% 6.9% 4.8% 9.8% 7.2% 7.9% 6.7%

Maidstone Hospital 0.4% 0.1% 0.2% 0.1% 0.4% 0.0% 0.0% 0.4% 0.1% 0.6% 0.5% 0.7% 0.2% 0.4%

Tunbridge Wells Hospital 0.7% 0.7% 1.0% 1.3% 1.9% 1.5% 1.1% 1.0% 0.4% 1.3% 0.7% 0.8% 0.3% 0.8%

No urgent operation should be cancelled for a second time

Target Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD

0 10 13 12 13 25 23 139 11 9 9 7 9 11 6 62

BSUH 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

ESHT 0 1 2 1 2 4 3 13 0 0 0 0 0 2 0 2

MTW 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

% of cancelled operations cancelled on or after the day of admission fo non-clinical reasons that are not offered another binding date within 28 days

Target Q1 Q2 Q3 Q4 Y/E Q1 Q2 Q3 Q4 YTD

N/A 7.1% 5.9% 6.0% 8.0% 6.8% 8.3% 6.3% 7.3%

BSUH N/A 12.3% 14.3% 13.2% 16.9% 14.4% 12.5% 10.3% 11.3%

ESHT N/A 6.9% 5.2% 2.1% 2.1% 3.4% 3.5% 1.0% 2.2%

MTW N/A 0.0% 0.0% 0.0% 16.5% 4.4% 4.0% 5.2% 4.7%

Number of never events

Target Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 YTD

BSUH 0 2 1 0 1 0 1 0 8 0 0 0 0 0 2 2

ESHT 0 0 0 3 1 0 0 0 4 1 0 0 0 0 0 1

MTW 0 0 0 1 1 0 0 0 2 0 0 0 0 1 0 1

% of referrals for a first outpatient appointment that are made using the NHS e-referral service

Target Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

HWLH 80% 4.0%

Number of personal health budgets in place per 100,000 CCG population

Q1 Q2 Q3 Q4

Actual 0

2015-16 2016/17

E.B

.S.2 National

2015/16 2016/17

E.B

.S.7

2015/16 2016/17

E.B

.S.6 National

BSUH: Jul: 1 (wrong site surgery), Aug: 2( wrong site surgery), Dec: 1 (from the perioperative directorate), MTW: Nov: 1 (retained specimen bag), Dec 15: 1 (blood transfusion-related), Aug 16: 1 (wrong sided

implant) , ESHT: Dec: 1 (wrong implant/prosthesis), Apr 16: 1 in Apr 16 ( medication administered via an incorrect route)

2014/15 2015/16

10

5a

2015-16

2016-17

10

5b

HWLH

Data for this measure is only available from Feb-16

Page 18 of 23

Number of reported medication error incidents as % of all reported incidents for that provider

Target N % N % N % N % N %

N/A 60092 10.9% 64425 11.0% 64079 10.3% 70576 11.2% 69062 10.5%

N/A 643 14.8% 712 16.3% 622 15.0% 671 16.1% 764 16.0%

N/A 338 7.9% 285 8.0% 391 10.3% 412 9.2% 375 7.6%

N/A 175 6.3% 191 7.1% 292 9.4% 285 8.9% 299 8.8%

The number of antibiotics prescribed in primary care per STAR-PU (12 monthly rolling data)

Apr Jul Oct Jan

Actual 1.03 1.04

Target 1.16 1.16

Apr Jul Oct Jan

Actual 12.1% 11.9%

Target 11.0% 11.0%

Friends & Family Test

A&E Target Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD

87% 87% 87% 86% 85% 84% 87% 86% 85% 86% 85% 87% 86% 86% 86%

7% 7% 7% 7% 8% 9% 7% 8% 8% 7% 8% 7% 8% 8% 8%

88% 89% 90% 88% 88% 87% 88% 89% 89% 91% 89% 88% 88% 89% 89%

4% 4% 4% 6% 7% 5% 5% 5% 5% 4% 5% 5% 5% 5% 5%

88% 90% 91% 88% 88% 88% 88% 88% 87% 90% 87% 87% 87% 86% 87%

6% 5% 5% 7% 8% 8% 6% 7% 8% 6% 7% 8% 8% 8% 8%

87% 89% 88% 92% 90% 86% 88% 91% 88% 87% 86% 87% 86% 87% 88%

5% 5% 4% 3% 5% 6% 5% 4% 5% 9% 6% 5% 6% 5% 6%

89% 88% 90% 86% 86% 86% 88% 89% 92% 93% 90% 89% 89% 91% 91%

3% 3% 3% 6% 6% 4% 3% 4% 3% 2% 3% 3% 3% 3% 3%

InpatientTarget Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Y/E Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 YTD

95% 95% 95% 95% 95% 95% 95% 96% 96% 95% 95% 95% 95% 95% 95%

2% 2% 2% 2% 2% 2% 2% 1% 2% 2% 2% 2% 2% 2% 2%

96% 97% 97% 97% 97% 97% 97% 97% 97% 96% 97% 96% 95% 96% 96%

1% 1% 1% 1% 1% 1% 1% 0% 1% 1% 1% 1% 1% 1% 1%

94% 93% 97% 97% 98% 99% 96% 96% 98% 95% 96% 95% 96% 95% 96%

1% 2% 1% 1% 1% 0% 1% 1% 1% 2% 2% 1% 1% 2% 1%

MTW

2016/17

10

7a

HWLH

The number of broad spectrum antibiotics as a % of the total number of selected antibiotics prescribed (12 monthly rolling data)

2016/17

Oct 13 - Mar 14 Apr 14 - Sep 14 Oct 14 - Mar 15 Apr 15 - Sep 15 Oct 15 - Mar 16

E.A

.9

Acute (non-specialist)

BSUH

ESHT

10

7b

HWLH

2015/16 2016/17

E.A

.6

National% recommended

TBC% not recommended

HWLH*

ESHT% recommended


MTW% recommended


% recommendedTBC

% not recommended

BSUH% recommended


2015/16 2016/17

E.A

.6

National% recommended


HWLH*% recommended


BSUH% recommended


There has been a change to the way in which providers are split for benchmarking purposes, BSUH, ESHT and MTW are now classified as acute non-specialists

Page 19 of 23

97% 99% 99% 97% 98% 97% 97% 98% 98% 97% 98% 97% 97% 97% 97%

1% 0% 0% 0% 0% 1% 1% 0% 1% 1% 1% 1% 1% 1% 1%

96% 97% 95% 96% 96% 96% 95% 97% 96% 95% 95% 96% 93% 95% 95%

1% 1% 1% 1% 1% 1% 0% 0% 1% 1% 1% 0% 0% 1% 0%

* Please note that the HWLH figures have been estimated and therefore should be treated with caution

E.A

.6MTW

% recommendedTBC

% not recommended

ESHT% recommended


Page 20 of 23

GP spend per 1000 weighted patients as at October 2016 - Highlighted where above locality Average

GP Performance

Code Practice Name

G81024 Ashdown Forest Health Centre 8215 £327,796 £18,332 £53,198 £114,972 £54,452 £86,842

G81019 The Beacon Surgery 9882 £312,730 £14,816 £56,172 £96,181 £53,308 £92,253

G81030 Belmont Surgery 7845 £339,914 £19,607 £60,992 £113,977 £61,843 £83,496

G81614 Groombridge & Hartfield Medical Group 4434 £339,423 £17,251 £63,701 £103,217 £61,278 £93,977

G81043 Rotherfield Surgery 6288 £327,529 £17,808 £61,368 £95,146 £63,849 £89,357

G81055 Saxonbury House Surgery 9545 £312,657 £15,467 £52,313 £105,362 £56,101 £83,414

G81040 Woodhill Surgery 2829 £309,697 £16,229 £52,144 £106,212 £52,483 £82,629

Crowborough 49037 £323,725 £16,984 £56,808 £105,045 £57,433 £87,454

G81086 Bird-In-Eye Surgery 6548 £314,521 £15,212 £64,277 £107,595 £49,069 £78,368

G81102 The Buxted Surgery 10313 £330,344 £13,439 £52,552 £113,911 £47,996 £102,446

G81088 Heathfield Surgery 12412 £282,068 £11,881 £57,786 £80,253 £46,134 £86,014

G81097 Manor Oak Surgery 3582 £297,888 £12,128 £52,290 £92,362 £43,761 £97,346

G81037 The Meads Surgery 7772 £336,988 £14,411 £63,892 £124,517 £53,783 £80,385

Uckfield Uckfield and Heathfield 40627 £311,455 £13,319 £58,187 £102,740 £48,334 £88,875

High WealdHIGH WEALD TOTAL 89664 £318,165 £15,323 £57,433 £104,000 £53,310 £88,098

G81007 Newick Health Centre 7410 £352,420 £17,610 £60,813 £123,003 £56,005 £94,988

G81035 River Lodge Surgery 10196 £305,851 £14,248 £58,347 £101,485 £52,083 £79,688

G81021 School Hill Medical Practice 7457 £318,779 £14,864 £53,570 £108,988 £54,902 £86,456

G81045 St Andrews Surgery 8197 £270,689 £13,850 £50,235 £79,884 £57,973 £68,747

Lewes 33259 £310,459 £15,037 £55,826 £102,638 £55,040 £81,918

G81061 Chapel Street Surgery 6648 £357,819 £21,773 £70,004 £128,330 £57,424 £80,289

G81100 Meridian Surgery 13532 £313,844 £19,500 £53,088 £112,233 £49,542 £79,481

G81016 Quayside Medical Practice 9424 £289,071 £18,531 £55,992 £91,136 £48,011 £75,401

G81053 Rowe Avenue Surgery 8541 £334,939 £20,363 £55,235 £120,699 £63,781 £74,861

Havens 38145 £320,111 £19,850 £57,235 £111,721 £53,726 £77,579

Lewes-HavensLEWES-HAVENS TOTAL 71404 £315,615 £17,608 £56,579 £107,490 £54,338 £79,600

HWLH HWLH Total 161068 £317,035 £16,336 £57,054 £105,547 £53,766 £84,331

Outpatients Local Items Prescribing

Spend per 1,000 weighted patientsW. List (average

over last 12

months) Total A&E Elective

Non

Elective

Page 21 of 23

IAPT

Access to IAPT services: People entering IAPT services as a % of those estimated to have anxiety/depression

Q2 Q3 Q4 Y/E Q1 Q2 YTD

Actual 4.36% 3.91% 5.46% 17.63% 4.54% 2.46% 6.99%

Target 3.75% 3.75% 3.75% 1.50% 3.75% 3.75% 7.50%

Dementia

Estimated diagnosis rate for people with dementia

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

Actual 58.30%12

6a

HWLH

2016/17

37

HWLH

2016/17

2015/16

Local Quality Requirements

Please note that 2016/17 Q2 only consists of Jul and Aug data

Code Practice Name

G81024 Ashdown Forest Health Centre 8215 £327,796 £18,332 £53,198 £114,972 £54,452 £86,842

G81019 The Beacon Surgery 9882 £312,730 £14,816 £56,172 £96,181 £53,308 £92,253

G81030 Belmont Surgery 7845 £339,914 £19,607 £60,992 £113,977 £61,843 £83,496

G81614 Groombridge & Hartfield Medical Group 4434 £339,423 £17,251 £63,701 £103,217 £61,278 £93,977

G81043 Rotherfield Surgery 6288 £327,529 £17,808 £61,368 £95,146 £63,849 £89,357

G81055 Saxonbury House Surgery 9545 £312,657 £15,467 £52,313 £105,362 £56,101 £83,414

G81040 Woodhill Surgery 2829 £309,697 £16,229 £52,144 £106,212 £52,483 £82,629

Crowborough 49037 £323,725 £16,984 £56,808 £105,045 £57,433 £87,454

G81086 Bird-In-Eye Surgery 6548 £314,521 £15,212 £64,277 £107,595 £49,069 £78,368

G81102 The Buxted Surgery 10313 £330,344 £13,439 £52,552 £113,911 £47,996 £102,446

G81088 Heathfield Surgery 12412 £282,068 £11,881 £57,786 £80,253 £46,134 £86,014

G81097 Manor Oak Surgery 3582 £297,888 £12,128 £52,290 £92,362 £43,761 £97,346

G81037 The Meads Surgery 7772 £336,988 £14,411 £63,892 £124,517 £53,783 £80,385

Uckfield Uckfield and Heathfield 40627 £311,455 £13,319 £58,187 £102,740 £48,334 £88,875

High WealdHIGH WEALD TOTAL 89664 £318,165 £15,323 £57,433 £104,000 £53,310 £88,098

G81007 Newick Health Centre 7410 £352,420 £17,610 £60,813 £123,003 £56,005 £94,988

G81035 River Lodge Surgery 10196 £305,851 £14,248 £58,347 £101,485 £52,083 £79,688

G81021 School Hill Medical Practice 7457 £318,779 £14,864 £53,570 £108,988 £54,902 £86,456

G81045 St Andrews Surgery 8197 £270,689 £13,850 £50,235 £79,884 £57,973 £68,747

Lewes 33259 £310,459 £15,037 £55,826 £102,638 £55,040 £81,918

G81061 Chapel Street Surgery 6648 £357,819 £21,773 £70,004 £128,330 £57,424 £80,289

G81100 Meridian Surgery 13532 £313,844 £19,500 £53,088 £112,233 £49,542 £79,481

G81016 Quayside Medical Practice 9424 £289,071 £18,531 £55,992 £91,136 £48,011 £75,401

G81053 Rowe Avenue Surgery 8541 £334,939 £20,363 £55,235 £120,699 £63,781 £74,861

Havens 38145 £320,111 £19,850 £57,235 £111,721 £53,726 £77,579

Lewes-HavensLEWES-HAVENS TOTAL 71404 £315,615 £17,608 £56,579 £107,490 £54,338 £79,600

HWLH HWLH Total 161068 £317,035 £16,336 £57,054 £105,547 £53,766 £84,331

Outpatients Local Items Prescribing

Spend per 1,000 weighted patientsW. List (average

over last 12

months) Total A&E Elective

Non

Elective

Page 22 of 23

Health Checks

% of people who were offered a health check

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 YTD

2.5% 3.9% 5.0% 8.8% 5.1% 5.1%

Target 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%

% of people offered a health check who receive one

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 YTD

100.0% 49.7% 39.2% 33.6% 44.5% 44.5%

Target 50.0% 50.0% 50.0% 50.0% 50.0% 50.0%

Smoking

Number of people successfully quitting smoking with help from the NHS stop smoking service

Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 YTD

83 237 261 281 320 359 374 404 453 501 33 53 74 74

235 313 392 470 549 627 705 862 1,018 1,175 84 168 252 252

35.3% 75.7% 66.6% 59.8% 58.3% 57.3% 53.1% 46.9% 44.5% 42.6% 39.3% 31.5% 29.4% 29.4%

Falls

Total number of spells of inpatients with diagnosis including fall

Q1 Q2 Q3 Q4 YTD

776 795 829 859 208 206 228 205 847

2041 2036 2059 2118 2016 1984 2199 2078 2069

2015/16 2016/17

HWLH

Offered

2015/16 2016/17

15/16 16/17

2015/16 2016/17

HWLH

Actual (cumulative)

Target (cumulative)

HWLH

Offered and received

15/16

Number of admissions

Age/sex standardised rate

% of Target Achieved

HWLH11/12 12/13 13/14 14/15

0%

5%

10%

Q1 Q2 Q3 Q4 Q1

15/16 16/17

Offered

Target

0%

25%

50%

75%

100%

Q1 Q2 Q3 Q4 Q1

15/16 16/17

Offered andreceived

Target

Former Local Quality Requirements

Please note: 15/16 data is provisional only

Page 23 of 23



Item Number:


Title of report: Update on the Patient Transport Service (PTS) in Sussex

Recommendation: The Governing Body is recommended to review this update and raise any matters they have regarding the PTS during and beyond the transitional period.

Summary: In October 2016, Coperforma wrote to the CCG seeking a ‘no fault’ exit to the PTS contract as the contract was uneconomic in the long term. The Sussex CCGs agreed to this proposal to secure a managed and orderly transfer to a new provider. In order to minimise disruption to patients, the transfer will be phased over the next few months, with South Central Ambulance NHS Foundation Trust (SCAS) taking complete responsibility from April 2017. The Sussex CCGs posted a Voluntary Ex Ante Transparency Notices (VEAT) in the Official Journal of European Union (OJEU) on 4 November 2016 as part of a transparent process to communicate our intention to directly award a 3+1 year contract for the provision of non–emergency patient transport across Sussex to SCAS. No challenges in response to the VEAT were received and the Sussex CCGs have begun the process of negotiating the detailed terms and conditions of that contract with SCAS. This contract will be in place prior to the 1 April 2017 commencement date. On behalf of the seven Sussex Clinical Commissioning Groups (CCGs), NHS High Weald Lewes Havens CCG has signed a Memorandum of Agreement with SCAS to allow for the immediate planning of the operational transfer of services from Coperforma to SCAS in a phased and managed way over the coming months. This phased transfer will be complete by the contract “go live” date of 1 April 2017. In conjunction with SCAS (incoming Provider) and Coperforma (outgoing Provider) the CCGs have developed a detailed transition plan. An executive level PTS Programme Board including membership from each CCG has been established to provide oversight and scrutiny of this transition.

Governing Body sponsor: Wendy Carberry, Chief Officer

Author(s): Maninder Singh Dulku, PTS Programme Director


Review by other committees: Reviewed by the CCG’s PTS Project Management Team

Health impact: The service will safely, effectively and sustainably transport eligible patients between their nominated place of residence to, from and between NHS-funded


healthcare facilities in a timely manner, in support of their health care.

Financial implications: The contract value as stipulated in the VEAT notice is £50,100,000 based on a contract duration of 3 years with an option to extend for 1 further year.

Legal or compliance implications: The CCGs have an obligation to comply with the procurement regulations i.e. Public Contract Regulations 2015.

Link to key objective and/or principal risks: The CCGs have developed a risk register that is monitored and updated on a daily basis.

How has patient and public engagement informed this work: There is an established Sussex PTS Patient, Carer and Public Forum that meets once a month. One of their priorities is to monitor the transition plan for the service to ensure that patient, carer and public interests are fully considered.


☐ ☐ ☐ ☐ ☒


☒ ☐ ☐


Update on the Patient Transport Service in Sussex Summary

Feedback from provider trusts whose patients use the service, and from patients themselves, remains constant in telling us that the service is improving across Sussex.

Docklands Medical Services (DMS), a transport subcontractor, is still not providing a service in Sussex and ex South East Coast Ambulance Service NHS Foundation Trust (SECAmb) staff employed by DMS, continue to be available for work.

The Clinical Commissioning Groups (CCGs) are prioritising actions to bring these staff back to work, subject to due diligence checks.

The additional capacity sourced by Coperforma to mitigate the loss of DMS is maintaining service delivery.

The CCGs have worked with Coperforma and the unions to put in place a mechanism coordinated by GMB to pay DMS staff any outstanding payments via a third party payroll. This has ensured staff have now been paid standard pay up to December 2016, and this pay arrangement will continue until the longer term employment status for these staff is resolved.

In October 2016, Coperforma wrote to the CCG seeking a ‘no fault’ exit to the PTS contract as the contract was uneconomic in the long term. The Sussex CCGs agreed to this proposal to secure a managed and orderly transfer to a new provider. In order to minimise disruption to patients, the transfer will be phased over the next few months, with South Central Ambulance NHS Foundation Trust (SCAS) taking complete responsibility from April 2017.

The Sussex CCGs posted a Voluntary Ex Ante Transparency Notices (VEAT) in the Official Journal of European Union (OJEU) on 4 November 2016 as part of a transparent process to communicate our intention to directly award a 3+1 year contract to SCAS.

The CCGs have now developed a detailed transition plan with SCAS and Coperforma.

Quality and CQC issues The Care Quality Commission (CQC) announced on 1 November 2016, that it would continue to monitor the PTS while the service is in transition and published its full report on the service provided by Coperforma Ltd following an unannounced inspection in July 2016. The CQC told the company that it must sustain significant improvements to the service in Sussex and served six requirement notices to the service to ensure improvements are undertaken. A full report of this inspection has been published on the CQC website http://www.cqc.org.uk/location/1-220377477. Areas for improvement include:

The provider must ensure a robust system is in place for handling, managing and monitoring complaints and concerns.

There must be robust systems in place to assess, monitor and improve the quality and safety of the services provided.

The vehicles and equipment used by contracted services must be appropriate for safe transportation of patients, including wheelchair users.

Patients must receive timely transport services so they can access the health services they need from other providers.

A manager must be registered with the Commission.

http://track.vuelio.uk.com/z.z?l=aHR0cDovL3d3dy5jcWMub3JnLnVrL2xvY2F0aW9uLzEtMjIwMzc3NDc3&r=7290697271&d=2131499&p=1&t=h&h=644b0beb0de489116ca73dd52093f51c


CQC must be notified of safeguarding incidents and incidents affecting the running of the service.

Performance

The feedback we are receiving from patients and staff tells us that the service level is being maintained with the latest patient user survey shows patient satisfaction at 4.1 out of 5.

The CCG recently visited Coperforma and performed a full quality audit on the policies and processes. A full report is available on request.

The monthly performance report from Coperforma continues to show improvement in service delivery across the majority of their key performance measures.

Transition The Sussex CCGs posted a VEAT in OJEU on 4 November 2016 as part of a transparent process to communicate our intention to directly award a 3+1 year contract for the provision of non–emergency patient transport across Sussex to SCAS. No challenges in response to the VEAT were received and the Sussex CCGs have begun the process of negotiating the detailed terms and conditions of that contract with SCAS. This contract will be in place prior to the 1 April 2017 commencement date. On behalf of the seven Sussex CCGs, NHS High Weald Lewes Havens CCG has signed a Memorandum of Agreement with SCAS to allow for the immediate planning of the operational transfer of services from Coperforma to SCAS in a phased and managed way over the coming months. This phased transfer will be complete by the contract “go live” date of 1 April 2017. An executive level PTS Programme Board including membership from each CCG has been established to provide oversight and scrutiny of this process. PTS Transition Governance Structure

New PTS management team for CCGs In addition to the CCGs Specialist PTS Advisor, a Programme Manager for PTS and a PTS Programme Director have recently been deployed to oversee the transition.


Recommendation The Governing Body is recommended to review this update and raise any matters they have regarding the PTS during and beyond the transitional period. Maninder Singh Dulku PTS Programme Director Report date: 11 January 2017



Item Number:

Date of meeting: 26 October 2016 10/17 Title of report: Patient and Public Involvement (PPI) report — January 2017

Recommendation: The Governing Body is recommended to note this report.

Summary: 1. Personnel The Lay Member for Patient and Public Engagement (PPE) returned to the Governing Body during November 2016 and wishes to acknowledge the invaluable contribution by Dorothy Goodman in substituting for him during his absence. 2. Patient Participation Groups (PPG) Planning Two meetings have been held with two representatives each of Lewes Havens and High Weald PPG Forums, the Head of Corporate Services, Engagement Officer, HealthWatch representatives and the Lay Member for PPE to review the current position with all our patient groups and consider any steps deemed necessary to further strengthen them and enhance cooperation across the CCG. The group will be reporting back to the locality groups and other relevant CCG committees. How often and for how long it will meet is yet to be decided. The first action has been to update and consolidate the Terms of Reference for the two localities, which should be put before their January 2017 meetings. 3. Consultation The CCG continues to involve patients in meetings on Connecting 4 You, which will be ongoing. It is also in the course of consulting on proposals for revised stroke care, which will be concluded shortly. At meetings in Uckfield and Lewes the proposals were approved by those attending.

Governing Body sponsor: Alan Keys, Lay Member, Patient and Public Engagement

Author(s): : Alan Keys, Lay Member, Patient and Public Engagement


Review by other committees: none

Health impact: Involving patients and public in identification of their health needs, care experiences and service priorities strengthens effective commissioning of health services.

Financial implications: There are none.

Legal or compliance implications: Health and Social Care Act 2012: duty to involve patients and the local community in health planning.

Link to key objective and/or principal risks: Putting patients at the heart of everything NHS High Weald Lewes Havens Clinical Commissioning Group does.

How has patient and public engagement informed this work: The report describes


key PPE activity during the reporting period.


☐ ☐ ☐ ☐ X


X ☐ ☐


Item Number:


11/17

Title of report: Reporting from Sub-Committee Chairs and Leads - January 2017

Recommendation: The Governing Body is recommended to note the updates, which will be provided verbally at the meeting.

Summary: This report includes:

High Weald locality report

Lewes Havens locality report

Quality and Performance Committee report

Clinical Executive Committee report

The above reports will be provided in verbal updates.

Governing Body sponsors: David Roche, Neil Myers, Denise Matthams, Sarah Richards,

Author: Tim Crowhurst (Board Services Officer) Date of report: 17/01/17


Health impact: N/A

Financial implications: N/A

Legal or compliance implications: N/A

Link to key objective and/or principal risks: Review of Locality Activity

Patient and public engagement: Information to be detailed in verbal reports where applicable


☐ ☐ ☐ ☐ ☒

EA Summary: An EIA is not required for this report.

Privacy Impact Assessment: N/A, no personal data used.


Item Number: 12/16


Title of report: Assurance Framework (AF) – January 2017

Recommendation: The Governing Body is recommended to: 1. Review the attached report and note the levels of assurance being provided in relation to the

strategic objectives. 2. Note the controls in place to mitigate the risks and agree the resulting levels of assurance

based on this. 3. Agree whether all high level risks to strategic objectives have been identified. 4. Where necessary, identify further actions necessary to address the potential threats to

objectives. 5. Approve the Assurance Framework for January 2017

Summary: The Assurance Framework (AF) contains the highest level risks and details their potential impact upon the CCG objectives. The AF is used by the Governing Body to:

Be informed of the level of risk to each of the organisation’s key objectives;

Assess the assurance provided by the operation of the controls placed upon these risks; and

Where necessary, prioritise resources to address further either some or all of those threats. The AF has been developed from:

The organisation’s key objectives;

Principal risks to those objectives (identified by the Governing Body); and

High scoring risks reported and escalated within the wider system of risk management across the organisation.

In this way, Governing Body members are aware of the totality of the high level risks to the key objectives, together with the actions to address them. The regular, detailed review and scrutiny of the AF ensures that appropriate controls and assurances are in place to assure the mitigation of these risks. This report contains information on the level of risk and any changes since the AF was last submitted by the Governing Body on 28 September 2016. All risks have been reviewed by their owners at least bi-monthly. Risk owners reviewed the high levels risks, their mitigating actions, and the available controls and assurances for each risk at the middle of December 2016, and the AF (Appendix 1) was reviewed by the Senior Management Team in January 2017. The Quality and Performance Committee has reviewed the individual risks on the AF at its meetings (the most recent review being on 18 January 2017). A verbal update, including any key issues from the Quality and Performance Committee and Audit Committee will be given at the Governing Body meeting. The attached report details the risks and their potential impact on the key objectives. The current total level of risks on the risk register is 188; this has decreased from the 189 reported at the last

Governing Body meeting. The current total level of risks on the Assurance Framework is 163. The Governing Body will receive details of the assurances within other agenda items at this meeting.

Committee sponsor: Alan Beasley, Chief Finance Officer

Author: Michele Newman, Corporate Services Officer Date of report: 13/01/17

Review by other committees: In line with the CCG risk policy, the AF and the individual risks were reviewed by the Quality and Performance Committee on 21 January 2017. Verbal updates may be given at the Governing Body meeting.

Health impact: Individual risks may have potential health impact, as detailed.

Financial implications: Individual risks may have potential financial impact, as detailed.

Legal or compliance implications: Individual risks may have potential legal impact, as detailed.

Link to key objective and/or principal risks: The AF is attached (Appendix 1).

Patient and public engagement: Individual risks may have potential impact for patient and public engagement.

Equality Analysis (EA) outcome: Negative Impact Neutral Impact Positive Impact No Impact Not required for report

☐ ☐ ☐ ☐ ☒

The Risk Management Strategy and Policy have been separately assessed. An assessment for the updated AF itself is not required. Individual risk areas may also be subject to impact assessments if they relate to a development in strategy, policy or process.


☒ ☐ ☐

1

Assurance Framework 1. Introduction

The purpose of the Governing Body’s Assurance Framework (AF) is to report on the level of principal risk to the achievement of each of the organisation’s key objectives (including the four objectives relating to core business) and the levels of control and assurance surrounding these risks. Principal risks are those where the combination of their likelihood of occurring and their potential impact is high. This report contains information on the current level of risk and a summary of changes to the level of risk since the AF was last reviewed by the Governing Body on 28 September 2016.

2. Levels of Risk

Figure 1 shows the total of the scores of all the Principal Risks (those risks scoring, through the product of their impact and likelihood, 15 or above) tracked across the rolling year to establish whether the total level of principal risk is changing. The current total level of risks on the risk register is 188. The current total level of risks on the Assurance Framework is 163.The score of each risk on the register is counted once here.

- Figure 1-

The register records new risks identified and actions identified to mitigate previously identified risks. The key controls and action plans for AF risks have been reviewed and updated in the period since the last report was presented to the governing body. No new risks have been added to or any risks removed from the Assurance Framework.

Figure 2 shows the totals of the Principal Risk scores against each key objective. This identifies the objective(s) at greatest risk. Each risk is counted against every objective that it may impact. (The overall total of risk scores on this chart may therefore be higher in this table than in Figure 1.)

Where there are insufficient controls or assurances for a particular risk the proportion of uncontrolled or unassured risk will be shown by additional bars on the chart below. Such risks will also be labelled as uncontrolled/unassured (control score ‘2’ on the AF – Appendix 1).

2

There are 7 risks which have gaps in assurance or control:

Risk H002 (760) – If the Out-of Hours (OOHs) provider is unable to meet contractual requirements then this may lead to wider system impacts. Score 4x5 = 20

Risk H003 (746) – There is a risk that the current operational difficulties experienced in the delivery of the new Patient Transport Service will continue. Score 4x5=20

Risk H005 (755) – There is a risk that Brighton and Sussex University Hospitals NHS Trust will continue to be unable to achieve the constitutional pledges and rights and national targets. Score 5x5=25

Risk H006 – There is a risk that our residents are failing to be diagnosed with dementia and, as a result, not getting the required support and care. Score 4x5=20

Risk H010 – There is a risk that South East Coast Ambulance Service (SECAmb) continues to be unable to achieve national targets and quality assurance. Score 3x5=15

Risk H011 – There is a risk that East Sussex Healthcare NHS Trust (ESHT) will have continuing issues on the quality of care to patients and may be unable to achieve all the constitutional pledges and rights and national targets.

Risk H012 – There is a risk that the Clinical Navigation Hubs (CNH), which ensure 111 callers have rapid access to clinical advice, will not be able to receive calls by March 2018. Delivery of the CNH across 5 CCGs is complex. There are multiple dependencies with the potential to significantly impact upon the key design/development stages and ultimate delivery of the service.

The Governing Body may wish to propose further risks for addition to the AF or that further controls or assurances are placed on the existing risks.

- Figure 2-

1 Commission safe, patient centred, high quality, effective and affordable care from birth to end of life

4 More timely diagnosis and risk management

2 Achieve financial balance

5 Transfer patient care and resources from

secondary care to the community setting wherever possible to enhance the patient experience

3 Engage effectively with patients and the public

6 Improve the delivery, quality and safety of mental health services

Shading indicates which objective is principally impacted.

3

3. Analysis of Objectives The objective currently at the greatest level of risk is objective 1 (commission safe, patient centred, high quality, effective and affordable care from birth t end of life).Full details of all principal risks are shown on the attached AF where they are mapped against the objective on which they have the greatest impact. The Governing Body may wish to make recommendations regarding the mitigation and reporting in place in order to improve the available levels of assurance.

4. Conclusion

An Assurance Framework that is clear and meaningful to the Governing Body can trigger decisions and actions in direct support of the organisation’s objectives.

An effective System of Risk will enable the Senior Management to:

Be informed as to the totality of risk across the organisation

Act to mitigate those risks that are beyond the ‘risk appetite’ of the Governing Body

Provide assurance of the effectiveness of the system through an agreed schedule of review and independent scrutiny.

An effective Assurance Framework will enable the Governing Body to:

Be informed of the level of risk to each of the organisation’s Key Objectives

Prioritise resources to address some or all of those threats

Assess the assurance provided by the operation of the controls placed upon these risks.

These contribute to the three roles that are identified as core to any highly effective Governing Body:

1. gaining insight and foresight 2. clarifying priorities and defining expectations 3. holding to account and seeking assurance.

5. Recommendations

The Governing Body is recommended to: 1. Review the attached report and note the level of assurance being provided in

relation to the strategic objectives. 2. Note the controls in place to mitigate the risks and agree the resulting levels of

assurance based on this, 3. Agree whether all high level risks to strategic objectives have been identified. 4. Where necessary, identify further actions necessary to address the potential

threats to objectives. 5. Approve the Assurance Framework for January 2017.

Michele Newman, Corporate Services Officer January 2017

HWLH Assurance Framework – January 2017

1 Commission safe, patient centred, high quality, effective and affordable care from birth to end of life

4 More timely diagnosis and risk management

2 Achieve financial balance

5 Transfer patient care and resources from secondary care to the

community setting wherever possible to enhance the patient experience

3 Engage effectively with patients and the public

6 Improve the delivery, quality and safety of mental health services

Principal risk identified Risk owner

Last reviewed

Initial score

Current score

Residual score

Gaps in controls

/ assuranc

e

Strategic Objectives

1

2 3 4 5 6

H002 (760) - There is a risk that the Out of Hours (OOHs) Provider is unable to meet its contractual requirements due to a number of issues including workforce availability and the increased indemnity costs for OOH GPs. This may lead to the wider system impact of overflow into other services such as A&E Departments, 111 and primary care. This may also impact upon the quality of service experience by patients

Hugo Luck

12/12/16 16 16 12 YES

√

H003 (746) – There is a risk that the continuity of the patient service maybe affected during the phased transition of the contract from Coperforma to South Central Ambulance Service NHS Foundation Trust (SCAS), which will be finalised by 31/03/17

Sally Smith

12/12/16 12 20 16 YES

√ √

H004 (493) - There is a risk that the CCG is unable to deliver a balanced year-end financial position

Alan Beasley

12/12/16 16 16 16 NO

√

H005 (755) - There is a risk that Brighton and Sussex University Hospitals Trust (BSUH) will have continuing issues on the quality of care to patients and may be unable to achieve all the constitutional pledges and rights and national targets

Peter Finn

12/12/16 20 25 20 YES

√ √ √ √

Shading indicates

which objective is

principally

impacted.

HWLH Assurance Framework – November 2016

2

H006 - There is a risk that our residents are failing to be diagnosed with dementia and, as a result, not getting the required support and care

Ashley Scarff

07/11/16 16 20 9 YES

√ √ √ √

H007 (769 & 770) - There is a risk that we do not achieve the CCG objectives or mitigate risks due to shortage of workforce across all specialities in primary care, community care and secondary care resulting in the inability to transform services

Wendy Carberry

07/11/16 12 16 12 NO

√ √ √ √

H010: There is a risk that South East Coast Ambulance Service (SECAmb) continue to be unable to achieve national targets and quality assurance.

Ashley Scarff

07/11/16 15 15 15 YES √ √

H011: There is a risk that East Sussex Healthcare NHS Trust (ESHT) will have continuing issues on the quality of care to patients and may be unable to achieve all the constitutional pledges and rights and national targets

Peter Finn

07/11/16 16 20 20 YES √ √

H012: There is a risk that the Clinical Navigation Hubs (CNH), which ensure 111 callers have rapid access to clinical advice, will not be able to receive calls by March 2018. Delivery of the CNH across 5 CCGs is complex. There are multiple dependencies with the potential to significantly impact upon the key design/development stages and ultimate delivery of the service.

Hugo Luck

07/11/16 16 16 12 YES √ √


3

Principal risk: H002 (760)

There is a risk that the Out of Hours (OOHs) Provider is unable to meet its contractual requirements due to a number of issues including workforce availability and the increased indemnity costs for OOH GPs. This may lead to the wider system impact of overflow into other services such as A&E Departments, 111 and primary care. This may also impact upon the quality of service experience by patients

Director lead: Hugo Luck

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life

Date risk added: 14/08/2015 Date last reviewed: 12/12/2016

Risk Rating Current 4x4=16 Original 4x4=16 Residual (Appetite) 4x3=12

Graph to show initial risk rating and residuals score

Existing controls: (what is in place to mitigate the risk?):

Contract meetings and conversations with providers.

Discussions at SRG, Sussex Wide Urgent Care meeting and Sussex Wide Commissioning Executive.

Pharmacist in place to cover repeat prescription requests received by OOHs at weekends.

Impact: Strategic Objectives

Commission safe, patient centred, high quality, effective and affordable care from birth to end of life

Sources of assurance: (What evidence do you have that your controls are effective?)

Reporting to Quality and Performance Committee.

Reporting to Governing Body.

Gaps in controls or assurances: Yes – Incidence of non-provision is increasing due to gaps in Sussex wide workforce availability. A multi shift incentive scheme has now been approved which has ensured there are fewer gaps in the HWLH area.

Mitigating actions (What else is being done to mitigate the risk or reduce gaps, and by when?)

1. CCG to meet with IC24 and the CCG Clinical Lead for Urgent Care to understand the actions required to assist the provider. On-going to 31/03/2016

2. Having explored re-procurement options, the CCG will work with the existing provider to develop the service. Completed 31/03/2016

3. Interim solutions have been agreed by the CCGs to support multi shift incentive and role of prescribing pharmacist in OOH to improve clinical rota fill and maximise efficiency of GP clinical expertise in the service. Commencing November 2015.

Completed 27/10/2015

4. Options for risk sharing and larger practices undertaking OOH shifts circulated to GP practices across East Sussex; no offers of support received from practices. Action closed and new action opened below.


5. Options around OOH base location and sustainable delivery model to safely meet demand for the duration of existing contract to be developed.


6. Future sustainable 24/7 urgent primary care model being developed under Connecting for You urgent care re-design programme: County wide and CCG wide working groups with GP locality leads to co design primary care model.

Target 01/11/2016

7. GP locality leads to co design primary care model: model proposed April 2016 Completed May 2016

0

5

10

15

20

Initial Current

Risk Score

Residual


4

8. Establish agreement to extend procurement process Completed June 2016

9. Establish 111/Out of Hours Project Group Target October 2016


5


There is a risk that the continuity of the patient service maybe affected during the phased transition of the contract from Coperforma to South Central Ambulance Service NHS Foundation Trust (SCAS), which will be finalised by 31/03/17

Director lead: Wendy Carberry

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life also linked to 4. More timely diagnosis and risk management





Programme Board oversight & scrutiny

Weekly CCG/Coperforma management meeting

Monthly meetings with Coperforma /acute trusts/community providers

Monthly contract management meeting

Additional Programme Management capacity sourced to oversee the transition of PTS from Coperforma to SCAS

PTS specialist advisor appointed

Patient Forum Meeting

Transition and Contract Group



More timely diagnosis and risk management


Reporting to PTS Programme Board

Reporting to Quality and Performance Committee

Gaps in controls or assurances: Yes - Business continuity in the event of continuing poor performance.


1. Trusts have own bespoke vehicles Ongoing

2. Business Continuity Plan 30/11/16

3. Increased number of transport providers Ongoing

4. CCG supporting Coperforma to source additional clinical governance expertise 31/07/16 - plan of work around quality and patient safety has commenced jointly with Coperforma and the CCGs

0

5

10

15

20

25

Initial Current

Risk Score

Residual


6

5. Transition and mobilisation project plan detailing actions, milestones for PTS transition. 30/11/16


7

Principal risk: H004

There is a risk that the CCG is unable to deliver a balanced year-end financial position. Director lead: Alan Beasley

Principal Objective: 2: Achieve financial balance Date risk added: 25/04/2016 Date last reviewed: 12/12/2016




Robust PMO processes (agreed 3:1 Rol) and increased investment in PMO workforce

Clear QIPP initiatives identified through benchmarking and review of best practice and already identified in baseline contracts

Good internal and external control systems

0.5% contingency held and 1% uncommitted expenditure in line with NHS England business rules


Achieve financial balance


Reporting to Audit Committee from Internal and External Audit

Reporting to Governing Body

Service Audit Reports (SARs) and CSU’s

Gaps in controls or assurances: None – gaps in controls and assurance are subject to constant review.


1. Increased focus on referral management from primary to secondary care DATE

2. Quarter One finance stocktake with Governing Body 31/08/16

3. Clarification of use of 1% non recurrent reserve

4. Increased number of layout providers 31/08/16

5. Establishment of QIPP Remedial Action Planning Group 01/10/16

6. Expenditure controls implemented with Executive Team taking gate keeper role 24/10/16

7. Target spend reductions allocated to Executive Directors 07/11/16

8. Business Case presented to NHS E re funding PTS business cost 07/11/16

9. Executive level /clinical lead visits to 9 practices showing increased non elective / A&E referrals 07/11/16

0

2

4

6

8

10

12

14

16

18

Initial Current

Risk Score

Residual


8


There is a risk that Brighton and Sussex University Hospitals NHS Trusts (BSUH) will have continuing issues on the quality of care to patients and may be unable to achieve all the constitutional pledges and rights and national targets.

Director lead: Peter Finn

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life also linked to, 2: Achieve financial balance, 3: Engage effectively with patients and the public and 4. More timely diagnosis and risk management





CQC Action Plans and Working Groups

System Resilience Group

Joined up approach across Sussex CCGs

Urgent Care Boards




Engage effectively with patients and the public




Gaps in controls or assurances: Yes – combining the 18 week RTT backlog at BSUH with the current rate of increase, there is currently insufficient surgical capacity across Sussex to meet the 18 week target before 2017/18.


1. CQC Action Planning Ongoing

2. Elective care Board working to redesign pathways Ongoing

3. Central Sussex working together to address quality issues, urgent care issues and RTT targets Ongoing

4. Urgent care workstream Ongoing

5. Havens project Ongoing

0

5

10

15

20

25

30

Initial Current

Risk Score

Residual


9

Principal risk: H006

There is a risk that our residents are failing to be diagnosed with dementia and, as a result, not getting the required support and care

Director lead: Ashley Scarff

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life, also linked to, 2: Achieve financial balance, 3: Engage effectively with patients and the public and 4. More timely diagnosis and risk management





Monitoring and performance management at localities

Dementia Steering Group

Monitoring of performance to individual practice level

Support packages available for practices to improve diagnosis rates

where necessary







Reporting to locality meetings

Reporting to Senior Management Team

Reporting to Quality & Performance Committee


Gaps in controls or assurances: Yes


1. Incentivise practices to action results from the data harmonisation and PRIMIS work undertaken by the CCGs Primary Care Facilitator

28/02/17

2. The Dementia Golden Ticket model of care to continue to be rolled out in a phased model approach 04/04/17

3. Peer to peer performance and Executive Support continuing to be advocated On-going

4. Opportunities with the SE CN to deliver educational sessions and attend the CCGs Clinical Executive Committee being explored

31/09/16

0

5

10

15

20

25

Initial Current

Risk Score

Residual


10

5. GPs and Primary Care Practitioners offered to attend the BMS Dementia Fellowship Sept 16-Mar 17

6. NHS England providing support commencing January 2017.


11

Principal risk: H007 (769 & 770)

There is a risk that we do not achieve the CCG objectives or mitigate risks due to shortage of workforce across all specialities in primary care, community care and secondary care resulting in the inability to transform services

Director lead: Wendy Carberry

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life, also linked to, 2: Achieve financial balance, 3: Engage effectively with patients and the public and 4. More timely diagnosis and risk management





HEKKS workforce group

Provider workforce groups









Gaps in controls or assurances: None


1. Workforce as part of Connecting For You 30/06/16

2. Refocused OD group to include primary care 30/04/16

3. Working through the STP 05/07/16

4. Workforce workstream across Sussex and East Surrey to consider shared functions

5. Primary Care Organisational Development 19/07/16

6. Central Sussex and East Surrey Alliance to look at effectiveness across the footprint to include sharing of lessons learnt 19/07/16

7. CCG reviewing and retargeting workforce resources against main priorities

8. CCG reviewing vacant positions within CCG.

0

5

10

15

20

Initial Current

Risk Score

Residual


12

Principal risk:

H010: There is a risk that South East Coast Ambulance Service (SECAmb) continue to be unable to achieve national targets and quality assurance.

Director lead: Ashley Scarff

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life, also linked to 4. More timely diagnosis and risk management


Risk Rating Current 3x5=15 Current 3x5=15 Residual (Appetite) 3x4=15



Sussex level 999 contract management meetings

CQUIN on rural response time investigation

Joint review of case notes has previously shown no actual harm.


Commission safe, patient centred, high quality, effective and affordable care from birth to end of life More timely diagnosis and risk management




Gaps in controls or assurances: Yes – gaps in effective management of handover delays at hospital A&E departments which impact on SECAmb capacity to respond. Gap in the standard contract for ambulance services with regards to contracting for performance at CCG levels.


1. Joint work with SECAmb to review risk of harm and to 'tail' of activity responded to outside of national targets October 2016

2. Monitor possible impact effects of SECAmb new 'make ready station' opening in Polegate which should release resource to increase response times

Monthly

3. Handover delays at acute sites to release resource and improve response times

On-going

0

2

4

6

8

10

12

14

16

Initial Current

Risk Score

Residual


13

4. Regulators (CQC and NHS IP) monitoring provider trust requiring improvements to service delivery performance and quality. Progress reviewed via unified recovery plan at Sussex Wide Programme Board.

Quarterly

5. Review the impact of SECAmb not hitting the targets Quarterly


14

Principal risk:

H011: There is a risk that East Sussex Healthcare NHS Trust (ESHT) will have continuing issues on the quality of care to patients and may be unable to achieve all the constitutional pledges and rights and national targets

Director lead: Peter Finn

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life, also linked to 4. More timely diagnosis and risk management





CQC Quality Improvement Plan

System Resilience Group

Single Performance Conversation

Joined up approach across East Sussex CCGs

Urgent Care Board

Monthly monitoring of ESHT trajectory for delivery of current NHS constitution standards

Impact: Strategic Objectives:




Delivery and improved performance on most of the CQC requirements.

Gaps in controls or assurances: Yes – while significant progress has been made on the CQC Action Plan there are significant concerns from deteriorating performance against A&E and RTT targets.


1. ESHT has a number of actions in train to address quality issues – notably with the CQC Action Plan. The Urgent Care and Elective Care workstreams are addressing A&E and RTT performance issues.

On-going

0

5

10

15

20

25

Initial Current

Risk Score

Residual


15

Principal risk:

H012: There is a risk that the Clinical Navigation Hubs (CNH), which ensure 111 callers have rapid access to clinical advice, will not be able to receive calls by March 2018. Delivery of the CNH across 5 CCGs is complex. There are multiple dependencies with the potential to significantly impact upon the key design/development stages and ultimate delivery of the service.

Director lead: Hugo Luck

Principal Objective: 1: Commission safe, patient centred, high quality, effective and affordable care from birth to end of life also linked to 5: Transfer patient care and resources from secondary care to the community setting wherever possible to enhance the patient experience





Effective governance of the CNH programme in place (CNH Programme Board supported by the CNH Working Group).

Effective oversight of alignment across NHS 111/CNH (key resource will sit across both programmes to ensure alignment)

Impact: Strategic Objectives:


Transfer patient care and resources from secondary care to the community setting wherever possible to enhance the patient experience


Gaps in controls or assurances: Yes – delays in analysis of activity data


1. CCGs to confirm resource for both NHS 111 / CNH Oct 2016

2. Agree timescales for data reconciliation/analysis/modelling Oct 2016

3. Additions to existing integrated Health & Social Care service (Health and Social Care Connect) can be mobilised to provide a CNH service

June 2017

0

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15

20

Initial Current

Risk Score

Residual


Item Number: 13-17


Title of report: Policies (various) for Review and Ratification

Recommendation: The Governing Body is recommended to ratify the attached policies, which have been approved by either the Audit Committee or the Governance Committee.

Summary: The following policies are attached for the Governing Body’s review and ratification: Sponsorship and Joint Working Recent updates include:

a reference to the new guidance on “Managing Conflicts of Interest: Revised Statutory Guidance to CCGs” from NHSE which includes a section on sponsorship;

under “Responsibilities of Staff” and “Joint Working with the Pharmaceutical Industry” – that all applications for sponsorship and joint working should be reviewed by the Head of Medicines Management” before being sent to the Chief Finance Officer (CFO). The CFO will present the application to the Audit Committee for approval;

under “Governance” – a paragraph stating that an annual report will be presented to the Audit Committee on Sponsorships and Joint Working has been removed. As applications for sponsorship are remote, it is proposed that where they are received they are presented to the next Audit Committee for approval rather presenting an annual report.

Gifts and Hospitality As a result of the new guidance on “Managing Conflicts of Interest” (referred to above), there have been a number of changes to the policy including: adding a narrative under “Introduction” that “the CCG must ensure that staff do not accept gifts or hospitality or other benefits, which might reasonably be seen to compromise their professional judgement or integrity. All staff must consider the risks associated with accepting gifts, hospitality and entertainment when undertaking activities for or on behalf of the CCG or their GP practice”; the process for declaring gifts has been extensively updated; and significant changes have been made to the “Hospitality and Meetings” section to comply with the new guidance. Conflicts of Interest Policy This policy has been completely revised and updated in line with new national guidance for CCGs on Conflicts of Interest. This includes a new requirement for the CCG to report to NHS England quarterly and annually. Purchasing Card Policy The CCG has three Purchasing Cards allocated to the Chief Officer, Chief Finance Officer and Chair. This Policy has been issued to ensure there is appropriate governance over the use of the cards. The purchasing cards have not been assigned as an alternative to normal procurement systems and the Policy states that they should be

used only in urgent or exceptional circumstances. Whistleblowing (Freedom to Speak Up) Policy This policy, drafted following the issue of a national template, is one of a number of recommendations of the review by Sir Robert Francis into whistleblowing in the NHS, aimed at improving the experience of whistleblowing. It is expected that this policy will be adopted by all NHS organisations in England as a minimum standard to help to normalise the raising of concerns for the benefit of all patients. The CCG’s local processes have been integrated into this policy and it provides detail about how it will look into a concern. Any person who victimises someone who has raised genuine concerns under this policy will be subject to disciplinary action. However, abuse of the process through the raising of unfounded malicious allegations will also be regarded as a disciplinary matter. The Governing Body will be given high level information about all concerns raised by staff through this policy and what is being done to address any problems. Similar high level information will be included in the annual report. Social Media Policy The world of communication is changing and the CCG aims to be a dynamic organisation embracing new technologies and ways of working. The rise of social media is changing the way we, and every organisation in the world conducts its business. Millions of people use social media everyday responsibly and it is becoming an increasingly important communications tool. This policy has been developed to help staff understand how social media can be used effectively to contribute to CCG work, while acting in a respectful, professional and meaningful way that protects the CCG image and reputation, whether they are using social media for approved CCG purposes or on a personal basis. Complaints Policy This policy outlines the principles and the process for handling complaints to the CCG from patients, carers, and the general public. The policy also outlines the way in which we will work to resolve complaints. It was last approved by the Governing Body in November 2012; amendments have now been made to reflect: updates to various regulations and the names of national complaints bodies; the updated procedures for dealing with abuse and assault of CCG staff as a result of a complaint; and that the CCG no longer uses third party agencies to perform and manage elements of the complaints function and that it is now dealt with ‘in-house’. Risk Management Policy and Procedure and Risk Management Strategy These documents have undergone a routine annual review. There have been no major changes, except a flowchart has been added to the Policy to help clarify the process and a section on Risk Appetite has been added to the Strategy. Reporting & Managing Incidents and Serious Incidents Policy This policy provides guidance to CCG staff and has been developed for HWLH CCG from existing policy in Brighton & Hove CCG and using national guidance. It provides a procedure for the reporting, investigation and management of all incidents allowing the CCG to learn and share valuable lessons, and continually improve systems and processes. This will lead to the organisation having an improved ability to commission high quality, safe, accountable healthcare, minimising risks to patients, clients, staff and the CCG, and maximising available resources.

Governing Body sponsor: Alan Beasley, Hugo Luck

Author(s): Head of Corporate Services, Head of Finance, IG Manager, Head of IM&T.


Review by other committees: Audit Committee or Governance Committee

Health impact: Contained in the individual policies.

Financial implications: Contained in the individual policies.

Legal or compliance implications: Contained in the individual policies.

Link to key objective and/or principal risks: The Audit Committee or Governance Committee were required to review the adequacy and effectiveness of the policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements.

Patient and public engagement: Not applicable.

Equality Analysis (EA) completed: Negative Impact Neutral Impact Positive Impact No Impact Not required for report

☐ ☐ ☐ ☒

EA Summary: Not applicable.


☒ ☐ ☐


SPONSORSHIP AND JOINT WORKING

POLICY

To be read in conjunction with the following CCG policies:

G08 Conflicts of Interests Policy

F06 Fraud Bribery and Corruption Policy

F02 Gifts and Hospitality

IG06 Confidentiality Staff Code of Conduct

F08 Joint LCFS and HR working protocol for Parallel Criminal and Disciplinary Investigations

G07 Whistleblowing Policy (Freedom to Speak Up)

HR10 Disciplinary Policy and Procedure

2

Document Details

Title Sponsorship and Joint Working Policy

Ref No F01

Document objective

Audience All CCG staff and officers (including temporary and seconded staff and contractors)

Dissemination All policies will be published on the intranet and the CCG website, in the staff newsletter and staff induction pack.

Author Head of Finance / Head of Medicines Management

Approval process

Reviewed by Audit Committee

Date of review 25 November 2016

Approved by Governing Body

Date of approval 25 January 2017

Equality Impact Assessment There are no negative impacts of this policy on people with protected characteristics (amend accordingly)

Category Finance

Review date 2 Years

Version History

Version number

Date Amendment By whom

0.1 14/11/14 Created Head of Finance

3

Contents

Section No.

Section title Page

1. Background

4

2. Definitions

4

3. Purpose

5

4. Duties and responsibilities

8

5. Policy

8

6. Implementation, Compliance, Training

13

7. Monitoring, Review, Archiving

13

Appendix 1: Procedure for the Approval of Sponsorship and Joint Working 14

Appendix 2: Application for Sponsorship and Joint Working Approval Form 16

4

1. BACKGROUND Department of Health (DH) Guidance encourages NHS organisations and their employees to consider opportunities for joint working with the pharmaceutical industry, where the benefits that this could bring to patient care and the difference it can make to their health and well-being are clearly advantageous. The DH issued guidance on joint working between the NHS and the pharmaceutical industry in March 2008. This policy reflects the advice given in that guidance. NHS organisations are required to consider fully the arrangements of any sponsorship deal on the wider impact on healthcare services. Guidance on standards of business conduct for NHS employees issued by the NHS in 1993 still applies. 2. DEFINITIONS For the purpose of this policy and associated documents the following definitions will apply: 2.1 CCG EMPLOYEES

Members of the CCG;

Employees (including students) employed by or seconded to posts within the CCG;

Other individuals who undertake work on a contract for services basis with the CCG (e.g. Bank staff, locums);

Members of CCG professional committees, subcommittees and working groups

2.2 PHARMACEUTICAL INDUSTRY

Companies, partnerships or individuals in the manufacture, sale, promotion or supply of medicinal products subject to the licensing provisions of the Medicines Act.

Companies, partnerships or individuals involved in the manufacture, sale, promotion or supply of medical devices, appliances, dressings and nutritional supplements that are used in the treatment of patients within the NHS.

Trade associations representing companies involved with such products.

5

Companies, partnerships or individuals who are directly concerned with research, development or marketing of a medicinal product that is being considered by or would be influenced by, decisions taken by the CCG or one of its sub-committees or groups;

Pharmaceutical Industry related industries, including companies, partnerships or CCG individuals directly concerned enterprises that may be positively or adversely affected by decisions taken by the or one of its sub-committees or groups.

2.3 JOINT WORKING Situations where for the benefit of patients, organisations, pool skills, experience and/or resources for the joint development and implementation of patient centred projects and share a commitment to successful delivery. Joint working agreements and management arrangements are conducted in an open and transparent manner. Joint working differs from sponsorship, where pharmaceutical companies simply provide funds for a specific event or work programme. 2.4 SPONSORSHIP This includes funding provided to the NHS from an external commercial source, whether in cash, goods, services or other benefits in kind. This includes funding of all or part of the costs of a member of staff, staff training, training of primary care contractors and their employees when organised by the CCG, pharmaceuticals, medical devices, dressings, nutritional supplements, equipment, hotel and transport costs, and provision of free services (speakers etc.) buildings or premises. This list is not exhaustive and it would be prudent to include any other benefits, goods or services that would otherwise be funded through NHS resources. 3. PURPOSE 3.1 RATIONALE

This policy has been drawn up in response to various national guidelines and also to acknowledge the risk-benefits of working with the pharmaceutical industry. The policy will assist the CCG to achieve its objectives and delivery of national and local priorities by building effective and appropriate working relationships with the pharmaceutical industry. This policy draws upon good practice locally and elsewhere, as well as reflecting the content of Department of Health (DH) guidance. The philosophy underpinning the relationship between the CCG and the pharmaceutical industry is such that:

6

The CCG acknowledges the interdependent relationship between the pharmaceutical industry and the NHS;

The CCG seeks to explore and develop the relationship between itself and the pharmaceutical industry for the benefit of the people of High Weald Lewes Havens within a clear ethical framework;

The CCG recognises the needs of the pharmaceutical industry to maintain profitability and promote specific drugs and the needs of the NHS to ensure evidence based decision making, value for money and equity;

The CCG believes that ethical members of the pharmaceutical industry hold a clear desire to improve health and healthcare as well as maintain profitability;

The CCG recognises the requirement of the pharmaceutical industry to promote its products in an ethical manner to the prescribing practitioners aligned to the CCG.

This policy also provides the CCG with a subjective checklist on assessing offers of commercial sponsorship and gives advice to all health professionals on how to deal with:

Gifts and Hospitality

Use of Samples

Meeting with representatives outside work

Sponsorship for meetings and training

Commercial Partnership

3.2 SCOPE

This document is intended as policy for the CCG and its employees who are involved in joint working with the pharmaceutical industry and/or sponsorship by the pharmaceutical industry. In general, all NHS staff and independent contractors (e.g. GPs, Practice Nurses, Practice Managers, Community Pharmacists, Dentists, Opticians, Locum Practitioners) working under NHS terms and conditions should be working towards the Department of Health (2008). Best practice guidance for joint working between the NHS and the pharmaceutical industry and the Department of Health (2000) Commercial Sponsorship – Ethical Standards for the NHS. CCG is based on the core principles of the above DH guidance and applies to all CCG employee staff and should apply equally to non-commercial organisations such as PMS, NHS Direct, Walk–in Centres etc. This Policy is recommended good practice for independent contractors and should be referred to for guidance when dealing with the pharmaceutical industry. DH Best Practice Guidance for Joint Working between the NHS and the Pharmaceutical Industry defines joint working as situations where, for the benefit of patients, organisations pool skills, experience and/or resources for the joint development and implementation of patient centred projects and share a commitment to successful delivery. Joint working agreements and management

7

arrangements are conducted in an open and transparent manner. Joint working differs from sponsorship, where pharmaceutical companies simply provide funds for specific events or work programmes. For the purpose of this policy all collaborative projects with the pharmaceutical industry, with the exception of Sponsorship: hospitality and meetings, should be considered as joint working and Approval of Joint Working form (Appendix 2) completed. Sponsorship covering hospitality and meetings should be recorded on an Approval of Sponsorship form (Appendix 1). 3.2 PRINCIPLES

3.2.1 Working in the interests of patients to deliver high quality care:

Joint projects between the CCG and the pharmaceutical industry must be for the benefit of the people of High Weald Lewes Havens;

Any joint project between the CCG and the pharmaceutical industry must adequately respect and safeguard confidential patient information;

Any relationship between the pharmaceutical industry and the CCG must promote and enhance equitable access to evidence based high quality healthcare for the people of High Weald Lewes Havens;

Joint working between the CCG and the pharmaceutical industry must promote evidence based medicine and support only those drugs and treatments that have an acceptable evidence base and which have local formulary approval where applicable.

3.2.2 Supporting the delivery of CCG strategic objectives and local needs:

The CCG will not undertake joint working or accept sponsorship from the pharmaceutical industry to support projects that are contrary to its strategic priorities;

The CCG will consider the implications for the entire Health and Social Care Community and other key stakeholders of any proposal prior to approving the joint working project;

The continuity of any services funded through sponsorship or joint working must be fully considered before entering into any arrangements.

3.2.3 Selection and approval of sponsorship and joint working partners:

Where sponsorship or joint working is being sought by the CCG, the opportunity to participate should be offered to an appropriate range of companies within the pharmaceutical industry

All joint working or sponsorship must be assessed using the CCG Approval of Joint Working form or Approval of Sponsorship form (Appendix 2 ) and approval documented before commencement of the joint working or sponsorship;

The CCG may pursue joint working with any interested company of good standing within the pharmaceutical industry regardless of their size.

8

3.2.4 Transparency and openness:

All relationships with the pharmaceutical industry must be handled in an open and transparent manner as befits a publicly funded body;

Joint working or sponsorship will not be accepted for projects that have the prime objective of increasing the usage of a specific brand of pharmaceutical or other product.

3.2.5 Relationship between the CCG and the pharmaceutical industry:

The CCG seeks to develop long term relationships with the pharmaceutical industry and will look favourably on undertaking joint projects with companies that have a proven history of ethical and productive joint working;

The CCG will preferentially support sponsorship and joint working that develop the expertise and capabilities of the employees and organisations within the CCG Health and Social Care Community to provide high quality care for the people of High Weald Lewes Havens.

All joint working projects and associated materials must comply with the current Association of the British Pharmaceutical Industry (ABPI) code of practice, whether or not the company is a member of the ABPI;

Any learning or products (protocols, guidelines, intellectual property etc.) developed through joint working will be the property of the CCG unless specifically agreed otherwise in a signed contract with the company(s) and may be shared with other NHS organisations. The CCG will consider supporting the dissemination of lessons learned from joint working, but retains the right of approval of associated literature and material.

4. DUTIES AND RESPONSIBILITIES 4.1 RESPONSIBILITIES OF STAFF Staff members are responsible for keeping themselves informed and up to date about changes to the procedural documents, particularly Policy changes. This information will be provided via e-mail, website, Healthcare Governance Bulletin, six monthly updates for the Healthcare Governance Committee, Staff meetings and Professional Forums. Staff members are obliged to adhere strictly to all Policies and a failure to do so may result in disciplinary action. 5. POLICY 5.1 JOINT WORKING WITH THE PHARMACEUTICAL INDUSTRY

Joint working must be for the benefit of patients or of the NHS and preserve patient care. Any joint working between the NHS and the

9

pharmaceutical industry should be conducted in an open and transparent manner. Arrangements should be of mutual benefit, the principal beneficiary being the patient. The length of the arrangement, the potential implications for patients and the NHS, together with the perceived benefits for all parties, should be clearly outlined before entering into any joint working;

The CCG has a mechanism in place for approval, recording and monitoring, and evaluating any joint working arrangements. The project lead should fill out the Approval of Joint Working form or Approval of Sponsorship form (Appendix 2) and send it to the Head of Medicines Management. The joint working proposal will be considered by the Head of Medicines Management using the ‘Joint working with the pharmaceutical industry – issues to consider’ checklist (Appendix 1)

For more complex projects, a Business Case may be required, Joint Working Agreement and Project Initiation Document (PID). Information on these frameworks can be found on DH Moving beyond sponsorship: Interactive toolkit for joint working between the NHS and the pharmaceutical industry, March 2008.

A mutually agreed and effective exit strategy will be in place at the outset of any joint working arrangement detailing the responsibilities of each party and capable of dealing with a situation where premature termination may become necessary.

Examples of particular areas of potential joint working include:

o Training and development of staff – some companies offer management and organisational development training;

o Development and implementation of prescribing strategies, protocols or guidelines (including guideline publication costs);

o Educational leaflets – companies may contribute to the cost of producing leaflets in exchange for the company logo being printed on the leaflet;

o Information technology and other data collection tools.

Joint working is unlikely to be approved in the following areas:

o The provision of free pharmaceutical starter packs - This promotes prescribing of a particular product and compromises purchasing decisions;

o Business meetings / General Medical Services - The NHS organisation should be seen to be impartial and independent of a commercial organisation. Sponsorship will not be accepted for any service that attracts an item of service fee;

o Equipment- Equipment for use in the NHS should be procured by the NHS. Small items of equipment with low intrinsic value may be acceptable.

10

5.2 MEETINGS, HOSPITALITY AND GIFTS

As a general rule, acceptance of gifts, hospitality and entertainment should be declined. In some parts of the NHS, hospitality /gifts such as diaries, calendars, post-it pads of low intrinsic value may be seen as acceptable. CCG policy is that “gifts” should be refused by its employees, or where a member of staff wishes to accept such a gift, or it is essential to their attendance at a conference related to their employment, they should check with their line manager and obtain consent. This is not meant to include small tokens of gratitude from patients or their relatives. In all cases of doubt, staff should check with their line manager, or politely decline acceptance.

Modest hospitality provided it is normal and reasonable and is secondary to the purpose of the meeting e.g. lunches in the course of working visits, will normally be acceptable. This should be within the scale of hospitality which the NHS, as an employer, would be likely to offer. Where the level of hospitality exceeds £25 a day e.g. residential conferences, line management approval should be sought where appropriate and interest declared and recorded on the CCG’s register of hospitality via governance.

Provision of hospitality from the sponsoring company must be non-promotional and unconditional.

5.3 SAMPLES OF MEDICINAL PRODUCTS

Acceptance of samples of products must comply with ABPI code clause 17.

o Samples are primarily for health professionals to familiarise

themselves with the packaging, for purposes of identification etc. o As a rule, professionals are discouraged from using samples to treat

patients or themselves. CCG staff should seek approval from their line manager or Head of Medicines Management before utilising samples within their practice.

According to the ABPI code of practice, samples of a product can only be provided to a health professional in response to a written request, which has been signed and dated. They must not be provided to administrative staff and should not be left in clinics or health centres. Issuing pharmaceutical samples to patients by non-medical health professionals e.g. nurses without a prescription or outside a Patient Group Direction is in breach of the Medicines Act 1968.

11

Any health professionals, who issue a sample to a patient or client, should be aware that he/she may be held liable for any adverse effect that occurs.

5.4 TRAINING AND EDUCATION 5.4.1 Offers of Commercial Sponsorship for Training: Sponsorship may be used to support CCG organised training and educational events to include the provision of appropriate hospitality and reasonable actual cost e.g. room hire and speakers fees. The level of hospitality must not exceed the level which the recipients would normally adopt when paying for themselves or that which could be reciprocated by the NHS. A “sponsorship approval form”, Appendix 2 must be completed and returned to the CCG’s Head of Medicines Management for approval. It should not extend beyond those whose role makes it appropriate for them to attend the meeting. Sponsorship can only be accepted on the understanding that:-

The course organiser retains overall control of the training event;

The sponsor does not have a right to present teaching material;

Where the organiser considers additional value may be gained from a presentation by the sponsor, that the content of the material is agreed in advance of the meeting;

The sponsor does not use the CCG contact to promote products outside the meeting;

Any stand the sponsor uses to promote products is to be outside the main meeting room where practical;

Attendance of the meeting by the sponsor is at the discretion of the course organiser;

Where course material is provided by a pharmaceutical company, that there is no promotion of specific products (the name of the company supporting the training event is acceptable);

Where meetings or events are sponsored by external sources, that fact must be disclosed in the papers relating to the function and in any published proceedings.

5.4.2 Training Provided by Pharmaceutical Industry:

Employers should be careful to ensure that staff are not pressurised by the sponsors of training, to alter their own activity to accord with sponsors' wishes, where these are not backed up by appropriate evidence;

12

Training provided by the pharmaceutical industry is acceptable if it is unbiased, has benefit for the NHS, is evidence based and the hospitality is appropriate.

Participants should assess whether they may be influenced unduly and also bear in mind what benefits the company might derive (e.g. exposure to NHS, professional contacts, potential allies to use later, names of who to influence, often without the participants realising).

Employees must seek authorisation by their line-manager before attending industry-sponsored events. A record of sponsored education and training received by staff members should be retained by line managers.

5.4.3 Sponsorship for the development of individual staff members:

Sponsorship from the Pharmaceutical Industry is not acceptable for the training of individual members of staff;

There may be a case under joint working arrangements for a “development fund” to be established from contributions from a number of organisations. Individuals may be eligible to apply for monies from this fund for development if the CCG feels it is equitable and will be of benefit to the patients of High Weald Lewes Havens. Such arrangements must be in conjunction with the usual Trust learning and development process.

5.5 INTERFACE ISSUES NHS organisations should consider the wider health economy implications of sponsorship arrangements that may have an impact on neighbouring partner organisations, particularly sponsored posts, but also including, for example, provision of services or guideline development. Commissioners should work with providers to ensure that the NHS Guidance on Commercial Sponsorship is considered when agreeing any Service Level Agreements with Trusts. Where there are several CCGs commissioning a single service this should be agreed and compliance ensured through the Lead Commissioner. This is particularly relevant with services where there are sponsored posts, these should be specified and subject to the agreement of the commissioners and fall within the guidance on commercial sponsorship. 5.6 RESEARCH AND CLINICAL TRIALS Any research, including clinical trials involving medicines, must comply with the research governance framework and related policies.

If a joint project between the CCG and the pharmaceutical industry concerns research, the CCG will follow best practice research through its research governance arrangements and the Local Research Ethics Committee. Clinicians undertaking sponsored research or post-marketing surveillance must be guided only by their patients’ interest and not be influenced by any sponsorship remuneration offered. The wider

13

implications of undertaking the research will be considered, including responsibilities for patient care once the study has been completed;

A local register must be available with all research activities occurring in the Health Economy, including those undertaken by secondary care;

The mechanism for continued prescribing, if appropriate, after cessation of the trial (exit criteria) must be discussed specifically on appropriate discharge of responsibilities;

The Research and Ethics committee should work closely with primary care to avoid trials which effectively are “seeding trials” in primary care. The current process is for all research proposals for primary care to be sent to the Head of Medicines Management.

6. IMPLEMENTATION, COMPLIANCE, TRAINING

Proposals and the outcome of assessment by the CCG will be entered on a register of submitted proposals. Where appropriate, proposals should be accompanied by an Action Plan that sets out what should be done by whom and by when. Joint working agreements will be monitored according to agreed outcome measures. Either side can terminate if these outcome measures are not achieved. 7. MONITORING, REVIEW, ARCHIVING 7.1 MONITORING Information relating to this policy is recorded in a database run by the Governance team. 7.2 REVIEW The Database Administrator will ensure this document is reviewed in accordance with the Review Date. Where staff become aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local/national directives that affect, or could potentially affect policy documents, they should advise the Sponsoring Director as soon as possible, via line management arrangements. The Sponsoring Director will then consider the need to review the procedural document outside of the agreed timescale.

14

APPENDIX 1 - PROCEDURE FOR THE APPROVAL OF SPONSORSHIP AND JOINT WORKING This procedure provides the framework to seek approval of sponsorship and joint working with the pharmaceutical industry. Please refer to the main Policy document for clarification of definitions used. 1. SCOPE

This procedure applies to sponsorship and joint working arrangements whether alone or in conjunction with other NHS organisations, where any funding (actual or in kind) is provided by the pharmaceutical industry.

All sponsorship and joint working arrangements must have a lead manager who is responsible for overseeing the sponsorship or joint working, and ensuring compliance with the policy.

Where there are linked events or joint working arrangements, the lead manager should group these within the same application.

2. PROCESS

Applications for sponsorship with an external funding value of £500 or less

The lead manager must complete and sign the Application for Sponsorship and Joint Working Approval form below, and submit it to PA of the CFO for approval.

The CFO should ensure that the application fully complies with the Policy on Sponsorship and Joint Working before giving approval.

Following approval, the lead manager will be able to take forward the arrangements as detailed in their application. No significant amendments to the arrangements may be made after approval.

The details will be logged and the application will be presented for information at the Audit Committee.

Applications for joint working or sponsorship with an external funding value of more than £500

The lead manager must complete and sign the Application for Sponsorship and Joint Working Approval form, and obtain CCG approval to indicate their support.

The completed Application for Sponsorship and Joint Working Approval form must be submitted to the CFO who will convene a sponsorship and

15

joint working panel for consideration. (This can be sent electronically, but the original signed paper copy must also be sent).

Incomplete or illegible forms will be returned for clarification and / or amendment before consideration.

The lead manager will be informed in writing of the outcome of the application following review bt the panel.

Following approval, the lead manager will be able to take forward the arrangements as detailed in their application. No significant amendments to the arrangements may be made after approval.

3. GOVERNANCE

The CFO will be responsible for maintaining a Sponsorship Register detailing all sponsorship applications (both under and over £500), and the decisions regarding approval.

An annual report to the relevant Audit Committee will be produced giving details of all applications which have been received, and the decisions taken. Any queries regarding this procedure should be directed to the CCG CFO.

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APPENDIX 2

APPLICATION FOR SPONSORSHIP AND JOINT WORKING APPROVAL FORM

(NHS HIGH WEALD LEWES HAVENS CCG)

FROM:

TEL:

FAX:

EMAIL:

Address:

SPONSORSHIP OR JOINT WORKING DETAILS

Organiser:

Event or Project name:

Sponsorship/Joint working (delete as applicable)

Date(s):

Location:

Brief outline and statement of objectives (attach full details if applicable):

Objectives:

PHARMACEUTCIAL INDUSTRY DETAILS

Company:

Contact name:

Contact tel:

17

• Outline of sponsorship (financial value, what provided, what in return, attach full details if applicable)

Page 18 of 18

Benefits:

Potential risks:

Financial

REPORTING BACK PROCESS

Proposal for reporting back to the CCG the outcome:

Interim review

Please return to:

Cathryn Goodman, PA to CFO, High Weald Lewes Havens CCG, 36-38 Friars Walk, Lewes, BN7 2PB.

This should be received at least 21 days before the proposed event (if sponsorship)

SIGNED: DATE:

1

GIFTS AND HOSPITALITY POLICY


F01 Sponsorship and Joint working Policy




G08 Conflicts of Interest Policy


CCG Standards of Business Conduct – in the CCG Constitution

2

Document Details

Title Gifts and Hospitality Policy

Ref No F02

Document objective To inform staff of their responsibilities when offered gifts and hospitality, and to consider the risks their acceptance may bring when undertaking tasks on behalf of the CCG (or their GP practice).



Author Head of Finance

Approval process





Equality Impact Assessment There are no negative impacts of this policy on people with protected characteristics

Category Finance

Review date January 2018

Version History

Version number


0.1 October 2016 Reviewed and revised in line with national guidance

Head of Finance

1.0 January 2017 Approved by Governing Body

3

Contents

Section No.

Section title Page

1. Gifts and Hospitality Policy – Quick Reference Guide …………………….. 4

2. Introduction ……………………………………………………………………… 5

3. Scope ……………………………………………………………………………. 5

4. Position of GP Members ..…………………………………………………….. 5

5. Gifts ………………………...…………………………………………………… 6

6. Hospitality and Meetings ……………………………………………………… 7

7. Paid Engagements …………………………………………………………….. 8

8. Governance and Responsibilities ……………………………………………. 8

9. Application to Committees and Sub-Committees ………………………….. 9

10. Policy Implementation and Review ………………………………………….. 9

Appendix 1:

A: Gifts and Hospitality Approval Form …………………………………………………..

B: External Remunerated Activity Declaration Form ……………………………………

10

11

4

1. Gifts and Hospitality Policy - Quick Reference Guide

This policy document informs staff of their responsibilities when offered gifts and hospitality, and to consider the risks their acceptance may bring when undertaking tasks on behalf of the CCG (or their GP practice). In addition, GPs undertaking or influencing decision-making within the CCG are encouraged to declare gifts and hospitality.

All gifts offered by suppliers or contractors linked (currently or prospectively) to the CCG’s business should be declined whatever their value.

Gifts offered from other sources should be declined if accepting them might give rise to a perception of bias or favouritism. Exceptions would be gifts of little financial value (less than £25) and items such as flowers and small tokens of appreciation from members of the public to staff for work well done.

Modest hospitality, such as being provided with tea, coffee or light refreshments, are generally acceptable and do not need to be declared. A common-sense approach should be adopted as to whether the hospitality being offered is “modest”. Offers going beyond modest should be refused. E.g. hospitality with a value greater than £25 or offers of foreign travel or accommodation.

In limited circumstances, hospitality may be contemplated. In which case, express prior approval should be sought from the Chief Financial Officer who will give consideration as to whether acceptance would give rise to a perception of bias or favouritism towards the organisation or individual making the offer.

Form A, in appendix 1, should be completed if:

An offer of a gift with a value greater than £25 (whether accepted or not) has been made;

Several small gifts have been offered worth a total greater than £100 from the same, or closely related source, in a 12 month period;

Hospitality has been offered with a value greater than £25 (whether accepted or not);

Several small offers have been offered worth a total greater than £100 from the same, or closely related source, in a 12 month period.

Form B should be completed where a committee member has accepted remunerated activity.

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2. Introduction

This document sets out the CCG’s policy for the management of Gifts and Hospitality. A separate policy covers Sponsorship and Joint Working with the Pharmaceutical Industry. This policy document is intended to inform all CCG staff of their responsibilities when offered or accepting gifts and hospitality and to advise them to consider fully the implications of their actions in respect of the various probity issues contained in this policy. The CCG must ensure that staff do not accept gifts or hospitality or other benefits, which might reasonably be seen to compromise their professional judgement or integrity. All staff must consider the risks associated with accepting gifts, hospitality and entertainment when undertaking activities for or on behalf of the CCG or their GP practice. The CCG’s Governing Body is determined to ensure the organisations inspire confidence and trust amongst the public, patients, staff, partners, funders and suppliers by demonstrating integrity and avoiding any potential or real situations of undue bias or influence in the decision-making of the membership, governing bodies or staff. This policy should be read in conjunction with:

Conflict of Interests Policy

Fraud, Bribery and Corruption Policy

Policy on Sponsorship and Joint Working with the Pharmaceutical Industry

The Procurement Policy

Guidance on Standards of Business Conduct for NHS Staff published in circular HSG (93)5

NHSE Guidance “Managing Conflicts of Interest: Revised Statutory Guidance for CCGs”

ABPI Code of Professional Conduct relating to hospitality and gifts from pharmaceutical and other external industry

CCG Standing Orders, Prime Financial Policies

All CCG Staff must comply with the Bribery Act 2010.

3. Scope

This policy applies to all staff including employees, temporary employees, contractors, seconded staff, clinical leads and governing body members.

4. Position for GP Members

The CCG is a membership organisation with a statutory responsibility for commissioning specified services for their population. It is recognised that individual GPs, whose practices are members of the CCG and who may have a role within the CCG, have a separate role as providers of services. High standards of probity and transparency are required when fulfilling each role, however activities undertaken as providers of services are regulated and governed

http://www.nhsbsa.nhs.uk/Documents/NHSBSACorporatePoliciesandProcedures/Standards_of_Business_Conduct.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/revsd-coi-guidance-june16.pdf


http://www.pmcpa.org.uk/thecode/Documents/Code%20of%20Practice%202016%20.pdf

http://www.legislation.gov.uk/ukpga/2010/23/contents

6

through separate processes, including the GMC and adhering to the principles set out in Good Medical Practice.

While the CCG policy relates to activities undertaken in relation to fulfilling CCG responsibilities, in practice it will be impossible ever to draw a completely separate distinction between the two roles.

The primary objective of this policy is to ensure transparency and openness in all dealings. GPs undertaking or influencing decision making within the commissioning organisation are encouraged to declare all gifts and hospitality (excepting those specifically excluded as detailed below) for the purposes of full transparency and openness.

GPs that may be considered as having decision making powers are:

Nominated Practice representatives who are members of the CCG/Locality Group.

Clinicians, selected or elected, serving on the Governing Body and/or committees.

GPs undertaking short term project work for the CCG.

5. Gifts A 'gift' is defined as any item of cash or goods, or any service, which is provided for personal benefit, free of charge or at less than its commercial value. All gifts of any nature offered to CCG staff, governing body and committee members and individuals within GP member practices by suppliers or contractors linked (currently or prospectively) to the CCG’s business should be declined, whatever their value. The person to whom the gifts were offered should also declare the offer by completing form A in appendix 1, obtaining appropriate authorisation (see section 7), and submitting to Finance Department for inclusion in the Gifts and Hospitality register. Gifts offered from other sources should also be declined if accepting them might give rise to perceptions of bias or favouritism, and a common sense approach should be adopted as to whether or not this is the case. The only exceptions to the presumption to decline gifts relates to items of little financial value (i.e., less than £25) such as diaries, calendars, stationery and other gifts acquired from meetings, events or conferences, and items such as flowers and small tokens of appreciation from members of the public to staff for work well done. Gifts of this nature do not need to be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality, nor recorded on the register. The offer of any gifts with a value exceeding £25 (whether accepted or declined) or several small gifts worth a total of over £100 from the same or closely related source in a 12 month period must be reported to the Chief Financial Officer (CFO) of the CCG (using form 2A of the Finance Manual in Appendix 1 attached) and will be recorded in the Gifts and Hospitality Register.

7

Any personal gift of cash or cash equivalents (e.g. vouchers, tokens, offers of remuneration to attend meetings whilst in a capacity working for or representing the CCG) must always be declined, whatever their value and whatever their source, and the offer which has been declined must be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality and recorded on the register. It is not appropriate to give monetary or non-monetary gifts to individuals or organisations at public expense.

6. Hospitality and Meetings Modest hospitality provided in normal and reasonable circumstances may be acceptable, although it should be on a similar scale to that which the CCG might offer in similar circumstances (e.g., tea, coffee, light refreshments at meetings). A common sense approach should be adopted as to whether hospitality offered is modest or not. Hospitality of this nature does not need to be declared nor recorded on the register, unless it is offered by suppliers or contractors linked (currently or prospectively) to the CCG’s business in which case all such offers (whether or not accepted) should be declared and recorded. Offers of hospitality which go beyond modest or of a type that the CCG itself might offer, should be politely refused. A non-exhaustive list of examples includes:

Hospitality of a value of above £25; and

In particular, offers of foreign travel and accommodation. There may be some limited and exceptional circumstances where accepting the types of hospitality referred to in this paragraph may be contemplated. Express prior approval should be sought from the Chief Finance Officer before accepting such offers, and the reasons for acceptance should be recorded in the CCGs register of gifts and hospitality. Hospitality of this nature should be declared to the team or individual who has designated responsibility for maintaining the register of gifts and hospitality, and recorded on the register, whether accepted or not. In addition, particular caution should be exercised where hospitality is offered by suppliers or contractors linked (currently or prospectively) to the CCG’s business. Offers of this nature can be accepted if they are modest and reasonable but advice should always be sought from the Chief Finance Officer as there may be particular sensitivities, for example if a contract re-tender is imminent. All offers of hospitality from actual or prospective suppliers or contractors (whether or not accepted) should be declared and recorded. The following extract from the ABPI Code of Professional Conduct 2011 is useful in framing the extent of acceptable hospitality and this is consistent with “Commercial Sponsorship – Ethical Standards for the NHS” and The Medicines (Advertising) Regulations 1994: “Companies must not provide hospitality to members of the health professions and appropriate administrative staff except in association with scientific meetings,

8

promotional meetings, scientific congresses and other such meetings, and training. Meetings must be held in appropriate venues conducive to the main purpose of the event. Hospitality must be strictly limited to the main purpose of the event and must be secondary to the purpose of the meeting i.e. subsistence only. The level of subsistence offered must be appropriate and not out of proportion to the occasion. The costs involved must not exceed that level which the recipients would normally adopt when paying for themselves. It must not extend beyond members of the health professions or appropriate administrative staff.” The CCG has decided that hospitality or sponsorship will not be accepted for its meetings Clarity for GPs: Where a Practice accepts reasonable hospitality in the sponsorship of meetings related specifically to practice business this can be excluded. Individual GPs with roles of responsibility within the CCG should consider if practice sponsorship is of a frequent or enduring nature whether it should be disclosed if it could be perceived to have an impact on CCG business.

7. Paid engagements

It is recognised that some GP members undertaking roles of responsibility within the CCG will also be offered remunerated engagements such as speaking at conferences or serving on advisory panels. These engagements may be related to their CCG role i.e. the individual is invited because they are the Chair of a CCG. Equally they may be related to their professional GP status – such as service on an advisory panel. Because of their self-employed status, GPs will be able to accept such payments in circumstances where a CCG employee would not expect to receive a fee or would if undertaken during work time, pay the fee to the employing organisation in recompense for their time. In these circumstances, the payment is not strictly a gift or hospitality and those terms could give the wrong impression. However in line with the principle of openness and transparency it would be preferable that these are declared and known. If undertaking public office, additional sources of income could be judged to be in the public interest. This policy therefore covers the inclusion of such paid engagements for persons covered by this policy – please see Appendix 1B. It should be noted that any standing and on-going interests will be declared in the CCG Register of Interests for all members, so this inclusion relates to events occurring outside of these standing interests.

8. Governance and Responsibilities

The CFO will ensure that all declarations in respect of Gifts and Hospitality are recorded on the appropriate Register which will be subject to regular scrutiny.

9

All staff are responsible for ensuring that a record is kept of all offers of gifts or hospitality (whether accepted or not) as per Form 2. Approval must be obtained in advance for any acceptance of a gift or hospitality as described above. Any gifts or hospitality declined must still be documented and brought to the relevant approver’s notice. The approval form is included as Form 2 in Appendix 1 to this document and the level of approval required is set out in the table below:

Applicant Approval required

Governing Body member (excluding Chair & Chief Officer)

Two other Governing Body members (one to be a lay member)

Chief Officer / CCG Chair Lay member for Governance (Audit Committee Chair) and one other Governing Body member

GP Member with CCG responsibilities CCG Chair and one other Governing Body member

All other staff members

Line Manager of band 8c or above

It is a criminal offence under the Prevention of Corruption Act 1906 and 1916 for employees corruptly to accept any gifts or consideration as an inducement or reward for:

Doing, or refraining from doing, anything in their official capacity, or

Showing favour or disfavour to any person in their official capacity. Under the Prevention of Corruption Act 1916, any money, gift or consideration received by an employee in public service from a person or organisation holding or seeking to obtain a contract will be deemed by the courts to have been received corruptly unless the employee proves the contrary. A breach of the provisions in these Acts renders staff liable to prosecution and may also lead to loss of employment and superannuation rights in the NHS.

9. Application to Committees and Sub–committees

The provisions of this policy apply to any committee or sub-committee and each member of a committee or sub-committee established by the CCG

10. Policy implementation and review

There are no specific training requirements associated with this policy. All existing members of the CCG will be provided with a copy of this policy and it will form part of

10

the induction checklist for new members. This policy will be available to all staff on the CCG’s intranet. This policy will be reviewed on an annual basis.

11

Appendix 1 Form 2

A - Gifts and Hospitality Approval Form

To be completed on all occasions where :- 1. An offer of a gift with a value exceeding £25 (whether accepted or declined) has been

made. 2. Several small gifts worth a total of over £100 from the same or closely related source in a

12 month period have been made. 3. An offer of hospitality with a value exceeding £25 (whether accepted or declined) has

been made. 4. Several small offers of hospitality worth a total of over £100 from the same or closely

related source in a 12 month period have been made.

Date:

Department

Name:

Offer received from:

Offer : Declined / Accepted*

Approximate Value:

Details of Gift or Hospitality:

* Where a gift or hospitality is to be accepted, prior approval is required. I declare that the proposed hospitality is entirely consistent with the requirement of the Code of Conduct for NHS managers that decisions are not improperly influenced by gifts or advancements. Signed: (Applicant) …………………………………………………………………………… Approving signatory: Signed ………………………………….. Position ………………………………………….

Approving signatory

Signed ………………………………….. Position ………………………………………….

Please return the form to Natalie Adams, Management Accountant, Finance Department

12

B - External Remunerated Activity Declaration form

To be completed on all occasions where:

A committee member has accepted remunerated activity not covered by the register of interests

Activity may be in person’s own time but must be declared in the interests of transparency and openness

Date:

Department:

Name:

Nature of Engagement: e.g. speaking / advisor

Honorarium / Fee received

Was this in CCG funded time?

Was this in connection with your CCG Role?

Details:

Signature……………………………….. Position………………………………….

Please return the form to: Natalie Adams, Management Accountant, Finance Department

Managing Conflicts of Interest Policy


F01 Sponsorship and Joint working Policy

F02 Gifts and Hospitality Policy





CCG Standards of Business Conduct in the CCG Constitution

2

Document Details

Title Managing Conflicts of Interest Policy

Ref No G08

Document objective To outline the CCG policy for declaring and managing conflicts of interest. The full detail of the policy should be followed in order to ensure legislative and regulatory duties relating to COI are met.

Audience All CCG staff and officers (including temporary and seconded staff,

and contractors).

Dissemination All policies will be published on the intranet and the CCG website, in

the staff newsletter and staff induction pack.

Author Head of Corporate Services

Approval process





Equality Impact Assessment There are no negative impacts of this policy on people with

protected characteristics

Category Governance policy

Review date February 2018

Version Control

Version

number


0.1 01/2015 Initial version based on December 2014 NHS England Managing Conflicts of Interest: Statutory Guidance for CCGs.

Head of Governance & Corporate Affairs

1.0 01/2015 Approved by Audit Committee

1.1 02/2016 Review and update by Head of Governance and Business Planning

Head of Governance & Business Planning

1.2 09/2016 Revised taking account of new guidance from NHSE

Head of Corporate

Services

3

Contents Section Title Page

1. Managing Conflicts of Interest Quick Reference Guide ……………….. 3

2. Introduction …………………………………………………………………. 5

3. Definition of a Conflict of Interest ………………………………………… 6

4. Principles …………………………………………………………………… 7

5. Declaring Conflicts of Interest ……………………………………………. 7

6. Registers of Interest ……………………………………………………….. 8

7. Roles and Responsibilities ……………………………………………….. 9

8. Managing COI throughout the commissioning cycle …………………… 14

9. Raising concerns and breaches of policy ……………………………….. 15

10. References and further information ……………………………………… 16

11. Equality statement …………………………………………………………. 16

12. Review ………………………………………………………………………. 17

Appendix 1: The four types of Conflict of Interest …………………………………. 18

Appendix 2: Good Governance Principles ………………………………………….. 20

Appendix 3: Process Chart : Declarations, Assessment and Recording ……….. 23

Appendix 4: Process Chart: Scrutiny, Assurance, Breaches and Publication ...... 24

Appendix 5: Declaration of Interests Form for CCG members and employees … 25

Appendix 6: Template Register of Interests …………………………..……………. 27

Appendix 7: Template Checklist for Chairs of Meetings ..………………………… 28

4

1. Managing Conflicts of Interest (COI) – Quick Reference Guide

1.1. The Standards of Business Conduct are outlined in the CCG Constitution and form part of our day to day work. The CCG is responsible for large sums of public money and CCG staff (including temporary and seconded staff, and contractors), member practices, and Governing Body and Committee members are required to act fairly, transparently and in the best interest of patients and the local population.

1.2. The CCG must make sure that decisions made are taken, and seen to be taken, without the influence of conflicts of or private interests. The CCG, therefore, has a duty to appropriately manage conflicts of interest, and potential conflicts of interest, and to do so in a transparent way.

1.3. Effective handling of COI is crucial to give confidence to patients, tax payers, healthcare providers and Parliament that CCG commissioning decisions are robust, fair and transparent and offer value for money. It is essential in order to protect healthcare professionals and maintain public trust in the NHS. Failure to manage COI could lead to legal challenge and even criminal action in the event of fraud, bribery and corruption.

1.4. Conflicts of interest are inevitable in commissioning; it is how we manage them that matters. Section 14O of the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) (“the Act”) sets out the minimum requirements of what both NHS England and CCGs must do in terms of managing COI.

1.5. This document outlines the CCG policy for declaring and managing COI. This policy meets the statutory obligations applicable to the CCG, therefore, the full detail of the policy should be followed in order to ensure legislative and regulatory duties relating to COI are met.

1.6. The summary below is a list of actions required by all CCG staff (including temporary and seconded staff, and contractors) and member practices, Governing Body members and Committee members.

You must:

i) Complete, submit and then keep up to date your declaration of interest (DOI) form. The form must be completed on joining the CCG and also if you change roles or responsibilities, have a new interest to declare, if a declared interest ends or if you are involved in commissioning, de-commissioning or re-commissioining of services. This form must be updated every 6 months, even if there is no change to your situation.

ii) Further declare any interest if and when it arises, in order for the interest to be recorded and appropriate action taken. For example, you must declare an interest at a meeting where the interest relates to an agenda item. This includes those interests which have previously been declared on your form.

iii) Follow any instructions or arrangements given to you regarding the management of COI, either your own or someone else’s. The arrangements will be in place in order to mitigate actual, potential or perceived conflicts and to protect you.

iv) Make sure that interests (your own and for others) are declared and that COI are robustly managed when making commissioning decisions, in line with NHS Procurement Regulations.

v) Keep appropriate records regarding the declaration and management of a COI, including evidence of how the conflict was mitigated in the specific situation.

5

For example, if an action is taken to exclude the person with the conflict from a discussion or decision making process, you need to make sure you have kept an accurate record of that.

vi) Make sure that the right people, including the chair of any meeting attended and the lead in any commissioning exercise you are involved in, are notified about a COI. This is so that it can be recorded, published and managed appropriately.

vii) Contact the Chief Finance Officer, Head of Finance or Head of Corporate Services for more information, to discuss managing a conflict or if there is anything you are not sure about.

viii)Read the NHS England guidance on Managing Conflicts of Interest.

ix) Complete annual mandatory training on conflicts of interest.

1.7. For staff, failure to comply with the CCG Constitution and this policy can result in individual disciplinary action in line with the CCG’s Disciplinary Policy.

1.8. For Governing Body members, failure to make known a declaration of interest can result in removal from office.

1.9. Statutorily regulated healthcare professionals who work for, or are engaged by, the CCG are under professional duties imposed by their relevant regulator to act appropriately with regard to conflicts of interest.

1.10. The CCG will report statutorily regulated healthcare professionals to their regulator if it believes that they have acted improperly, so that these concerns can be investigated.

1.11. Instances of non-compliance with this policy will be reported to the Audit Committee for review and are required to be published on the CCG website.

1.12. Key Staff Contacts:

Conflict of Interest Guardian Audit Chair: Peter Douglas E: [email protected] T: 01273 403645

Chief Finance Officer Alan Beasley E: [email protected] T: 01273 403645

Head of Corporate Services Sue Pumphrey E: [email protected] T: 01273 403662

NHS Counter Fraud Specialist Chris Lovegrove E: [email protected] T: 01424 776750 M: 07879 434976

Freedom to Speak up Guardian Governing Body Nurse Member: Denise Matthams E: [email protected] T: 01273 403645






6

2. INTRODUCTION 2.1. As a clinical commissioner, the CCG is committed to improving the health of local

people. The CCG is responsible for large sums of public money and CCG staff (including temporary and seconded staff, and contractors), member practices and Governing Body and Committee members are required to act fairly, transparently and in the best interest of patients and the local population.

2.2. The CCG must ensure the integrity of the processes it follows when making decisions

for the community, so that they are taken without the influence of external or private interest. Part of this is making sure that perceived, potential or actual conflicts of interest (COI) are declared and appropriately managed, including by making sure we do our business appropriately and in line with best practice.

2.3. The requirement to manage COI already forms part of the CCG Constitution, which

outlines that employees, member practices, committee members and members of the Governing Body will at all times comply with the Standards of Business Conduct. The COI principles and requirements form part of these Standards.

2.4. There are also specific statutory COI requirements the CCG must meet. Under Section 14O (conflicts of interest) of the National Health Service Act 2006 (which was inserted by the Health and Social Care Act 2012) the CCG is required to:

Maintain and publish (or make arrangements to ensure that members of public have access on request to) appropriate registers of interest, including for members of the CCG, members of the Governing Body, members of Committees and sub-committees and for individual employees.

Make arrangements requiring the prompt declaration of interests by all members and employees and ensure that these are entered into the register.

Make arrangements for managing COI to ensure that a conflict does not affect (or appear to affect) the integrity of the CCG’s decision making process (e.g. developing policies and procedures).

2.5. Under the NHS (Procurement, Patient Choice and Competition) (No. 2) Regulations 2013 (and related substantive guidance) the CCG is required to:

Have regard to national guidance published by NHS England and Monitor in relation to COI.

Not award a contract for the provision of NHS health care services where conflicts (or potential conflicts) between the interests involved in commissioning services and those involved in providing them affect (or appear to affect) the integrity of the award of the contract; and

Keep appropriate records of how any conflict in relation to NHS commissioning contracts was managed – and publish these details.

2.6. The CCG also needs to adhere to relevant guidance issued by professional bodies on conflicts of interest, including:

The British Medical Association.

The Royal College of General Practitioners.

The General Medical Council.

And to procurement rules including:

http://www.bma.org.uk/advice/employment/commissioning/ensuring-transparency-and-probity

http://www.rcgp.org.uk/~/media/Files/CIRC/Managing_conflicts_of_interest.ashx

http://www.gmc-uk.org/guidance/good_medical_practice.asp

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The Public Contract Regulations 2015.

The National Health Service (procurement, patient choice and competition) (no.2) Regulations 2013.

The Bribery Act 2010. 2.7. The most recent guidance on COI published by NHS England in June 2016 (available here) has been incorporated into this policy and the attached procedures.

3 DEFINITION OF A CONFLICT OF INTEREST

3.1. A COI occurs where an individual’s ability to exercise judgement, or act in a role is, could be, is seen to be or could be seen to be impaired or otherwise influenced by his or her involvement in another role or relationship. In some circumstances, it

could be reasonably considered that a COI exists even when there is no actual COI. In these cases it is still important to manage these perceived COI in order to maintain public trust.

3.2. The individual does not need to exploit his or her position to obtain an actual benefit, financial or otherwise for there to be a COI. A potential for competing interests and/or a perception of impaired judgement or undue influence can also be a COI.

3.3. Therefore the perception of wrongdoing, impaired judgement or undue influence can sometimes be as damaging as this occurring.

3.4. Whether or not an interest held by another person gives rise to a COI will depend upon the nature of the relationship between that other person and upon the individual, and the role of the individual within the CCG. 3.5. For the purpose of this policy, the reference to COI includes actual, potential or perceived conflicts. 3.6. For more information and examples of COI, please refer to the CCG Constitution (under Standards of Business Conduct – Conflict of Interest). 3.7. Types of COI come under four categories. For more details and examples please see Appendix 1:

3.7.1. Financial interests Where an individual may get direct financial benefits from the consequences of a commissioning decision. 3.7.2. Non-financial professional interests Where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. 3.7.3. Non-financial personal interests Where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit.

http://www.legislation.gov.uk/uksi/2015/102/contents/made

http://www.gov.uk/government/publications/regulations-on-healthcare-procurement-patient-choice-and-competition-laid

http://www.gov.uk/government/publications/regulations-on-healthcare-procurement-patient-choice-and-competition-laid

http://www.gov.uk/government/publications/bribery-act-2010-guidance


8

3.7.4. Indirect interests Where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision.

3.8. The above categories are not exhaustive and each potential COI will be assessed on a case-by-case basis, in order to decide whether any other role, relationship or interest would impair or otherwise influence an individual’s judgement or actions in their role within the CCG. If so, this will be declared and appropriately managed.

4. PRINCIPLES

4.1. Principles of good governance for consideration include those set out in the following: 4.2. The Seven Principles of Public Life (commonly known as the Nolan Principles): www.gov.uk/government/publications/the-7-principles-of-public-life

Selflessness.

Integrity.

Objectivity.

Accountability.

Openness.

Honesty.

Leadership.

4.3. The Good Governance Standards of Public Services: www.jrf.org.uk/report/good-governance-standard-public-services

4.4. The Seven Key Principles of the NHS Constitution: www.gov.uk/government/publications/the-nhs-constitution-for-england

4.5. The Equality Act 2010: www.legislation.gov.uk/ukpga/2010/15/contents www.gov.uk/guidance/equality-act-2010-guidance

4.6. This policy supports these principles by outlining the duties in relation to COI and detailing related processes to help discharge this duty. This includes:

Making, recording and publishing declared COI.

Assessing possible impacts of these declarations.

Managing perceived, potential and actual COI.

Monitoring and reporting arrangements. 4.7. For more details on the principles of good governance, please see Appendix 2.

5. DECLARING CONFLICTS OF INTEREST 5.1. Statutory requirements

According to the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) CCGs must make arrangements to ensure individuals declare

https://www.gov.uk/government/publications/the-7-principles-of-public-life

https://www.jrf.org.uk/report/good-governance-standard-public-services

https://www.gov.uk/government/publications/the-nhs-constitution-for-england


https://www.gov.uk/guidance/equality-act-2010-guidance

9

any COI or potential COI in relation to a decision to be made by the group as soon as they become aware of it, and in any event within 28 days. CCGs must record the interest in the registers as soon as they become aware of it.

5.2. See Appendix 3 for a process chart on the assessment and recording of declarations of interest and Appendix 4 for a process chart on scrutiny, assurance, breaches and publication of declarations of interest.

6. REGISTERS OF INTERESTS

6.1. Statutory Requirements CCGs must maintain one or more registers of interest of:

The members of the group.

Members of its governing body.

Members of its committees or sub-committees.

Its employees.

CCGs must publish, and make arrangements to ensure that members of the public have access to these registers on request.

6.2. A register of interests is maintained for:

All CCG employees, including: o all full and part time staff; o any staff on sessional or short term contracts; o any students and trainees (including apprentices); o agency staff; o seconded staff.

6.3. In addition, any self-employed consultants or other individuals working for the CCG under a contract for services should make a declaration of interest in accordance with this guidance, as if they were CCG employees.

Members of the governing body. All members of the CCG’s committees, sub-committees/sub-groups, including: o co-opted members; o appointed deputies; o any members of committees / groups from other organisations.

6.4. Where the CCG is participating in a joint committee alongside other CCGs, any interests which are declared by the committee members should be recorded on the register(s) of interest of each participating CCG.

All members of the CCG (i.e. each practice). This includes each provider of primary medical services which is a member of the CCG under Section 14O (1) of the 2006 Act. Declarations should be made by the following groups: o GP partners (or where the practice is a company, each director); o any individual directly involved with the business or decision-making of the

CCG.

6.5. Declared COI (including amendments to previous declarations) will be added to the register of interests as soon as the CCG is notified – and no later than 28 days.

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6.6. A COI will remain on the public register for a minimum of six months after the interest has expired. In addition, the CCG will retain a record of historic COI for a minimum of six years after the date on which they expired. The CCG’s published register of interests will state that historic COI are retained by the CCG for at least six years, with contact details for submitting a request for this information. 6.7. The registers of interests are available on the CCG websites at:

www.highwealdleweshavensccg.nhs.uk.

7. ROLES AND RESPONSIBILITIES

7.1 Individuals

Including temporary staff, contractors and seconded staff, members of the CCG (member practices), members of the Governing Body and related committees are required to:

Comply with the CCG Constitution, available on the CCG website, and be aware of their responsibilities outlined in it relating to COI and general business conduct.

Complete their own declaration of interests (DOI) form (Appendix 5) to be recorded and published in the relevant public register of interests. The DOI form must be completed on joining the CCG (and will be sent out to member practices for completion). The form must be completed even it is it a nil return.

Keep up to date the declaration of interest (DOI) form. This form must be updated every six months, even if there is no change to your situation. The CCG must be notified if there are any changes as soon as they are known by completing a new form (and within a maximum of 28 days). This includes where there is a change in roles / responsibilities or there is a new interest to be declared or a declared interest has ceased.

Declare at the start of any relevant meeting - or during a commissioning process - relevant COI relating to the agenda or commissioning decision to be made. This is in order for the declaration to be recorded as part of the minutes of the meeting / commissioning process and for the appropriate action to mitigate the conflict to be taken.

Declare at the start of any relevant meeting – or during a commissioning process - relevant offers of gifts or hospitality (whether accepted or not). This is in order for the declaration to be recorded as part of the minutes of the meeting / commissioning process and to ensure that the CCG’s register of gifts and hospitality is up-to-date.

Ensure that details of the arrangements in place to manage the COI are received and understood before participating in any commissioning activity, following a DOI.

Ensure that arrangements that have been put in place for managing COI are followed (either for themselves or for others).

Ensure that the chair of any meeting attended is aware of any arrangements in place for managing the COI, where the item arises.

Declare a COI if they are not sure from the guidance whether or not it should be declared; that way it can be managed appropriately either way.

Report any concerns with implementation of the policy, including any failure to adhere to the policy, to the Head of Corporate Services in the first instance.

Complete annual mandatory training on conflicts of interest.

http://www.highwealdleweshavensccg.nhs.uk/

11

7.2 Commissioning / procurement processes and decisions

Staff and members are required to:

Comply with regulatory and legislative requirements. This includes the NHS Act, the Health and Social Care Act, associated NHS Procurement Regulations, policies and guidance and Public Contracts Regulations 2015 (PCR 2015). Part of managing COI is doing business appropriately and following the principles and general safeguards already embedded in best practice.

Make sure that DOI are made by those involved as part of the commissioning / procurement process - and that any COI are managed appropriately. This may include, for example, managing COI for potential bidders seeking information in relation to procurement or those participating in a procurement exercise (or otherwise engaging with the CCG in relation to the potential provision of services).

Keep appropriate records regarding the declaration and management of COI, including the evidence of how the COI was mitigated in the specific circumstances. For example, documentary evidence should be kept to demonstrate that no one with an interest in the successful provider organisation was involved in the procurement process and how any DOI were assessed and managed.

Ensure that the appropriate COI procurement guidance are used and understood if commissioning services from GP practices.1

Make sure that if commissioning from GPs / member practices, that decision making committees have a quorate, non-conflicted majority where possible. For example, by using out of area GPs, clinicians with relevant experience and lay and executive person involvement.

Where appropriate, ensure the involvement or review of decisions by third parties (Health and Wellbeing Board / out of area GPs, clinicians with relevant experience, independent lay persons) should a COI arise that affects, or appears to affect, the integrity of an award.

Provide the details of the declaration and management of COI to the Corporate Services Team for the inclusion in the Register of Procurement Decisions. This forms part of the requirement to publish a record of contracts awarded, outlined in Regulation 9 of the NHS Procurement Regulations.

Make sure that COI are managed on an ongoing basis, for example by monitoring a contract that has been awarded to a provider in which an individual commissioner has a vested interest.

7.3 The Governing Body

The Governing Body has overall accountability and is responsible for ratifying this Managing Conflicts of Interest Policy.

Governing Body members are required to make their own declarations, which are also made in line with the Nolan Principles and the Code of Accountability for NHS Boards, as incorporated in the CCG Standing Orders.

In order for the CCG to identify the risk of COI at the earliest opportunity, DOI forms are required as part of any selection or election process when individuals join the Governing Body (or CCG committees).

1 Please also refer to the Procurement Policy, templates available in the December 2014 NHS England

Guidance (National Guidance) and Monitor’s Substantive Guidance on the Procurement, Patient Choice and Competition Regulations.

http://www.legislation.gov.uk/uksi/2013/257/regulation/9/made

https://www.gov.uk/government/collections/procurement-choice-and-competition-in-the-nhs-documents-and-guidance

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Whilst the Conflicts of Interest Guardian has an important role within the management of COI, executive members of the CCG’s governing body have an ongoing responsibility for ensuring the robust management of COI, and all CCG employees, governing body and committee members and member practices will continue to have individual responsibility in playing their part on an ongoing and daily basis.

Key considerations when appointing governing body or committee members including the following: o whether COI should exclude individuals from appointment; o assessing materiality of interest; o determining the extent of the interest.

7.4 Lay Members Lay members play a critical role in CCGs, providing scrutiny, challenge and an independent voice in support of robust and transparent decision-making and management of COI. The CCG has the recommended three lay members due to their expanding role in relation to delegated primary care commissioning.

7.5 Conflict of Interest Guardians

To further strengthen scrutiny and transparency of CCG decision-making processes, the CCG has a Conflicts of Interest Guardian. This role is undertaken by the CCG audit chair, provided they have no provider interests. The Conflicts of Interest Guardian should, in collaboration with the CCG governance lead:

Act as a conduit for GP practice staff, members of the public and healthcare professionals who have any concerns with regards to COI.

Be a safe point of contact for employees or workers of the CCG to raise any concerns in relation to this policy.

Support the rigorous application of COI principles and policies.

Provide independent advice and judgment where there is any doubt about how to apply COI policies and principles in an individual situation.

Provide advice on minimising the risks of COI.

7.6 Audit Committee The CCG Audit Committee is responsible for overseeing the management of COI on behalf of the CCG, with arrangements for the COI generally to be determined by the Audit Committee (unless a Governing Body decision is required).

Actions Once a COI has been declared, actions to mitigate the risk should be agreed by the line manager or a senior CCG manager as soon as possible. Advice may be sought from the Conflicts of Interest Guardian, Chief Finance Officer, Procurement Lead or Head of Corporate Services, as appropriate.

The arrangements will be documented and recorded on the Register. The arrangements will confirm the following: o when an individual should withdraw from a specified activity, on a temporary

or permanent basis; and/or o how monitoring of the specified activity by the individual will be undertaken,

either by a line manager, colleague or other designated individual.

The Audit Committee will review COI and mitigating arrangements at regular intervals, including the documented arrangements for managing a COI.

The Audit Committee will annually review and approve the process (including this policy) for managing COI and for the Register of interests, including for annual accounts and audit purposes.

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7.7 The Chief Officer

The Chief Officer (Accountable Officer) has overall responsibility for ensuring the CCG has appropriate policies and procedures in place and compliance with relevant legislation.

7.8 Meeting Chairs Meeting chairs have responsibility for ensuring that DOI are a standing agenda item and addressed at the start of all meetings. Chairs must also follow any arrangements in place to manage existing COI and follow the processes outlined for the structure and quorum of meetings.

Following a DOI at a meeting, the chair is responsible for managing any COI and for informing the member / attendee of their decision, with advice from the Conflict of Interest Guardian, Chief Finance Officer, Procurement Lead or Head of Corporate Services, as appropriate.

Where no arrangements have been confirmed prior to the meeting, the chair may require the individual to withdraw from the meeting or part of it.

The chair is responsible for ensuring that any DOI made at a meeting (and any subsequent decision relating to COI management for that meeting) is captured as part of the minutes.

Meeting chairs must make sure that this information is communicated to the CCG Corporate Services Team as soon as possible after the meeting. This is both for advice on managing any COI and for the information to be recorded on the relevant register of interests.

Where the chair of any meeting has a personal interest (previously declared or otherwise) in relation to the business of the meeting, they must make a declaration and the deputy chair will act as chair for the relevant part of the meeting.

7.9 The Deputy / Vice Chair of the Governing Body or committee When the Chair of the Governing Body or a committee has a COI, the Deputy / Vice Chair will chair the meeting or the relevant part of the meeting.

7.10 The Head of Corporate Services The Head of Corporate Services (with the Conflicts of Interest Guardian and the Chief Finance Officer) will provide advice and assistance on governance arrangements for declarations and COI management. The Head of Corporate Services will also:

Ensure management of the policy, and co-ordinate the declarations review and approval process via relevant committees, or other bodies / persons delegated to do so.

Ensure that the COI review process is audited appropriately including carrying out a sample check of declarations or nil declarations on a rotational basis, along with a check that verbal declarations made at meetings match those on the Registers.

Support the processes outlined in Appendices 4 and 5.

Raise awareness of this COI policy including training when this is made available.

Manage the day-to-day management of COI matters and queries.

Maintain the CCG register of interests.

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Support the Conflicts of Interest Guardian to enable them to carry out the role effectively.

Provide advice, support, and guidance on how COI should be managed.

Ensure a ratified version of this policy is stored electronically on the shared network drive, on the staff intranet and on the CCG website.

Co-ordinate the review of the policy within the allotted timescale.

7.11 Line Managers Line Managers are responsible for:

Ensuring the policies and supporting procedures are followed and that staff are aware of their obligations regarding the declaration and management of COI.

Familiarising staff with CCG policies as part of the staff induction process and making sure that the DOI form has been completed and returned to the relevant point of contact.

Carrying out the initial assessment of DOI from their staff as part of the six-monthly appraisal process and proposing any mitigating arrangements to the Head of Corporate Services.

Overseeing activity regarding COI and helping to manage situations where a conflict or potential conflict arises to ensure that the COI is mitigated.

7.12 Those participating in procurement activity

This includes bidders / potential bidders and contractors.

The CCG recognises the importance in making decisions about the services it procures in a way that does not call into question the motives behind the procurement decision that has been made. The CCG will procure services in a manner that is open, transparent, non-discriminatory and fair to all potential providers.

The CCG will comply with NHS England’s document ‘Managing Conflicts of Interest: Statutory Guidance for CCGs’ (December 2014), including where GP Practices are potential providers of CCG commissioned services.

Anyone participating in a procurement activity, or otherwise engaging with the CCG in relation to the potential provision of services or facilities to the CCG, will be required to make a declaration of any COI.

The Chief Finance Officer is responsible for maintaining and publishing the Register of Procurement Decisions, to include details of how any conflicts that arose in the context of the decision were managed by the CCG. The CCG Procurement Policy and the Register of Procurement Decisions are reviewed annually.

The appropriate Procurement Templates and guidance should be used and followed if commissioning services from GP practices.

If commissioning from GPs / member practices, where possible the CCG will ensure that decision making committees have a quorate, non-conflicted majority. For example, by using out of area GPs, clinicians with relevant experience and lay and executive person involvement.

Should a COI arise that affects or appears to affect the integrity of an award, the CCG will ensure the involvement or review of decisions by third parties (Health and Wellbeing Board / out of area GPs, clinicians with relevant experience, independent lay persons).

Anyone contracted to provide services or facilities directly to the CCG will be subject to the CCG constitution in relation to managing COI.

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8. MANAGING COI THROUGHOUT THE COMMISSIONING CYCLE

8.1. The management of COI applies to all aspects of the commissioning cycle,

including contract management.

8.2. If COI are not managed effectively, confidence in commissioning decisions and the integrity of the individuals and clinicians involved could be undermined.

8.3. Even if a COI does not actually affect the integrity of a contract awarded, a COI

that appears to do so can damage reputation and public confidence in the CCG and Regulation 6 of the Procurement, Patient Choice and Competition Regulations can prohibit awarding contracts in these circumstances.

8.4. If a contract that has been awarded to a provider in which an individual

commissioner has a vested interest, contract leads will ensure that COI are managed on an on-going basis during contract monitoring.

8.5. Any contract monitoring meeting needs to consider COI as part of the process i.e., the chair of a contract management meeting should invite declarations of interests; record any declared COI in the minutes of the meeting; and manage any COI appropriately and in line with this guidance. This equally applies where a contract is held jointly with another organisation such as the Local Authority or with one or more other CCGs under lead commissioner arrangements.

8.6. The individuals involved in the monitoring of a contract should not have any direct or indirect financial, professional or personal interest in the incumbent provider or in any other provider that could prevent them, or be perceived to prevent them, from carrying out their role in an impartial, fair and transparent manner.

8.7. COI need to be managed appropriately throughout the whole commissioning

cycle from needs assessment, planning and prioritisation to service design, procurement and monitoring.

8.8. At the outset of a commissioning process, the relevant interests of all individuals

involved will be identified and clear arrangements put in place to manage any COI. This includes consideration as to which stages of the process a conflicted individual should not participate in, and, in some circumstances, whether that individual should be involved in the process at all.

8.9. The CCG must comply with the NHS (Procurement, Patient Choice and

Competition (No.2)) Regulations 2013: made under S75 of the 2012 Act and the European Public Contracts Regulations 2015 (PCR 2105). The PCR 2015 are focussed on ensuring a fair and open selection process for providers

8.10. The Procurement, Patient Choice and Competition Regulations (PPCCR) requires commissioners:

To ensure that they adhere to good practice in relation to procurement.

To run a fair, transparent process that does not discriminate against any provider.

https://www.gov.uk/government/publications/regulations-on-healthcare-procurement-patient-choice-and-competition-laid


http://www.nhsconfed.org/regions-and-eu/nhs-european-office/influencing-eu-policy/public-procurement

http://www.nhsconfed.org/regions-and-eu/nhs-european-office/influencing-eu-policy/public-procurement

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Not to engage in anti-competitive behaviour that is against the interest of patients.

To protect the right of patients to make choices about their healthcare.

To secure high quality, efficient NHS healthcare services that meet the needs of the people who use those services.

8.11. The CCG will maintain a register of procurement decisions taken, either for the

procurement of a new service or any extension or material variation of a current contract. This will include:

The details of the decision.

Who was involved in making the decision (including the name of the CCG clinical lead, the CCG contract manager, the name of the decision making committee and the name of any other individuals with decision-making responsibility.

A summary of any COI in relation to the decision and how this was managed by the CCG.

The award decision taken. 9. RAISING CONCERNS AND BREACHES 9.1. It is the duty of every CCG employee, governing body member, committee or

sub-committee member and GP practice member to speak up about genuine concerns in relation to the administration of the CCG’s policy on COI management, and to report these concerns. See the table of Key Staff Contacts on page 4.

9.2. Any non-compliance with the CCG’s Conflicts of Interest policy should be reported to the Head of Corporate Services under this policy. The CCG has a Whistleblowing Policy (Freedom to Speak Up) available on the staff intranet. The CCG’s Freedom to Speak Up Guardian is Denise Matthams. Email: [email protected].

9.3. All notifications will be treated confidentially. The person making a disclosure will

be kept informed of any decisions taken as a result of any investigation. 9.4. Providers, patients and other third parties can make a complaint to NHS

Improvement at: improvement.nhs.uk/ in relation to a commissioner’s conduct under the Procurement Patient Choice and Competition Regulations.

9.5. Anonymised details of breaches will be published on the CCG’s website for the purpose of learning and development. See Appendix 4 for a process chart.

9.6. Fraud, Bribery and Corruption

Genuine suspicions of Fraud, Bribery and Corruption can also be reported to the NHS Fraud and Corruption Reporting Line on free phone 0800 028 4060, again in strict confidence, or via the online reporting form at www.reportnhsfraud.nhs.uk.

9.7. Suspicions of fraud can be reported within the CCG to the Chief Finance Officer or to the NHS Counter Fraud Manager, Chris Lovegrove. Email: [email protected] . Tel: 07879 434976 or 01424 776750.


https://improvement.nhs.uk/

http://www.reportnhsfraud.nhs.uk/


17

9.8. Please also see the Fraud, Bribery and Corruption Policy for more details, available on the staff intranet.

10. REFERENCES AND FURTHER INFORMATION

The Bribery Act 2010: www.legislation.gov.uk/ukpga/2010/23/contents www.gov.uk/government/publications/bribery-act-2010-guidance

British Medical Association (BMA). Guidance on Conflicts of Interest for GPs in their role as commissioners and providers: www.bma.org.uk/advice/employment/commissioning/ensuring-transparency-and-probity

General Medical Council (GMC: www.gmc-uk.org/guidance/good_medical_practice.asp www.gmc-uk.org/guidance/ethical_guidance.asp

The National Health Service (procurement, patient choice and competition) (no.2) regulations 2013: www.gov.uk/government/publications/regulations-on-healthcare-procurement-patient-choice-and-competition-laid www.gov.uk/government/publications/procurement-patient-choice-and-competition-regulations-guidance

The Public Contract Regulations 2015: www.legislation.gov.uk/uksi/2015/102/contents/made

Public Contracts Regulations 2015 (PCR 2015): www.legislation.gov.uk/uksi/2015/102/contents/made

Royal College of General Practitioners. Managing Conflicts of Interest in clinical commissioning groups: www.rcgp.org.uk/~/media/Files/CIRC/Managing_conflicts_of_interest.ashx

11. EQUALITY STATEMENT

In applying this policy, the CCG will have due regard for the need to eliminate unlawful discrimination, promote equality of opportunity, and provide for good relations between people of diverse groups, in particular on the grounds of the following characteristics protected by the Equality Act (2010); age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic.

12. REVIEW

12.1. This policy will be reviewed annually, or sooner if required. Where review is

necessary due to legislative change, this will happen immediately. The revised policy document will be approved by the CCG Audit Committee.


https://www.gov.uk/government/publications/bribery-act-2010-guidance

https://www.bma.org.uk/advice/employment/commissioning/ensuring-transparency-and-probity

https://www.bma.org.uk/advice/employment/commissioning/ensuring-transparency-and-probity

http://www.gmc-uk.org/guidance/good_medical_practice.asp

http://www.gmc-uk.org/guidance/ethical_guidance.asp



https://www.gov.uk/government/publications/procurement-patient-choice-and-competition-regulations-guidance

https://www.gov.uk/government/publications/procurement-patient-choice-and-competition-regulations-guidance



http://www.rcgp.org.uk/~/media/Files/CIRC/Managing_conflicts_of_interest.ashx

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12.2. An Equality Analysis Initial Assessment has been carried out on this policy. As a result, there is no anticipated detrimental impact on any equality group.

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APPENDIX 1: The four types of Conflict of Interest

1. Financial interests. 2. Non-financial professional interests. 3. Non-financial personal interests. 4. Indirect interests. These categories are not exhaustive and each potential COI will be assessed on a case-by-case basis, in order to decide whether any other role, relationship or interest could (or could be seen to) impair or otherwise influence an individual’s judgement or actions in their role within the CCG. If so, this will be declared and appropriately managed. 1. Financial interests Where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:

A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely to do, or possibly seeking to do, business with health or social care organisations.

A shareholder (or similar ownership interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely to do, or possibly seeking to do, business with health or social care organisations.

A management consultant for a provider. This could also include an individual being:

In secondary employment. Examples of work which might conflict with the business of the CCG, including part-time, temporary and fixed term contract work, include; o with another NHS body, o with another organisation which might be in a position to supply goods / services

to the CCG, o directorship of a GP federation, o self-employment, including private practice, in a capacity which might conflict

with the work of the CCG or which might be in a position to supply goods/services to the CCG.

Individuals are required to obtain prior permission to engage in secondary employment, and the CCG reserves the right to refuse permission where it believes a conflict will arise which cannot be effectively managed.

In receipt of secondary income from a provider.

In receipt of a grant from a provider.

In receipt of any payments (for example honoraria, one-off payments, day allowances or travel or subsistence) from a provider.

In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role.

Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider).

20

2. Non-financial professional interests. Where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

An advocate for a particular group of patients.

A GP with special interests e.g., in dermatology, acupuncture etc.

A member of a particular specialist professional body (although routine GP membership of the RCGP, British Medical Association (BMA) or a medical defence organisation would not usually by itself amount to an interest which needed to be declared).

An advisor for the Care Quality Commission (CQC) or the National Institute for Health and Care Excellence (NICE).

A medical researcher.

GPs and practice managers, who are members of the governing body or committees of the CCG, should declare details of their roles and responsibilities held within their GP practices.

3. Non-financial personal interests. Where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

A voluntary sector champion for a provider.

A volunteer for a provider.

A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation.

Suffering from a particular condition requiring individually funded treatment.

A member of a lobby or pressure group with an interest in health. 4. Indirect interests. Where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above) for example, a:

Spouse / partner.

Close relative e.g., parent, grandparent, child, grandchild or sibling.

Close friend.

Business partner.

21

APPENDIX 2: Good Governance Principles a) Nolan Principles 1. Selflessness.

Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

2. Integrity.

Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

3. Objectivity. In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

4. Accountability.

Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

5. Openness. Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

6. Honesty. Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

7. Leadership.

Holders of public office should promote and support these principles by leadership and example.

b) The Seven Key Principles of the NHS Constitution 1. The NHS provides a comprehensive service, available to all.

This is irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.

2. Access to NHS services is based on clinical need, not an individual’s ability to

pay. NHS services are free of charge, except in limited circumstances sanctioned by Parliament.

3. The NHS aspires to the highest standards of excellence and professionalism.

https://www.gov.uk/government/publications/the-7-principles-of-public-life

http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx

22

In the provision of high-quality care that is safe, effective and focused on patient experience; in the planning and delivery of the clinical and other services it provides; in the people it employs and the education, training and development they receive; in the leadership and management of its organisations; and through its commitment to innovation and to the promotion and conduct of research to improve the current and future health and care of the population.

4. NHS services must reflect the needs and preferences of patients, their families

and their carers. Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment.

5. The NHS works across organisational boundaries and in partnership with other

organisations in the interest of patients, local communities and the wider population. The NHS is an integrated system of organisations and services bound together by the principles and values now reflected in the Constitution. The NHS is committed to working jointly with local authorities and a wide range of other private, public and third sector organisations at national and local level to provide and deliver improvements in health and well-being.

6. The NHS is committed to providing best value for taxpayers’ money and the most cost-effective, fair and sustainable use of finite resources. Public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves.

7. The NHS is accountable to the public, communities and patients that it serves.

The NHS is a national service funded through national taxation, and it is the Government which sets the framework for the NHS and which is accountable to Parliament for its operation. However, most decisions in the NHS, especially those about the treatment of individuals and the detailed organisation of services, are rightly taken by the local NHS and by patients with their clinicians. The system of responsibility and accountability for taking decisions in the NHS should be transparent and clear to the public, patients and staff. The Government will ensure that there is always a clear and up-to-date statement of NHS accountability for this purpose.

c) The Good Governance Standards of Public Services 1. Good governance means focusing on the organisation’s purpose and on

outcomes for citizens and service users.

Being clear about the organisation’s purpose and its intended outcomes for citizens and service users.

Making sure that users receive a high quality service.

Making sure that taxpayers receive value for money. 2. Good governance means performing effectively in clearly defined functions and

roles.

Being clear about the functions of the governing body.

Being clear about the responsibilities of non-executives and the executive, and making sure that those responsibilities are carried out.

Being clear about relationships between governors and the public.

https://www.jrf.org.uk/report/good-governance-standard-public-services

23

3. Good governance means promoting values for the whole organisation and demonstrating the values of good governance through behaviour.

Putting organisational values into practice.

Individual governors behaving in ways that uphold and exemplify effective governance.

4. Good governance means taking informed, transparent decisions and managing risk.

Being rigorous and transparent about how decisions are taken.

Having and using good quality information, advice and support.

Making sure that an effective risk management system is in operation. 5. Good governance means developing the capacity and capability of the

governing body to be effective.

Making sure that appointed and elected governors have the skills, knowledge and experience they need to perform well.

Developing the capability of people with governance responsibilities and evaluating their performance, as individuals and as a group.

Striking a balance, in the membership of the governing body, between continuity and renewal.

6. Good governance means engaging stakeholders and making accountability real.

Understanding formal and informal accountability relationships.

Taking an active and planned approach to dialogue with and accountability to the public.

Taking an active and planned approach to responsibility to staff.

Engaging effectively with institutional stakeholders.

24

APPENDIX 3: PROCESS CHART – Declarations, Assessment and Recording

12.3.

Advice from COI

Guardian in complex

cases

Reviewed and approved by Chief Finance Officer /

Head of Corporate Services

Complete and submit form*

Assessed by Line Manager and any arrangements proposed

New joiner

New interest New role Interest ceases

(Re-)Commissioning

starts Six-monthly

update

Declaration added to the COI register

Mitigating

arrangements

documented and

notified to individual

and line manager

Actions

Triggers

Nil return

*The COI Declaration form is at Appendix 5 of the Conflicts of Interest Policy

No arrangements

necessary

Register

COI register of declared interests

published on CCG website

25

APPENDIX 4: PROCESS CHART – Scrutiny, Assurance, Breaches and Publication

Triggers

Updated

declarations

Updated

registers

Suspected breach

or non-compliance

Report to each Audit

Committee meeting of COI

mitigating arrangements and

any breaches

Six-monthly updated

COI registers

Remedial actions agreed

with COI Guardian

No issue –

NFA

Breach or non-

compliance identified


investigates

Reported to Head of Corporate

Services

Actions

Report to Audit Committee

including annual review of

COI Policy and Processes

Anonymised

details of

breach

Individual and

Line Manager

notified and

arrangements

implemented

Reporting

Report to NHS

England

Publish on CCG

website

26

APPENDIX 5: Declaration of Interests Form for CCG members, officers and employees

Name:

Position within, or relationship with, the CCG (or NHS England in the event of joint committees):

Detail of interests held (complete all that are applicable):

Type of Interest*

*See

reverse

of form

for

details

Description of Interest (including for indirect Interests, details of the relationship with the person who has the interest)

Date interest relates

From & To

Actions to be taken to mitigate risk

(to be agreed

with line

manager or a

senior CCG

manager)

The information submitted will be held by the CCG for personnel or other reasons specified on this form and to comply with the organisation’s policies. This information may be held in both manual and electronic form in accordance with the Data Protection Act 1998. Information may be disclosed to third parties in accordance with the Freedom of Information Act 2000 and published in registers that the CCG holds. I confirm that the information provided above is complete and correct. I acknowledge that any changes in these declarations must be notified to the CCG as soon as practicable and no later than 28 days after the interest arises. I am aware that if I do not make full, accurate and timely declarations then civil, criminal, or internal disciplinary action may result. I do / do not [delete as applicable] give my consent for this information to published on registers that the CCG holds. If consent is NOT given please give reasons:

Signed: Date:

Signed: Position:

Date:

(Line Manager or Senior CCG Manager)

Please return to: Head of Corporate Services via email at [email protected] or via post to: High Weald Lewes Havens CCG, 36-38 Friars Walk, Lewes, BN7 2PB.


27

Types of interest

Type of Interest

Description

Financial Interests

This is where an individual may get direct financial benefits from the consequences of a commissioning decision. This could, for example, include being:

A director, including a non-executive director, or senior employee in a private company or public limited company or other organisation which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations;

A shareholder (or similar owner interests), a partner or owner of a private or not-for-profit company, business, partnership or consultancy which is doing, or which is likely, or possibly seeking to do, business with health or social care organisations.

A management consultant for a provider;

In secondary employment (see paragraph 56 to 57);

In receipt of secondary income from a provider;

In receipt of a grant from a provider;

In receipt of any payments (for example honoraria, one off payments, day allowances or travel or subsistence) from a provider

In receipt of research funding, including grants that may be received by the individual or any organisation in which they have an interest or role; and

Having a pension that is funded by a provider (where the value of this might be affected by the success or failure of the provider).

Non-Financial Professional Interests

This is where an individual may obtain a non-financial professional benefit from the consequences of a commissioning decision, such as increasing their professional reputation or status or promoting their professional career. This may, for example, include situations where the individual is:

An advocate for a particular group of patients;

A GP with special interests e.g., in dermatology, acupuncture etc.

A member of a particular specialist professional body (although routine GP

membership of the RCGP, BMA or a medical defence organisation would not usually by itself amount to an interest which needed to be declared);

An advisor for Care Quality Commission (CQC) or National Institute for

Health and Care Excellence (NICE);

A medical researcher.

Non-Financial Personal Interests

This is where an individual may benefit personally in ways which are not directly linked to their professional career and do not give rise to a direct financial benefit. This could include, for example, where the individual is:

A voluntary sector champion for a provider;

A volunteer for a provider;

A member of a voluntary sector board or has any other position of authority in or connection with a voluntary sector organisation;

Suffering from a particular condition requiring individually funded treatment;

A member of a lobby or pressure groups with an interest in health. Indirect Interests

This is where an individual has a close association with an individual who has a financial interest, a non-financial professional interest or a non-financial personal interest in a commissioning decision (as those categories are described above). For example, this should include:

Spouse / partner;

Close relative e.g., parent, grandparent, child, grandchild or sibling;

Close friend;

Business partner.

28

29

APPENDIX 6: Template Register of Interests

Name: Current position (s) held in the

CCG:

Declared Interest:

Type of Interest: Is the Interest: Nature of Interest: Date of Interest: Action taken to mitigate risk:

Fin

an

cia

l

Inte

res

t

No

n-F

ina

ncia

l

Pro

fes

sio

na

l

Inte

res

t

No

n-F

ina

ncia

l

Pe

rso

nal

Inte

res

t

Dir

ec

t

Ind

ire

ct

From: To:

30

APPENDIX 7: Template Checklist for Chairs of Meetings

Under the Health and Social Care Act 2012, there is a legal obligation to manage Conflicts of Interest (COI) appropriately. It is essential that Declarations of Interest (DOI) and actions arising from DOI are recorded formally and consistently across all CCG governing body, committee and sub-committee meetings. This checklist has been developed with the intention of providing support in COI management to the Chair of the meeting prior to, during and following the meeting. It does not cover the requirements for declaring COI outside the committee process.

Timing Checklist for Chairs Responsibility

In advance of the meeting

1. The agenda to include a standing item on DOI to enable individuals to raise any issues and/or make a declaration at the meeting.

2. A definition of Conflicts of Interest should

also be accompanied with each agenda to provide clarity for all recipients.

3. Agenda to be circulated to enable attendees

(including visitors) to identify any interests relating specifically to the agenda items being considered.

4. Members should contact the Chair as soon as an actual or potential COI is identified.

5. A copy of the members’ declared interests is

checked to establish any actual or potential COI that may occur during the meeting.

Meeting Chair and secretariat Meeting Chair and secretariat Meeting Chair and secretariat Meeting members Meeting Chair

During the meeting

6. Check and declare the meeting is quorate and ensure that this is noted in the minutes of the meeting.

7. Chair requests members to declare any

interests in agenda items which have not already been declared, including the nature of the COI.

8. Chair makes a decision as to how to manage

each interest which has been declared, including whether / to what extent the individual member should continue to participate in the meeting, on a case-by-case basis, and this decision is recorded.

9. As minimum requirement, the following should

be recorded in the minutes of the meeting:

Meeting Chair Meeting Chair Meeting Chair and secretariat Secretariat

31

Individual declaring the interest;

At what point the interest was declared;

The nature of the interest;

The Chair’s decision and resulting action taken;

The point during the meeting at which any individuals retired from and returned to the meeting – even if an interest has not been declared;

Visitors in attendance who participate in the meeting must also follow the meeting protocol and declare any interests in a timely manner.

After the meeting

10. All new interests declared at the meeting should be promptly updated onto the declaration of interest form;

11. All new completed declarations of interest

should be transferred onto the register of interests.

Individual(s) declaring interest(s) Designated person responsible for registers of interest

32

Notes on DOI and managing COI at Meetings

1.1 DOI is a required standing agenda item at every meeting of the Governing Body, related Committees / Sub-Committees and other decision making forums.

1.2 COI should additionally be declared at the time the conflicted item arises – e.g.

where it is an agenda item or where it relates to a decision is to be made by the CCG. Declarations should be made even if the COI has been declared previously.

1.3 The chair is responsible for ensuring the declaration is managed appropriately

and recorded at the meeting (whether the COI has been previously declared or otherwise). The information should be recorded as part of the minutes.

1.4 Where arrangements have been confirmed for the management of COI in

relation to the chair’s own interests, the meeting must ensure these are followed.

1.5 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.

1.6 Where more than 50% of the members of a meeting are required to withdraw

from a meeting or part of it, owing to the arrangements agreed for the management of COI or potential COI, the chair (or deputy) will determine whether or not the discussion can proceed.

1.7 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 standing orders. 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.

1.8 Where a quorum cannot be convened from the membership of the meeting,

owing to the arrangements for managing COI, the chair of the meeting shall consult with the Chief Officer or Chief Finance Officer on the action to be taken.

1.9 This may include:

requiring the CCG Governing Body or a committee / sub-committee (as appropriate) which can be quorate to progress the item of business, or if this is not possible;

inviting on a temporary basis one or more of the following to make up the quorum (where these are permitted members of the governing body or committee / sub-committee in question) so that the group can progress the item of business:

o a member of the CCG who is an individual; o an individual appointed by a member to act on its behalf in the

dealings between it and the CCG; o a member of a relevant Health and Wellbeing Board; o a member of a governing body of another CCG.

These arrangements must be recorded in the minutes.

33

1.10 If commissioning from GPs / member practices who have a COI, the CCG

should ensure that decision making Committees have a quorate, non-conflicted majority. For example, by using out of area GPs, other clinicians with relevant experience and lay and executive person involvement.

1.11 Where this is not possible the CCG should ensure the involvement or review of

decisions by third parties (Health and Wellbeing Board / out of area GPs, clinicians with relevant experience, independent lay persons) should a COI arise that affects or appears to affect the integrity of an award or decision.

1.12 The person making the declaration should complete and return a DOI form to the address on the form.

1.13 If the COI arises in a meeting / other situation, written notification should be

sent the Head of Corporate Services, who will arrange for the formal declaration to be made (if not already). The meeting chair should ensure that this has been done.

PURCHASING CARD POLICY

To be read in conjunction with the following CCG policies and documents:

CCG Constitution CCG Prime Financial Instructions F02 Gifts and Hospitality Policy F06 Fraud Bribery and Corruption Policy G08 Conflicts of Interest Policy

2

Document Details

Title Purchasing Card Policy

Ref No F07

Document objective To ensure that there is a robust system of internal control over the use of a CCG purchasing card.

Audience All CCG staff and officers (including temporary and seconded staff, and contractors)

Author Chris Tait


Approval process


Date of review 23 September 2016


Approval Date 25 January 2017

Equality Impact Assessment There are no negative impacts of this policy on people with protected characteristics.

Category Finance policy


Version Control

Version number

Date Action By whom

0.1 August Policy developed Chris Tait

3

Contents

1. Objectives .…………………………………………………………………………… 4

2. Availability ……………………………………………………………………………. 4

3. CCG Constitution and Financial Procedures …………………………………….. 4

4. Key Controls …………………………………………………………………………. 5

5. Reconciliation and Authorisation ………………………………………………….. 5

4

1. OBJECTIVES The overall objectives of the system in place surrounding the use of Clinical 1.1.

Commissioning Group’s purchasing card is to ensure that:

The use of purchasing card is restricted and the usage closely monitored and reviewed.

All expenditure is properly identified.

All expenditure is accounted for and authorised under the appropriate management control.

Management receives timely and adequate information to confirm the above.

2. AVAILABILITY The Clinical Commissioning Group has three purchase cards. The cards are 2.1.

allocated as follows:

Wendy Carberry, Chief Officer

Alan Beasley, Chief Finance Officer

Elizabeth Gill, Clinical Chair

3. CLINICAL COMMISSIONING GROUP CONSTITUTION AND FINANCIAL PROCEDURES All Clinical Commissioning Group finance staff are required to familiarise themselves 3.1.

with the requirements of the clinical commissioning group constitution, namely the Prime Financial Policies. In respect of the use of the purchasing card, particular attention should be given to the following sections:

3.1.1. Prime Financial Policies:

Bank accounts;

Income, fees and charges and security of cash, cheques and other negotiable instruments;

Non-pay Expenditure.

5

4. KEY CONTROLS The Clinical Commissioning Group purchasing card should not be used as an 4.1.

alternative to the normal procurement systems. The card should only be used in urgent or exceptional circumstances and for authorised business. The following guidelines should be followed unless exceptional circumstances can be justified:

To avoid interest payments, payment is made automatically via direct debit to the credit card company (on the due date as specified on each statement).

A copy of the statement is sent to the respective card holder for detailed explanation of each identified item of expenditure.

The card is to be used purely for Clinical Commissioning Group business use. No personal expenditure should be made with the card. If private expenditure items are incurred in error these should be settled immediately. An investigation and detailed explanation should be provided on these occasions to the Chief Finance Officer or the Head of Finance.

All business expenses are to be contained within the Clinical Commissioning Group’s travel and subsistence budget levels and scheme of reservation and delegation limits. Any expenses incurred above this value will be reported to the Audit Committee as a breach of clinical commissioning group policies unless prior authorisation has been obtained to exceed the stated limits.

The purchasing card can only be used for hospitality in accordance with clinical 4.2.commissioning group policy. Where it is deemed economically viable, in emergency situations, or to make purchases for the benefit of patients / service users. Such items will still need to comply with health and safety requirements and the relevant procurement law for the NHS at the time of purchase. It should be remembered that the card is allocated to a specific card holder (named) and all expenditure detail can be requested under freedom of information requirements, so careful consideration needs to be made to any expenditure made.

5. RECONCILIATION AND AUTHORISATION Reconciliations between the purchasing card control account and the statements 5.1.

received from the card supplier are completed on a monthly basis. A log of purchases made is held by Finance.

Whistle Blowing Policy (Freedom to Speak Up)

To be read in conjunction with the following CCG policies and documents: Clinical Commissioning Group Constitution F02 Gifts and Hospitality Policy F04 Conflicts of Interest Policy F06 Fraud Bribery and Corruption Policy F08 Joint LCFS and HR working protocol for Parallel Criminal and Disciplinary Investigations HR10 Disciplinary Policy and Procedure HR17 Dignity at Work (Bullying and Harassment) Policy HR34 Individual Grievance Policy ITG06 Confidentiality Staff Code of Conduct QS03 Reporting and Managing Incidents and Serious Incidents Policy

Page 2 of 14

Document Details

Title Whistleblowing Policy (Freedom to Speak Up)

Ref No G07

Document objective This ‘standard integrated policy’ is one of a number of recommendations of the review by Sir Robert Francis into whistleblowing in the NHS, aimed at improving the experience of whistleblowing in the NHS.




Approval process

Reviewed by Governance Committee

Date of review 28 October 2016


Date of approval Jan meeting

Equality Impact Assessment There are no negative impacts of this policy on people with protected characteristics

Category Governance

Review date [usually 1 or 2 years after final approval]

Amendments History

Version number


0.1 September 2016 Policy drafted following issue of national template


Page 3 of 14

Contents

Section No.

Section title Page

1. Staff Quick Reference Guide 4

2. Raising a Concern 5

3. CCG Contacts and Support Services 9

4. Taking Concerns Outside the CCG 10

5. Monitoring And Review 11

Appendix 1: Process for Raising a Concern 12

Appendix 2: A Vision for Raising Concerns in the NHS 14

Page 4 of 14

1. STAFF QUICK REFERENCE GUIDE

1.1 Speaking up about any concern CCG staff have at work is important. In fact, it

is vital because it will help the CCG to keep improving services for all patients and the working environment for staff.

1.2 Staff may feel worried about raising a concern, but shouldn’t be put off. In

accordance with the duty of candour, CCG senior managers and the governing body are committed to an open and honest culture. The CCG will investigate what staff say and staff will have access to any support needed. Staff raising legitimate concerns are protected by the Public Interest Disclosure Act 1998.

1.3 This ‘standard integrated policy’ is one of a number of recommendations of the review by Sir Robert Francis into whistleblowing in the NHS, aimed at improving the experience of whistleblowing in the NHS. It is expected that this policy (produced by NHS Improvement and NHS England) will be adopted by all NHS organisations in England as a minimum standard to help to normalise the raising of concerns for the benefit of all patients.

1.4 Key contacts for staff are:

Fraud: CCG Chief Finance Officer Alan Beasley Tel: 01273 403657 Email: [email protected]

NHS Counter Fraud Manager Chris Lovegrove Tel: 07879 434976 or 01424 776750. Email: [email protected]

Freedom to Speak Up Guardian Denise Matthams Email: [email protected]

Head of Corporate Services Sue Pumphrey Tel: 01273 403662 Email: [email protected]

Executive director with responsibility for whistleblowing

Name. Wendy Carberry Tel: 01273 403538 Email: [email protected]

Non-executive director with responsibility for whistleblowing

Lay Member (Governance) and Audit Chair: Peter Douglas Email: [email protected]

CCG Caldicott Guardian Dr Sarah Richards Email: [email protected]








Page 5 of 14

1.5 CCG local processes have been integrated into this policy, adhere to the principles of this policy and provide more detail about how the CCG will look into a concern.

1.6 Any person who victimises someone who has raised genuine concerns under this policy will be subject to disciplinary action.

1.7 However, abuse of the process through the raising of unfounded malicious allegations will also be regarded as a disciplinary matter.

1.8 There are several sources of advice and information available to staff who are unsure whether or how to raise a concern, see sections 3 and 4 of this policy.

2. RAISING A CONCERN

2.1 What concerns can be raised?

A concern can be raised about any risk, malpractice, fraud or wrongdoing in the CCG or that is harming the service(s) the CCG commissions. Examples of this include:

Unsafe patient care.

Unsafe working conditions.

Inadequate induction or training for staff.

Lack of, or poor, response to a reported patient safety incident.

Suspicions of fraud bribery or corruption (which staff can also report direct to the local counter-fraud team).

A bullying culture (across a team or organisation rather than individual instances of bullying).

For further examples, please see the Health Education England video at wbhelpline.org.uk/new-video-for-staff-who-work-in-healthcare/

2.2 Remember that a healthcare professional may have a professional duty to

report a concern. If in doubt, please raise it. 2.3 Don’t wait for proof. The CCG would like the matter raised while it is still a

concern. It doesn’t matter if it turns out to be a mistake as long as it was a genuine concern.

2.4 This policy is not for staff with concerns about employment issues that affect

only them. That type of concern is better suited to the CCG grievance policy. Please see HR34 Individual Grievance Policy.

http://wbhelpline.org.uk/new-video-for-staff-who-work-in-healthcare/

Page 6 of 14

2.5 Feel Safe to Raise Your Concern. If a member of staff raises a genuine concern under this policy, there is no risk of them losing their job or suffering any form of reprisal as a result. Staff raising legitimate concerns are protected by the Public Interest Disclosure Act 1998. The CCG will not tolerate the harassment or victimisation of anyone raising a concern. Nor will the CCG tolerate any attempt to bully staff into not raising a concern. Any such behaviour is a breach of CCG values as an organisation and, if upheld following investigation, could result in disciplinary action.

2.6 Provided staff act honestly, it does not matter if they are mistaken or if there is an innocent explanation for their concerns.

2.7 Any person who victimises someone who has raised genuine concerns under

this policy will be subject to disciplinary action.

2.8 However, abuse of the process through the raising of unfounded malicious allegations will also be regarded as a disciplinary matter.

2.9 Confidentiality

The CCG hopes staff will feel comfortable raising concerns openly, but also appreciates that they may want to raise it confidentially. This means that while staff are willing for their identity to be known to the person they reported their concern to, they do not want anyone else to know their identity. Therefore, the CCG will keep identity confidential, if that is what is wanted, unless required to disclose it by law (for example, by the police).

2.10 Staff can choose to raise their concern anonymously, without giving anyone their name, but this may make it more difficult for the CCG to investigate thoroughly and give feedback on the outcome.

2.11 Who can raise concerns?

Anyone who works (or has worked) in the NHS or for an independent organisation that provides NHS services can raise concerns. This includes agency workers, temporary workers, students, volunteers and governors.

2.12 Who should staff raise concerns with?

In many circumstances the easiest way to get a concern resolved will be to raise it formally or informally with your Line Manager. See Appendix A for the difference between raising a concern formally and informally and more details on the process of a concern.

2.13 Where staff do not think it is appropriate to do this, they can use any of the

options set out below.

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2.14 If raising it with your Line Manager does not resolve matters, or a member of

staff does not feel able to raise it with them, they can contact one of the following people:

The Freedom to Speak Up Guardian. This is an important role identified in the Freedom to Speak Up review to act as an independent and impartial source of advice to staff at any stage of raising a concern, with access to anyone in the organisation, including the chief officer, or if necessary, outside the organisation. The Guardian for the CCG is Denise Matthams, [email protected].

The Head of Corporate Services: Sue Pumphrey, [email protected], 01273 403662.

For issues related to Fraud Bribery or Corruption, your Local Counter Fraud Officer: Chris Lovegrove, 07879 434976 or 01424 776750 or [email protected].

2.15 If staff still remain concerned after this, they can contact:

The executive director with responsibility for whistleblowing; Wendy Carberry, [email protected].

The non-executive director with responsibility for whistleblowing; Peter Douglas [email protected].

2.16 All these people have been trained in receiving concerns and will give

information about where staff can go for more support. 2.17 If for any reason staff do not feel comfortable raising their concerns internally,

they can raise concerns with external bodies, see section 4 below.

2.18 What will we do? The CCG is committed to the principles of the Freedom to Speak Up review and its vision for raising concerns, and will respond in line with them. See Appendix B for the vision for raising concerns in the NHS.

2.19 The CCG is committed to listening to staff, learning lessons and improving patient care. On receipt, the concern will be recorded and the member of staff will receive an acknowledgement within two working days. The central record will record the date the concern was received, whether confidentiality was requested, a summary of the concerns and dates when updates or feedback were given.

2.20 Investigation. Where staff have been unable to resolve the matter quickly (usually within a few days) with their Line Manager, the CCG will carry out a proportionate investigation – using someone suitably independent (usually from a different part of the organisation) and properly trained – and will reach a conclusion within a reasonable timescale (which staff will be notified of).





Page 8 of 14

2.21 Wherever possible, the CCG will carry out a single investigation. For example,

where a concern is raised about a patient safety incident, a single investigation will usually be undertaken that looks at the concern and the wider circumstances of the incident. If the concern suggests a Serious Incident has occurred, an investigation will be carried out in accordance with the CCG QS03 Reporting and Managing Incidents and Serious Incidents Policy.

2.22 The investigation will be objective and evidence-based, and will produce a report that focuses on identifying and rectifying any issues, and learning lessons to prevent problems recurring.

2.23 The CCG may decide that the concern would be better looked at under another process; for example, bullying and harassment. If so, this will be discussed with the member of staff.

2.24 Any employment issues that affect only the member of staff who raised the concern and not others identified during the investigation will be considered separately.

2.25 Communication. The CCG will treat staff with respect at all times and will thank them for raising their concern. The concern will be discussed with the member of staff to ensure the CCG understands exactly what they are worried about. The member of staff will be told how long the investigation is expected to take and be kept up to date with its progress. Wherever possible, the full investigation report will be shared with the member of staff while respecting the confidentiality of others.

2.26 How will we learn from the concern raised? The focus of the investigation will be on improving the service the CCG provides. Where it identifies improvements that can be made, they will be tracked to ensure necessary changes are made, and are working effectively. Lessons will be shared with teams across the organisation, or more widely, as appropriate.

2.27 Governing Body oversight.

The Governing Body will be given high level information about all concerns raised by staff through this policy and what is being done to address any problems. Similar high level information will be included in the annual report. The Governing Body supports staff raising concerns and wants them to feel free to speak up.

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3. CCG CONTACTS AND SUPPORT SERVICES

3.1 Concerns can be raised with any of the people listed below in person, by phone or in writing (including email).

3.2 Whichever route is chosen, please be ready to explain fully the information and circumstances that gave rise to the concern.

3.3 Fraud

The primary points of contact, if staff wish to raise any concerns or report any suspicions of fraud bribery or corruption are:

CCG Chief Finance Officer: Alan Beasley, [email protected], 01273 403657

Local NHS Counter Fraud Specialists are available to all CCG staff. They will receive information, or offer advice, about fraud bribery or corruption affecting the NHS: NHS Counter Fraud Manager – Chris Lovegrove. Tel: 07879 434976 or 01424 776750. Email: [email protected] By post at Tiaa Ltd, Regent House, Mitre Way, Station Approach, Battle, East Sussex TN33 0BQ NHS Counter Fraud Officer – Clive Leadley Tel: 07979 503198 or 01424 776750. Email: [email protected] NHS Counter Fraud Officer – Claire Friend Tel: 07768 888793 or 01323 417400 ext. 6254 Email: [email protected]

The NHS Fraud and Corruption Reporting Line is available on 0800 028 4060 (Monday to Friday 8am to 6pm). An online reporting form is available at: www.reportnhsfraud.nhs.uk. All calls or reports are confidential, dealt with by trained staff, and will be professionally investigated.

3.4 Caldicott Guardian

The CCG Caldicott Guardian is ultimately responsible for safeguarding patient information:

Dr Sarah Richards, [email protected]

3.5 Counselling in Confidence The CCG offers an Employee Assistance Programme Counselling in Confidence (CiC). CiC is available to both employees and family members. It is an independent, free and confidential advice service available 24/7/365. Call: 0800 085 1376 or 0207 938 0963. Email: [email protected]. Website: www.well-online.co.uk. Text Relay (for people with hearing or speech impairments): 18001 0800 085 1376.





http://www.reportnhsfraud.nhs.uk/



http://www.well-online.co.uk/

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3.6 Occupational Health

Employees may also self-refer to the Occupational Health Department. Call: 01227 864206. Email: [email protected]

4. TAKING CONCERNS OUTSIDE THE CCG

4.1 There may be occasions when staff, having reported serious concerns, will

feel that these have not adequately been dealt with by the CCG and that they have no alternative but to take them further. There may also be occasions when concerns are about actions of the Governing Body or CCG Chair and staff will feel unable to raise them within the CCG.

4.2 Employees have an implied duty of confidentiality and loyalty to their

employer. Making allegations to a third party can breach this duty. Staff are therefore advised to consult representatives from their professional association or trade union before taking the matter further.

4.3 There are very specific criteria that need to be met for an individual to be covered by whistleblowing law when they raise a concern (to be able to claim the protection that accompanies it). There is also a defined list of “prescribed persons”, similar to the list of outside bodies below at 4.5, who staff can make a protected disclosure to under the Public Interest Disclosure Act 1998.

4.4 To help staff consider whether they might meet these criteria, independent advice should be sought from the Whistleblowing Helpline, Public Concern at Work (see below) or a legal representative.

4.5 The new National Guardian (once fully operational) can independently review how staff have been treated having raised concerns where NHS trusts and foundation trusts may have failed to follow good practice, working with some of the bodies listed below to take action where needed. www.cqc.org.uk/content/national-guardians-office

Care Quality Commission. www.cqc.org.uk/

General Medical Council. www.gmc-uk.org/ www.gmc-uk.org/DC5900_Whistleblowing_guidance.pdf_57107304.pdf

Health Education England. www.hee.nhs.uk

NHS Improvement. improvement.nhs.uk/

NHS Protect. www.nhsbsa.nhs.uk/Protect.aspx

Nursing and Midwifery Council. www.nmc.org.uk/ www.nmc.org.uk/concerns-nurses-midwives/


http://www.cqc.org.uk/content/national-guardians-office

http://www.cqc.org.uk/

http://www.gmc-uk.org/

http://www.gmc-uk.org/DC5900_Whistleblowing_guidance.pdf_57107304.pdf

http://www.hee.nhs.uk/


http://www.nhsbsa.nhs.uk/Protect.aspx

https://www.nmc.org.uk/

https://www.nmc.org.uk/concerns-nurses-midwives/

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Public Concern at Work – the Whistleblowing Charity. Tel: 020 74046609 www.pcaw.co.uk/

Whistleblowing Helpline – free advice for the NHS and Social Care. Tel: 08000 724725 wbhelpline.org.uk/ wbhelpline.org.uk/resources/raising-concerns-at-work/

5. MONITORING AND REVIEW 5.1 This policy will be reviewed annually. Where review is necessary due to

legislative change, this will happen immediately.

5.2 The implementation of this policy will be audited on an annual basis, or when changes in legislation dictate

5.3 An Equality Analysis Impact Assessment has been carried out on this policy.

As a result, there is no anticipated detrimental impact on any equality group. 5.4 The policy adheres to the NHS LA Standards, AFC Terms and Conditions, is

legally compliant and takes account of best practice. 5.5 It makes all reasonable provision to ensure equity of access to all staff. There

are no statements, conditions or requirements that disadvantage any particular group of people with a protected characteristic as defined by the Equality Act (2010); age, disability, gender, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief and sexual orientation, in addition to offending background, trade union membership, or any other personal characteristic.

http://www.pcaw.co.uk/

http://wbhelpline.org.uk/

http://wbhelpline.org.uk/resources/raising-concerns-at-work/

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Appendix 1: Process for Raising a Concern

Step one If staff have a concern about a risk, malpractice or wrongdoing at work, we hope you will feel able to raise it first with your Line Manager. This may be done orally or in writing. If the concern is about Fraud Bribery or Corruption this can be raised directly with the CCG Chief Finance Officer, or any of the CCG’s Local NHS Counter Fraud Specialists. Step two If staff feel unable to raise the matter with their Line Manager, for whatever reason, please raise the matter with:

The local Freedom to Speak Up Guardian Denise Matthams, [email protected]

This person has been given special responsibility and training in dealing with whistleblowing concerns. They will:

Treat your concern confidentially unless otherwise agreed.

Ensure you receive timely support to progress your concern.

Escalate to the Governing Body any indications that you are being subjected to detriment for raising your concern.

Remind the organisation of the need to give you timely feedback on how your concern is being dealt with.

Ensure you have access to personal support since raising your concern may be stressful.

If you want to raise the matter in confidence, please say so at the outset so that appropriate arrangements can be made. You can also raise a concern with Sue Pumphrey, [email protected] Step three If these channels have been followed and you still have concerns, or if you feel that the matter is so serious that you cannot discuss it with any of the above, please contact:

Executive director with responsibility for whistleblowing

Name. Wendy Carberry Tel: 01273 403538

Non-executive director with responsibility for whistleblowing

Lay Member (Governance) and Audit Chair: Peter Douglas Email: [email protected]

CCG Caldicott Guardian Dr Sarah Richards Email: [email protected]



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Step four You can raise concerns formally with external bodies. The new National Guardian (once fully operational) can independently review how staff have been treated having raised concerns where NHS trusts and foundation trusts may have failed to follow good practice, working with some of the bodies listed below to take action where needed. www.cqc.org.uk/content/national-guardians-office

Care Quality Commission. www.cqc.org.uk/

General Medical Council. www.gmc-uk.org/ www.gmc-uk.org/DC5900_Whistleblowing_guidance.pdf_57107304.pdf

Health Education England. hee.nhs.uk/

NHS Improvement. improvement.nhs.uk/

NHS Protect (Whistleblowing or concerns about Fraud). www.nhsbsa.nhs.uk/Protect.aspx

Nursing and Midwifery Council. www.nmc.org.uk/ www.nmc.org.uk/concerns-nurses-midwives/

Public Concern at Work – the Whistleblowing Charity. Tel: 020 74046609 www.pcaw.co.uk/

Whistleblowing Helpline – free advice for the NHS and Social Care. Tel: 08000 724725 wbhelpline.org.uk/

http://www.cqc.org.uk/content/national-guardians-office

http://www.cqc.org.uk/

http://www.gmc-uk.org/

http://www.gmc-uk.org/DC5900_Whistleblowing_guidance.pdf_57107304.pdf

https://hee.nhs.uk/


http://www.nhsbsa.nhs.uk/Protect.aspx

https://www.nmc.org.uk/

https://www.nmc.org.uk/concerns-nurses-midwives/

http://www.pcaw.co.uk/

http://wbhelpline.org.uk/

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Appendix 2: A Vision for Raising Concerns in the NHS

Source: Sir Robert Francis QC (2015) Freedom to Speak Up: an independent report into creating an open and honest reporting culture in the NHS. webarchive.nationalarchives.gov.uk/20150218150343/https:/freedomtospeakup.org.uk/

http://webarchive.nationalarchives.gov.uk/20150218150343/https:/freedomtospeakup.org.uk/

SOCIAL MEDIA POLICY



IG10 Email and Internet Acceptable Use Policy

IG11 IG Training Needs Assessment

Document Details

Title Social Media Policy

Ref No IG13

Document objective - To develop understanding about how social media can be used effectively to contribute to CCG work

- To help staff participate online in a respectful, professional and meaningful way that protects the CCG image and reputation, whether they are using social media for approved CCG purposes or on a personal basis.



Author Information Governance Manager

Approval process

Reviewed by Information Governance Sub-Committee/Governance Committee



Date of approval

Equality Impact Assessment There are no negative impacts of this policy on people with protected characteristics (amend accordingly)

Category Information Governance

Review date January 2019

Version History

Version number


1.0 October 2016 Created Information Governance Manager

1.1 January 2017 Amendments made following review by Governance Committee

Information Governance Manager

Contents

Section No.

Section title Page

1. Introduction ...................................................................................................................................4 3

2. Purpose ........................................................................................................................................4 3

3. Definitions .....................................................................................................................................4 3

4. Responsibilities .............................................................................................................................4 3

5. Social media in your personal life .................................................................................................5 3

6. Business Use ................................................................................................................................6 4

7. Line Manager Guidance ...............................................................................................................6 5

8. Training requirements ...................................................................................................................6 5

9. Monitoring…………………………………………………………………

5

Appendix 1: Business consultation to support the use of Social Media 6

1. INTRODUCTION

The world of communication is changing and the CCG aims to be a dynamic organisation embracing new technologies and ways of working. The rise of social media is changing the way we, and every organisation in the world conducts its business. Millions of people use social media everyday responsibly and it is becoming an increasingly important communications tool.

2. PURPOSE

The purpose of the policy is to:

Understand how social media can be used effectively to contribute to CCG work

Help staff participate online in a respectful, professional and meaningful way that protects the CCG image and reputation, whether they are using social media for approved CCG purposes or on a personal basis.

We are seeing the boundary between work and private life becoming blurred on social websites. Employees may not appreciate the implications that their activity can amount to misconduct and employers will need to take disciplinary action for that misconduct. There are two general types of misconduct: inappropriate behaviour exposed by social media and inappropriate comments made on social media.

3. DEFINITIONS

Examples of social medial platforms:

Microblogging – for example, Twitter

Blogging – for example, WordPress and Tumblr

Photo/Video sharing – for example, Flickr and Instagram

Social Bookmarking – for example, Reddit and StumbleUpon

Social sharing – for example, Facebook

Professional sharing – for example, Linkedin 4. RESPONSIBILITIES

It is the responsibility of everyone within the organisation to use social media responsibly. Whenever employees engage with social media and post information about their work or employer it is highly likely that the information will be circulated to a wide audience. Although members of staff are not acting on behalf of the organisation in a formal capacity when engaging with social media in their personal lives they must be mindful that depending on the content their online posts could potentially be damaging to the CCG if they are inaccurate or flippant.

5. SOCIAL MEDIA IN YOUR PERSONAL LIFE

The CCG recognises that many employees make use of social media in a personal capacity. While they are not acting on behalf of the organisation, employees must be aware they can damage the organisation if they are recognised as being one of our employees. Any staff who choose to identify themselves as NHS or CCG staff members as part of their social media profiles MUST ensure that their profile carries the following disclaimer: “The postings on this site are my own opinion and don’t necessarily represent NHS or CCG policy or opinion”. Staff who do not identify themselves as NHS or CCG staff members on their profile do not need to use the disclaimer. Any communication that employees make in a personal capacity through social media must not:

Bring the CCG into disrepute, for example by o criticising or arguing with customers, colleagues or rivals; o making defamatory comments about individuals; o linking to inappropriate content; o expressing political bias.

Breach confidentiality, for example by o revealing information owned by the organisation; o giving away confidential information about an individual (such as a colleague

or customer contact). o discussing the CCG’s internal workings or its future business plans that have

not been communicated to the public. o sharing photographs of patients or the public without consent o discussing colleagues or patients, even if identities have been removed.

Breach copyright, for example by; o using someone else’s images or written content without permission; o failing to give acknowledgement where permission has been given to

reproduce something.

Do anything that could be considered discrimination against, or bullying or harassment of any individual, for example by,

o making offensive or derogatory comments relating to sex, gender reassignment, race (including nationality), disability, sexual orientation, religion/belief or age;

o posting images that are discriminatory or offensive (or links to such content). Incidents of any of the above which take place via social media will be managed in line with CCG Disciplinary Policy by the HR team. If staff are unsure about anything they are intending to do within their personal social media use, and whether it may contravene any of the above, they should first discuss this with a member of Executive Management Team (EMT).

As per the guidelines within the Email and Internet Acceptable Use Policy (IG10), staff are prohibited from accessing social networking sites for personal use within working hours/using CCG equipment. The only exception to this is where access to such sites is required for business purposes (see below). 6. BUSINESS USE

Only the Communications Team can conduct campaigns on social media, as it has responsibility for external communications.

Written permission should be requested from the CCG Communications team before developing a CCG project presence in any form of social media.

The request must describe which social media is involved, the nature of the CCG project presence, the purpose of the presence, a risk analysis, how the presence is to be resourced and managed, how the information on the social media site will be stored for FOI purposes and finally an exit strategy.

A copy of the business case must be submitted at the same time to the Communications Department for comment.

You must respect copyright, fair use and financial disclosure rules.

You must have methods (e.g. excel, CSV, XML, HTML or PDF format) or a plan in place to capture the content of any external social media you use so that it can be held on High Weald Lewes Havens CCG systems as part of an information governance audit trail. This should form part of the project exit plan.

7. LINE MANAGER GUIDANCE

Under this policy, managers should be clear on the social media participation for any project and that individual staff members should be identified for managing the agreed social media for the project once appropriate approvals have been received. Managers requiring guidance should contact the Communications Department. Managers should bear in mind concerns about impartiality, confidentiality, conflicts of interest or commercial sensitivity.

8. TRAINING REQUIREMENTS

All staff should undertake annual mandatory information governance training, constituting 2 modules available on the IG Training Tool: Introduction to Information Governance (or refresher) and Secure Transfers of Personal Data. For more information please refer to the CCGs Information Governance Training Needs Assessment policy.

9. MONITORING

This policy will be monitored by the Information Governance Sub-committee with HR Support where required.

APPENDIX 1 - BUSINESS CONSULTATION TO SUPPORT THE USE OF SOCIAL MEDIA

Does this use of social media fit with your team’s business needs?

Is it part of your wider communications strategy?

Is it technically feasible? Have you discussed the proposed use with the IT service/ Communications team?

Have you considered if a Privacy Impact Assessment is needed? If not sure, contact the IG Manager for advice

Is there clear governance in place over significant new content and participation?

Have you identified sufficient resource to maintain the site over the long term e.g. responding to questions/comments or moderating a forum? Have you discussed the resource requirements with the IT service/ Communications team?

How are you going to evaluate the success of the proposed channel?

Does it meet CCG branding and style guidelines?

Are there clear terms and conditions?

Are there clear user rules?

Have you considered your exit strategy should you no longer wish to maintain your social media platform?

Complaints Policy This policy should be read in conjunction with the following policies:

G02 Risk Management Strategy G01 Risk Management Policy and Procedures HR10 Disciplinary Policy and Procedure HR17 Dignity at Work (Harassment and Bullying) Policy HS04 Managing Violence at Work Policy IG02 Information Governance Policy IG03 Information Security Policy IG04 Records Management Policy IG05 Data Protection and Confidentiality Policy QS03 Reporting and Managing Incidents and Serious Incidents

1

Document Details

Title Complaints Policy

Ref No G03

Document objective To outline the principles and the process for handling complaints to the CCG from patients, carers, and the general public.

Audience All CCG staff and officers (including temporary and seconded

staff, and contractors)


Dissemination All policies will be published on the intranet and the CCG

website, in the staff newsletter and staff induction pack.

Approval process









Version Control

Version

number


1.0 Nov 2012 Approved by Governing Body

1.1 Sept 2016 Reviewed and updated prior to CCG taking over handling complaints


1.1 28 Oct 2016 Reviewed by Governance Committee

2

Contents – example

Section No.

Section title Page

1. Purpose and Scope …………………………………………………………………………………………. 3

2. Policy Statement …………………………………………………………………………………………….. 3

3. Definition of a Complaint ……………………………………………………………………………….. 4

4. General Principles in Complaints Handling ...…………………………………………………… 4

5. National and Legislative Context for this Policy……………………………………………….. 4

6. Responsibility For Complaints Arrangements………………………………………………….. 5

7. Persons Who May Make Complaints to the CCG……………………………………………… 5

8. Complaints Not Included Within This Policy…………………………………………………….. 7

9. Duty to Co-operate…………………………………………………………………………………………… 7

10. Time Limit For Making A Complaint………………………………………………………………….. 8

11. Procedure Before Investigation………………………………………………………………………… 8

12. Investigation and Response……………………………………………………………………………… 8

13. Responding To A Complaint…………………………………………………………………………….. 10

14. Concluding Local Resolution…………………………………………………………………………….. 11

15. Learning From Complaints………………………………………………………………………………… 11

16. Electronic Communication……………………………………………………………………………….. 11

17. Monitoring……………………………………………………………………………………………………….. 12

18. Annual Report…………………………………………………………………………………………………… 12

19. Confidentiality………………………………………………………………………………………………….. 13

20 Mediation…………………………………………………………………………………………………………. 13

21. Publicity…………………………………………………………………………………………………………….. 14

22. Training…………………………………………………………………………………………………………… 15

23. Pals and Healthwatch………………………………………………………………………………………… 15

3

24. The Role of the Parliamentary and Health Service Ombudsman……………………… 15

25. Role Of seAp Advocacy And Other Patient Advocates………………………………………. 16

26. Complaints Regarding CCG Contractors……………………………………………………………. 17

27. Complaints and Disciplinary Procedures…………………………………………………............ 17

28. Staff Support……………………………………………………………………………………………………… 17

29. Getting Redress And Remedy When a Complaint Is Upheld………………………………. 18

30. Legal Action during or following a Complaint…………………………………………………….. 18

31. Withdrawal of a Complaint……………………………………………………………………………….. 18

32. Dealing with Abuse and Assault of CCG staff as a result of a Complaint…………….. 18

33. Complaining whilst Appealing against a CCG Decision……………………………………….. 19

34. Complaints reported in the News Media…………………………………………………………… 19

35. Ensuring Human Rights, Equity and Fairness for Complainants………………………… 19

36. Habitual Complaints………………………………………………………………………………………….. 20

37. Communication with Stakeholders……………………………………………………………………. 20

38. Approval……………………………………………………………………………………………………………. 20

39. Ratification Process…………………………………………………………………………………………… 20

40. Review……………………………………………………………………………………………………………….. 21

41. Dissemination and Implementation…………………………………………………………………… 21

42. Monitoring Compliance and Effectiveness…………………………………………………………. 21

Appendix 1: Investigation Report Checklist

Appendix 2: Action Plan and Lessons Learnt Form

Appendix 3: Equalities Monitoring Form

Appendix 4: Policy for Identifying and managing Habitual Complaints or Vexatious Individuals

Appendix 5: Complaints Management-Process Map

Appendix 6: Grading Matrix

4

1. PURPOSE AND SCOPE OF THIS POLICY This policy is designed to outline the principles to be adhered to during the process for handling complaints generated by patients, carers, and the general public. The policy also outlines the way in which we will work to resolve complaints. This policy applies to High Weald Lewes Havens CCG. All staff of the CCG and its agents are responsible for co-operating with the development and implementation of the Complaints Policy as part of their normal duties and responsibilities. Temporary and Agency staff, Contractors and Subcontractors will be expected to comply with the requirements of the CCG’s Complaints Policy. It also has implications for other NHS Trusts, independent providers and social care all of which have a responsibility to have a complaints policy in place in line with national requirements. The CCG has a duty to ensure that information about the CCG’s complaints processes are available to patients and the public. 2. POLICY STATEMENT 2.1 The CCG is committed to providing an accessible, equitable and effective

means for people (and/or their representative) to express their views about the services the CCG provides or is responsible for commissioning. If a person is unhappy about any matter reasonably connected with the exercise of the CCG’s functions they are entitled to make a complaint, have it considered, and receive a response from the CCG. We aim to provide a complaints process which has easy access and is supportive and open, which results in a speedy, fair and, where possible, local resolution. The purpose of local resolution is to provide an opportunity for the complainant and the CCG to achieve a prompt and fair resolution to the complaint and to provide the opportunity to put things right for complainants as well as improving services as a result of feedback.

2.2 The CCG aims to promote a culture which fosters openness and

transparency for the benefit of all stakeholders, including staff and in which all forms of feedback are listened to and acted upon. It is recognised that such information is invaluable as a means of identifying problems and issues and also areas of good practice and, as such, can be used as a means of improving services. The CCG recognises complaints as being a valuable tool for improving the quality of health services.

2.3 Members of staff at the CCG and its agents will work closely with

complainants to find an early resolution to complaints and every opportunity should be taken to resolve complaints as close to the source as possible, through discussion and negotiation. Local procedures should be conciliatory and should encourage communication on all sides. Where

5

possible, complaints should be dealt with immediately but where this is not possible, local resolution should be completed as soon as practicable.

3. DEFINITION OF A COMPLAINT A complaint is defined as an expression of dissatisfaction (written or verbal) about a function, decision or service the CCG has commissioned or purchased from another organisation which requires a response. 4. GENERAL PRINCIPLES IN COMPLAINTS HANDLING In general, the CCG, its staff and agents will ensure that:

Complaints are investigated in an open and efficient way within the shortest possible timescale

Confidentiality is maintained at all times

As many complaints as possible will be resolved quickly through an immediate response or through subsequent investigation and conciliation by the procedure of ‘local resolution’. Local resolution is the process by which we will aim to ensure we have undertaken all possible steps to resolve a complaint. Local resolution should be open, honest, fair, flexible and conciliatory

In the interests of safety and quality, any lessons learnt through the complaints process will be identified and changes will be brought into practice

The principles of ‘fair blame’ are followed. In line with the CCG's open, positive, non-punitive culture, constructive criticism is actively encouraged. These principles do not, however, negate the right of the CCG to pursue disciplinary or legal action against individuals where malicious, criminal, repeated or gross misconduct is involved

Complaints management and investigation processes follow the principles of Root Cause Analysis

Patients are always assured that making a complaint will in no way affect their eligibility for, or the nature of, current or future treatment. This is achieved through the complete separation of complaint documentation from the patient’s medical records

5. NATIONAL & LEGISLATIVE CONTEXT FOR THIS POLICY

The CCG Complaints Policy is written in accordance with The National Health Service (Complaints) Regulations 20091 which came into force on 1st April 2009 and follows the proposals for reform in the Department of Health’s consultation

1 The National Health Service (Complaints) Regulations 2009. Available at

http://www.dh.gov.uk/en/Managingyourorganisation/Legalandcontractual/Complaintspolicy/nhscomplaintsprocedure/index.htm

6

document, “Making Experiences Count” published in March 2007. It also takes account of guidance by the Department of Health contained within ‘Listening, Responding, Improving – a guide to better customer care’ 2and the Ombudsman’s ‘Principles of Good Complaint Handling’3 6. RESPONSIBILITY FOR COMPLAINTS ARRANGEMENTS Under the regulations, the CCG’s Chief Officer is designated as the ‘responsible person’ for ensuring compliance with the regulations and in particular for ensuring that any action is taken if necessary in the light of the outcome of the complaint. A person designated as ‘Complaints Officer’ or ‘Manager’ will be responsible for managing the procedures for handling and considering complaints in accordance with the regulations. This person may be an employee of the CCG or an employee of an agency appointed by the CCG to manage complaints. 7. PERSONS WHO MAY MAKE COMPLAINTS TO THE CCG 7.1 What can people complain about? Complaints can be made about any NHS service provided or commissioned by the CCG on behalf of the population served including:

CCG Commissioning decisions – this covers all the decisions the CCG makes about where and how it will purchase health and social care services from NHS, private/independent and community and voluntary sector providers. Complaints could be about a wide ranging decision taken on behalf of the whole population or as specific as about a decision the CCG took about an individual patient’s care.

CCG Appeals process – this covers the process by which a patient or their representative can ask for an appeals panel to consider issues they have about a CCG commissioning or funding decision. In cases regarding funding requests to the CCG Individual Review Panel or Continuing Health Care Panel, a complaint can be made about the appeals panel process but not the decision. An appeal against a funding decision must go through the appropriate appeal process.

CCG Staff – this covers any situation where a patient, carer, member of the public or organisation experiences poor service from a member of the CCGs staff.

2 Listening, Responding, Improving – a guide to better customer care. Available at

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH_095408 3 The Ombudsman’s ‘Principles of Good Complaint Handling’. Available at

http://www.ombudsman.org.uk/improving_services/principles/complaint_handling/principles_good_complaint_handling.html

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7.2 Who can complain? A person who wishes to raise a complaint is known as a ‘complainant’. A

complaint can be made by:

Someone who has received or is receiving a service from the CCG

A patient or person affected or likely to be affected by the actions, omissions or decisions of the CCG

Carers and other representatives of NHS Patients as long as they can demonstrate they have the permission of the person concerned or legal status to do so (A Member of Parliament or other elected representative such as a County Councillor may not require the written consent of his or her constituent in order to make a complaint or enquiry on their behalf although in exceptional circumstances the patient should be informed regarding the disclosure of information to their MP. 4)

A person raising a complaint on behalf of a child as long as they can demonstrate they have the legal responsibility to do so

A person raising a complaint on behalf of a deceased person as long as they can demonstrate they have the legal responsibility to do so

A person raising a complaint on behalf of a person who is unable to make the complaint themselves because of a physical incapacity or who lacks capacity within the meaning of the Mental Capacity Act 2005. Proof will need to be provided of this

If the CCG employee or agent handling the complaint does not have assurance that the person claiming that they are representing the complainant/child/deceased is appropriate or is not acting in the best interests of the person on whose behalf they are complaining, then this must be put in writing to that person and the complaint must not be considered further until such time as assurance can be provided.

7.3 Where the CCG receives a complaint about services provided under

contract with the CCG, the details should be sent to the provider as soon as practicable. If the CCG considers it is more appropriate for the complaint to be dealt with by the provider, and the complainant consents, the CCG must notify the complainant and the provider, and the provider must handle the complaint. If, however, the CCG considers that it is more appropriate for the CCG to deal with the complaint, then it must notify the complainant and provider. The complaint will be forwarded with consent to the provider for initial investigation and response to the CCG. Before responding it may be appropriate to obtain clinical or contractual advice.

4 The Data Protection – Processing of sensitive Personal Data – Elected

Representatives. Order SI 2002/2905 http://www.legislation.hmso.gov.uk/si/si20022905.htm & http://www.parliament.uk/documents/documents/upload/snha-01936.pdf

http://www.legislation.hmso.gov.uk/si/si20022905.htm

http://www.parliament.uk/documents/documents/upload/snha-01936.pdf

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7.4 A person wishing to initiate a formal complaint can do so either orally or in

writing (including by telephone or email). The Complaints Officer should be notified immediately on receipt of a complaint.

8. COMPLAINTS NOT INCLUDED WITHIN THIS POLICY

8.1 The following complaints are excluded from the scope of the arrangements described within this policy:

A complaint relating to a service commissioned by NHS England (NHSE)

A complaint made by an NHS body, independent provider or local authority about any matter relating to arrangements made by the CCG with that provider

A complaint made by an employee about any matter relating to his/her contract of employment

A complaint which has previously been investigated and closed under these or previous regulations

A complaint which is being or has been investigated by the Parliamentary and Health Service Ombudsman (PHSO).

A complaint arising out of the CCG’s alleged failure to comply with a subject access request under the Data Protection Act 1998 or a request for information under the Freedom of Information Act 2000. In such circumstances an internal review adhering to the complaints management process will be led in line with the Freedom of Information Policy.

8.2 The CCG must notify complainants in writing if it decides not to consider

the complaint for any of the reasons outlined in 8.1 and the reason for the decision.

8.3 Complaints not falling within the scope of this policy may be raised with the

CCG through other means. Examples of these are staff grievances, disciplinary procedures and legal action etc. These are dealt with under separate policies.

9. DUTY TO CO-OPERATE Where the CCG is considering a complaint which is also about another one or more health or social care providers, all parties must co-operate in the handling of and in responding to the complaint. In particular, agreement should be reached on which organisation will take the lead and communicate with the complainant and they should be provided with all the relevant information needed to respond. Where the CCG is considering a complaint which partly relates to services commissioned by NHSE, the CCG and NHSE will co-operate to assign lead responsibility as above.

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10. TIME LIMIT FOR MAKING A COMPLAINT Complaints must be made within twelve months after the date on which the matter which is the subject of the complaint occurred or within twelve months of it coming to the notice of the complainant. The time limit will not apply if the Complaints Manager is satisfied that the complainant had good reason for not making the complaint within the time limit and it is still possible to investigate the complaint effectively and fairly. 11. PROCEDURE BEFORE INVESTIGATION

A complaint may be made orally, electronically or in writing

Complaints should be acknowledged in writing within three working days after the day on which they are received. If factors beyond the control of the CCG make acknowledgement within writing impossible within this timescale, it may acknowledge the complaint verbally. This is a statutory requirement.

The acknowledgement must contain an offer to discuss with the complainant the manner in which the complaint is to be handled and the likely timescales for the investigation and response

If the offer of a discussion is not accepted, the Complaints Officer must determine the response period and notify the complainant in writing.

12. INVESTIGATION AND RESPONSE 12.1 The Complaints Officer will arrange for the complaint to be investigated in

a manner appropriate to resolve it speedily and efficiently. The purpose of investigation is not only “resolution” but also to establish the facts, to learn, to detect poor practice where this is the case, and to improve services.

12.2 The investigation into a complaint must be undertaken by a suitable person

and the Complaints Officer should ensure an appropriate level of investigation. Investigations should be conducted in a manner that is supportive to all those involved, without bias and in an impartial and objective manner.

The investigation must not be adversarial and must uphold the principles

of fairness and consistency. The investigation process is best described as listening, learning and improving.

Investigators should be able to seek advice from the Complaints Officer/

senior person, wherever necessary, about the conduct or findings of the investigation. Whoever undertakes the investigation should seek to

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understand the nature of the complaint and identify any issues which may affect the investigation.

Complaints must be approached with an open mind, being fair to all

parties. The complainant and those identified as the subject of a complaint should be advised of the process, what will be investigated and what will not, those who will be involved, the roles they will play and the anticipated timescales. All those involved should be kept informed of progress throughout.

Where the complaint requires clinical assessment, for example where it

relates to clinical care, advice will be sought from the CCG’s relevant clinical lead.

12.3 The Complaints Officer will initially ensure that the complaint is made

within the appropriate time limits (see section 10) and from a person entitled to make the complaint (see section 7.2). The Complaints Officer will need to take the necessary action if one or both of these conditions have not been met in order that the complaint can be investigated.

12.4 The Complaints Officer will send an acknowledgement letter within three

working days of the receipt of the complaint. This letter must offer the complainant information about the Support Empower Advocate Promote Service (SEAP).

12.5 The Complaints Officer will identify the appropriate senior manager who

will be responsible for conducting an investigation into the issues raised within the complaint.

12.6 The investigator should use a range of investigating techniques that are

appropriate to the nature of the complaint, such as interviews, root cause analysis, and document reviews, and to the needs of the complainant. Those responsible for investigation will be able to choose the method that they feel is the most appropriate to the circumstances. (see Complaints and Compliments Guidelines for Staff – Appendix 2)

12.7 The investigator should establish the facts relating to the complaint and

assess the quality of the evidence. Depending on the subject matter and complexity of the investigation the investigator may wish to call upon the services of others. There are a number of options available to assist in the resolution of complaints. These should be considered in line with the assessment of the complaint and also in collaboration with the complainant and may include the involvement of:

Senior managers/professionals at an early stage

Mediators

Independent advocates

Independent experts

Lay persons

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12.8 The senior manager will ensure that a response is sent back to the

Complaints Officer within the timeframe set (normally 15 working days). The draft response should address all the issues raised by the complainant, should be written in a style of language that the complainant can easily understand, with any medical terminology and abbreviations avoided or, where appropriate, clearly explained. Where shortcomings have been identified, an apology should be made. In all instances the response should be sympathetic to the complainant and focus on resolving the concerns. Any actions that the CCG is planning to take or has taken as a result of the complaint should also be included in the response.

12.9 Where the complaint involves clinical/professional issues, the draft

response must be shared with the relevant clinicians/professionals to ensure the factual accuracy and to ensure clinicians/professionals agree with and support the draft response. (Appendix 6).

13. RESPONDING TO A COMPLAINT Where appropriate, alternative methods of responding to complaints must be considered whether through an immediate response from front-line staff, a meeting, or direct action by a senior person. It may be appropriate to conduct a meeting in complex cases, in cases where there is serious harm/death of a patient, in cases involving those whose first language is not English, or, for example in cases where the complainant has a learning disability or mental health illness. Where a meeting is held, it is more likely to be successful if the complainant knows what to expect and can offer some suggestions towards resolution. Complainants have a right to choose from whom they seek support and should be encouraged to bring a relative or friend to meetings. Where meetings do take place they should be recorded and that record shared with the complainant for comment. On completion of the investigation, a written response, signed by the Chief Officer (CO), will be sent, although the CO may delegate responsibility for responding to a complaint to a senior person. The Complaints Officer should ensure that the complainant and anyone who is a subject of the complaint understand the findings of the investigation and the recommendations made. (Appendix 3 – Lessons learnt form) The response should be clear, accurate, balanced, simple and easy to understand. It should avoid technical terms, but where these must be used to describe a situation, events or condition, an explanation of the term should be provided. (Appendix 2) The letter should:

offer an explanation of how the complaint has been considered

address the concerns expressed by the complainant and show that each element has been fully and fairly investigated

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report the conclusion reached including any matters which it is considered remedial action is needed

include an apology where things have gone wrong

report the action taken or proposed to prevent recurrence

indicate that a named member of staff is available to clarify any aspect of the letter

advise of the complainant’s right to take their complaint to the PHSO if they remain dissatisfied with the outcome of the complaints procedure

14. CONCLUDING LOCAL RESOLUTION 14.1 The CCG should offer every opportunity to resolve the complaint through

local resolution. Once the final response has been signed and issued, the Complaints Officer, on behalf of the CO should liaise with relevant local managers and staff to ensure that all necessary follow-up action has been taken. Arrangements should be made for any outcomes to be monitored to ensure that they are actioned. Where possible, the complainant and those named in the complaint should be informed of any change in system or practice that has resulted from their complaint. (Appendix 3 – Lessons learnt form)

14.2 All correspondence and evidence relating to the investigation should be

retained. The Complaints Officer should ensure that a complete record is kept of the handling and consideration of each complaint. Complaints records should be kept separate from health records, subject only to the need to record information which is strictly relevant to the complainant’s ongoing health needs.

15. LEARNING FROM COMPLAINTS Learning from complaints is used to improve service delivery and performance and to capture and review lessons learned from complaints so that they contribute to developing services 16. ELECTRONIC COMMUNICATION Any communication with the complainant can be sent electronically, provided the complainant has consented in writing or electronically. In such cases, it will be sufficient to sign the documents by typing the authors name or produce it using an electronic signature.

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17. MONITORING The Complaints Officer will be required to maintain a record of the following:

Each complaint received

The subject matter and outcome of each complaint

The agreed response timescales, any agreed amendments to those timescales and whether the CCG sent its response within the timescales

Equality and diversity monitoring

Complaints referred to ombudsman All complaints will be recorded on the CCG’s database and complaint files maintained for a period of not less than 10 years 18. ANNUAL REPORT The Complaints Manager will prepare an annual report for each financial year which must:

Specify the number of complaints received

Specify the number of complaints considered well-founded

Specify the number of complaints referred to the Parliamentary and Health Service Ombudsman

Summarise the subject matter of complaints

Any matter of general importance arising out of those complaints or the way in which they were handled

Specify any matters where remedial action or service improvement has taken place as a result of the complaints

This report should be available to any person on request and will also be available on the CCG website 19. CONFIDENTIALITY 19.1 All CCG staff should be aware of their legal and ethical duty to protect the

confidentiality of patient information. The legal requirements are set out in the Data Protection Act 1998 and the Human Rights Act 1998. The common law duty of confidence must also be observed. Ethical guidance is provided by the respective professional bodies.

19.2 It is not necessary to obtain the service user’s express consent to the use

of their personal information to investigate a complaint. Even so, it is good practice to explain to the service user that information from his/her health records may need to be disclosed to the people investigating the complaint, but only if they have a demonstrable need to know and for the

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purposes of investigating. If the complainant objects to this, it should be explained to him/her that this could compromise the investigation and his/her hopes of a satisfactory outcome to the complaint. The complainant’s wishes should always be respected, unless there is an overriding public interest in continuing with the matter.

19.3 The duty of confidence applies equally to third parties who have given

information or who are referred to in the patient’s records. Particular care must be taken where the patient’s records contain information provided in confidence, by, or about, a third party who is not a health professional. Only that information which is relevant to the complaint should be considered for disclosure and then only to those within the CCG who have a demonstrable need to know in connection with the complaint investigation. Third party information must not be disclosed to the complainant unless the person who provided the information has expressly consented to the disclosure. Disclosure of information provided by a third party outside the CCG also requires the express consent of the third party. If the third party objects, then it can only be disclosed where there is an overriding public interest in doing so.

20. MEDIATION 20.1 Mediation is a voluntary process available to both the complainant and

those named in the complaint. Either party may request mediation but both must agree to the process being used. The CCG must have access to suitably trained, competent and accredited mediators where this assistance is requested.

20.2 Mediation is a process of examining and reviewing a complaint with the

help of an independent person. The mediator will assist all concerned to a better understanding of how the complaint has arisen and prevent the complaint being taken further. He/she will work to ensure that good communication takes place between both parties involved to enable them to resolve the complaint.

20.3 All discussions and information provided during the process of mediation

are confidential. This allows staff to be open about the events leading to the complaint so that both parties can hear and understand each others’ point of view and ask questions. Using mediation does not affect the right of a complainant to pursue their complaint if they are not satisfied. The mediator should advise when mediation has ceased and whether a resolution was reached. No further details should be provided.

21. PUBLICITY 21.1 The CCG should ensure that the complaints process is well publicised

locally and it must make information available to the public on its arrangements for dealing with complaints and how further information can be obtained. This means that complainants should be made aware of:

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Their right to complain

All possible options for pursuing a complaint, and the types of help available (including advocacy and interpreters)

The support mechanisms that are in place

Their right to receive information in a suitable format to ensure they are not required to share it with others just to get it explained, wherever possible.

21.2 Information about services and what to expect, the various stages involved

in the complaints process, response targets and independent support and advice should be available. Clear lines of communication are required to ensure complainants know who to communicate with during the lifetime of their complaint. The provision of information will improve attitudes and communication by staff as well as support and advice for complainants

21.3 Information should:

Be visible, accessible and easily understood

Be available in other formats or languages as appropriate

Be provided free of charge

Outline the arrangements for handling complaints, how to contact complaints staff, the availability of support services, and what to do if the complainant remains dissatisfied with the outcome of the complaints process. It should also be clear that future treatment will not be adversely affected by making a complaint

22. TRAINING Relevant staff should be trained to deal with complaints as they occur. Appropriately trained staff will recognise the value of the complaints process and, as a result will welcome complaints as a source of learning. Staff have a responsibility to highlight training needs to their line managers. Line managers, in turn, have a responsibility to ensure needs are met to enable the individual to function effectively in their role and the CCG has a responsibility to create an environment where learning can take place. It is essential that staff recognise that their initial response can be crucial in establishing the confidence of the complainant. 23. PALS AND HEALTHWATCH If a patient, their families or carer have a concern which may form the basis of a complaint, the Patient Advice and Liaison Service (PALS) at the provider Trust can provide information and help. PALS can also act as the gateway to

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Independent Advice and Advocacy Support (ICAS) if a person wishes to make a formal complaint. Healthwatch East Sussex has a role in receiving feedback from patients and the public about services commissioned by the CCG. 24. The Role of the Parliamentary and Health Service Ombudsman The Ombudsman is completely independent of the NHS and of government and derives her powers from the Health Service Commissioners Act 1993. The role of the Health Service Commissioner (Ombudsman) includes the scrutiny of clinical and non-clinical complaints against GPs, NHS Dentists, NHS Opticians or Pharmacists, NHS Trusts and commissioners. The Ombudsman will normally only consider complaints once the local procedure has been exhausted. The Ombudsman is the final arbiter in the complaints process where it has not been possible to resolve concerns locally. The CCG provides information regarding how to request a review by the Ombudsman and will co-operate fully with any investigation undertaken by the Ombudsman’s officers. Further information on the role and work of the Ombudsman is available from:

The Parliamentary and Health Service Ombudsman Millbank Tower Millbank London, SW1P 4QP Tel: 0345 015 4033 e-mail: [email protected] website: www.ombudsman.org.uk

25. ROLE OF seAp ADVOCACY AND OTHER PATIENT ADVOCATES seAp has an important role in helping complainants at each stage of the process. The service is independent, free and confidential. The purpose of the service is to:

Advise people on how to complain

Support people through the formal complaints process

Provide information on who to complain to

Provide support with drafting complaints correspondence

Provide representation or support at complaint meetings.

Under the Mental Capacity Act 2005, in the event that a patient lacks capacity, and does not have an appropriate nearest relative to act on their behalf, an IMHA (Independent Mental Health Advocate) can be allocated through the IMCA (Independent Mental Capacity Advocate) service. Complainants may


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also receive support from specialist advocacy services or from the Citizens Advice Bureau. seAp can be contacted at:

seAp Hastings Upper Ground Floor Aquila House Breeds Place Hastings East Sussex TN34 3UY Tel: 0330 440 9000 Text: SEAP to 80800 Web: www.seap.org.uk

26. COMPLAINTS REGARDING CCG CONTRACTORS 26.1 The CCG will ensure, via contractual agreement, that all NHS providers

and any private providers with whom it has a Contract or Service Level Agreement have arrangements in place for handling complaints made about the services they provide which should follow the national statutory regulations.

26.2 CCG Managers responsible for commissioning and monitoring these

services via contractual agreements will ensure these contractors report regularly on the number and nature of complaints being received.

27. COMPLAINTS AND DISCIPLINARY PROCEDURES The Complaints procedure is concerned only with resolving complaints and not with investigating disciplinary matters. Whether disciplinary action is warranted is a separate matter for management, outside of the Complaints Procedure, and there must be a separate process of investigation. 28. STAFF SUPPORT 28.1 CCG staff who are being complained against are entitled to be supported

both professionally and personally through the supervision process. In some circumstances staff may suffer stress or be adversely affected due to the difficult or stressful nature of a complaint. If a member of staff feels that they are being adversely affected as a result of dealing with such a complaint, they should inform their line manager as soon as possible in order to engage appropriate support. This support may be offered at local level through discussion with colleagues and line managers, or at a wider level, via complaints staff, Human Resources and the Occupational Health Department.

http://www.seap.org.uk/

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28.2 The member of staff being complained about may also seek support from their union representative where appropriate.

29. GETTING REDRESS AND REMEDY WHEN A COMPLAINT IS UPHELD Redress and remedy following the upholding of a complaint will be appropriate and may include:-

An apology

An explanation

Remedial action

Reassessment of a need

Provision of a service

Change of procedure to prevent recurrence (the complainant should be advised)

Appealing to the Ombudsman and seeking a legal remedy are other options. The Health Service Ombudsman may conclude that the CCG should reimburse costs. If a legal route is pursued, the CCG’s Claims Policy will be followed

30. LEGAL ACTION DURING OR FOLLOWING A COMPLAINT 30.1 If the complainant explicitly states an intention to take legal action or

indicates that formal legal action has been initiated, the NHS complaints procedure should, normally, cease and the complainant and those complained against should be advised in writing. However, complaints can proceed if there are existing parallel investigations relating to the case such as disciplinary processes, police investigations or legal action not brought by the complainant, as long as it does not compromise or prejudice that other investigation.

30.2 If a complainant decides to take legal action after a complaint has been

deemed to have reached resolution by the NHS Ombudsman they have a right to do so.

31. WITHDRAWAL OF A COMPLAINT If a complainant withdraws a complaint at any stage in the procedure, parties complained against should be informed immediately. 32. DEALING WITH ABUSE AND ASSAULT OF CCG STAFF AS A RESULT

OF A COMPLAINT Abuse and assault of staff is not acceptable under any circumstances. The CCG has agreed procedures setting out its stance on such incidents:

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HR17 Dignity at Work (Bullying and Harassment) Policy

HS04 Managing Violence and Aggression at Work Policy

Policy for identifying and managing habitual or vexatious individuals complaints and habitual individuals (Appendix 4)

Ultimately the CCG will support the involvement of the police where cases become threatening, abusive or violent. 33. COMPLAINING WHILST APPEALING AGAINST A CCG DECISION The CCG has processes for patients/representatives to request that a review and appeals panel be formed to consider cases of dissatisfaction with a commissioning or funding decision made by the Individual Funding Review Panel and to consider requests for Continued Healthcare Funding. Whilst the person cannot raise a complaint about the decision of the relevant appeal panel they can complain about the appeals panel process. In certain cases it may be appropriate to delay investigation of a complaint until the process is complete. 34. COMPLAINTS REPORTED IN THE NEWS MEDIA Complaints to the CCG will be dealt with on a strictly confidential basis (for the complainant and complained against) at all times. The policy of the CCG is not to discuss complaints with any outside party and particularly not the media. However, some complaints may come to the attention of the media through the actions of complainants, or unconnected third parties. Responses to any approaches from the media will be managed by the CCG’s,Executive Directors, communications staff or appointed agents. Complaints handling should remain separate although the links between the Communication Manager and the CCG complaints personnel will be strong. The fact that complainants may have gone to the media locally or nationally does not absolve the CCG from its responsibility to maintain confidentiality. 35. ENSURING HUMAN RIGHTS, EQUITY AND FAIRNESS FOR

COMPLAINANTS 35.1 Making a complaint does not mean that a patient, carer, member of the

public or staff member will receive less care or that things will be made difficult for them within any aspect of the NHS. Under various International, European and UK laws everyone can expect to be treated fairly and equally regardless of nine protected characteristics of the Equality Act 2010:

Age

Disability

Gender Reassignment

Marriage and Civil Partnership

Pregnancy and Maternity

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Race

Religion or belief

Sex

Sexual orientation 35.2 Patients, carers, members of the public and staff members must also have

their human rights respected at all times. No aspect of the handling of any complaint should prejudice their human rights.

35.3 For people who need language or signed interpreting or other forms of

communication, this can be arranged. 35.4 The CCG has an equal opportunities approach and along with all CCG

policies this policy has been assessed for its impact on anyone with protected characteristics under the Equality Act 2010.

36. HABITUAL COMPLAINTS It is recognised that barriers to communication and understanding from language barriers, learning disabilities etc may be contributing factors to complainants appearing to be vexatious. However there are times where nothing further can reasonably be done to assist a caller or complainant to rectify a real or perceived problem. On rare occasions, complainants may repeatedly contact complaints officers, regarding the same issue, or become persistent in their calls. These may be classed as habitual or vexatious complainants. The difficulty in handling such callers can place a strain on time and resources and cause undue stress for staff who may need support in difficult situations. Staff are trained to respond in a professional and helpful manner to the needs of all callers and implementation of this policy would only occur in exceptional circumstances. See Appendix 4 – Identifying and Managing Habitual complainants or vexatious Individuals. 37. COMMUNICATION WITH STAKEHOLDERS

This policy was considered by representatives of senior managers and heads of departments with responsibility for investigation of complaints. The policy is available on the CCG’s intranet and website. 38. APPROVAL The HWLH CCG Governing Body is responsible for approving this policy. 39. RATIFICATION PROCESS The policy has been reviewed by the Governance Committee before being ratified by the Governing Body.

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40. REVIEW The Complaints Officer is responsible for reviewing this policy. The review is scheduled for one year after ratification, or when legislation or DH guidance requires a review (which ever is the sooner). 41. DISSEMINATION AND IMPLEMENTATION 41.1 Senior Managers and Heads of Departments are responsible for the

dissemination of procedural documents and the destruction of hard copy versions in their areas when revised documents are distributed.

41.2 All staff who commission third parties or contractors to work on behalf of

the CCG are responsible for ensuring that third parties or contractors follow this policy.

41.3 All CCG staff are responsible for cooperating with the development and

implementation of this policy. 42. MONITORING COMPLIANCE AND EFFECTIVENESS 42.1 Compliance with this policy will be inferred by the complaints process and

will be monitored through the complaints reporting systems. 42.2 Any formal action relating to staff non-compliance with this policy will be

handled through the CCGs’ disciplinary procedures as indicated within procedural documents.

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APPENDIX 1

Guidelines for Staff

INVESTIGATION REPORT CHECKLIST

Your report must contain the following details in a logical order: 1. Complainant Mr / Mrs (Title) (Block capitals) Name Age / DOB Occupation (if appropriate) Address Telephone number 2. Complaint/Allegation (A summary of the complaint – What has happened, where and when, what was the outcome for the complainant and/or others)

3. How made (verbal/written/electronic) 4. Person(s) subject of complaint (staff involved) 5. Investigator’s report (a synopsis of each witness statement is required) 6. Conclusions – (Factual, evidenced based) 7. Recommendations – (Recommendations should be feasible – do not make

promises that cannot be kept)

8. Action Plan completed - Yes / No

APPENDIX 2

Action Plan and Lessons Learnt Form

Complaints Investigation Action Plan and Progress Report

Lead Manager

Complainant (inc preferred contact e.g. phone, letter, e-mail) Is consent required? Yes No

Has consent been received? Yes Date received:

Risk Category

Summary of complaint (complaints handling team)

What has been agreed to resolve

the issue?

Key Actions (Manager)

Timescale Progress Additional information

Changes or improvements (as appropriate)

Lessons Learned

Appendix 3

Equalities Monitoring Form

Helping us improve our services NHS High Weald Lewes Havens CCG is committed to ensuring high quality and accessible services for everybody. We want to ensure that no person receives less favourable treatment on the grounds of gender, ethnic or national origin or disability. Any information you give us will be treated in the strictest confidence and will only be used by us to help improve our services. This is really important to us and we would be pleased if you would take a few moments to answer the following questions. Please tick the appropriate box Gender: Male Female Transgender Ethnic Origin I would describe my ethnic origin as: White: British Irish Any other please specify:________________________________________________________ Mixed: White & Black Caribbean White & Black African White & Asian Any other Mixed background, please specify: ________________________________________ Asian or Asian British: Indian Pakistani Bangladeshi Any other Asian background, please specify: _______________________________________ Black or Black British: Caribbean African Any other Black background, please specify: Chinese or other ethnic group: Chinese Other If other background, please specify: _________________________________________________

Traveller: Traveller of Irish Origin Gypsy/Roma Other, please specify:_____________________________________________________________ First Language: English Other, please specify: ___________________________________________________ Disability: Do you consider yourself to be disabled? Yes No We define this as ‘having physical or mental impairment that has a substantial and long-term adverse affect on your ability to carry out day to day activities’. Physical impairment Hearing impairment Visual impairment Communication/ speech impairment Learning Difficulties Mental Health Other, please specify: ____________________________________________________________

Thank you

Appendix 4

1. Policy for Identifying and managing Habitual Complaints or Vexatious Individuals

Vexatious or habitual complaints are defined by their behaviour. The behaviour must be defined over a reasonable period of time. This also includes contact with any other CCG department or commissioned service. Complainants (and/or anyone acting on their behalf) may be deemed to be habitual where previous or current contact with them shows that they meet at least two of the following criteria: Where complainants:

a) Persist in pursuing a complaint where the NHS complaints procedure has been fully and properly implemented and exhausted.

b) Seek to prolong contact by changing the substance of a complaint or continually raising new issues and questions whilst the complaint is being addressed. (Care must be taken not to discard new issues which are significantly different from the original complaint. These might need to be addressed as separate complaints).

c) Are unwilling to accept documented evidence of treatment given as being factual e.g. drug records, GP records, nursing notes.

d) Deny receipt of an adequate response despite evidence of correspondence specifically answering their questions.

e) Do not accept that facts can sometimes be difficult to verify when a long period of time has elapsed.

f) Do not clearly identify the precise issues which they wish to be investigated, despite reasonable efforts of Clinical Commissioning Group (CCG) staff and, where appropriate, independent advocacy, to help them specify their concerns, and/or where the concerns identified are not within the remit of the CCG to investigate.

g) Focus on a trivial matter to an extent which is out of proportion to its significance and continue to focus on this point. (It is recognised that determining what a ‘trivial’ matter is can be subjective and careful judgement must be used in applying this criteria).

h) Have, in the course of addressing a registered PALS query or complaint, had an excessive number of contacts. Discretion must be used in determining the precise number of "excessive contacts" applicable under this section using judgement with the CCG placing unreasonable demands on staff. (A contact may be in person or by telephone, letter, e-mail or fax. This also includes:

- Telephoning repeatedly with no clear issues other than the original complaint.

- Turning up at CCG offices or other places of work of CCG board members (e.g. GP surgeries) without notice and demanding to be seen

i) Are known to have recorded meetings or face to face/telephone conversations without the prior knowledge and consent of the other parties involved.

j) Display unreasonable demands or expectations and fail to accept that these may be unreasonable (e.g. insist on responses to complaints or enquiries being provided more urgently than is reasonable or normal recognised practice).

k) Have threatened or used actual physical violence towards staff or their families or associates at any time - this will in itself cause personal contact with the complainant and/or their representatives to be discontinued and the complaint will, thereafter, only be pursued through written communication. (All such incidents should be documented in line with the Zero Tolerance Procedures).

l) Have harassed or been personally abusive or verbally aggressive on more than one occasion towards staff dealing with their complaint or their families or associates. (Staff must recognise that complainants may sometimes act out of character at times of stress, anxiety or distress and should make reasonable allowances for this.) Staff should document all incidents of harassment in line with the Zero Tolerance Procedures, completing an incident form.

m) Repeated refusal to attend local resolution/conciliation meetings to explore their concerns.

n) Do not accept independent investigation and review of their case

2. PROCEDURE FOR DEALING WITH HABITUAL COMPLAINANTS

a) Check to see if the complainant meets sufficient criteria to be classified as a habitual complainant. Describe the defining behaviour to the Clinical Chair and the Chief Officer.

Discussions should decide if the complainant should be assigned a designated contact point within the CCG management team Where there is an on-going investigation b) The CCG clinical chair or an executive board member should write to the

complainant setting parameters for a code of behaviour and the lines of communication. If these terms are contravened consideration will then be given to implementing other action.

Where the investigation is complete c) At an appropriate stage, the Chief Officer or Chair should write a letter

informing the complainant that: - The CCG has responded fully to the points raised, and - Has tried to resolve the complaint, and - There is nothing more that can be added, therefore, the

correspondence is now at an end.

The CCG may also wish to state that future letters will be acknowledged but may not be responded to.

d) In extreme cases the CCG should reserve the right to take legal action

against the complainant.

Record Keeping: The CCG should keep an up to date and accurate record of all contacts with the complainant to support action taken. This record will include all relevant actions taken and letters issued to the complainant and will be held by a nominated CCG officer.

Proposed Record of Contact template:

Date of Contact Method (phone, letter) Time spent New or repeat issue

APPENDIX 5

Complaints Management – Process Map

Can the complaint be resolved within

24 hours?

Is the complaint directed at HWLH

CCG?

Notify the complainant and if permission given refer to appropriate organisation.

NO

YES

Complaint falls outside complaints arrangements. Good practice to record

any learning for organisation

YES

Acknowledge the complaint within 3 working days

Does the complaint fall within the list of exclusions?

Contact the complainant as soon as possible to explain the decision

YES

Does the complaint involve more than one health or adult social provider?

The organisations must agree which will take the lead in responding and

communicating with the complainant.

YES

If considering the complaint, notify the complainant and receive consent to send the complaint to the provider,

then offer discussion with the complainant on an action plan, how

the complaint will be handled and the expected timescale. (Aim for 25 days)

NO

Investigate the complaint. Is the investigation concluded within

25 days?

NO

Send the final report, to the complainant, signed off by a designated person within the organisation. Include the conclusion of the investigation and

organisational learning where applicable. Include recourse to the Ombudsman if the complainant is not happy.

NO

Review the case to see if it can be concluded any faster, and inform the complaint of the expected date of resolution

APPENDIX 6

Grading Matrix

Please indicate the impact and likelihood of the complaint recurring by circling the appropriate number below.

Re: Ref:

IMPACT

LIKELIHOOD NEGLIGIBLE / NONE

LOW / MINOR

MEDIUM / MODERATE

VERY HIGH / MAJOR

EXTREME / CATASTROPHIC

Rare 1 2 3 4 5

Unlikely 2 4 6 8 10

Possible 3 6 9 12 15

Likely 4 8 12 16 20

Almost certain 5 10 15 20 25

GRADING BANDS

1 – 3 = LOW

4 – 6 = MODERATE

8 – 12 = SIGNIFICANT

15 – 25 = HIGH

RISK MANAGEMENT POLICY AND

PROCEDURE

To be read in conjunction with the following CCG policies and documents:

G02 Risk Management Strategy IG02 Information Governance Policy CCG Assurance Framework CCG Corporate Risk Register CCG Team Risk Register

Page2 of 15

Document Details

Title Risk Management Policy and Procedure

Ref No G01

Document objective To direct the implementation of the CCG’s Risk Management Strategy and to ensure as far as is reasonably practicable that all risks are identified and appropriately managed according to the CCG’s Risk Appetite.

Audience

All CCG staff and officers (including temporary and

seconded staff, and contractors)

Dissemination All policies will be published on the intranet and the

CCG website, in the staff newsletter and staff induction

pack.


Approval process


Date of review


Date of approval

Equality Impact Assessment There are no negative impacts of this policy on people

with protected characteristics


Review date 1 year from approval

Version Control

Version

number


1.0 Sept 2015 Approved by Governing Body

1.1 Sept 2016 Reviewed and updated Head of Corporate Services


2.0 Jan 2017 Approved by Governing Body

Page3 of 15

Contents

Section No.

Section title Page

1. Staff Quick Reference Guide .……………………………………………… 4

2. Policy Statement..……………………………………………………………. 6

3. Responsibilities……………………………………………………………….. 6

4. Activities ………………………………………………………………………. 7

Appendix 1: Risk Management Procedures 8

Appendix 2: CCG Model Risk Matrix 10

Appendix 3: Sample Risk Action and Reporting Requirements 15

Page4 of 15


This Policy and Procedure sets out the process for risk management within High Weald

Lewes Havens CCG, (henceforth referred to as ‘the CCG’) promoting high quality, safe,

accountable healthcare, minimising risks to the organisation and staff and maximising

available resources. It should be read in conjunction with the Risk Management Strategy.

This Policy and supporting procedures set out the process for risk management within the

CCG, promoting high quality, safe, accountable healthcare, minimising risks to the

organisation and staff and maximising available resources. It should be read in

conjunction with the Risk Management Strategy.

This policy provides staff with information on how the risk management strategy will be put into place and provides an overview of the risk management process as outlined in Appendices 1 and 2. The risk management process (Appendix 3) provides staff with guidance as to how risks can be identified and reported. Key responsibilities of all staff include:

Staff have a responsibility to co-operate with managers and they are encouraged to identify risks and advise their line managers.

Being familiar with and complying with the Risk Management Strategy, Policy and supporting procedures.

Reporting incidents, accidents and near misses following procedures set out in the Incident Reporting and Investigation Policy and supporting procedures.

Being aware of their duty under legislation to take reasonable care for personal safety and the safety of all others who may be affected by the organisation’s business.

Complying with CCG rules, regulations and instructions to protect the health, safety and welfare of anyone affected by CCG business.

Neither intentionally nor recklessly interfering with nor misusing any equipment provided for the protection of safety and health.

Being aware of emergency procedures, e.g. First Aid, evacuation and fire precaution procedures relevant to their own individual department locations.

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Risk Management Process Flowchart

Risk identified and assessed (this may be by member of staff, department manager or Executive Director)

If score less than 12: Put on team/project

register

If score 12 or above:

Discuss with Corporate Services Officer and inform responsible Executive

Director

Monthly review with team/project risk owner

Bi-monthly review of Corporate risk register and Assurance Framework with

Executive Management Team

Reports on Corporate Risk Register and Assurance Framework submitted to:

Audit Committee

Quality & Performance Committee

Governing Body

Decision made by Executive

Director to add to team/project

risk register

Identify team/project risk owner

Bi-monthly review of risks with Executive Director level

risk owner Risk Owner

Decision made by Executive Director

to add to corporate risk

register

Page6 of 15

POLICY STATEMENT

The purpose of this Policy is to direct the implementation of the CCG’s Risk Management

Strategy and to ensure as far as is reasonably practicable that all risks are identified and

controlled.

Risks will always occur. Many risks are trivial, but others pose a more serious possibility of

impact to the organisation, staff, patients or the general public. Once identified risks must

be assessed, recorded, managed according to their severity, reported and scrutinised.

2. RESPONSIBILITIES The general accountabilities, duties and responsibilities of the following roles are detailed in the CCG Risk Management Strategy, page 8 (*) and the Information Governance Policy, page 6 (^):

CCG Governing Body and its committees * ^

Chief Officer * ^

Chief Finance Officer *

Head of Corporate Services *

Corporate Services Officer *

Member Practices *

Managers * ^

CCG Staff * ^

Caldicott Guardian ^

Senior Information Risk Owner ^

The Corporate Services Officer has responsibility for maintaining and updating the Corporate Risk Register and the Assurance Framework, the post-holder also provides advice and expertise to managers across the organisations and reviews the local/team risk registers. In addition, all managers have particular responsibilities within these procedures which are:

Ensuring that the organisation’s risk management processes, including risk assessments, are in place within their scope of responsibility.

Implementing and monitoring any risk management actions within their designated area. Where local actions are considered to be inadequate, senior managers are responsible for bringing these risks to the attention of the Quality and Performance Committee if local resolution has not been satisfactorily achieved.

Page7 of 15

Reviewing a summary of all incidents within their teams or their scope of responsibility on a regular basis and disseminating this information to ensure that appropriate learning takes place to reduce future risks.

Ensuring that all staff are given the necessary information and training to enable them to be aware of the risks to their local objectives, those in their work environment and of their personal responsibilities and to work safely.

Managers are responsible for ensuring staff compliance with this document.

3. ACTIVITIES

Risk management involves the following activities:

Identify the risk/hazard What, why and how can the successful achievement of an objective be prevented. Hazards can be identified from a variety of internal and external sources including all other feedback and reporting systems.

Analyse the risk/hazard A managerial assessment of the impact on the organisation of the risk materialising. (See Appendix 1)

Evaluate the risk A managerial assessment of the likelihood of the risk materialising. Calculate the total score and assess whether this is high enough to require action.

Report the risk The scoring of the risk will dictate whether it is to be reported locally or directly and immediately to a member of the senior management team.

Treat/close/transfer the risks Each risk will require either a specific action plan (which includes consideration of funding) to reduce the impact or likelihood scores to an acceptable residual level, approval of closure or the transfer to another organisation. (The latter is rare.)

These activities are detailed in the supporting procedures at Appendix 1 of this policy.

Page8 of 15

APPENDIX 1 - RISK MANAGEMENT PROCEDURES

Assessment of risks A risk assessment is a careful and measured examination of any risk identified – i.e., what, in your work, could cause harm to:

People – including yourself, patients and their friends or relatives, carers, staff - bank and temporary, independently contracted domestic and maintenance staff, visitors, etc., or to:

The organisation – including strategic objectives, day to day tasks, operations, our environment, services, etc.

Remember - a risk assessment should provide a means of communicating the hazards or threats identified and control measures available to minimise risks. The risk assessment should be explicit, so that it is easy for anyone, who doesn’t yet know of the issue, to understand it. Abbreviations should not be used, only facts (not opinion) and staff roles (not names) should be used. Reporting risks The following information is required in order to be able to add a risk to the Register:

The date the risk was identified

The name of the person who assessed the risk

The senior manager who owns the risk

A description of the risk

Initial Scores and the domain of the risk impact (See appendix 2)

Actions including identified owners and target dates

The residual risk rating (assuming effective implementation of the agreed actions)

The names of other CCGs to which the risk applies.

Without this information risks cannot be monitored and managed correctly. Information on new risks, updates to risks and authority to close risks should be reported to: The Corporate Services Officer or Local/Team Risk Register owner. A risk reporting pro-forma is available and managers are encouraged to discuss all new risks with the Corporate Services Officer.

Page9 of 15

Monitor and review The following actions are implemented to ensure there is a regular review:

Teams carry out a review of the risks in their areas of responsibility at least monthly to identify any new risks, to update action plans and advise any changes. The risk register is updated.

All Extreme and High risks (see Appendix 3) are then reviewed at the management meeting. The risk register is and further updated where necessary.

The updated register of Extreme and High risks is submitted for scrutiny at the governance meeting(s) to ensure that the risks fully reflect risks to the achievement of strategic objectives and that appropriate controls and actions are in place.

Assurance of the Process NHS organisations are required to have systems of Risk Management, policies and processes. It is usual for the highest level risks to be overseen by the Governing Body (via the Assurance Framework).

The Quality and Performance Committee holds the delegated authority for scrutinising risks. The Corporate Risk Register and the Assurance Framework are submitted to its meetings. This committee also reviews the non-corporate register.

The Audit and Risk Committee holds the delegated authority for scrutinising the robustness of the Risk System and its deployment. This is undertaken at each meeting.

The opinions of both committees and any resulting actions taken by the Senior Management Team are incorporated in the submission of the Assurance Framework to each meeting of each Governing Body.

The necessary independent scrutiny of an organisation’s risk system is be achieved through scrutiny by Lay members and Independent Clinical members of the Governing Body, external organisations or both. Communication and consultation Communication and consultation with internal and external stakeholders will take place as appropriate at each stage of the risk management process and concerning the process as a whole.

Page10 of 15

APPENDIX 2 - CCG MODEL RISK MATRIX

Further guidance is available at http://www.nrls.npsa.nhs.uk

Instructions for use:

a. Define each risk explicitly in terms of both the possible risk event and the adverse impact(s) that might arise.

b. Determine the impact score (I) for the potential adverse outcome(s) using table 1. Choose the most appropriate ‘domain’ for the identified risk from the left hand side of the table then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the score, which is the number given in the top of the column.

c. Then determine the likelihood score (L) for the risk event using table 2. Calculate the score for the likelihood either by the frequency of occurrence of the adverse outcome or the probability of the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions on table 2 to determine the most appropriate score.

d. Calculate the risk score by multiplying the impact by the likelihood: I (impact) x L (Likelihood) = R (risk score).

e. Use the score and table 3 to identify the level at which the risk will be managed in the organisation. Assign priorities for remedial action. Report the risk to the Risk Team for inclusion in the risk register at the appropriate level.

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59833&q=0%c2%acrisk%c2%ac&p=1

Page11 of 15

Table 1- Impact (Consequence) scores

Impact (consequence) score (severity levels) and examples of descriptors

1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Impact on the safety of patients, staff or public (physical/ psychological harm)

Minimal injury requiring no/minimal intervention or treatment. No time off work.

Minor injury or illness, requiring minor intervention. Requiring time off work for >3 days Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention. Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident. An event which impacts on a small number of patients

Major injury leading to long-term incapacity/disability. Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects

Incident leading to death Multiple permanent injuries or irreversible health effects. An event which impacts on a large number of patients

Quality/ complaints/audit

Peripheral element of treatment or service suboptimal Informal complaint/ inquiry

Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Non-compliance with national standards with Multiple complaints/ independent review Low performance rating Critical report Significant risk to patients if unresolved

Totally unacceptable level or quality of treatment/service Inquest/ombudsman inquiry Gross failure to meet national standards Gross failure of patient safety if findings not acted on

Page12 of 15


1 2 3 4 5


Human resources/ organisational development/ staffing/ competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale. Poor staff attendance for mandatory/key training.

Uncertain delivery of key objective/ service due to lack of staff. Unsafe staffing level or competence (>5 days). Loss of key staff. Very low staff morale. No staff attending mandatory/ key training

Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis

Statutory duty/ inspections

No or minimal impact or breech of guidance/ statutory duty.

Breech of statutory legislation. Reduced performance rating if unresolved.

Single breech in statutory duty. Challenging external recommendations/ improvement notice.

Enforcement action. Multiple breeches in statutory duty. Improvement notices. Low performance rating. Critical report.

Multiple breeches in statutory duty. Prosecution. Complete systems change required. Zero performance rating. Severely critical report

Page13 of 15


1 2 3 4 5


Adverse publicity/ reputation

Rumours Potential for public concern

Local media coverage Short-term reduction in public confidence

Local media coverage Long-term reduction in public confidence

National media coverage <3 Days Service well below reasonable public expectation

National media coverage with >3 days service well below reasonable Public expectation. MP concerned (questions in the House). Total loss of public confidence

Business objectives/ projects

Insignificant cost increase Schedule slippage

Elements of public expectation not being met. <5 per cent over project budget Schedule slippage

5–10 per cent over project budget Schedule slippage

Non-compliance with national 10–25 per cent over project budget Schedule slippage Key objectives not met

Incident leading to >25 per cent over project budget

Page14 of 15


1 2 3 4 5


Finance including claims Service/business interruption Environmental impact

Small loss Risk of claim remote Loss/interruption of >1 hour Minimal or no impact on the environment

Loss of 0.1–0.25 per cent of budget Claim less than £10,000 Loss/interruption of >8 hours Minor impact on environment

Loss of 0.25–0.5 per cent of budget Claim(s) between £10,000 and £100,000 Loss/interruption of >1 day Moderate impact on environment

Uncertain delivery of key objective Loss of 0.5–1.0 per cent of budget Claim(s) between £100,000 and £1 million Purchasers failing to pay on time Loss/interruption of >1 week Major impact on environment

Schedule slippage / Failure to meet specification/ slippage. Key objectives not Met / Non-delivery of key objective Loss of >1 per cent of Budget. Payment by results Claim(s) >£1 million Permanent loss of service or facility Catastrophic impact on environment

Table 2 - Likelihood scores (L)

Likelihood score

1 2 3 4 5

Description Rare Unlikely Possible Likely Almost certain

Frequency How often might it/does it happen

This will probably never happen/recur

Do not expect it to happen/recur but it is possible it may do so

Might happen or recur occasionally

Will probably happen/recur but it is not a persisting issue

Will undoubtedly happen/recur possibly frequently

Table 3 - Risk Scoring = impact x likelihood (I x L)

Impact/ Consequence

Likelihood

1 2 3 4 5

Rare Unlikely Possible Likely Almost certain

5 Catastrophic

5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

Page15 of 15

APPENDIX 3 - SAMPLE RISK ACTION AND REPORTING REQUIREMENTS

Score Risk Action Reporting

Requirements

1 –

7

Low Risk: Tolerate/managed

through normal control

measures.

Report to local manager.

Manage and monitor at

team level.

8 –

10

Moderate Risk: Control treat/review

control measures.

Report to local manager. Enter on to the departmental risk register. Managed by local manager.

12+ High Risk Treatment plans to be

developed, implemented

and monitored.

Report to Executive Management Team. Enter on to the Corporate Risk Register. Managed by CCG Executive Management Team. Scrutinised by Quality and Performance Team.

15 –

25

Extreme

Immediate action required. Treatment plans to be developed, implemented and monitored.

Report to CCG Executive Management Team. Enter on the Corporate Risk Register and the Assurance Framework, managed and reviewed by the CCG Executive Management Team. Scrutinised by Quality and Performance Committee and Audit Committee. Monitored by CCG Governing Body.

This process, its robustness and its deployment are scrutinized by the CCG Audit and Risk Committee. The Risk System is subject to annual scrutiny by Internal Audit and a report to the Governing Body

RISK MANAGEMENT STRATEGY To be read in conjunction with the following CCG policies and documents: G01 Risk Management Policy and Procedure G07 Whistleblowing (Freedom to Speak Up) Policy HS06 Health and Safety Policy QS03 Reporting and Managing Incidents and Serious Incidents CCG Constitution

Page2 of 15

Document Details

Title Risk Management Strategy

Ref No G02

Document objective To set out the structure, system and accountabilities for High Weald Lewes Havens CCG for the management of all types of risk to which the organisation may be exposed.

Audience All CCG staff and officers (including temporary and

seconded staff, and contractors)

Dissemination All policies will be published on the intranet and the CCG

website, in the staff newsletter and staff induction pack.


Approval process


Date of review


Date of approval




Review date 1 year from approval

Version Control

Version

number


1.0 24 Sept

2015


1.1 September 2016

Reviewed and updated Head of Corporate Services


2.0 Jan 2017 Approved by Governing Body

Page3 of 15

Contents

Section No.

Section title Page

1. Staff Quick Reference Guide………………………………………………… 4

2. Purpose ……………………………………………………………………….. 5

3. Governing Body Level Commitment………………………………………… 5

4. Definitions Of Risk and Risk Management………………………………….. 6

5. Objectives Of The Strategy………………………………………………….. 7

6. Accountabilities, Duties, Responsibilities……………………………….. 8

7. Implementation………………………………………………………………… 10

8. Risk Management Structure………………………………………………….. 10

9. Risk Management System…………………………………………………….. 11

10. Risk Assessment and Risk Appetite Statement…………………………….. 13

11. Risk Management Process………………………………………………….. 14

12. Training…………………………………………………………………………. 14

13. Consultation and Communication With Stakeholders……………………..

14

14. Ratification Process and Review………………………………………………….. 14

15. Dissemination and Implementation……………………………………………… 14

16. Monitoring Compliance and Effectiveness…………………………………. 14

17. References…………………………………………………………………….. 15

18. Bibliography……………………………………………………………………. 15

Page4 of 15


This strategy sets out the CCG structure, system and accountabilities for the

management of all types of risk to which the CCG may be exposed.

Risk Management is the responsibility of all CCG employees. They have a

responsibility to co-operate with managers and they are encouraged to identify risks

and advise their line managers.

Key responsibilities of all staff include:

Being familiar with and complying with the Risk Management Strategy, Policy and supporting procedures and with all other relevant policies and procedures.

Reporting incidents, accidents and near misses following procedures set out in the Incident Reporting and Investigation Policy and supporting procedures.

Being aware of their duty under legislation to take reasonable care for personal safety and the safety of all others who may be affected by the CCG’s business.

Complying with CCG rules, regulations and instructions to protect the health, safety and welfare of anyone affected by the CCG’s business.



If you have any questions or queries regarding the Risk Management Strategy or

policy and procedure, please contact the Corporate Services Officer.

Page5 of 15

2. PURPOSE

NHS organisations are required to sign an Annual Governance Statementi to provide

reasonable assurance that they have been properly informed about the totality of

their risks and can evidence they have identified the CCG’s Principal Objectives and

managed the principle risks to achieving them. This includes all measures and

practices that are used to control and manage risks. The system operates at all

levels within the CCG and is continuously monitored for effectiveness on behalf of

and by the Governing Body.

Although not mandatory for commissioning only organisations, the CCG continues to

work to the best practice of the ‘NHS Litigation Authority (NHSLA) Risk Management

Standards’ii. These require a Governing Body approved policy and strategy for

managing risk that identifies accountability arrangements and resources available.

The purpose of this document is to define the Strategy that the CCG uses to support

the development of a rigorous risk management process. The separate CCG Risk

Management Policy and supporting procedures assist staff in ensuring, as far as is

reasonably practicable, that all risks are identified and controlled.

3. GOVERNING BODY LEVEL COMMITMENT

The Governing Body recognises that risk management is an integral part of good

management practice and to be most effective it must become part of the CCG’s

culture. The Governing Body is therefore committed to ensuring that risk

management forms a part of its philosophy, practice and planning (rather than being

viewed or practiced as a separate programme) and that responsibility for

implementation is accepted at all levels of the CCG.

The Governing Body acknowledges that the provision of appropriate training is

central to the achievement of this aim. (See section 12)

3.1 A Fair Blame Culture

The CCG supports a ‘fair blame’ culture. Staff reporting or directly involved in

incidents are assured that any investigation will be carried out fairly, without

prejudice and with the aim of identifying and correcting the underlying causes of

the incident to prevent recurrence.

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3.2 Raising Matters of Concern (Whistle Blowing)

All CCG staff should be familiar with the Whistle Blowing Policyiii which sets out

procedures and guidance to staff on raising concerns and the requirements of

the Public Interest Disclosure Act 1998 (Department of Health Circular HSC

1999/198).

4. DEFINITION OF RISK AND RISK MANAGEMENT

Risk can be defined as ‘the possibility of incurring misfortune or loss’ (Oxford English

Dictionary) for example through the occurrence of an event that may either cause

harm or have an impact upon patients, staff, visitors, partner organisations, strategic

objectives, assets and/or reputation. In particular:

Any element which has the potential to damage or threaten the achievement of the objectives, programme or service delivery of the organisation.

Anything that could damage the reputation of the organisation and undermine the public’s confidence in the organisation.

Failure to guard against impropriety, malpractice, waste or poor value for money.

Failure to comply with regulations or legislation such as those covering Health & Safety and the environment.

An inability to respond to or manage changed circumstances in a way that prevents or minimises adverse effects on the delivery of the organisation’s strategic objectives.

‘Risk management involves managing to achieve an appropriate balance between

realising opportunities for gains while minimising losses. It is an integral part of good

management practice and an essential element of good corporate governance. It is

an iterative process consisting of steps that, when undertaken in sequence, enable

continuous improvement in decision-making, and facilitate continuous improvement

in performance.’ (Australian Standard, Risk Management AS/NZS 4360:2004).

4.1 Risk Management in the CCG occurs using the following risk assessment

tools:

Analysis and evaluation of the likelihood and consequences of risks.

Management of risks through development of action plans to eliminate, control or transfer them, ensuring reduction of likelihood and/or severity of impact to an acceptable level.

Page7 of 15

Monitoring and reviewing risks and the implementation of their action plans by risk register review.

Communicating through a documented process, risks associated with an activity or process.

Ensuring the reporting, monitoring of investigations, recording and trend analysis of all commissioner and provider related Serious Untoward Incidents reported.

Application of the Incident Reporting and Investigation Policy and Procedure; however, where the cause of an incident cannot be immediately eliminated, the risk(s) identified as a result of any incident reported will then also go on to be managed proactively, through risk assessment and management.

5. OBJECTIVES OF THE STRATEGY

There should be a holistic approach to risk management across the CCG which

embraces financial, organisational, clinical and non-clinical risks and in which all

parts of the CCG should be involved.

In terms of risk management one aim of the CCG is to take all reasonable steps in

the management of risk with the overall objective of protecting patients, staff, the

public and assets. A primary concern is the provision of safe, risk free environments

together with working policies and practices which take into account assessed

commissioning risks.

The Strategy provides a framework for managing risks to the CCG’s objectives and

to achieve the following:

The integration of risk management with the CCG’s Principal Objectives and Strategic Goals and with local objectives that support these.

The convergence of organisational controls & assurance, financial controls & assurance and clinical & social governance systems.

Compliance with Department of Health and legislative requirements.

In order to achieve these objectives the organisations will adopt a pro-active

approach with a Risk Management Policy and supporting procedures which aim to

meet its strategic objectives, preserve its assets and reputation and to provide

protection against preventable injury and loss to employees, patients and the general

public.

Page8 of 15

6. ACCOUNTABILITIES, DUTIES, RESPONSIBILITIES

CCG Governing Body holds the authority for the systems of internal control –

financial, organisational, clinical and non-clinical. It seeks regular assurance on

whether CCG Risk Management systems are in place and functioning properly and

therefore makes fully informed Annual Governance Statements.

It receives reports and information from relevant sources from both within and

outside of the organisation. It receives the Assurance Framework (see section 9),

reviews key controls and assurances in place for those risks and monitors action

plans for any identified gaps in controls or assurances.

The Chief Officer/Accountable Officer has overall responsibility for ensuring that

an effective risk management system is in place. S/he is also responsible for

ensuring there is an adequate control system in place.

The Chief Finance Officer is accountable to the Chief Officer and is responsible for

ensuring (and reporting to the CCG Governing Body and the Audit and Risk

Committee) that systems and structures are in place for the effective management of

financial risk and organisational controls.

The Head of Corporate Services has delegated responsibility for managing the

development and implementation of risk management systems. He/she is

responsible for ensuring that there are effective systems for risk management.

The Caldicott Guardian ensures that the Caldicott principles, for managing

information and ensuring its security and integrity, are adhered to by staff within the

CCG and acts as an advisor for Member Practices.

Senior Information Risk Owner has responsibility for managing Information Risks

across the organisation.

The Corporate Services Officer has responsibility for maintaining and updating the

Corporate Risk Register and the Assurance Framework. The postholder also

provides advice and expertise to managers across the CCG and reviews the Non

corporate risk register.

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Member Practices

It is recognised that member practices will have their own risk management

processes in place. However, when individuals are undertaking the business of the

CCG this Risk Management Strategy and the associated Risk Management Policy

and supporting procedures will apply.

Managers

Managers are responsible for implementing the Risk Management Policy and

procedures within their span of control and for ensuring that staff undertake all

relevant mandatory training. Managers must ensure that relevant risks are identified

and appropriately managed by entering them on risk registers and discussing risks

with relevant Senior Managers.

CCG Staff

Risk Management is the responsibility of all CCG employees. They have a

responsibility to co-operate with managers and they are encouraged to identify risks

and advise their line managers.

Key responsibilities of all staff include:

Being familiar with and complying with the Risk Management Strategy, Policy and supporting procedures and with all other relevant policies and procedures.

Reporting incidents, accidents and near misses following the procedures set out in the Incident Reporting and Investigation Policy and supporting procedures.

Being aware of their duty under legislation to take reasonable care for personal safety and the safety of all others who may be affected by the CCG’s business.

Complying with CCG rules, regulations and instructions to protect the health, safety and welfare of anyone affected by the CCG’s business.



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7. IMPLEMENTATION

CCG Senior Managers, or their designated representatives, will implement this

Strategy by:

Having adequate knowledge of and/or access to all relevant legislation in order to ensure that compliance to such legislation is maintained.

Making adequate resources available to provide safe systems of work. This will include making risk assessments, having appropriate control measures, raising outstanding concerns, ensuring safe working procedures/practices and continued monitoring and revision.

Discussing with staff how they seek to achieve their individual objectives and consider how ‘risks’ related to achievement of their objectives are identified, prioritised and tackled.

Providing mandatory training and updates for all employees to attend and to ensure compliance with these.

Monitoring relevant performance in commissioned services.

Making adequate provision to ensure that fire and other emergencies are appropriately dealt with.

8. RISK MANAGEMENT STRUCTURE

The CCG Governing Body receives assurance as to whether risks are being

effectively managed. The Governing Body reviews and approves its Assurance

Framework at each of its meetings in order to monitor the actions and assurance

against the strategic risks. In this way it ensures that the reported risks fully reflect

the level of risk to the achievement of strategic objectives and that appropriate

controls and actions are in place. The Governing Body also receives assurance

through its own governance arrangements.

Head of Internal Audit is responsible for implementing a programme of verification

to ensure that the systems and controls the CCG has in place are sufficient and to

provide an opinion to the Chief Officer and the Audit and Risk Committee.

The CCG Audit Committee provides objective views on internal control and risk

management to the CCG Governing Body that is independent of executive and line

management. The Audit and Risk Committee scrutinise the CCG Assurance

Framework and the accompanying report on the deployment of the risk system. This

provides assurance as to the robustness of risk management systems within the

CCG and the levels of deployment across the CCG. (The Terms of Reference for the

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Audit and Risk Committee can be found appended to the CCG Constitution on the

CCG Website)

The CCG Quality and Performance Committee scrutinise the corporate risks and

the Assurance Framework and provide assurance that individual risks are being

effectively managed and that the actions to treat the high level risks are sufficient

and are having the desired effect within the agreed timescales. It periodically reviews

any other relevant Risk documentation. (The Terms of Reference for the Quality and

Performance Committee can be found on the CCG website).

Health and Safety Committee

This committee comprises representatives from the CCGs who receive support from

a single supplier. It monitors the effectiveness of the Health & Safety Policy and the

minutes from this committee are forwarded to the CCG’s Quality and Performance

Committee along with recommendations on Health & Safety issues.

9. RISK MANAGEMENT SYSTEM

The risk management system is designed to focus management attention on risks at

the appropriate level in the organisation. In particular it is designed to set the most

significant, ‘principal’ risks before the CCG Governing Body in order that resources

can be applied to implement controls that mitigate the risks, and to gain assurances

that those controls are effective.

The Risk Management Policy and supporting procedures set out how the system

delivers this Risk Management Strategy. The key components of the Risk

Management System are:

Non Corporate Risk Register – This register contains all identified risks

scoring greater than 6 but less than 12. This is monitored by the relevant

senior managers and reviewed by the Corporate Services Officer. Any risks

which, on review, increase their scores to 12 or above are escalated to an

Executive Director for consideration of whether to include on the the

Corporate Risk Register.

Corporate Risk Register – This contains all identified risks scoring 12 and

above, which which are acted upon in a timely fashion. They are reviewed by

the CCG’s Quality and Performance Committee. The detailed scrutiny of

these risks ensures that appropriate actions are being taken to mitigate the

risks.

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The Assurance Framework – The framework incorporate the key risks which

score 15 and above (which may compromise the achievement of the

organisation’s Principal Objectives) and are the primary tool for monitoring

these risks within the organisation. These documents are submitted to every

meeting of the Audit and Risk Committee and every meeting of the CCG

Governing Body to ensure awareness of the totality of the risks which face the

organisation together with action plans to address them. The detailed scrutiny

of this document ensures that appropriate controls and assurances are in

place to manage the mitigation of these risks.

In addition to risk details (as detailed in the CCG Risk Management Policy and

supporting procedures), the Assurance Framework will also contain following

information:

Key controls to assist in managing the risk to secure the achievement of the objective.

Sources of evidence on which reliance of the effectiveness of the systems is placed.

Detailed assurances obtained showing the evidence presented to the Governing Body, including internal assurances on the effectiveness of its systems and from external bodies; the Audit Commission, NHS Litigation Authority, etc.

Any gaps in control i.e. systems not in place.

Any gaps in assurance i.e. systems in place but evidence not available.

10. RISK ASSESSMENT AND RISK APPETITE STATEMENT

The process for consistent assessment of risks (including use of the Model Risk

Matrix originally provided by the National Patient Safety Agencyiv) is contained in the

Risk Management Policy and procedure. The organisation recognises that it is not

possible to totally eliminate all risks and that systems of control should not be so rigid

that they stifle imaginative use of limited resources in order to provide an effective

service.

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Risk Appetite Statement

The CCGs risk appetite statement describes what levels and types of risk the CCG is

prepared to accept in pursuance of the CCGs goals.

The draft CCG risk appetite has been discussed at the Audit Committee and the

Quality & Performance Committee in November 2016. The plan is for the Governing

Body to agree this at the February 2017 meeting.

11. RISK MANAGEMENT PROCESS

Regular reviews are undertaken across the CCG to ensure that new risks are

identified and assessed, that existing risks and their mitigating actions are tracked

and kept up to date and that risks that have been successfully mitigated are closed.

The recording of these actions is detailed in the Risk Management Policy and

supporting procedures.

12. TRAINING

Risk Management training is made available to all staff – it is mandatory and an

update is required every 3 years. Risk Management training is also provided to all

staff as part of their induction. A full range of Health & Safety and other mandatory

training packages are made available to all relevant staff. Mandatory training

requirements for all staff groups are explicitly detailed in the CCG’s Mandatory

Training Schedule. Records of attendance are kept and levels of compliance

reported to the CCG Governing Body.

13. CONSULTATION AND COMMUNICATION WITH STAKEHOLDERS

The CCG has a duty to keep relevant stakeholders informed and, where appropriate,

to consult them on the management of significant risks faced by the organisation.

This is particularly important where risks are shared with or may impact upon partner

organisations.

14. RATIFICATION PROCESS AND REVIEW

This document will be reviewed annually or earlier as required in order to ensure that

it is current, relevant and reflects the strategic aims, objectives, organisational

Page14 of 15

structures and responsibilities of the CCG. It will then be ratified by the CCG

Governing Body.

15. DISSEMINATION AND IMPLEMENTATION

Following ratification this strategy will be made available to all staff, all staff will be

notified of its existence and training materials will be updated. Managers will be

responsible for ensuring that staff are aware of the document. New staff will be

alerted to the strategy and the supporting policy & procedure at induction training.

On notification of a revised version of the procedural document, managers will be

responsible for the destruction of all superseded paper based versions and

electronic versions retained in their area.

16. MONITORING COMPLIANCE AND EFFECTIVENESS

The CCG will review its performance in the area of risk management through a

specific annual internal audit on the Risk and Assurance Processes. This annual

audit is reported to the Audit and Risk Committee and will form the basis of the

annual Head of Internal Audit Opinion on the CCG’s arrangements for risk

management and internal control. The Accountable Officer will review compliance

with, and effectiveness of the risk management and internal control system annually

in preparing the Annual Governance Statements.

Any trends resulting from possible policy non-compliance will be raised with staff

through management routes. Relevant committee terms of reference will be

reviewed annually to maintain accuracy and appropriate focus.

17. REFERENCES:

NHSLA Risk Management Standards for PCT’s, 2008

Successful Health and Safety Management HSG65 HSE Books, 1997

Australian/New Zealand Standard 4360:2004 Risk Management

National Patient Safety Agencyv Risk Assessment Tool 2004 for assessment of levels of incident investigation

Seven Steps to Patient Safety for Primary Care, NHS National Patient Safety Agency, 2006

Management of Health and Safety at Work Regulations, 1999

Integrated Governance Handbook, Department of Health, 2006

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Chapter 21, Government Accounting, HM Treasury, www.government-accounting.gov.uk

World Class Commissioning Assurance handbook 2009, The Department of Health.

Internal Control – Guidance for Directors on the Combined Code, The Institute of Chartered Accountants in England and Wales, 1999, revised October 2005 by the Financial Reporting Council, www.frc.org.uk

Care Quality Commission reviews in 2009/10 Consultation, Care Quality Commission 2009.

18. BIBLIOGRAPHY

The Risk Management Process, Federation of European Risk Management Associations (FERMA), 2005

A Risk Management Standard, The Association of Insurance and Risk Managers, (AIRMIC), 2002

International Organisation for Standardisation (ISO) /IEC Guide 73:2002 Risk Management

Risk Management Model (HSG65), Successful Health & Safety Management, HSE Books, 1997

Risk and public Services, The London School of Economics and Political Science 2009

i Further information is available at http://www.dh.gov.uk/health/2012/03/annual-governance-statements/. ii Further information is available at http://www.nhsla.com/RiskManagement/.

iv The functions of the National Patient Safety Agency transferred to NHS England on 1

st June 2012.

The CCG has amended the model matrix to reflect the commissioning nature of the organisation.

http://www.government-accounting.gov.uk/

http://www.government-accounting.gov.uk/

http://www.frc.org.uk/

http://www.dh.gov.uk/health/2012/03/annual-governance-statements/

http://www.dh.gov.uk/health/2012/03/annual-governance-statements/

http://www.nhsla.com/RiskManagement/

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Policy and Procedures for Reporting and Managing Incidents and Serious Incidents


Emergency Plan

Whistleblowing Policy

Complaints Policy

Claims Policy

Fire Safety Policy

Risk Management Policy

Infection Control Policy

Child and Adult Safeguarding Policy

Medicines Policy

All reasonable steps have been taken to ensure that this Policy reflects the:

Equality and diversity agenda

Relevant articles of the Human Rights Act 1998

Philosophy of Clinical Governance, providing evidence for compliance with the requirements of the Standards for Better Health of the Department of Health and the NHS Litigation Authority Risk Management Standard for PCTs

Health and Safety at Work Act 1974 and associated legislation

Freedom of Information Act 1998 (amended 2000)

Disability Discrimination Act 1995 (amended 2005)

Sex Discrimination Act 1975 (amended 2003)

Race Relation Act 2000

Age Discrimination Act 2006

National Patient Safety Agency “ National Framework for Reporting and Learning from Serious Incidents Requiring Investigation” (2010)

NHS England Policy 2013

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Document Details

Title Policy and Procedures for Reporting and Managing Incidents and Serious Incidents

Ref No QS03

Document Objective To provide guidance to CCG staff on reporting and managing incidents, and to provide the framework for reporting and managing serious incidents (SIs)



Author Head of Quality

Approval process

Reviewed by Governance Committee / Q&P Committee

Date of review 28 October 2016 / 18 January 2017


Approval Date 25 January 2017

Equality Impact Assessment This policy does not impact negatively anybody with protected characteristics.

Category Quality and Safety


Policy History

Version No Date Amendment By whom

0.1 July 2016 Policy developed for HWLH CCG from existing policy in B&H CCG and using national guidance.

J Habben

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CONTENTS 1 Introduction and Purpose ..........................................................................4 2. Scope .......................................................................................................4 3. Definitions .................................................................................................5 4. Type of Incidents and Reporting ...............................................................5 5. Serious incidents ......................................................................................7 6. Never events.............................................................................................9 7. Requirements ...........................................................................................9 8. Policy Statement ..................................................................................... 10 9. Supporting organisational structures ...................................................... 11 10. Accountability and Responsibility for Policy and Implementation............ 11

11. Communication of Policy – Method and Responsibility...........................11

Appendix 1: CCG incident reporting form .......................................................... 12 Appendix 2: Incident Grading Matrix ................................................................. 15 Appendix 3: Examples of Serious Incidents for all settings ............................... 16 Appendix 4: Terms of Reference for Scrutiny panel .......................................... 17

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1 Introduction and Purpose 1.1 In organisations as large and complex as the NHS, things will sometimes go

wrong. High Weald Lewes Havens (the CCG) is committed to complying with the legislation and standards that require organisations to have a procedure in place for the reporting, investigation and management of all incidents allowing the organisation to learn and share valuable lessons, and continually improve systems and processes. This will lead to the organisation having an improved ability to commission high quality, safe, accountable healthcare, minimising risks to patients, clients, staff and the CCG, and maximising available resources.

1.2 Incident reporting is a fundamental tool of risk management, the aim of which is

to collect information about adverse incidents, including near misses, to facilitate wider organisational learning.

1.3 The CCG endeavours to improve commissioning by embedding risk

management into all areas of its business and ensures that the lessons are learned and improvements are made to the services as a result of an incident.

2 Scope 2.1 This policy details how to report all incidents and near-misses whether clinical or

non-clinical, including serious incidents and notifiable incidents. It applies to incidents that involve commissioned services, and CCG incidents; i.e. for patients, carers, visitors, staff, premises, property, other assets, data, or any other aspect of the organisation.

2.2 All CCG incidents should be reported following completion of an incident form

(see Appendix 1). Forms can be accessed via the CCG’s staff intranet or available from the Corporate Services Team. All incident forms should be completed using the Incident Grading Matrix (see Appendix 2).

2.3 Commissioned services will report and record incidents on their own incident

reporting systems. 2.4 All serious incidents are logged on a national database system called STEIS

(Strategic Executive Information System). Serious incidents occurring in Sussex are managed by a Patient Safety Team hosted by Brighton and Hove CCG (BHCCG), which provides this service on behalf of all the Sussex CCGs.

2.5 Incidents occurring in Primary Care service should be reported by the GP

provider directly to the CCG, as the responsible co-commissioners for Primary Care. Incidents deemed to be Serious Incidents will be reported on the STEIS system by the CCG for High Weald Lewes Havens practices.

2.6 Incidents occurring in other independent providers that provide NHS services, but

not directly commissioned by the CCG, are reported and recorded by the individual organisation, in accordance with their incident reporting policy. Incidents deemed to be serious incidents will be reported by the provider (if they

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have their own STEIS account), or the CCG where the service is located, on behalf of the independent provider.

2.7 The CCG and all service providers providing NHS care are expected to comply

with the NHS England Serious Incident Framework 20151.

3 Definitions 3.1 Incident: Any event or circumstance arising that could have or did lead to

unintended or unexpected harm, loss or damage to CCG commissioned services, patients, carers, visitors, staff, other members of the public, premises, property, other assets, information, or any other aspect of the organisation. They can involve any number of different factors, e.g. injury, damage, loss, fire, theft, violence, abuse, accidents, ill health, disruption to services etc.

3.2 Near Miss: An incident that did not lead to harm, loss or damage but had serious

potential to do so, where lessons can be learnt to implement changes in procedures, processes and systems, for example a prevented clinical/patient safety incident. This can be explained by the premise ‘if the harm did not reach the object’. ‘Object’ can be a patient, visitor, member of the public, staff, organisation, the service etc.

4 Types of Incidents & Reporting 4.1 Health and Safety Incident:

An unplanned and uncontrolled event that has led to or could have caused injury, ill health, harm to persons, damage to equipment or loss. These should be reported to the Head of Corporate Services (using Appendix 1). Examples of health and safety incidents include health compromise or illness directly work related, e.g. sharps injury, allergy, illness, disease, unsafe exposure to substances hazardous to health, infection, musculoskeletal injury, slips, trips and falls etc.

If immediate urgent medical attention is needed, the person/s affected should attend the Accident and Emergency Department as soon as possible - the details of the health professional attending to the person should be recorded on the relevant section of the incident form.

The person’s Line Manager should arrange Occupational Health follow up for staff as soon as possible where appropriate, at:

East Sussex County Council County Hall, St Anne's Crescent, Lewes, BN7 1UE

1 https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-

upd2.pdf

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/04/serious-incidnt-framwrk-upd2.pdf

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Tel: 01273 336335

Some accidents at work constitute an Injury or Dangerous Occurrence reportable under RIDDOR. If so, the Line Manager should report the incident to the Health and Safety Executive (HSE) via: http://www.riddor.gov.uk/.

4.2 Buildings Incident:

Where an incident occurs due to defects and failures in NHS Property Services Estates and Facilities:

The area must be made safe, preserving any evidence of defects or failures wherever possible.

Report to NHS Property Services.

4.3 COSHH (Control of Substances Hazardous to Health): Staff experiencing an incident associated with substances hazardous to health must report it to their Line Manager immediately, who will risk assess the situation and will immediately arrange an Occupational Health assessment. The Line Manager will ensure that the hazardous substance is quarantined pending further investigation and that the environment is safe and will liaise with HWLH CCG Health and Safety Manager to review the Departmental COSHH Assessment of the substance in order to prevent recurrence of the incident.

4.4 Medical Devices and Community Equipment Incidents: Managers should report any medical devices-related incidents to the relevant regulatory body and ensure that any devices involved are isolated for inspection. These are not likely to be common in the CCG.

4.5 Violence/Abuse/Discrimination:

Violence/Abuse: CCG staff who experience violence or verbal abuse should report to their Line Manager who will carry out an investigation. The staff member should also complete an Incident Report (Appendix 1) and send to the Head of Corporate Services. Incidents of discrimination are reportable to the Local Authority, including social, racial, religious, sexual, ethnic or age-related discrimination, etc. On receipt of an incident report detailing an incident of racism, the Head of Corporate Services (or other relevant person) will report the incident to the Local Authority’s Racial Harassment Forum, which co-ordinates responses to racist incidents within Sussex, via the following link: http://www.safeineastsussex.org.uk/anti-social-behaviour-and-hate-incidents-help.html

4.6 Fire Incident: Any incident involving a fire or any incident where the fire alarm sounds requiring evacuation (unplanned). A log of these are kept by the Head of Corporate Services.

4.7 Security Incident (including Information Governance breaches):

http://www.riddor.gov.uk/

http://www.safeineastsussex.org.uk/anti-social-behaviour-and-hate-incidents-help.html

http://www.safeineastsussex.org.uk/anti-social-behaviour-and-hate-incidents-help.html

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Any incident where a breach or a lapse of security is the dominating factor, e.g. theft or vandalism, premises window left open overnight, or data security incidents, e.g. missing health records, theft of a PC or unauthorised disclosure of patient identifiable information. Any data security or information governance incidents must be reported to the Information Governance Manager as soon as possible. Incidents will be graded in accordance with the IG toolkit. All other security incidents should be reported to the Head of Corporate Services as soon as possible after the incident has occurred. Where fraud is suspected, the local Counter Fraud Specialist service should be informed as soon as possible. Incidents of suspected theft or vandalism should also be reported to the police – in such cases, the crime number should be recorded on the incident form.

4.8 Patient Safety Incident:

Any unintended or unexpected incident that could have or did lead to harm (e.g. injury, suffering, disability or death – physical, psychological or social) for one or more persons receiving CCG commissioned, NHS-funded healthcare, e.g. an occurrence, procedure or intervention which has or could have given rise to actual injury, or to an unexpected or unwanted effect. All patient safety incidents will be assessed to see if it meets the criteria for a Serious Incident. These will be reported by the provider.

4.9 Medication Incidents:

The CCG Medicines Management and Quality team provides advice and support to service providers for managing and reporting medication incidents, including notification to the National Reporting and Learning System (NRLS). In the event of the CCG being notified of a controlled drugs (CD) incident, this will be escalated to the Controlled Drugs (CDs) Accountable Officer for Surrey and Sussex based at the NHS England Area Team.

4.10 Infection Control Incident: MRSA Bacteraemia/Clostridium Difficile and outbreaks. Incidences of community acquired MRSA bacteraemia and Clostridium Difficile are reported to the CCG Quality and Patient Safety team via the surveillance mechanism in place. A Post Infection Review (PIR) is coordinated by the CCGs Infection Control Specialist Nurse for MRSA blood stream infections allocated to the CCG, in line with national requirements. For Clostridium Difficile incidences, a root cause analysis (RCA) is conducted by the service provider where the incidence has been reported.

5 Serious Incidents (SIs)

In broad terms, serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare.

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The occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm to patients or staff, future incidents of abuse to patients or staff, or future significant reputational damage to the organisations involved. Serious incidents therefore require investigation in order to identify the factors that contributed towards the incident occurring and the fundamental issues (or root causes) that underpinned these. Serious incidents can be isolated, single events or multiple linked or unlinked events signalling systemic failures within a commissioning or health system.

There is no definitive list of events/incidents that constitute a serious incident and lists should not be created locally as this can lead to inconsistent or inappropriate management of incidents. However, examples of possible serious incidents are illustrated in Appendix 3.

5.1 Serious Incident (SI) reporting STAGE 1 – Initial reporting within the CCG

When it is suspected that an incident may fulfill the criteria of an SI the CCG Quality and Patient Safety team should be contacted and given a summary of the incident. The incident should also be reported to the appropriate senior manager and the Head of Corporate Services, in order to assess with the Communications Manager whether the SI will attract significant media interest. The Communications team will inform the NHS England (NHSE) Area Team Communications department and CCG Executive Team as required.

Out of hours, Serious Incidents should be reported to the CCG Duty on-call Manager. The on-call manager will liaise with NHS England on-call lead as appropriate.

A Scrutiny Assurance Group meeting will be convened by CCG leads to establish what actions are needed, and whether the incident constitutes a serious incident. Representatives at these meetings will vary in accordance with the nature of the incident.

STAGE 2 – Reporting onto the national STEIS database

If an incident is agreed to be a serious incident, the incident will be recorded and entered onto STEIS by the BHCCG-hosted Patient Safety Team, completing as much of the detail as is possible at the time of entry.

All SIs should be entered onto STEIS no later than two working days after the organisation becomes aware of the incident. If the organisation is not able to make a decision on the incident being a SI within this time then the BHCCG-hosted Patient Safety Team will inform NHS England of the delay.

STAGE 3 – Investigating an incident or serious incident

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Investigation of incidents and serious incidents, attributed either to the CCG, commissioned services or independent providers of NHS care, are carried out in accordance with the National Patient Safety Agency (NPSA) and NHS England framework for managing serious incidents. The usual method of investigation is a Root Cause Analysis.

Where a serious incident is also subject to investigation via the Safeguarding process (for children and adults at risk), the CCG will work together with the Local Authority and NHSE Area Team to ensure a thorough investigation is concluded that meets the requirements for both Safeguarding and Serious Incident investigation processes.

The Patient Safety Team will monitor that investigations of serious incidents are completed and submitted to the CCG within agreed timescales, i.e. 60 working days from the date submitted on STEIS.

STAGE 4 – closure of incidents and serious incidents

All SIs reported submitted to the Patient Safety Team will be reviewed initially by the Patient Safety Manager prior to submitting to the pan-Sussex Serious Incident Scrutiny Group, which meets on a fortnightly basis - see appendix 4 for Terms of Reference of the group.

Since the removal of grading of incidents in the NHSE Serious Incident Framework (2015) the Serious Incident Scrutiny Group approves closure or otherwise of all serious incidents for services commissioned by CCGs. Serious incidents in services commissioned by NHS England (e.g. secure and forensic mental health) will be forwarded to NHS England for scrutiny and closure.

Formal written feedback from the scrutiny panel (including requests for further information to enable closure) is given via the Patient Safety Team to the service provider’s patient safety and/or governance leads.

SIs given conditional closure status by the SI scrutiny group can be closed by the respective CCG Heads of Quality (or delegated Quality lead) following a satisfactory response to the SI panel feedback. SIs given a ‘kept open’ status are submitted back to the SI scrutiny panel for further scrutiny following receipt of additional information.

Extensions to submission deadlines of investigations reports may be granted for any delay in the investigation which is outside of the organisations control. Examples include:

Police investigation; Safeguarding investigation; Awaiting statements or reports from individuals not employed by the

Provider organisation; Awaiting external investigation reports; Extensive investigation required;

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Complexities around implementing the Being Open policy.

6 Never Events

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. The SI Scrutiny team will report all Never Events to the HWLH CCG Governing Body. A list of all Never Events will be published in the CCG annual report.

NHS England has defined 14 types of incidents as never events in 2015/16 (reduced from 25 in 2014/15), as described in the following link: http://www.england.nhs.uk/ourwork/patientsafety/never-events/

7 Requirements

7.1 NHS England:

HWLH CCG will inform NHS England of any exceptional Serious Incidents, including those with potential significant media interest and/or press enquiries from national media. This enables NHS England to offer advice and support in managing the incident, ensures that ministers and other relevant parties are briefed as appropriate and that the NHS is prepared to deal with enquiries from staff, patients, members of the public and other stakeholders.

7.2 NHS National Patient Safety Agency (NPSA): Patient safety incidents should continue to be reported to the National Reporting and Learning System (NRLS), in order to share lessons learned both locally and nationally to minimise the risk of recurrence.

7.3 NHS Litigation Authority (NHSLA): The NHSLA Risk Management Standard for CCGs requires the CCG to hold an approved document for the management of risks associated with all internally and externally reportable incidents, to include the reporting process for all incidents/near misses, involving staff, patients and others, along with the process for reporting to external agencies, the process for full and open communication with those directly involved in the incident and with other organisations e.g. neighbouring NHS trusts, other stakeholders, etc, and the process for monitoring the effectiveness of all of the above.

7.4 NHS Protect: NHS Protect is hosted by the NHS Business Services Authority (NHSBSA), but is directly accountable to the Department of Health (DH) for its work. NHS Protect provides national leadership for NHS anti-crime work by applying a strategic, coordinated, intelligence-led and evidence based approach and works in partnership with the NHS, DH, NHS England and key stakeholders including the police, Crown Prosecution Service and local authorities to take action against those who commit offences against the NHS. A Local Security Management Specialist (LSMS) – accredited by NHS Protect will work with the CCG to

http://www.england.nhs.uk/ourwork/patientsafety/never-events/

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establish a safe and secure environment that has systems and policies in place to protect NHS staff from violence, harassment and abuse; safeguard NHS property and assets from theft or criminal damage. The Counter Fraud Security Management Specialist (CFSMS) will lead investigations into serious, complex and/or organised cases of fraud, bribery and corruption.

7.5 NHS Information Governance (IG) Toolkit: The IGT requires the CCG to have documented incident control and investigation procedures that are accessible to all staff. Incidents relating to breaches of IG should be reported on a CCG incident form. IG incidents are to be managed by the CCG IG manager. After receipt of the completed incident form, the details will be logged into the Information Governance Toolkit Incident Reporting Tool by the IG Manager and an initial assessment will be obtained. If the incident is assessed at Level 1 or below on the tool, the incident will be managed by the usual incident process as detailed in this policy. If assessed at Level 2 or above on the tool it is then automatically reported to the Information Commissioner’s Office and DH via the tool and the SI process will be followed.

8 Policy Statement

The organisation can learn many important lessons through an open approach, which would not otherwise be learned where blame is apportioned or staff feel under threat through incident reporting. The CCG promotes a just, fair and responsible culture that fosters learning and improvement whilst encouraging accountability. The CCG is committed to an open and fair culture, promoting a non-punitive approach to the investigation of incidents reported. The Incident Reporting and Investigation Policy and Procedure is not primarily concerned with the disciplining of staff. The CCG recognises that a root cause analysis approach to investigating incidents focusses on systems processes and failures that allow errors to happen, and identifies lessons learned to enable improvements to be made that eliminate (or prevent as far as possible) the incident or error from re-occurring. Staff reporting and involved in incidents are assured that any investigations will be carried out fairly, without prejudice and with the aim of identifying and correcting underlying causes to prevent recurrence. They will not be subject to disciplinary action or suffer any material loss or disadvantage unless they have been negligent in their acts or omissions or willfully failed to comply with professional standards and codes of practice.

9 Supporting Organisational Structures

9.1 The contact points within the CCG for incident reporting for the above are as follows:

Clinical/ patient safety and Safeguarding incidents/near misses – Quality and Patient Safety team;

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Non-clinical incidents – Corporate Services team and/or Quality and Patient Safety team;

Non-clinical risk management issues – Corporate Services team;

Health and Safety incidents/near misses – Corporate Services team;

Risk Management System Administration – Corporate Services team;

Complaints – Complaints Manager, Corporate Services team;

Information Governance incidents – Information Governance manager, Corporate Services team and Quality team.

10 Accountability and Responsibility for Policy and Implementation

10.1 Chief Officer: The Chief Officer of the CCG has ultimate accountability for ensuring that effective systems of incident reporting, investigation and action are in place within the organisation.

10.2 Director of Quality and Primary Care: The Director of Quality and Primary Care has executive responsibility for ensuring the policy is followed.

10.3 BHCCG-hosted Patient Safety Team: The CCG Patient Safety Team Manager will manage the hosted Sussex-wide SI service, overseen by the BHCCG Quality and Patient Safety Lead. The CCG Quality and Patient Safety team will support staff to complete incident forms when needed.

10.4 Information Governance Manager: The Information Governance Manager will be copied into all incident reports relating to data security or information governance (IG) incidents. They are responsible for following the process detailed under section 7.5 of this policy. A quarterly Information Governance Committee will oversee all IG incidents reported, and monitor all actions are completed.

10.5 Quality Assurance Committee:

Monthly reports on SIs (including any new serious incidents reported and investigations submitted to the fortnightly Serious Incident Scrutiny Group) will be submitted to the CCG Quality Performance Committee.

11 Communication of Policy

The Incident Reporting and Management of Incidents Policy and Procedures will be provided to all new staff as part of the CCG induction included on the intranet. The Incident Reporting and Management of Incidents Policy and Procedures will be integral to HWLH CCG Risk Management Training programme. Department Managers must ensure that all relevant staff within their department have seen and follow the policy.

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Appendix 1: Incident Report Form Please read the High Weald Lewes Havens CCG Policy and Procedures for the Reporting of Incidents for further information about completing this form You should ensure that this form contains FACTS AND NOT OPINION. Serious Incidents must be reported immediately, regardless of the time of day.

Date of incident:

Time of incident:

Organisation(s) involved:

Location where the incident occurred:

Who/what was involved:

Member of staff ☐ / Patient ☐ / Visitor ☐ / Contractor ☐ / Equipment ☐

Other ☐ (please describe – for example theft, breach of confidential information):

Name and contact details of the person or persons involved with the incident (if any):

Did the incident involve:

Accident (e.g. slip, trip or fall) ☐ / Physical assault ☐ / Verbal abuse ☐ /

Other ☐ (please state):

Was the incident:

An actual event ☐ / A near miss ☐

What happened:

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What harm was caused (actual and/or potential):

Describe any immediate action taken to protect and/or improve patient/visitor/staff safety:

What, if any, immediate follow up action was taken to alleviate harm and/or prevent a reoccurrence

Please provide the name and contact details of any witnesses to the incident:

Were the police called?

Yes ☐ No ☐

Did Police attend?

Yes ☐ No ☐

Crime Reference No. (if applicable) Date

Name of Investigating Manager (usually the Line Manager):

If an investigation has been undertaken in respect of this incident, what was the outcome? Was Root Cause Analysis (RCA) used?

Please provide details of any ongoing action plan

Please specify whether information regarding this incident has, or will be reported to any other agency or body, e.g. Caldicott Guardian, Information Commission Office, Health and Safety Executive etc.

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Grade of incident Record your assessment by circling or highlighting the appropriate box on the

grid below. (See Incident Reporting Policy for guidance on assessing grade).

Consequence

Likelihood Negligible 1

Minor 2

Moderate 3

Major 4

Catastrophic 5

Certain 5

LOW 5

LOW 10

MODERATE 15

VERY HIGH 20

VERY HIGH 25

Likely 4

LOW 4

LOW 8

MODERATE 12

HIGH 16

VERY HIGH 20

Possible 3

VERY LOW 3

LOW 6

MODERATE 9

HIGH 12

HIGH 15

Unlikely 2

VERY LOW 2

VERY LOW 4

LOW 6

MODERATE 8

HIGH 10

Rare 1

VERY LOW 1

VERY LOW 2

LOW 3

MODERATE 4

HIGH 5

Your name and job title……………………………………………………….

Signature.………………………………………………………………………

Date……………………………………………………………………………..

Return completed and signed form to the Head of Corporate

Services at the High Weald Lewes Havens CCG office.

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Appendix 2: Incident Grading Matrix

Risk Scoring: Consider 2 aspects: 1. Likelihood of

the risk occurring

Versus:

2. Impact of the

risk occurring

Once you have decided upon the Likelihood and Impact of the risk that you are assessing, use the Risk Scoring Matrix to cross-reference these two aspects and determine the Risk Score. e.g. If you decide that the Likelihood of the risk occurring is ‘Unlikely’ (2) and the Impact is ‘Major’ (4), then the Risk Score is Moderate (8) It is important to record how you arrive at your score,

e.g. 2 x 4 = 8.

Impact: Negligible

1 Minor

2 Moderate

3 Major

4 Catastrophic

5

Potential impact on patients, staff, visitors, contractors, others: No real harm physically or psychologically. Minor non-compliance with standards. Minor cuts/bruises.

Temporary/low harm up to 1 month (physical or psychological). Staff sickness < 3 days. Single failure to meet national and/or internal standards or follow protocol. Includes healthcare associated infection.

Semi-permanent/ moderate harm (up to 1 year). Physical or psychological, but full recovery anticipated long term. Repeated failures to meet national and/or internal standards. Includes healthcare associated infection.

Permanent/severe harm, ie, loss of body part, misdiagnosis, poor prognosis, RIDDOR reportable injury. Failure to meet professional and national standards.

Unexpected avoidable death/s, suicide/homicide, multiple fatalities. Gross failure to meet professional standards. Absolute failure to meet national standards.

Potential impact on organization and resource implications: Minimal impact. No service disruption. No real risk of public concern/complaint. Negligible financial loss (consider theft, damaged equipment, compensation).

Some risk of property damage (broken chairs, windows, room closure). Some loss of user/patient confidence, small risk of user complaint. Extended length of hospital stay < 2 days. Increased level of care > 8 days. Litigation > £50k

MHRA reportable. Staff sickness > 3 days. RIDDOR reportable. Moderate loss of service user confidence. Local adverse publicity. Probable complaint maybe adverse publicity. Significant damage – requiring ward/service closure. Extended length of hospital stay > 2 days. Increased level of care > 8-15 days. Litigation > £50 - £500k

HSE Investigation. Inspection by Healthcare Commission, Public Inquiry, serious complaint anticipated. Staff sickness > 20 days. Breach of legislation or formal regulation. Public outrage. Loss of public confidence. Temporary service closure. Extended length of hospital stay > 15 days. Increased level of care >115 days. Litigation >£500k-£1m

Criminal prosecution. Extended service closure. Loss of essential service and contingency failure. Increased frequency of inspections (HSE, Healthcare Commission). Permanent removal of service. National adverse publicity andsevere loss of public confidence. Litigation >£1m

Number of persons affected: N/A

1-2

3-15 ie, toxic gas emission, violent incident, poor standard of hygiene – DandV outbreak

-50 ie, lost specimens, Hostage situation, DandV outbreak with ward closure

> 50 ie, vaccination errors, cervical screening concerns – failure to recall

Likelihood:

Rare: Hazard is not

expected to occur LOW

1

Green

LOW

2

Green

MODERATE

3

Yellow

HIGH

4

Amber

HIGH

5

Amber

Unlikely: Hazard occurs

infrequently, but remains a possibility

LOW

2

Green

LOW

4

Green

MODERATE

6

Yellow

HIGH

8

Amber

HIGH

10

Amber

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Possible: Hazard may

occur occasionally, ie, once or twice a year

LOW

3

Green

MODERATE

6

Yellow

HIGH

9

Amber

HIGH

12

Amber

HIGH

15

Amber

Likely: Hazard will

probably occur. We know from our experience that the hazard does present itself from time to time

MODERATE

4

Yellow

HIGH

8

Amber

HIGH

12

Amber

VERY HIGH

16

Red

VERY HIGH

20

Red

Certain: Hazard occurs

frequently. It is a constant threat, or is custom and practice, ie, daily, weekly, monthly

MODERATE

5

Yellow

HIGH

10

Amber

HIGH

15

Amber

VERY HIGH

20

Red

VERY HIGH

25

Red

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Appendix 3: Examples of Serious Incidents for All settings (Not exhaustive, intended as a guide only)

Serious incidents involving patients e.g. operation on wrong limb, screening errors, serious drug errors (including medical gases e.g. oxygen)

Unexpected patient death on NHS premises in unusual or suspicious circumstances.

Any situation whereby death causes significant media interest.

Serious injury, injury resulting in permanent harm, or unexpected death involving patients, a member of staff, visitor, contractor or another person to whom the organisation owes a duty of care.

Suicide or homicide committed by a patient with or without mental health problems, including service users who may have been discharged into the community but are still under the care of mental health services.

Serious damage to NHS property e.g. through flood, fire or criminal activity.

Outbreak of significant HCAI where there are 2 or more (epidemiologically) linked cases of a similar nature e.g. Clostridium difficile. Outbreaks of minor self limiting illnesses do not need to be reported as SUIs unless there is a significant impact on service provision or a significant impact on an individual patient.

An increase in the observed incidence of cases over the expected within a given time period. (HPA 2003)

All HCAI related deaths where MRSA or Clostridium difficile has been mentioned in part 1 of the death certificate (even if it was a secondary cause).

Major health risk e.g. outbreak of infection such as Salmonella, Legionella.

Chemical, biological, radiological or nuclear incidents (CBRN incidents).

Large scale theft, fraud, large confidentiality breaches or major litigation.

Suspension of health professional because of concerns about professional conduct, practice or criminal activity.

Incidents affecting large numbers of people.

Death, potentially life threatening injury, or permanent impairment of health or development through abuse, neglect or serious sexual assault.

Any loss or breach of confidentially where person/patient or service users are

identified. This can be paper documents, paper files, or electronic data which is

person identifiable.

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Appendix 4: Terms of Reference for the pan-Sussex SI Scrutiny Group

Pan-Sussex Clinical Commissioning Groups

Serious Incidents Scrutiny Group ___________________________________________________________________

Terms of Reference

Updated January 2016

Overall purpose:

The purpose of this group will be to agree closure of all Serious Incidents Requiring Investigation (SIRIs) for all NHS provider organisations and independent organisations whom NHS care is commissioned by CCG’s across Sussex as reported on SthEIS (Strategic Executive Information System). The decisions from the group will be authorised by the Head of Quality/Chief Nurse for each participating CCG and reported to the respective CCGs’ Quality Committees for assurance. For the purpose of the TOR, SIRI will be referred to as Serious Incident (SI). The closure group will:

Improve quality and patient safety through using a planned and robust approach to scrutiny and ensure organisational learning

Identify and action any recurrent themes in SI reporting

Provide economies of scale through central processing (administrative and clinical review) via the Patient Safety Team hosted by Brighton and Hove Clinical Commissioning Group for the Sussex CCGs

Ensure parity of SI closure for all providers SIs

Provide assurance to the CCGs’ Quality Committees and on to the relevant executive committees and Governing Bodies of each participating CCG

Duty of Candour legislation/CQC Regulation 20 - ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment

Review national reports and independent investigations (level 3) pertinent to patient safety and serious incident

The closure group will adhere to the Sussex CCG’s Incident Reporting and Management policies, which will align to the NHS England Serious Incident Framework (April 2015) and the National Patient Safety Agency National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (2010).

Membership: A core group of representative members are required:

- Chair (Head of Quality/Chief Nurse) – rotational from each participating CCG - Quality Assurance Managers ( or nominated representatives) from: - Eastbourne, Hailsham and Seaford CCG - Hastings and Rother CCG - High Weald, Lewes Havens CCG - Coastal West Sussex CCG - Crawley CCG - Horsham and Mid Sussex CCG

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- Brighton and Hove CCG - Patient Safety Manager (hosted by Brighton and Hove CCG) - Patient Safety Officer (hosted by Brighton and Hove CCG)

To be quorate the HOQ for each CCG or their representative presenting SI’s for closure must be in attendance at Scrutiny Panel.

Members will need to have a sufficient level of seniority in the clinical commissioning groups and have sufficient knowledge (or represent the views of other relevant clinicians outside the group) in order to aid decision making. The Patient Safety Manager may seek specialist opinion from clinical and non-clinical experts (e.g. adult and child safeguarding/ infection prevention and control, IT) for certain categories of SIs. In addition SI’s that involved specialist commissioning or public health will be sent to the NHSE South (South East) teams for review and comment prior to submission to the SISG. It is the responsibility of the meeting chair to ensure appropriate expert opinion has been sought and received at the beginning of the meeting. All closure reports generated by a quorate meeting will be forwarded to the executive sponsor. The sponsor will have ten working days to veto or amend closure reports, return to the BandH CCG Patient Safety Service for distribution to CCG’s and providers. If a member of the group has been directly involved as either an investigator or contributor in a RCA investigation, then this would be deemed as a conflict of interest and that person will not have involvement with the decision to close the incident.

Submission and Standard Documentation No SI will be submitted for closure unless a full comprehensive Root Cause Analysis (RCA) report has been submitted with accompanying action plan and evidence of compliance with appropriate provider level scrutiny. All RCA reports and action plans submitted to Brighton and Hove Clinical Commissioning Group Patient Safety Team by commissioned providers will be submitted on an approved NPSA template. All SI’s submitted for closure will be submitted with a Standard SI closure Submission Form front sheet attached with completed check list (Serious Incident Framework 2015 Appendix 8) and an expert review sheet if required.

Closure criteria SIs should only be closed when evidence of the following has been submitted:

A comprehensive, objective, analytical report of the incident

Duty of Candour legislation followed and clearly demonstrated

Clear and robust Investigation process and RCA methodology followed

The Root Causes and service/care delivery issues accurately identified

The learning identified for each Root Cause and significant service/care delivery issue

A SMART* action plan that covers all identified learning, including responsible individuals (By Role) and timescales. Evidence of completion should be submitted.

Evidence that it the final report has been scrutinised via the provider governance process, and authorised at corporate director level with no concerns raised

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The final report should be submitted in a format that can be wholly understood by patients, families and carers alike. All medical terminology and abbreviations should be fully explained either in the sub text (footer) or in a glossary. An easy read version should be made available for any patients with a learning disability, Braille version for any patients who are registered blind and evidence that an interpreter has been considered if a language barrier is identified.

*Specific Measurable Achievable Relevant Time-bound Providers may be invited to meetings in order to present investigation reports to the panel. Following closure of SIs via the scrutiny panel, action plans for individual SIs will be followed up via quality monitoring arrangements that are in place between Coordinating CCGs and their respective providers.

Reporting arrangements A Closure report will be produced for each provider using the standard template. All Closure reports will be sent to the Executive sponsor for each participating CCG on a bi weekly basis dependant on when meetings are convened. The decisions will then be reported by the Head of Quality to the respective CCG’s Quality Committees for further assurance. It is proposed that the current standardised proforma is used for the purpose of recording outcomes from the meeting, to include the following:

STEIS No.

Incident

Location/Trust

Closed – Yes/No

Conditional Closure – Yes/No

If no, action to take, by whom etc. In the event that the SI is ‘conditionally’ closed, the provider will be informed of the further information/assurance required in order to close the SI. The SISG Chair will request a response date. When the assurance has been received, this will be communicated to the provider lead commissioner, to agree final closure. The CCG where the patient is registered will also be updated. Downgrading an incident If following the submission of the final investigation report the members of the SISG agree that the SI does not meet the SI criteria, a ‘downgrade’ of the incident can be agreed and the incident can be removed from STEIS.

Frequency of meetings Any new RCA reports received by the BandH CCG Patient Safety Team from providers will be first line reviewed by Brighton and Hove CCG Patient Safety Team and assessed for closure at the Serious Incidents Scrutiny Group meetings. Reports will be forwarded to the group one week before the meeting. It is proposed the group meets on a monthly or 2 weekly basis according to volume of SI’s, in order to manage the number of reports from organisations, and enable timely review of closure of SIs in line with national standards.

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There will be occasion when an extraordinary meeting may be convened e.g. for a high profile incident or homicide review, or when a high volume of SI reports have exceeded their submission date and require closure.

Secretariat Meetings will be planned at least six months in advance by the Patient Safety Officer. Agenda will be circulated with the RCA’s embedded within, a week in advance of the meeting by the Patient Safety Officer. Minute taking / action log will be co-ordinated by the Patient Safety Officer. In the absence of the PSO the Patient Safety Manager will record the minutes/action log.

Addendum to TOR 10/07/2014 Legacy Serious Incident Investigations (Pre- April 2013/14). The Legacy Serious Incident (SI) investigations can be closed when the following criteria have been met:

Relevant learning and actions has been evidenced, audited and monitored by the provider.

There is continuous monitoring through the Clinical Commissioning Groups quality management review meetings between commissioner and provider.

The Head of Quality representing the commissioning CCG for the provider has the authority to agree closure, or to disseminate to the Serious Incident Scrutiny Group panel for further discussion with other HOQ/Chief Nurses as appropriate.