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Governing Body Meeting to be held on Thursday 6th February 2014 at 1:30pm in the Boardroom,
Nutgrove Villa, Westmorland Road, Huyton, L36 6GA
ITEM
1. Welcome and Introductions
Dr Andrew Pryce Chair
2. Apologies for Absence
Dr Andrew Pryce Chair
3. Declarations of Interest
Dr Andrew Pryce Chair
4. Minutes of the Meeting Held on 5th December 2013 & Matters Arising
Document 23(01)01 Dr Andrew Pryce
Chair
5. Community COPD Contract The Governing Body is asked to NOTE the content of the report and APPROVE a twelve month contract extension.
Document 23(01)02 Alison Van Dessel
Programme Manager
6.
Corporate Performance Dashboard 6.1 Exception report – Updated Clostridium
Difficile Action Plan The Governing Body is asked to NOTE the performance of the CCG and the updated Cdiff position and action plan.
Document 23(01)03
Mark Broderick Assistant Chief Officer
7.
HR Policies The Governing Body is asked to APPROVE the HR Policies and PDDR Procedure for immediate implementation.
Document 23(01)04
Dawn Boyer Head of Corporate Services
8.
Information Governance Policies The Governing Body is asked to APPROVE the information governance strategy and associated policies.
Document 23(01)05
Dawn Boyer Head of Corporate Services
PART B Please note that due to the nature of the business Part B of the meeting will
take place without press and public being present.
9.
Financial Allocations 2013-2019 and their impact The Governing Body is asked to NOTE the financial allocations and the relevant longer term assumptions.
Document 23(01)06
Paul Brickwood Chief Finance Officer
10.
Contracting update The Governing Body is asked to NOTE the progress made to date.
Document 23(01)07
Clare Barrow Head of Finance & Contracts
11.
Better Care Fund The Governing Body is asked to NOTE the content of the draft submission and AGREE to delegate to the Accountable Officer & the Chair the authority to approve the revised draft and final detailed two year plan.
Document 23(01)08
Philip Thomas Programme Director –
Transformational Change
GOVERNANCE COMMITTEE’S – KEY ISSUES
12. Clinical Quality & Safety Committee – September 2013 & October 2013
Document 23(01)09 Dr Robin Macmillan
Secondary Care Doctor
13. Finance & Performance Committee – September 2013 & November 2013
Document 23(01)10
Su Bramley Lay Advisor – Audit &
Governance
14. Audit Committee – December 2013
Document 23(01)11
Su Bramley Lay Advisor – Audit &
Governance
15. HR Committee – December 2013
Document 23(01)12 Ruth Austen-Vincent
Lay Advisor – Patient & Public Involvement
DATE AND TIME OF NEXT MEETING:
Thursday 6th March 2014 at 1:30pm
Boardroom, Nutgrove Villa
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Document 23(01)01
NOTES OF THE GOVERNING BODY MEETING held on Thursday 5th December 2013
in the Boardroom, Nutgrove Villa
Present Apology MEMBERS
Dr Andrew Pryce (Chair) Chair Dianne Johnson Accountable Officer Paul Brickwood Chief Finance Officer Dr Faisal Maassarani Clinical Lead - Unplanned Care Dr Aftab Hossain Clinical Lead - Prescribing Dr Peter Ayegba Clinical Lead - Mental Health Dr Pervez Sadiq Clinical Lead - Women & Children Dr Paul Conway Clinical Lead - Quality and Safety Dr David Stokoe Clinical Lead - Primary Care Quality Dr Ronnie Thong Clinical Lead – Strategy & Planning Dr Shweta Tewari Clinical Lead – Planned Care Dr Robin Macmillan Secondary Care Doctor Breeda Worthington Head of Quality & Safety/Lead Nurse Susan Bramley Lay Advisor – Audit & Governance Dilys Quinlan Lay Advisor – Quality & Safety Ruth Austen-Vincent Lay Advisor – Patient & Public Involvement Sheena Ramsey Chief Executive, Knowsley Council
IN ATTENDANCE Dr Simon Perritt Deputy Clinical Lead – Unplanned Care Clare Barrow Senior Finance Manager Matthew Ashton Director of Public Health, Knowsley Council Mary Spreadbury Chair of Healthwatch Present: Dawn Boyer Head of Corporate Services Mark Broderick Assistant Chief Officer Philip Thomas Programme Director – Transformational Change Victoria Parsonage-Howard Business Manager Debra Lawson Head of Commissioning, Knowsley Council Virgina Martin Local Counter Fraud Specialist, Mersey Internal Audit
Agency Andrea Kelly Personal Assistant
1 Welcome and Apologies for Absence: Action
Dr Pryce welcomed everyone to the meeting. Apologies were received from Paul Brickwood, Dr Simon Perritt and Matthew Ashton.
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2 Declarations of Interest:
There were no declarations of interest made.
3 Minutes of the previous meeting:
Philip advised that on Page 5, Paragraph 5 of the notes, ‘stretched resource’ should read ‘stretched performance’. With the above amendment, the minutes of the previous meeting held on 7th November 2013 were agreed as a true and accurate record. Matters Arising: Dr Macmillan confirmed that he did receive the information from Paul Brickwood relating to trust activity levels against the UK average and suggested it may be worth sharing further with the Governing Body. Mark confirmed that two exception reports will come to a future meeting regarding the rate of mortality in the under 75’s from cancer and did not attend (DNA) rates for mental health patients.
4 Patient Engagement Report: Action
Dr Thong introduced this item and confirmed Knowsley CCG’s commitment to involving the public in decisions it makes. He noted that public engagement is one of the more enjoyable aspects of his role and gave thanks to Ruth Austen-Vincent, Patient Participation Groups (PPG’s), Healthwatch and the CCG’s Corporate Services team for their work in producing this report. Dawn Boyer introduced this report which seeks to brief the Governing Body on the patient and public involvement activity undertaken by the CCG over the last year. Dawn explained that the CCG’s Communication & Engagement Strategy sets out the CCG’s strategy for patient and public involvement which includes:
• A commitment to involving patients and the public fully in the work of the CCG.
• The creation of a Patient Experience Group to ensure the CCG has effective arrangements for listening to patients.
• Building links into existing networks and groups. • Developing existing mechanisms for engagement with
patients who are not actively sharing their views. • Support the ongoing development of Patient Participation
Groups and their role in shaping CCG priorities. Dawn discussed in further detail the specific activities relating to each of the above priorities and acknowledged the time and support of the patients involved in these areas of work.
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Dawn explained that the CCG is now looking to refresh the Communication & Engagement plan. Ruth acknowledged the significant progress which has been made so far and explained that the CCG is keen to understand what has worked well and continue the work with Healthwatch and other partners. Mary Spreadbury acknowledged and gave thanks to the Healthwatch support team and their involvement in targeting hard to reach groups in the community. Dr Pryce noted the importance of using the information generated from this work. Dianne Johnson confirmed that this work is being built into the CCG’s future plans for improvement. The Governing Body noted the content of the report.
5 Winterbourne View Progress Report:
Dr Ayegba introduced this item which provides an update to the Governing Body on the actions being taken to meet the requirements of the Winterbourne Concordat: Programme of Action. Dr Ayegba thanked Debra Lawson and her team for the work involved in the production of this report and into the actions undertaken to ensure compliance. Debra referred to Appendix 1 of the report which shows the Winterbourne response action plan. There are six actions which have been completed and four which remain ongoing. Debra highlighted the ongoing actions:
• Maintain a local register of people with learning disabilities in secure units commissioning by Specialised Commissioning – There are new limitations in information sharing which mean that it is no longer possible to access patient level data about Knowsley patients place by Specialised Commissioning. Debra explained that conversations around this issue is ongoing and both parties are working together for the most joined up approach.
• Maintain an enhanced register that exceeds the recommendations of the report and identifies all out of borough residential placements – This work is ongoing.
• The Safeguarding and Quality Assurance Unit to review arrangements with all Local Authority areas where service users live – This work is ongoing.
• Commissioners to review contracts and service user access to complaints procedure and independent advocacy within all placements – This work is ongoing.
Debra gave a current status update which is that there are two adults in secure settings, one person is in assessment and treatment unit (ATU) provision with discharge planning already underway, and one young person is in secure provision with plans
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in place to return to Knowsley when they are 18. Debra noted some issues around obtaining similar information relating to patients who do not have learning disabilities. This needs to be looked at on a national level as well as locally. Debra explained that the Positive Behaviour Support Service (PBSS) is proving to be very successful in avoiding ATU and out of area placements. Dr Macmillan raised some concerns regarding the new information sharing limitations and asked if there was anything that could be done to ‘undo’ this. Debra agreed with these concerns and confirmed that work in this area is ongoing with NHS England (Merseyside). Dianne explained that Knowsley CCG is working towards becoming an accredited safe haven, which will allow the CCG to hold necessary patient information. The Governing Body noted the content of the briefing and progress on the local action plan.
6 Corporate Performance Dashboard: Action
Mark introduced the Corporate Performance Dashboard which provides information to update the Governing Body in key performance and to highlight exceptions. Performance Indicators Mark drew the Governing Body’s attention to the indicators which are currently showing at either red or amber and the accompanying narrative. Mary asked around the Friends & Family Test figure and asked if this means that people’s views are not being received. Mark confirmed that this is a response rate to this specific test rather than detail of people’s views on their care. Dr Macmillan noted the need to have a sufficient response rate in order to be able to analyse the data provided. Dr Conway confirmed that the CCG is involved in scrutinizing qualitative data at provider quality boards. Ruth asked if there is any more information available on the emergency readmissions within 30 days of discharge. Dianne explained there is some work ongoing in this area to find out more detail, information on this area will be brought back to a future meeting. Action – Further detail on the emergency readmissions within 30 days of discharge to come back to a future meeting. Ruth referred to the maternal smoking at time of delivery indicator and noted that there has been a change in the way this is being
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checked which may have an impact on figures. Dianne asked Mark to check this figure and bring back to the next meeting. Action – Mark to check the figures for maternal smoking at time of delivery. Finance Clare Barrow introduced the finance report and confirmed that the CCG is on target to achieve its 1% surplus, despite an overspend in acute contracts. Clare explained that QIPP remains on target with a £67,000 surplus to date, although the CCG is behind on the prescribing QIPP target. Exception Reports 7.1 – Clostridium Difficile Action Plan Dr Stokoe introduced this exception report which shows that the CCG has reached the annual threshold for Clostridium Difficile (Cdiff) cases as of November 2013. Dr Stokoe explained that these cases are predominantly in the elderly and those with long term conditions. Breeda Worthington advised that there have been some investigations into the suggested link between domiciliary care visits and Cdiff; these investigations have found no correlation between the two. It has been found that people with long term conditions history, the elderly and a people with a history of hospital admissions are the highest risk groups. Dr Stokoe explained that a revised trajectory has been internally set for monitoring which gives a new maximum of 48 cases for the year. 7.2 – Stroke Exception Report Dr Conway introduced the stroke exception report which highlights the areas for concern. These are:
• Not all patients being admitted to a stroke unit with 4 hours of hospital arrival
• St Helens & Knowsley Teaching Hospitals NHS Trust have a performance level lower than other providers.
• The position reflected within national reporting is not inclusive of those patients suffering a stroke whilst already admitted (approximately 20% of total stroke figure).
Dr Conway talked through concerns for each of the CCG’s stroke care providers. Dr Ayegba noted the increasing mortality rates for stroke in Knowsley and the differing outcome levels for patients seen during the day or in the evening and asked what pressure was
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being applied to raise standards. Dr Conway confirmed that this is happening through the Provider Contract Quality Boards. Ruth suggested that public information campaigns relating to stroke need to be tested with the Knowsley population and asked if there was any way the CCG could influence this. Dianne asked Hannah Cruikshank in Communications for further information on this. Action – Hannah Cruikshank to find out when the next national stroke campaign is scheduled. Clare explained that providers are incentivised to meet this four hour target and that it may be worth investigating whether this area can be incentivised any further. 7.3 – Paediatric Lower Respiratory Tract Infection (LRTI) Exception Report Dr Sadiq introduced this exception report and highlighted the key issues to the Governing Body. There has been a rise in A&E presentations and admissions at both Alder Hey Children’s Hospital and at St Helens & Knowsley Teaching Hospitals Trust. Dr Sadiq noted that 13% of attendances at A&E are admitted and 87% are sent home with advice and highlighted the need to target this area of education and improve the management of these children. Dr Sadiq described the actions being taken by the CCG to address this area. Dilys asked about the number of specialist asthma nurses. Dr Sadiq informed her that there are no paediatric asthma nurses at the moment; the plan is to look at using health visitors to address this need. Mary asked whether deprivation in the community can account for these high figures. Dr Sadiq confirmed that it does, and that education in this area for parents is one of the key areas to work on. Dr Maassarani agreed and felt there are also some issues with coding and once these are addressed performance in this area may improve. Ruth suggested it may be useful to talk to parents at A&E and discover the reasons why they chose to attend A&E. Corporate Services Mark explained there are no exceptions in this area to report. Susan Bramley asked about the sickness levels and whether this can be split down further into long and short term. Mark confirmed this can be done and confirmed there is currently no long term sickness. Susan also asked when the risk information will be available in
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this section. Dawn Boyer confirmed this would be available in the New Year. Dr Ayegba referred to the numbers of staff who have completed the training regarding Safeguarding and felt this needs to be looked at further. Action – Dawn Boyer & Breeda Worthington to look at the figures regarding Safeguarding training. The Governing Body noted the content of the performance dashboard and the areas highlighted within the exception reports.
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7 Contract Negotiation Process:
Clare Barrow presented this report to the Governing Body which identifies the key issues to consider in the contract negotiation process and looks at lessons learned from the previous round. Clare explained that it is currently the early stages of the contract negotiation process and that the Annual Planning Guidance is due to be published by NHS England. It has been established that further resource is required for this process, with two temporary analysts coming into post. Clare informed the Governing Body that the Commissioning Support Unit (CSU) held an event in November to agree the principles for this contracting process and agreed on a collaborative approach. Clare confirmed that a further update will come to the Governing Body in February. Dr Maassarani noted that the CQUIN schemes have allowed for significant improvements over the past 12-24 months and that the Clinical Membership Group (CMG) has highlighted some issues to work on for future schemes. Clare confirmed that the commissioning priorities agreed at the recent Protected Time Event (PTE) are being worked into this contracting process. Breeda advised the Governing Body that Quality Boards have been looking at current CQUINs to see if they have been achieved. The Governing Body noted the content of the report.
8 Anti-Bribery Compliance Strategy
Virginia Martin introduced the proposed Anti-Bribery Strategy and the accompanying report. Virginia explained that Paul Brickwood has reviewed this strategy and has approved in essence. The strategy has been developed to ensure compliance of the Bribery Act 2010. Bribery is defined as ‘an inducement or reward (either a financial or other advantage) offered/promised/provided or
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requested/agreed to receive/accept in order for someone to perform their relevant functions or activities improperly in order to gain a personal, commercial, regulatory and/or contractual advantage, on behalf of oneself or another’. Virginia explained that under this new Act, anyone can be personally prosecuted if they breach the Bribery Act and the organisation can be held responsible, unless it can show that it had in place ‘adequate procedures’ as part of anti-bribery corruption. Mersey Internal Audit Agency (MIAA) has developed and put in place an action plan for its clients, this is shown in the back of the report which reflects the new guidance. The Governing Body agreed to adopt the strategy, approved that the Chief Finance Officer is made the lead for taking forward the strategy and approved that assurance on this process is delegated to the Audit Committee.
9 Integration Transformation Fund:
Dr Maassarani presented this report which seeks to inform the Governing Body of the Integration Transformation Fund (ITF) and the required steps to ensure a local submission is made to the Department of Health by 14th February 2014. During the June 2013 Spending Review it was announced that a £3.8billion Integration Transformation Fund would be established to drive closer integration between health and social care in England. Dr Maassarani explained that ITF guidance has recently been released, a letter has been attached in Appendix 1 which provides initial information on the fund and the conditions and requirements for the CCG and local authority to work in partnership. The CCG has to provide a proposal to the Department of Health in February 2014 and the Transformational Change Programme Board has begun this process. Dr Pryce asked how much money this involves for Knowsley. Clare explained that the exact details need to be worked through, but we do know there is no new money available; it may be that the CCG needs to make more efficiency savings. On the 16th December 2013 official guidance will be released, and between now and then the CCG needs to shape its plans and programmes to hit the 14th February 2014 deadline. Ruth noted it is important to ensure the public are able to influence plans. The Governing Body noted the content of the report and the
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requirement of the Integration Transformation Fund.
10 Business Continuity Plan/Incident Response Plan
Breeda Worthington introduced the Business Continuity Plan/Incident Response Plan and asked the governing Body to accept these plans and support further developments in this area. Breeda explained that the Accountable Officer has the responsibility to ensure the CCG is in a position to respond to any emergency. The CCG is required to have guidance in place, an Incident Response Plan, Business Continuity Plan and a robust 24/7 on call system. Breeda noted that these plans have been in place since April and there has been training undertaken but there is an ongoing requirement for training and to have a senior person on call at all time. Breeda informed the Governing Body that these plans were tested in June when power went down for a couple of hours in Knowsley. Susan asked if there are any plans to build in a test of the plans. Breeda confirmed this has been discussed with the CSU who are setting up events for further training and scenario planning. Mary asked if plans have been considered for a ‘rolling’ series of events which affect business continuity and whether providers will be trained on these plans. Breeda explained that these plans are just for the CCG, not providers who will have their own plans to follow, however there is a requirement to work collaboratively. The Governing Body agreed to accept and approve the plan.
11 Details of the next meeting:
Thursday 6th February 2014 the Boardroom, Nutgrove Villa Westmorland Road, Huyton
L36 6GA 1:30pm
The Chair opened the meeting to a Question and Answer Session from the public: Q. Do the LRTI problems in children have anything to do with the nano-particles in pollution? A. Dr Ayegba – the incidence in these problems does rise in urban areas as air pollution does increase.
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Q. Are the friends and family tests anonymous? A. Dr Pryce – The information in these tests are anonymously recorded, but these tests are completed whilst the patients are still in hospital. Breeda – Different providers do work differently. The friends and family test is one way of obtaining views on care but it is not the only source of feedback the CCG considers. Q. I am concerned by the podiatry waiting times. Is there a list available of AQP providers? A. Clare –5 Boroughs Partnership is the biggest provider in this area; we can check and respond with a list of providers. Q. Can we have assurance that the CCG is not identifying property to be sold off? A. Dr Maassarani – NHS Property Services own the NHS property in the area. There is currently a survey being undertaken to ensure all premises are being used correctly and the space is being maximised. Q. The Declaration of Interest on the website has not been updated since October. A. Dr Pryce – Updated declarations have been done and they will be available by the next Governing Body meeting on the website. Q. Are choices being restricted on Choose & Book? A. Dianne – There have been some changes recently which Liverpool CCG has instigated. It is a trial at a new triage system, choices have not been taken away but the route in has changed. Q. We asked for papers ahead of the meeting but we did not receive anything this time. When will these be available? A. Ruth – We would like to suggest a pre-meeting for members of the public to support a better understanding of the items covered on the agenda. Dianne & Ruth to develop this and take it forward. Q. My GP has told me I cannot have my bloods taken at Broad Green despite being told previously this was okay. A. Dr Pryce – As far as I am aware you can have your bloods taken at Broad Green. We will look into this for you.
Document 23(01)02
Report to Knowsley Clinical Commissioning Group Governing Body Date of meeting: 6th February 2014
Report title: Community Chronic Obstructive Pulmonary Disease Service
Report presented by: Alison Van Dessel, Programme Manager
Purpose of the report: To detail the recent review of the Community COPD Service and request a contract extension of 12 months.
Recommendations:
Action / Decision required
The Governing Body is recommended to: • Note the content of the report • Approve a twelve month contract
extension in line with the contract terms
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred X
2. Safe X
3. High quality X
4. Cost effective X
5. Outcome focused X
6. Closer to home X
7. Affordable X
[one page only]
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GOVERNING BODY
KNOWSLEY COMMUNITY COPD SERVICE 1. Purpose of the report
1.1 The purpose of this report is to provide the Governing Body with an overview of the
Knowsley Community Chronic Obstructive Pulmonary Disease (COPD) Service, the progress it has made within the first 2 years of the contract and to request approval to extend the contract for a further 12 months following the end of the 3 year contract period on 31st July 2014.
2. Recommendations
2.1 The Governing Body is requested to:
a) Note the content of the report. b) Approve a twelve month contract extension.
3. Background
3.1 Chronic obstructive pulmonary disease (COPD) is an umbrella term for people with chronic
bronchitis, emphysema, or both. With COPD the airflow to the lungs is restricted. COPD is not reversible, is progressive, results in disability and shortened survival. It is one of the leading causes of morbidity and mortality. COPD is usually caused by smoking.
3.2 According to GP registers in Knowsley, COPD is significantly higher than the national rate.
Prevalence in Knowsley is double the national average, 3.5% compared with 1.7%. Within Knowsley the range of prevalence of COPD in practices is from 1.7% to 5.6%, the highest being more than three times higher than national levels. There are no practice registers within Knowsley where recorded prevalence of COPD is lower than national prevalence.
3.3 Following extensive and innovative service redesign by Knowsley clinicians a single
cohesive Borough wide Community COPD service was commissioned to provide accurate diagnosis and treatment of COPD.
3.4 In brief, the Community COPD Service is a consultant led service supported by a single
management team. The gateway into the service is via spirometry with an access time within 10 working days. Following spirometry patients with results indicating a diagnosis of COPD attend a consultant led multidisciplinary clinic where a definitive diagnosis is made, treatment commenced and advice given. These clinics are held in 7 locations across the borough of Knowsley.
3.5 Following open competitive tender the Community COPD service contract was awarded to Liverpool Heart & Chest Hospital NHS Foundation Trust (LHCH) and service delivery
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commenced in August 2011. The contract length is three years with the option of an extension for a further 12 months. The total value of the contract is £4.53 million.
3.6 There is a Rapid Response Service provided by specialist nurses and physiotherapist for patients with COPD who are experiencing an exacerbation of their condition. There is a 24 hour free phone number for advice and between 7am to 10pm specialist nurses can be contacted and are available to visit the patients within their homes within 2 hours of contact.
3.7 Pulmonary Rehabilitation, provided in leisure centres, can improve patients’ ability to
function and improve quality of life.
3.8 The service model puts patient experience at the heart of the service. The philosophy is that the service works for the benefit of patients as a seamless whole rather than a fragmented series of different administrative processes through which patients have to navigate. This ensures patients and their families/carers do not get lost in the interfaces between the different elements of the overall service.
3.9 The service was commissioned to deliver outcomes and this approach enabled the CCG to
improve quality and access while releasing resources for investment in other service initiatives. To achieve this, a quality outcomes framework was developed and meaningful incentives attached to delivery of the outcomes, i.e. the payment structure ranges from 80% block and 20% quality in year 1 to 60% block and 40% quality in year 3.
4. Evidence and Consultation
4.1 A comprehensive review of the first two years of the Knowsley Community COPD Service,
provided by Liverpool Heart & Chest Hospital, has been undertaken. The review covers all aspects of the service and covers primary care, patient/carer satisfaction and the impact of the service.
4.2 In order to achieve desired outcomes there was a meaningful quality incentive scheme with
outcome measures for each year of the contract. There are quality outcomes for each component of the service. The planned target percentage for each outcome increases each year of the contract.
4.4 In year one 80% of the total bid price was paid as a block payment with a further payment
to a maximum of 20% of the bid price paid if all outcome/quality measures were met. In year two 70% was a block payment with 30% of the bid price paid if measures were met with 40% of the bid price in year three being paid if the quality outcomes are met.
4.5 There were some concerns around the data supplied by LHCH to demonstrate
achievement of the outcome measures. A contract query was raised and an action plan was agreed by both the commissioner and provider who worked closely together to resolve the issue. The data has now been reconciled and LHCH has been able to evidence that it has achieved the required quality outcomes.
4.6 Diagnostics
4.6.1 Spirometry is the gateway to the service: once a diagnosis of COPD is made patients can access the other elements of the service including MDT clinics, pulmonary rehabilitation and the Rapid Response Service.
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4.6.2 Access time from referral to spirometry is 10 working days. Due to the way the
clinics were initially arranged the service was unable to meet this target however, by rearranging clinics the provider was able to meet this target.
4.6.3 All incentive targets for diagnostics were met. 4.7 Consultant Led Diagnostic, Treatment and Management Clinics
4.7.1 When designing the service the intention was for patients to access a high quality consultant led service in the community which would lead to reduced emergency admissions into secondary care.
4.7.2 Projected activity levels for the new service were shared with the CCG’s three acute
providers, reductions in activity plans were negotiated and funding was diverted into the community service.
4.7.3 All incentive targets were achieved for the consultant led MDT clinic element of the
service including the access target of 85% of patients being seen within 10 working days of referral from diagnosis.
4.7.4 The redirection of activity from secondary care and direct costs that can be attributed
to the impact of the service equate to £1,242,912 in financial terms. This has resulted in a reduction in emergency respiratory bed days in relation to COPD of 1,205 days. These savings are due to:
a. a reduction in the numbers of both short and longer stay inpatient spells b. reduction in NWAS call outs from home to hospital c. reduction of approximately 568 in COPD AED attendances d. reduction in outpatient first attendances.
4.8 Rapid Response Service
4.8.1 The Rapid Response Service is comprised of specialist respiratory nurses and physiotherapists. There is a 24 hour Freephone number for advice for patients experiencing an exacerbation of their COPD. The nurses are available from 7am to 10pm to respond to patients in their own homes within two hours. For some patients who may not require a home visit arrangements can be made for attendance at the next available consultant led multidisciplinary clinic. 99% of patients requiring face to face contact were seen within 2 hours of contact.
4.8.2 As part of the service’s winter plans reminder letters are sent to all patients on the
register to reinforce the signs and symptoms of an exacerbation, the appropriate action to be taken and the service’s contact details.
4.8.3 The service currently has 14 patients using telehealth and is currently exploring
using this technology as a way of minimising readmissions. This initiative was not specified in the contract and is something the provider has put in place.
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4.9 Pulmonary Rehabilitation
4.9.1 Pulmonary rehabilitation is an integral part of the clinical management and health
maintenance of patients with COPD. Pulmonary rehabilitation reduces patients’ symptoms, promotes self-management and helps patients to function better in day to day life. Pulmonary rehabilitation takes place in leisure centres and is offered in a variety of locations on different days and at different times in order to increase uptake and completion.
4.9.2 There are three quality outcome targets for Pulmonary Rehabilitation and all three
were met. In the past uptake of Pulmonary Rehabilitation had been poor so the service was incentivised to increase uptake and completion. 82% of eligible patients commenced rehabilitation against a target of 60% and 81% of patients completed rehabilitation against a target of 70%. Both targets increase in year three.
4.10 Early Supported Discharge
4.10.1 The service provides an Early Supported Discharge Service (ESD): specialist nurses have honorary contracts which allow them to go into local acute trusts, access case notes and assess patients with a primary diagnosis of COPD in order to assess their suitability for early discharge and support at home.
4.10.2 The acute trusts report that the Knowsley ESD service is effective and valued by
clinicians. The number of patients assessed does not match the number of patients reported as being admitted to hospital with a primary diagnosis of COPD. However as the CCG is no longer able to receive patient identifiable information there is currently no way to see if the numbers of patients are known to the service or had a discharge diagnosis of COPD.
4.11 Patient Experience and Satisfaction
4.11.1 The Community COPD Service was designed and procured in partnership with patients. The service was designed to put the patient at the centre of the service so that the service is designed around the patient. This is a concept embraced by the provider.
4.11.2 The service has been very well received by patients throughout Knowsley. The
provider obtains patient feedback constantly and presents the findings at each quarterly contract meeting. Reported patient satisfaction levels have been excellent from service commencement to the present time.
4.11.3 Knowsley CCG has undertaken patient and carer engagement to ascertain the level
of satisfaction with the service and to see if there are any areas that patients feel should be improved. Rather than hold events where patients would have to travel, members of the CCG team went to the patients, in the main. CCG support staff attended MDT clinics and pulmonary rehabilitation sessions. Healthwatch hosted a coffee morning and patients were randomly selected to attend to discuss their view on the service. Healthwatch also conducted telephone interviews with housebound
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palliative care patients and their relatives/carers. Responses regarding the service were very positive. Comments received are detailed in appendix 1.
4.12 Symptom control and management at end of life
4.12.1 The service provides symptom control and management for those patients identified as entering the palliative stage of the disease. The service offers a very high standard of symptom control and management for palliative care patients with COPD in collaboration with 5 Boroughs Partnership and the palliative care service. Each patient is assigned a staff member as a key worker to ensure that patients symptoms are managed appropriately and advanced care planning needs are met. All targets for this element of the service were achieved.
4.13 General Areas
4.13.1 An overall incentive target is a reduction in Emergency related bed days. This was an outcome incentivised to ensure the provider was motivated to continue to develop and improve the service. The table below shows the reduction in bed days since the COPD service commenced in August 2011.
Emergency respiratory bed days
Provider 2009/10 2010/11 2011/12 2012/13 2013/14 St Helens and Knowsley Hospitals NHS Trust 2157 2321 1973 2050 871 Aintree University Hospital NHS Foundation Trust 1507 1085 1319 1163 352 Royal Liverpool and Broadgreen University Hospitals NHS Trust 429 290 432 215 86 Liverpool Heart and Chest NHS Foundation Trust 14 7 138 Others 30 53 17 83 19 Grand Total 4137 3756 3741 3511 1466
* 2013/14 calculations are to month 6. 4.13.2 Another outcome of the service was to reduce the number of emergency
admissions to hospital and so to improve patient care and experience. In order to incentivise the provider of the community service to reduce emergency admissions a target was included stating that there would be a reduction of emergency admissions and COPD spells. This reduction is demonstrated in the table below.
Spells by provider by year Provider 2009/10 2010/11 2011/12 2012/13 2013/14 St Helens and Knowsley Hospitals NHS Trust 393 451 369 389 155 Aintree University Hospital NHS Foundation Trust 223 215 194 182 70 Royal Liverpool and Broadgreen University Hospitals NHS Trust 69 41 50 40 11 Liverpool Heart and Chest NHS Foundation Trust 2 2 11 Others 5 11 6 6 3 Grand Total 692 720 619 617 250
* 2013/14 calculations are to month 6.
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4.13.3 A survey questionnaire of GPs and Practice Nurses shows that they value the
service and in particular the communication in respect of receiving typed letters within 48 hours of the patient being seen. However there have been some comments regarding the content of the letters: patients receive copies of the letters and can find some of the medical terminology difficult to understand which results in patients visiting the GP seeking an explanation of the content of the letter. Generally comments were favourable and are included in appendix 1.
4.13.4 The provider recruited two respiratory consultants dedicated to the Community
COPD Service. They have been very proactive and have introduced many initiatives including working with North West Ambulance Service in order to reduce emergency admissions and have ensured evidence based care is provided.
4.13.4 The service team has worked very hard to build and maintain effective relationships
with other providers within Knowsley. This has resulted in patients moving smoothly between providers for services such as dietetics or palliative care for example and to facilitate the ESD service.
4.13.5 Knowsley CCG and LHCH won the HSJ Care Integration award in July 2013 for this
service and were finalists for the HSJ Primary Care and Community Redesign award category in November 2013.
4.13.6 LHCH has partnered with the British Lung Foundation who badged 14 of the
Community COPD Specialist Nurses. As badged BLF nurses they can share ideas with other badged nurses, attend study days and conferences and keep up to date with latest respiratory health developments all of which to support the improvement of patient care.
4.13.7 The Pulmonary Rehabilitation Service has been benchmarked against BTS
guidelines with the service meeting all recommendations and good practice points. 4.13.8 There is a counsellor attached to the service who has seen a rise in referrals of
COPD patients, their families and carers. 5. Proposals 5.1 The review of the current service demonstrates that the service has been successful in
achieving its targets, is valued by patients and has received good feedback from primary care clinicians. It has also demonstrated the willingness of the provider to work with the commissioner and to explore ways to enhance the care of patients with COPD.
5.2 The service is now into its third year of a three year contract and consideration is needed as
to what happens at the end of the term of the contract: 5.3 Two options are available:
5.3.1 Option 1 – Extend the contract by 12 months: by extending the contract for a further
12 months it would ensure continuity of a high quality local service for patients with
7
COPD. There will also be a reduced reliance on hospital services. Care would be managed smoothly via the administration hub. This would allow time to re-specify the service in line with the CCG’s year strategic plan.
5.3.2 Option 2 – Do not extend the contract: In this option if the contract is not extended
then the contract and service would finish at the end of July 2014. If the service were to finish the consequence would be that COPD care would return to the Acute Trusts. The service was commissioned in order to provide a high quality COPD service, however if the care returned to secondary care there would be inequity of service provision across Knowsley with the ethos of care closer to home being negated as patients would need to travel to hospital rather than a local venue for their care. Also there would not be a cohesive service that proactively acted to prevent hospital attendances and admissions. As there would no longer be an administration hub there would be “hand offs” and delays between different elements of COPD care.
6. Impact on Services to the Population 6.1 All groups of the population are able to access the service in a variety of community
localities should they have a clinical need to do so. The service provides easy access to support information 24 hours per day.
7. Resource Implications
7.1 Financial
7.1.1 If option one is the preferred option and the contract is extended for a further year then the contract cost for 2013/14, £1,509,304, would apply with an inflation increase of 2.5%. The quality incentive scheme would still apply with 60% of the bid price paid as a block payment and 40% of the bid price being paid if the quality outcomes are met.
7.1.2 If option two is the preferred option this would mean activity would return to
secondary care savings would be lost and costs will increase.
7.2 Human Resources
7.2.1 LHCH is the current provider of the service, if the contract is not extended then the staff that provide the service would be affected.
7.3 Technology
7.3.1 There are no technology issues.
7.4 Physical Assets
7.4.1 The current provider uses estate owned by Propco, and would continue to do so. In the future there will be charges to providers for accommodation that is used. The actual cost is not yet known.
8
8. Risk Assessment
8.1 If the contract is not extended there will be no Community COPD Service, which could lead to reliance on secondary care to provide COPD services which in turn would lead to the CCG paying national tariff for services and no savings made. This would also lead to inequity of care across the borough and reduced level of quality of COPD care.
9. Summary 9.1 The contract with LHCH to provide the Knowsley Community COPD serviceends on July
31st 2014. Consideration needs to be given to the future of the service as outlined in the options above.
9.2 If the contract is not extended a quality service will be lost, care will be spread out to
different providers with inequity of care across Knowsley. A dedicated team, including two respiratory consultants, will be “lost” including their ambition to further improve the service.
9.3 There is clear evidence of the Community COPD Service performing well including positive
patient feedback and experience, reduction in hospital admissions and is in line with the ethos of managing ill patients in the community with appropriate support.
Clinical Lead: Dr Shweta Tewari Managerial Lead: Alison Van Dessel, Programme Manager
Contact details: Alison Van Dessel
[email protected] 0151 244 4166
Background Documents: None Appendices:
• Feedback report
Appendix 1
Community Chronic Obstructive Pulmonary Disease (COPD) Service
Patient, Carer and Referrers
Feedback Report
November 2013
2
Contents
Title Page 1. Purpose of the Report
3
2. Review Methodology 3-5 3. Respondent sample 5 4. Results and analysis 6.-21 5. Respondents 6. Conclusions and Recommendation
21-22 22-23
6. Appendix 24-39
3
1. Purpose of the Report 1.1 The community COPD service which is delivered by Liverpool Heart and Chest Hospital
NHS Foundation Trust (LHCH) has undergone a full service review as the existing contract comes to an end in July 2014. This document serves as one part of the review. The review seeks to elicit the views of the people who are currently using or have recently used the service. The core of the review is trying to establish what works well and identify any improvement needed within the service. This report feeds back the information gathered from patients/ carers/ family members and other stakeholders.
2. Review Methodology 2.1 Overview
2.1.1 The CCG sought the views of patients who have accessed the different elements of the community COPD service. The methodology began with defining the areas of service to be explored. The defined areas of services are:
a. MDT Clinics (including Spirometry/Oxygen Assessment); b. Pulmonary Rehabilitation; c. Rapid Response; d. Housebound.
2.1.2 The CCG identified who it wanted to speak to and who should be involved in the
review. It then set up various types of review to get the most holistic results. The four types of review are detailed below:
a. Patient/carer Questionnaires, Face to Face b. COPD Patient and Carer Coffee Morning c. Telephone Interviews d. On line survey
2.2 Patient/carer Questionnaires, Face to Face.
2.2.1 This part of the review sought the views of individuals who were current patient/carers and also included carers or family members. The questions asked were based on experience of MDT Clinics, Pulmonary rehabilitation and the Rapid Response service.
4
2.2.2 Questionnaires were developed and completed by patients in a variety of locations.
2.2.3 The patient/carers were then given an explanation of the purpose of the
questionnaire, some direction on the format of the questions and were asked to complete it openly and honestly. If requested by patients/carers CCG staff scribed their answers.
2.3 COPD Patient and Carer Coffee Morning
2.3.1 This part of the review sought the views of individuals who were current
patient/carers. The questions asked were based on experience of MDT Clinics, Pulmonary rehabilitation and Rapid Response service.
2.3.2 The coffee morning provided a setting for a group discussion and was facilitated by
colleagues from Healthwatch Knowsley. 2.3.2 The setting and the discussion was informal with prompts only when needed. This
was done purposely to allow the conversation to flow more naturally and to encourage the group to speak to each other about their experiences. This was recorded on a flip chart as the discussion took place and there was also a note taker recording the discussion points.
2.4 Telephone Interviews Palliative Patient/carers
2.4.1 This part of the review was targeted to obtain the views of patients with COPD who
are housebound and their carers. 2.4.2 The patient/carers were identified by the COPD consultants. Once identified
permission was obtained and Healthwatch Knowsley carried out the telephone interviews.
2.4.3 The purpose of the telephone interviews was to get a detailed patient/carer view of
the service, giving the CCG an in-depth insight into those patient/carer experiences.
Venue Activity Date Manor Farm
Health Centre COPD Clinic
Questionnaire Wed
20/11/13 Huyton Leisure Centre
Pulmonary Rehabilitation
Questionnaire
Thurs 21/11/13
Kirby Leisure Centre
Pulmonary Rehabilitation
Questionnaire
Tue 26/11/13
Halewood Leisure centre
Pulmonary Rehabilitation
Questionnaire
27/11/13
5
2.5 On line survey 2.5.1 This part of the review was to elicit the views of GPs and Practice Nurses who refer
patients into the community COPD service. 2.5.2 A survey monkey was chosen to obtain views from referrers because this has
previously been a successful way of obtaining feedback.
2.5.3 The survey asked questions which specifically looked at the service from a clinicians point of view.
3. Sample and response rate
3.1 Patient/carer Questionnaires, Face to Face
3.1.1 5 clinics were targeted with a total of approximately thirty eight patient/carers in attendance. Twenty six agreed to take part in the review. Of that twenty six there were 13 males, 13 females.
Target 5 clinics Number of patients/carers 38 Number agreeing to take part 26 Female 13 Male 13 Over 60 22 Under 60 4
3.2 COPD Patient and Carer Coffee Morning
3.2.1
Number invited 50 Number attended 13 Female 10 Male 3 Over 60 13 Under 60 0
3.3 Telephone Interviews Palliative Patient/carers
3.3.1 Equality and diversity data isn’t available on these patients as the interviewer was unable to collect the additional data. Five patients and their carers were identified for interview. Five patients and two carers took part. Three patients were male and two were female.
3.4 On-line survey
3.4.1 The survey was sent to 150 Knowsley GP’s and practice nurses. 30 responses were received giving a response rate of 20%.
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4. Results and Analysis 4.1 Review 1 (Patient/carer Questionnaires, Face to Face)
4.1.1 Types of services
(a)
(b) All the patient/carers had had experience of Spirometry and attended clinic, all had an awareness of rapid response but not all had had the need to use it. 3 of the 4 questionnaires were completed in rehabilitation sessions. This is not necessarily in indicative figure of the percentage of COPD service users attending rehabilitation.
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12 13
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Spiro Oxygen Assess Rapid Response Pulm Rehab
Number of Consulted Patients with Experience of the Varying COPD Services
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4.1.2 Clinic
) (b) The above graph indicates how the patient/carers feel about certain aspects of
clinic. All the patient/carers were satisfied with venues, times and treatment at clinic. One patient said they didn’t receive an appointment so missed it first time but has since been satisfied. Patient/carers who said they didn’t receive reminders said that they didn’t feel they needed one. Those that did receive reminders had welcomed them. This suggests that the reminder service is not offered to all patients.
(c)
What the patient/carers said was good about the COPD clinics
• Really helpful, nice staff • Flexible • Treated really well, brilliant • Happy with the service • General service was good on every level this includes the
consultants, nurses and the 8 week course at rehabilitation • All the staff are friendly and happy to answer questions • With each test undertaken staff explain what the results mean and
what I should do in certain circumstances. • Professional • Weren't too pushy but nice and polite - gradual • Efficient and caring • The team check you before you start and explain everything in detail • People are good and know their job. • Excellent • They explained about inhalers and what I was doing right • They put you at ease, they relax you and explain everything
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Yes No Yes No Yes No Yes No Yes No
Happy with clinictimes and venues
A choice of am/pm Communicationbefore appointment
Receive a reminder Treated with Dignityand Respect
Satisfaction with Aspects of Clinic Appointments
8
• I can really feel the COPD team are helping me a great deal. I feel better in my mind and body
• Felt i could talk to the doctor and she listened well to my queries and concern
• I got feedback and respect • It's local, the staff are extremely polite and it's good to know there is
someone at the end of the phone. • Met all expectations • Wonderful people • Very considerate • I am treated as an individual • I felt believed
What the patient/carers said we could do to improve the COPD clinics • Bit of distance from West Derby, Stockbridge would be better but
restricted by time due to work • I am happy with the service I receive and the experience is fine • Satisfied with services as they are • You can't it was fine • It would be very hard to improve • Nothing x 11
(d)
Other comments about the Clinics • It's really good to have the backup of the unit. I don't need to access
the GP - the service can assess me • All the staff offer good support • Good service • It's great • Really good service, didn't know anything but I feel informed and
supported now • The service is very good • Everything is fantastic • Got the answers I was looking for • The COPD team have been excellent in their advice and help with
my exercises • Great guidance • Referred me to rehabilitation • It is a great service
(e) The patient/carers had some good comments about what they liked about the
clinic, in general they seemed to feel supported and listened to which gave them great reassurance. Comments indicated a good flexible approach to patient care. The only one negative was due to there not being a clinic in the right area on the right day, the lady had been offered nearer clinics but couldn’t attend due to work commitments but she said they had arranged taxis for her so she could still attend.
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4.1.3 Rapid Response
(a)
(b) The graph above shows that patient/carers who have used rapid response have had a good quick service. Over half of the patient/carers waited less than an hour and the rest between one and two hours. They all seemed happy with the speed of the response from the team. All but one person felt the staff were extremely responsive: one patient felt they were reasonably responsive but wasn’t happy as she had been advised to call an ambulance and she didn’t like hospitals. They all said they felt fully supported by this aspect of the service. The patient/carers who were consulted felt the rapid response had helped them to manage their condition but some couldn’t say fully as they were still working with the team to get it under control, this wasn’t a negative reflection of the rapid response service.
(c)
What the patient/carers said is good about the rapid response service • Being able to have preventative treatment with advice • A dedicated team specialising in COPD removes the need for GP
appointments for general monitoring and treatment • Efficient • The service felt personal - it felt like staff cared • It saves you going to hospital • Nurses are there at the end of the phone call - you can't get an
appointment with the GP • They get to know you • You are treated as an individual • You feel they have time for you • Everything • All of it
1
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0 0 0 1
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2-4h
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Not
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Fully
How did youreceive
response
How long did you wait How responsivewere staff
Did you feelfully
supported
Did the adviceenable you to
manage condition
Satisfaction with Rapid Response Service
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How the patient/carers said we improve the rapid response service • They should get to know you • You couldn't • I am happy with the service at present • No cannot improve they are very quick • No improvements needed • It would be difficult to improve
(d) The patient/carers who had used rapid response felt it was a quality service.
They very much felt like they were listened to and more importantly they were understood and cared for. Some of the patient/carers mentioned how it stopped them having to keep going to GP and prevented them from worsening so much they would end up in hospital. They all felt reassured by the service being there. Just one patient said she felt they didn’t take enough time to get to know her and her circumstance; this is her experience and it is valued but not reflected in others views.
4.1.4 Pulmonary rehabilitation
(a)
(b) Everyone agreed that the time of the rehabilitation sessions were great, when asked if they’d prefer more choice they individually said they choose when and where they want to attend anyway. One person wasn’t happy with times and wanted early morning. All seemed happy with their programmes and totally understood the reason for it and how each exercise worked for them. They may or may not been involved in the design but all were happy with the fact that they felt at ease to say if it was comfortable or not and if they wanted it changing.
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Yes No Yes No Yes No
Does the time of sessions suit Was you included in thedesign of your programme
Do you Understand theProgramme
Satisfaction with Elements of the Pulmonary Rehabilitationilitationilitation Service
11
(c)
What is good about the pulmonary rehabilitation service • Good advice given • Everything • Confident in knowing people will respond and rehabilitation provides
good fitness management and camaraderie exists between patients • Everything • I feel much better after I have been • You are not pushed too far too soon brilliant I will miss it • I am not getting worse • The atmosphere is very sociable • There are different talks every week • The personal attention from staff • The staff are very good at their job, explaining what each exercise does
for you It teaches me to cope with COPD • I feel in control of COPD • Everything - I like coming here • It is flexible - I feel it is definitely helping - there is a friendly and social
aspect • Lovely • The help, advice and courtesy from all of the staff • There is a social aspect • I have confidence doing exercises knowing i am being monitored • Lovely staff • There are additional people who come into the group to give advice • Everything • It helps to feel reassured especially through the winter • I enjoy the challenge, it helps with motivation and confidence in walking • I love it, it's really helpful. I feel less raspy, I think it's marvellous. Learn
from others, and good socially • Coming together with people who understand. It is comforting to know
the service is here • Physiotherapists help and explain and support is excellent
How could improve the pulmonary rehabilitation service • They could do with some upgraded equipment
(d) Very positive comments about pulmonary rehabilitation. There seems to be general themes that the patient/carers feel are a positive aspect and come through strongly. The three themes are the health benefits, the social aspect and the reassurance and support it brings.
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4.2 Review 2 (COPD Patient and Carer Coffee Morning)
4.2.1 Clinics
The Staff and General Care: • Very nice at the clinics, they are very positive and caring. • I cannot fault the clinics. My mum has COPD and lung cancer. The
COPD nurses do more for my mum than the GP’s. • The clinics are there when you need them, there is no pressure – they
advise you what you can do. • You feel that they listen. They ask whether you need any help. • They treat you as an individual. • Nurses at the clinic have advised me to contact them sooner rather than
later and they will get me an appointment to see a nurse at a clinic as a preventative measure.
• The services are there when you need them • The service is a safety net • The service is very person centred
Analysis: the patient/carers felt very well supported and cared for and couldn’t find any fault with their treatment at the clinics. The patient/carers felt listened to and treated with respect. They all felt the service adapted to their needs.
(b)
The Time and Place of the Clinics: • They come to Manor Farm surgery and ask what time suits you. • They know I can’t attend before 11am so they make my appointment for
11:30am. • They are there for you at a time that you want. • They will order you a taxi if you need one. • I travel to North Huyton for my oxygen. • They can do your arterial gases at home. • Information on what will happen during you appointment is explained in
the letter you get prior so you have an idea of how long you can expect to be there and what procedures will be carried out.
• You only wait between 5 and 7 minutes for your appointment and they don’t rush you.
• They care about you as an individual. • I have never had a problem. • I was at the clinic for 1.5 hours. I don’t mind waiting because they listen
to you. • The consultant asks whether you have any questions and listens to you.
They are interested in what you are saying. • If you go on a good day for you, they don’t make you feel like you are
wasting their time. • Evolution & improvement in the service has come from patient/carer
feedback
13
Analysis: Everyone said they have choices about when and where they attend clinic. The group agreed waiting times are short apart from when seeing the consultant. They did say they don’t mind waiting to see the consultant because she is very good and will listen to them for and keep explaining for as long as it takes, as a result the consultant appointments may run late but they wouldn’t change that.
4.2.2 Rapid Response
(a)
General discussion in the group brought about the following comments about Rapid Response: Staff and General Care • Very, very good, they used to come to my husband. • Excellent, always on the end of the phone, they will come out from 7am
to 10pm after that they are there to give you advice. You are never on your own. I am alive thanks to them
• They will do anything they can to keep you away from hospital. • If you need anything they will help you • Best COPD service in the country • I feel safe and supported • Service makes you feel safer in the community • They are responsive to each individuals needs • They have leant over backwards to allow my sister to go to a wedding in
London, the delivered the oxygen to the hotel • If I go home to Ireland, my oxygen is delivered there – there is good
liaison between the services • They go above and beyond – it is down to the dedication of the staff • I cannot fault the COPD team in any way – the service is second to
none. It has changed since it has moved to The Heart and Chest Hospital for the better in some ways Analysis: The patient/carers valued this service and it very much meant they could relax and not panic about their condition. It was seen as a vital lifeline.
14
(c)
General discussion in the group brought about the following comments about Rapid Response: Response Time • The COPD nurse came out within 30 minutes which avoided my friend
going into hospital • There is a difference in COPD service in Liverpool - you often have to
wait, it is not rapid response, whereas Knowsley COPD rapid response came out within about within 1-2 hours. The response is in the main under an hour.
4.2.3 Pulmonary Rehabilitation (a)
Staff and General Program • At the moment, I can’t do exercises or commit, they have told me I can
go on the exercise programme “when I am ready” • I would like to be able to continue with the fitness regime in the gym
after rehabilitation finishes(move to rehabilitation one) • My husband is going to the gym today and they have called him to
make sure he is up to it. • Makes me feel ‘beyond excellent’ • Teach you the exercises so you can continue when the sessions stop
(c)
Venues and Times • If you can’t get there they will come to you • They come out for an hour at my house • Venues are nice and local
(d)
Analysis: Again the comments were agreed by the entire group and demonstrate the flexibility and the personalisation of the COPD care given to the patients. Comments demonstrated both the physical and social aspects of pulmonary rehabilitation were positive. Some patient/carers had not experienced this service yet but were looking forward to getting started when the time was right for them.
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4.2.4 Other Comments about the COPD Service (a)
The things we like most: • They ask about you and your family which relaxes you. • They make you feel relaxed as you can be quite nervous when you go
in. • They ask you as a carer how you are feeling. • My mum says that she trusts the COPD nurses more than her GP. • COPD nurses can prescribe medication. • I have a real trust in the service. • You see a lot of different nurses but they know you. There is excellent
communication. Even the person on the end of the phone knows you. • If you went private you would not get a better service Analysis: The group couldn’t praise the overall service enough it was evident they felt safe, supported and cared for. They really had to be pushed for suggestions on improvements. One of the improvements suggested is that this service needs to be held as best practise and other services should be modelled on it.
(b)
What could be improved upon: • The COPD service should use their service as a best practice model
“blow their own trumpets more”. They are an example of good practice. They are a benchmark for other services
• Social isolation can be an issue – details of social activities should be included in leaflets about the service, Leaflets should be distributed to alternative locations such as hairdressers/barbers where patients would have the time to sit and read about the service, alternatively leaflets could go to chemists and be put in the bag with the medication if this is appropriate to COPD
• Having support groups in the day so people can attend. • Masks for the nebulisers are not easily accessible, you cannot get these
locally. • CHAS support group is currently running but group members were not
aware of it Analysis: There was a lot of agreement in the group that they weren’t informed enough about other services outside of the ones provided by the COPD provider. They felt there should be more information given to them via their COPD nurses regarding groups. There were also other suggestions on how to get the word out about support groups etc. They felt Pulmonary rehabilitation was very much enjoyed for the social aspect and there should be more opportunities to meet socially with other COPD sufferers.
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4.3 Review 3 (Telephone Interviews Palliative Patient/carers)
4.3.1
(a) Patient A’s Experience: Both the patient and her husband use the service and they care for each other so this is their joint opinions of the service as patients and carers. They think the COPD service is marvellous, and feel fully supported within this service. They find that they have been given lots of information about COPD and have a good understanding of their condition from this. They said they feel the COPD nurses are Wonderful and that they are treated with dignity and respect. Patient A and her partner have been signposted to Willowbrook Hospice and social service. They have also been signposted to the Princes trust for carer support.
(b) Patient A and her partner used to have to go to Whiston for appointments and although they felt the staff there were very supportive the access was an issue with longer travelling time, limited car parking and paying to park, whereas now it is easier more local and free and plentiful parking and this makes a big difference to their patient experience.
(c) Patient A and her partner said the best thing about the service is that they are there for you, you are never left waiting or wondering and you get what you ask for. They said the nurses are brilliant and named Alma as a specifically brilliant nurse. They also commented that Dr Sara is brilliant. They feel there is no way to improve the service as it is wonderful.
4.3.2 (a)
Patient B’s Experience: Patient B felt the service came at the right time and that they have been treated with dignity and respect, they feel they have been well informed. The only other service they have been signposted to is Physiotherapy.
(b)
The biggest difference the service has made to them is having the reassurance of the knowledge that if you need them they will be with them within 2 hours. They suggested that the service should be extended to cover Liverpool.
17
4.3.3 (a)
Patients Cs Experience: As told by carer. Patient C’s wife explained that they were informed about this service before they needed it, but when they did need it was the first place they turned to. Having the knowledge they were there was a reassurance. They feel they are very much treated with dignity and respect and that they are supported 110% by the service. They have been given plenty of information about COPD and have a good understanding of the condition.
(b)
Patient C was signposted to several services, they haven’t accessed them all but feel it is good to know about them. The services they have been told about include; therapy groups, physiotherapy, breathing exercise groups and a dietician. Patient C feels that the biggest difference the service makes to them is that they now get the correct information, the right support and the correct medication. Prior to this they would be visiting GP’s but they feel the COPD clinic are more experienced and qualified to treat them correctly.
(c)
Patient C’s most positive experience is the quality of life they give and the knowing that they are always there when you need them. They both feel they are given the right support when they need it and the professionalism of the staff is evident. They feel no improvements can be made to the service; they are 100% happy from reception right up to consultants.
4.3.4 (a)
Patient D’s Experience: Patient d said the service is wonderful and it came at the right time for her. She said she is treated with respect and fully supported. Patient D has been given plenty of information and said you cannot fault the staff.
(b)
Patient D said they have been referred to other services such as physiotherapy and complimentary therapies. The biggest difference to patient D is the reassurance she has knowing they are there 24/7.
(c)
Patient D says the best thing about the service is the knowledge that she is safe and looked after. Under improvements she said that sometimes when seeing different nurses they can give you conflicting advice.
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4.3.5
(a)
Patient E’s Experience: Patient E said that in his experience the service is very good, it came at the right time and he is treated with dignity and respect. He said he is given enough information and is fully supported he sees his consultant regularly and has visits at home.
(b)
Patient E was signposted to Willowbrook Hospice and has just finished a four month course. The consultant from hospital visits him at home. The best thing about the service for patient E is knowing that someone is there and he knows he can call and someone will be with him within 2 hours. He can’t think of any improvements to the service he is very pleased with it.
4.3.6 In conclusion all the patient/carers felt very happy with the service and they
felt cared for and reassured by having the service available to them. Signposting was mainly to in house services but the patient/carers seemed to be signposted to the service they need. All patient/carers said they had a quality service with just one saying she received some conflicting information. The main thing that comes out from these interviews is the sense of feeling reassured and that someone is always there if needed.
4.4 Review 4 (Survey Monkey) G.P and Practise Nurses
4.4.1 (a) General experience
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How do you rate the Community COPD ServiceOverall
Is Acess to theService
Satisfactory
How do you rate the Rapid Responseelement of the service?
The Referrer Experience of the Service
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(b) The graph above shows that most referrers think the service meets expectations or exceeds them with a small minority feeling the service needs improvement. All but one referrer feel access to the service is satisfactory. A number of referrers have concerns regarding the rapid response service but still more than 60% feel it meets expectations or more.
(c)
(d) All referrers who answered the question felt they receive timely communication from the service. All except one referrer felt the quality of the consultant letters met expectations or more. Other communication was rated as needing development by 5 referrers but the rest felt it met expectations or beyond. Most felt that spirometry results were clear and accurate. All but four referrers felt they were informed about patients accessing pulmonary rehabilitation.
4.4.2
What works well with the service • Communication , information for the patient , and also easy access • Communications very good, patients appreciate service but rapid access
service needs development • Good Communication • Notifying of changes in patients conditions • Clear concise and speedy examination results • Consultant appointments, discharge letters • The service gives the patients prescriptions so less pressure on us to do so
that day
02468
1012141618202224262830
Yes
No
Uns
atisf
acto
ry
Nee
ds D
evel
opm
ent
Mee
ts e
xpec
tatio
ns
Exce
eds E
xpec
tatio
ns
Exce
ptio
nal
Uns
atisf
acto
ry
Nee
ds D
evel
opm
ent
Mee
ts e
xpec
tatio
ns
Exce
eds E
xpec
tatio
ns
Exce
ptio
nal
Yes
No
Yes No
Do you thinkyou get a
timelycommunicationfrom the COPD
Service?
Please rate the quality of consultantletters
Please rate the quality of otherinformation received
Do you findspirometry
results clearand accurate?
Do you getinformed when
patientsundergo
pulmonaryrehabilitation
Communication
20
• Spirometry • It provides a basic spirometry service. • Having quick access to one of specialist nurses so can give best advice and
treatment options for patients. • They see the patients • Easy patient access to clinics. • Patients are quickly seen • From referral to appointment, the time wait is very short. Patient given very
good explanations and advice • Rapid response service • Good follow up by the nurse • Timely reviews • Consultants reviews • Timely assessment, rescue packs, annual spirometry, OPD review by
consultants • High quality service • Most things • I think it is a well led service that is functioning at a high standard and keen to
develop further • Have also used the service for education for myself re management plans
when I have been unsure • Patients are seen quickly and response times and quality of response is good.
Patients give verbal good feedback • Nursing team
4.4.3 What would you alter about the service • Going well at the moment , no changes required • Nothing • Nothing • Rapid access service improved, refuse to see patients if not 'registered' with them
even though a have previously had spirometry by other providers i.e. are true diagnoses of COPD
• We are on the Knowsley/ St Helens border. As a result of this the rapid response team have told several of our patients that they are not covered by the service and should attend A&E. This has resulted in unnecessary concern by the patients and meant that we have had to waste time phoning the service to point out they have a Knowsley doctor
• Increase awareness of rapid access team as patients still coming to surgery or WIC for exacerbations
• Patients do not always seen to be aware that they can contact the COPD team during an exacerbation-i.e. patients need to be better informed about this service
• Better access to patients who have moved recently in to practice with a diagnosis of COPD we feel that we have to send numerous letters to the service explaining the reason why the patient needs to be under their care
• Needs clearer information, i.e. when they say needs consultant review, will they organise and what is the outcome?
• Some written reports very difficult to read • Better communication - especially removing the unhelpful "if you don't understand
this letter talk to your GP" phrase.
21
• Communication from the specialist nurses is nice but I've no idea who they are - they don't seem to have introduced themselves to us nor asked us how we want them to work!!
• It doesn't always state any advice or recommendations the amount of letters from the service requesting standby abx and oral steroids on a daily basis.
• Patients with "normal" spirometry, but unable scoring poorly on MRC dyspnoea scale. History says COPD spirometry says no – some recognition of this in results
• Improved feedback on spirometry results that show an FEV1 which is >65% or show restrictive pattern or tests which are equivocal.
• More input into palliative care for COPD • There is little acute COPD nursing service. This was lost since the discharges
from the acute services at Aintree are not transferred • Leniency over the need to request chest X-rays prior to referral • Increase prescribers within team to avoid need for requests for standby
antibiotics and steroids • Perhaps employment of nurse prescribers for the above, this would provide a
fluid more effective service - rather than waiting a few days for the gp/nurse prescriber to issue the many requests from the above service.
• I would like all the COPD nurses to be prescribers • The prescribing of standby medications by the service, better emphasis on
smoking cessation • Few new patients are being seen. • Regular checks on patients waiting for annual spiro who are not sent for and then
have to be referred again from the gp surgery.
4.4.4 Analysis
a. When talking about what works well about the service there was a lot of mention of communication, ease of access for patients good follow up systems and high standard high quality staff and service. When looking at would make it better access for those who were a little bit not run of mill due to diagnosis from other providers, geographic location or new patients or similar came up as an issue with some specific references to this in relation to rapid response. Some referrers felt that the communication although it was there it sometimes lacked depth or wasn’t fully explained. There was also a common theme of referrers requesting more nurse prescribers be within the service to try to ebb the flow of prescription requests back into practices.
5. Respondents
5.1 The community COPD service has approximately 5000 patients the selection consulted with was a random mix of patients who are using different services and are at different stages of COPD.
5.2 Review took place on 5 separate occasions, at 5 different locations. Over the 5 venues there were 44 patients/carers who took part and 32 who completed the Equality & Diversity monitoring forms.
22
5.3 Of those 32 the demographics were:
a. Gender: 56% were women 44% were men. b. Ethnicity: 88% of respondents were White British with 3% White Scottish, 3% White c. Welsh, 3% White Irish & 3% White English respectively. d. Disability: 69% of respondents considered themselves as having a disability, with
28% not considering themselves to have a disability and 3% who preferred not to state if they felt they had a disability or not.
e. Age; 3% of respondents were under 50, 10% were aged 50-60, 28% aged 60-70, 31% 70-80 with 3% aged over 80, with the remaining 25% preferring not to disclose their age.
f. Religion: 59% of all respondents surveyed stated their religion or belief to be Christianity, with 38% stating no religion and the remaining 3% as other religion.
6. Conclusions and Recommendations 6.1 Patient/carer experience:
6.1.1 The majority of patient/carers were very happy with all aspects of the service.
The overarching positives where a sense of being heard and the feeling of reassurance they experience from knowing the service is there. They have great confidence in the service and say they couldn’t get better treatment anywhere else. The majority saying the service saves multiple trips to GP’s and hospitals.
6.1.2 The patient/carers feel clinic times are flexible and venues are local, they do not
feel rushed, they feel listened to and they feel they are treated as an individual with respect and care. They are confident in the opinions, diagnosis and treatments from the professionals at the clinic.
6.1.3 Those who use rapid response were very positive about the service some going
as far as to say they wouldn’t be here if it wasn’t for that service. A lot saying it keeps them calm and stops them panicking and that the quality and speed of the service gives them much needed quality of life from the reassurance of knowing there is always someone there to help.
6.1.4 There was unanimous agreement that pulmonary rehabilitation is a great
service. Patients all seemed to enjoy the sessions but more than that a lot were commenting on the positive effects on their health. The only improvement suggested was more sessions or opportunity to do it twice a year and possibly some better equipment from one patient.
6.1.5 Those patient/carers in receipt of palliative care and their carers praised the
professionalism and care give to them by the service, none could think of anyways it could be improved.
6.1.6 The only ways to improve the service that came out with any strength from the
patient/carers was to signpost into other services because social isolation is a big thing for them so it would be good to hear more about other groups. Also to fly the flag of this service so it can be used a model for other services.
23
6.2 Referrer Experience
6.2.1 Overall the ratings in from the referrers were very positive with 25 out of 30
saying the service met expectations or beyond. 5 referrers felt the service needed some further development. A lot of the suggestions for development were around more prescribing nurses. There were some referrers wanting more flexibility in access for patients who may need referring into the service without an initial assessment from the provider, i.e. those who have been assessed elsewhere. It was also about raising awareness of the services with patients and ensuring Rapid Response is available for all those registered with Knowsley GP’s. There were also some suggestions about written communication been clearer and having not just results but explanations and recommendations on them.
6.2.2 Overall a very positive review from all participants with many aspects of the
service been described as outstanding.
24
Appendix
Contents
Appendix 1 Questionnaire (face to face)
Appendix 2 Table Notes for Coffee Morning
Appendix 3 Prompts for Interviews
Appendix 4 Survey Monkey Questions
Appendix 5 Coffee Morning Invite
Appendix 6 Evaluation of Review Process
25
APPENDIX 1
Knowsley COPD Service - Review of the service patient engagement at Pulmonary Rehabilitation.
As part of the review of the Knowsley COPD service Knowsley Clinical Commissioning Group are asking patients for their views on the current service that they are receiving.
Please indicate if the participant is a patient or a carer?
Patient Carer Family Member
(All answer Qs 1-9)
1. What services have you used
Clinics (Spiro/MDT) Oxygen Assessment RAPID Response (also answer qs 10-16) Pulmonary Rehabilitation (also answer qs 17-20)
2. Are you happy with the clinic times and venues offered to you? Yes No
3. Would you prefer a choice of AM/PM each time?
Yes No
4. Was communication before appointment satisfactory
5. Did you receive a reminder?
Yes No
Yes No
26
6. Did you feel you were treated with dignity and respect?
7. What was good about the service?
8. How can we improve your experience?
9. Do you have any other comments?
Yes No
27
RAPID RESPONSE
10. Was the response via a home visit or a phone call?
11. How long did you wait for the response following your initial phone call?
Under 1 hour 1-2 Hours 2- 4hours over 4 hours
12. How responsive were the staff?
13. Did you feel fully supported?
14. If you received advice did you feel it enabled you to manage your condition?
15. What is good about this service?
16. How could we improve this service?
Home Visit Phone Call
Not very responsive Reasonably Responsive Extremely Responsive
Yes No
Not at All Some way Fully
28
PULMONARY REHABILITATION
17. Does the time of the sessions suit you?
18. Do you feel you were included in the design of your programme?
Yes No
19. Do you fully understand your programme?
Yes No
20. Is there anything else you would like to be included in your programme to improve it?
21. What do you feel is good about the service?
Yes No
If not what would be better?
29
Equality and Diversity Monitoring
Please help us to ensure that our services are accessible to everyone by filling in the following information:
Sex
Male Female Trans Prefer not to say
Race Select one section
A. Asian or Asian British: Bangladeshi Indian Pakistani
Other Asian background
B. Black or Black British: African Caribbean Other Black background:
C. Chinese, Polish or any other ethnic group: Chinese Polish
Other ethnic group
D. Mixed Heritage: White & Asian White & Black African
White & Black Caribbean Other mixed heritage background
E. White:
British English Irish Scottish Welsh
Other white background Prefer not to say
Disability
Do you consider yourself to have a disability or long-term health condition?
Yes No Prefer not to say
Please identify the disability or condition: Prefer not to say
Sexual orientation
Bisexual Gay man Gay woman/Lesbian Heterosexual/Straight
Prefer not to say
Age Please fill in your age: Prefer not to say
Religion or Belief
Buddhism Christianity Hindu Judaism Islam Sikhism Atheism
Prefer not to say Other Religion or Belief No Religion or Belief
30
APPENDIX 2
Knowsley Community COPD Service - Review of the service Health Watch Coffee Morning.
Name of Facilitator: ………………………………………
To be completed by Facilitator: Type of clinic (Spiro, MDT, Rapid Response, and pulmonary Rehabilitation).
……………………………………………………………………
As part of the review of the Knowsley Community COPD Service Knowsley Clinical Commissioning Group we are asking patients for their views on the current service that they either are receiving or have received in the past.
What services has the patient experienced
• Clinics (Spiro/MDT) • Oxygen Assessment • RAPID Response • Pulmonary Rehabilitation
• What has been your experience of the Service?
(Positives/negatives)
• Please give us your thoughts in relation to venues & times of clinics?
(Waiting times/locations/parking/signage/would they like a choice of Am or PM Clinics)
• Are you happy with the setting?
(Hospital v community setting)
• Do you feel the support and service you use suits your needs? Yes/no Why?
• How could we improve your experience?
(Access – weekends etc.)
31
APPENDIX 3
Knowsley Community COPD Service - Review of the service with particular focus on end of life patient .
The following are for prompts for the interviewer and not direct questions, we’d like it to be more of an in depth discussion about their experience of the service, more a case study
than a questionnaire.
Interview Prompts – COPD End of Life service
Did they feel the service came at the right time?
Did they feel Supported by the service?
Have they been given enough information regarding your condition?
Are they treated with dignity and respect?
Did they get signposted to other relevant services? Which ones
How has this service made a difference to them? Positive and negative What has been the most positive thing about the service? Where do they think we can make improvements to the service? For Carer if present Do they feel supported by the service? Do they feel they have been given enough information to help care for the patient?
32
APPENDIX 4 1. How do you rate the Community COPD service overall?
How do you rate the Community COPD service overall? Unsatisfactory
Needs development
Meets expectations
Exceeds expections
Exceptional
2. Is access to the service satisfactory?
Is access to the service satisfactory? Yes
No
3. Are there sufficient appointments?
Are there sufficient appointments? Yes
No
4. Do you think you get a timely communication from the COPD Service?
Do you think you get a timely communication from the COPD Service? Yes
No
5. Do you find spirometry results clear and accurate?
Do you find spirometry results clear and accurate? Yes
No
Comments
6. Please rate the quality of consultant letters:
Please rate the quality of consultant letters: Unsatisfactory
Needs development
Meets expectations
Exceeds expectations
Exceptional
33
7. Please rate the quality of other information received:
Please rate the quality of other information received: Unsatisfactory
Needs development
Meets expectations
Exceeds expectations
Exceptional
8. Do you get informed when patients undergo pulmonary rehabilitation?
Do you get informed when patients undergo pulmonary rehabilitation? Yes
No
9. How do you rate the Rapid Response element of the service?
How do you rate the Rapid Response element of the service? Unsatisfactory
Needs development
Meets expectations
Exceeds expectations
Exceptional 10. What works well with the service?
11. What would you alter about the service?
34
Coffee Morning COPD Service Review
Thursday 28th November, 10am—12noon at
The Old School House, St Johns Road, Huyton, L36 0UX
Refreshments are provided free of charge and transport is available if required. Places are Limited and will be allocated on a first come basis. To
secure your place please contact us by the 21st November on 0151 449 3954 or email
Knowsley CCG is currently reviewing Knowsley Community COPD Service and
as part of the review Healthwatch invites you to a coffee morning.
This will provide an opportunity for you to share your experiences and views of the
Knowsley COPD Service. We would love to hear your experience of the service and any
comments you may wish to make in how we can improve the service. The coffee
morning is open to patients, family
This is an opportunity to discuss the COPD
service you have experienced and have
your voice heard!
APPENDIX 5
35
APPENDIX 6
Evaluation of The Methods of the COPD Review
Questionnaires
What went well:
• The aspect of a member of the commissioning team helping the patient to complete the questionnaire meant we were able to gather quantitative and qualitative data
• Helped the participant’s to see the bigger picture of who the CCG are. • Helped us get more individual responses.
Even better Ifs
• We would have been able to attend more clinics to elicit patient views • It was bit complicated the way the questionnaire it was set there was some
misunderstanding of which aspect of the service they were commenting on. This was helped by members of CCG been available to help, but meant they had trouble completing it independently. The sections were labelled but I think the elements needed to be mentioned in each question to make it clearer.
Coffee Morning
What went well
• Very professionally facilitated by Healthwatch • Good mix of participants
Even better Ifs:
• This aspect went really well but maybe some opportunity for splitting the group into twos or threes for some small discussions as some people seemed a little uncomfortable talking in the big groups. It would just have allowed us to get a little more from the session
Interviews
What went well
Identification of the patients from the consultant and then permissions and transfer details to Healthwatch all went smoothly
Even better Ifs:
• The telephone interview prompts were used as questions rather than a prompt for a discussion, which was a shame as it meant the case studies were very brief and not as in-depth as we would have liked
• We would have like the carers to be interviewed separately from the patient, they gave us feedback on experience of patient rather than their experience as a carer
• The format was communicated to Healthwatch but maybe next time it needs to be a conversation between the commissioners directly with the person doing the interviews so the key messages are not lost in translation.
36
Survey Monkey
What went well:
• A good number of responses from this method, quick and easy to navigate the questions.
Overall All
What went well:
• A diverse mix of patients in varying stages of COPD • A good mix of methods to ascertain the view of patients • Good partnership work with Healthwatch
Even better Ifs:
• Maybe have more than one method of responding for each selection of respondents
Document 23(01)03
Report to Knowsley Clinical Commissioning Group Governing Body Date of meeting: 6th February 2014
Report title: Corporate Performance Dashboard
Report presented by: Mark Broderick, Assistant Chief Officer
Purpose of the report: To update the Governing Body on key performance and to highlight exceptions
Recommendations:
Action / Decision required
The Governing Body is recommended to:
Note the performance of the CCG and the following exception reports:
1. Updated CDiff position and action plan
Delegated Powers:
For decision reports only
Not applicable
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred X
2. Safe X
3. High quality X
4. Cost effective X
5. Outcome focused X
6. Closer to home X
7. Affordable X
[one page only]
‹#›
Performance Management Dashboard October 13
1
‹#›
Purpose of the Dashboard
This corporate dashboard has been developed to provide a Knowsley specific overview of performance across a number of specific areas: • CCG Assurance Framework; • CCG National Outcomes Indicator Framework; • Finance; • Prescribing; • Corporate Services; and • Governance and Assurance It has been designed to provide an overview of performance to the Governing Body. Should further, more detailed information be required on any of the areas contained within this dashboard, this can be provided by the CCG management team. Contents 1. Knowsley CCG Vision 2. Assurance Framework 3. Outcomes 4. Finance 5. Prescribing 6. Corporate Services 7. Closing Statement Appendix 1 – CCG Assurance Framework indicators Appendix 2 – CCG Outcome Indicator Framework
2
‹#›
Vision
In 5 years’ time, the population of Knowsley will be happier and enjoy better health. When they need to access health and wellbeing services, they will be high quality services with improved access and which use the latest evidence based treatments and therapies. We shall see people living longer. They will be healthier and enjoying a better quality of life. They will be safer and there will be a reduction in health inequalities. They will have greater independence, more self care, more responsibility and greater involvement in decisions about their care In order to make these aspirations a reality, the services that the CCG commissions will be: a) Patient centred b) Safe c) High quality d) Cost effective e) Outcome focussed f) Closer to home g) Affordable From the patient’s perspective, all services will be integrated and appear seamless. Where appropriate, the CCG will seek to foster greater integration of services across secondary care, primary care, community care, the local authority and the 3rd sector
3
‹#›
Knowsley CCG – Assurance Framework
4
Knowsley CCG – Assurance Framework
Performance Indicator Exceptions Overall rating Narrative
1. Are local people getting good quality care?
2. Are patient rights under the NHS constitution being promoted?AMBER INDICATORS
CB_S6 - Number of patients waiting more than 52
weeks
CB_B13 - % of patients receiving first definitive
treatment for cancer within 62 days from ref from
screening programme
CB_S6 - This measure is cummulative throughout the year, the CCG has had two long
waiters reported to date. The patients and their family were informed of their constitutional
rights, likely wait and were offered choice of another provider at various stages of
treatment but decided to continue waiting at their chosen trust, this choice essentially
nullifies the NHS constitutional wait threshold for the CCG.
CB_B13 - Performance in October had slipped to 66% against a plan of 90% (1pt out of 3)
this was at St Helens & Knowsley Hospitals trust and was due to a medical priority.
Cumulatively this indicator is performing at 88.9%. The CCG is working collaboratively
with its co-commisisoners and local providers to ensure recovery is achieved swiftly,
access to treatment within 62 days forms part of the quality premium indicator set.
3. Are health outcomes improving for local people?RED INDICATORS
CB_A2- <75 mortality for CVD
CB_A4 - <75 mortality for liver disease
CB_A5- <75 mortality from Cancer
CB_A6_04 - Emergency admissions for children with Lower
Respiratory Tract Infections(LRTI)
CB_A10 - Emergency readmissions within 30 days of
dischage
CB_A15 - Incidence of Healthcare Acquired Infection (HCAI)
measure (MRSA)
CB_A16 - Incidence of Healthcare acquired infection (HCAI)
measure (clostridium difficile infections)
C1.8 (OF) - Emergency admission s for Alcoholic Liver
disease
CB_S5 - Improving access to psychological therapies
Note: CB_A15 & CB_A16 are counted twice in this indciator
series accounting for the total count of 11 red indicators
when there are infact 9.
CB_A2 through CB_A5 will be addressed jointly via the Health & Welllbeing board in
conjunction with Knowsley intelligence network.
CB_A6_04 - Performance has improved, the CCG is over plan by 3 cases cumulatively
YTD, jointly between Alderhey and St Helens & Knowsley trust's, this has previously
been exception reported and work continues to improve performance.
CB_A10 - Performance has recovered slightly from last months position as there were 20
fewer emergency readmissions ytd when compared to the same point in time last year ,
annual planning and contract negotiation will take this into account.
CB_A15 - The CCG has reported one case of MRSA to date, this was at the Royal
Liverpool & Broadgreen University Hospitals.
CB_A16 - CDifficile is above plan by 17 cases at Oct. with 36 reported, largely attributable
to Community acquired cases (13/17 cases).
CB_S5 - cumulative position at October is projecting an end of year position circa 7.8%
against a target of 12% first seens. This is due to a less people being seen than
contracted early on in the year and subsequent drop of in performance in November of
80% against Octobers 308 first contacts to 61. Work is underway with the provider to
recover the position.
C1.8 (NHS OF)- Currently reporting a 12mths position of 55 cases against a threshold of
47 - as this indicator is delivered jointly between the CCG & LA it will be addressed via the
HWB in collaboration with the Knowsley intelligence network, a report will be brought to
this body in the near future.
4. Is Knowsley CCG commissioning services within financial allocations?RED/AMBER INDICATORS
7
7Total Indicators =
GREEN
18
2
20
GREEN
7
2
Total Indicators = 9
GREEN
33
38
8
11
90Total Indicators
Total Indicators =
AMBER
‹#›
Knowsley CCG – Outcomes 1
5
Outcome Indicator Grouping Exceptions Narrative
Preventing people from dying prematurely
RED INDICATORS
CB_A2 - Under 75 mortality from Cardiovascular disease
CB_A4 - Under 75 mortality from Liver disease
CB_A5 - Under 75 mortality from Cancer
C1.8 - Emergency admissions for Alcoholic Liver disease
The majority of the indicators within this domain are annual, although a
refresh has been undertaken by the Health and Social Care Information
Centre (HSCIC). These areas are to be addressed jointly through the Health &
well being board & Knowsley intelligence network.
CB_A2 - An increase in the number of deaths from CVD of 5 patients from the
rolling baseline of 137 in 2011/12
CB_A4 - An increase of 5 more deaths due to liver disease from the rolling
baseline of 38 in 2011/12.
CB_A5 - An increase of 12 more deaths resulting from cancers than reported
in the rolling baseline of 249 in 2011/12.
C1.8 - Preventative & Treatment Services to impact on this area are
commissioned by the local Authority - as such the Knowsley intelligence
network will report back to this body in the near future.
Enhancing quality of life for people with long term conditions
The indicators that are currently grey, in the main, are not yet reportable on
a monthly basis as they are annual indicators
Helping people to recover from episodes of ill health or following injury
RED INDICATORS
CB_A6_04 -Emergency admissions for children with Lower Respiratory
Tract Infections(LRTI)
CB_A10 - Emergency readmissions within 30 days of dischage
Refer to page 4
Ensuring that people have a positive experience of care
AMBER INDICATORS
CB_A13 - Friends & Family Test
The majority of the indicators within this domain are annual.
The F&F test outcome was changed to measure response rate rather than an
absolute numerical value, this is set to 15%.
All of the CCG's providers achieved this combined score with the notable
exception of Liverpool Womens (9.2% total response), St Helens & Knowsley
trusts recently improved performance was impacted by a lower AED
response rate(11%). Performance at the Royal Liverpool & Broadgreen
University Hospitals Tust continues to show Improvements
10
5
4
19Total Indicators
8
6
14Total Indicators
2
4
2
8Total Indicators
6
1
1
8Total Indicators
‹#›
Knowsley CCG – Outcomes 2
6
Outcome Indicator Grouping Exceptions Narrative
Treating and caring for people in a safe environment and protecting them from avoidable harm
RED INDICATORS
CB_A15 - Incidence of Healthcare acquired infection (HCAI) measure
(MRSA)
CB_A16 - Incidence of Healthcare acquired infection (HCAI) measure
(clostridium difficile infections)
AMBER INDICATORS
C5.1 - Patient Safety incidents reported
CB_A15 - Refer to page 4.
CB_A16 - Refer to page 4.
C5.1 - There was 1 SUI reported in October for Knowsley registered patients
and a total of 18 in the year to date. This related to a scanning / radiological
incident at Liverpool Womens hospitals foundation trust and is being
reviewed through the CCG's goverenance processes.
Local Priorities
AMBER INDICATORS
LI_01 - Reduction in emergency admissions for COPD
LI_03 - Increased utilisation of Choose & Book
LI_01 - Year to date position for COPD emergency admissions is slightly above
that planned (6) , this has decreased since last months report (12) but will
need close scrutiny over the coming winter period - however the CCG is still
projecting achievement of its full year plan at this time.
LI_03 - Performance has deteriorated, in part due to practices migrating their
clinical systems over to a newer version, or a completely different one in
some instances, this has caused some teething problems that seem to be
rectified now. Utilisation of one system will in future help with standardising
processes. Current aggregate utilisation is 41% against a planned threshold of
55%, last months position was 43%
Quality Premium Indicators
RED INDICATORS
CB_S5 - Improving access to psychological therapies
CB_A15 - Incidence of Healthcare acquired infection (HCAI) measure
(MRSA)
CB_A16 - Incidence of Healthcare acquired infection (HCAI) measure
(clostridium difficile infections)
AMBER INDICATORS
CB_A6 - Composite measure on Emergency Admissions
CB_B4 - Diagnostic test waiting times
CB_S4 - Total Accident & Emergency Attendances
CB_S6 - Number of patients waiting more than 52 weeks
CB_S5 - Please refer to page 4
CB_A15 & CB_A16 - Refer to page 4
CB_A6 - The total composite indicator is at Amber due to an increase in the
numbers of emergency admissions for acute conditions amenable to
healthcare and LRTI's combined at October.
CB_B4 - The Diagnostic wait target of 99% in 6wks was breached in October
due to staff sickness at Royal LIverpool and Broadgreen hospitals trust
(ultrasounds 24 pts). Extra capacity and additional clinics were put into place
to counter this but issues still remain in November, significant changes are
anticipated when January's figures are released as the provider entered into a
contractual arrangement with Spire Liverpool to help deal with this problem.
CB_S4 - Accident & Emergency attendances for the CCG are projected to come
in slightly above plan, this in part is due to a large variance to plan at St Helens
& Knowsley Hospitals Trust - whilst activity has decreased at other providers it
does appear to be increasing at St Helens & Knowsley with no evidence of
activity shifts from other local providers. Overall Performance is -1.3% under
that planned, 37,205 against a plan of 37,716.
CB_S6 - previously reported under assurance framework on page 4
1
1
2
4Total Indicators
1
2
3Total Indicators
7
20
4
3
Total Indicators 34
‹#›
Knowsley CCG – Finance
7
Allocations Recurring
£000
Non-Rec
£000
Total
£000
Expenditure Ann. Bud
£000
YTD Bud
£000
YTD Act
YTD Var
Trend Since Last
Report
Recurring Base 236,027 236,027 Acute 130,943 88,895 88,895 -
Current Year Growth 5,429 5,429 Community Health 28,574 19,147 19,147 -
Other In-Year 1,685- 4,765 3,080 Continuing Care & Pools 12,793 8,476 8,476 -
Total Programme 239,771 4,765 244,536 Mental Health 24,264 16,452 16,452 -
Running Cost Allowance 3,730 3,730 Primary Care 33,541 22,500 22,512 12-
Total 243,501 4,765 248,266 Other -Spend 9,576 5,701 4,068 1,633 On Track to Target
Other-Reserves 4,845 -
Programme Budgets 244,536 161,171 159,550 1,621
Running Cost 3,730 2,325 2,325 -
Total (-ve = deficit) 248,266 163,496 161,875 1,621
Forecast Out-turn Target
£000
Forecast
£000
Variance
£000
Total (- = deficit) 2,460 2,460 -
Reserves Recurrent
£000
Non-Rec
£000
Total
£000
Committed 852 3,280 4,132
Uncommitted 1,511 1,397 2,908
Efficiency (-ve) -
Total (- = deficit) 2,363 4,677 7,040
Finance Performance
SummaryRAG
RAG TREND
Underlying recurrent surplusGREEN
Surplus - year to date
performance GREEN
Surplus - full year forecastGREEN
QIPP ** - year to date deliveryGREEN
QIPP ** - full year forecastGREEN
Running costs GREEN
Management of 2% NR funds
within agreed processesGREEN
Activity trends - year to date GREY
Activity trends - full year
forecastGREY
£70k ahead of trajectory
Changes Since Last Report:
Presentational change only at montrh 6. Specialised Commisining
Movement of £1.4m reduced from Recurring Base at month 7 should
be reduced from Other In-Year adjustments report updated at month
7 for accuracy.
OVERALL
The CCG Reports an overall surplus of £1.62m on Programme Costs to month 8 and remains on
track to deliver the required surplus of £2.46m by year end. Running Costs expenditure is reported
within plan and the CCG retains a current contingency balance of £287k. The CCG has funded
over spend against budget from earmarked reserves at M8.
QIPP Comments: There is a year to date QIPP surplus of £70k against plan. This is due to
greater than anticipated savings on CVD and COPD over and above those withdrawn from
contracts at the start of the year. The Prescribing QIPP is slightly behind target at month 8 by
£19k, which is an improvement from M7 due to impact of Cat M drug tariff impact reported in FOT.
Full achievement of QIPP plan is anticipated at M12.
Please see the following page for further detail.
On track to achieve 2%
On track
On track with reserves
On Track - prescribing risk reducing
On track
Awaiting criteria from AT
Do not have national definitions,
therefore not sure of position
Do not have national definitions,
therefore not sure of position
-6.5% -6.5% -6.5%
2.2%
6.5%
1.1% 1.0%
-20%
-15%
-10%
-5%
0%
5%
10%
15%
20%
QiPP Plan v/s Actual
YTD Actual
‹#›
Knowsley CCG – Finance (Month 7)
8
Budget AreaMonth7
Rating
Year End
Rating
Mental Health Commissioning A A
Acute Commissioning A A
Primary Care G A
Continuing Care G G
Community Health G A
Other G G
Running Costs G G
Reserves G G
At month 8 the CCG retains £4.8m of reserves, £2.2m having been released in
month to fund spending pressures identified in Acute Commissioing detailed above.
The remaining balance will be utilised to support the current FOT financial position
and any emerging financial risks in year.
Commentary
High cost mental health Rehab cases and Psychiatric Intensive Care continue to
cause cost pressures for the CCG. An additional £197k was funded from reserves
in M8. The CCG is continuing to monitor expenditure in this area closely. Work is
ongoing with CMCSU and Mental health providers to manage the risk through the
contracting process for 2014-15 onwards.
The Acute position is reported breakeven at M8 however this is after the allocation of
earrmarked reserves to fund the Non-Recurrent Aintree Transformational Fund of
£900k, Mid Mersey Winter Pressures Fund of £600k, plus additional over-
performance of £600k on Acute Contracts. Over-performance On Elective
Outpatient, Inpatient and Daycase Activity at Aintree continues to grow in line with
forecasts (especially in Trauma & Ortho and Gastro) and remains the most
significant area of over-performance in Acute Commissioning. The consistent
application of IR rules at Provider level to determine if activity is Specialised or
Secondary Care remains in question. The CCG awaits the outcome of a M8 review
to determine if any further allocation adjustments will be imposed. The CCG
anticpiates meeting the current FOT over-performance on Acute contracts from
within existing resources, however, the Specialised Commissioning issues remains
a risk.
Majority of Primary Care Budgets remain on plan at M8. A further imrpovement in
the prescribing postion moves this to a FOT overspend of £29k which is reflective of
the price change in Cat M drugs and the ongoing work between practices and the
Medicines Management team. A minor deficit of £11k is reported on GP IT which is
the over-spend to date against resources devolved from NHSE, due to additional
costs associated with EMIS web implementation. The CCG has been successful in
securing capital monies in year which will remove this cost from Programme Spend
in future months.
There is a minor deficit of £5k at M8 in respect of CHC Assesment Support. This is
as a result of additional payments made to CMCSU to support the processing of
backlog restitution claims. There is a potential risk of settlement of Restitution
claims in excess of the provision inherited fromthe PCT, but this will not be fully
quantified until all claims have been reviewed by CMCSU.The CCG awaits Q3
pooled budget forecast from KMBC which will include an updated forecast out-turn.
M8 assumes a prudent break-even position (£118k surplis FOT M7) until this data
becomes available.
The majority of community contracts remain on plan. Risk of growth in AQP
contract above anticipated levels remains a risk for the CCG and the potential impact
is yet to be reflected in the financial position year to date. The latest charges from
5BP suggest additional costs above levels anticipated at the beginning of the
financial year but this remains under challenge until the underlying data quality
issues are resolved. It is expected a position will be agreed at M9.
The total underspend of £1.63m includes released surplus reserve of £1.63m ytd.
The previously reported risk associated with NHS Propoerty Services is no longer
expected to materialise. A Letter has been recived from NHSE stating the CCG will
pay only the amount of resources it recived in its allocation to cover these costs.
Running Costs are in line with plan at Month 8 and the CCG remains on track to
maintain running costs expenditure within allocation. The contingency reserve of
£287k will be allocated out in M9 based on known spending profiles. Any surplus
remaining can be used to offset over-spend on Programme Costs but this is not
anticipated to be necessary at this stage.
‹#›
Quality Premium Dashboard
9
Performance IndicatorsStandard
QP %
ContributionNov QP Achieve?
Rate of potential years of life lost from causes amenable to healthcare (Females) reduce by at least 3.2% from 2013 to 2014
Rate of potential years of life lost from causes amenable to healthcare (Males) reduce by at least 3.2% from 2013 to 2014
Emergency Admissions Composite Indicator (rate per 100000) 25.0% 1483.2 Yes
Patient experience of hospital care ( Friends & Family Test)Rollout and improvement of scores - Q1 13/14
to Q1 14/1512.50% 19% Yes
Incidence of healthcare associated infection (HCAI) MRSA 0 2
Incidence of healthcare associated infection (HCAI) C.difficile 36 - Annual Plan 39
Reduction in Eme adms for COPD from 12/13 baseline 10% Reduction 12.5% 364 Risk
Reduction in Eme adms in MH specs for children & adults from 12/13 baseline 5% Reduction 12.5% 516 Yes
Increase referrals via C&B from 12/13 OT baseline 30% 12.5% 14623 Risk
Patients on incomplete pathways should wait no more than 18 weeks from referral 92% 95.3% Yes
Percentage of patients who spent 4 hours or less in A&E 95% 98.2% Yes
Maximum 62-day wait from urgent GP referral to first treatment for cancer 85% 87.3% Yes
Ambulance clinical quality – Category A (Red 1) 8 minute response time 75% 79.7% Yes
Measure % Quality Premium Value £ Achieve? Funding £
Domain 1 - Preventing people dying prematurely 12.5% £100,000 Risk £0
Domain 2 & 3 - Composite indicator on emergency admissions 25.0% £200,000 Yes £200,000
Domain 4 - Ensuring people have apositive experience of care 12.5% £100,000 Yes £100,000
Domain 5 - Treating / Caring for people in a safe environment 12.5% £100,000 No £0
Local Measure 1 - Reducing COPD emergency admissions 12.5% £100,000 Risk £0
Local Measure 2 - Reducing EME admissions for MH related events 12.5% £100,000 Yes £100,000
Local Measure 3 - Choice & Transparency ( C&B utilisation) 12.5% £100,000 Risk £0
Total £800,000 £400,000
Quality Dashboard Narrative.
The quality premium is intended to reward clinical commissioning groups for improvements in the quality of services that they commission and for associated
improvements in health outcomes whilst also reducing inequalities.
This dashboard is provided to show current and expected achievement against the 7 national quality premium indicators under Everyone Counts. Whilst it is
important to achieve against all of the of those indicators in order to receive the full premium, the four NHS Constitution indicators are pivotal to overall
achievement of the premium. Each overall failure to deliver under the “NHS Constitution” is weighted at -25% of the total premium available. Therefore failure to
achieve against;
• Referral to Treatment - Patients to wait no longer than 18 weeks from referral to the start of treatment (25%)
• A&E waits - patients to be admitted , transferred or discharged within 4 hours of arrival within AED (25%)
• Maximum 62 day wait from urgent GP referral to first definitive treatment for cancer (25%)
• Category A Ambulance calls - To arrive within 8 minutes of call (25%)
Will reduce the overall premium available to the CCG accordingly.
NHS Constitution Indicators
Composite Indicator of Domains 2 & 3
Everyone Counts - Expected Rights & Pledges Measures
Domain 1 - Preventing people from dying prematurely
12.50% NYA Risk
Domain 4 - Ensuring that people have a positive experience of care
Domain 5 - Treating and caring for people in a safe environment and protecting them from avoidable harm
12.5% No
Local Priorities
Referral to Treatment
A&E waits
Cancer waits
Category A ambulance calls
‹#›
Knowsley CCG – Prescribing
10
Practice prescribing budgets for 2013/14 Prescribing Narrative:
Over the last few years the growth in prescribing volume (items) has been balanced by a fall in the overall average cost per item and a number of frequently used drugs losing their patent protection (branded medicines becoming generic can result in savings of 90% on the branded list price).
Recent data has shown that some drug cost growth is rising at the same rate as volume growth, or even exceeding it contributing to an increased cost in prescribing of 1.86% when compared to the same point in time last year although this is somewhat offset by an increase in the numbers of items prescribed (3.06%) when compared to the same time last year.
As at October (month 7) there is currently a forecast overspend against budget circa 1.03% (£177,590) with a financial forecast for the year of a £300,033 overspend.
Respiratory system drugs have seen a large cost growth of 5.1%, over that of the Regional Area team (2.2%) and national positions (-0.4%). Whilst this will need close monitioring, it is in line with CCG expectations and the resultant reductions in emergency admisisons for chronic respiratory diseases such as COPD that these drugs help to manage, currently contributing to a QIPP saving circa £122k as at October.
To support practices to manage any financial pressure arising from prescribing in 2013-14 a monthly prescribing report has been compiled and is now circulated to all practices.
‹#›
Knowsley CCG – Corporate Services
11
Human Resources
Human Resources Narrative
N/A 2
No ExceptionsCOMPLAINTSSTATUTORY RETURNS No Exceptions
Board Assurance Audit Rating
Narrative
The Governing Body Assurance Framework is
received annually by MIAA. As this is completed at
year end the rating is currently not yet available
IG Toolkit Compliance
Narrative
The CCG self-assessed at 31/3/13 at level 2 in all areas except
pseudonymisation which was assessed as 1, working towards achieving
level 2 in all areas for next assessment due on 31/3/14.
There are 51 employees in the CCG as at October , a whole time equivalent of 45.25, there are
currently 6 vacancies, 4 of which have been appointed to. Start dates have now been agreed
for November and early December.
Governance & Assurance
0.3%
2.0%
0.4%0.8%
1.8% 1.8%
4.1%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
Sickness Absence Total Sick Days/Total WTE Days in monthNHS Average
8
6
8
11
16
2
6.0 5.6
7.2
9.4
15.0
2.0
0.041
21
0 00 0 0 0 0 00
2
4
6
8
10
12
14
16
18
Executive/Secretariat Corporate Services ClinicalCommissioning
Quality & Safety Finance Team Transformation
Staff Employment
No of Employees WTE Vacancies Fixed term vacancies
40
42
32
23
29
43
24
27
15
13
23
32
26
12
31
28
0 10 20 30 40 50 60
Counter Fraud
Equality & Diversity
Fire Safety
Health & Safety Awareness
Infection Control
Information Governance
Safeguarding Adults - Level 1
Safeguarding Children Level 1
Mandatory Training
Completed To Complete
‹#›
Main EC Indicator Descriptions - 1 Everyone Counts
Outcome Indicator
Grouping
Indicator Description
CB_A1 Potential years of life lost (PYLL) from causes considered amenable to healthcare
CB_A2 Under 75 mortality rate from cardiovascular disease
CB_A3 Under 75 mortality rate from respiratory disease
CB_A4 Under 75 mortality rate from liver disease
CB_A5 Under 75 mortality rate from cancer
CB_A8 Health-related quality of l ife for people with long-term conditions
CB_A7 Proportion of people feeling supported to manage their condition
CB_A6_01 Unplanned hospitalisation for chronic ambulatory care sensitive conditions
CB_A6_02 Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s
CB_A6_03 Emergency admissions for acute conditions that should not usually require hospital admission
CB_A10 Emergency readmissions within 30 days of discharge from hospital
CB_A11 Total health gain assessed by patients: i . Hip replacement; i i . Knee replacement; i i i . Groin hernia; iv. Varicose veins
CB_A6_04 Emergency admissions for children with Lower Respiratory Tract Infections(LRTI)
CB_A12 Patient experience of primary care i) GP Services i i) GP Out of Hours services
CB_A14 Patient experience of hospital care
CB_A13 Friends and family test
CB_A15 Incidence of Healthcare acquired infection (HCAI) measure (MRSA)
CB_A16 Incidence of Healthcare acquired infection (HCAI) measure (clostridium difficile infections)
LI_01 Reduction in Emergency admissions for COPD as a primary diagnosis
LI_02 Reduction in Emergency admissions in Children & Adults for Mental Health primary diagnosed events
LI_03 Increased util isation of Choose & Book - Patient Choice
CB_A6 Composite measure on emergency admissions
CB_B1 Referral to Treatment Non Admitted Pathways
CB_B6 All Cancer 2 week waits
CB_B7 Cancer 2 week wait for breast sypmtoms (where cancer not initially suspected)12
‹#›
Main EC Indicator Descriptions - 2 Everyone Counts
Outcome Indicator
Grouping
Indicator Description
CB_B8percentage of pts receiving first definitive treatment within one month of cancer diagnosis (from decision to treat
date)
CB_B9 31 day standard for subsequent cancer treatemnts - surgery
CB_B10 31 day standard for subsequent cancer treatments - anti cancer drug regimens
CB_B11 31 day standard for subsequent cancer treatments - radiotherapy
CB_B12% of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent ref for
suspected cancer
CB_B13 % of patients receiving first definitive treatment for cancer within 62 days from ref from screening programme
CB_B14% of patients receiving first definitive treatment for cancer within 62 days of a cons decesion to upgrade their
priority
CB_B15_01 Ambulance clinical quality – Category A (Red 1) 8 minute response time
CB_B15_02 Ambulance clinical quality – Category A (Red 2) 8 minute response time
CB_B16 Ambulance clinical quality - Category A 19 minute transportation time
CB_B17 Mixed Sex Accommodation (MSA) Breaches
CB_B18 Cancelled Operations
CB_B19 Mental Health Measure – Care Programme Approach (CPA)
CB_S1 Non-elective FFCEs (First Finished Consultant Episode)
CB_S2 All first outpatient attendances
CB_S3 Elective finished first consultant episodes (FFCEs)
CB_S4 A&E Attendances
CB_S5 Mental Health Measure- Improved access to psychological services
CB_S6 Number of 52 week Referral to Treatment Pathways
CB_S7 Ambulance handover time
CB_S8 Crew Clear
CB_S9 Trolley waits in A&E
CB_S1 Urgent operations cancelled for a second time
13
‹#›
Appendix
Appendix 1 - Health Care Acquired Infection and Clostridium Difficile Action Plan Appendix 2 – CCG Assurance Framework Indicators Appendix 3 – CCG National Outcome Indicators Appendix 4 – Glossary of Terms
14
1
Appendix 1
KNOWSLEY CCG CLOSTRIDIUM DIFFICILE ACTION PLAN
END OF QUARTER 3 (Oct 13 – Dec 13) 2013/14 1. Purpose of the report 1.1 To provide an update to the Governing Body on progress against the agreed
Clostridium Difficile action plan.
2. Aim of the Action Plan 2.1 To reduce the rise in preventable cases of Clostridium Difficile (Cdiff) cases
across Knowsley and implement actions to address them.
3. Key Objectives
a) Understand the root causes of the current Cdiff cases (Acute and Community)
b) Support implementation of practice to improve the management of avoidable Cdiff cases
4. Governance 4.1 The action plan will be reviewed and managed by the Clinical Quality & Safety
Committee and reported to the Governing Body. 5. Current Position 5.1 To the end of Quarter 3 2013/14, 43 cases of Cdiff have been reported against
a trajectory of 36, this is an increase of 11 since Quarter 2 2013/14 (July 13 – September 2013). Of these 15 are attributable to the acute trusts and the remaining 28 attributable to the community. Root cause analyses (RCA) have been undertaken on all community cases by the Five Boroughs Infection Control Team (commissioned service) with input from the CCG Medicines Management Team.
5.2 Table 1 below shows the outcome of the RCA and whether the Clostridium
Difficile (Cdiff) infection was avoidable or not. Where it is unclear whether the infection was avoidable or unavoidable further investigation is being undertaken.
2
Table1: RCA outcome
Avoidable ?Avoidable Unavoidable ?Unavoidable RCA not yet completed
2 3 15 7 1 5.3 The outcome of the individual RCA is discussed with the patient’s General
Practitioner by the Infection Control Team and the medicines element by the Medicines Management Team; advice is given to improve practice and prevent the further incidence of Cdiff.
6. Progress against the action plan 6.1 The outstanding medicines management RCA’s have been completed,
discussions with the relevant GP practices should be concluded by the end of January 2014.
5.2 5 Boroughs Partnership Foundation Trust medicines management team are
now completing the RCA’s as part of the commissioned service. 5.3 Progress for the agreement of PQP for 2014/15 is on track.
5.4 The non-medical prescribing audit against patient group directives (PGDs) is due for completion by the end of January 2014.
Clinical Lead - Dr Aftab Hossain
Management Lead - Breeda M Worthington, Head of Quality and Safety/Lead
Nurse
Report author Contact details: Sue Harris, Programme Manager Quality and safety [email protected]; Tel: 0151 676 5604
3
Knowsley CCG Clostridium Difficile Action Plan
Key: Red/Amber/Green Legend: Red: Not commenced/no progress made Amber: Initiated and in process/some progress made (outstanding actions) Green: Completed/measured progress achieved
Action Completion Date
Responsible Manager Comments/Progress to date
Rationale Impact (To be achieved)
RAG Commentary
1. Review of incidences of C.Difficile Knowsley Community
Oct 13 Jo Dillon (Public Health Infection Control)/ Julie Hughes (5 Boroughs Partnership Foundation Trust Infection Control Team (ICT))/Ian Stewart Planning Manager KCCG
Long list of community acquired cases produced. Knowsley CCG CDiff trajectory reviewed
Scale and scope of issue known
Priority concerns/areas identified by 20/10/13
Monitored action plan in place
2. Medicine Management RCA of all Knowsley Community acquired Cdiff cases
Oct 13 16-12-2013
Revised completion
date End Dec 2013
Graham Pimblett Medicines Management Team Leader KCCG
Medicines Management Team (MMT) identified where to carry out Medicines Management (MM) Root Cause Analysis (RCA)
Understand potential preventable causes
16/21 completed by 20/10/13 26/28 completed 16/12/13
Do to increase in case numbers 2 RCAs outstanding to be completed by Jan 14 24-01-2014 update RAG rating changed to green. The outstanding RCAs have now been completed. The function of completing the Medicines Management RCA has now been passed to the 5 Boroughs Partnership Medicines Management Team (commissioned service). – see action 13.
4
Action Completion Date
Responsible Manager Comments/Progress to date
Rationale Impact (To be achieved)
RAG Commentary
3. ICT RCA of all Knowsley Community acquired Cdiff cases
Oct 13 Julie Hughes/ KCCG GPs ICT identified Cdiff cases and completing care pathway RCA (excluding MM RCA). 5BP MMT now included in further RCA.
Understand context for infection and potential contributory factors
20/21 completed by 20/10/13 RCA analysis 28/28 completed 16/12/13
4. Patient personal management of Cdiff care
Oct 13 Julie Hughes/ KCCG GPs ICT to use patient face to face contacts and information leaflet to support patient support to Cdiff prevention. GP considers patient individual actions in HCAI and Cdiff prevention/management. On-going visits to patients continued. Although CDI leaflet available is being further updated to improve information given after patient feedback.
Educate patients to support personal Cdiff care, ICT have visited identified patients (as part of RCA)
Patients who are able to manage own care, do so following support from community infection control service 16/12/13 completed
GP and/or Practice Manager involved in contact dependant on practice preference
5. Infection Control Team to feedback to each Practice RCA findings to inform for potential changes
Sept 13 to March 14
Julie Hughes/ KCCG GPs Commenced practice and nursing home feedbacks. Care Homes training and feedback in progress. First session delivered 1/11 and further session 14/11. All GPs who attended GP Training session also informed of on-going
Support improvement actions
All nursing homes involved (3) feedback, and 2 individual practices feedback completed and prevention remedial actions in place and effective as evidenced. 16/12/13 Completed (as above)
Will remain as part of on-going training programme in care homes and under consideration of Prescribing Leads.
5
Action Completion Date
Responsible Manager Comments/Progress to date
Rationale Impact (To be achieved)
RAG Commentary
need to attend feedback session to further inform practice around C diff improvement work.
6. MMT to feedback MM RCA to all practices identified from analysis
Oct 13 16-12-2013 Revised completion date End Jan 2014
Graham Pimblett, Relevant GPs
About to commence Support improvement actions
Assured prescribing practice in evidence
16-12-2013 update RAG rating changed to amber. MMT pharmacists providing feedback to GP’s with results of RCA’s. All feedback to be completed by end Jan 2014. 24-01-14 update On track to complete feedback to relevant GP’s by the end of Jan 14.
7. Letter to all GPs re Cdiff
Nov 13 16-12-13 Revised completion date Jan 2014
Julie Hughes, identified GP Clinical Leads
Draft received and to be updated as agreed by KCCG. Amended to include updated algorithm.
Raise awareness of Cdiff issue to support improvement in Cdiff situation
Increased vigilance in HCAI prevention
Letter content agreed and to be distributed to relevant practices 24-01-2014 update RAG rating changed to green. The letter is now being used and is given to the GP as part of the RCA review process by the ICT.
8. Antibiotic management and Proton Pump Inhibitor (PPI) management training session to Prescribing leads
Oct 13 to Nov 13
Julie Hughes/Graham Pimblett/Prescribing Leads
Dates in place and communication sent out to leads in preparation for session (2 sessions planned and to use Knowsley cases
Raise awareness of Cdiff issue to support improvement in Cdiff situation, and enable leads to cascade training to practices
General Practice and community HCAI actions are consistent and mutually supportive. 16-12-13 completed
6
Action Completion Date
Responsible Manager Comments/Progress to date
Rationale Impact (To be achieved)
RAG Commentary
as learning). First session delivered on 29/10 and well received. Second session booked for 3/12.
9. Antibiotic management and PPI management training session District Nurse/Community staff
Oct 13 to Nov 13
Julie Hughes/Graham Pimblett
District Nurse Training planned. On-going Locality District Nurses Training in progress. Sessions also being delivered via IPC Link Worker Programme (next session 1/14). Training also delivered to Practice Nurse Forum on 22/10 and Continence Nurses Study Day 22/10. Also on conference programme planned for 6/3/14.
Raise awareness of Cdiff issue to support improvement in Cdiff situation
Community system wide HCAI education and support used
16-12-2013 update Training programme in place which includes Cdiff improvement work. 2 x prescribing lead meetings with C Diff as topic (well attended).
10. Review of General Practices Antibiotic and PPI prescribing (PQP/Work plan)
Oct 13 to March 14
Graham Pimblett/Neil Rotherham Primary Care Quality Officer/ Medicines Management Sub Committee
Proton Pump Inhibitor (PPI) Prescribing Quality Premium (PQP) established, Antibiotic work programme to be established with each Practice as part of their baseline improvement work
Raise awareness of Cdiff issue to support improvement in Cdiff situation, supported by prescribing analysis and targeted support
CCG supporting implementation of evidence based improvement to avoidable Cdiff cases
-Prescribing at patient level of antibiotics (RCA) - -Practice level prescribing and high risk drugs and compliance with guidelines. 16-12-2013 update Baseline data has been collated and given to practices. Audit against this data to
7
Action Completion Date
Responsible Manager Comments/Progress to date
Rationale Impact (To be achieved)
RAG Commentary
be part of 2014/15 PQP To be completed by March 14
11. (Added 16-12-2013) Audit of Non Medical Prescribing (NMP) and Patient Group Directions (PGD) for antibiotics use within Walk In Centres.
Jan 14 Graham Pimblett and Carol Humphries
(Commencing Oct 2013 and throughout 2014). NMPs given comparison in their prescribing practice against the agreed antibiotic formulary. PGD audit is being undertaken
Ensure NMPs aware of antibiotic formulary and their prescribing practice
NMP aware of own prescribing practice; its impact and their prescribing within formulary
NMP now receiving feedback on prescribing data PGDs audit due for completion in Jan 14
12. (Added 16-12-2013) Review evidence relating to the use of prophylactic antibiotics for patients with UTI’s
Jan 14 Graham Pimblett Evidence review underway.
GPs to consider if patients have relevant investigations before prescribing antibiotics.
Prescribing prophylactic antibiotics for Urinary Tract Infections only occurs if there is sound evidence base/ rationale.
Information requested from UK Medicine’s Information service to provide evidence base for sharing with prescribers. 24-01-14 update RAG rating changed to green. Regional information obtained.
13. (Added 24-01-2014) Medicine Management Team RCA of all Knowsley Community acquired Cdiff cases and provide information to the CCG MMT
Mar 14 Medicines Management Team (MMT) (5 Boroughs Partnership Foundation Trust) Graham Pimblett
5 Boroughs MMT have now taken over completing the MMT RCA’s. CCG MMT lead to monitor that information is received.
Understand potential preventable causes
Actions identified to address potential causes
8
Knowsley CCG Internal for monitoring monthly
Infection Trust Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Tota l / Forecast12/13 Plan 4 2 2 1 - 1 1 2 3 3 1 2 22
12/13 Actual 2 2 2 2 1 1 2 2 3 3 2 2 - 22 22
13/14 Plan 3 3.0 1.0 1.0 2.0 - 1.0 1.0 1.0 2.0 2.0 1.0 2.0 17 17 13/14 Actual 1.0 3.0 2.0 1.0 3.0 3.0 - 2.0 - 15
12/13 Plan 3 4 3 2 2 1 2 2 3 3 2 1 28 12/13 Actual 2 1 - 2 2 1 1 1 1 3 2 4 2 20 20
13/14 Plan 3 2.0 1.0 1.0 1.0 2.0 1.0 2.0 2.0 2.0 2.0 2.0 1.0 19 19 13/14 Actual 2.0 3.0 3.0 5.0 3.0 3.0 4.0 1.0 4.0 28
12/13 Plan 7 6 5 3 2 2 3 4 6 6 3 3 50 50 12/13 Actual 3 2 4 3 2 3 3 4 6 4 6 2 42 42 13/14 Plan 4 5 2 2 3 2 2 3 3 4 4 3 3 36
13/14 Actual 3 6 5 6 6 6 4 3 4 - - - 43
Internal for monitoring cumulative% Reduction
12/13 Plan 4 6 8 9 9 10 11 13 16 19 20 22 22
13/14 Plan 3 3 4 5 7 7 8 9 10 12 14 15 17 17 -23%12/13 Plan 3 7 10 12 14 15 17 19 22 25 27 28 28
13/14 Plan 3 2 3 4 5 7 8 10 12 14 16 18 19 19 -32%12/13 Plan 7 13 18 21 23 25 28 32 38 44 47 50 50
13/14 Plan 4 5 7 9 12 14 16 19 22 26 30 33 36 36 -28%
NHS CB set an expectation that the CCG will have <=25% of yearly threshold by Q1 2013/14 (36*25% = 9 cases)
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD12/13 Plan 4.0 2.0 2.0 1.0 0.0 1.0 1.0 2.0 3.0 3.0 1.0 2.0 22.012/13 Actual 2.0 2.0 2.0 1.0 1.0 2.0 2.0 3.0 3.0 2.0 1.0 1.0 22.013/14 Plan 3.0 1.0 1.0 2.0 0.0 1.0 1.0 1.0 2.0 2.0 1.0 2.0 17.013/14 Actual 1.0 3.0 2.0 1.0 3.0 3.0 0.0 2.0 0.0 15.0Aintree 0.0 1.0 2.0 1.0 2.0 3.0 0.0 1.0 0.0 10.0St Helen's & Knowsley 0.0 2.0 0.0 0.0 1.0 0.0 0.0 0.0 0.0 3.0Royal Liverpool 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0Warrington & Halton 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 1.0
12/13 Plan 3.0 4.0 3.0 2.0 2.0 1.0 2.0 2.0 3.0 3.0 2.0 1.0 28.012/13 Actual 1.0 0.0 2.0 2.0 1.0 1.0 1.0 1.0 3.0 2.0 6.0 4.0 24.013/14 Plan 2.0 1.0 1.0 1.0 2.0 1.0 2.0 2.0 2.0 2.0 2.0 1.0 19.013/14 Actual 2.0 3.0 3.0 5.0 3.0 3.0 4.0 1.0 4.0 28.0Aintree 1.0 1.0 0.0 1.0 0.0 2.0 0.0 0.0 1.0 6.0St Helen's & Knowsley 1.0 2.0 3.0 3.0 2.0 1.0 4.0 0.0 2.0 18.0Royal Liverpool 0.0 0.0 0.0 1.0 1.0 0.0 0.0 1.0 1.0 4.0
Actuals 3.0 6.0 5.0 6.0 6.0 6.0 4.0 3.0 4.0 0.0 0.0 0.0 43.0
Combined planned Totals 5.0 2.0 2.0 3.0 2.0 2.0 3.0 3.0 4.0 4.0 3.0 3.0 36.0
Monthly Variance -2.0 4.0 3.0 3.0 4.0 4.0 1.0 0.0 0.0 17.0
Trust-Acquired
Community-Acquired
1 Please note that these targets apply only to Knowsley CCG-responsible patients.2 Activity from HPA website.3 Target divided between trust- and community-acquired. 4 Target set by NHS Commissiong Board (Objectives)
C-Di ffici le
Trust-Acquired
Community-Acquired
Tota l
C-Diffici le
Trust-Acquired
Community-Acquired
Total
1.0
3.0
2.0
1.0
3.0 3.0
0.0
2.0
0.00.0
1.0
2.0
3.0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Num
ber
Trust Aquired C-difficile 2013/14 13/14 Actual
13/14 Plan
2.0
3.0 3.0
5.0
3.0 3.0
4.0
1.0
4.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Num
ber
Community Aquired C-difficile 2013/1413/14 Actual
13/14 Plan
9
Knowsley CCG - Healthcare Acquired Infections - C-Difficile Revised position for Internal use only against the provider Action Plan (Not for national performance monitoring)
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar12/13 Actual 2.0 2.0 2.0 1.0 1.0 2.0 2.0 3.0 3.0 2.0 1.0 1.0 22.0
Trust-Acquired 13/14 Plan 3.0 1.0 1.0 2.0 0.0 1.0 1.0 1.0 2.0 2.0 1.0 2.0 17.013/14 revised trajectory 3.0 1.0 1.0 2.0 0.0 1.0 1.0 1.0 2.0 2.0 1.0 2.0 17.013/14 Actual 1.0 3.0 2.0 1.0 3.0 3.0 0.0 2.0 0.0 0.0 15.0Aintree 0.0 1.0 2.0 1.0 2.0 3.0 0.0 1.0 0.0 0.0 10.0St Helen's & Knowsley 0.0 2.0 0.0 0.0 1.0 0.0 0.0 0.0 0.0 0.0 3.0Royal Liverpool 1.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0Warrington & Halton 0.0 0.0 0.0 0.0 0.0 0.0 0.0 1.0 0.0 0.0 1.0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb MarCommunity-Acquired
12/13 Actual 1.0 0.0 2.0 2.0 1.0 1.0 1.0 1.0 3.0 2.0 6.0 4.0 24.0
13/14 Plan 2.0 1.0 1.0 1.0 2.0 1.0 2.0 2.0 2.0 2.0 2.0 1.0 19.013/14 revised trajectory 2.0 3.0 3.0 4.0 3.0 3.0 4.0 2.0 2.0 2.0 2.0 1.0 31.013/14 Actual 2.0 3.0 3.0 5.0 3.0 3.0 4.0 1.0 4.0 3.0 31.0Aintree 1.0 1.0 0.0 1.0 0.0 2.0 0.0 0.0 1.0 0.0 6.0St Helen's & Knowsley 1.0 2.0 3.0 3.0 2.0 1.0 4.0 0.0 2.0 2.0 20.0Royal Liverpool 0.0 0.0 0.0 1.0 1.0 0.0 0.0 1.0 1.0 1.0 5.0
Actuals 3.0 6.0 5.0 6.0 6.0 6.0 4.0 3.0 4.0 3.0 0.0 0.0 46.0
Combined planned Totals 5.0 4.0 4.0 6.0 3.0 4.0 5.0 3.0 4.0 4.0 3.0 3.0 48.0
Monthly Variance -2.0 2.0 1.0 0.0 3.0 2.0 -1.0 0.0 0.0 5.0
1.0
3.0
2.0
1.0
3.0 3.0
0.0
2.0
0.0 0.00.0
1.0
2.0
3.0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Num
ber
Trust Aquired C-difficile 2013/14
13/14 Actual
13/14 revisedtrajectory
2.0
3.0 3.0
5.0
3.0 3.0
4.0
1.0
4.0
3.0
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Num
ber
Community Aquired C-difficile 2013/1413/14 Actual
13/14 revisedtrajectory
Document 23(01)04
Report to Knowsley Clinical Commissioning Group Governing Body
Date of meeting: 6th February 2014
Report title: Human Resource Policies
Report presented by: Dawn Boyer, Head of Corporate Services
Purpose of the report: To seek approval to updated, harmonised Human Resources (HR) policies and to the Personal Development and Delivery Review (PDDR) Procedure for the CCG
Recommendations:
Action / Decision required
The Governing Body is recommended to approve the HR Policies and PDDR Procedure attached to this report for implementation with immediate effect, from 7th February 2014.
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred
2. Safe
3. High quality X
4. Cost effective X
5. Outcome focused X
6. Closer to home
7. Affordable
[one page only]
1
GOVERNING BODY
HUMAN RESOURCE POLICIES
1. Purpose of the report 1.1 The purpose of the report is to seek approval from the Governing Body for the
updated, harmonised Human Resources (HR) policies and to the Personal Development and Delivery Review (PDDR) Procedure for the CCG.
2. Recommendations 2.1 The Governing Body is recommended to approve the HR Policies and PDDR
Procedure attached to this report for implementation with immediate effect, from 7th February 2014.
3. Background 3.1 Upon establishment of Knowsley CCG a significant proportion of staff employed by
the CCG were subject to a TUPE transfer from the former Knowsley, Halton & St.Helens and Liverpool Primary Care Trusts. As part of that transfer the Terms and conditions, including HR policies of these organisations, transferred along with the staff.
3.2 At the same time a process has been undertaken across Cheshire and Merseyside to
review, harmonise, consult and agree a consistent set of HR policies, reflecting legislative requirements and NHS national terms and conditions, which bring together the varying policies into a single form.
3.3 The attached policies are necessary to ensure consistent treatment of staff employed
within the CCG which, as a statutory body, is required to manage its resources in a responsible manner. Whilst the proposed harmonised HR Policies have been developed with reference to Agenda for Change (AfC) terms and conditions and established national employment legislation some local discretion can be applied.
3.4 The purpose of the PDDR process is to review individual performance level, identify
personal development needs and support, to meet the priorities and objectives of the CCG while also supporting the career aspirations of staff members.
4. Evidence and Consultation 4.1 The HR policies were developed in consultation with all CCGs across Cheshire and
Merseyside, including Knowsley, with the opportunity to comment on each of the policies listed. CCG staff, through the staff side representatives on the Partnership Forum, were consulted on each of the Policies listed and were provided with opportunities to comment prior to approval at the Partnership Forum. The policies
2
have been adjusted and formatted to reflect the CCG’s governance and managerial arrangements.
4.2 The HR policies were reviewed and discussed by the CCG’s Human Resources (HR)
Committee on 3rd December 2013 and, subject to two changes, were recommended for approval by the Governing Body. The ‘Special Leave Policy’ has been renamed the ‘Flexible Working and Special Leave Policy’ and within this policy domestic violence is now added as a potential factor meriting consideration.
4.3 The PDR process has been developed by the CCG’s Commissioning Support
Provider based on good practice in the NHS and other organisations, and has been reviewed by the Head of Corporate Services to ensure that it meets the needs of the CCG.
5. Proposals 5.1 The policies attached are the first set of policies emerging from this process and
further policies will follow. 5.2 The HR Policies listed below and appended to the report were approved by the
Partnership Forum in September 2013 and reviewed by the CCG’s HR Committee in December 2013:
• Attendance Management Policy • Annual Leave& Bank Holiday Policy • Disciplinary Policy • Grievance and Disputes Policy & Procedure • Family Leave Policy • Flexible Working and Special Leave Policy • Capability Policy • Whistleblowing Policy
5.3 The PDDR procedure appended to the report focuses on ensuring a positive and
effective conversation between line managers and staff and not upon completing paperwork and is divided into three essential elements;
a) Pre-appraisal b) Setting performance objectives c) Learning and development plan
5.4 This is underpinned by an emphasis upon both performance against work objectives
and performance against the organisational values and measures. Combining these elements will result in overall individual and organisational alignment.
5.5 It is proposed that the HR Policies and PDDR Procedure are approved for
implementation with immediate effect, from 7th February 2014. 5.5 Communication is planned to cascade the Policies throughout the CCG and this will
take the form of:
• A team briefing • Intranet publication
3
• More detailed manager briefings by HR in respect of the HR policies, as necessary
• Individual line manager discussions with staff in respect of the PDDR process
This will be supported by training sessions for managers conducting personal development and delivery reviews and overview sessions for other staff participating in reviews.
6. Impact on Services to the Population 6.1 There is no direct impact upon services to the population although effective
management of human resources, in accordance with legislative requirements, forms part of an effective service response to the local population.
6.2 All of the Policies are subject to an equality impact assessment which ensures that
there is no detriment to any group with protected characteristics. This includes black and minority ethnic groups, younger or older people, disabled people, gender, gender reassignment, marriage & civil partnership, pregnancy & maternity, religion & belief, and sexual orientation.
6.3 Agreed employment policies and processes may impact as follows: 6.3.1 Quality – impact of improved working environment upon the quality of services to
patients & the public.
6.3.2 Innovation – no anticipated impact.
6.3.3 Productivity – impact upon productivity through confidence of staff in employment arrangements.
6.3.4 Prevention – no anticipated impact.
7. Resource Implications 7.1 Financial 7.1.1 It is expected that there would be no cost in implementation of HR Policies to the
CCG. However, the implementation of such policies can create savings in the longer term through the efficient and effective management of staff and the avoidance of challenges and disputes. Certain policies will financially impact upon the CCG in terms of agreed obligations to provide support to staff although such costs would be determined by the individual circumstances involved.
7.2 Human Resources 7.2.1 The implementation of HR Policies will ensure the consistent treatment of all staff
employed in the CCG reflecting NHS national terms and conditions and legislation requirements. Staff have been consulted, through their representatives, on the content of the policies.
4
7.3 Technology 7.3.1 There are no technology implications in relation to the attached policies. 7.4 Physical Assets 7.4.1 There are no physical asset implications in relation to the attached policies. 8. Risk Assessment
8.1 There are no significant risks attached to the implementation of the proposed Human Resources policies. If the policies aren’t approved there is a risk that the CCG will have ineffective arrangements for managing its human resources, which are inconsistent between staff drawn from different predecessor organisations and which fail to keep pace with legislative and other changes in national requirements. If the PDDR procedure isn’t implemented there is a risk that CCG staff aren’t sufficiently informed regarding their personal performance objectives and priorities and development needs aren’t identified or met linked to these objectives.
Managerial Lead –Dawn Boyer, Head of Corporate Services
Signatory Details: Tom Fairclough, [email protected], 0151 244 4128
Background Documents:
None
Appendices:
Policy documents:
• Attendance Management Policy • Annual Leave& Bank Holiday Policy • Disciplinary Policy • Grievance and Disputes Policy & Procedure • Family Leave Policy • Flexible Working and Special Leave Policy • Capability Policy • Whistleblowing Policy • Personal Development and Delivery Review Procedure
Hard copies of the policies have not been circulated with the agenda due to the volume of paper. Instead these can be accessed in the CCG directory at the following link: L:\Knowsley CCG\SECRETARIAT\Secretariat\Meetings\Governing Body Meeting\Governing Body\2014\(23) February 2014\HR Policies
Document 23(01)05
Report to Knowsley Clinical Commissioning Group Governing Body
Date of meeting: 6th February 2014
Report title: Information Governance Policies
Report presented by: Dawn Boyer, Head of Corporate Services
Purpose of the report: To seek approval to the updated Information Governance (IG) Strategy and supporting IG and IT policies.
Recommendations:
Action / Decision required
The Governing Body is recommended to approve the IG Strategy and associated IG policies, and IT policies appended to this report.
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred X
2. Safe X
3. High quality X
4. Cost effective X
5. Outcome focused
6. Closer to home
7. Affordable
[one page only]
1
GOVERNING BODY
INFORMATION GOVERNANCE POLICIES
1. Purpose of the report 1.1 The purpose of the report is to seek approval of the updated Information
Governance (IG) Strategy and supporting IG and Information Technology (IT) policies.
2. Recommendations 2.1 The Governing Body is recommended to approve the IG Strategy and associated IG
policies, and IT policies appended to this report. 3. Background 3.1 There are many different standards and legal rules that apply to information
handling. Information Governance provides a framework to bring together all of these legal rules, guidance and best practice. At its heart, information governance is about setting a high standard for the handling of information and giving organisations the tools to achieve that standard. The ultimate aim is to demonstrate that the organisation can be trusted to maintain the confidentiality and security of personal information, by helping individuals to practice good information governance and to be consistent in the way they handle personal and corporate information.
3.2 At its meeting in March 2013 the Governing Body approved the IG Strategy and
supporting IG policies listed below:
a) Information Governance Strategy – which sets out the approach to be taken by the CCG to provide a robust IG framework for the future management of information assets.
b) Information Governance Policy – which sets out the CCG’s policy for the local management of information.
c) Corporate Records and Retention Policy – which sets out the CCG’s policy and arrangements for meeting its statutory duty for the safekeeping and eventual disposal of records.
d) Subject Access Request Policy – which sets out the CCG’s policy and requirements for its staff and commissioning support provider to manage requests to access records.
2
e) Confidentiality and Data Protection Policy – which sets out how the CCG will meet its legal obligations and NHS requirements concerning confidentiality and information security standards.
3.3 In addition the Governing Body approved and adopted the IT policies in respect of information governance developed by the CCG’s Informatics provider.
3.4 This report presents the results of the annual review of those policies where
required, and seeks approval to updated policies. 4. Evidence and Consultation 4.1 The CCG has reviewed and updated the Information Governance Strategy and
Policies in conjunction with its Commissioning Support Provider to reflect any changes in legislation, guidance and good practice and any organisational changes. This has resulted in a number of minor changes in respect of changing roles and responsibilities, reporting requirements and updates to the Caldicott principles.
4.2 A number of the Information Security policies were also due for review and have
similarly been updated by the Health Informatics Service. 4.3 The revised policies have been reviewed and agreed by the Information
Governance Management Group and by the Audit Committee and are recommended for approval by the Governing Body.
4.4 The Freedom of Information Policy has not been included at this stage as a more
fundamental review is required to reflect proposed changes in the CCG’s commissioning support arrangements currently under discussion.
5. Proposals 5.1 The Governing Body is requested to approve the updated policies listed below and
appended to the report:
a) Information Governance Strategy V1.2 b) Information Governance Policy V1.2 c) Confidentiality and Data Protection Policy V1.2 d) Subject Access Requests Policy V1.2 e) Corporate Records and Retention Policy V1.2 f) Remote Access Policy V2 g) Mobile Device Policy V5 h) Back Up Policy V3
5.2 This will enable the CCG to demonstrate as part of its IG toolkit submission at the end of March that it has reviewed and updated its policies as required.
6. Impact on Services to the Population 6.1 The information governance arrangements will protect the confidentiality of patient
and other personal information across all population groups.
3
7. Resource Implications 7.1 Financial
7.1.1 There are no financial implications as a direct result of the proposals.
7.2 Human
7.2.1 All staff are required to undertake mandatory information governance training, including briefings on specific CCG policies and procedures.
7.3 Information Technology
7.3.1 Information technology plays a significant role in the storage, processing and transmission of confidential information and IT security measures are a significant element of the IG requirements. These requirements are met through the service level agreement with Health Informatics.
7.4 Physical Assets
7.4.1 There are no physical asset implications as a direct result of the proposals.
8. Risk Assessment 8.1 There are no significant risks associated with the approval of the updated strategy
and policies. If the updated policies are not approved there is a risk that the CCG will fail to demonstrate that it has met the requirements of the IG toolkit at level 2.
Managerial Lead – Dawn Boyer, Head of Corporate Services
Contact details: Dawn Boyer, [email protected], 0151 244 4127 Background Documents: None Appendices: Policy documents
• Information Governance Strategy V1.2 • Information Governance Policy V1.2
4
• Confidentiality and Data Protection Policy V1.2 • Subject Access Requests Policy V1.2 • Corporate Records and Retention Policy V1.2 • Remote Access Policy V2 • Mobile Device Policy V5 • Back Up Policy V3
Hard copies of the policies have not been circulated with the agenda due to the volume of paper. Instead these can be accessed in the CCG directory at the following link: L:\Knowsley CCG\SECRETARIAT\Secretariat\Meetings\Governing Body Meeting\Governing Body\2014\(23) February 2014\IG Policies
1
Document 23(01)06
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred
2. Safe
3. High quality
4. Cost effective X
5. Outcome focused
6. Closer to home
7. Affordable X
Report to Knowsley Clinical Commissioning Group
Governing Body Date of meeting: 6th February 2014
Report title: CCG Allocations 2013-2019 and Their Impact
Report presented by: Paul Brickwood, Chief Finance Officer
Purpose of the report: This report reviews the recent resource allocations to the CCG for 2014/15 and 2015/16 and the longer term assumptions required to update and extend the Financial Strategy to 2018/19. It also informs the 2014/15 budget setting process.
Recommendations:
Action / Decision required
The Governing Body is recommended to:
Note the financial allocations and the relevant assumptions which will underpin the Operational and Strategic Commissioning Plans to 2018/19.
Delegated Powers:
For decision reports only
2
CCG ALLOCATIONS 2013-2019 AND THEIR IMPACT
1. Background
1.1 Following the NHS England (NHSE) Board meeting on 17th December 2013, which included a decision on allocation policy, NHSE published programme cost allocations for CCGs for 2014-2015 and 2015-2016. These allocations were given in the context of the overall funding envelope give to NHSE of £96.64bn in 2014/15 and £98.84bn in 2015/16 available for distribution – an overall uplift of 3.1% and 2.3% respectively. Note that the commissioner inflation assumes that real terms growth equals 2.1% and 1.5% over the 2 years. Table 2 below shows the high level allocation of these resources.
1.2 This distribution was based on a number of assumptions key of which are: • CCGs receive real terms growth plus an additional allocation of £250m
in 2014/15 and £400m in 2015/16 to cover cost pressures and support the pace of change to target allocations.
• Payment of provisions relating to continuing healthcare, estimated at c£250m, constitute a pressure on the funding envelope for CCGs in 2014/2015. (the current estimate for this CCG is £0.7m)
• CCGs will achieve 75% of their quality premium. • A structural deficit of £330m in specialised commissioning will be funded
in 2014/15. • The commissioning sector, including CCGs, receives no additional
funding for inflation in its admin budget in either year and needs to achieve a cost reduction of 10% in 2015/16. (See section 5 below.)
1.3 It should be noted that the table shows that CCGs will need to find significant
efficiencies over the 2 years – 3.3% in 2014/15 and 5.9% in 2015/16. The latter
Table 1 High Level Allocation of NHS England Resources
3
reflects the level of local funding expected to be found to support the Better Care Fund which should become fully operational in that year. Although the bulk of efficiency will be delivered through the efficiency requirement built into tariffs the CCG will need to develop robust commissioning schemes which deliver improved more efficient service models.
2. CCG Target Allocations
2.1 During 2013 the Advisory Committee on Resource Allocation (ACRA) had independently reviewed the methodology for the “target allocation” (also known as the “fair shares” formula) for the future funding of CCGs. In August 2013 NHSE published details of the funding allocations that CCGs would have received had the ACRA fair shares formulae been implemented for 2013-2014 with no adjustment for unmet need. For Knowsley CCG this would have meant a reduction in resources of circa £16m per annum. NHSE concluded that ACRA’s proposal did not take into account “unmet need” which is a particular issue within deprived communities where the population may not access services in the best or right way.
2.2 The allocation policy paper presented to the NHSE Board considered 7 options
about the addition of an inequalities component and the pace of change. They agreed to Option 4 which was the least radical regarding allocation movements, so that the “pace of change towards target is relatively slow. It means that in 2014/15:
• the most under target CCGs will see 2.64% per head growth; • this reduces progressively to 1.22% for those less far below target; • all CCGs see total allocation growth of at least 2.14%, thereby getting
real terms growth; and • the most over target CCGs have their total growth limited to 2.14% even
if their population is growing rapidly. 2.3 Appendix 1 shows the impact of this policy for the Merseyside CCGs. As can
be seen the re-introduction of the inequalities component has helped most of the Mersey CCGs. The distance from target for Knowsley decreased from 7.27% to now being 6.05% (£15.1m) over target by the end of 2015/16. Communication with NHSE has shown that whilst Knowsley has benefitted from the inequalities component this has been offset by the impact of allocation transfers into the CCG between the original allocation announced in December 2012 and the position as at September 2013 and also the relatively low registered population growth estimates compared to the national average.
2.4 The planning guidance recently released suggests that for the longer term
strategic plans CCGs should assume a continuation of the NHSE’s current allocation policy although no decisions on allocation beyond 2015/16 have yet been taken. “Commissioners should assume that income growth increases in line with the GDP deflator” (1.8% for 2016/17 and 1.7% for the remaining 2 years) and that the current pace of change towards target should continue using the 2014/15 and 2015/16 allocations trajectory. This would suggest that over target CCGs will get 0.4% less than the average CCG allocation uplift per year which for this CCG would be approximately £1m less growth. Unfortunately the guidance does not make it clear whether the GDP deflator
4
figures will be the allocation floor or whether they will reflect the average CCG uplift and would therefore be reduced by the 0.4% for over target CCGs. It is hoped that this will be confirmed before the submission of the strategic plans but in the meantime will be used as down side scenario in the revised financial strategy being produced.
3. CCG Allocations 2014-2015 and 2015-2016
3.1 The NHSE’s decisions mean that this CCG’s programme budget allocations will be as follows:
Table 2: Knowsley CCG Allocations 2014-2016
3.2 The CCG will receive a funding increase 2.14% in 2014-2015 and 1.7% in 2015-2016. Additionally the CCG will receive an allocation of £4.48m in 2015-2016 towards the Better Care Fund. This represents a transfer to the CCG of the share of monies currently held by NHSE and paid directly to LAs under section 256 arrangements.
3.3 This allocation (excluding the Better Care Fund) will mean that Knowsley CCG
resources per head is 6.3% above the Mersey average and above both national and NHS North averages by 26.5% and 18.8% respectively.
2013/14 2014/15 2014/15 2015/16 2015/16 2015/16 2015/16Programme
Budget Baseline
Allocation
Growth 2014/15 2.14%
CCG Programme
Budget Allocation
Growth 2015/16 1.70%
CCG Programme
Budget Allocation
Better Care Fund
Additional Allocation
Total Allocation
£m £m £m £m £m £m £m239.57 5.13 244.69 4.16 248.85 4.48 253.33
Note: Numbers may not add due to rounding
5
4. Better Care Fund
4.1 The CCG continues to work in partnership with the Local Authority to plan for the implementation of the Better Care Fund (BCF) from April 2015. In relation to allocations it is the CCG’s understanding that for 2014-2015 NHS funds related to social care will continue to flow from NHSE directly to the MBC under the existing section 256 partnership arrangement. A 2 year agreement was put in place between NHSE and the Knowsley MBC in 2013 covering 2013-2014 and 2014-2015. For 2014-2015 NHSE has allocated a further £200m nationally to transfer from the NHS to adult social care. Knowsley’s share of this is £0.9m and is conditional on the MBC jointly agreeing and signing off two year plans for the BCF. The intention is that LAs should use the additional resources in 2014-2015 to prepare for the implementation of BCF pooled budgets in April 2015 and to make early progress against the national conditions and performance measures set out in the locally agreed plan.
4.2 For 2015-2016 NHSE have identified a total transfer of NHS resources to the
Better Care Fund for Knowsley of £13.4 million. This includes £4.5m to be added to the CCG’s allocation in that year effectively representing Knowsley’s share of the resources currently paid directly to LAs from NHSE. Work is underway with colleagues at the LA to complete the planning template required by NHSE in mid-February as a “first cut” of the BCF plan and to ensure that plans are agreed by the CCG Governing Body, Local Authority Cabinet and Health and Wellbeing Board prior to submission in mid-February. A final version of the BCF has to be approved and submitted to NHSE by 4 April 2014.
4.3 The £13.4m identified by NHSE for Knowsley is the minimum level of resources
to be included in the Better Care Fund. As well as the additional Better Care Fund allocation it is also expected to include the reablement and carers funds already included in the CCG’s budgets. The level of existing resources have yet
6
to be confirmed – although it is clear that there will need to an element of new monies. Other pooled budgets could be included within the remit of the Fund – such as the proposals for adult complex and continuing health care section 75 arrangements within the Borough.
Table 3 Better Care Fund 2015/16
4.4 As with the Programme Budget Allocations the Better Care Fund minimum
levels set out within the guidance reflect local health inequalities as shown in chart 2. As with the Programme budget Allocations Knowsley is above the Mersey, NHS North and national levels.
Knowsley£000
NHS Resources Minimum Level 13420
Comprising:CCG Allocation 2015/16 4478
Balance Existing & New Resources 8942
NHS BCF Funding Minimum 13420
Non-NHS FundingDisability Fund Capital Grant 1206Community Capacity Cap Grant 544
1750
Better care Fund Minimum 15170
7
4.5 A potential risk for the future would be if the Better Care Fund additional allocation were to be added to CCG Programme Budget Baselines as whilst the higher than national average level of Better Care Funding is to be welcomed it would move the CCG further from target thereby further depressing future allocation growth relative to the national average uplift for CCGs. At this stage however there is no way of assessing the likelihood of this risk occurring.
5. CCG Running Cost Allowance (RCA)
5.1 In line with the announcement in the Comprehensive Spending Review, NHS administration costs are to be reduced by 10% in 2015/16. From the guidance contained in the Allocation of Resources paper which went to the NHSE Board - 2 options for calculating CCG Running Cost Allowances were put forward. The first option kept the link to population but in recognition of the increase with the move to registered population suggested a revised price 2014/15 of £24.78 per head compared to £25 as now. The price would drop by the 10% in 2015/16 to £22.11 (also allowing for further population growth in that year). The alternative option would be that the 2013/14 RCA would be treated as a baseline which would then be reduced by 10% in 2015/16. Unfortunately the NHSE paper does not set out a preferred choice between the options and CCGs have yet to be given confirmed RCA allocations. The impact of these 2 options is shown in Table 4. As can be seen the population method gives a slightly better position for CCG RCA allocations if this method is chosen.
Table 4 CCG Running Cost Allowances Population Method 2013/14 2014/15 2015/16 Overall Change
RCA per head £25.00 £24.78 £22.11 From 2013/14
ONS Pop £000 Reg Pop £000 Reg Pop £000 %
NHS Halton CCG 124,104 3103 129,294 3204 129,716 2868 -8%
NHS Knowsley CCG 149,108 3728 161,301 3997 161,694 3575 -4%
NHS St.Helens CCG 186,743 4669 194,675 4824 195,425 4321 -7%
Baseline Method Deflator 0% -10%
ONS Pop £000 £000 £000 %
NHS Halton CCG 124,104 3103 3103 2792 -10%
NHS Knowsley CCG 149,108 3728 3728 3355 -10%
NHS St.Helens CCG 186,743 4669 4669 4202 -10%
6. Impact On The Financial Strategy
6.1 In July 2013, the CCG approved a draft Financial Strategy covering the period to 2017/18. Clearly the recent planning guidance has now confirmed some of missing information that had to be assumed within the draft Financial Strategy for the years after 2013/14. Table 5 compares the allocation assumptions made last year with the allocations and planning guidance received.
Table 5 Comparison of Draft Strategy Allocation Uplifts with Latest Planning Guidance and Allocations
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The assumptions made in the draft Strategy were more pessimistic than the
confirmed allocations for 2014/15 and 2015/16 - the total uplift being 3.9% compared to the 2% previously assumed. Looking beyond 2015/16 although no decisions have been made by the NHSE on allocations the planning guidance suggests a continuation of the current policies which suggests that all CCGs would get a minimum uplift in line with the GDP deflator. However it is possible that future Government Spending Reviews may end the priority funding the NHS has enjoyed. Downside Scenario 2 assumes that the GDP deflator level of funding is the average CCG uplift and that over target CCGs like Knowsley receive 0.4% less in line with the 2014/15 and 2015/16 allocations policy. Downside scenario 2 assumes that the pace of change would be accelerated or that the overall level of funding for the NHS is reduced below inflation.
6.2 Work has commenced on updating the Financial Strategy to reflect the
assumptions shown above. The Strategy will need to support the Operational and Strategic Commissioning Plans with are also under development including the use of the Better Care Fund in collaboration with the Local Authority. The financial plans will need to show that the CCG can deliver the business rules requirements for CCGs over the next 2 years and which are also likely to continue to apply beyond 2015/16. These are summarised in Table 6
Table 6 Business Rules for CCGs 2014-2016
2014/15 • Minimum 0.5% contingency • 1% cumulative surplus carry
forward • 2.5% non-recurrent spend
(incl. 1% for transformation)
2015/16 • Minimum 0.5% contingency • 1% cumulative surplus carry
forward • 1% non-recurrent spend • BCF spend as notified
separately
2016/17-2018/19 Assumption • Minimum 0.5% contingency • 1% cumulative surplus carry
forward • 1% non-recurrent spend • BCF spend as notified
separately
Previous Assumptions 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
Base Scenario 1 2.30% 1.00% 1.00% 1.00% 1.00%
Downside Scenario 2 2.30% 2.00% 2.00% 0.00% 0.00%
Downside Scenario 3 2.30% 2.00% 2.00% -2.50% -2.50%
Revised Figures 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19
Base Scenario 1 2.30% 2.14% 1.70% 1.80% 1.70% 1.70%
Downside Scenario 2 2.30% 2.14% 1.70% 1.40% 1.30% 1.30%
Downside Scenario 3 2.30% 2.14% 1.70% 0.00% 0.00% 0.00%
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7. Conclusions
7.1 The announcement of the 2014/15 and 2015/16 allocations before Christmas allows the CCG to plan with more certainty and the guidance also suggests that the worse impacts of the change in allocation formula are likely to be mitigated by the NHSE. The financial position will continue to be very challenging over the next 5 years with real reductions in spending required and the achievement of efficiencies through the commissioning of “transformed services” using the Better Care Fund as a major vehicle towards achieving this.
Managerial Lead – Paul Brickwood, Chief Finance Officer
Contact details: Paul Brickwood, [email protected] 0151 244 4148
10
Appendix 1 Mersey CCG Programme Allocations 2014/15 & 2015/16
2013/14 2013/14 2013/14 2014/15 2014/15 2014/15 2015/16 2015/16 2015/16 2015/16 2015/16
Programme Budget
Baseline Allocation
Registered Population
Allocation Per Head
Estimated Registered Population
CCG Programme
Budget Allocation
Distance From
Target
Estimated Registered Population
CCG Programme
Budget Allocation
Distance From
Target
Better Care Fund Additional Allocation
Total Allocation
CCG £000 £ £000 % £000 % £000 £000 NHS Halton CCG 174,720 128,894 1,356 129,294 178,459 2.24 129,716 181,493 2.39 2,929 184,422 NHS Knowsley CCG 239,567 160,886 1,489 161,301 244,694 5.81 161,694 248,854 6.05 4,478 253,332 NHS South Sefton CCG 221,894 155,065 1,431 155,213 226,643 9.80 155,386 230,496 10.20 4,105 234,601 NHS Southport & Formby CCG 159,704 122,468 1,304 122,585 163,122 4.04 122,721 165,895 4.41 2,884 168,779 NHS St.Helens CCG 261,792 193,958 1,350 194,675 267,394 3.46 195,425 271,940 3.55 4,413 276,353 NHS Liverpool CCG 704,044 498,111 1,413 497,356 719,111 7.02 496,646 731,336 7.67 13,553 744,889 Merseyside 1,761,721 1,259,382 1,399 1,260,424 1,799,423 5.88 1,261,588 1,830,014 6.29 32,362 1,862,376
Document 23(01)07
Report to Knowsley Clinical Commissioning Group Governing Body
Date of meeting: 6th February 2014
Report title: Contract Negotiation 2014/15 Briefing
Report presented by: Clare Barrow, Head of Finance & Contracts
Purpose of the report: To provide an update on progress made towards agreeing NHS Standard Contracts with Acute, Mental Health & Community providers for 2014/15.
Recommendations:
Action / Decision required
The Governing Body is recommended to note the progress to date.
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred X
2. Safe
3. High quality X
4. Cost effective X
5. Outcome focused X
6. Closer to home
7. Affordable X
[one page only]
1
GOVERNING BODY
CONTRACT NEGOTIATION 2014/15 BRIEFING 1. Purpose of the Briefing 1.1. To update the Governing Body on progress made towards agreeing NHS Standard
Contracts with Acute, Mental Health and Community providers for 2014/15. 2. Background 2.1 Knowsley CCG has significant contractual relationships with a number of provider
organisations across Merseyside. Four main providers, however, are recognised as “key” Providers for Knowsley CCG in that the CCG contributes >5% towards the overall level of Provider income. These are:
a) St Helens & Knowsley Hospitals NHS Trust b) Aintree University Hospitals NHS Foundation Trust c) 5 Boroughs Partnership NHS Foundation Trust d) Liverpool Women’s Hospital NHS Foundation Trust
2.2 Total contracted services which are subject to this annual negotiation process amount to £119 million with 89% (£106m) of this value being attributable to the four “key” providers above.
2.3 The Governing Body received a report at its meeting in December which detailed the main issues to be addressed through the contract negotiation process 2014/15. This document outlined the key steps that would need to be taken to ensure contracts deliver improved quality in a cost effective manner whilst working towards a challenging sign off date of 28th February 2014 imposed by the Department of Health.
2.4 This briefing updates the Governing Body on progress made in the key areas as
follows:
a) Contracting Principles b) Finance and Activity c) Assurance of Cost Improvement Schemes d) Quality Incentives e) Service Development & Improvement Plans
2.5 As in 2013/14 the CCG will utilise collaborative commissioning arrangements with
neighbouring CCGs. These agreements enable Co-ordinating CCGs to lead
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contract negotiations with a Provider on behalf of all CCGs in the collaboration, within an agreed set of Contract Principles.
2.6 Appendix 1 details the collaborative CCG partners that Knowsley will be working
closely with in respect of contracted providers for 2014/15. Knowsley is the Co-ordinating Commissioner for Five Boroughs Partnership Foundation Trust.
3. Progress to Date
3.1 Contracting Principles
3.1.1 Contracting principles determine the key themes and guidance that will be followed to agree a mutually accepted contract that is signed by all parties. Contracting Principles have been drafted by each of the Co-ordinating CCGs for the main providers across Cheshire & Merseyside. CCGs are in the process of reviewing these documents to determine if the principles are acceptable and will deliver in terms of both quality and cost effectiveness.
3.1.2 At this stage there are currently no risks identified within the principles that would prevent Knowsley from agreeing contracts with its providers by the deadline of 28th Feb 2014.
3.2 Finance and Activity
3.2.1 It is anticipated that the majority of acute hospital contracts will operate under normal Payment by Results (PbR) rules (where applicable) in 2014/15 and national guidance regarding efficiency and inflation will apply consistently across contracts. The guidance indicates that the CCG should expect to deliver efficiency savings of 4% from Contracts and a standard uplift of 2.5% (Acute) and 2.2% (Non Acute) will apply resulting in a net saving of 1.5% (Acute) or 1.8% (Non Acute).
3.2.2 Mental Health services will remain on block contract arrangements in 2014/15,
however the CCG will expect Providers to share shadow monitoring information on a regular basis to enable a greater understanding of the financial impact in transitioning to a Payment by Results system.
3.2.3 A number of commissioning developments have been identified as 'contract
ready' with all necessary service developments in place and associated financial and activity analysis complete. These intentions have documented in the commissioning intentions which will be shared with providers to agree inclusion of these items within contracts from 1st April 2014.
3.3 Assurance of Cost Improvement Schemes
3.3.1 In 2014/15, there will be a continuing requirement for CCGs to submit self-certification of assurance that provider cost improvement plans (CIPs) are deliverable without impacting on the quality and safety of patient care.
3.3.2 The impact assessments for each provider are still to be determined at this
stage, however, it is likely this will take a similar form to that adopted in 2013/14 and will be based upon:
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a) Details of all CCG provider relevant cost improvement schemes (samples not
being sufficient) b) The assurance process that is undertaken at the provider with timescales c) The schemes providing a clear outline of the division/Borough impact as
CCGs need to understand the local impact in order to sign these off d) Copies of the signature of Medical and Nursing Director stating that they
have agreed that the cost improvement schemes are assured as being clinically safe.
3.3.3 The CCG will utilise its Commissioning Support Provider in requesting, collating
and disseminating provider evidence to support this requirement. Discussions will shortly commence with partner CCGs to reach an agreement in respect of evidence required to provide the assurance needed for self-certification.
3.3.4 The CCGs Contract Task & Finish group will facilitate the clinically led quality
impact assurance process on the provider cost improvement plans as required for Knowsley CCG.
3.3.5 This requirement will form part of the overall contracting plan and the Governing
Body will be kept appraised of the process in future contracting updates.
3.4 Quality incentives
3.4.1 The Commissioning for Quality and Innovation (CQUIN) framework was published in December 2013 and is available by following the link shown below.
http://www.england.nhs.uk/wp-content/uploads/2013/12/cquin-guid-1415.pdf
3.4.2 This seeks to support CCGs in securing improvements in quality of services and better outcomes for patients, whilst also maintaining strong financial management. CQUIN for 2014/15 is set at a level of 2.5 per cent value for all healthcare services commissioned through the NHS Standard Contract, excluding high cost drugs, devices and a defined list of procedures. One fifth of this value (0.5% of overall contract value) is to be linked to the national CQUIN goals, where these apply. Remaining CQUIN funds are retained for locally determined schemes.
3.4.3 Unlike 2013/14, there will be no innovation pre-qualification criteria for 2014/15, however NHSE continues to expect full compliance with applicable high impact innovations identified in ‘Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS’.
3.4.4 There are four national CQUIN goals for 2013/14 which attract 0.5% are:
a) The Friends and Family Test, where commissioners will be empowered to incentivise high performing Trusts;
b) Improvement against the NHS Safety Thermometer (excluding VTE), particularly pressure sores;
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c) Improving dementia and delirium care, including sustained improvement in Finding people with dementia, Assessing and Investigating their symptoms and Referring for support (FAIR); and
d) Improving diagnosis in mental health – where providers will be rewarded for better assessing and treating the mental and physical needs of their service users
3.4.5 After three years of funding through the national CQUIN scheme, the VTE
CQUIN will no longer be included. Providers will still be expected to continue to improve their management of VTE risk and contract penalties can now be applied for any deterioration against current levels.
3.4.6 In 2014/15 Commissioners are expected to target their efforts at a small number of high impact outcomes, with a recommended maximum of ten local CQUIN goals per contract.
3.4.7 The Lead Nurse from each of the Co-ordinating CCGs have agreed to develop a small number of local CQUINs that will deliver the required improvements in quality. The exact details of the schemes is to be worked up over the coming weeks with the support of CMCSU colleagues and the final decision will be made on a Provider basis with consensus being obtained from associated via the collaborative commissioning arrangements.
3.5 Service Development & Improvement Plans
3.5.1 Service development and improvement plans will be derived from the commissioning intentions; work will continue with the CCG Commissioning Support Provider to ensure that service development and improvement plans are included in all of the contracts, reflect the CCG’s priorities and will be progress monitored in year.
4. Summary
4.1 The CCG is fully engaged in the contracting process to agree NHS contracts for 2014/2015 and will continue to work closely with Co-ordinating commissioners throughout the contract negotiation process to ensure Commissioning Intentions, SDIPs and CQUN schemes included in contracts accurately reflect the CCG’s commissioning plan.
4.2 The CCG will also continue to work with partners to ensure that planning and delivery of contracting for NHS providers is supported in a flexible, timely and commissioner focussed manner.
Managerial Lead – Paul Brickwood, Chief Finance Officer
Contact details: Clare Barrow, [email protected] 0151 244 3361
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APPENDIX 1
PROVIDER COLLABORATIVE PARTNERS
St Helens & Knowsley Teaching Hospitals
NHS Trust
St Helens CCG, Halton CCG
Aintree University Hospitals NHS Trust Liverpool CCG, South Sefton CCG
Royal Liverpool & Broadgreen University
Hospitals Trust
Liverpool CCG, South Sefton CCG
Five Boroughs Partnership Foundation
Trust (Mental Health) *
St Helens CCG, Halton CCG, KMBC
Mersey Care Mental Health Trust Liverpool CCG, South Sefton CCG, Southport & Formby CCG
Liverpool Womens Hospital FT Liverpool CCG, South Sefton CCG
Alder Hey Childrens NHS FT
Liverpool CCG, South Sefton CCG, Southport & Formby CCG, St Helens CCG, Halton CCG
Liverpool Heart & Chest Hospital FT
Liverpool CCG, South Sefton CCG
Warrington & Halton Hospitals NHS Trust
Warrington CCG, Halton CCG, St Helens CCG
Southport & Ormskirk Hospitals
South Sefton CCG, North Sefton CCG
Document 23(01)08
Report to Knowsley Clinical Commissioning Group Governing Body
Date of meeting: 6 February 2014
Report title: Better Care Fund Plan
Report presented by: Philip Thomas, Programme Director – Transformational Change
Purpose of the report: The purpose of this report is to: • Update the Governing Body on the Better Care Fund, its
purpose, funding arrangements, and national set conditions and requirements;
• Seek the Governing Body’s support for the draft Better Care Fund Plan;
• Seek delegated authority for the Accountable Officer and the Chair of the CCG to approve further amendments to the plan to enable timely submission to NHS England, subject to Health and Wellbeing Board sign-off.
Recommendations:
Action / Decision required
The Governing Body is recommended to:
Note the draft plan for submission to NHS England as part of the national assurance process, following endorsement and sign-off by the Health and Wellbeing Board. The plan is attached as appendix 4 to this report. Delegate to the Accountable Officer and the Chair of the CCG authority to approve the revised draft and final detailed two year plan, amended following comment from the Governing Body, Cabinet of Knowsley Council and NHS England.
Commissioning Values Which area(s) does this support? Please insert ‘x’ that apply
1. Patient centred X
2. Safe X
3. High quality X
4. Cost effective X
5. Outcome focused X
6. Closer to home X
7. Affordable X
[one page only]
1
GOVERNING BODY
BETTER CARE FUND PLAN 1. Purpose of the report 1.1 The purpose of this report is to:
1.1.1 Update the Governing Body on the Better Care Fund, its purpose, funding arrangements, and national set conditions and requirements;
1.1.2 Seek the Governing Body’s support for the draft Better Care Fund Plan;
1.1.3 Seek delegated authority for the Accountable Officer and the Chair of the CCG to
approve further amendments to the plan to enable timely submission to NHS England, subject to Health and Wellbeing Board sign-off.
2. Recommendations 2.1 The Governing Body is recommended to:
2.1.1 Note the draft plan for submission to NHS England as part of the national assurance process, following endorsement and sign-off by the Health and Wellbeing Board. The plan is attached as appendix 4 to this report.
2.1.2 Delegate to the Accountable Officer and the Chair of the CCG authority to approve
the revised draft and final detailed two year plan, amended following comment from the Governing Body, Cabinet of Knowsley Council and NHS England.
3. Background 3.1 At its meeting on 7 November 2013, the governing body received a report introducing the
Integration Transformation Fund (subsequently renamed to the Better Care Fund), a pooled budget to drive forward health and social care integration.
3.2 Knowsley has a long tradition of joint working across health and social care and has
significant pooled budget arrangements already in place. The CCG currently contributes just over £9.5m to the pool, broken down as follows:
Mental Health 1,572,850
Community Support Services 5,132,230 Learning Disabilities 2,820,000
9,525,080 3.3 The Council also contributes to the pool, bringing together a larger ‘pooled’ budget capable
of delivering improved outcomes via greater integration and efficiency
2
4. Better Care Fund Planning Guidance (BCF) 4.1 Detailed BCF planning guidance was published on 20 December 2013 as part of the NHS
England Planning Guidance and comprises:
4.1.1 Developing Plans for the Better Care Fund an Annex to the NHS England Planning Guidance and attached as Appendix 1. The annex provides information on the fund, including a set of national conditions and the requirement for CCGs and local government to work in partnership, how the pooled fund will be distributed, funding arrangements and conditions.
The guidance also sets out the requirement for a draft BCF plan to be submitted to NHS England by 14 February 2014 and a final plan by 4 April 2014, with sign-off by statutory Health and Wellbeing Boards.
4.1.2 Better Care Fund Planning Template – Part 1. Attached as Appendix 2, this is a mandated template to support production of the BCF plan, requiring the actual BCF pooled value, a 5 year vision and 2 year operational plan, a description of the governance and engagement arrangements plus how the national conditions are to be met.
4.1.3 Better Care Fund Planning Template – Part 2. Attached as Appendix 3, this is a mandated template to support the financial and performance management aspects of the plan.
5. BCF Funding Arrangements 5.1 The total value and composition of the Better Care Fund was also published as part of the
CCG financial allocations. Although there will be some increase in the level of funds transferred between the NHS and the council in 2014/15, the BCF will not come into effect until 2015/16.
5.2. In 2014/15 a further £200m is being made available nationally in addition to the existing
£900m NHS transfer to adult social care (s256 transfer). The purpose of this funding is to enable CCGs and local authorities to build momentum toward delivering the expected transformation.
5.3 For Knowsley, this means an additional £0.814m transfer from the NHS to the Council, the
release of which is dependent upon there being a jointly agreed and signed off two-year plan for the BCF.
5.4 In 2015/16 there will be a national BCF allocation of £3.8bn. Knowsley’s BCF allocation and
minimum BCF budget is £15.170m, which breaks down as follows:
Additional funding from NHS Allocations: £7.585m
Existing NHS Funding: Carers Breaks Funding £0.343m Reablement Funding £1.015m NHS Transfer Funding £4.477m
Existing Capital funding:
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Disabilities Facilities Grant: £1.206m Social Care Capital Grant: £0.544m
Total: £15.170m
5.4.1 This funding will be held by the Council under a s75 pooled budget arrangement.
6. Performance Payment Mechanism 6.1. Allocation of a proportion of the BCF will be dependent on performance against 6 outcome
measures. CCGs and local authorities will need to set and then monitor the achievement of these outcomes in 2014/15. For Knowsley this is £3.879m of the minimum BCF budget requirement of £15.17m.
6.1.1 The payment schedule and metrics are as follows:
When: Payment for performance amount
Paid for:
April 2015 £250m Progress against four of the national conditions:
• protection for adult social care services • providing 7-day services to support patients
being discharged and prevent unnecessary admissions at weekends
• agreement on the consequential impact of changes in the acute sector;
• ensuring that where funding is used for integrated packages of care there will be an
£250m Progress against the local metric and two of the national metrics:
• delayed transfers of care; • avoidable emergency admissions
October 2015 £500m Further progress against all of the national and local metrics.
Metric April 2015 payment based on performance in
October 2015 payment based on performance in
Admissions to residential and care homes
N/A Apr 2014 - Mar 2015
Effectiveness of reablement N/A Apr 2014 - Mar 2015
Delayed transfers of care Apr – Dec 2014 Jan - Jun 2015
Avoidable emergency admissions
Apr – Sept 2014 Oct 2014 – Mar 2015
Patient / service user experience
N/A Details TBC
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6.2. The local metric can either be one from a menu of nationally suggested possible local
metrics or one developed locally. The menu of possible local metrics is:
NHS Outcomes Framework
2.1 Proportion of people feeling supported to manage their (long term) condition
2.6i Estimated diagnosis rate for people with dementia
3.5 Proportion of patients with fragility fractures recovering to their previous levels of mobility / walking ability at 30 / 120 days
Adult Social Care Outcomes Framework 1A Social care-related quality of life
1H Proportion of adults in contact with secondary mental health services living independently with or without support
1D Carer-reported quality of life
Public Health Outcomes Framework 1.18i Proportion of adult social care users who have as much social
contact as they would like 2.13ii Proportion of adults classified as “inactive” 2.24i Injuries due to falls in people aged 65 and over
6.3 It is proposed that Avoidable Ambulatory Care Sensitive (ACS) Admissions be used. 6.4 A new national patient/service user metric is under development. Whilst there is the option
to adopt this or develop a local measure, it is proposed that the national metric be adopted. 6.5 In the event that agreed levels of performance are not achieved, funding may be allocated
elsewhere. However, given the scale and complexity of the challenge of developing plans for the first time, ministers have agreed that such a sanction will not be applied for 2015/16, although a recovery plan may be required which would be developed with the support of a peer review process.
7. BCF Plan Requirements 7.1 The BCF plan is being developed as a fully integral part of the CCG’s wider five year
strategic and two year operational plan, with the BCF elements being capable of extraction so that it may be seen as a stand-alone plan.
7.2 Attached as appendices 1 and 2 are national templates which are to be used when developing, agreeing and publishing the BCF plan. The templates set out the key information and metrics that the Health and Wellbeing Board needs to assure itself that the plan addresses the conditions of the fund. These include six national conditions, namely: 7.2.1 Plans to be jointly agreed by the CCG and council and signed off by the Health and
Wellbeing Board; 7.2.2 Protection for social services (not spending);
5
7.2.3 As part of agreed local plans, 7 day working in health and social care to support patients being discharged and prevent unnecessary admissions at weekends;
7.2.4 Better data sharing between health and social care, based on the NHS number; 7.2.5 Ensure a joint approach to assessments and care planning and ensure that, where
funding is used for integrated packages of care, there will be an accountable professional;
7.2.6 Agreement on the consequential impact of changes in the acute sector
7.3 As the Fund includes some existing money for reablement, carers breaks, disabilities
facilities grants and existing NHS transfer funding, these need to be incorporated into BCF plans. The plan must also show how the new duties from care and support reform are being met, including a range of new duties as a result of the Care Bill.
7.4 Impact on the acute hospital sector must be articulated in the plan, with providers, the
council and CCG having a shared view on the future shape of services. The plan must also be underpinned by a CCG and council shared and agreed risk register, including an agreed approach to risk sharing and mitigation, including the steps that will be taken if activity volumes do not change as planned.
8. Draft BCF Plan 8.1 The report considered by the Governing Body at its meeting in November set out the
arrangements to develop a BCF plan for Knowsley through the CCGs Transformation Programme Board, Planning Group and BCF Planning Sub-group. Since then, the Transformation Programme Board, Planning Group and BCF Planning Sub-group have developed a draft BCF Plan for Knowsley. Attached as Appendix 4 is the version of the plan available at time of publication of this report. An updated draft will be made available at the meeting of the Governing Body.
8.2 Vision
8.2.1 The plan sets out the 2018/19 vision for health and social care in Knowsley is one of transformed, effective and efficient services that adopt a holistic approach to health and wellbeing within shared available resources.
8.2.2 Knowsley residents will live longer, healthier and happier lives. They will be safer
and there will be a reduction in health inequalities. They will have greater independence, be able to self-manage more effectively and become active participants in ensuring their own and their family’s health and wellbeing, having more responsibility and greater involvement in decisions about any care and support they receive.
8.2.3 People will experience increasingly integrated, patient-centred services that deliver
better health and wellbeing outcomes and experience. Delivered closer to home and more easily accessible, services will promote independence and support people to remain at home. Ensuring the sustainability of the local health and care economy, service delivery will support effective use of available resources and value for money through a focus on sustainable impact to deliver improved outcomes, management of demand through earlier and better prevention and intervention, patient engagement and prioritisation
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8.3 Aims and Objectives
8.3.1 The overall aim is of an integrated system that demonstrates the following characteristics: a) High impact and quality: safe services delivering improved experience and
outcomes in line with national and international best practice and supported by practitioner education
b) Increasingly integrated: health and social care assessment and commissioning with provision integrated across secondary, primary, community care, local authority and the third sector led by co-ordinating providers or professionals
c) Personalised and patient centred: seamless from the patient’s perspective d) Empowering: enabling independence through self-care, prevention and early
detection, supporting people to remain at home e) Closer to home: increasingly in the community, improving efficiency and
patient experience and outcomes f) Locality based: delivered through a virtual and physical ‘hub’ – with services
being delivered and co-ordinated on a locality basis g) More easily accessed: simplified, earlier, more timely access, supported by
7-day working and informed patient choice h) Affordable and sustainable: through managing demand and prevention,
prioritisation, increased efficiency, appropriate, effective use of resources and value for money
i) Prevention: From promoting health to preventing illness and exacerbations, reducing demand on more intensive health and social care services
j) Appropriate: developed to deliver outcomes that meet identified population needs and involving public, provider, partner and other stakeholders in their co-design
k) Efficient: streamlined processes and effective information sharing – benefitting individuals and organisations
l) A changed culture: population, provider and commissioner m) Information technology enabled: improving access, supporting culture
change and informed choice. n) Assistive technology enabled: helping people to remain in their own homes
enjoying safety and independence o) Strategically aligned: enabling the achievement of local, regional and
national strategy, policy and other requirements, including those for the Better Care Fund
8.4 2 Year Operational Plan
The 2 year operational plan comprises the following schemes:
SAFE SUPPORTED DISCHARGE AND SUPPORT TO REMAIN AT HOME
YEAR 1: 2014/15
8.4.1 Improving performance and integration of Community and Bed based intermediate care. Ensuring that people are supported to maintain optimum functional health and retain their place within the community, staying at home for longer, but if admitted that discharge planning commences at initial decision to admit and includes structured support to facilitate a sustainable outcome.
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YEAR 2: 2015/16
Community Frailty Service
8.4.2 A consultant-led, person-centred service focussing on frail patients with complex conditions/high care needs, including careful targeting to provide case managed, inter-professional team care. The model will employ a lead provider with appropriate governance and accountability arrangements ensuring the co-ordination of multi-disciplinary and multi-provider delivery to citizens, in their own, residential or nursing homes 7-days a week.
PHYSICAL NEIGHBOURHUB
YEAR 1: 2014/15
8.4.3 Enhanced and improved engagement and clinical leadership from Primary Care practitioners and GPs in the Multi Disciplinary Process.
8.4.4 GP leadership of and accountability for effective use of case management approach to ensure the holistic assessment and care of patients with the most complex health and care needs, those people over 75 and / or at risk of admission or readmission to secondary care. To include preventative programmes such as lifestyle services, Healthy Homes, IKAN and falls assessment services and alcohol support services
YEAR 2: 2015/16
The Neighbourhub: Locality Health and Care Team (Transformed Primary Care Team)
8.4.5 Commencement of implementation of fully comprehensive locality based Multi Disciplinary Team approach in existing primary care, local authority or other community facilities.
8.4.6 Driving integrated working across health, social care and prevention, supporting single diagnosis and assessment of need that is inclusive of carer assessment, including improving understanding of and access to carer breaks in emergency situations, co-ordination and delivery of services with oversight from a senior clinician or accountable GP.
8.4.7 The hub will serve both as a locality focal point for primary assessment of health and wellbeing needs, delivery of locality based services and co-ordination, via named lead clinician, of more specialised treatment and care.
DIGITAL NEIGHBOURHUB / KNOWLEDGE HUB
YEAR 1: 2014/15
8.4.8 Digitising information, empowering citizens through self-service and informed choice to access the full range of Knowsley health and wellbeing services, linking in to other publically funded, third sector community and voluntary services that impact on health and wellbeing.
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8.4.9 Physical locations, in existing Primary Care, local authority or other community facilities, where citizens will be able to easily access information, self-refer and, if needed, receive advice, guidance and support on their health and wellbeing needs as well as the range of wider determinants such as housing conditions, the environment, work, social contact, access to leisure and culture, opportunities, experience or fear of crime and transport access to services and facilities.
YEAR 2: 2015/16
8.4.10 Increasingly comprehensive, improving user experience and take up, employing an innovative range of access channels
8.5 This is an ambitious plan for Knowsley, built upon firm foundations of integrated working. 8.6 The need to transform the health and social care system will require wide ranging system
reform, introducing innovative models of commissioning and provision, potentially requiring some decommissioning of existing services.
8.7 In 2015/16 the BCF for Knowsley will be £15.170m in line with the published allocations,
the detail of which is set out in section 5.5, above. Whilst this will stimulate health and wellbeing transformation, the scale of the BCF plan may also require transformation of the commissioning and provision of services funded outside of the BCF and the opportunity the BCF offers for transformation is limited only by the plan’s ambition.
9. BCF Plan Approval Processes 9.1 The guidance requires that each statutory Health and Wellbeing Board sign off the BCF
plan agreed between its constituent councils and CCGs. However, given the arrangements in Knowsley, the council and CCG will need to approve the joint plan in advance of consideration by the Health and Wellbeing Board.
9.2 Draft BCF Plan Submission: 14 February 2014
9.2.1 This report seeks the Governing Body’s approval of the appended version of the BCF plan. A parallel process is taking place in the Council to secure it’s agreement. As these processes have the potential to require refinement of the plan, the governing body is also recommended to delegate to the Accountable Officer and the Chair of the CCG authority to approve the revised draft for submission by 14 February 2014.
9.3 Final BCF Plan Submission: 4 April 2014
9.3.1 It is anticipated that comments will be received from NHS England on the draft BCF
plan, potentially requiring further revisions to that plan. It is not anticipated that the detailed plan will be significantly different to the draft plan and it is recommended that the decision to sign off the two year detailed plan is delegated to the Accountable Officer and the Chair of the CCG
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10. Resource Implications 10.1 Financial
10.1.1 As previously identified the national Better Care Fund is £3.8bn and one of the conditions attached to the funding is this will be a pooled budget under a section 75 arrangement to be hosted by the Council. The NHS announced the two year allocations for all CCG’s in December 2013. The Knowsley allocation is as follows:
2014/15 Additional NHS transfer to social care - £0.814m
2015/16 NHS Funding £13.42m Disabilities Facilities Grant £1.206m Social Care Capital Grant £0.544m Total £15.170m
10.1.2 The allocation letter only specifies the minimum amount that is expected to form part
of the pool and this figure forms part of the draft BCF plan.
10.1.3 It is important to note that the identified NHS funding is already committed. Whilst a proportion will be released by reductions in emergency activity enabled by implementation of the plan, there will be a requirement to release funding from existing areas of spend via efficiencies, disinvestment and most significantly transformation.
10.1.4 Furthermore, as set out in paragraph 3.2, the CCG already makes a significant
contribution to existing pooled budget arrangements, which in part relate to activities falling within the scope of the BCF plan. This too will need to be part of the wider funding considerations.
10.1.5 At the current time the BCF pooled fund will be limited to existing joint funding
arrangement and national guidance. As the transformation programme develops the opportunity to pool and align more budgets will be considered to ensure achieving the outcomes identified in the plan. All financial decisions and commitments to pool funds will need to be mindful of CCG and Council wider financial strategy and future budget reductions that will need to be made.
10.2 Human resources
10.2.1 There are no Human Resource implications at this stage, however as the
programme develops there are likely to be changes in the way services are delivered across the Borough which might impact on the workforces of the council, other partners and providers operating in the Borough.
10.3 Information Technology
10.3.1 There are no significant information technology implications at this stage. 10.3.2 However, as demonstrated by the better data sharing national condition, there is an
intention for integration to be supported by safe, secure sharing of data based on NHS number. This will require effective systems and processes across the CCG,
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council and providers, supported by a culture of secure, lawful and appropriate sharing of data to support better care.
10.3.4 There will also be a need to provide virtual access to services across health, social
care and other sectors to support development of the “Knowledgehub” model.
10.4 Physical Assets 10.4.1 There are no physical asset implications at this stage. The “Access Knowsley”
model introduces the concept of “Neighbourhubs” which are planned to be in existing primary care, local authority and other community facilities.
11. Risk Assessment
11.1 Whilst the BCF provides genuine opportunity to transform health and wellbeing in Knowsley, it is not without risks. An initial risk assessment is provided for within this report but as the transformation agenda is developed a full and detailed risk log will be developed and monitored within the subgroups and reported into the transformation board and planning groups
. Risk / Issue Mitigation Governance and risk sharing A Section 75 agreement to be put in place.
Joint working and decision making through Programme Board and Planning Groups, with individual accountable organisation oversight.
Performance Targets not met and funding is withdrawn or withheld.
Ambitious but realistic targets need to be set and monitored, with recovery plans implemented where performance of trajectory is not to plan. Good governance of the transformation will also mitigate this.
Lack of capacity to deliver Agreement on scope of plan and commitment from partners to resource the transformation will be a requirement to deliver it.
Financial pressures Sound financial modelling based upon known and anticipated income and expenditure and future budgetary pressures will need to be factored into the transformation programme.
Plans insufficiently ambitious to protect social care / health and wellbeing economy
Impact of delivery modelled against specified outcomes that ensure sustainability of health and social care.
Plans too ambitious to deliver
Plans must be ambitious to deliver required outcomes. The Transformation Programme Board will be tasked with checking that plans are credible but challenging.
Plans are too health or social care focussed
Joint working and decision making through Programme Board and Planning Groups, with individual accountable organisation oversight Articulated outcomes inherently deliver health and social care benefits but there are opportunities to look at the
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wider determinants of health and wellbeing to ensure other partners in housing and employment and skills can contribute.
Lack of public, patient, service user buy-in
Programme of engagement to ensure that plans are aligned to population need.
Lack of provider buy-in Programme of engagement to ensure that providers shape, understand and, wherever possible, buy into plans.
Lack of partner buy-in and the need for the right balance between all partners.
This is a partnership and integration transformation agenda and the Governance for this will be via the joint working and decision making in the Programme Board and Planning Groups. Programme of engagement to ensure that partners shape, understand and, wherever possible, buy into plans.
12. Conclusion
12.1 The BCF presents a real opportunity to improve the quality and value for money of health and social care within Knowsley. Delivery of the 5 year vision and 2 year operational plan set out in Knowsley’s BCF plan will ensure people receive better coordinated care and support, with improved outcomes for patients and service users. It will also ensure the sustainability of health and social care services within the Borough through increased efficiency, improved appropriate/effective use of resources and an increased focus on prevention, thus reducing demand for both acute and social care services.
Clinical Lead – Dr Faisal Maassarani
Managerial Lead – Philip Thomas
Signatory details: Philip Thomas, [email protected], 0151 244 4149
FEBRUARY 2014
Background Documents:
Integration Transformation Fund report, Knowsley CCG Governing Body Meeting, 7 November 2013
Appendices:
Appendix 1 Developing Plans for the Better Care Fund an Annex to the NHS Planning Guidance
Appendix 2 Better Care Fund Planning Template – Part 1
Appendix 3 Better Care Fund Planning Template – Part 2
Appendix 4 Draft Knowsley Better Care Fund Plan
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Annex to the NHS England Planning Guidance
Developing Plans for the Better Care Fund
(formerly the Integration Transformation Fund) What is the Better Care Fund? 1. The Better Care Fund (previously referred to as the Integration Transformation
Fund) was announced in June as part of the 2013 Spending Round. It provides an opportunity to transform local services so that people are provided with better integrated care and support. It encompasses a substantial level of funding to help local areas manage pressures and improve long term sustainability. The Fund will be an important enabler to take the integration agenda forward at scale and pace, acting as a significant catalyst for change.
2. The Better Care Fund provides an opportunity to improve the lives of some of the most vulnerable people in our society, giving them control, placing them at the centre of their own care and support, and, in doing so, providing them with a better service and better quality of life.
3. The Fund will support the aim of providing people with the right care, in the right place, at the right time, including through a significant expansion of care in community settings. This will build on the work Clinical Commissioning Groups (CCGs) and councils are already doing, for example, as part of the integrated care “pioneers” initiative, through Community Budgets, through work with the Public Service Transformation Network, and on understanding the patient/service user experience.
What is included in the Better Care Fund and what does it cover?
4. The Fund provides for £3.8 billion worth of funding in 2015/16 to be spent locally on health and care to drive closer integration and improve outcomes for patients and service users and carers. In 2014/15, in addition to the £900m transfer already planned from the NHS to adult social care, a further £200m will transfer to enable localities to prepare for the Better Care Fund in 2015/16.
5. The tables below summarise the elements of the Spending Round announcement on the Fund:
The June 2013 Spending Round set out the following:
2014/15 2015/16
A further £200m transfer from the NHS to adult social care, in addition to the £900m transfer already planned
£3.8bn to be deployed locally on health and social care through pooled budget arrangements
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In 2015/16 the Fund will be created from:
£1.9bn of NHS funding
£1.9bn based on existing funding in 2014/15 that is allocated across the health and wider care system. This will comprise:
£130m Carers’ Break funding
£300m CCG reablement funding
£354m capital funding (including £220m Disabled Facilities Grant)
£1.1bn existing transfer from health to adult social care.
6. For 2014/15 there are no additional conditions attached to the £900m transfer
already announced, but NHS England will only pay out the additional £200m to councils that have jointly agreed and signed off two-year plans for the Better Care Fund.
7. In 2014/15 there are no new requirements for pooling of budgets. The
requirements for the use of the funds transferred from the NHS to local authorities in 2014/15 remain consistent with the guidance1 from the Department of Health (DH) to NHS England on 19 December 2012 on the funding transfer from NHS to social care in 2013/14. In line with this:
8. “The funding must be used to support adult social care services in each local authority, which also has a health benefit. However, beyond this broad condition we want to provide flexibility for local areas to determine how this investment in social care services is best used.
9. A condition of the transfer is that the local authority agrees with its local health partners how the funding is best used within social care, and the outcomes expected from this investment. Health and wellbeing boards will be the natural place for discussions between NHS England, clinical commissioning groups and councils on how the funding should be spent, as part of their wider discussions on the use of their total health and care resources.
10. In line with our responsibilities under the Health and Social Care Act, an additional condition of the transfer is that councils and clinical commissioning groups have regard to the Joint Strategic Needs Assessment for their local population, and existing commissioning plans for both health and social care, in how the funding is used.
11. A further condition of the transfer is that local authorities councils and clinical commissioning groups demonstrate how the funding transfer will make a positive difference to social care services, and outcomes for service users, compared to service plans in the absence of the funding transfer”
1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213223/Funding-
transfer-from-the-NHS-to-social-care-in-2013-14.pdf
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12. Councils should use the additional £200m to prepare for the implementation of pooled budgets in April 2015 and to make early progress against the national conditions and the performance measures set out in the locally agreed plan. This is important, since some of the performance-related money is linked to performance in 2014/15.
13. The £3.8bn Fund includes £130m of NHS funding for carers’ breaks. Local plans
should set out the level of resource that will be dedicated to carer-specific support, including carers’ breaks, and identify how the chosen methods for supporting carers will help to meet key outcomes (e.g. reducing delayed transfers of care). The Fund also includes £300m of NHS funding for reablement services. Local plans will therefore need to demonstrate a continued focus on reablement
14. It was announced as part of the Spending Round that the Better Care Fund would include funding for costs to councils resulting from care and support reform. This money is not ring-fenced, but local plans should show how the new duties are being met.
i. £50m of the capital funding has been earmarked for the capital costs (including IT) associated with transition to the capped cost system, which will be implemented in April 2016.
ii. £135m of revenue funding is linked to a range of new duties that come in from April 2015 as a result of the Care Bill. Most of the cost results from new entitlements for carers and the introduction of a national minimum eligibility threshold, but there is also funding for better information and advice, advocacy, safeguarding and other measures in the Care Bill.
What will be the statutory framework for the Fund?
15. In 2015/16 the Fund will be allocated to local areas, where it will be put into
pooled budgets under Section 752 joint governance arrangements between CCGs and councils. A condition of accessing the money in the Fund is that CCGs and councils must jointly agree plans for how the money will be spent, and these plans must meet certain requirements.
16. Funding will be routed through NHS England to protect the overall level of health
spending and ensure a process that works coherently with wider NHS funding arrangements.
17. DH will use the Mandate for 2015/16 to instruct NHS England to ring-fence its contribution to the Fund and to ensure this is deployed in specified amounts at local level for use in pooled budgets by CCGs and local authorities.
18. Legislation is needed to ring-fence NHS contributions to the Fund at national and local levels, to give NHS England powers to assure local plans and performance, and to ensure that local authorities not party to the pooled budget can be paid from it, through additional conditions in Section 31 of the Local
2 Sec 75 of the NHS Act, 2006, provides for CCGs and local authorities to pool budgets.
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Government Act 2003. This will ensure that the Disabled Facilities Grant (DFG) can be included in the Fund
19. The DFG has been included in the Fund so that the provision of adaptations can be incorporated in the strategic consideration and planning of investment to improve outcomes for service users. DFG will be paid to upper-tier authorities in 2015/16. However, the statutory duty on local housing authorities to provide DFG to those who qualify for it will remain. Therefore each area will have to allocate this funding to their respective housing authorities (district councils in two-tier areas) from the pooled budget to enable them to continue to meet their statutory duty to provide adaptations to the homes of disabled people, including in relation to young people aged 17 and under.
20. Special conditions will be added to the DFG Conditions of Grant Usage (under
Section 31 of the Local Government Act 2003) which stipulate that, where relevant, upper-tier local authorities or CCGs must ensure they cascade the DFG allocation to district council level in a timely manner such that it can be spent within year. Further indicative minimum allocations for DFG have been provided for all upper-tier authorities, with further breakdowns for allocations at district council level as the holders of the Fund may decide that additional funding is appropriate to top up the minimum DFG funding levels.
21. DH and the Department for Communities and Local Government (DCLG) will also use Section 31 of the Local Government Act 2003 to ensure that DH Adult Social Care capital grants (£134m) will reach local areas as part of the Fund. Relevant conditions will be attached to these grants so that they are used in pooled budgets for the purposes of the Fund. DH, DCLG and the Treasury will work together in early 2014 to develop the terms and conditions of these grants.
How will local Fund allocations be determined?
22. Councils will receive their detailed funding allocations in the normal way. NHS
allocations will be two-year allocations for 2014/15 and 2015/16 to enable more effective planning.
23. In 2014/15 the existing £900m s.256 transfer to councils for adult social care to benefit health, and the additional £200m, will continue to be distributed using the social care relative needs formula (RNF).
24. The formula for distribution of the full £3.8bn fund in 2015/16 will be based on a financial framework agreed by ministers. The current social care transfer of £1.1bn and the £134m of adult social care capital funding included in the Fund in 2015/16 will be allocated in the same way as in 2014/15. DFG will be allocated based on the same formula as 2014/15. The remainder of the Fund will be allocated on the basis of the CCG allocations formula. It will be for local areas to decide how to spend their allocations on health and social care services through their joint plan.
25. The announcement of the two-year CCG allocations, communicated to CCGs and councils alongside this planning guidance, includes the Fund allocations in 2015/16. In 2014/15, the additional £200m will be transferred directly from NHS
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England to councils along with the rest of the adult social care transfer. The local authority and CCGs in each Health and Wellbeing Board area will receive a notification of their share of the pooled fund for 2014/15 and 2015/16 based on the aggregate of the allocation mechanisms. The allocation letter also specifies the amount that is included in the payment-for-performance element, and is therefore contingent in part on planning and performance in 2014/15 and in part on achieving specified goals in 2015/16.
26. Allocation letters will specify only the minimum amount of funds to be included in pooled budgets. CCGs and councils are free to extend the scope of their pooled budget to support better integration in line with their Joint Health and Wellbeing Strategy.
27. The wider powers to use Health Act flexibilities to pool funds, share information and staff are unaffected by the new Better Care Fund requirements, and will be helpful in taking this work forward.
How should councils and CCGs develop and agree a joint plan for the Fund? 28. Each statutory Health and Wellbeing Board will sign off the plan for its constituent
councils and CCGs. The Fund plan must be developed as a fully integral part of a CCG’s wider strategic and operational plan, but the Better Care Fund elements must be capable of being extracted to be seen as a stand-alone plan.
29. Where the unit of planning chosen by a CCG for its strategic and operational plan is not consistent with the boundaries of the Health and Wellbeing Board, or Boards, with which it works, it will be necessary for the CCG to reconcile the Better Care Fund element of its plan to the Health and Wellbeing Board level. NHS England will support CCGs in this position to ensure that plans are properly aligned.
30. The specific priorities and performance goals in the plan are clearly a matter for each locality but it will be valuable to be able to:
aggregate the ambitions set for the Fund across all Health and Wellbeing Boards;
assure that the national conditions have been achieved; and
understand the performance goals and payment regimes that have been agreed in each area.
31. To assist Health and Wellbeing Boards we have developed a template which we
expect everyone to use in developing, agreeing and publishing their Better Care Plan. This is attached as a separate Word document and Excel spread sheet. The template sets out the key information and metrics that all Health and Wellbeing Boards will need to assure themselves that the plan addresses the conditions of the Fund.
32. As part of this template, local areas should provide an agreed shared risk register. This should include an agreed approach to risk sharing and mitigation covering, as a minimum, the impact on existing NHS and social care delivery and
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the steps that will be taken if activity volumes do not change as planned (for example, if emergency admissions or nursing home admissions increase).
33. CCGs and councils must engage from the outset with all providers, both NHS
and social care (and also providers of housing and other related services), likely to be affected by the use of the fund in order to achieve the best outcomes for local people. The plans must clearly set out how this engagement has taken place. Providers, CCGs and councils must develop a shared view of the future shape of services, the impact of the Fund on existing models of service delivery, and how the transition from these models to the future shape of services will be made. This should include an assessment of future capacity and workforce requirements across the system. It will be important to work closely with Local Education and Training Boards and the market shaping functions of councils, as well as with providers themselves, on the workforce implications to ensure that there is a consistent approach to workforce planning for both providers and commissioners.
34. CCGs and councils should also work with providers to help manage the transition to new patterns of provision including, for example, the use of non-recurrent funding to support disinvestment from services. It is also essential that the implications for all local providers are set out clearly for Health and Wellbeing Boards and that their agreement for the deployment of the Fund includes agreement to all the service change consequences.
What are the National Conditions? 35. The Spending Round established six national conditions for access to the Fund:
National Condition
Definition
Plans to be jointly agreed
The Better Care Fund Plan, covering a minimum of the pooled fund specified in the Spending Round, and potentially extending to the totality of the health and care spend in the Health and Wellbeing Board area, should be signed off by the Health and Well Being Board itself, and by the constituent Councils and Clinical Commissioning Groups. In agreeing the plan, CCGs and councils should engage with all providers likely to be affected by the use of the fund in order to achieve the best outcomes for local people. They should develop a shared view of the future shape of services. This should include an assessment of future capacity and workforce requirements across the system. The implications for local providers should be set out clearly for Health and Wellbeing Boards so that their agreement for the deployment of the fund includes recognition of the service change consequences.
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National Condition
Definition
Protection for social care services (not spending)
Local areas must include an explanation of how local adult social care services will be protected within their plans. The definition of protecting services is to be agreed locally. It should be consistent with the 2012 Department of Health guidance referred to in paragraphs 8 to 11, above.
As part of agreed local plans, 7-day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends
Local areas are asked to confirm how their plans will provide 7-day services to support patients being discharged and prevent unnecessary admissions at weekends. If they are not able to provide such plans, they must explain why. There will not be a nationally defined level of 7-day services to be provided. This will be for local determination and agreement. There is clear evidence that many patients are not discharged from hospital at weekends when they are clinically fit to be discharged because the supporting services are not available to facilitate it. The recent national review of urgent and emergency care sponsored by Sir Bruce Keogh for NHS England provided guidance on establishing effective 7-day services within existing resources.
Better data sharing between health and social care, based on the NHS number
The safe, secure sharing of data in the best interests of people who use care and support is essential to the provision of safe, seamless care. The use of the NHS number as a primary identifier is an important element of this, as is progress towards systems and processes that allow the safe and timely sharing of information. It is also vital that the right cultures, behaviours and leadership are demonstrated locally, fostering a culture of secure, lawful and appropriate sharing of data to support better care. Local areas should:
confirm that they are using the NHS Number as the primary identifier for health and care services, and if they are not, when they plan to;
confirm that they are pursuing open APIs (ie. systems that speak to each other); and
ensure they have the appropriate Information Governance controls in place for information sharing in line with Caldicott 2, and if not, when they plan for it to be in place.
NHS England has already produced guidance that relates to both of these areas. (It is recognised that progress on this issue will require the resolution of some Information Governance issues by DH).
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National Condition
Definition
Ensure a joint approach to assessments and care planning and ensure that, where funding is used for integrated packages of care, there will be an accountable professional
Local areas should identify which proportion of their population will be receiving case management and a lead accountable professional, and which proportions will be receiving self-management help - following the principles of person-centred care planning. Dementia services will be a particularly important priority for better integrated health and social care services, supported by accountable professionals. The Government has set out an ambition in the Mandate that GPs should be accountable for co-ordinating patient-centred care for older people and those with complex needs.
Agreement on the consequential impact of changes in the acute sector
Local areas should identify, provider-by-provider, what the impact will be in their local area, including if the impact goes beyond the acute sector. Assurance will also be sought on public and patient and service user engagement in this planning, as well as plans for political buy-in. Ministers have indicated that, in line with the Mandate requirements on achieving parity of esteem for mental health, plans must not have a negative impact on the level and quality of mental health services.
How will Councils and CCGs be rewarded for meeting goals? 36. The Spending Round indicated that £1bn of the £3.8bn would be linked to
achieving outcomes. Ministers have agreed the basis on which this payment-for-performance element of the Fund will operate.
37. Half of the £1bn will be released in April 2015. £250m of this will depend on progress against four of the six national conditions and the other £250m will relate to performance against a number of national and locally determined metrics during 2014/15. The remainder (£500m) will be released in October 2015 and will relate to further progress against the national and locally determined metrics.
38. The performance payment arrangements are summarised in the table below:
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When: Payment for performance
amount
Paid for:
April 2015 £250m Progress against four of the national conditions:
protection for adult social care services
providing 7-day services to support patients being discharged and prevent unnecessary admissions at weekends
agreement on the consequential impact of changes in the acute sector;
ensuring that where funding is used for integrated packages of care there will be an accountable lead professional
£250m Progress against the local metric and two of the national metrics:
delayed transfers of care;
avoidable emergency admissions; and
October 2015 £500m Further progress against all of the national and
local metrics.
National and Local Metrics
39. Only a limited number of national measures can be used to demonstrate
progress towards better integrated health and social care services in 2015/16, because of the need to establish a baseline of performance in 2014/15. National metrics for the Fund have therefore been based on a number of criteria, in particular the need for data to be available with sufficient regularity and rigour.
40. The national metrics underpinning the Fund will be:
admissions to residential and care homes;
effectiveness of reablement;
delayed transfers of care;
avoidable emergency admissions; and
patient / service user experience.
41. The measures are the best available but do have shortcomings. Local plans will need to ensure that they are applied sensitively and do not adversely affect decisions on the care of individual patients and service users.
42. Further technical guidance will be provided on the national metrics, including the detailed definition, the source of the data underpinning the metric, the reporting schedule and advice on the statistical significance of ambitions for improvement.
43. Due to the varying time lags for the metrics, different time periods will underpin the two payments for the Fund as set out in the table below. Data for the first two
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of these metrics, on admissions to residential and care homes and the effectiveness of reablement, are currently only available annually and so will not be available to be included in the first payment in April 2015.
Metric April 2015 payment based on performance in
October 2015 payment based on performance in
Admissions to residential and care homes
N/A Apr 2014 - Mar 2015
Effectiveness of reablement
N/A Apr 2014 - Mar 2015
Delayed transfers of care
Apr – Dec 2014 Jan - Jun 2015
Avoidable emergency admissions
Apr – Sept 2014 Oct 2014 – Mar 2015
Patient / service user experience
N/A Details TBC
44. For the metric on patient / service user experience, no single measure of the
experience of integrated care is currently available, as opposed to quality of health care or social care alone. A new national measure is being developed, but will not be in place in time to measure improvements in 2015/16. In the meantime, further details will be provided shortly on how patient / service user experience should be measured specifically for the purpose of the Fund.
45. In addition to the five national metrics, local areas should choose one additional indicator that will contribute to the payment-for-performance element of the Fund. In choosing this indicator, it must be possible to establish a baseline of performance in 2014/15.
46. A menu of possible local metrics selected from the NHS, Adult Social Care and Public Health Outcomes Frameworks is set out in the table below:
NHS Outcomes Framework
2.1 Proportion of people feeling supported to manage their (long term) condition
2.6i Estimated diagnosis rate for people with dementia
3.5 Proportion of patients with fragility fractures recovering to their previous levels of mobility / walking ability at 30 / 120 days
Adult Social Care Outcomes Framework
1A Social care-related quality of life
1H Proportion of adults in contact with secondary mental health services living independently with or without support
1D Carer-reported quality of life
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Public Health Outcomes Framework
1.18i Proportion of adult social care users who have as much social contact as they would like
2.13ii Proportion of adults classified as “inactive”
2.24i Injuries due to falls in people aged 65 and over
47. Local areas must either select one of the metrics from this menu, or agree a local
alternative. Any alternative chosen must meet the following criteria:
it has a clear, demonstrable link with the Joint Health and Wellbeing Strategy;
data is robust and reliable with no major data quality issues (e.g. not subject to small numbers);
it comes from an established, reliable (ideally published) source;
timely data is available, in line with requirements for pay for performance;
the achievement of the locally set level of ambition is suitably challenging; and
it creates the right incentives.
48. Each metric will be of equal value for the payment for performance element of the Fund.
49. Local areas should set an appropriate level of ambition for improvement against each of the national indicators, and the locally determined indicator. In signing off local plans, Health and Wellbeing Boards should be mindful of the link to the levels of ambition on outcomes that CCGs have been asked to set as part of their wider strategic and operational plans. Both the effectiveness of reablement and avoidable emergency admissions outcomes metrics are consistent with national metrics for the Fund, and so Health and Wellbeing Boards will need to ensure consistency between the CCG levels of ambitions and the Fund plans.
50. In agreeing specific levels of ambition for the metrics, Health and Wellbeing Boards should be mindful of a number of factors, such as:
having a clear baseline against which to compare future performance;
understanding the long-run trend to ensure that the target does not purely reward improved performance consistent with trend increase;
ensuring that any seasonality in the performance is taken in to account; and
ensuring that the target is achievable, yet challenging enough to incentivise an improvement in integration and improved outcomes for users.
51. In agreeing levels of ambition, Health and Wellbeing Boards should also consider
the level required for a statistically significant improvement. It would not be appropriate for the level of ambition to be set such that it rewards a small improvement that is purely an artefact of variation in the underlying dataset.
How will plans be assured? 52. Ministers, stakeholder organisations and people in local areas will wish to be
assured that the Fund is being used for the intended purpose, and that the local plans credibly set out how improved outcomes and wellbeing for people will be
12
achieved, with effective protection of social care and integrated activity to reduce emergency and urgent health demand.
53. To maximise our collective capacity to achieve these outcomes and deliver
sustainable services the NHS and local government will have a shared approach to supporting local areas and assuring plans.
54. The most important element of assurance for plans will be the requirement for them to be signed-off by the Health and Wellbeing Board. The Health and Wellbeing Board is best placed to decide whether the plans are the best for the locality, engaging with local people and bringing a sector-led approach to the process.
55. The plans will also go through an assurance process involving NHS England and the LGA to assure Ministers. The key elements of the overall assurance process are as follows:
Plans are presented to the Health and Wellbeing Board, which considers whether the plans are sufficiently challenging and will deliver tangible benefits for the local population (linked to the Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy).
If the Health and Wellbeing Board is not satisfied, and the plan is still lacking after a process of progressive iteration, an element of local government and NHS peer challenge will be facilitated by NHS England and the LGA.
NHS England’s process for assuring CCG strategic and operational plans will include a specific focus on the element of the plan developed for the Fund. This will allow us to summarise, aggregate and rate all plans, against criteria agreed with government departments and the LGA, to provide an overview of Fund plans at national, regional and local level.
This overview will be reviewed by a Departmental-led senior group comprised of DH, DCLG, HMT, NHS England and LGA officials, supported by external expertise from the NHS and local government. Where issues of serious concern are highlighted the group will consider how issues may be resolved, either through provision of additional support or escalation to Ministers.
Where necessary, Ministers (supported by the senior group) will meet representatives from the relevant LAs and CCGs to account for why they have not been able to produce an acceptable plan and agree next steps to formulate such a plan.
Ministers will give the final sign-off to plans and the release of performance related funds.
What will be the consequences of failure to achieve improvement? 56. Ministers have considered whether local areas which fail to achieve the levels of
ambition set out in their plan should have their performance-related funding
13
withdrawn, to be reallocated elsewhere. However, given the scale and complexity of the challenge of developing plans for the first time, they have agreed that such a sanction will not be applied in 2015/16. Further consideration will be given to whether it should be introduced in subsequent years.
57. If a local area achieves 70% or more of the levels of ambition set out in each of the indicators in its plan, it will be allowed to use the held-back portion of the performance pool to fund its agreed contingency plan, as necessary.
58. If an area fails to deliver 70% of the levels of ambition set out in its plan, it may be required to produce a recovery plan. This will be developed with the support of a peer review process involving colleagues from NHS and local government organisations in neighbouring areas. The peer review process will be co-ordinated by NHS England, with the support of the LGA.
59. If the recovery plan is agreed by the Health and Wellbeing Board, NHS England and the local government peer reviewer, the held-back portion of the performance payment from the Fund will be made available to fund the recovery plan.
60. If a recovery plan cannot be agreed locally, and signed-off by the peer reviewers, NHS England will direct how the held-back performance related portion of the Fund should be used by the local organisations, subject to the money being used for the benefit of the health and care system in line with the aims and conditions of the Fund.
61. Ministers will have the opportunity to give the final sign-off to peer-reviewed recovery plans and to any directions given by NHS England on the use of funds in cases where it has not been possible to agree a recovery plan.
Support for BCF Planning
62. CCGs and councils can access additional support for Better Care Fund planning from the same routes as for NHS operational and strategic plans: local support via CSUs or external providers, workshops and webinars, and specific tools and resources. Links to these, and contact details can be found on NHS England and the LGA’s websites.
When should plans be submitted?
63. Health and Wellbeing Boards should provide the first cut of their completed Better Care Plan template, as an integral part of the constituent CCGs’ Strategic and Operational Plans by 14 February 2014, so that we can aggregate them to provide a composite report, and identify any areas where it has proved challenging to agree plans for the Fund.
64. The revised version of the Better Care Plan should be submitted to NHS England, as an integral part of the constituent CCGs’ Strategic and Operational Plans by 4 April 2014.
Appendix 2 Better Care Fund planning template – Part 1 Please note, there are two parts to the template. Part 2 is in Excel and contains metrics and finance. Both parts must be completed as part of your Better Care Fund Submission. Plans are to be submitted to the relevant NHS England Area Team and Local government representative, as well as copied to: [email protected] To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites. 1) PLAN DETAILS a) Summary of Plan
Local Authority <Name of Local Authority> Clinical Commissioning Groups <CCG Name/s> <CCG Name/s> <CCG Name/s> <CCG Name/s> <CCG Name/s>
Boundary Differences <Identify any differences between LA and CCG boundaries and how these have been addressed in the plan>
Date agreed at Health and Well-Being Board: <dd/mm/yyyy>
Date submitted: <dd/mm/yyyy>
Minimum required value of ITF pooled budget: 2014/15 £0.00
2015/16 £0.00
Total agreed value of pooled budget: 2014/15 £0.00
2015/16 £0.00 b) Authorisation and signoff
Signed on behalf of the Clinical Commissioning Group <Name of ccg> By <Name of Signatory> Position <Job Title> Date <date>
<Insert extra rows for additional CCGs as required> Signed on behalf of the Council <Name of council> By <Name of Signatory> Position <Job Title> Date <date> <Insert extra rows for additional Councils as required> Signed on behalf of the Health and Wellbeing Board <Name of HWB> By Chair of Health and Wellbeing Board <Name of Signatory> Date <date> <Insert extra rows for additional Health and Wellbeing Boards as required> c) Service provider engagement Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it d) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it e) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition. Document or information title Synopsis and links
2) VISION AND SCHEMES a) Vision for health and care services Please describe the vision for health and social care services for this community for 2018/19.
• What changes will have been delivered in the pattern and configuration of services over the next five years?
• What difference will this make to patient and service user outcomes? b) Aims and objectives Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover:
• What are the aims and objectives of your integrated system? • How will you measure these aims and objectives? • What measures of health gain will you apply to your population?
c) Description of planned changes Please provide an overview of the schemes and changes covered by your joint work programme, including:
• The key success factors including an outline of processes, end points and time frames for delivery
• How you will ensure other related activity will align, including the JSNA, JHWS, CCG commissioning plan/s and Local Authority plan/s for social care
d) Implications for the acute sector Set out the implications of the plan on the delivery of NHS services including clearly identifying where any NHS savings will be realised and the risk of the savings not being realised. You must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. The details of this response must be developed with the relevant NHS providers. e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes
3) NATIONAL CONDITIONS a) Protecting social care services Please outline your agreed local definition of protecting adult social care services. Please explain how local social care services will be protected within your plans. b) 7 day services to support discharge Please provide evidence of strategic commitment to providing seven-day health and social care services across the local health economy at a joint leadership level (Joint Health and Wellbeing Strategy). Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends. c) Data sharing Please confirm that you are using the NHS Number as the primary identifier for correspondence across all health and care services. If you are not currently using the NHS Number as primary identifier for correspondence please confirm your commitment that this will be in place and when by Please confirm that you are committed to adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK)) Please confirm that you are committed to ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, professional clinical practise and in particular requirements set out in Caldicott 2.
d) Joint assessment and accountable lead professional Please confirm that local people at high risk of hospital admission have an agreed accountable lead professional and that health and social care use a joint process to assess risk, plan care and allocate a lead professional. Please specify what proportion of the adult population are identified as at high risk of hospital admission, what approach to risk stratification you have used to identify them, and what proportion of individuals at risk have a joint care plan and accountable professional.
4) RISKS Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers Risk Risk rating Mitigating Actions <Risk 1> <Risk 2> <Risk 3> <Risk 4>
BCF Planning Template Finance - Summary DRAFT
DRAFT BCF Feb 2014 App 3
OrganisationHolds the pooled budget? (Y/N)
Spending on BCF schemes in 14/15
Minimum contribution (15/16)
Actual contribution
(15/16)Local Authority #1CCG #1CCG #2Local Authority #2etcBCF Total
Contingency plan: 2015/16 Ongoing
Outcome 2
Planned savings (if targets fully achieved)Maximum support needed for other services (if targets not achieved)
Finance - Summary
Approximately 25% of the BCF is paid for improving outcomes. If the planned improvements are not achieved, some of this funding may need to be used to alleviate the pressure on other services. Please outline your plan for maintaining services if planned improvements are not achieved.
For each contributing organisation, please list any spending on BCF schemes in 2014/15 and the minimum and actual contributions to the Better Care Fund pooled budget in 2015/16.
Outcome 1
Planned savings (if targets fully achieved)Maximum support needed for other services (if targets not achieved)
Appendix 4 Better Care Fund planning template – Part 1 Please note, there are two parts to the template. Part 2 is in Excel and contains metrics and finance. Both parts must be completed as part of your Better Care Fund Submission. Plans are to be submitted to the relevant NHS England Area Team and Local government representative, as well as copied to: [email protected] To find your relevant Area Team and local government representative, and for additional support, guidance and contact details, please see the Better Care Fund pages on the NHS England or LGA websites. 1) PLAN DETAILS a) Summary of Plan
Local Authority Metropolitan Borough of Knowsley
Clinical Commissioning Groups NHS Knowsley Clinical Commissioning Group
Boundary Differences None Date agreed at Health and Well-Being Board: 13/02/2014
Date submitted: 14/02/2014
Minimum required value of ITF pooled budget: 2014/15 £814,000.00
2015/16 £15,170,000.00
Total agreed value of pooled budget: 2014/15 £814,000.00
2015/16 £15,170,000.00 b) Authorisation and signoff
Signed on behalf of the Clinical Commissioning Group Knowsley CCG By Dianne Johnson Position Chief Accountable Officer Date <date> <Insert extra rows for additional CCGs as required> Signed on behalf of the Council Knowsley MBC By Sheena Ramsey
Position Chief Executive Date <date> <Insert extra rows for additional Councils as required> Signed on behalf of the Health and Wellbeing Board Knowsley By Chair of Health and Wellbeing Board Councillor Jayne Aston Date <date> <Insert extra rows for additional Health and Wellbeing Boards as required> c) Service provider engagement Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it Engagement to Date The Better Care Fund (BCF) plan for Knowsley is closely aligned to existing CCG, Joint Health and Wellbeing and Local Authority strategic aims and intentions and is the mechanism for their delivery. The plan is also aligned to Knowsley Partnership’s 10 year strategy and will support and enable the achievement of many of the objectives contained therein. The development of these strategies was informed by extensive stakeholder engagement undertaken with a wide range of organisations currently commissioned to provide services to the borough’s population. As part of its annual planning processes, the CCG holds a stakeholder event which includes representatives from a wide range of providers. At the 2013/14 event, delegates described how seamless services would feel, what needed to change and the challenges preventing seamless service delivery. A large scale provider event was held by Knowsley's Health and Wellbeing Board on 29th October 2013. This event was well attended with over 70 delegates from a wide range of organisations. The event was used to promote the Board, raise awareness of the Joint Health and Wellbeing Strategy and the Board’s priorities and as an opportunity to engage with providers and discuss how they can support this work. Areas identified by providers included improved information sharing systems, liaison services and navigators to support across pathways, shared protocols and jointly funded and commissioned services, linking disciplines and providers. Knowsley CCG’s protected time event on 14th November 2013 was attended by 116 delegates representing 31 of the groups 33 practices. The event was used to discuss and determine commissioning priority areas to be addressed in 2014/15 and beyond. Key priorities were voted on by attendees and included improving access to physical and mental health services, dementia and elderly medicine, intermediate care and single point of access, community nursing redesign and directory of service access. A number of working groups also operate within the borough, bringing together provider and commissioning perspectives. These have been supported to ensure close
communication, sharing of ideas and to develop solutions and outcomes-focussed working. In many cases there is now daily contact between services and this responsiveness is supporting collaborative working and future workforce planning and development. Next Steps The draft plan will continue to be developed with further consultation and input from providers, through the Health and Wellbeing Provider Forum, 2014/15 CCG stakeholder event, and CCG member practices, working groups and formal contract negotiations and monitoring meetings prior to finalisation. Scheme development and implementation will engage providers in the co-production of the detail to ensure buy-in and best outcomes across both Health and Social Care. d) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it Engagement to Date Healthwatch Knowsley is a key member of the Borough’s Health and Wellbeing Board and will have a formal role in commenting on and endorsing the final plan. The Health and Wellbeing Board Engagement Forum support and influence the Joint Health and Wellbeing Strategy priorities, which will be delivered though the Better Care Fund plan. The Forum will also be utilised to ensure effective engagement has been undertaken with a wider range of stakeholders including S.P.A.R.K (Shout Participation All Round Knowsley), Knowsley User Led Organisation, Knowsley Council for Voluntary Services , CCG member practice participation groups, Area Partnership Boards and others “Call to Action” is a programme of engagement, allowing everyone to contribute to the debate about the future of health and care provision in England. This programme will be the broadest, deepest and most meaningful public discussion ever undertaken. The engagement will be patient and public centred through hundreds of local, regional and national events, as well as through online and digital resources. It will produce meaningful views, data and information that CCGs can use to develop their 3-5 year commissioning plans setting out their commitments to patients and how services will improve. The Knowsley CCG Patient and Community Participation Forum held a “Call to Action” Event on the 17th October 2013 which facilitated public and patient discussion on what they thought worked well within the existing services and what else they thought would improve their experience. Included in the top 10 priorities where improved communication; greater integration of social care and voluntary sector; better planned and supported discharge; improved access to services; improved patient education and ability to ‘self manage’; listen to patient experience when designing services; address waste and inefficiencies, all of which will the BCF plan intends to address. Next Steps Patients, service users and the public will continue to be engaged in the development of the Better Care Fund plan prior to its finalisation, specifically through the Health and
Wellbeing Board Engagement Forum, CCG 2014/15 Planning Stakeholder Event, CCG Patient Participation Forum and Healthwatch. Scheme development and implementation will also involve wide-ranging public, patient and service user involvement in the co-production to ensure they best meet the borough’s needs and deliver best outcomes. e) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition. Document or information title Synopsis and links Joint Health and Wellbeing Strategy Joint Strategic Needs Assessment Strategy for Knowsley CCG 5 year plan? Knowsley Council Corporate Plan Relevant Council service plans
2) VISION AND SCHEMES a) Vision for health and care services Please describe the vision for health and social care services for this community for 2018/19.
• What changes will have been delivered in the pattern and configuration of services over the next five years?
• What difference will this make to patient and service user outcomes? The 2018/19 vision for health and social care in Knowsley is one of transformed, effective and efficient services that adopt a holistic approach to health and wellbeing within shared available resources. Knowsley residents will live longer, healthier and happier lives. They will be safer and there will be a reduction in health inequalities. They will have greater independence, be able to self-manage more effectively and become active participants in ensuring their own and their family’s health and wellbeing, having more responsibility and greater involvement in decisions about any care and support they receive. People will experience increasingly integrated, patient-centred services that deliver better health and wellbeing outcomes and experience. Delivered closer to home and more easily accessible, services will promote independence and support people to remain at home. Ensuring the sustainability of the local health and care economy, service delivery will support effective use of available resources and value for money through a focus on sustainable impact to deliver improved outcomes, management of demand through earlier and better prevention and intervention, patient engagement and prioritisation. In 5 years time care will be delivered using innovative models of service provision, potentially requiring new organisational models and lead providers, enabling increasing levels of acuity to be managed in the community, supported by wide-ranging prevention interventions; from promoting health to preventing ill-health and exacerbations. Key to this will be locality-based integrated provision through the ‘Neighbourhub’ model, with one philosophy of care based on supporting people to retain their place within the community. Joint assessment, co-ordinated by a lead practitioner or professional, adopting a case management approach, will allow citizens to co-produce a single, holistic, care plan over which they feel a real sense of ownership, and which will be delivered as close to home as possible. Pro-active identification and management of people (starting with our older and most complex patients) will allow integrated teams to rapidly draw on specialist support when necessary. This will include further building community resilience our through third and voluntary sectors. But it will also mean empowering individuals to make better lifestyle choices and supporting and encouraging citizens to have increased awareness of and better access to services that support them to maintain good health and wellbeing, There will be targeted investment in skills, capacity and infrastructure to support a more holistic, co-ordinated, integrated, efficient and person-centred approach to the delivery of health and social care. This will allow us to develop health and social care ‘navigators’
confident in working outside of their professional boundaries, allowing citizens to work with fewer professionals but in a more targeted way. Improvements will be seen across the range of life course outcomes adopted by Knowsley’s Joint Health and Wellbeing Strategy, namely: • Mothers and fathers are well prepared for pregnancy and choose to have babies • Healthy conception, pregnancy and birth • Children are ready for school physically, emotionally and developmentally • Children make a positive transition between primary and secondary school • Young people have the skills and resources required to make positive transition
choices into adulthood • Adults have the resources and support to enable them to manage their own health
and wellbeing and have a good quality of life • People are able to maintain independence for as long as possible • People are able to approach the end of life with dignity
b) Aims and objectives Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover:
• What are the aims and objectives of your integrated system? • How will you measure these aims and objectives? • What measures of health gain will you apply to your population?
The overall aim is of an integrated system that demonstrates the following characteristics:
• High impact and quality: safe services delivering improved experience and outcomes in line with national and international best practice and supported by practitioner education
• Increasingly integrated: health and social care assessment and commissioning with provision integrated across secondary, primary, community care, local authority and the third sector led by co-ordinating providers or professionals
• Personalised and patient centred: seamless from the patient’s perspective • Empowering: enabling independence through self-care, prevention and early
detection, supporting people to remain at home • Closer to home: increasingly in the community, improving efficiency and patient
experience and outcomes • Locality based: delivered through a virtual and physical ‘hub’ – with services being
delivered and co-ordinated on a locality basis • More easily accessed: simplified, earlier, more timely access, supported by 7-day
working and informed patient choice • Affordable and sustainable: through managing demand and prevention,
prioritisation, increased efficiency, appropriate, effective use of resources and value for money
• Prevention: From promoting health to preventing illness and exacerbations, reducing demand on more intensive health and social care services
• Appropriate: developed to deliver outcomes that meet identified population needs and involving public, provider, partner and other stakeholders in their co-design
• Efficient: streamlined processes and effective information sharing – benefitting individuals and organisations
• A changed culture: population, provider and commissioner • Information technology enabled: improving access, supporting culture change and
informed choice. • Assistive technology enabled: helping people to remain in their own homes
enjoying safety and independence • Strategically aligned: enabling the achievement of local, regional and national
strategy, policy and other requirements, including those for the Better Care Fund The integrated system will support more people via community-based prevention and early intervention initiatives which will reduce demand on more intensive health and social care services. It will promote independence and help people and their carers to better manage their own health and social care needs. Health and social care needs will be identified at an early stage, with citizens involved in shaping a personalised care plan to meet their needs. Seamless care will be delivered through improved inter-professional team working and co-ordination, delivering care as close to home as possible. System sustainability will be supported by actions that reduce the need for urgent and high cost interventions and provide value for money services and interventions within available future resources. What will this mean to the residents of Knowsley? • Feeling more reassured because their needs and the needs of their carers have been
shared with the professionals involved in supporting them • Knowing that decisions about their care will be made in their whole health and social
care context, made with them more quickly and as a single plan • Knowing their personal goals will inform these decisions and they will have more
control over their health, helping them to live a full and independent life • Feeling that all agencies are working with them to help them stay well • Wider determinants of health and wellbeing will be addressed as part of a holistic,
person-centred approach to care. What will success look like? In line with Knowsley’s vision for health and social care in Knowsley success will look like the following: • People empowered to direct their care and support, and to receive the care they need
in the community. • Reduced pressures on acute settings through shifting of resources to primary care
services - from bed based care to community based care – and effective prevention interventions
• Increasingly integrated, patient centred services that deliver better health and wellbeing outcomes and experience.
• A shift to whole system joint commissioning across Health and Care • There will be a reduction in health inequalities
As per the outcomes and metrics section, key performance measures will be monitored
over time to ensure the Better Care Fund Plan is delivering these aims and objectives. The plan will also ensure that Disability Facilities Grant, Carers breaks and Care Act requirements are met. c) Description of planned changes Please provide an overview of the schemes and changes covered by your joint work programme, including:
• The key success factors including an outline of processes, end points and time frames for delivery
• How you will ensure other related activity will align, including the JSNA, JHWS, CCG commissioning plan/s and Local Authority plan/s for social care
SCHEME: SAFE SUPPORTED DISCHARGE AND SUPPORT TO REMAIN AT HOME
YEAR 1: 2014/15
Improving performance and integration of Community and Bed based intermediate care. Ensuring that people are supported to maintain optimum functional health and retain their place within the community, staying at home for longer, but if admitted that discharge planning commences at initial decision to admit and includes structured support to facilitate a sustainable outcome.
YEAR 2: 2015/16
Community Frailty Service
A consultant-led, person-centred service focussing on frail patients with complex conditions/high care needs, including careful targeting to provide case managed, inter-professional team care. The model will employ a lead provider with appropriate governance and accountability arrangements ensuring the co-ordination of multi-disciplinary and multi-provider delivery to citizens, in their own, residential or nursing homes 7-days a week.
STAGES
2014/15 Q1 Improving co-ordination and efficient use of existing health and social care services, including introduction of 1yr new services / functions required to improve outcomes for patients
2014/15 Q1&2 Co-production of Community Frailty service model 2014/15 Q3&4 Procure Community Frailty service 2015/16 Q1 Community Frailty service ‘go-live’
SCHEME: PHYSICAL NEIGHBOURHUB
YEAR 1: 2014/15
Enhanced and improved engagement and clinical leadership from Primary Care practitioners and GPs in the Multi-Disciplinary Process.
GP leadership of and accountability for effective use of case management approach to ensure the holistic assessment and care of patients with the most complex health and care needs, those people over 75 and / or at risk of admission or readmission to secondary care. To include preventative programmes such as lifestyle services, Healthy Homes, IKAN and falls assessment services and alcohol support services
YEAR 2: 2015/16
The Neighbourhub: Locality Health and Care Team (Transformed Primary Care Team)
Commencement of implementation of fully comprehensive locality based Multi-Disciplinary Team approach in existing primary care, local authority or other community facilities.
Driving integrated working across health, social care and prevention, supporting single diagnosis and assessment of need that is inclusive of carer assessment, including improving understanding of and access to carer breaks in emergency situations, co-ordination and delivery of services with oversight from a senior clinician or accountable GP.
The hub will serve both as a locality focal point for primary assessment of health and wellbeing needs, delivery of locality based services and co-ordination, via named lead clinician, of more specialised treatment and care.
STAGES
2014/15 Q1 Development of practice plans for case management 2014/15 Q2 Holistic case management approach implemented, including
health, social care, preventative and wellbeing for defined groups
2014/15 Q1-3 Co-production of transformed primary care model 2014/15 Q3&4 Stakeholder engagement 2015/16 Q1 Commencement of phased implementation of transformed
primary care model SCHEME: DIGITAL NEIGHBOURHUB / KNOWLEDGE HUB
YEAR 1: 2014/15
Digitising information, empowering citizens through self-service and informed choice to access the full range of Knowsley health and wellbeing services, linking in to other publically funded, third sector community and voluntary services that impact on health and wellbeing.
Physical locations, in existing Primary Care, local authority or other community facilities,
where citizens will be able to easily access information, self-refer and, if needed, receive advice, guidance and support on their health and wellbeing needs as well as the range of wider determinants such as housing conditions, the environment, work, social contact, access to leisure and culture, opportunities, experience or fear of crime and transport access to services and facilities.
YEAR 2: 2015/16
Increasingly comprehensive, improving user experience and take up, employing an innovative range of access channels
STAGES
2014/15 Q1&2 Commence compilation of compendium of services available to the citizens of Knowsley that may impact on health and wellbeing, including wider determinants
2014/15 Q1&2 Develop user interface, enabling virtual access to compendium for practitioners and citizens, based upon need
2014/15 Q2&3 Launch web-enabled Knowledge hub 2014/15 Q2&3 Introduction of ‘community navigators’ and ‘care champions’ 2014/15 Q3&4 Community outreach to understand how citizens learn about
services available to them 2015/16 Q1 Improve user interface to include search facility 2015/16 Q1 Commence roll out of additional access channels
d) Implications for the acute sector Set out the implications of the plan on the delivery of NHS services including clearly identifying where any NHS savings will be realised and the risk of the savings not being realised. You must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. The details of this response must be developed with the relevant NHS providers. Knowsley’s Better Care Fund plan is in line with existing strategies that have been developed with extensive engagement from all local providers. A clear implication of both the shift in care from hospital to community settings and use of preventative measures to avoid the need for more intensive interventions will be reductions in non-elective emergency admissions and readmissions, admission for Ambulatory Care Sensitive conditions and reductions in length of stay at local acute providers. During 2015/16 there will be further reductions in outpatient activity as the Community Frailty service becomes operational. The CCG is developing its commissioning intentions for its main NHS providers, which it will be sharing in the context of the 2014/15 commissioning round, during the final quarter of 2013/14. The CCG will be looking to establish contractual terms with NHS providers affected by the BCF and its other QIPP plans that help mitigate against the risk of any planned
savings not materialising whilst maintaining quality and standards and the achievement of key delivery targets. Thereafter, through regular and close monitoring of activity and cost in year, any material variation to the plans will be managed through the relevant and appropriate contractual terms. e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes. The Health and Wellbeing Board tasked the Transformational Change Programme Board to develop the BCF Plan. Comprising CCG, Council, NHS England and Healthwatch representatives, the Board will oversee the ongoing development and implementation of the BCF Plan. The Transformational Change Programme Board is accountable to the CCG Governing Body, Council Cabinet and Health and Wellbeing Board (in respect of the BCF plan). Regular progress reports will be provided to the Programme Board and upwards to the Governing Body and Cabinet, with day to day management implementation of the plan delegated to the CCG’s Programme Director for Transformational Change, subject to agreed programme tolerances not being exceeded, performance measures and national conditions being met.
3) NATIONAL CONDITIONS a) Protecting social care services Please outline your agreed local definition of protecting adult social care services. Adult Social Care Services in Knowsley are provided in accordance with relevant legislation; the NHS and Community Care Act 1990 associated regulations and a range of specialist legislation, that meet the assessed eligible social care needs of people who are ordinarily resident in Knowsley. Services are available to all eligible adults over the age of 18 and for young people in transition to Adult services from the age of 16. All Social Care Services in Knowsley have a direct link to the health and wellbeing of the individual receiving the service and the family and carers. The protection of adult social care services means Knowsley residents will be supported to remain at home and manage their own wellbeing for as long as practicably possible. This will be achieved by not simply preserving the exiting supply of adult social care services but by refocusing all health and social care interventions on empowering residents to self care and self direct solutions that keep them well. In a context of reducing resources `care at home’ will be reinforced to challenge an over reliance on more expensive models of care and acute sector provision. A commitment to the value of social care within an integrated whole person model of delivery will ensure maximum benefit and impact to Knowsley residents. The protection of adult social care will be governed by the implementation of the Care Bill and whole social care system transformation; Knowsley’s eligibility criteria will be maintained at substantial and critical, assessment and care management will be extended to people who fund their care and supporting carers will be central to all social care interventions. This transformation will ensure that residents will;
• Receive short term rehabilitative interventions at the earliest opportunity that prevent a dependency on care and support services.
• Receive assistive technology, equipment, telehealth and telecare as part of a prevention programme.
• Receive an `outcome focussed’ approach to the statutory assessment of their individual need.
• Be empowered to `self direct’ a broader range of community based support options when meeting their eligible assessed need.
• Have continuous access to advice, information and advocacy which serves to minimise dependency on social care services.
• Receive good quality care that maximises independence • Receive good quality residential care that promotes dignity and respect • Receive a broader range of carer support
Please explain how local social care services will be protected within your plans. The BCF plans will help to protect these services by:
• Providing acceptable levels of provision within available future resources • Supporting the development of preventative services to reduce demand • Facilitating the development of integrated services which deliver better outcomes for
individuals and improved efficiency for commissioners and providers • Effective management and functional optimisation of those individuals who require
social care input to ensure that unmet health needs do not manifest as social care requests
• Supporting improvements in quality and efficiency of existing services through the development of integrated initiatives such as lead professional, data sharing and increased hours of operation
• Developing integrated 7 day services which improve efficiency through reduction and elimination of duplication, delay, error and waste
In year 1 and 2 this programme will ensure that the Care Bill is implemented and all statutory requirements met. This programme will ensure that Social Care has the necessary capacity to implement all new requirements by establishing joint governance of both programmes of work. Funding currently allocated under the Social Care to Benefit Health grant has been used to enable the local authority to achieve the following:
• To sustain the current level of eligibility criteria and to provide timely assessment, care management and review and commissioned services to clients who have substantial or critical needs
• Development of Integrated Crisis and Rapid response services • Early Hospital Discharge Schemes • Other preventative services • Telecare • Community Equipment and Adaptations.
It is proposed that additional resources will continue to be invested in social care to deliver enhanced rehabilitation / reablement services which will reduce hospital readmissions and admissions to residential and nursing home care. b) 7 day services to support discharge Please provide evidence of strategic commitment to providing seven-day health and social care services across the local health economy at a joint leadership level (Joint Health and Wellbeing Strategy). Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends. The Scheme ‘Safe Supported Discharge, Supporting People to Remain at Home’ will support 7 day discharge through the consistent provision of services throughout the week. In line with SDIP plans with health service providers, year 1 will see therapy, social care and other services that are currently provided Monday – Friday move to 7 day provision. A significant majority of social care services are already delivered over seven days but development work will be undertaken to ensure will be undertaken to support any planned changes.
Year 2 will see the commencement of the Community Frailty Unit, operating on a 7-day basis to support hospital discharge. c) Data sharing Please confirm that you are using the NHS Number as the primary identifier for correspondence across all health and care services. NHS number is used as the primary identifier in all correspondence between health services. Knowsley MBC undertakes an on-going programme of data quality assurance to ensure that both NHS number and details of registered GP practice are included within the Northgate SWIFT (adults) and Liquid Logic ICS (Children’s) social care systems and can be used as primary identifier for correspondence. If you are not currently using the NHS Number as primary identifier for correspondence please confirm your commitment that this will be in place and when by Please confirm that you are committed to adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK)) Knowsley is committed to adopting systems that are based on Open API and Open Standards. The CCG’s Information Management & Technology Strategy and Programme plan outline how progress will be delivered for Integration, Interoperability and Data Sharing. The Local Authority’s ICT Strategy states that applications will be developed to promote integration, ease use, reduce duplication of data input, share information and to provide streamlined processes across all channels. APIs are used extensively along with the NDL middleware product to deliver integrations. Please confirm that you are committed to ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, professional clinical practise and in particular requirements set out in Caldicott 2. Both organisations have designated Caldicott Guardians. The requirements of the Caldicott2 review are also fully supported by both organisations. The CCG has established an Information Governance Management group, led by its Head of corporate services and reporting to audit committee. The group is undertaking a comprehensive review and where appropriate rewrite of all IG protocols, policies and procedures to ensure compliance with all NHS requirements, in particular Caldicott2. The Local Authority has an Information Government (IG) group chaired at Director level and reporting to the Senior Information Risk Owner (Deputy Chief Executive). The group is tasked with reviewing and where appropriate rewriting IG policies, protocols and
procedures to ensure compliance with relevant requirements. d) Joint assessment and accountable lead professional Please confirm that local people at high risk of hospital admission have an agreed accountable lead professional and that health and social care use a joint process to assess risk, plan care and allocate a lead professional. Please specify what proportion of the adult population are identified as at high risk of hospital admission, what approach to risk stratification you have used to identify them, and what proportion of individuals at risk have a joint care plan and accountable professional. The existing ‘Care Campus’ approach in operation throughout Knowsley utilises the methodology of Kings Fund’s Combined Predictive Risk Tool as well as more traditional ‘case finding’ to risk stratify patients with Long Term Medical condition at `high risk’ of admission or re-admission to hospital.
The process brings together Community Nursing ‘Intensive Support Teams’ and social care professionals to work closely with GP’s in assessing and responding to those patients .
In line with the requirements of Everyone Counts, the BCF schemes for years 1 and 2 will ensure GP leadership of, and accountability for, effective use of this case management approach being extended to ensure the holistic assessment and care of patients with the most complex health and care needs, and all patients over 75. High risk patients will be managed with active leadership from named GP whilst those at lower risk levels will be supported other clinicians or care workers with oversight from GP.
This will ensure a consistent multi-disciplinary approach is in place and create easy access to an expanded menu of health and social care professionals, assessment and support provision.
4) RISKS Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers. The Key risks are currently outlined below with an allocated risk rating ranging between 1 and 5 with 1 being low risk and 5 being high risk. Risk Risk rating Mitigating Actions Performance targets not met and funding is withdrawn or withheld.
3 Ambitious but realistic targets need to be set and monitored, with recovery plans implemented where performance of trajectory is not to plan. Good governance of the transformation will also mitigate this.
Lack of capacity to deliver 3 Agreement on scope of plan and commitment from partners to resource the transformation will be a requirement to deliver it.
Financial pressures 4 Sound financial modelling based upon known and anticipated income and expenditure and future budgetary pressures will need to be factored into the transformation programme.
Plans insufficiently ambitious to protect social care / health and wellbeing economy
4 Impact of delivery modelled against specified outcomes that ensure sustainability of health and social care.
Plans too ambitious to deliver
2 Plans must be ambitious to deliver required outcomes. The Transformation Programme Board will be tasked with checking that plans are realistic but challenging.
Plans are too health or social care focussed
2 Joint working and decision making through Programme Board and Planning Groups, with individual accountable organisation
oversight Articulated outcomes inherently deliver health and social care benefits but there are opportunities to look at the wider determinants of health and wellbeing to ensure other partners in housing and employment and skills can contribute.
Lack of public, patient, service user buy-in
3 Programme of engagement to ensure that plans are aligned to population need.
Lack of provider buy-in 3 Programme of engagement to ensure that providers shape, understand and, wherever possible, buy into plans.
Lack of partner buy-in and the need for the right balance between all partners.
3 This is a partnership and integration transformation agenda and the Governance for this will be via the joint working and decision making in the Programme Board and Planning Groups. Programme of engagement to ensure that partners shape, understand and, wherever possible, buy into plans.
Shift of significant activity from acute to community could have a destabilising impact on the acute sector
3 Work with co-commissioners and acute providers to model impact. Business development opportunity for acute sector to deliver improved quality and value for money in a community setting. Multiple acute providers has potential to mitigate impact
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Document 23(01)09
QUALITY & SAFETY COMMITTEE
KEY ISSUES
October & November 2013
Key Issues
October 2013:
• New Chair – Dr Robin Macmillan • End of Life patient experience event facilitated by CCG very well received • Community – Care Homes noted as an area requiring further quality and safety
improvement work • Acute & Community – rise in Clostridium Difficile cases noted in acute and
community, dip in Stroke performance noted. • Safeguarding – service model being reviewed after 6 months in place. • Quality Surveillance Group – Keogh, key lines of enquiry referenced to committee.
November 2013:
• Mental Health – to be added to committee workplan • Primary Care – noted increase in outpatient referrals, peer reviews commenced,
Choose and book figures still appear low. Comments noted regarding A & E activity and patient venues e.g. walk in centres.
• Acute – St H & K still at enhanced level of surveillance, Liverpool community health also being closely monitored due to staffing issues raised. Aintree also remain on remedial action plan. Stroke performance remains a concern and has been challenged at Provider Quality Boards
• Safeguarding – quarter 1 and 2 provider assurance evidence received and now being reviewed by safeguarding staff. Care homes remain a concern and the CCG is working with KMBC colleagues. Noted; Ofsted and new style CQC inspections likely to occur before 2015
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Knowsley CCG Clinical Quality & Safety Committee
Notes of Meeting: Friday 4th October 2013: 1.30pm
Publically Disclosable
St. Chads Health Centre, Kirkby
Present Apology MEMBERS
Dr Robin Macmillan Chair of the Committee - Secondary Care Doctor Breeda Worthington Head of Quality & Safety/Lead Nurse Dr Paul Conway Clinical Lead for Quality & Safety Dianne Johnson Accountable Officer Ruth Austen-Vincent Lay Member, Patient and Public Involvement Sarah McNulty Public Health Consultant, Knowsley MBC Helen Smith Head of Safeguarding for Adults Paul Coogan Healthwatch Knowsley Trish Drew Designated Nurse Safeguarding Children Sandra Kanczes Daly Nurse Clinician Dr David Stokoe Clinical Lead for Primary Care Quality
IN ATTENDANCE Jane Calveley Healthwatch Knowsley Ann Shone Secretary Sue Harris Programme Manager, Quality & Safety
ACTION 1. WELCOME & INTRODUCTIONS
Breeda Worthington welcomed all those present to the meeting and round-the-table introductions took place.
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2. APOLOGIES FOR ABSENCE
Apologies for absence were received from Helen Smith; Sandra Kanczes-Daly; Sarah McNulty; David Stokoe
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3. DECLARATIONS OF INTEREST
Breeda asked if members had any conflicts of interests to declare. None declared.
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4. MATTERS ARISING
Minutes of the previous meeting Minutes of the 2nd August 2013 meeting were agreed to be an accurate record. Matters arising Breeda explained to the group that the CCG had gone through a governance audit of its corporate processes. The CCG had been recommended to ensure each of the organisation’s committees and sub-committees be chaired by an independent Lay Member. Therefore Dr Macmillan has agreed to become the Chair of Quality & Safety Committee with immediate effect. Dr Macmillian asked the committee to support and formally record their appreciation of the work of Breeda in facilitating and chairing the Quality & Safety Committee which worked well. Matters arising from meeting 2nd August 2013 Page 5, 6.3.4 Complaints Reporting/Analysis. Breeda informed the committee that Paul Boyce the Director of People at Knowsley Metropolitan Borough Council has agreed to be a member of the Clinical Quality & Safety committee. Quality & Safety meetings – Frequency and alignment of corporate meetings being reviewed. NHS England email response to PALS/Complaints read out by Breeda.
(see attached)
5. PATIENT EXPERIENCE
5.1 Patient Story (Safeguarding) By making reference to a specific Knowsley Serious Case Review, Trish Drew gave a presentation on ‘The Voice of the Child’ as the patient story. A group discussion took place. Dr Macmillan asked what this committee and the CCG can do to help reduce the risk of such an event occurring again. Trish said to ensure provider organisations reflect some of the key issues highlighted. Dianne Johnson said safeguarding is made up of Children and Adults. What do we do and what is going to change as a result? Trish said the Safeguarding Service are dependent on the CCG and other agencies. Commitment to Multi-Agency Safeguarding Hub (MASH) is going to be key with the intelligence brought into this centralised Hub. Dr Macmillan asked if we knew how many children in Knowsley were not registered with a GP. Dianne responded that this something we
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could do by liaising with the schools. Trish informed the group that if a professional had a concern about a child they should communicate via a Common Assessment Framework (CAF). Everybody then gets together to talk about that child. Jane Calveley asked how can we ensure that services join up at an early stage? Dr Macmillan responded that we could ask their opinion to identify the ‘at risk’ family and child. After that it could be complicated. Dianne asked Trish to find out how many out of borough children there were. We need to have the process stated clearly and the GPs are key, therefore we need to be clear that they know about it, we are the responsible commissioner. Dr Macmillan said we could request some more investigation/information processes for people being moved 20 miles or more. Action: Trish to prepare a short briefing on how many children in care are placed out of the borough and are known to Safeguarding Service and to audit these to ascertain who has had a CAF completed. Dianne asked is our provider actually in contact and monitoring “that” child’s health. If that is the case can we evidence it? Trish responded that this is done through the quality schedule and KPI’s within the providers contract. Dianne said the next step is to see how it is all working. 5.2 Patient Experience Group (Verbal) Ruth informed the group that the Patient Experience Group (PEG) is continuing to develop work. Their last meeting focussed on End of Life Themes. Forty people attended from a wide range of organisations such as hospices, members of the public and people who use the services. Information will be written up and taken to the Patient Experience Group in November and there will be a range of actions to be taken forward. It is intended to get more patient stories. Following the development session, a business meeting was held; as a result PEG have decided to hold a Business meeting at the end of each meeting as the members found it beneficial. Ruth mentioned the hard work done by members of the CCG specifically Dawn and Jacqui to pull the development event together. Action: It was agreed that this committee should receive the notes of the PEG.
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Dawn Boyer
6. SAFETY
6.1 Safeguarding Update (Adults) Trish presented the Adults Safeguarding update briefing on behalf of Helen Smith.
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Only limited evidenced assurance regarding the safeguarding at Knowsley commissioned provider organisations can be provided due to the lack of data. However, meetings are taking place with the commissioned provider organisations where action plans are developed to address and mitigate identified risks. A full report will be presented to the committee in November 2013. Issues around Care Homes were discussed, specifically those with CQC or Safeguarding notifications. Breeda said that Care Homes are being monitored and the Safeguarding Team are notified of all alerts for Nursing Homes across Merseyside. Breeda stated it has come to her attention that there was a risk that non-clinical members of the Adult Safeguarding team were expected to assess patients which was not acceptable and that this is being addressed. Action: Tracey Forshaw is undertaking a trend analysis, compiling the evidence and working closely with the Healthwatch team around Knowsley Nursing Homes. An issue was highlighted, related to inadequate staffing within some Care Homes. Paul Coogan stated that there needs to be work around how this is monitored perhaps through unannounced visits to see how many staff are on a particular unit at one time? The guidance around staffing within Nursing Homes needs to be clarified. Action: Helen Smith to source and provide Best Practice Guidance on Care Home standards including staff ratios. 6.2 Safeguarding Update (Children) Trish reported two new incidents this month. Safeguarding team recruiting two new Deputy Designated Nurses following the resignation of Denise Roberts and Paula Simpson who are moving to other positions within the NHS. There have been 13 applicants and 6 are being interviewed. Trish will highlight if there is a capacity issue. 6.3 SUI update Key Issues - List of risks to be discussed in PART B. Breeda gave an update in respect of SUIs open. There are 72 open cases at 5BPFT, 15 relate to Knowsley patients. A portion of the 72 cases are in a NHS England (Merseyside) cluster review, these are being managed by NHSE(M).
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7. QUALITY
7.1 Acute Care Quality (briefing)
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Dr Conway gave an update on the provider quality status for August 2013 for Knowsley. Issue noted: Increase of Clostridium Difficile cases across Knowsley generally. Early Warning Dashboard – Section B. 7.1.1 – 5 Boroughs Partnership Foundation Trust – Concern over management of Central Alerts, staff morale and sickness levels. 7.1.2 - Aintree University Hospital Foundation Trust - 1 case of Clostridium Difficile reported. National CQUIN for Dementia has not been achieved. Concerns over mortality – work in progress. CCG currently leading the Patient Experience work stream within the trust Remedial Action Plan. 7.1.3 - Royal Liverpool University Hospital Foundation Trust – CQUIN for Dementia a national issue across the country, but also not achieved by the trust. 7.1.4 - Liverpool Women’s Hospital – The Care Quality Commission (CQC) carried out an unannounced visit around staffing and deemed it not to meet all the essential standards of care it needed to. Concerns relating to staff morale and above average sickness. 7.1.5 - St Helens and Knowsley Hospital Trust – STHK has initiated a Health Economy Group to support improvement in health care acquired infection care. 7.1.6 – Liverpool Heart and Chest Foundation Trust – Concerns remain related to achievement of the Heart Failure care bundle; Central Alerting System compliance; and slightly above average staff sickness. 7.1.7 – Liverpool Community Health – Concerns raised around staffing and clinical leadership in intermediate care provision. 7.1.8 – Mersey Care – Main concern is cost improvement and staffing levels. 7.2 Primary Care Quality (briefing) – Members were invited to raise any concerns from the briefing in the notes. None were raised. 7.3 Other – Nothing to report.
8. SPECIAL AGENDA ITEM
8.1 Safeguarding update (verbal) Breeda updated the meeting. Knowsley CCG Safeguarding Service is made up of Adults and
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Children. There have been discussions across the CCG Network as to whether it is the right model for us - 6 months down the line is it working, and what do we need to change? Those conversations are on-going. Trish stated that our residents do move across the boundary and it is useful/interesting to have that overview. If it is not working for the CCG then we have to look at it. Ruth said this is really important. NHS England (Merseyside) have initiated a Safeguarding Forum as detailed in the Accountability Safeguarding Framework (NHSE 2013) Action: Breeda to update committee on wider CCG network discussions/decisions about safeguarding provision. 8.2 Quality Surveillance Group (verbal) Breeda updated the meeting. Quality Surveillance Group meeting took place on Tuesday 1st October 2013. A discussion took place on membership of the group. Breeda informed the committee that some QSG’s have providers in attendance and some do not. Dr Conway felt it should be all commissioners. Clare Duggan will take this information back to NHS England (Merseyside) and feedback. Keogh Review – Key lines of enquiry document was shared by the QSG. This will be attached to the notes of the committee for information. Action: Keogh Review – briefing to be shared with minutes.
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Part B – Quality & Safety Committee Knowsley CCG Monthly SUI Report: Discussion. At this point Jane Calveley and Paul Coogan left the room.
9. FUTURE AGENDA ITEMS
As per Work Plan.
10. ANY OTHER BUSINESS
Members of the committee requested a change of venue for future meetings. Ann Shone to contact Andrea Kelly regarding availability of Nutgrove Boardroom. Dianne requested that we look at Stroke Services and quality of stroke at the next meeting.
DATE & TIME OF NEXT MEETING
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Friday 8th November 2013 at 1.30 pm Nutgrove Boardroom, 1st Floor, Nutgrove Villa, Westmorland Road, Huyton. L36 6GA
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Knowsley CCG Clinical Quality & Safety Committee
Notes of Meeting: Friday 8 November 2013: 1.30pm
Publically Disclosable
Nutgrove Villa, Boardroom
Present Apology MEMBERS
Dr Robin Macmillan Chair of the Committee - Secondary Care Doctor Breeda Worthington Governing Body Nurse Dr Paul Conway Clinical Lead for Quality & Safety Dianne Johnson Accountable Officer Ruth Austen-Vincent Lay Member, Patient and Public Involvement Sarah McNulty Public Health Consultant, Knowsley MBC Helen Smith Head of Safeguarding for Adults Paul Coogan Healthwatch Knowsley Trish Drew Designated Nurse Safeguarding Children Sandra Kanczes Daly Nurse Clinician, Clinical Membership Group Dr David Stokoe Clinical Lead for Primary Care Quality Roy Choudhury Safeguarding - Metropolitan Borough Council Sharon Fryer Head of Safeguarding Knowsley Metropolitan
council
IN ATTENDANCE Jane Calveley Healthwatch Knowsley Sue Harris Programme Manager, Quality & Safety Natalie Nawaz Administration Officer
ACTION 1. WELCOME & INTRODUCTIONS
The Chair welcomed all those present to the meeting and round-the-table introductions took place.
Chair
2. APOLOGIES FOR ABSENCE
Apologies for absence were received from new committee member Sharon Fryer, Head of Safeguarding for Knowsley Metropolitan Council.
All
3. DECLARATIONS OF INTEREST
The Chair asked if members had any conflicts of interests to declare. None declared.
All
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4. MATTERS ARISING
All
Minutes of the previous meeting dated 4 October 2013 were accepted as an accurate record subject to the following amendments: Trish referred to the action log and agreed she had completed an audit to ascertain how many children in care had been placed out of the borough; not to obtain details relating to which ones has had a CAF completed. Action: Natalie to amend action log accordingly 6.3 SUI Update – Paul Coogan representation for Healthwatch made reference to a discussion that had taken place regarding Lay Members in the SUI Group, had been omitted from the minutes. Action: Breeda will discuss with SUI Group a process that will need to be followed regarding Lay Members. All members agreed all representatives will be required to complete declarations concerning confidentiality to avoid any potential breaches. Chair referred to embedded document relating to PALS (insert here) Chair has asked for a response to be sent, as follows:
1. Is it suggesting secondary care is supported by PALS? 2. To seek clarity about the PALS service within primary care?
Action: Breeda to follow up. Action Log referred the need for 5BPFT representation to be included in membership for future meetings. Frequent questions raised and someone with that expertise would be valued and able to support any concerns. Action: No definitive decision made, who ideally would be a suitable member from 5BPFT perhaps we should ensure representation rather than an individual member. Action: Breeda to ensure 5BPFT will be included on the Quality and Safety Work Plan.
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5. Patient Experience RAV
I) Patient Story II) Patient Experience Group Feedback (verbal) Ruth confirmed the group will meet again December in which we will be in receipt of a summary of comments concerning End of Life Care who has/ not been consulted. We anticipate 5BPFT representation at the next meeting to ensure communication and engagement is maintained to ensure patients questions can be answered appropriately. Anita Watkinson is working on identifying issues arising from PPG’s,
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especially regular issues. This information will then be incorporated within the Primary Care Quality Network Meetings. The purpose of the information will be to address issues and act accordingly if deemed necessary. Ruth expressed productive conversations that she has had with 5BPFT and DAS relating to DNA patients. Explored possibilities of ways in which we require a different way of delivering a system. Dianne’s reply that a scale change referral system would need to happen across the borough.
6. SAFETY HS/TD/BMW
i) Safeguarding update (Adults) Discussed ahead of schedule as both Helen and Sue attending a nursing home for review and will need to leave meeting at 2.30pm. Documents were provided by Helen and tabled for open discussion. Helen provided an adult safeguarding KPI analysis report referred to document 07 (11) 03 and provided an update to Safeguarding (Adults). Difficulties obtaining information as held within different organisations, particularly Local Authority. Helen reassured the board data collection will be easier to obtain quarterly or annually rather than over a five year period. Both Healthwatch and Local Authority conscious the requirement for a system wide understanding will need to be put in place to extract essential data. All nursing homes have had an inspection within twelve months. CQC data identified inconsistencies. Helen shared with the team that a number alerts had been raised regarding one specific nursing home and is currently under investigation. Current position tends to be reactive to any situations that may arise, working on ideally early intervention as the better position. The meetings will be monthly from 2014 this will allow action plans to be put in place following each reported incident alongside evidence of improvements. Breeda reiterated the importance of still being informed in between meetings, Helen can report directly to Breeda to keep her abreast of any safeguarding issues. All members agreed that the process of capturing an alert notification is in process but still concern as the monitoring process and how each complaint is being dealt with and how we are assured what is being done to resolve. It was confirmed not all nursing homes are included on the “North West Framework”, and therefore may fail to achieve shared expectations. A joint action plan is enforced when a safeguarding issue is raised for a
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Knowsley resident residing outside the borough this ultimately involves a joint action plan. Breeda informed the board that we have asked for an alert for Knowsley residents residing outside the area if any safeguarding issues arise then we would expect a notification. NHSE (Merseyside) looking at Safeguarding on a national level to see if resources need to be allocated more locally. Recruitment is in progress for a Safeguarding and Commissioning Nurse Lead once someone has been successfully appointed this will help with provisions. Both Helen and Sue left the meeting at this point. ii) Safeguarding Update (children) Documents were provided by Trish and tabled for open discussion. Two new staff will join the team in February within that time due to capacity issues, there may be an element of “risk” between December and January, due to the volume and demand of work. Designated nurses will prioritise work as agreed with the CCG. A significant improvement for quarter two against quarter one period. Action plans in place and working hard against them to achieve results. Fundamental delay is due to not obtaining data from CSU in adequate time. Data being provided but without necessary evidence to support assurance. Trish advised that ‘Looked After Children’ are not included in the audit when they have been completed by another provider. Action: Trish to have a full, audit and annual report at December’s meeting (three reports in total) Breeda believed we are receiving reassurance verbally but do not have all necessary documents to demonstrate or evidence to support some provider conversations. Trish believes that the data is recorded on ACS. Roy Choudhury added that it is not easy to print from ACS. CQC inspections will be taking place in the next 5 months by April 2014. Two days’ notice will be given prior to inspection. The CQC visits will be discussed at a providers meeting scheduled 25 November. CQC will visit Dianne and Trish will co-ordinate. Uncertainty if contraception and sexual health could be a subject topic for CQC to discuss. Roy confirmed Ofsted inspections will continue until 2015. iii) SUI Briefing and Complaints Update (CCG, Acute and Primary Care briefing. Breeda advised members the format of the report has been changed for SUI’s, this task was given to CSU regarding content and the format
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to ensure future reports will be presented regularly. Sue has experienced SUI reporting with acute trusts in Bolton and Manchester and will add to the benchmark capacity from different areas. 5BPFT now under a review process related to a “formal cluster review”. Seventeen cases of suicide have been reported in the 2010-2012 period. Not all cases have been closed. NHSE (Merseyside) are performance managing these cases. There are eight SUIs outstanding since June. One case remains open relating to an internal governance issue at Aintree. Quarter two from July – September period shows an increase from eight to eleven cases relating to 5BPFT. A letter is drafted and will be sent to the provider which will include a request for a trend analysis report. Once the letter has been received we expect a response by December. A meeting has been scheduled 28 November for the internal clinical SUI review group to review SUI’s. One case in particular to ensure the correct process is followed, and to gain assurance that we are doing everything that be done. Ruth requested the outcomes of the SUI to be reported to each Quality and Safety Committee Meeting. Action: Breeda to debrief members the outcomes of any reported SUI’s. iv) Complaints Update As a CCG we need internal assurance as to what is being reported from other trusts providers. CCG currently has no documented trail of complaints dealt with by provider for Primary Care. The process is a three tier, complaint received by NHSE (Merseyside) redirected for investigation. CCG will be made aware of complaint, however NHSE (Merseyside) manages, sort, filters and resolves. CCG Knowsley CCG has two recent complaints. NB Aware a complaint has been received regarding the baby changing facilities at a St Chads Practice however details limited at present time. Breeda made reference to Jacqui Johnson, Corporate Services Manager, working extremely hard to obtain information from CSU. Jacqui is ensuring processes are being followed, systems are in place and the reliability of data received.
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Providers CSU have global complaints for each provider, although providers are not obliged to inform CCG until the annual report. Contracts are being considered to improve complaints reporting to at least quarterly.
7. QUALITY DS/PC i) Acute Care Quality (briefing)
Paul Conway briefed members with three key concerns for the CCG and provided a report which was validated September 2013. The total number of Clostridium Difficile cases relating to Knowsley CCG patients year to date stands at 32 cases, of these 13 have been apportioned to the acute providers and 19 apportioned to the community. Following Governing Body Meeting (7 November 2013) an action plan has been put in place regarding increase number of CDiff cases. Aintree Aintree continues to create concern in key performance areas such as complaints and stroke. Chair asked what concerns the greatest, Dr PC’s response was Staffing Levels, On-going risk at Whiston and indicators at Aintree. 5 Boroughs Partnership Foundation Trust Sickness absence rates – there has been a decrease in Quarter (Qtr) 1 2013/14 compared with Quarter 4 2012/13, although the overall rate remains above the national average. Royal Liverpool University Hospital Foundation Trust National CQUIN Dementia - The Trust is failing to achieve the targets set for two measures of this indicator, screening and assessing patients. Liverpool Women’s Hospital Central Alerting System – The Trust currently has four on-going alerts which have passed the deadline date. St Helens and Knowsley Hospital Trust 1 case of Clostridium Difficile (C.Diff) (apportioned to the community) and 1 case of MRSA was reported in September. Liverpool Heart and Chest Foundation Trust Venous thromboembolism (VTE) risk assessment – The Trust has failed to achieve the 95% target in June and July. The Trust has attributed this to the new Electronic Patient Record system ‘going live’ in June. Liverpool Community Health – the trust whilst provides a small proportion of the CCGs commissioned services to Knowsley patients. However it continues to be closely monitored to ensure recent concerns raised about pressures related to intermediate care are safely and appropriately addressed. Mersey Care – the trust whilst not a main provider for the CCG does
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provide specific commissioned support to some Knowsley patients (specifically Kirby). The Trust has reported that in August, Knowsley CCG patients attributed to 25.2%, 30 patients who DNA outpatient appointments provided by the Positive Care Partnerships. ii) Primary Care Quality (briefing) Dr Stokoe has requested the agenda item to be brought forward as he needs to leave at 3.00pm. Document 07(11)08, contents discussed. Key issues identified:
• High increase in number of outpatient referrals. • Low uptake on Choose and Book, practices to be encouraged to
use Choose and Book- actually works well with Emis Web. • Practices currently doing internal peer reviews. • NHSE (Merseyside) currently in process of contacting practices
regarding winter pressures. • CQC intend to visit all GP practices.
Dr Stokoe reminded that figures for walk in attendances when patients are seen within less than four hours will show in national statistics incorporated with A&E admissions. Peer reviews give an opportunity for practices to explore their own practice data as they can view, however not formally sent otherwise. From a positive perspective, consultancy rate increased perhaps more referrals and obviously people living longer could increase referral figures. Action: David to meet with Sarah at PCQN meeting to discuss further. Ruth felt that patients needed to be involved. A suggestion was made that perhaps two cohorts of patient groups should be identified, one that has a high number of referrals and the other being a low percentage of referrals. Action: Subject to be discussed at next call to action. The opportunity will give patients a share in their own experiences; perhaps they felt they unnecessarily referred or perhaps not referred when they felt they should have been. iii) Other Commissioned Services (COPD, CVD, Diabetes)
Dementia is now a Direct Enhanced Service (DES) this will encourage and promote clinicians to early screen their patients. Winter pressure and increase of COPD patients during this time, NHSE (Merseyside) has confirmed, currently in process of contacting practices regarding winter pressures. Alison Van Dessel, Commissioning Manager currently has work in progress for the Diabetes service. Information will be provided at the
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next Primary Care Quality Network to ascertain what work has been completed. Both David and Sarah left the meeting at this point.
8. SPECIAL AGENDA ITEMS PC
Stroke - Documents were tabled at the meeting for further discussion. An additional document was provided by Paul, members felt this was beneficial. The document consists of a diagram that illustrates the calculation of appropriate care scores (ACS) and Composite Quality Scores (CQS) Noted number of stroke patients being identified is less but a significant increase of deaths as a result of a stroke. Aintree University Hospital Foundation Trust The Trust reported a drop in performance particularly in May (42.86%), with the ACS of 53.64% not being achieved. Royal Liverpool University Hospital Foundation Trust Although there has been an increase in performance (76.9% in May) compared to the previous month (70.2% in April) this falls below the ACS target of 89.81%. St Helens and Knowsley Hospital Trust The Trust has reported a drop in performance achieving an ACS of 36.7% in May against the target of 55.1%. The Trust has seen the highest number of Knowsley Dianne made a suggestion that it would be better to know the number of stroke patients in Knowsley rather than just specific provider data.
DATE & TIME OF NEXT MEETING
Friday 6 December 2013 at 1.30 pm Nutgrove Boardroom, 1st Floor, Nutgrove Villa, Westmorland Road, Huyton. L36 6GA
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Document 23(01)10
FINANCE & PERFORMANCE COMMITTEE
KEY ISSUES
September, November & December 2013
Key Issues
Finance
• Financial Position for Month 7 was presented at the meeting Delivery of 1% surplus (£2.4m) remains on track
• Over-performance against contract plans at Acute Trusts continue to be main cause of over-spend in Programme costs. Being managed through activity and contingency reserves allocated at the start of the year.
• Risk in respect of NHS Property charges being in excess of allocation has diminished due to national agreement
Better Care Fund (Formerly known as Integrated Transformation Fund ITF)
• Draft Planning submission to be completed by 14th Feb • Detail of schemes and financial envelope still to be determined and quantified via
joint planning group with Local Authority Pooled Budget Governance
• Recently developed governance scorecard measuring health and social care
outcomes shared and agreed as regular item on future agendas • Q3 Pooled Budget Finance report to be presented at next meeting
Contract Management/Performance/Negotiations
• Month 6 Contract Management report presented • Over-performance at Aintree hospitals against planned activity levels for elective
activity continues to be most significant issue • Red/Amber Performance indicators continue to be managed through individual
Provider quality boards. • Action plans to be shared with F&P committee for underperforming trusts
December minutes not formally ratified, therefore not shared with Governing Body
members – key issues included on update.
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NOTES OF THE FINANCE & PERFORMANCE COMMITTEE held on Wednesday, 18th September 2013
in the Boardroom, Nutgrove Villa
Present Apology MEMBERS
Mark Broderick F& P Committee Chair/Lay Member – Audit & Governance
Dianne Johnson Accountable Officer Dr Andrew Pryce CCG Chair Dr Ronnie Thong GP/Clinical Lead – Strategy & Planning Dr Shweta Tewari GP/Clinical Lead – Planned Care Paul Brickwood Chief Finance Officer Breeda Worthington Head of Quality and Safety/Governing
Board Nurse
Louise Carrington Head of Integrated Commissioning (Older People & Intermediate Care)
Clare Barrow Senior Finance Manager Tom Fairclough Head of Clinical Commissioning
IN ATTENDANCE Richard Holford Head of Public Health Strategy and
Intelligence
Ian Stewart Performance Manager Ian Campbell Merseyside CSU Karen Newbury Merseyside CSU
Lorraine Frodsham Note Taker Action: 1. Apologies for Absence Apologies for absence were received from Dr Pryce, Clare Barrow
and Karen Newbury.
2. Declarations of Interest There were no declarations of interest made.
3. Minutes of the Meeting Held on 17th July 2013 The minutes of the meeting held on 17th July 2013 were accepted
as a true and accurate record.
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4. Review of Action Log 1) Louise Carrington informed that the Accountability
Framework has been completed and there is also an additional document which provides greater detail in terms of who does what etc. Dianne Johnson said she had not had sight of this and was still confused about who was doing what. The CCG is paying a number of organisations and she was not convinced whether the CCG was getting value for money for what it was paying for. Louise Carrington said that in terms of getting the Accountability Framework signed off, some organisations were not happy to sign due to the risks. The accompanying paper to the framework sets out the risks and the proposals to deal with these/ It was agreed that the Accountability Framework and accompanying paper will be brought to the next meeting. This item to remain on the log. 2) Ian Campbell had unfortunately not produced the split of recurrent and non-recurrent funding and it will, therefore, be brought to the next meeting. This item to remain on the log. 3) Ian Stewart informed that the 5 Boroughs Performance Information Sub-Group was looking into contact figures for 10 of the high level contracts to determine how accurate reporting is. This is an ongoing process. Dianne Johnson queried whether the CSU could do this as part of their contract management role and Ian Campbell said this would be picked up by the FARG for the various Trusts. Ian Stewart said the CSU were involved and the 10 areas being looked at linked into the CCG’s strategic priorities. The next meeting of the 5 Boroughs Information Sub-Group is being held next Wednesday and the issue of FNC contact figures would be discussed then. Ian Stewart agreed to report back to this Committee at the next meeting. This item to remain on the log. 4) Ian Stewart said that for the CCG to gain safe haven status it would need to achieve Level 3 of the IG toolkit. This would have a significant financial implication. A paper is to be produced on what is required and the cost/resource implications to the next meeting. This item to remain on the log.
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5) Tom Fairclough confirmed that he had gone through the finance details on the Commissioning Plan with Clare Barrow. It was agreed that this information be shared with Dianne Johnson and Paul Brickwood. This item to be removed from the log. 6) Ian Campbell had provided the CSU report on over- performance issues to Paul Brickwood. This item to be removed from the log. 7) Ian Campbell had shared a report on over-performance on non-elective activity at StHK Hospitals Trust with Paul Brickwood. Paul Brickwood said that St.Helens CCG had also received a report on this issue and had raised some further questions and asked for underlying information on this issue. Ian Campbell said this had been provided to Julie Abbott yesterday and that it was intended to produce a monthly report on this issue until clarity had been achieved. This item to be removed from the log. 8) The Executive Summary is now provided in the Contract Management Report. This item to be removed from the log. 9) The cost and usage of the MerseyCare service is reported on in the Contract Management Report. This item to be removed from the log. 10) Ian Campbell said that all contracts had now been signed apart from Southport & Ormskirk. This item to be removed from the log.
5. MONTH 4 FINANCE REPORT Paul Brickwood presented this report which detailed the financial
performance of the CCG to month 5 (31st August 2013). He informed that since production of the report a couple of things had changed. The DH has reissued the prescribing forecast which now shows an overspend in this area and there have also been some changes around continuing care with the latest quarter’s position showing an underspend of £280,000 for the CCG. The impact of these changes is that there is an overall operational budget deficit of £13,000 to month 5. However, through the use of reserves the CCG remains on target to deliver the 1% surplus of £2.64 million required by NHS England. At month 5 the CCG’s reserve position is £7.3 million. In addition the CCG retains non-recurrent reserves of £4.9 million.
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Regarding acute commissioning, contract over-performance continues to be evident at St.Helens & Knowsley Hospitals Trust, Aintree University Hospitals Trust and to a lesser extent Alder Hey. In addition a number of minor acute contracts also indicate over- performance to month 5. In recognition of this the CCG has started to deploy earmarked reserves to fund certain cost pressures and is also using contract levers via the C&M CSU to manage over- performance. In relation to the issue of specialist commissioning, the CCG is currently anticipating a resource adjustment in its favour of £1.3 million from Specialised Commissioning. However, the latest unvalidated information available from Specialised Commissioning suggests this may reduce to £0.3 million. This position is in common with other CCGs in the North West. However, the data on which this forecast has been based has not been validated by the CCGs. Work is ongoing with Specialised Commissioning to ensure that costs are correctly attributed to commissioners. The Chair said it was good to hear that the CCG was on track to achieve a financially balanced position at year end. Paul Brickwood explained that NHS England requires the CCG to show it is on track throughout the year and the ISFE ledger has to include the forecast outturn position. Discussion had taken place previously around the possibility of a potential over-surplus and how to handle this to ensure the CCG retains the resources in the area. Ian Campbell queried what would happen if the CCG for example achieved a 2% surplus and what would happen to the extra 1%. Paul Brickwood said at the moment this was not known and he planned to take the opportunity at a forthcoming HFMA national event to raise this question. Dianne Johnson said that with regard to the over-performance on the Podiatry AQP contract held with 5BP, more information on this was required. Tom Fairclough said a meeting was taking place after this meeting to discuss this further but there were a number of contributing factors including a change in currency and a potential change in criteria. Dianne Johnson said a report needs to be produced on this issue and what is happening with other AQP providers. Breeda Worthington said this issue had been discussed at the Primary Care Quality Network meeting and Richard Holford said it might be useful to do an equality audit in terms of access to the service etc. Tom Fairclough agreed to produce a report for the October meeting.
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In terms of financial risks to the CCG these related to specialised commissioning as previously discussed, and there is a further issue relating to the uncertainty around recharges to CCGs for property services. At the moment the CCG is paying over the budget which was inherited from the PCT for these buildings to NHS Property Services. However, they are looking at the actual costs and then charging out to users of the buildings. Within contracts with providers (e.g. 5BP) there is no money included for use of buildings, so contracts will need to be increased to reflect these costs once NHS Property Services start to send out bills, which will probably be in October. Action : Tom Fairclough to produce a report on AQP for October meeting. Action : Clare Barrow to work with NHS Property Services and providers to determine contract adjustments. The Finance & Performance Committee noted the contents of this report.
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6. CONTRACT MANAGEMENT REPORT (MONTH 4) Ian Campbell presented this report which provided an Executive
Summary and also drilled down in greater detail into certain areas. In terms of key risks to the CCG, an overspend is showing on Acute Provider Trusts of £791,000 against plan. This includes the £241,000 relating to the unplanned care block element of the Aintree Hospital contract. The risks associated with data quality and submissions by provider have been highlighted in the report as these could lead to an incorrect statement of the Finance & Activity position of the CCG. Discussion took place over the new format of the report and the Chair said he liked the way the Executive Summary was presented. Paul Brickwood expressed concern that the over- performance at Aintree was not mentioned in the Key Risks section of the summary. He would also like to see the report split by Trust contract rather than split into urgent care, planned care etc for all Trusts, so that detail was provided regarding any issues for the CCG at these main providers. If any issues were identified then the CCG could send a representative to the next Contract Board meeting of that Trust to raise them. It was agreed that in future the report would concentrate on the following Trusts – StHK, Aintree, Royal, Liverpool Women’s, 5 Boroughs KIPs, Merseycare, Alder Hey and LHCH Community and show any areas of concern that the CCG needs to be notified about. If any significant issues came up relating to other Trusts these could also be included in the report.
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Dianne Johnson said that the information shown in the report regarding LHCH needed to include the COPD, CVD community services as the table just shows acute information. She also reported that the CCG was involved in work around IAPT services and that she would like to see this included in the report provided to the November meeting. Dr Thong commented on the figures shown regarding the Admiral Nurses. He said that it was known there was an under-diagnosis of dementia patients yet the contacts were high and he queried whether some of the contacts were for the same patient. Ian Campbell agreed to raise this issue at the FARG and report back to Dr Thong. Regarding the items in the report listed as for CCG decision, a brief update was given on each of these issues:- 1) StHK Trust – Discussion on the issues was taking place at the Contract Review Board. Dianne Johnson informed that if the CCG wanted to take further action they could do so even if the co-ordinating commissioner did not agree. 2) Fairfield – Paul Brickwood thought this was more of an issue for St.Helens CCG. However, Ian Campbell said that Knowsley agreement would still be required to the counter- proposal. 3) 5BP – the issue of AQP had been previously discussed. Work is ongoing on this issue. 4) MerseyCare – The Dementia Care Home Liaison Service is currently under-utilised service and work is ongoing to understand why. The question was asked whether nursing homes know about this service and Louise Carrington is to look into this and report back to the next meeting. 5) Liverpool Based Hospitals – LHCH are thinking about moving £2 million of secondary care income into tertiary care. Further information is awaited on this. Action : Ian Campbell to produce the report in the revised format for the next meeting. Action : Ian Campell to raise the issue of contact counting with regards to the Admiral Nursing Service at the FARG and report back to Dr Thong. Action : Louise Carrington to report back on nursing home use of the Dementia Care Home Liaison Service.
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The Finance & Performance Committee noted the contents of this report.
7. POOLED BUDGET PERFORMANCE REPORT Louise Carrington briefly went through the report highlighting areas
of particular risk to the CCG. Regarding the service provided by Vivark for provision of a home improvement agency to enable vulnerable residents to remain living independently, funding to date is only for a 2 year period. If the contract is not extended beyond this date it will increase pressure on related health contracts and alternative provision will be required to meet statutory obligations. Louise agreed to provide an update on this at a later date. The Home Care Link contract which provides an Assistive Technology service covering Telehealth and Telecare is due to expire in April 2014. At present the service is funded from the Community Services pooled budget. As the service is due to be retendered there is a risk that the costs of providing the service in the future may increase. The Council has now agreed a package of financial support for Age UK but will continue to monitor the situation. The contract with the 5BP for intermediate care and reablement is due to end on 31st March 2014. A whole system tender for Intermediate Care is to be advertised by April 2014. Regarding the contract with Halton MBC for the Positive Behaviour Support Service (PBSS), discussion took place on why admission to assessment and treatment units had fallen by over 50% since the adoption of the PBSS as part of the Model of Care for Learning Disabilities. Louise Carrington is to have further discussions with Dianne Johnson regarding this. Louise Carrington queried whether members were happy with the format of the report and Ian Campbell said he thought it would be helpful to include a column showing some kind of benefit score so that the reader understands how benefits are measured. Dianne Johnson said that performance data also needs to be included. The Finance & Performance Committee noted the contents of this report.
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8. KNOWSLEY CCG PERFORMANCE BRIEF Ian Stewart explained that the purpose of this briefing was to
highlight by exception any variances to the organisation’s plans submitted to the DH as part of the Everyone Counts 2013 submission and the actions being taken to address these variances. The overall summary position of the balanced scorecard is showing a number of triggers based upon self-certification at that time, the majority of which relate to commissioned provider performance at catchment level and are not based upon the CCG’s actual performance relating to its registered population. Discussion took place over the issue regarding StHK relating to Domain 1 and Dianne Johnson said that a request for a Risk Summit needs to happen rather than put a TDA enforcement action in place. Regarding Domain 2, Knowsley CCG patients do not have any significant issues in terms of the quality of care they receive and access times. Accident & Emergency Department access times as an aggregate for the organisation were reported to be 98.89% in quarter 1. Regarding 62 day cancer waits, performance cumulatively at quarter 1 for this indicator was reported to be 93.1% against the 94% threshold. The Finance & Performance Committee noted the contents of this report.
9. OPERATIONAL PERFORMANCE GROUP NOTES The notes from the meeting held on 21st August were received by
the Committee. Discussion took place on the increased number of Community acquired HCAIs and a suggestion was made to ask our Public Health colleagues for more information on this as there is a real risk of failure to achieve the quality premium regarding this. Breeda Worthington said there was an issue with CDiff at Aintree and that commissioners were working with the Trust over this issue which will be dealt with by the Quality & Safety Committee. The Finance & Performance Committee noted the contents of these minutes.
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10. DATE AND TIME OF NEXT MEETING 16th October 2013 at 1.00 p.m. in the Boardroom, Nutgrove Villa.
Dianne Johnson informed that this was the last time Mark Broderick would be chairing this Committee as he was due to take up his new role in the CCG from Monday. She thanked Mark for establishing and developing the Committee and advised that a new lay member, Susan Bramley, will Chair the Committee in future.
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NOTES OF THE FINANCE & PERFORMANCE COMMITTEE held on Wednesday, 20th November 2013
in the Boardroom, Nutgrove Villa
Present Apology MEMBERS
Susan Bramley F&P Committee Chair/Lay Member – Audit & Governance
Dianne Johnson Accountable Officer Mark Broderick Assistant Chief Officer Dr Andrew Pryce CCG Chair Dr Ronnie Thong GP/Clinical Lead – Strategy & Planning Dr Shweta Tewari GP/Clinical Lead – Planned Care Paul Brickwood Chief Finance Officer Lynn Matthews Programme Director – Contracted
Services
Louise Carrington Head of Integrated Commissioning (Older People & Intermediate Care)
Clare Barrow Senior Finance Manager Richard Holford Head of Public Health Strategy and
Intelligence
IN ATTENDANCE Simon Anderson Public Health – Contract and
Performance
Ian Stewart Performance Manager Ian Campbell Merseyside CSU Karen Newbury Merseyside CSU Lorraine Frodsham Note Taker Action: 1. Apologies for Absence Apologies for absence were received from Dianne Johnson,
Dr Pryce, Dr Tewari and Richard Holford. Su Bramley introduced herself to the Committee as the new Chair and introductions were made from all present.
2. Declarations of Interest There were no declarations of interest made.
3. Minutes of the Meeting Held on 18th September 2013 The minutes of the meeting held on 18th September 2013 were
accepted as a true and accurate record.
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Matters Arising Louise Carrington said that it had now been agreed to undertake a whole system stocktake of the Intermediate Care Service and work was underway on this. However, with regards to the tender for this service a way forward had not been agreed. She said that with regards to St.Bart’s there was no contract in place but there was a formal form of words but she was concerned that post April 2014 there will be a risk to all partners, but specifically to the Council. The Chair queried what was the target date for the whole system stocktake to be completed. Louise Carrington said she was not sure but she would be supporting the whole process. Lynn Matthews thought it might be worth setting up a steering group to look at this whole issue and she agreed to speak to Louise about this further outside of the meeting. The Chair felt that this item needed to be included on the CCG’s Risk Register and Louise Carrington agreed to provide a form of words regarding this.
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4. REVIEW OF ACTION LOG 1) Louise Carrington presented the Continuing Healthcare
and Complex Care Accountability Framework to the Committee. She explained that she had been working with the 5 Boroughs Partnership and the CSU to produce this document which shows who does what and when. All parties had agreed in principle of what should happen and when in terms of the current service. Louise Carrington also presented a short briefing to update the Committee on the current issues and risks that are present in the Continuing Healthcare and Complex Care process and pathway. The three main risks are:-
• None of the providers within the pathway are commissioned to provide care co-ordination.
• There is no resource provided to the Local Authority to support the commissioning of CHC packages of care and support.
• The resource required to commission CHC and CC should be considered against the requirement for all CCG’s to offer personal health budgets by August 2013.
A brief explanation was given of these risks but Louise Carrington said that the majority of systems were working well, albeit that the service was fragmented and the pathway to resolve this was not clear.
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After discussion it was agreed that Mark Broderick would arrange a meeting with Dianne Johnson to discuss this further. The Chair asked whether the Quality & Safety Committee had been made aware of the risks identified and Ian Campbell queried whether this needed to be added to the Risk Register. Clare Barrow said that it was for the Quality & Safety Committee to decide whether this should be added to the Risk Register, but in terms of the financial risk that the Local Authority has insufficient resources to manage practical commissioning of the packages within the pooled budgets, this needed to be discussed in the meeting with Dianne Johnson. The Chair said that she thought this should be added to the Risk Register if there was not a meeting of the Quality & Safety Committee shortly. This item to be removed from the action log. 2) Ian Campbell said that the split of recurrent and non- recurrent funding had only just been done and, therefore, Clare Barrow had not yet had an opportunity to review this. It was agreed to bring this to the next meeting. This item to remain on the log. 3) Ian Stewart said this issue had been discussed at the 5BP Information Sub-Group and he had been informed that the 5BP Performance Report is not generated within internal systems but provided by the Provider themselves so an approach would have to be made to them to clarify historical data. Paul Brickwood asked if the current 5PB Performance Report was correct and Ian Stewart confirmed that it was so this issue can be removed from the log. The Chair asked whether the amended historical figures could be brought back to the Committee. Ian Stewart thought this might be problematic but could be done. He agreed to speak to them and report back at the next meeting. This item to be added to the log. 4) Ian Stewart informed he had produced a paper on the implications of the CCG obtaining safe haven status and this had been forwarded to Mark Broderick and the Information Governance Team. Mark Broderick advised that the work done by Ian Stewart was being used by the IT Strategy Group and Dawn Boyer is producing a report which will be brought back to the Committee. This item to remain on the log.
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5) Mark Broderick advised that Tom Fairclough was originally going to produce a report on AQP but that Lynn Matthews had now taken over on this. However, as Lynn is relatively new in post she had not had the opportunity to do this yet and the report will be brought back to the next meeting. Clare Barrow said that the 5BP had been given a month’s grace to get their recording of data correct as only referrals from 1st April 2013 should be recorded as AQP. Karen Newbury queried whether this was just about 5BP or should also include other AQP providers. Paul Brickwood thought it would be quite a complex task to pull this information together for all AQP providers and as it was the 5BP where the major issues were being reported (particularly around Podiatry) with an over-performance amounting to £200k, that the report produced by Lynn Matthews should concentrate on them in the first instance. Ian Campbell thought it would also be useful to list the lessons learned regarding miscommunication issues etc and this could be shared with other AQP providers. This item to remain on the log. 6) Ian Campbell said the format of the Contract Management Report had been revised for the month 6 report. However, the report on the agenda today was for month 5 so the report in the new format will be brought to the next meeting. This item to be removed from the log. 7) Ian Campbell said that the next FARG meeting was on 25th November so he will report back to Dr Thong at the next meeting of this Committee on contact counting for the Admiral Nursing Service. This item to remain on the log. 8) Louise Carrington said that there appeared to be an under-utilisation of the Dementia Care Home Liaison Service by nursing homes, which from feedback received seemed to be due to lack of awareness that this service exists. She said the North Team were also unaware of the service. Lynn Matthews suggested the service managers be invited to attend a meeting to make them aware of the service and she agreed to set this up. This item to be removed from the log.
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5. APPOINTMENT OF VICE CHAIR After discussion it was decided to ask Dianne Johnson if she wished
to appoint the Vice Chair of the Committee or whether the Committee should ask for a volunteer, and if so where there any stipulations about who could hold this position on the Committee. Action : Lorraine Frodsham to contact Dianne Johnson to clarify.
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6. MONTH 6 FINANCE REPORT Paul Brickwood presented this report which detailed the financial
performance of the CCG to 30th September 2013 (month 6). However, the underlying data used to report upon the Acute financial position is based on month 5 flex data, forecast to month 6 position and prescribing data is based on the month 4 position. The report covers programme and running cost budgets, year to date and full year forecast, reserves, key financial risks, QIPP performance monitoring and Acute contract performance. NHS England requires that the CCG plans for a £2.64m surplus for 2013-14 and the CCG remains on track to deliver this with £1.32m being held on the balance sheet at the half year stage for this. There are over-performance issues at both St.Helens & Knowsley and Aintree Trusts and looking to the future these are the key risk areas. The pooled budget is showing a small under-performance. The PPA outturn overspend on prescribing is moving back to balance. At month 6 the CCG is holding £3.7m in reserves and Paul Brickwood said he was confident this would cover the overall cost pressures. QIPP performance is on track in terms of delivery of where we need to be at this stage of the year, and a report on this issue is on the agenda later. Ian Campbell asked if there was any further information about specialised commissioning. Paul Brickwood said that £1.4m had been taken back from the CCG but this had been taken into account in the reserves position. Ian Campbell asked was there any risk that more could be taken back from the CCG and Paul Brickwood said it was a possibility as Specialised Commissioning were due to undertake a review on the month 8 reconciliation process. Dr Thong queried who decides what sits in specialised commissioning and what does not. Paul Brickwood said a national panel decides this and Identification Rules (IR) linked to the SUS system are used to split the PbR activity. Clare Barrow agreed to check that this issue is on the CCG’s Risk Register. The Chair asked that where providers were over-performing how does the CCG gain assurance regarding their actions to correct this. Paul Brickwood said that Aintree was over-performing on elective work. Debate was currently taking place over how far ahead they are getting on this work so they do not have to carry out these procedures during the winter months, given the usual
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winter pressures. At St.Helens & Knowsley Trust the over- performance mainly relates to A&E attendances and it is difficult to challenge the Trust on this. Detailed work is being carried out by the CSU on non-elective activity and this will be discussed at the FARG meeting. The national Trust Development Agency (TDA) are also proposing to do a further review of non- elective work at the Trust and this will commence shortly. The Chair asked if a slow-down in over-performance could be expected to be reported at the next meeting and Paul Brickwood confirmed this and said this had already started to happen. However, Lynn Matthews said the that non-elective over-performance could be expected to rise again with the Winter pressures. Action : Clare Barrow to check that the issue of specialised commissioning is contained on the CCG Risk Register. The Finance & Performance Committee noted :-
• the forecast financial performance to month 6, this being an operational budget surplus across both programme and running costs of £3,601 over and above the £1.22m surplus target set by the DH held on the balance sheet. The CCG remains on target at this stage of the financial year to achieve its planned surplus of £2.64m which has been set aside in reserves.
• the impact of the specialised commissioning allocation
adjustment on the CCG reserves and the continuing uncertainty regarding application of IR rules.
• that the CCG has invested £650,000 from earmarked reserves in relation to initiatives to deal with Winter pressures.
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7. QIPP Paul Brickwood presented this report to provide a briefing on the
continued need to deliver QIPP as an integral part of the CCG’s commissioning plans. He explained that a high proportion of QIPP savings are effectively automatically generated by national target decisions. For Knowsley CCG the total QIPP plan for 2013-14 is £10.9m. The CCG is on track to achieve this by the financial year end being £83,000 ahead of its savings trajectory.
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In terms of the future, Paul Brickwood said that it is likely that there will be less allocation increases for CCGs. Discussion also took place on whether formulas will be changed. More should be known at the end of December. Paul Brickwood said the current Financial Strategy will be updated in December and it was likely that the CCG will need to increase its scheme driven transformational savings. The Finance & Performance Committee noted the contents of the report and recognised that to deliver the efficiencies required in the longer term will require strategic leadership and collaboration between commissioners and providers. Reporting of financial delivery of QIPP plans to NHS England by the Shared Finance Team will continue on a monthly basis.
8. POOLED BUDGET PERFORMANCE This report presents an update on the Mental Health, Disability
and Community Support Services pooled budgets and outlines any issues that are affecting the forecast levels of expenditure for the year. The forecast outturn position against each of the pooled budgets is as follows:-
• Mental Health £0.088m deficit • Community Support £0.018m surplus • Disability £0.220m deficit
The total forecast deficit at outturn across all 3 pooled budgets is £0.290m. However, the CCG share was an underspend of £0.078 million. Paul Brickwood said that pooled budgets will be significantly increased by the introduction of the Integrated Transformation Fund. This will lead to major changes in the way pooled budgets will work, the likelihood being that there will be a one pooled budget arrangement rather than split into different sections. Clare Barrow said that in future Jo Serridge (Finance, Local Authority) will attend to answer any questions. Louise Carrington and Debra Lawson manage the budgets and also attend the Committee meetings so will also be available to answer any queries. Louise Carrington said she was aware of some high cost packages which will hit the adult budget shortly.
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Paul Brickwood advised that a meeting was due to be held in
Halton CCG to look at KPIs around pooled budgets comparing these with Halton Council. The Finance & Performance Committee noted the contents of this report.
9. CONTRACT MANAGEMENT REPORT Ian Campbell presented the month 5 report which gave an
overview of the key risks and items for decision by the CCG. Knowsley CCG is showing an overspend on Acute Provider Trusts of £1.132m (1%) against plan at month 5. This includes the £241k relating to the unplanned care block element of the Aintree Hospital contract. Ian Campbell commented that the ‘block’ agreement had not worked well for Knowsley and this should be perhaps be considered in future contract negotiations. Risks associated with data quality and submissions by providers are highlighted in the report as these could lead to an incorrect statement of the finance and activity position of the CCG. Knowsley CCG does not commission bed days for the Rivington Unit, 5BPs community intensive care unit. However, the CCG continues to have admissions to the unit, with 150 occupied bed days in the unit at month 5 (£105k year to date). Regarding items for CCG decision, the report suggests the CCG may consider writing to StHK Trust regarding supplying of data in a timely manner. In addition consideration should be given to the rebasing of the non-elective activity plan. It was confirmed that these items have already been actioned by the CCG. Regarding Aintree Hospitals Trust, the CSU presented options for managing the over-performance in planned care to the Aintree Commissioning Collaborative Forum on 10th October. Alder Hey has approached Liverpool CCG and the CSU to consider recognising the Audiology attendance immediately prior to an ENT consultation as sequential outpatient activity with effect from 1st April 2014. The CCG should consider whether to accept Fairfield Hospital’s counter-proposal regarding the Communications CQUIN revision. Regarding the 5BP Trust, AQP data is currently incorrect and is causing a pressure to CCG finances.
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The report then provided a drill down by describing finance and activity in planned care and urgent care. Discussion took place on the format of the report which was considered too lengthy. Ian Campbell advised that the month 6 report had been produced in a new shorter format but unfortunately this had not been received in time to circulate with the papers for this meeting. The new format focuses on key providers and gives an executive summary for each of these showing the annual plan, annual budget and activity to date. Paul Brickwood said this information would facilitate discussion at the various Contract Board meetings with providers and allow queries to be raised. The general consensus was that the new format was also too lengthy and Ian Campbell agreed to work on this for month 7. Paul Brickwood asked if the overall position at each Trust could be provided then the ‘Knowsley @’ position. Action : Ian Campbell to look at the format of the report again with the new version for month 7 being brought to the February 2014 meeting. The Finance & Performance Committee noted the contents of this report.
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10. CONTRACT NEGOTIATION UPDATE (Verbal Report) Lynn Matthews informed that the CCG was at the start of the
contract negotiation process. She had recently attended a CSU event to kick off the process and the CCG had held a PTE last Thursday which had resulted in a lot of good suggestions being made regarding CQUIN. She had agreed to meet with Dr Conway and the Quality Lead to drill down on these suggestions and to determine membership of a group to discuss this further. She said the CCG now had a clear pathway with clear ambitions. Paul Brickwood said there was talk of a national review of CQUIN which may impact on local CQUIN schemes. It had been suggested that from a provider point of view there should only be 1 CQUIN scheme per contract. The Chair queried when the contracts had to be signed off and Lynn Matthews said ideally by 28th February 2014. Simon Anderson asked what was Monitor’s stand about competition. Ian Campbell said he had recently attended a workshop which had a live link to the authors of the report on competition. However, no clear answers were given to the questions raised.
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Clare Barrow informed that a Task & Finish Group is to be established, the membership of which was currently being drawn up. Clinicians and representatives from the CSU will be included and Simon Anderson said a Public Health representative would be happy to attend if required. The Finance & Performance Committee noted this verbal update.
11. CCG ASSURANCE QUALITY PERFORMANCE (Verbal Report) A paper was circulated showing the Quarter 1 Balanced Scorecard
summary. Ian Steward said the process for the CCG looks at StHK Trust, Aintree, Liverpool Women’s and the 5BP and provides assurance in terms of delivery. There are 5 domains contained on the Balanced Scorecard and a brief description of performance in each was given. Domain 1 : Showing Amber/Green. This indicates there are a number of issues at the Trusts but action plans are in place. Domain 2 : Showing Green. All indicators met. Domain 3 : Showing Amber/Red. There are 32 indicators within this domain. There is 1 indicator showing a fail which related to a patient at Alder Hey who waited over 52 weeks for an operation. The patient was offered choice during this time to have the procedure undertaken elsewhere but declined. Domain 4 : Showing Green. All indicators met. Domain 5 : No outstanding conditions. The quarter 1 assurance meeting with NHS England had gone very well and they were impressed on how the CCG monitors this and no specific issues were raised. Louise Carrington queried whether the introduction of personal health budgets would impact on Domain 2 and Ian Stewart he was unsure at this point. The Finance & Performance Committee noted the content of this verbal report.
12. EXCEPTION REPORTS Ian Stewart presented this report to highlight by exception to the
Committee actions being taken to address the higher than anticipated rates of emergency admission for Paediatric Asthma and for Under 19s Lower Respiratory Tract Infection.
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In relation to unplanned admissions for paediatric asthma, diabetes and epilepsy the CCG had reported for May 2013 a cumulative position of 24 admissions (15 for asthma) against a plan of 21. In relation to Lower Respiratory Tract Infection admissions the CCG reported a cumulative position to May 2013 of 8 against a plan of 6. Sarah Carberry is working with Dr Sadiq to form an action plan on how the CCG plans to address these issues. The report brought to the Committee today has been presented to the Governing Body and will be presented to the Business Meeting in terms of what we are doing as a CCG to address these issues. Lynn Matthews said she had signed off on a Business Case on this which will be presented to the Business Meeting. Louise Carrington said that if it was found that there were particular areas in the Borough with housing conditions which may be adding to the problem (i.e. damp, mold etc) then she would be more than happy to also be involved in trying to resolve these. The Finance & Performance Committee noted the content of this report.
13. OPERATIONAL PERFORMANCE GROUP NOTES Mark Broderick said that a lot of work had been done by the group
recently. The format of the meeting had now changed. There are a set of indicators which Ian Stewart updates and he then links in with the Programme Managers who prepare on exception report on indicators which are showing Red. This enables the group to focus on areas of poor performance. The Finance & Performance Committee noted the content of these notes.
14. NOTES OF THE MAIN PROVIDER CONTRACT REVIEW BOARDS
Lynn Matthews presented these minutes from the recent Contract Review Boards of the CCG’s main providers. Actions from these meetings are contained within the Performance Report. The Finance & Performance Committee noted the contents of these minutes.
15. DATE AND TIME OF NEXT MEETING 18th December 2013 at 1.00 p.m. in the Boardroom, Nutgrove Villa.
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Document 23(01)11
AUDIT COMMITTEE
KEY ISSUES
9th December 2013
Key Issues
Governing Body Assurance Framework This document is the method by which the Governing Body is provided with assurance that the CCG is on track with its commissioning actions and is controlling/mitigating significant risks. The Audit Committee suggested some amendment to the format of the report. Information Governance Compliance Report This updated Audit Committee on delivery of Information Governance compliance by the CCG. This included review of the IG Strategy, audit of staff compliance and investigation work. The report was noted but need ensure issue of access to confidential information by carers is included in the relevant policies. Internal Audit Progress Report Plan is on track for delivery by the end of March. Internal Audit Charter produced by Mersey Internal Audit Agency which sets out the standards for their work was accepted by the Audit Committee. Agreement of the Final Accounts Timetable and Plans Need to ensure that Accounts are completed in time but key guidance Manual for Accounts not yet released by NHS England. External Audit may struggle to complete their work in the reduced time as final audited accounts to NHS England one week earlier than usual on 3rd June The Audit Committee agreed that a provisional hold be put on their diaries for 28th May 2014 in case the earlier submission date was confirmed which would mean the Audit Committee meeting scheduled for June would have to be held earlier. Anti-Bribery Compliance Strategy Information was provided to the Committee on how this strategy would be developed with the CCG.There is a risk, albeit small, that the CCG could suffer financial loss or suffer reputational risk as a result of bribery. The Audit Committee noted that the Governing Body had adopted the Strategy, approved that the CFO is made the lead to take this forward and delegated assurance on progress to the Audit Committee.
December minutes not formally ratified, therefore not shared with Governing Body members key issues included for an update.
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Document 23(01)12
HR COMMITTEE
KEY ISSUES
December 2013
Key Issues
• Human Resources Policies – the first tranche of harmonised policies for the CCG were reviewed and endorsed for approval by the Governing Body
• Performance Development Review (PDR) – the PDR process for employees of the CCG was reviewed and endorsed for approval by the Governing Body. Further discussion will take place to ensure effective evaluation of the process.
• Induction Pack – the CCG’s induction pack was ratified subject to minor amendments. This will be supplemented by guidance for managers and a more condensed version will be produced for wider circulation.
December minutes not formally ratified, therefore not shared with Governing Body members key issues included for an update.
