Islington Clinical Commissioning Group Governing Body …€¦ · 05/12/2012 · Spinel Room, The New North Academy, 32 Popham Road, London, N1 8SJ. Lead Action required Appendices

AGENDA – PART I

Lead Action required

Appendices Page

1. Introduction 1.1 Apologies for Absence and

Declarations of Interest Chair Note Oral --

1.2 Chair’s Introduction and Opening Remarks

Chair Note Oral --

1.3 Part 1 and Part 2 Minutes of the Meeting held on 7 November 2012

Chair For approval

Appendix 1.3 1-14

1.4 Matters Arising Chair -- Oral -- 1.5 Questions from the Public Chair -- Oral --

NB: Members of the public will be given the opportunity to ask questions. These must relate to items that are on the agenda for this meeting and should not take longer than three minutes per person.

2. Overview Reports 2.1 Chief Officer’s Report

Chief Officer For

informationAppendix 2.1

15-20

3. Governance and Assurance

3.1 Governance Review Director of Quality and Integrated Governance

For approval

Appendix 3.1

21-28

3.2 Shadow Audit Committee Report

Chair, Shadow Audit Committee

For discussion

Appendix 3.2

29-36

3.3 Governance and Quality Group Report

Chair, Governance and Quality Group

For discussion

Appendix 3.3

37-40

4. Strategy

4.1 Commissioning and Planning for 2013/14

Interim Director of Commissioning / Programme Director Authorisation and QIPP

For approval

Appendix 4.1

41-76

Islington Clinical Commissioning Group Governing Body Wednesday, 5 December 2012 10.30-12.30pm Spinel Room, The New North Academy, 32 Popham Road, London, N1 8SJ

Lead Action required

Appendices Page

4.2 Developing a Performance and Information Strategy – Health Intelligence Management Framework, Islington CCG (draft)

Interim Director of Performance and Information

For discussion

Appendix 4.2

77-94

5. Performance and Finance 5.1 Integrated Quality, Finance

and Performance Report Period ending 31 October 2012

Chief Finance Officer / Interim Director of Performance and Information

For discussion

Appendix 5.1

95-110

5.2 Psychotic Disorders Health Intelligence Profile

Interim Director of Public Health

For discussion

Appendix 5.2 111-136

5.3 Report from Finance and Performance Group

Chair, Finance and Performance Group

For discussion

Appendix 5.3

137-140

6. For Information 6.1 Approved Minutes of the

Governance and Quality Group (October)

Chair, Governance and Quality Group

For information

Appendix 6.2

141-147

7. Date of Next Meeting – 6 February 2013, 10.30-12:30pm

REGISTER OF INTERESTS A register of members’ interests is available. The register will be available at the

meeting or during working hours within the Executive Office, Islington Borough Office, 338-346 Goswell Road, London EC1V 7LQ

PART II MEETINGS To resolve that as publicity on items contained in Part II of the agenda would be

prejudicial to public interest by reason of their confidential nature, representatives of the press and members of the public should be excluded from the remainder of the meeting. Section 1 (2) Public Bodies (Admission to Meetings) Act 1960

NHS North Central London is a collaborative working arrangement between Barnet, Camden, Haringey, Enfield and Islington Primary Care Trusts.

Minutes – Part 1 Meeting of the Islington Shadow Clinical Commissioning Group Governing Body

3 October 2012 at 10:30am Large Conference Room, Voluntary Action Islington, 200a Pentonville Road, N1 9JP

Members Present: Dr Gillian Greenhough Chair, Islington Shadow Clinical Commissioning Group Dr Mo Akmal Secondary Care Clinician Dr Sharon Bennett Central Locality GP representative Dr Penny Bevan Interim Director of Public Health Alison Blair Chief Officer Sorrel Brookes Non-Executive Director (PCT) / Lay member (CCG) Dr Anjan Chakraborty North Locality GP representative Dr Katie Coleman Joint Vice Chair (Clinical) Dr Sabin Khan Co-opted Salaried / Sessional GP Martin Machray Director of Quality and Integrated Governance Dr Rathini Ratnavel South Locality GP representative Dr Jo Sauvage Joint Vice Chair (Clinical) Dr Karen Sennett South Locality GP representative Deborah Snook Practice Manager representative Anne Weyman Vice Chair (PCT) / Vice Chair – non-clinical (CCG) Non-Voting Members Present:

Dr Robbie Bunt LMC Representative Marian Harrington Interim Director of Adult Social Care and Health, London Borough of

Islington Jacky Kutner Interim Director of Information and Performance Sophie Lusby Programme Director – Authorisation and QIPP Gerry McMullan Health Watch Observer Paul Sinden Interim Director of Commissioning In Attendance: None. Apologies: Jennie Hurley Practice Nurse representative Minutes: Sharon Jackson Board Secretary

Appendix: 1.3a ICCG GB - 1


1. INTRODUCTION Action 1.1 Apologies for Absence: The apologies were noted as above. Declaration of interests There were no declarations of interest. The Chair noted that the updated Register

of Interests had been provided for information.

1.2 Chair’s Introduction and Opening Remarks 1.2.1 The Chair welcomed all to the meeting in public of the NHS Islington CCG

Governing Body. She introduced Dr Mo Akmal from Imperial College Hospital, the newly appointed secondary care clinician member of the Governing Body, and welcomed Dr Penny Bevan, interim Director of Public Health.

1.3 Minutes of the meeting held on 5 September 2012 1.3.1 The minutes were APPROVED as an accurate record of the meeting subject to

two amendments: · Section 4.3.1 should read “Greg Cairns, Director of Primary Care Strategy

for the Local Medical Committee (LMC)” · Section 5.2.4 should read “Dr Katie Coleman advised that a dashboard…”

1.3.2 The Governing Body reviewed the action log: 1.3.3 Action 10/12-12: Jacky Kutner provided an update on the implementation of

DocMan and EMIS web. She reported that EMIS had gone live at 11 GP practices in Islington and the remaining would be completed by March 2013. Key issues for practices included broadband width, training and support, and technical hardware issues. DocMan funding had been agreed and NHS North Central London was paying for the license from the GP IT fund. It was noted that it was the intention to assist practices in setting up the functionality for patients to make bookings online. It was suggested that there should be a regular EMIS web update in the weekly GP newsletter to ensure that the feedback mechanism was well advertised and any issues were communicated to GPs.

1.3.4 ACTION 11/12-1: To provide a regular update on EMIS web for the weekly GP

newsletter. JK

1.4 Matters Arising 1.4.1 There were no matters arising. 1.5 Questions from the Public 1.5.1 The Chair invited questions from the public which were responded to under the

relevant agenda item.

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1.5.2 A member of the public asked for clarity about what was covered in the part 2 session. Martin Machray advised that the Commissioning Support Unit service level agreement had been discussed but only those parts that could not be divulged due to commercial confidentiality. There was a substantive item on the part 1 agenda which provided the information which could be in the public domain.

1.5.3 A member of the public asked how the Governing Body intended to ensure that

patients’ views were heard as per the mission statement. It was noted that there were three active locality patient and public participation groups, along with a pan-Islington patient and public participation group.

2. OVERVIEW REPORTS 2.1 Chief Officer’s Report 2.1.1 Alison Blair presented her report which provided an update to the Board on issues

that were not elsewhere on the agenda including: · Islington CCG’s objectives – these had been revised for the period until

April 2013. It would be necessary to focus on the next stage of objectives following authorisation. It was noted that the objectives needed to be more explicit about working with patients;

· Board Assurance Framework and Risk Register – work was underway to develop the CCG’s assurance framework and risk register. These would be in draft until 1 April 2012 and were essential to managing the business going forward;

· Provision of out of hours – this service was provided at St Pancras Hospital however it was proposed to widen the provision to other sites. A consultation would be undertaken if the proposals were agreed;

· Barnet and Chase Farm Hospitals NHS Trust – there was a proposal for the Trust to work with Royal Free Hospitals Hampstead NHS Foundation Trust to come together as one organisation. Islington CCG had been asked for their support as commissioners by registering an interest in working on these plans. It was noted that the CCG’s focus must be on ensuring that the quality of services remained high whilst the proposal was developed.

2.1.2 The Governing Body:

· NOTED the report; and · DELEGATED AUTHORITY to the Chair to sign a letter on behalf of

Islington CCG supporting the proposal for the merger of Barnet and Chase Farm Hospitals NHS Trust and Royal Free Hospitals Hampstead NHS Foundation Trust that clearly stated the need to maintain quality through the process.

3. GOVERNANCE AND ASSURANCE 3.1 Service Level Agreement between Islington Clinical Commissioning Group

and North and East London Commissioning Support Unit

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3.1.1 Alison Blair presented the item and noted that the service level agreement had been discussed in detail in the part 2 session and had been approved subject to a number of caveats. The service level agreement approved would cover the period until March 2013 and set out the parameters by which the CCG would work with the Commissioning Support Unit (CSU). The CSU was in the process of making appointments to its structure following which more detailed discussions would be held about the service level agreement from April 2013.

3.1.2 The caveats included:

· Individual Funding Requests – clarity was needed on who was responsible for these and a policy needed to be developed;

· Key Performance Indicators – these were considered critical and would need to be measurable and able to demonstrate that the CCG was getting good value for money;

· Governance arrangements – the CSU’s governance arrangements needed to be clear in terms of how decisions would be made and audit arrangements;

· Communications – clarity was needed about the offer for public relations and involving the public;

· Working arrangements – the CCG wanted to see that the CSU was working smartly and were providing high quality service. Accuracy was important;

· Care pathways – clarity was needed about the support that would be provided for the development of care pathways;

· Review arrangements – there needed to be a clear agreement on how issues would be addressed.


· NOTED the letter from North and East London Commissioning Support Unit Commissioning Support Director to the Islington CCG Chief Officer; and

· NOTED the list of services which North and East London Commissioning Support Unit would provide for Islington CCG;

· NOTED that the Service Level Agreement for the period until 31 March 2013 had been approved in the part 2 session.

· AGREED that a letter of response be drafted outlining the caveats discussed.

3.1.4 ACTION 11/12-2: To draft a letter of response to the Service Level Agreement

with North and East London Commissioning Support Unit outlining the caveats agreed.

PS

3.2 Islington CCG Governing Body Terms of Reference 3.2.1 Martin Machray introduced the revised terms of reference for the Governing Body,

which had been approved by the Islington Primary Care Trust (PCT) Board on 27 September 2012. It was suggested that the terms of reference should be clear about the areas of commissioning that had been delegated to the CCG from the PCT. Martin Machray advised that the Corporate Governance Framework Manual provided the PCT’s scheme of reservation and delegation which detailed this information.

3.2.2 The Governing Body ADOPTED the revised terms of reference.

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3.3 Governance and Quality Group Report 3.3.1 Sorrel Brookes, Chair of the Governance and Quality Group, provided an update

on its business. Concern had been raised about the extent that the Clinical Quality Review Groups provided assurance and consideration was being given to collaborating with the contracting team. There was agreement from the Governing Body that the joining up of the clinical quality review groups and contracting processes was important. The Clinical Quality Review Group clinical leads would need to work together to do this.

3.3.2 The group had discussed the planned governance review in detail which would

feed in to the Governing Body seminar scheduled for 21 November 2012. It had been suggested that it would be useful to have more clinical input in to committees as there were practical issues with achieving a quorum for the December meeting.

3.3.4 The group had received an excellent report on Adult Safeguarding which was very

accessible and well written.

3.3.5 The Governing Body NOTED the report. 4. STRATEGY 4.1 Update on Operating Plan for 2013/14 4.1.1 Paul Sinden presented the paper which provided an update on the development

of the Operating Plan for the next financial year and set out the engagement process undertaken to develop priorities. It also outlined the development of savings plans to enable investment in services.

4.1.2 Paul Sinden noted that challenge panels had been set up to screen proposals and

the results of these would be presented to the December meeting of the Governing Body. The investment fund for 2013/14 would be between £3.2million and £5.2million depending on finances at the end of 2012/13. The savings plan target was £6.5million which was lower than 2012/13 (£11.5million).

4.1.3 In response to a question, Paul Sinden advised that an evaluation process would

need to be put in place to ensure that savings programmes were appropriate and to put right any mistakes. It was suggested that the Service Improvement Group would be the best forum to do this.

4.1.3 It was noted that the planned savings for children’s services was about the work

done in hospitals that would be more appropriately provided in a community setting. A number of suggestions were made in regards to the priorities that were identified at stakeholder events. It was noted that the priorities were a collation of information not a final draft:

· 2.2.2 self-management of care should include telehealth but not be limited to it;

· 2.2.3 elderly with multi-morbidity should be included in the range of services provided by general practice;

· 2.2.4 in regards to outpatient services in the community it was noted that learning should be taken from previous experience with gynaecology services which had been found to be more expensive when provided in the community.

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4.1.4 The Governing Body NOTED the update on developing the Operating Plan for

2013/14, and the process to completion.

4.1.5 ACTION 11/12-3: To present the proposals for savings and investment for

2013/14 to the December meeting. PS

4.2 Referral Management Report 4.2.1 Paul Sinden presented the report and noted the concerns of the Governing Body

about the lack of emphasis on the improvement of quality of referrals. He advised that the purpose of referral management was to improve patient experience in terms of onward referral from GP practices; however this was not appropriately reflected in the report.

4.2.2 Paul Sinden advised that the Service Improvement Group had considered two

options for referral management; a peer review system; and a referral management system. The preferred option was the peer review system with an educational focus, however the process for this needed to be worked through. It was suggested this should be done by a person external from the practice.

4.2.3 It was noted that the figures showed an increase in referrals to secondary care

and it would be necessary to think about the community pathways that were in place in terms of accessibility. It was also noted that the practice visits had been helpful to look at referral rates and had highlighted that there were issues with access to community services and with clinical coding in hospitals. Gerry McMullan asked that patients were kept informed and were advised of the options.


· APPROVED the proposal to implement the peer review system as set out in the paper, subject to further development and with: - Participation of all practices; - Targeted early interventions with those practices with referrals

significantly above or below the Islington average including prospective review of referrals; and

- The review of referrals by GP Locums and Salaried GPs by all practices.

4.3 Patient Involvement and Engagement Strategy: the next steps 4.3.1 Dr Katie Coleman presented an update on the progress made with patient

involvement and engagement. She reported that equality and diversity had been the first issue taken forward since the inclusion of patients in the core work of the CCG. It would be necessary for the CCG to develop its own equality and diversity objectives once it was a statutory body.

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4.3.2 In regards to patient involvement, Dr Katie Coleman advised that all GP practices had patient participation groups which were supported through the introduction of a local enhanced service (LES). There were three active locality patient participation groups alongside pan-Islington meetings. It was noted that the locality meetings were administrated by practice managers and Gerry McMullan offered them the support of the Local Involvement Network (LINk). Work was being done to make documentation more patient friendly and to develop ways to access hard to reach communities.

4.3.3 There was a discussion about patient members on groups. It was noted that the

CCG was working closely with the LINk to look at how patient members could be supported so that they felt they could contribute effectively. It was also noted that the governance review looked at how patient input linked up across the Governing Body’s groups.

4.3.4 Jacky Kutner advised that work was being done to develop a story board for the

Islington website about patient feedback and would include information about services in regards to quality. There would be a “you said, we did” page to provide examples of where patient feedback has led to the commissioning or improvement of a service.

4.3.5 The Governing Body NOTED the update on patient involvement and engagement. 4.4 Integrated Care Programme Update 4.4.1 Dr Jo Sauvage provided an update on the Integrated Care Programme which was

intended to improve the quality of service for patients with long term conditions and to make their care seamless. The programme was a collaborative venture with all agencies in Islington including the local authority, mental health, acute trusts and the voluntary sector. The workstreams included older adults, diabetes, Chronic Obstructive Pulmonary Disease (COPD), cardiovascular disease and self-care.

4.4.2 In response to a question about the inclusion of complex pain management, Dr Jo

Sauvage advised that there was an existing muscolo-skeletal (MSK) pathway that had elements of pain management. In addition, conversations were underway in regards to community pain management and an event was scheduled for the following day to discuss the topic. It was noted that it would be necessary to develop a communications strategy for the integrated care programme.

4.4.3 The Governing Body NOTED the progress made in Islington on implementing the

Integrated Care Strategy.

4.5 Update from Service Improvement Group 4.5.1 Paul Sinden presented the update which provided an overview of the business of

the Service Improvement Group. The group had: · discussed the procurement process for the termination of pregnancy; · reviewed the content of the Local Enhance Service (LES) for diabetes and

the closing of the prevalence gap. It was noted that the financial element of this was approved outside of the CCG; and

· looked at pathology services and how to ensure greater quality of testing.

4.5.2 The Governing Body NOTED the report from the Service Improvement Group.

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5. PERFORMANCE AND FINANCE 5.1 Integrated Finance and Performance Report – Month 6 5.1.1 Ahmet Koray and Jacky Kutner introduced the first integrated finance and

performance report.

5.1.2 Ahmet Koray reported that the CCG had a surplus of £702,000 in-month 6 and

remained on target to achieve the control total. The forecast outturn had improved to £16.4million primarily because of an improvement to the acute position. The CCG was on target to achieve both its investment and savings programmes.

5.1.3 Jacky Kutner reported that Islington were performing well against the key

indicators and local priorities and provided an update on each of the key areas:

· Under 18 conceptions – the rates in Islington had fallen, although they remained above the national average

· Maternity 12 week access – the figures were included in the scorecard for the first time

· New birth visits – 81% were seen in 18 days. It was noted that this was linked to issues with recruiting health visitors but was likely to improve as there were some health visitors returning to work after an absence

· Accident and Emergency 4 hour wait – it was the plan to start including weekly results as both UCLH NHS Foundation Trust and Whittington Health had missed their targets in recent weeks. The issue would be discussed at contract review groups.

· Improving access to psychological therapies – a paper had been presented to the Finance and Performance Group. A detailed plan was in place to improve the waiting times and two additional posts had been recruited to.

5.1.3 Jacky Kutner advised that future reports would include metrics on contracts and

patient experience. It was suggested that if there was scope for changing the indicators it would be useful to see a metric for diabetes such as percentage screened for retinopathy. It was noted that there was an issue for the frail elderly in accessing this service as the only hospital providing transport was the Royal Free Hospital Hampstead. It was also suggested that it was no longer useful to continue to see the NHS health checks metric as there was continued good performance.

5.1.4 There was a discussion about the continued slippage on the surplus. Anne

Weyman, Chair of the Finance and Performance Group, reported that there was an on-going issue with expenditure in relation to the acute contract and activity varied from month to month. In regards to the non-recurrent funds a mechanism had been put in place for immediate discussion about how best to invest the money.

5.1.5 The Governing Body NOTED the report. 5.2 Update on the Operating Plan for 2012/13

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5.2.1 The Governing Body noted that the update on performance for 2012/13 would be incorporated in the integrated finance and performance report for the next month. The CCG was reporting a forecast of £9.5million savings against a target of £11.5million for 2012/13. The shortfall was largely accrued from not achieving savings from acute as fast as expected however overall performance was within plan on hospital services.

5.2.2 Discussions were underway with partners about how best to spend the non-

recurrent funds. Islington was piloting innovative work on self-management for people with diabetes, chronic kidney disease and prescribing for older people.

5.2.3 The group discussed Procedures of Limited Clinical Effectiveness (PoLCE). In

response to a question about why the savings were not being achieved, Paul Sinden advised that the target had been set too high for 2012/13 and would be lower for the following year. Also, for the policy to be effective there needed to be gate keeping in both primary and secondary care. It was noted that the PoLCE process was lengthy and costly however it was being reviewed by a D’arzi fellow to improve the co-ordination and pathways.

5.2.5 The Governing Body NOTED the update on implementing the Operating Plan for

2012/13 (Quality, Innovation, Productivity and Prevention (QIPP) savings and investment).

5.3 Islington Annual Public Health Report 2012: One too many? 5.3.1 Charlotte Ashton attended the meeting to present the report which focused on

alcohol which had a major impact on the health economy and anti-social behaviour. The report provided an outline of the health impacts of alcohol and showed that Islington had the highest number of alcohol related hospital admissions in London. There were five core areas for Islington to focus on which were to; increase awareness; increase screening; strengthen enforcement; provide accessible treatment services; and continue collaborative working between agencies.

5.3.2 The Governing Body welcomed the introduction of a single point of access to

services. Charlotte Ashton reported that a website based campaign was to be launched to promote this and to increase awareness.

5.3.3 Public Health was commended for an excellent report that was accessible for the

public. It was noted that the report would be presented to the Health and Wellbeing Board the following week.

5.3.4 The Governing Body NOTED the annual public health report. 5.4 Public Health Performance Report: Drug Treatment 5.4.1 Dr Penny Bevan presented the performance report which showed a reduction in

those referred to treatment and those completing treatment. An action plan had been developed to address the issue and the Governing Body were asked for comments to prioritise the actions.

5.4.2 It was noted that there was an issue with identifying people as drug users and

there were significant societal effects and links to crime. It was further noted that many of the actions were shared with alcohol and these should be prioritised.

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5.4.3 The Governing Body was informed that the funding for drug and alcohol services

had been reduced that year and both the local authority and the Primary Care Trust had invested additional funding to cover the shortfall. It was hoped that some of this funding would be reinstated. Public Health was working closely with Joint Commissioning in regards to both matters.

5.4.4 The Governing Body NOTED the current performance on the number of people in

effective treatment in Islington.

5.5 Report from Finance and Performance Group 5.5.1 Anne Weyman, Chair of the Finance and Performance Group gave an oral update

on the business of the group. She reported that the Group had focused on the question of provider performance in relation to waiting times and the disruption in services to Hornsey Street Health Centre, which had been closed temporarily following a flood.

7. FOR INFORMATION 7.3 Approved Minutes of the Finance and Performance Group 7.3.1 The Governing Body RECEIVED the minutes from the August meeting of the

Finance and Performance Group.

7.4 Approved Minutes of the Governance and Quality Group 7.4.1 The Governing Body RECEIVED the minutes from the July meeting of the

Governance and Quality Group.

8. DATE OF NEXT MEETING 8.1 Wednesday, 5 December 2012

These minutes are agreed to be a correct record of the meeting of the Islington

Shadow Clinical Commissioning Group Board held on 7 November 2012

Signed: ………………………………………. Date: ………………………….

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Minutes – Part 2

Meeting of the Islington Shadow Clinical Commissioning Group Governing Body 3 October 2012 at 10:30am

Large Conference Room, Voluntary Action Islington, 200a Pentonville Road, N1 9JP Members Present: Dr Gillian Greenhough Chair, Islington Shadow Clinical Commissioning Group Dr Mo Akmal Secondary Care Clinician Dr Sharon Bennett Central Locality GP representative Dr Penny Bevan Interim Director of Public Health Alison Blair Chief Officer Sorrel Brookes Non-Executive Director (PCT) / Lay member (CCG) Dr Anjan Chakraborty North Locality GP representative Dr Katie Coleman Joint Vice Chair (Clinical) Dr Sabin Khan Co-opted Salaried / Sessional GP Martin Machray Director of Quality and Integrated Governance Dr Rathini Ratnavel South Locality GP representative Dr Jo Sauvage Joint Vice Chair (Clinical) Dr Karen Sennett South Locality GP representative Deborah Snook Practice Manager representative Anne Weyman Vice Chair (PCT) / Vice Chair – non-clinical (CCG) Non-Voting Members Present:

Dr Robbie Bunt LMC Representative Marian Harrington Interim Director of Adult Social Care and Health, London Borough of

Islington Jacky Kutner Interim Director of Information and Performance Sophie Lusby Programme Director – Authorisation and QIPP Gerry McMullan Health Watch Observer Paul Sinden Interim Director of Commissioning In Attendance: None. Apologies: Jennie Hurley Practice Nurse representative Minutes: Sharon Jackson Board Secretary

Appendix: 1.3b ICCG GB - 11


8. Commissioning Support Unit Service Level Agreement Action 8.1 Alison Blair presented the Service Level Agreement (SLA) between Islington

Clinical Commissioning Group and North and East London Commissioning Support Unit. The full report was presented in part 2 for approval due to the commercially sensitive nature of the document. The SLA was intended to cover the transitional period until March 2013 at which time a three year agreement would be proposed. The SLA set out the resource envelope and a list of services that would be provided. Over the next few months the key performance indicators (KPIs) would be developed in more detail and an issues log had been established to lay out the topics of discussion and how issues would be addressed in a systematic way.

8.2 In response to a question Alison Blair advised that the national template for the

SLA, which had been published the previous day, would be used as the base for the three year SLA and would be locally adaptable. There were concerns about the North and East London Commissioning Support Unit’s ability to provide services for areas such public relations and patient and public involvement. It was noted that additional capacity had been built in to the CCG structure for these areas.

8.3 The group discussed areas which needed further development and agreed some

caveats which included: · The work on GP IT would be the responsibility of the CCG. It was agreed

that the GP IT Group, which had representation from the Local Medical Council, would be the forum to take this forward.

· The development of the KPIs was critical to ensure they were high level, measurable and had clear timeframes.

· Clarity was needed around the support for the development of care pathways.

· Consideration should be given to a break clause for the three year contract.

· Clarity was needed on the responsibility for Individual Funding Requests and a policy developed.

8.4 It was noted that primary care prescribing advice would not be purchased from

the Commissioning Support Unit as Islington CCG provided this in-house. The Commissioning Support Unit offer for equalities and diversity had also been turned down.

8.5 The Governing Body:

· NOTED the letter and Service Level Agreement Issues Log from the North and East London Commissioning Support Unit Commissioning Support Director to the Islington CCG Chief Officer; and

· APPROVED the Service Level Agreement and list of services which North and East London Commissioning Support Unit will provide for Islington CCG.

These minutes are agreed to be a correct record of the meeting of the Islington Shadow Clinical Commissioning Group Board Part 2 meeting held on 7 November

2012

Signed: ………………………………………. Date: ………………………….

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Appendix: 1.3c

Meeting Date Action No. Minutes Reference Action Description Responsibility Target Date Progress details

02/05/2012 05/12-7 3.2 Child Protection and Safeguarding Annual Report 2011/13

To reissue the guidance on requirements for Children’s Safeguarding Training that was published in the GP bulletin.

Jane Chapman Oct-12 Action completed.

13/06/2012 06/12-4 3.6.1 SLA with NHS North Central London for Commissioning Support Services (CSS)

To develop outcomes based performance indicators for the CSS Service Level Agreement.

Jacky Kutner Jul-12 There have been a number of meetings to discuss service standards and outcomes for each of the service lines. Will move to establishing overarching KPIs. This will be completed once the SLA is in the final draft. Two further meetings are planned in October and November

20/07/2012 07/12-9 3.1 Update on authorisation

To circulate an up to date timetable of meetings to members

Sharon Jackson Action underway. Meetings are being scheduled until the end of the financial year for the full suite of groups and the timetable will be circulated once this is complete.

05/09/2012 09/12-6 4.3 Whittington Health Integrated Business Plan for Foundation Trust Status

To email members to provide an update on the Dental tender process.

Paul Sinden The Alcatel period has just ended for the Dental tender process and update will be provided at the meeting.

03/10/2012 10/12-01 2.1 Chief Officer’s Report

To feed back to the Governing Body on the Ofsted/Care Quality Commissioning (CQC) visit.

Marian Harrington November A presentation will be made to the November Governing Body seminar.

03/10/2012 10/12-10 4.2 Social Housing and Health Profile

To provide a proposal on what actions should be undertaken as a result of the Social Housing and Health Profile report to the Health and Wellbeing Board.

Dr Penny Bevan The report and action plan on health and housing were due to be presented to the Health & Wellbeing Board in November 2012. This has now been deferred to the meeting on 16 January 2012.

03/10/2012 10/12-11 4.3 Primary Care Strategy Update on Information Technology

To provide an update on the Information Technology component of the Primary Care Strategy to the December meeting.

Jacky Kutner January This item has been deferred to the January meeting.

07/11/2012 10/12-01 1.3 Minutes of the meeting held on 5 September 2012

To provide a regular update on EMIS web for the weekly GP newsletter.

Jacky Kutner Action completed.

07/11/2012 10/12-02 3.1 Service Level Agreement between Islington Clinical Commissioning Group and North and East London Commissioning Support Unit

To draft a letter of response to the Service Level Agreement with North and East London Commissioning Support Unit outlining the caveats agreed.

Paul Sinden Action completed

07/11/2012 10/12-03 4.1 Update on Operating Plan for 2013/14

To present the proposals for savings and investment for 2013/14 to the December meeting.

Paul Sinden Action completed - paper on agenda.

ACTION LOG: Islington Clinical Commissioning Group Board - Part I

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Chief Officer’s Report LEAD DIRECTOR: Alison Blair, Chief Officer AUTHOR: Alison Blair, Chief Officer CONTACT DETAILS:

[email protected]

SUMMARY: This report provides the Governing Body with an update on key local developments and broader policy areas not otherwise covered on the agenda. SUPPORTING PAPERS: None.

RECOMMENDED ACTION: The Governing Body is asked to:

· NOTE the items in this report.

GOVERNANCE:

Members with voting rights Members without voting rights Dr Gillian Greenhough Chair

Marian Harrington Local Authority Representative

Alison Blair Chief Officer

Gerry McMullan Health Watch Representative

Dr Jo Sauvage/Dr Katie Coleman

Joint Vice Chairs (Clinical) Robbie Bunt LMC Representative

Dr Sharon Bennett Central Locality GP representative

Paul Sinden Director of Commissioning

Dr Karen Sennett South Locality GP representative

Jacky Kutner Interim Director of Performance and Information

Dr Rathini Ratnavel South Locality GP representative

Sophie Lusby Programme Director – Authorisation/QIPP

Dr Anjan Chakraborty North Locality GP representative

Dr Sabin Khan Salaried GP representative

Deborah Snook Practice Manager representative

Jennie Hurley Practice Nurse representative

Sorrel Brookes Lay Member

Anne Weyman Lay Member Vice Chair (Non-clinical)

Penny Bevan Interim Director of

Appendix: 2.1

ICCG GB - 15

Public Health Ahmet Koray Chief

Finance Officer

Martin Machray Director of Quality & Integrated Governance

Dr Mo Akmal

Secondary Care Representative

Objective(s) / Plans supported by this paper: Key initiatives underpin delivery of the strategic objectives set out in the CSP: · Ensuring that every child has the best start in life · Preventing and managing long term conditions to extend both length and quality of life

and reduce health inequalities · Improve mental health and wellbeing · Delivery of high quality, efficient services within available resources. Audit Trail: None Patient & Public Involvement (PPI): Not appropriate Equality Impact Assessment: None Risks: Risks attached to transition, provider development and the commissioning support service are on the risk register. Resource Implications: None

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1. Whittington Health On 14 November, Whittington Health's Chief Executive Dr Yi Mien Koh announced that following a review, the Whittington Health Trust Board has agreed with NHS London to postpone the next stage of its foundation trust application process by three months.

The Trust announced that “The progress so far confirms that many important aspects of Whittington Health's plans including quality and governance are on track. However, due to the significant financial challenges posed by the local health economy, the trust wishes to take more time to strengthen a number of key aspects of its strategic and financial plans.”

During the next three months the CCG will work with Whittington Health on strengthening their application in preparation for its submission in early 2013.

2. NHS 111

Members will be aware that the Department of Health has established a national programme, rolling out the urgent care telephone service known as NHS 111. This is a service designed to provide the public with easier access to urgent care services that do not require the emergency services. In the five boroughs of North Central London the NHS 111 programme is currently being set up with a great emphasis on ensuring the services that will be provided are safe and effective. This is being done through the development of a clinical governance framework. This, along with other aspects of the programme, is to be assessed by colleagues from the Department of Health in mid-December. Further reports about the development of NHS 111 will be provided at future Governing Body meetings.

3. Developing a Commissioning Support Unit

The November 2012 Islington Clinical Commissioning Group (CCG) Governing Body approved the Service Level Agreement (SLA) with the North East London Commissioning support unit (NELSCU). The SLA covers the period to 31 March 2013.

The letter sent to NELCSU recognises that the relationship between the CCG and NELCSU will evolve, and that it is therefore important to note that whilst agreeing the content of the SLA for 2012/13 (and the constituent £15 per head funding) the core offer from the c£14 per head will require renegotiation for 2014/15.

In the letter to NELCSU Islington CCG asks that the focus of the CSU in 2012/13 is in delivery of core products:

a) A world-class informatics service, with informatics for both contract monitoring and planning in support of the Commissioning Strategy Plan refresh;

b) An effective contracting function to ensure that CCG Commissioning intentions are reflected in Provider contracts and that contract baselines are within operating plan financial envelopes;

c) Developing key performances indicators to inform the SLA with CCG.

The CCG response to the additional services offered by NELCSU is set out below:

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a) Information Governance. Islington CCG considers this to be an integral part of the informatics offer and should be provided at the baseline offer rather than as an additional item

b) Equality and Diversity. Islington CCG does not want to purchase this additional service.

The CCG will also be picking up the areas the Governing Body highlighted in their discussion at the November meeting with the CSU to seek clarity. These included:

· Key Performance Indicators · Individual Funding Requests – responsibilities and the policy framework · Governance arrangements in the CSU · Clarity about the offer for public relations and involving the public · Working arrangements to assure quality and accuracy · The support for the development for care pathways · Clear review arrangements.

Following November’s Governing Body meeting, discussions have continued between the Commissioning Support Unit (CSU) and the CCG in relation to developing the Service Level Agreement for Commissioning Support services from March 2013. The CSU has sent a revised document which is intended to describe the standards of service delivery for each of the service lines they are providing as part of the core offer. The CCG is currently going through this and will respond by 30th November as agreed. The CCG is also discussing which services should be seen as 'core' and which services may be available as 'additional'. Following this, work will commence on establishing the Key Performance Indicators the CCG wish to introduce to be assured that the services provided meet our business and commissioning support requirements.

4. Governing Body Members’ Visits to Practices The Governing Body agreed early in 2012 to establish a series of visits to all the 37 practices that make up the membership of the CCG by Governing Body members. These visits are progressing well having started in late October, with 16 GP visits completed by 23 November. The intention is to develop a meaningful and direct communication between practices and the CCG, ensuring the clinical input of as many members as possible. Although there are clearly some individual and Practice specific issues being discussed, there are already some common themes emerging and there is significant agreement from participating lead GPs and Executives that the visits are proving to be extremely valuable. The issues raised are being logged and will be collated and fed back into the relevant CCG forums to ensure that issues are picked up, acted upon where appropriate and the results fed back to the GPs. The CCG intends to introduce regular, monthly GP information from January 2013. We are also developing a range of material to support GPs in discussing with their patient where they would like to go for their diagnostic tests, outpatient appointments or inpatient stays.

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5. Approach to Referral Management

At the November 2012 Governing Body it was agreed that referral management in Islington would be through a peer review and education process rather than through establishing a Referral Management Centre. The Governing Body indicated that further work was required on the peer review methodology. Following the Governing Body the GP Forum held on 14th November was asked to specify the principles for a peer review process in Islington, and then how to apply these principles in practice. The responses from the GP Forum indicated:

· A preference for retrospective peer review rather than prospective review, as is this does not cause delay to patient care and has fewer logistical issues.

· Any referral management process should have an education component, with GPs valuing the opportunity to learn more from consultants in specialist areas with events targeted to specialties with relative high referral rates. Education opportunities also could come from learning across practices

· The need for benchmarking information to help understand referral behaviour. · Carrying out some audit work to understand what specific skills and expertise

exist in primary care across Islington. Identifying “high and low skill” practices harnessing available skills and supporting development accordingly such as having GP with a Special Interest within a practice

· On-going access to consultant advice and support via phone and or e-mail in order to ask key questions before making a referral is particularly important.

· The use of a comprehensive range of web tools such as Choose & Book pop ups, Map of Medicine, Templates on EMIS web and the extranet were considered important decision making aids.

· Accurate and up to date information on available services including community services as an alternative to acute referral.

6. Barnet & Chase Farm

As discussed at the last Governing Body meeting, Islington CCG has signed the NHS North Central London wide letter of commissioner support for the development of the Strategic Outline Case (SOC) of the acquisition of Barnet and Chase Farm Hospitals NHS Trust by the Royal Free London NHS Foundation Trust, following the decision by the former not to pursue an individual application to become a Foundation Trust. The letter includes the requirement that the focus of this work does not compromise quality, performance and access in Royal Free Hospital services accessed by Islington residents.

7. Collaborative Working and Risk Share

As previously discussed in Board workshops and as part of the authorisation process the CCG is in discussion with the other CCGs in North Central London to develop an approach to risk share and collaborative working. We are integrally involved in the development of the proposals which will be discussed further at the CCG’s Finance and Performance Committee and presented to the Governing Body.

Alison Blair Chief Officer Islington Clinical Commissioning Group

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Governance Review LEAD DIRECTOR: Director – Quality and Integrated Governance AUTHOR: Martin Machray CONTACT DETAILS:

[email protected]

SUMMARY: It was proposed at the Governance and Quality Group in July to undertake a review of our current governance arrangements during the autumn. This paper describes the principles underpinning review, the scope of it and the progress made to date along with a series of recommendations for change. SUPPORTING PAPERS: No additional papers RECOMMENDED ACTION: The Governing Body is asked to:

· APPROVE the recommendations made within this report; · CONSIDER any additional changes or amendments; and · REQUEST the Executive Team to develop a plan for implementing the

recommendations including the production of new terms of reference for the committees of the Governing Body and a timetable for delivery.

Appendix: 3.1 ICCG GB - 21

GOVERNANCE:

Members with voting rights Members without voting rights Dr Gillian

Greenhough Chair

Marian

Harrington Local Authority Representative


Gerry McMullan

Health Watch Representative



Dr Sharon Bennett Central Locality GP Representative

Paul Sinden Interim Director of Commissioning

Dr Karen Sennett South Locality GP Representative

Jacky Kutner Interim Director of Performance and

Information Dr Rathini Ratnavel South Locality GP

Representative Sophie Lusby Programme Director –

Authorisation/QIPP Dr Anjan

Chakraborty North Locality GP Representative

Dr Sabin Khan Salaried GP Representative

Deborah Snook Practice Manager Representative

Jennie Hurley Practice Nurse Representative



Penny Bevan Interim Director of Public Health

Ahmet Koray Chief Finance Officer


Dr Mo Akmal


Objective(s) / Plans supported by this paper: Beyond authorisation: Developing a high performing organisation through the transition Audit Trail: Discussion with individual governing body members, at the Executive Team, in a Governing Body Seminar and at the newly established Audit Committee. Patient & Public Involvement (PPI): A section of the paper considers this. Equality Impact Assessment: Not required Risks: No new risks identified Resource Implications: No new resource implications identified Next Steps: A detailed implementation plan to be developed on approval.

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Introduction This year is one of preparation and establishment for Islington Shadow Clinical Commissioning Group. In terms of governance this has meant the setting up and running of the committee structures, the regular meeting of the Governing Body and the adoption of policies that have enabled us to fulfil our delegated responsibilities. This delegation was awarded in full at the end of March 2012 and the expectation is that, following the authorisation process, the Clinical Commissioning Group will become an independent NHS Body with all the responsibilities that come with that. It was proposed at the Governance and Quality Group in July to undertake a review of our current governance arrangements during the autumn. This was for two reasons. Firstly because it is good practice for organisations to take stock of how they are structured and therefore how able the organisation is to deliver against corporate objectives and for the CCG to realise it’s constitutional commitments. Secondly it has been recognised that, as our groups and committees have taken on their various roles and duties (identified in the terms of reference agreed by the Governing Body), there might be gaps or duplication, particularly as more detailed guidance is issued about operating in the new system. It was agreed that a paper be brought back to the Governance and Quality Group in October with any recommendations for change or adaption to our governance arrangements. Subsequent to this the NHS Commissioning Board and Department of Health (DH) have published further guidance on associated issues. Most notably the DH publication on the “The Functions of CCGs” and the 20 August 2012 letter from Sir David Nicholson on the arrangements for commissioning from October this year. The review has therefore been extended and broadened to ensure compliance with guidance. This paper describes the principles underpinning the review, the scope of it and the recommendations that have been made following discussions and debates on the issues. Principles The recommendations made to the Governing Body have been made using the following set of principles. All changes to current structures and arrangements should be made to:

• Better deliver the vision, mission statement and values of the CCG. • Realise the commitments set out in the CCG’s constitution. • Meet current national and regional guidance on CCG Governance arrangements. • Support the CCG throughout the first year of operation as an authorised NHS body. • Promote a flexible organisation, able to respond to the changing landscape of

commissioning within the NHS. • Avoid gaps or duplication of effort for the Governing Body, its committees and

members in carrying out the duties and responsibilities contained within the Constitution.

• Enable partnership working, particularly with the London Borough of Islington, that best serves the population of the Borough.

Scope It was agreed that governance arrangements should be reviewed from three different perspectives.

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1. Constitutional – The development of the constitution has been a key activity in the preparation of our application for authorisation. Any subsequent alterations or suggestions made this year will need to be made at an appropriate time in 2013 rather than alter things so soon.

2. Procedural – All our committees are now established and meeting regularly. There is an expectation that each of them operates according to their terms of reference and the review established that this had been the case. The review looked at the frequency of meetings, quorums, attendance and record keeping. In this year of shadow operation it has not been possible for any group to have delegated responsibilities (i.e. double delegation). So the review makes recommendation’s in preparation for future delegations from the Governing Body

3. Functional – The key is that the Governing Body and its committees are able to

exercise the full set of duties and responsibilities of a Clinical Commissioning Group. All the recommendations are consistent with our application for authorisation.

Questions and Issues Members have considered a variety of particular issues including the following:

· Have we got the best balance of work between committees and the Governing Body?

· Is the spread of work across the committees appropriate? · Is there duplication or gaps in the work undertaken? · Is the membership of committees appropriate in terms of size as well as the skills,

roles and experience members bring to them? · Are there any functions identified in the guidance that we are not yet undertaking?

The Review Process A discussion document was developed which identified a number of areas where changes could be made to structures and processes. There were discussions on this document at the Governance & Quality meeting in October as well as the Executive Team and between members of the Governing Body through email and face to face. A number of proposals for changes to current arrangements were suggested and some issues identified that were not easily resolved or had more than one potential solution It was agreed at the October Governance & Quality Group that these questions needed greater debate. Therefore a Governing Body seminar in late November considered:

· The roles and responsibilities of what have been referred to as the “key committees”. Currently there are a number of groups reporting to the Governing Body (see figure 1). Whilst there was a consensus to reduce the number of committees there had not been agreement on what the new model might be.

ICCG GB - 24

Figure 1

· The role and position of the Patient and Public Participation Group. This has been a

direct report to the Governing Body but conceivably could become a subgroup of the committee that deals with quality. An alternative is for this group to play an oversight role on the work of the CCG, ensuring the voice of the patient is heard in all decision making processes.

· The frequency of meetings. · The membership of committees and groups · How service groups and working groups should fit into the new structures.

Subsequent to this seminar and with the benefit of face to face meetings considering very specific issues it is possible to make a series of recommendations. Recommendations from the Review Many of the recommendations from the review are dependent upon the proposed committee structure of the Governing Body. Currently there are 6 “true” committees of the Governing Body. Of these the Audit Committee and Remuneration Committee are required in statute and will continue in any new structure. PPP is considered separately in this paper. At the seminar there was general agreement for us to move to the structures in figure 2. This would mean the three committees of Finance & Performance, Service Improvement and Governance & Quality being replaced by two. That is a Strategy & Finance Committee and a Quality and Performance Committee. The duties and functions of the previous groups would be distributed between the new committees and the Audit Committee. These functions can be summarised as covering the following with the designated committee in the proposed structure being identified in parenthesis:

1. Financial Performance - In year (Strategy & Finance) 2. Financial Planning, Commissioning Strategy Plan (Strategy & Finance) 3. Strategic Planning, Commissioning Strategy Plan (Strategy & Finance) 4. Strategy Implementation - In year (Quality & Performance) 5. Contract Performance - In year (Quality & Performance) 6. Quality Performance - In year (Quality & Performance) 7. Quality Assurance - systems and processes (Quality & Performance) 8. Financial Assurance (Audit Committee) 9. Governance Assurance (Audit Committee) 10. Governance systems and policy approval (various)

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Footnote 1&2

The Executive Team is shown as underpinning and supporting the activity of the whole committee structure. All Governing Body Members have been keen to emphasise the pivotal role played by the Patient & Public Participation Committee (PPP). The current functions for the PPP Committee are:

• Reviewing and oversight of delivery of PPP strategy • Reviewing and oversight of Equalities and Diversity • Receiving patent feedback and ensuring that this is considered by the Committee

dealing with quality • Being assured that patient experience is not only considered, but shapes the

decisions we make about any services we look to commission. The recommendation is for the PPP Committee to continue reporting directly to the Governing Body. This will keep everyone informed about the work being done to deliver the Participation and Equality & Diversity Strategy and underscore the responsibility every member and committee has to involve and engage with the patients and public. Patient experience reports should go to the Quality and Performance Committee and to include primary care, voluntary/third sector providers, secondary care and any reports from LINKs (Healthwatch). LINKs therefore should be invited to attend this committee. Further work is required on how we can assure ourselves that any new services we want to commission have a good track record of patient experience and ensuring this information is fed into the commissioning cycle. Patient stories are to be part of the Governing Body seminars ensuring that as many clinicians/governing body members are party to these powerful stories thus maximising impact. The self-care aspects of the strategy should be taken up by the self-care working group of the Integrated Care programme. 1 The Health & Wellbeing Board is not a committee of the CCG but is shown here to recognise the important strategic relationship. 2 Statutory Committees are highlighted with a white background.

Figure 2

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All other recommendations are made in support of the proposed committee structure. These are not significant changes but are incremental changes proposed against the principles described above. It is recommended:

1. To review the constitution in a year to ensure it is fit for purpose and the Governing Body is meeting the requirements laid down.

2. To involve the public in the proposed review of the constitution. 3. To review the performance of the Governing Body in fulfilling the requirements

described within the constitution in April 2003 4. To reduce the number of Governing Body meetings to six per year with decision

making to the committees described in figure 2 above. 5. Risk management to be an executive led function (consistent with the Audit

Committee Handbook) with oversight from the Governing Body and Audit Committee. All committee’s will be responsible for reviewing their risks.

6. The Board Assurance Framework and risk register to be developed from new rather than adaptation of the PCT risk register

7. Audit Committee to be made up from the two lay members and a GP Member. 8. Governing Body seminars to be used less for development and more to promote

debate of difficult/topical/strategic issues to inform decision making (but never to be a decision making forum).

9. The Remuneration Committee to be established and have met early in 2013 10. PEC will cease to exist from April 2013 but until then the role of PEC should be

absorbed into the work of the Governing Body 11. The Executive Team Meeting to include Directors from the Council, Public Health

and the Commissioning Support Unit. 12. More work needs to be done to improve communications between the different

committees and all governing body members to promote good decision making. 13. Closer collaboration with the Local Authority’s structures should always be

considered and initially there should be thought given to how to collaborate on patient and public involvement.

14. Terms of reference and reporting structures should be agree by the Executive Team for the following:

• Child Protection Committee • Whittington Health Transformation Board • Integrated Care Programme Board • End of Life Steering Group • Medicines Management Group • Primary Care and Development Group • Children Group • Mental Health Group • Learning Difficulties Partnership Board • Clinical Pathway groups (COPD/Diabetes) • Camden & Islington Foundation Trust Associate Clinical Directors Meeting • Older People’s Partnership Board

If the Governing Body agree to these recommendations there will need to be a period of time in which to enact these changes. This will include the redrafting of terms of reference, developing a supportive annual cycle of business and agreeing reporting structures. Work is also needed to review membership of all committees and groups so that Governing Body Members’ time is best utilised.

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Shadow Audit Committee Report LEAD DIRECTOR: Anne Weyman, Chair of Shadow Audit Committee AUTHOR: Ahmet Koray, Chief Finance officer CONTACT DETAILS:

[email protected]

SUMMARY: This report outlines the role and purpose of the Audit Committee and provides an update on the first meeting held by Islington CCG’s shadow committee. SUPPORTING PAPERS: None. RECOMMENDED ACTION: The Governing Body is asked to:

· NOTE the contents of this report and the activity of the committee

GOVERNANCE:


Greenhough Chair

Marian



Gerry McMullan




Dr Sharon Bennett

Central Locality GP Representative




Information Dr Rathini Ratnavel

South Locality GP Representative


Dr Anjan Chakraborty

North Locality GP Representative



Jennie Hurley Practice Nurse


Representative Sorrel Brookes Lay Member





Dr Mo Akmal


Objective(s) / Plans supported by this paper: This report relates to delivery of constitutional and governance arrangements. Audit Trail: The Governing Body reviews the activity of the Audit Committee at each meeting after the committee meets. Patient & Public Involvement (PPI): There has been no patient and public involvement for this paper. Equality Impact Assessment: No Equality Impact Assessment is planned or has been undertaken for the report. Risks: This paper identifies risks arising from the review of internal and external audit reports. Resource Implications: There are no direct resource implications for this paper. Next Steps: The Audit Committees Report will be a standing item on future Governing Body agendas when the Committee has met.

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Page 1 of 5

1. Introduction

1.1. This report outlines the role and purpose of the Audit Committee and provides an update on the first meeting held by Islington CCG’s shadow committee.

2. Why do Audit Committees exist in the NHS?

2.1. The Codes of Conduct and Accountability, issued in April 1994, set out the requirement for every NHS Board to establish an Audit Committee. That requirement remains in place today and reflects not only established best practice, but the principle that the existence of an independent Audit Committee is a central means by which a Board ensures effective internal control arrangements are in place. 2.2. In essence, the Audit Committee provides a form of independent check on the executive arm of the Board.

3. What does the Audit Committee do?

3.1. The main focus of an Audit Committee’s work in the past has related to internal financial control matters, such as the safeguarding assets, maintenance of proper accounting records and the reliability of financial information. The importance of that financial scrutiny has not diminished, but there is now an expectation of a wider focus by the Audit Committee, particularly in the NHS where there is a need to meet the broad range of stakeholder needs. 3.2. As a consequence, the Audit Committee’s primary role is to conclude upon the adequacy and effective operation of the organisation’s overall internal control system.

3.3. In performing that role the Committee’s work will focus on the framework of risks, controls and related assurances that underpin the delivery of the organisation’s objectives (the Assurance Framework). As a result, the Committee has a pivotal role to play in reviewing the disclosure statements that flow from the organisation’s assurance processes and in particular the Statement on Internal Control, which is included in the Annual Report and Accounts. 3.4. It is clearly the job of executive directors and the Accountable Officer to establish and maintain processes for governance, but the Audit Committee independently monitors, reviews and reports to the Governing Body on the governance process and where appropriate, facilitates and supports through its independence, the attainment of effective processes.

4. Where should the Audit Committee begin its work?

4.1. The Committee needs to gain a clear understanding of the broad framework of governance in the organisation, particularly with regard to what other committees are doing. The starting point for this is to ensure that the overall

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Page 2 of 5

process for governance is established and operating. To this end the Committee will use the Assurance Framework as its central tool for planning its work. To rely on this, the Committee needs to spend time ensuring that the Assurance Framework provides a complete coverage of the organisation, at a strategic level, and that the controls and assurances within it are reasonable. 4.2. The Committee can then concentrate on the high risk areas, either where the inherent risk is high and the level of dependency upon the operation of controls is critical, or where the residual risk is high and the situation needs monitoring.

5. Islington CCG’s Shadow Audit Committee meeting (Wednesday, 14 November 2012)

5.1. The table below summarises the agenda items, the discussions and agreed actions from the meeting as follows: Agenda item Summary of report and discussion Terms of Reference

Membership shall include:

· 2 Governing Body Lay Members, one of which shall be Chair

· 1 external appointment It was proposed that Chair of the Governing Body should not be a member of the Audit Committee and that the Chief Finance Officer and appropriate representatives from Internal and External Audit should attend meetings. Other directors, including the Chief Officer will be invited to attend when the Committee is discussing areas of risk or operation that are their responsibility and also during the presentation of the annual accounts, annual report and statement of internal control. It was agreed that the Committee would meet at least four times a year.

Update on CCG Authorisation

It was reported that at the end of the site visit, the CCG was informed that of the 119 radio buttons, all but five were now turned ‘green’. The five red buttons are now proposed as ‘conditions’ that will need to be discharged before we can form as a fully operational statutory unit. On the basis of the evidence we have available and the process we are asked to undergo in the discharge of conditions, it was reported that there will be only one remaining condition following the meeting of the Authorisation Sub-Committee on the 5 December 2012.

Development of the Draft Board

The Audit Committee was asked to consider the approach to developing a risk management strategy, agreeing that:

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Page 3 of 5

Assurance Framework

· Risk management will be an executive led function (consistent with the Audit Handbook) with oversight from the Governing Body and Audit Committee.

· All committee’s should be responsible for reviewing the risks

associated with their duties and terms of reference. · The Governing Body will receive reports at each meeting on

the risks associated with the CCG’s Principal Objectives and any extreme risks (red rated) from the risk register.

The first draft of the Governing Body Assurance Framework for the Clinical Commissioning Group was presented for the Committee to consider.

Internal Audit and Counter Fraud Arrangements for 2013/14 Internal Audit – learning from 2012/13 work Internal Audit Plan 2013/14

RSM Tenon, the current Internal Audit providers, presented a paper on how the CCG’s objectives and Assurance Framework will be the starting point in the development of the Internal Audit strategy. From their experience, a list of potential areas for internal audit to consider as part of their planning was presented. RSM Tenon confirmed audits were continuing to be undertaken at a cluster-wide level and that there were no high recommendations raised in any of these reviews. However recommendations and comments relevant for the CCGs to learn lessons from were identified as follows: · Performance Management - action plans are produced

however improvement was possible to allow performance to improve and ensure the identified targets are met. Development of robust action plans with regular monitoring will assist CCGs to identify areas of weakness and addressing these to ensure that downward trends do not continue.

· IT Remote Access, Security and Account Management -

Review of IT Network Security Policies identified that these policies were not regularly updated to reflect current processes.

· Risk Management and Assurance Framework – the

mapping of assurances to controls, detail to demonstrate how the control is preventing the risk from materialising and distinguishing between internal and external sources of assurance.

· Acute Commissioning - contracts with providers need to be

signed off at the commencement of the financial period. The Terms of Reference for groups involved in the governance

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Page 4 of 5

arrangements were not always updated, reviewed and/or approved.

The Committee discussed the issue of how the CCG would gain sufficient assurance of the CSU relationship and that its systems of internal control and reporting were robust to meet the CCG’s own governance arrangements. It was acknowledged that further discussion was required and in particular to understand the CSU’s future audit and assurance arrangements.

External Audit Update

An update on the future of the Audit Commission and the new arrangements going forward was provided by the current NCL cluster external audit provider, KPMG. KPMG confirmed that Audit Commission used to undertake the majority of audits for local public bodies, but in July 2011 the government confirmed their preference for transferring this work to the private sector by outsourcing contracts. A procurement exercise for the Commission's audit work was undertaken with a view to all in-house work being outsourced in time for the audit of 2012/13 accounts. In March 2012 the Commission announced the results of the procurement exercise awarding five-year contracts to four private firms. The contracts cover the whole of England and are expected to save £250m for the public sector. For Islington CCG, KPMG is the designated audit firm covering London (North). This has taken effect from 1 November 2012. The Audit Commission remains in place to oversee the contracts and other statutory functions but is significantly smaller following the outsourcing.

Governance Review

It was proposed at the Governance and Quality Group in July to undertake a review of our current governance arrangements during the autumn. The paper presented to the Audit Committee described the principles underpinning the current governance review, the scope of it and the progress made to date along with a brief description of the main issues yet to be resolved. It was agreed that further discussion was required of future arrangements and this would also be covered during the Governing Body seminar on 21 November 2012.

Shadow Audit Committee Annual Cycle of Business

A draft annual cycle of business for the Islington Clinical Commissioning Group Shadow Audit Committee was presented. This is a work in progress and will be developed further once future arrangements were clearer.

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Page 5 of 5

6. Conclusion

6.1. The Committee agreed that the focus of the next meeting of the Audit Committee would be on the following:

· Governing Body Assurance Framework and the Corporate Risk Register · Internal Audit strategy and work plan · Audit Committee Handbook · CSU audit and assurance arrangements

6.2. The Governing Body is asked to:

· NOTE the activities of the Committee. · NOTE the contents of this report

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Governance & Quality Group Report LEAD DIRECTOR: Sorrel Brooks – Group Chair AUTHOR: Martin Machray, Director of Quality and Integrated Governance CONTACT DETAILS:

[email protected]

SUMMARY: This report provides a summary of the key topics discussed by the Group at its November meeting and highlights issues of note to the Governing Body. These included:

• The work of the Clinical Quality Review Group at University College of London Hospitals

• A report on a recent inspection by Ofsted and the Care Quality Commission • Response to the recent Savile Allegations

SUPPORTING PAPERS: None


· NOTE the contents of the report

GOVERNANCE:
















Jennie Hurley Practice Nurse


representative Sorrel Brookes Lay Member





Dr Mo Akmal


Objective(s) / Plans supported by this paper:

· Delivering high quality, efficient services within the resources available. Audit Trail: This is a summary report of the work of a Committee sub-group. Patient & Public Involvement (PPI): Not required for a summary report. Equality Impact Assessment: Not required for a summary report. Risks: No new risks identified Resource Implications: None Next Steps: To receive further reports on the work of the Governance and Quality Group.

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1 EXECUTIVE SUMMARY This report provides a summary of the key topics discussed by the Group at its November meeting and highlights issues of note to the Governing Body. 2 Clinical Quality Review Groups (CQRG)

The Committee considered quarterly reports about the activity of the CQRG for University College of London Hospital (UCLH) as part of the rolling cycle of reports about our main providers. Significant issues that were discussed included trends and themes from incident reporting over the first two quarters this year and infection control data showing a rise in reported rates of C-Diff. On this latter issue, the Trust has rapidly established an action plan to address this. Emergency admissions, including A&E attendance was also reported on and will remain on the CQRG agenda whilst this remains a concern. 3 Ofsted and Care Quality Commission Inspection

Ofsted/CQC recently undertook a thematic inspection of joint working between children’s and adult services in Islington when there are parental mental health or substance misuse issues. Overall this inspection went well. As it was a thematic inspection Islington doesn’t receive an individual report on our performance and there isn’t a pass or fail grade but a report on their overall findings across the 10 authorities they visited will be published in the Spring. However a joint action plan has been developed from the detailed feedback and agreed by Children’s services and adult mental health and substance misuse services to strengthen joint working and build on the momentum generated by the inspection. The action plan will be overseen by the Islington Child Safeguarding Board. 4 Response to the Savile Allegations Following the high profile allegations of abuse concerning the late Sir Jimmy Savile, some concerning NHS organisations and premises, all NHS providers had been requested to review current arrangements for safeguarding vulnerable adults and children. Whilst the CCG is not directly involved in providing patient services the Governance and Quality Group took the opportunity to reflect on the CCG’s work regarding safeguarding undertaken this year and to review the actions planned for the immediate future in light of the guidance issued by Sir David Nicholson.

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Commissioning and Planning for 2013/14 LEAD DIRECTOR: Paul Sinden, Director of Commissioning AUTHOR: Sophie Lusby, Project Director CONTACT DETAILS:

[email protected] 020 7527 1035

SUMMARY: The planning round for 2013/14 has begun, with a number of activities underway at CCG level with the support of the North and East London Commissioning Support Unit and collaboration with local CCGs. This paper updates the Governing Body on:

· The demands of the recently published NHS Mandate on all NHS bodies · The specific requirements laid out in the NHS Outcomes Framework, the Mandate

compliance ‘tool’ · Progress towards developing the CCG’s Commissioning Strategy Plan (CSP) 2013-

16 · Work underway to support the CSP and the Operating Plan for 2013/14 · Progress on the development of commissioning intentions, investment and savings

priorities. The Governing Body is asked to:

· Approve the development of a Commissioning Strategy Plan, with a draft for discussion at the February 2013 Governing Body meeting

· Acknowledge the work on-going in the development of the Operating Plan 2013/14, with the first draft that will have been submitted to the NHS Commissioning Board in mid-January reported at the February 2013 Governing Body meeting

· Note the emerging prioritisation and development process around the Savings and Investment Programme for 2013/14.

SUPPORTING PAPERS: Governing Body members should familiarise themselves with the swathe of documentation issued by both the Department of Health and the NHS National Commissioning Board. References are embedded in the document. Appendix 4.1a: Summary of the NHS Mandate Appendix 4.1b: Draft CCG Planning Guidance 2013/14



· APPROVE the development of a Commissioning Strategy Plan, with a draft for discussion at the February 2013 Governing Body meeting;

· ACKNOWLEDGE the work on-going in the development of the Operating Plan 2013/14, with the first draft that will have been submitted to the NHS Commissioning Board in mid-January reported at the February 2013 meeting; and

· NOTE the emerging prioritisation and development process around the Savings and Investment Programme for 2013/14.

GOVERNANCE:

Members with voting rights Members without voting rights Dr Gillian Greenhough

Chair

Marian Harrington

Local Authority Representative


Gerry McMullan



Joint Vice Chairs (Clinical)

Robbie Bunt LMC Representative





Dr Rathini Ratnavel













Dr Mo Akmal


Objective(s) / Plans supported by this paper: The development of Operating Plan for 2013/14 is an imperative and must be both underwritten by the Governing Body and the Islington Health and Well Being Board.

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Audit Trail: This is the first paper in which plans for the following year (2013/14) are to be discussed; however every meeting of the CCG receives and discusses a written report outlining progress against the 2012/13 plan. Patient & Public Involvement (PPI): PPI is inbuilt into commissioning plans. There will be a more public launch of the Commissioning Strategy Plan and how engagement will develop further iterations. Equality Impact Assessment: EIA will be assessed in line with the constituent elements of the commissioning intentions as appropriate; in triangulation there is EIA built into the NHS Outcomes Framework as standard. Risks: There are a number of risks inherent in the development of the plans for next year and those following. They can be briefly summarised as:

· Internal capacity is not fit for purpose · External support i.e. from the CSU and public health is not fit for purpose · Collaborative working with other CCGs around areas of common interest does not

produce the necessary result · The added value of direct clinical commissioning is not well enough represented

under the auspices of a traditional planning round discipline · Timing of decision making and sign off creates blockages in the system · The output of strategic commissioning plans is not well embedded in local contracts

and exposes us to system and fiscal risk in year. Draft ratings and potential mitigations are noted within the document. Resource Implications: At a strategic level, this paper outlines the application of the investment of almost the entire commissioning budget of the CCG. Next Steps: There are a number of steps following the paper, many of which are outlined within the document. There will be extensive coverage of the proposed actions in the paper at meetings over the next four months as we move from planning to implementation phase.

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1. EXECUTIVE SUMMARY The planning round for 2013/14 has begun, with a number of activities underway at CCG level with the support of the North and East London (NEL) Commissioning Support Unit and collaboration with local CCGs. This paper updates the Governing Body on:

· The demands of the recently published NHS Mandate on all NHS bodies · The specific requirements laid out in the NHS Outcomes Framework, the Mandate

compliance ‘tool’ · Progress towards developing the Commissioning Strategy Plan (CSP) 2013-16 · Work underway to support the CSP and the Operating Plan for 2013/14 · Progress on the development of commissioning intentions, investment and savings

priorities. 2. INTRODUCTION

In previous years Islington Primary Care Trust had to outline its health improvement priorities and demonstrate commissioning plans aligned to financial allocations in order to underwrite the offer of health services for local residents. The scope and quality of these plans was performance managed by NHS London.

Broadly this responsibility remains although as we know the commissioning portfolio of the Clinical Commissioning Group (CCG) is smaller in scope and budget than that of its operational predecessor due to the removal of the responsibility for primary care contractors and potentially significant elements of tertiary care to the NHS Commissioning Board (NHSCB). Significantly, the NHSCB carries these duties as well as the performance management role of CCGs in discharging their duties that will be enacted in statute on 1st April 2013 as the regional strategic health authorities are disbanded.

Previously, the main elements of planning were split into two key parts:

· Commissioning Strategy Plans (CSP) stretching over a 3 – 5 period · Operating Plans for the following business year

Put simply, there was delineation between the strategic planning over a longer term and the operational implementation of those plans over the following year within the financial allocations.

Despite the extensive changes apparent in the commissioning and departmental infrastructure of the health service, the traditional demands of the planning round are upon us again. This paper seeks to outline the process by which this is being undertaken for 2013/14 and the timetable for delivery.

3. The NHS Mandate and NHS Constitution

The NHS Mandate1 is given to the NHS Commissioning Board by the Secretary of State for Health and in itself demonstrates a change in structure in the NHS by tasking the nationalised service of the NHSCB to complete several objectives in meeting the health 1 http://www.dh.gov.uk/health/2012/11/nhs-mandate/

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needs of the UK population. The NHSCB is compelled through statute to pursue the objectives contained within the document although there appears to be some balance in reflecting the need for both State and NHSCB to promote the autonomy of local clinical commissioners and ‘others’, these being partner commissioning agencies across the public sector.

Although the Mandate itself has only recently published, each of the first five areas has a direct monitoring framework drawn from the NHS Outcomes Framework 2013/14 that has been in fluid development since its first iteration in 2010. The outcomes are illustrated as areas where there is a commitment to improve, sometimes relating to individual measures of success, for example under the prevention of premature death an indicator of improving rates of reduced mortality in the under 75s from cardiovascular disease.

Please see Appendix A for a simplified summary of the NHS Outcomes Frameworks.

4. NHS Outcomes Framework and ‘other’ Outcomes Frameworks

There are a number of different outcomes frameworks in use throughout the public sector. The ‘NHS Outcomes Framework’ addresses specific areas of service improvement, largely detailed in the ‘domains’ identified in the Mandate and, like other key performance indicators (for instance, Referral to Treatment waiting times or Health Care Acquired Infections) there will be an expectation for all commissioners and providers to report them.

Additionally there is what is called the ‘Commissioning Outcomes Framework’. The NHS Commissioning Board, supported by NICE and working with professional and patient groups, will develop a Commissioning Outcomes Framework (COF) that measures the health outcomes and quality of care (including patient reported outcome measures and patient experience) achieved by clinical commissioning groups. The COF will allow the NHS Commissioning Board to identify the contribution of clinical commissioning groups to achieving the priorities for health improvement in the NHS Outcomes Framework, while also being accountable to patients and local communities. It will also enable the commissioning groups to benchmark their performance and identify priorities for improvement.

There are also Outcomes Frameworks in existence for Public Health and Adult Social Care that will report separately through their own statutory mechanisms; the impact of both on the sophistication of our plans is extremely important and will be a key element of clarification in the Commissioning Strategy Plan.

Clearly, the reporting of the success against each framework is the only way in which the CCG and local partnership agencies can demonstrate overall improvement in services and commissioning approaches. Currently, the interim Director of Performance and Information is mapping these frameworks, together with our already operational local integrated performance report, to ensure that we have total coverage. Please note that whilst there is some technical guidance available on the measurement of outcomes this is a work in progress and we await the definitive draft, some elements of which will almost certainly not be available until some way into 2013/14.

5. CCG Planning Guidance

The NHS Commissioning Board has just this week published the Draft CCG Planning Guidance for 13/14 (Appendix B), complementing the guidance regarding the Mandate and

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the refresh of the NHS Outcomes Framework. What follows is a consideration of how that will affect the development of plans in both the shorter and longer term.

5.1 Commissioning Strategy Plan 2013 – 2016 As already stated, CSPs were required by NHS London to provide assurance to the Department of Health that there were robust plans at borough level agreed with all the necessary partners and identified within them clear trajectories for the improvement of the health of the local population. In a borough such as Islington the legacy of best-in-class public health data and joint commissioning arrangements enabled the PCT to be able to present a cohesive and credible plan to its partners.

However, after the creation of the cluster of five Primary Care Trusts of North Central London, the development of this plan was developed and approved centrally and renamed the ‘QIPP Plan’.

5.2 Rationale for developing a CSP for Islington CCG

As part of the preparations for CCG authorisation, Wave One applicants, unlike those in further waves, did not have to submit a strategic plan for 2013/14. Plans were afoot as early as September 2012 to initiate a Commissioning Strategy Plan in Islington. Since this time we have been informed that the NHSCB Local Area Team have not insisted on the production of a CSP. They are however still expecting an Operating Plan for 2013/14 (see section 6). The ‘rules’ aside however one must consider how else we would be able to demonstrate our plans and how those will be enacted within our new organisational structure.

We believe that the development of a partner and public facing CSP is something we wish to pursue, as have all other boroughs in North Central London. We feel that it is important to work through a cohesive and robust health strategy for the local population that accounts for sustainability and improvement over a number of years whatever challenges we face, particular in light of the potential for further public sector funding cuts post 2014/15. We feel that this in order to continue to collaborate on the issues of highest strategic importance and to get good value out of the North and East London Commissioning Support Unit the development of the CSP will grow out of a more centralised process. A collective of the planning leads from the five boroughs with the involvement of the Commissioning Support Directors is currently developing a process that will provide key elements of information for both the CSP and Operating Plan. What follows below is a summary of the expected content of the CSP.

5.3 CSP Structure and Headlines The suggested layout of the CSP is noted below; input from Governing Body members is welcomed at this point in time and in consideration of drafts as they develop.

a) Who we are and how we are progressing to becoming a CCG Ø Mission statement and vision Ø PCT legacy and changes to landscape (with expected budgetary impact

and narrative on significant changes e.g. relationships with networks) Ø Vision, Aims and Values (drawn from the Health and Well Being Board

priorities ‘triangle’) Ø A description of our key strategic partnerships

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Ø Joint Strategic Needs Assessment Ø Our statutory responsibilities Ø Our responsibilities as clinical commissioners, i.e. fiscal and quality

control in the health system Ø What we have achieved so far Ø The membership and the delegation of powers Ø Governing Body membership, ethos and work plan Ø Wider piece on organisational development and some specific enablers

b) Our strategic commissioning plans

Ø Our key strategies (i.e. our 4 strategies/enabling work streams) Ø The link between these and the Mandate and Outcomes Framework(s) Ø Infrastructure, i.e. governing body, membership and the Constitution Ø Provider landscape, including the voluntary sector

c) Challenges and opportunities

Ø Management of provider landscape and specific challenges (i.e. Whittington FT status, UCLH stability)

Ø Financial allocation and balance, i.e. savings versus investment, expectations around the underlying run rate in the local market

Ø Systematic patient involvement (identified as a key element of authorisation) and overall partner engagement strategy

Ø Use of information from enabling better health to outcomes based commissioning

Ø Getting a good deal out of the Commissioning Support Unit and summary expectation of SLA now and in future

Ø Collaboration between CCGs Ø Working with the NHSCB – this will need considerable refinement over

the years

d) Programmes Ø E.g. Integrated Care, Urgent Care etc Ø For each major programme analysis of the aims, methods of delivery,

risks to delivery and expected outcomes (where possible linking these to the relevant outcomes framework) and what impact this may have on patients and providers, i.e. new services, reduction of existing services

e) Implementation and Contracting Ø Narrative on the reconciliation to the Operating Plan 2013/14 Ø Process and system control Ø Clinical commissioning capacity Ø Leverage and local drivers (e.g. transformation opportunities,

investments/savings, CQUINs) Ø A specific piece on acute productivity given its opaqueness in the public

domain Ø Expected timetable (this is under discussion at the CSU)

It is important to recognise that the production of a CSP is not an ‘end point’ and the following caveats should apply:

· All elements of the CSP should be refreshed on an annual basis and the opportunity to continually refresh it must be explored, reflecting the developing nature of the

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outcomes frameworks and the refresh of the JSNA early next year, for instance, with a ‘live’ website-based approach

· Responsibility in support and partnership agencies for maintaining the CSP should be identified through lead officers that the planning lead at the CCG can co-ordinate as a ‘virtual’ team

· The CCG must put together a plan for communicating the CSP in the New Year to the public so that all sections of the local population are able to access it and have it in a format that is understandable and invites discourse.

These actions will be developed over the coming weeks.

6. Operating Plan 13/14

6.1 Planning responsibilities

In line with our establishment as a commissioner of health services, the development of an Operating Plan for 2013-14 is an incumbent responsibility of the CCG as it was for the Islington PCT (IPCT).

The timetable for development [is this a heading?]

This requirement upholds the focus identified in the CCG authorisation process on developing ‘clear and credible’ plans. Indeed, we know that one of the caveats to early discharge of conditions in the authorisation process is that any conditions relating to these plans or their underlying financial will not formally be discharged until the March 2013 review of CCG preparedness. It should be noted that there is one residual condition relating to the development of collaborative arrangements with other CCGs that we already know will be retained until this March deadline despite the significant advancements we have made recently with this.

The Operating Plan in previous years was a compulsory requirement performance managed by NHS London. As the London NHS Commissioning Board Local Area Team establishes itself, we will now report to them. Draft CCG Planning Guidance was issued on 19 November 2012 to London CCGs regarding the structure.

6.2 Progress to date

Draft CCG Planning Guidance was issued on 19 November 2012 to London CCGs regarding the structure in the form of a toolkit pro forma.

A planning group, consisting of the four Commissioning Support Directors and commissioning leads from the five local CCGs is now meeting regularly to support the development of the each local operating plan.

There are several areas that can be done ‘once for all’ and a number that will have to completed locally or have a specific local flavour. There are some supporting elements of work, for instance the process for agreeing financial allocations with the exiting NCL finance structure and the role of the clinical cabinet moving forward, that will need to be moved forward as a specific requirement of completing the Operating Plan for 2013/14 across North London or indeed the supporting CSU.

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Equally, there are elements of the Operating Plan and CSP that will be interchangeable or re-iterative. The maximisation of opportunities to manage both outputs should be paramount.

6.3 Health and Well Being Board Ownership

One of the stipulations of the Operating Plan submission is the requirement for sign off at HWBB level and, by proxy, the opportunity for the local scrutiny functions to have oversight of the content of health improvement plans and many of the key messages around structural change in the NHS that have been identified as important to them. The CCG will work with the local partnership structure over the coming weeks to ensure a suitable process is followed in order to make this happen.

6.4 Risks to delivery of Operating Plan 13/14 (draft only) There are a number of risks to the delivery of the Operating Plan for next year and thereby some of the underpinning work required for the Commissioning Strategy Plan.

Risk Mitigation Rating

Internal capacity is not fit for purpose

Temporary resource until end January 2013 with specific focus on completing the Operating Plan

Low

External support, i.e. from the CSU and public health, is not fit for purpose

Planning group put together and work programme identified with CSU; further work to do with other agencies

Medium

Collaborative working with other CCGs around areas of common interest does not produce the necessary result, e.g. pace, subject matter, ‘local’ issues over riding those prioritised centrally

Operating Plan ‘once for all’ responsibilities have been identified; however there are still some significant gaps e.g. urgent care

Resource identified from the Delivery Improvement Unit at the CSU to support CCGs

Medium to High

Traditional planning round discipline does not represent the shift from PCT to CCG, i.e. clinical commissioning

Skill on behalf of the executive and commissioning team is required to ensure that the added value of the new system is brought to life in the CSP and the circular process of involving and informing the membership

Low to Medium

Timing of decision making and sign off creates blockages in the system

Planning lead to contact lead officers immediately to make them aware of the deadlines and work this into planning for meetings, i.e. HWBB and OSC

Low

The output of strategic commissioning plans is not well embedded in local contracts and exposes us to system and fiscal risk in year

Work with the CSU and Camden CCG on how the contracts leads are briefed on commissioning plans (i.e. savings and investments in particular) and any service changes to prioritise these in the contract negotiation timetable

Medium

There will be a number of presenting risks and interdependencies that will arise over the coming days and weeks as the work programme develops. It is expected that with some external resource available to review progress we will have more of a stepwise project management approach with a risk register and interdependencies more formally agreed with other CCGs; we are currently sharing rather than collaborating and this will see a significant shift forward over the coming weeks.

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7. Prioritisation Process

7.1 Emerging Opportunities 13/14 and onwards

Despite the only recent development of guidance, the planning round is being moved on via established and new local processes. As reported in papers at the previous two meetings, the Governing Body will also be aware of the engagement that has been undertaken with locality based patient groups, the voluntary sector and CCG membership partners between August and today around what micro and macro health improvement priorities are desirable in Islington.

Emerging priorities include:

· A wide range of proposals from joint commissioning, with a range of new schemes to address dementia and alcohol dependency, for example

· Some new services proposed to support frequent users of primary care, including serious mental ill-health , those with personality disorders and autistic patients

· A number of proposals around new care pathways in primary care, including heart failure, one-stop gynaecology , musculo-skeletal and pain management

· Continued development of innovative medicines management schemes · A range of service specific developments in the children’s portfolio, Currently not

identified in these proposals are specific enablers for the integrated care approach · We have also had approaches from the Voluntary Sector regarding service offers

that will be considered in terms of market development opportunity and the procurement timetable currently forming for next year.

Commissioning leads across primary and joint commissioning teams have moved engagement on into more cohesive plans for investment and savings for 2013/14 and beyond. A panel process has been established to challenge the robustness and appropriateness of these plans, taking into consideration the following:

· These proposals are currently piecemeal; the Governing Body needs to consider the sum of their parts in January

· Enabling integrated care needs to be considered across the range of these proposals

· A number of cost pressures remain in the system due to public sector funding cuts · Invest-to-save needs to be more developed as a business methodology in the

commissioning team · Allocations are currently unknown and when published we will almost certainly need

to revise · Our position of financial strength is not guaranteed longer term. Investment now

needs to promote systemic long term reduction in costs as well as higher clinical quality.

7.2 Progress to Date

The QIPP team are working with the commissioning leads to develop the quality of the plans and how these may be translated into Project Initiation Documents and thereby commissioning plans for the following year. To reduce the sum this year’s unspent investment monies, where possible, robust plans will be brought forward for immediate implementation. The initial outputs of the panel are not available for representation in this paper but will feature in presentation of this paper to the Governing Body at the December meeting.

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7.3 Appraisal of 12/13

The QIPP team will also need to undertake a rigorous appraisal of this year’s savings and investment planning and external resource may be required to facilitate both that and how the commissioning plans are developed for the purposes of the Operating Plan.

8. Next steps

The Governing Body is asked to:

· Approve the development of a Commissioning Strategy Plan, with a draft for discussion at the February 2013 meeting

· Acknowledge the work on going in the development of the Operating Plan 13/14, with the first draft that will have been submitted to the NHSCB in January reported at the February 2013 meeting

· Note the emerging prioritisation and development process around the Savings and Investment Programme for 2013/14

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Appendix ‘4.1a’ Summary of the NHS Mandate

The objectives of the NHS Mandate are summarised follows. A complete copy of the NHS Mandate is available via the Department of Health website and should be read in conjunction with the NHS Constitution (links supplied at the end of this section).

1. Preventing people from dying prematurely, in particular: Ø Supporting earlier diagnosis Ø Tackling risk factors as precursors to serious ill health and premature death Ø Challenging avoidable deaths in hospital Ø Maximising the prevention of illness through the promotion of healthier

choices through all existing health services

2. Enhancing quality of life for people with long term conditions; i.e. the implementation of integrated care systems, including: Ø Empowerment of the individual to manage their condition Ø Personalised care planning, including the promotion of personalised health

budgets Ø Implementation of 111 as an underpinning resource Ø Digitalisation enabling support to integrated care, e.g. records, booking,

communication, telehealth Ø Via CCGs, the involvement of the wider stakeholder landscape in developing

services Ø Specific focus on dementia across diagnosis and treatment improvements Ø Mention of support to carers (this may be strengthened in future)

3. Helping people to recover from episodes of ill health or following injury, this being

enacted as: Ø Exposure of unsafe or unacceptable poor practice in this area Ø Promotion of good practice at various levels across the industry, e.g. at CCG

level and at consultant-led team level Ø Establishment of systematic patient feedback Ø Where change is indicated it must pass four tests, loosely replicating those

which Andrew Lansley had applied to service review upon his appointment, i.e. demonstrating consideration of patient and public engagement, regard for patient choice, clinical best practice and the will of the local clinical commissioning group (or multiples of such) to move it forward

4. Ensuring that people have a positive experience of care, therein: Ø Detailed emphasis on care as a concept and the preservation of dignity of

patients within NHS care Ø Specific signposting to the expected response of both commissioners and

services to the Francis Independent Inquiry (post Mid Staffordshire Hospitals NHS Trust crisis) and the Government response to the Winterbourne View review

Ø The development of a ‘Friends and Family Test’ to measure whether NHS staff would recommend the very services they run

Ø A renewed emphasis on maternity and early years, including a named midwife for pregnancy and postnatal care and better support for perinatal depression as well as more cohesive multi-agency services for infants and young children as well as more specialised care for children with special needs or diagnosed disabilities

Ø Involving children’s views in the development of health services

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Ø An emphasis on timely access and raising the bar in this area for individuals with diagnoses of both mental and physical illness

5. Treating and caring for people in a safe environment and protecting them from avoidable harm, including relevant crossover to the previous domain and: Ø Reductions in avoidable harm Ø Direct action on suicide prevention

There are four further elements of the Mandate that relate to the pledges made under the 2010 White Paper ‘Liberating the NHS’ including innovation, choice, public sector service pledges, management within financial envelopes and the commissioning portfolio to be held outside CCGs by the NHSCB.

Clearly, the Mandate therefore becomes the talisman for both services and commissioners of care as they carry out their functions over the coming years. It widely references the NHS Constitution as the founding document of the citizens’ right to healthcare and the various expectations that are built up within that of a choice of services free at the point of need of the highest possible quality.

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Page 0 of 22

Draft CCG Planning Guidance 2013/14

Appendix: 4.1bICCG GB - 54

Page 1 of 22

Contents Introduction 2 Approach 3 Overview of annual timeline and key milestones 5 Local strategic and collaborative commissioning intentions 6 Commissioning Development 6 The Pursuit of Excellent Care: The First Mandate to the 7 NHS Commissioning Board 2013/14 – 2014/15 NHSCB Mandate Requirements 7 QIPP 17 Choice and Competition 17 Emergency Preparedness, Resilience and Response 17 Informatics 18 Financial planning 18 Conclusion 19 Annex A 20 Annex B 21 Annex C - Toolkit

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Page 2 of 22

Introduction

This operating planning guidance has been developed in consultation with Clinical Commissioning Groups (CCGs), Health and Wellbeing Boards (HWBs), Commissioning Support Units (CSUs) and Direct Commissioners. The purpose of the guidance is to provide support to CCGs, Direct Commissioners and CSUs throughout the development and submission of their operating plans. The guidance sets out the national expectations and initiatives for which the NHS Commissioning Board (NHSCB) will require assurance. The guidance includes an outline of the principles and approach NHS Commissioning Board London (NHSCB London) has agreed with CCGs and Direct Commissioners. These principles include the need to ensure that the planning and contracting round supports this partnership approach both locally, between CCGs and HWBs and also regionally between CCGs and the NHSCB London. The approach aims to minimise the bureaucratic burden and therefore we strongly encourage CCGs to utilise existing plans they have developed as part of their authorisation process. The guidance includes supporting templates that have been developed for CCGs and Direct Commissioners to use in submitting their plans. These templates were developed after consultation with CCGs highlighted a need for a standardised reporting process, enabling CCG’s to collaborate on joint plans where necessary. This approach will also better facilitate aggregation and alignment of CCG and Direct Commissioning plans at a London level. The approach adopted in London is based on assumed autonomy for authorised CCGs to set their own priorities for quality improvement whilst providing assurance to the NHSCB London that the Mandate from the Government to the NHSCB will be delivered. In doing so, the expectation is that NHSCB London, in partnership with CCGs, will deliver improved quality of health services and outcomes for the population of London.

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Page 3 of 22

Approach

The Health and Social Care Act 2012 emphasised the principle that planning and contracting is managed locally by CCGs in partnership with HWBs. CCGs are leading the commissioning planning and contracting round and will need to develop local priorities in partnership with Local Authorities (LAs) and through HWBs. The NHSCB will provide guidance and support to CCGs to discharge their planning and contracting functions. The Act and subsequent guidance requires all planning to be underpinned by excellent and compelling information derived from local Joint Strategic Needs Assessments (JSNAs) and Joint Health and Wellbeing Strategies (JHWSs) with a focus on an approach that identifies opportunities rather than targets. These opportunities ensure CCGs respond to local strategic change programmes, local patient and public opinion, and insight. NHSCB London will be a partner at local HWBs with CCGs to represent Direct Commissioning and also provide system oversight of the planning process at a local level. NHSCB London will aggregate all CCG and Direct Commissioning plans once submitted to ensure that NHS commissioners can deliver the Mandate for London. A great deal of focus will be on supporting CCGs to deliver locally developed plans, and the same principles and standards for planning and contracting also apply to NHSCB London Direct Commissioning. Direct Commissioning will need to assure the CCGs that they are working towards the same contracting process. The NHS Trust Development Authority will assure NHS Trust provider plans. The NHSCB Mandate, NHS Outcomes Framework and NHS Constitution set out the key national expectations. In addition, Direct Commissioning and CCG commissioning intentions provide the basis of operating plans and contracts for 2013/14 (see diagram below).

NHS CB

CCG

DH Mandate NHS Constitution NHS Outcomes

Framework

Strategic & Collaborative CIs

Local CIs

CCG & Direct Commissioning Operating Plans

2013/14

Sign Contracts with Providers

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Page 4 of 22

The key deliverable from the planning and contracting round will be agreed CCG and Direct Commissioning plans. These plans will meet local need, national requirements and support delivery of major strategic change programmes. Key milestones are the submission of first drafts of CCG and Direct Commissioning plans by the second week in January and the final plans by the second week in March 2013. All contracts will need to be agreed by 1st April 2013 (see detailed planning timeline overleaf).

Signed contracts with providers

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Page 5 of 22

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Local strategic and collaborative commissioning intentions

All NHS commissioners are required to have clear and credible commissioning intentions that best meet the needs of their local populations within the resources available to them. They must actively manage the implementation of these commissioning intentions to ensure the delivery of safe and high quality care for patients and the public. As part of the operating planning process CCGs are asked to provide the vision for local commissioning, areas for improvement and a description of the initiatives that will be implemented to deliver the vision. All planning should be based on JSNAs and the priorities identified within the JHWS, where these exist. Given that CCG strategic commissioning intentions will build on existing plans, commissioners should review progress on current initiatives and take this into consideration as part of their planning process.

CCGs should outline how their plans reflect the outcomes of the local Joint Strategic Needs Assessments and support the delivery of their local Joint Health and Wellbeing Strategies. CCGs should set their key areas of focus, rationale for agreeing their strategic priorities, key risks and corresponding mitigations. To make this easier CCGs may wish to reproduce from their integrated plans their key strategic priorities and the main initiatives planned for 2013/14 to deliver these, indicating whether and how these will support improvements in delivering the NHS Outcomes Framework.

Commissioning development

As set out in Developing clinical commissioning groups: Towards authorisation, published in September 2011 the Government’s ambition for the best healthcare service in the world will be dependent on the development of highly effective CCGs. CCGs will need to be confident in their ability to take up the reins of commissioning the majority of healthcare safely, and to discharge responsibly their stewardship of the majority of the NHS budget to improve quality, efficiency, and reduce inequalities. It is important to recognise that CCG Authorisation is only the beginning of this journey and in achieving excellence CCGs will need to set out their plans for on going commissioning development. CCGs authorised with conditions are asked to set out a rectification plan for April 2013 onwards covering all outstanding conditions.

CCG are asked to include their development plan beyond authorisation along with any plans for the CCG to review its operating model including development of individual teams and at an organisational level. CCGs should consider including a description of their systematic succession planning to ensure sustainable clinical leadership is embedded throughout the CCG and its membership.

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The Mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015 The Mandate from the Government to the NHS Commissioning Board: April 2013 to-March 2015 will act as the main formal accountability mechanism for the NHSCB. The Mandate establishes the NHSCB's responsibilities and duties in a number of areas including: provider and commissioner autonomy; quality improvement; health inequalities; patient and carer involvement; research and innovation; integration; and patient choice. The Mandate sets out the expectations of the NHS in relation to the NHS Constitution, Outcomes Framework, Choice and Competition and Financial Planning. As part of the NHSCB’s role in assuring delivery of the Mandate, CCGs are asked to outline their plans to meet the requirements of the Mandate in relation to these key priority areas as outlined below.

NHSCB Mandate Requirements

NHS Outcomes Framework

The NHS Outcomes Framework 2013/14, published in November 2012, reflects the vision set out in the Act. Its purpose is threefold:

To provide a national overview of how well the NHS is performing;

To provide an accountability mechanism between the Secretary of State for Health and the NHS Commissioning Board for the effective expenditure of some £9.5bn of public money;

To act as a catalyst for driving quality improvement and outcome measurement throughout the NHS by encouraging a change in culture and behaviour, including a stronger focus on tackling health inequalities. CCGs are asked to summarise their performance against key NHS performance measures in 2012/13, identifying priorities for improved performance in 2013/14. It is anticipated that CCGs will be required to submit planning trajectories. Please see Annex A and Annex B for draft measures. In addition, CCGs and Direct Commissioners are asked to set specific plans as outlined below and in the toolkit.

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Domain 1: Preventing people from dying prematurely

Cancer services

A model of care for cancer services was published in August 2010, detailing clinically-developed solutions to ensure radical improvements to London’s cancer services. The model of care set out a proposal for the establishment of Integrated Cancer Systems (ICSs) of providers for London (to deliver greater consistency of care, consolidation of specialist services and the localisation of more common cancers), as well as services being commissioned more consistently across London. It is anticipated that there will be a joined up approach to cancer commissioning between CCGs and the NHSCB (as a commissioner of specialised cancer services).

Plans should demonstrate how the following priorities, recommended for adoption for 2013/14, are being taken forward:

Improving early detection o Improving GP access to diagnostic testing for suspected cancer,

ensuring direct access for specific tests (including endoscopy). Delivering care closer to home

o Implementation of four best practice commissioning pathways; o Improving the provision of chemotherapy services; o Improving the consistency of palliative care services.

Consolidating specialist care o Delivering appropriate consolidation of services in line with the model of

care; o Planning consolidation of highly-specialist services.

Improving consistency in care provision o Reduce unwarranted variation in care along pathways and ensure

compliance with IOG standards; o Recognising cancer as a long term condition; o Improving services for people living with and beyond cancer, including

implementing the National Cancer Survivorship Initiative recommendations;

o Improving communication between secondary/tertiary and primary care;

o Working towards the provision of seamless care for people with cancer. Delivering productivity and efficiency

o Ensuring the effective use of financial and performance data for commissioning purposes.

Innovation

Sir David Nicholson’s review Innovation, Health and Wealth tasks the NHS with promoting innovation for significantly better outcomes for patients within the available

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resources. CCGs have a duty to promote innovation and they will determine locally how best to focus and promote innovation, including its adoption and spread, as an enabler to better health and healthcare for their population. Operating Plans for innovation in primary care should demonstrate how:

The six high impact innovations (HII) will be achieved including planned investment, roll-out numbers, timetables and expected outcomes;

Adoption and diffusion of innovative best practice will be accelerated through the CCG including how the CCG works with and engages Academic Health Science Networks;

NICE TA (technology appraisals) are systematically included (where clinically appropriate) in local formularies. CCGs should confirm that local trusts have included all NICE TAs in their formularies. For those TAs that have not yet been included, plans should be described for ensuring their inclusion with a timetable for implementation.

Public Sector Equality Duty (PSED) The Public Sector Equality Duty (section 149 of the Equality Act 2010) requires public bodies to consider all individuals when carrying out their day-to-day work, shaping policy, delivering services and in relation to their own employees. It requires public bodies to give due regard to the need to eliminate discrimination, advance equality of opportunity, and foster good relations between different people when carrying out their activities. CCGs will need to provide assurance that they are compliant with the Public Sector Equality Duty (PSED), and that equality objectives are integrated into business planning processes, using the Equality Delivery System or an equivalent system as the framework.

Domain 2: Enhancing the quality of life for people with long-term conditions

Integrated Care

Up to one million people in London with long-term conditions could benefit from a more coordinated model of care. National and local learning from integrated systems shows that integrated care needs to be patient-centred, planned around a population and with a number of key enablers taken into consideration.

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CCG plans for integrated care should demonstrate how:

Integrated care will contribute to the achievement of the quality, experience and sustainability outcomes of the local out-of-hospital strategy;

Patients are firmly at the centre of the design of integrated care systems; Patient and carer experience is embedded into the commissioning cycle; Integrated systems are developed collaboratively across geographical and

organisational boundaries, bringing together health and social care; Data sharing is enabled to support proactive and coordinated delivery of care; Work is progressing with Local Education and Training Boards (LETBs) and

providers to shape a workforce with the required skill mix and competencies to deliver integrated care;

CCGs will commission in a way that aligns resource to need across all constituent providers;

Primary care improvement has been considered as an enabler to delivering a wider range of services in community settings.

Rollout of 111 and Directory of Services

Over the next few months London will be rolling out NHS 111 pilots, completing NHS 111 service coverage across the Capital by March 2013. The NHS 111 service provides CCGs with opportunities to integrate urgent care across primary, community and secondary care.

CCG’s plans for NHS 111 should demonstrate how they are:

Ensuring 111 is embedded in local urgent care strategies to deliver benefits across urgent and emergency care systems;

Engaged in the local implementation of their NHS 111 pilots, assuring performance, quality and benefits realisation of their local NHS 111 service;

Responding to the use of Directory of Services (DoS) and responding innovatively to the intelligence it provides on gaps in service delivery and the opportunities to commission new or innovative solutions;

Responding to the new level of data and information provided by NHS 111 and the DoS and responding to and sharing learning across London 111 pilots, informing the final London operating model for NHS 111 post pilots;

Deploying NHS 111 to improve access and service provision for high risk patients particularly those patients at the end of their life, patients in mental health crisis or frail elderly patients;

CCGs are responding to patient and professional feedback of their NHS 111 service, showing how user opinions and experience are driving service improvements across the urgent care pathway.

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Dementia and care of older people

Dementia is one of the biggest challenges facing the NHS, and the Prime Minister’s Challenge on Dementia sets a three-fold focus on improving the health and care of patients, creating dementia-friendly communities and promoting better research.

CCGs should in their plans demonstrate how they will:

Work with GPs and other clinical professionals to improve diagnostic rates, care and treatment;

Meet the quality standards set out in the NHS Outcomes Framework and National Institute for Health and Clinical Excellence (NICE) guidance;

Ensure that information regarding dementia is published in provider quality accounts;

Ensure participation in and publication of national clinical audits and other research initiatives;

Reduce inappropriate antipsychotic prescribing in the community and in care homes;

Eliminate mixed sex accommodation; Reduce inappropriate admissions including those directly to care homes from

hospital; Develop care pathways consistent with end of life care strategy; Ensure the provision of specialist in-reach teams to care homes including

dentistry, primary care and pharmacy; Ensure the provision of appropriate Liaison mental health services.

Carers The focus on carers reflects the ambition to improve the support available for those caring for people with mental illness, dementia and physical ill health. CCGs will need to show in their plans how they will:

Ensure joint needs assessments remain up to date with appropriate plans agreed by HWBs;

Ensure these plans are made publically available; Agree budgets with HWBs and voluntary groups to support carers including

the identification of the total budget to provide carers’ breaks.

Improving Primary Medical Services

CCGs have a statutory duty to improve primary medical services and a duty to promote innovation. CCGs will need a strategic plan for building capacity in primary

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care, improving quality and reducing health inequalities. CCGs are not responsible for performance management of primary medical services but they will require a detailed understanding of the quality of local primary care provision and identified priorities for improvement. CCGs will need to work collaboratively with NHSCB London’s primary care commissioning team so that any persistent performance concerns can be addressed through regional performance arrangements. CCG plans for primary care should demonstrate that:

A local primary care strategy is in place to support the out-of-hospital

strategy; The experience of patients and carers has informed service improvement

planning; There is an informed understanding of the current landscape of primary care

provision in the area, the degree of variation, comparison with relevant benchmarks and any unacceptable outcomes;

Local development goals for primary medical services have been agreed across CCG members;

Local, national and international service models have been explored to inform the improvement priorities for general practice locally;

Tailored models of service delivery for specific patient cohorts have been agreed to better support patients with co-morbidities and to reduce health inequalities;

New models of service provision will provide sufficient scale and population coverage;

Development goals will be underpinned by investment in: o Workforce o Premises o IM&T (digital/telephony)

New models of provision may provide sufficient scale and population coverage to transform general practice services;

Work is in progress to meet the objective of patients having access to their own health records held by their GP by March 2015;

Work is in progress to enable secure linking of electronic health records wherever they are held and for those records to be able to follow individuals (with their consent) to any part of the NHS or social care system by March 2015;

Work is progress to ensure everyone will be able to have secure electronic communication with their GP practice, with the option of e-consultations becoming more widely available by March 2015;

Plans for significant progress to be made towards patients with long-term conditions being able to benefit form telehealth and telecare by 2017.

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Domain 3: Helping people to recover from episodes of ill health or following injury

Mental Health

The NHSCB Mandate re-states the continuing commitment to put mental health on a par with physical health. The focus is on improving the lives of people with mental illness, reducing mortality and identifying and tracking outcomes including recovery. The No Health Without Mental Health Implementation Framework published in July 2012 sets the context for this and CCGs are expected to demonstrate how they will meet these ambitions in their plans including:

Continuing to meet expectations within No Health Without Mental Health policy and Implementation Framework and the NHS Outcomes Framework;

Reducing mortality from physical illness in those with mental illness; Focusing on mental health prevention and earlier intervention in children and

young people including looked-after children and other young people at risk; Achievement of Quality Innovation Productivity and Prevention (QIPP)

monitored against the mental health Performance Framework covering new cases of psychosis served by Early Implementation Trusts (EIT), gatekeeping of acute admissions by crisis teams, 7-day post discharge follow up for those on Care Programme Approach (CPA);

Elimination of mixed sex accommodation; Commissioning of liaison mental health services for general acute wards

including those that provide dementia care and A&E. Increasing Access to Psychological Therapies (IAPT) remains a key priority and CCGs will need to demonstrate that they are commissioning services effectively. CCGs will need to show in their plans how they will:

Meet 15% prevalence with recovery rate of at least 50% in all services; Extend focus to minority groups, older people, people with serious mental

illness and long term conditions; Extend IAPT services to children and young people.

Domain 4: Ensuring that people have a positive experience of care

Ensuring that people have a positive experience of care is a key priority for the NHS and is referenced in the Mandate. CCG should make progress in measuring and understanding how people really feel about the care they receive and take action to address poor performance.

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CCGs should ensure that they have plans in place to:

Ensure that from April 2013, the friends and family test is in place across all acute providers and all elements within the implementation and reporting guidance are met. Any improvement actions resulting from Friends and Family Test (FFT) should also be evidenced.

Ensure every woman has a named midwife who is responsible for ensuring personalised care throughout pregnancy, childbirth and during the postnatal period, including additional support for those who have a maternal health concerns.

Ensure women receive one-to-one care from a midwife during labour, birth and the period immediately after birth, and improve the identification of women with postnatal depression earlier and the support provided.

Ensure all waiting times commitments as set out in the NHS Constitution are met. This includes significantly improving access and waiting times for mental health services, including IAPT.

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

Safeguarding children and promoting their welfare

CCGs and the NHSCB will be statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children.

Safeguarding children is referenced in the Mandate and also published interim advice on arrangements to secure children’s safeguarding (the new accountability and assurance framework – interim advice). CCGs need to demonstrate in their plans that they have appropriate systems in place for discharging their responsibilities in respect of safeguarding children including:

CCG Governing Bodies have robust assurance processes in place relating to safeguarding children, including a clear line of accountability for safeguarding, properly reflected in the CCG’s governance arrangements;

CCGs have plans to train staff in recognising and reporting safeguarding issues;

Appropriate arrangements to co-operate with local authorities in the operation of Local Safeguarding Children’s Boards (LSCBs);

Securing the expertise of a designated doctor and nurse for safeguarding children;

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Securing the expertise of a designated nurse and doctor for looked-after children;

Securing the expertise of a designated paediatrician for unexpected deaths in childhood.

Safeguarding adults and learning disabilities

CCGs will need to demonstrate that they have appropriate systems in place for discharging their responsibilities in respect of safeguarding adults and learning disabilities including:

Plans to train staff in recognising and reporting safeguarding issues; A Clear line of accountability for safeguarding, properly reflected in CCG

governance arrangements; Appropriate arrangements in place to co-operate with Local Authorities in the

operation of the Local Safeguarding Adult’s Board (LSAB); Having a safeguarding adult lead and a lead for the Mental Capacity Act,

supported by relevant policies and training; Reducing premature death in people with learning disabilities (excess under

60 mortality); Having arrangements in place to involve and seek advice from learning

disability clinicians and practitioners; CCG to outline commissioning arrangements for people with learning

disabilities; Responding to abuse at Winterbourne View, CCGs should outline

commissioning arrangements (formed in partnership with Local Authorities) which reduces out of area placements and inpatient care for people with learning disabilities and autism.

A CCG’s leadership arrangements for adult safeguarding will need to include responsibility for ensuring that the CCG commissions safe services for those in vulnerable situations, including effective systems for responding to abuse and neglect of adults in vulnerable situations and effective inter agency working with local authorities, the police and third sector organisations. CCGs have a responsibility to participate in local networks and encourage providers to do so also. CCG leads for safeguarding adults will need to have a broad knowledge of healthcare for older people, people with dementia, people with learning disabilities and people with mental health conditions. The CCG will need to ensure that its designated clinical experts are embedded in the clinical decision-making of the organisation, with the authority to work within local health economies to influence local thinking and practice.

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Patient Safety

Patient safety is of paramount importance in terms of quality of care and to delivering better health outcomes. Improving safety is broader than just reducing the number of incidents – it also involves having an understanding of how safety can be continuously improved and developing a culture that supports improvement. This includes:

Patient safety incident reporting; Severity of harm (measuring the number of incidents resulting in severe harm

or death); Reducing the incidence of avoidable harm. The specific incidents which have

been selected in Domain 5 of the NHS Outcomes Framework are: hospital-related venous thromboembolism (VTE); the development of severe pressure ulcers while in NHS care; medication errors in acute, primary and community settings; and the incidence of the healthcare-associated infections (HCAIs) MRSA and C difficile;

Keeping patient groups with particular needs safe: all patients deserve safe care, but specific improvement areas have been selected for two groups with particular needs within the safety domain; namely children and pregnant women.

CCGs will need to demonstrate that they have appropriate systems for ensuring that patient safety is of paramount importance. They will need to provide the NHSCB with assurance that services are of appropriate quality, whilst also commissioning services effectively to ensure: Reliable and open incident reporting arrangements; Improvement in practice following serious incidents; Achievable plans for reducing the incidence of avoidable harm; Achievable plans for improving safety for pregnant women and children; Reduction in the number of C.Difficile cases in line with nationally-set objectives; Providers are applying a zero tolerance approach to avoidable MRSA

bloodstream infection; All reasonable steps are taken by mental health services to reduce the number of

suicides and incidents of serious self-harm or harm to others, including effective crisis response.

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QIPP

CCGs will need to continue to deliver against QIPP commitments throughout 2013/14. CCGs should include in their plans an overview of:

How the planned future state will ensure that the local health economy is sustainable both in terms of improvements in quality and outcomes and in terms of financial affordability;

Financial impact; Risks to delivering the CCG’s QIPP plans; Mitigations and contingency plans to manage QIPP risks; Governance of the CCG’s QIPP programme (including leadership and

Programme Management Office arrangements); The size of the QIPP challenge for the CCG in light of London’s overall QIPP

challenge for 2013/14 and actual QIPP delivery in 2012/13; Confirmation that providers have agreed their element of the QIPP plans.

Choice and Competition

Since 2010, the Government has been committed to increasing choice and personalisation in NHS-funded services. Choice for patients can be about the way care is provided, or the ability to control budgets and self-manage conditions. The Government has specifically committed to extending patient choice through Any Qualified Provider for appropriate services. CCGs should demonstrate the processes in place to offer choice to patients, including:

How areas have been needs assessed and prioritised; How areas have been assessed as appropriate for tender or Any Qualified

Provider.

Emergency Preparedness, Resilience and Response (EPRR)

The roles and responsibilities of the CCG in relation to EPRR derive from the Civil Contingencies Act (CCA) 2004 and the Health and Social Care Act 2012 (s46 relates to emergencies). The principles of the CCA are to ensure consistency of planning across all government departments and its agencies, whilst setting clear responsibilities for frontline responders at local level. Health Emergency Preparedness, Resilience and Response from 2013: Summary of the principle roles of health sector organisations (DH, July 2012, Gateway 17820)

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identifies the principal organisational roles and responsibilities of CCGs related to EPRR as:

Ensure contracts with provider organisations contain relevant emergency preparedness, resilience (including business continuity) and response elements;

Support the NHSCB in discharging its EPRR functions and duties locally; Provide a route of escalation for the Local Health Resilience Partnership

(LHRP) should a provider fail to maintain necessary EPRR capacity and capability;

Fulfil the responsibilities as a Category 2 responder under the CCA including maintaining business continuity plans for their organisation;

Will be represented on the LHRP (either on their own behalf of through representation by a ‘lead’ CCG).

Informatics

CCGs should provide in their plans:

Evidence of consideration of informatics capability and capacity necessary to support the transition;

A proposal for giving patients on-line access to their medical records, starting with their GP records;

An achievable trajectory for providing Summary Care Records. Financial planning

CCGs are accountable for managing public funds robustly and meeting their statutory duties within the available resources. This will require good financial management and unprecedented improvements in value for money. The Mandate states the requirement to continue the drive for efficiency savings, while maintaining quality, through the QIPP programme. CCGs need to demonstrate that they have effective financial planning arrangements and have a detailed financial plan that is consistent with their commissioning strategy, setting out how they will manage within their management allowance and any other requirements as set by the NHSCB. CCGs should demonstrate how they will deliver:

Financial balance; Cash management; QIPP targets; Mandate requirements, and;

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Other key deliverables. CCGs will be expected to demonstrate that their running costs are within £25 per head. Conclusion

NHSCB London is committed to working in partnership with CCGs to ensure operating plans for 2013/14 are robust and credible. This document and associated toolkit is intended to support CCGs in developing their plans and will be revised and reissued in light of any changes following the release of the national planning guidance, due in mid December. If you have any questions regarding planning please contact Khadir Meer, Interim Head of Assurance (NWL) at [email protected].

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mailto:[email protected]

Page 20 of 22

Annex A NHS Outcomes Framework measures for which data can be generated at CCG level and a baseline can be determined against which progress can be considered.

Domain Measures that are suitable for both in year and annual assessment

Measures that are suitable for annual assessment only

1. Preventing people from dying prematurely

None Under 75 mortality rate from cardiovascular disease

Under 75 mortality rate from respiratory disease

Under 75 mortality rate from liver disease

Cancer: vii under 75 mortality rate from cancer

2. Enhancing quality of life for people with long term conditions

Health-related quality of life for people with long-term conditions

Dementia Diagnosis Rates

Proportion of people feeling supported to manage their condition

Unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults)

Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

3. Helping people to recover from episodes of ill health or following injury

Emergency admissions for acute conditions that should not usually require hospital admission

Emergency readmissions within 30 days of discharge from hospital

Patient Reported Outcomes Measures (PROMs) for elective procedures: i)Hip replacement, ii)Knee replacement, iii)Groin hernia, iv)Varicose Veins

Emergency admissions for children with LRTI

4. Ensuring that people have a positive experience of care

Patient experience of i GP Services ii GP Out of Hours services

Friends and family test

Patient experience of hospital care

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

Incidence of healthcare associated infection: MRSA

Incidence of healthcare associated infection: C. difficile

None

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Annex B The following operational standards are reflected in the Mandate as either rights and pledges under the NHS Constitution or expressed directly. This may be revised in light of the Planning Guidance, due to be published mid December. Referral To Treatment waiting times for non-urgent consultant-led treatment Admitted patients to start treatment within a maximum of 18 weeks from referral – 90% Non-admitted patients to start treatment within a maximum of 18 weeks from referral – 95% Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral – 92% Diagnostic test waiting times Patients waiting for a diagnostic test should have been waiting no more than 6 weeks from referral – 99% A&E waits Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department – 95% Cancer waits – 2week wait Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP – 93% Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) – 93% Cancer waits – 31 days Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers – 96% Maximum 31-day wait for subsequent treatment where that treatment is surgery – 94% Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regimen – 98% Maximum 31-day wait for subsequent treatment where the treatment is a course of radiotherapy – 94% Cancer waits – 62 days Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer – 85% Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers – 90% Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers) – no operational standard set Category A ambulance calls Category A calls resulting in an emergency response arriving within 8 minutes – 75% (standard to be met for both Red 1 and Red 2 calls separately) Category A calls resulting in an ambulance arriving at the scene within 19 minutes – 95% Mixed Sex Accommodation Breaches Minimise breaches

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Mental health Improving Access to Psychological Therapies (IAPT): of those completing treatment it is expected that at least 50% will recover. Care Programme Approach (CPA): the proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the period – 95%.

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Developing a Performance and Information Strategy –

Health Intelligence Management Framework, Islington CCG (draft) LEAD DIRECTOR: Jacky Kutner, Interim Director of Performance and Information AUTHOR: Jacky Kutner, Interim Director of Performance and Information CONTACT DETAILS:

Katie McInerney, PA to Jacky Kutner, 020 7527 1361 [email protected] [email protected]

SUMMARY: The new NHS reforms herald new structures, organisations and dispersal of resources and new prospects to use information to help develop outstanding clinical leadership and patient engagement. With this, is a need for a new approach to delivering high quality information - to inform the new commissioning structures and processes, ensure clinicians and managers have the information they need at the time they need it; to inform the internal performance management of Islington CCG to achieve continuous improvement and spark innovation and to meet the requirements of the new NHS Commissioning Board performance framework which will assure them Islington CCG is meeting and surpassing contractual standards of service delivery, patient quality and performance. So the reforms mean more outcome focused measures and indicators, patient experience and innovation measures. Patient Information will need to be more readily available to clinicians and be meaningful and therefore accuracy and data quality needs to improve. The information will focus on specific patients, their journey and the health outcomes achieved, on a personal as well as a population level. The information should support patient risk stratification and integrated care and assist in decisions that support the shift in care away from hospital settings. This open new challenges and opportunities regarding the sharing of patient information between organisations. While not exhaustive, this strategy sets out the structures and processes required to rise to the new challenges, maintain a grip on organisational performance and support risk management. The flexible and cost effective infrastructure proposed will enable Islington CCG to respond to new requirements as it matures and grows and place more resources towards the patient services as the cost of the back office requirement for information and Analytics reduces. Islington CCG has the capacity and ability to become a truly ‘intelligent organisation’ The attached draft strategy sets out the framework for delivery of that aspiration.

Appendix: 4.2

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SUPPORTING PAPERS: Appendix 4.2a: Developing a Performance and Information Strategy – Islington CCG’s Health Intelligence Management Framework (Draft) RECOMMENDED ACTION: The Governing Body is asked to:

· DISCUSS and APPROVE the attached draft Strategy document to go to consultation with partner organisations and seek Public and Patient input.

GOVERNANCE:






















Dr Mo Akmal


Objective(s) / Plans supported by this paper: The strategy supports the delivery of the CCGs key aims and objectives Audit Trail: 1 November - Circulated to CCG Executive team for comment.

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15 November – comments added to draft strategy 21 November – Finance and Performance Group – approved to go to Governing Body 5 December – Governing Body for approval to go to consultation Patient & Public Involvement (PPI): Patients will be given an opportunity to contribute to the strategy during the consultation period Equality Impact Assessment: None specific Risks: The CCG require good information and organisational intelligence to mitigate several key risks. Resource Implications: These are contained in the strategy document Next Steps: Following submission of a final draft to the Governing Body in December, any further amendments will be made, prior to the documents going out to consultation with partner organisations. The views of patients and public will also be sought. After the consultation period, the document will return to the Governing Body for final approval and adoption.

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Developing a Performance and Information Strategy Health Intelligence Management Framework, Islington

CCG

October 2012 DRAFT


Appendix: 4.2a ICCG GB - 80

DRAFT

1. Overview The NHS White Paper, Equity and excellence: Liberating the NHS set out the Government’s long-term vision for the future of the NHS. It states of how GP- led Commissioning will:

· Put patients at the heart of every decision · Focus on continuously improving those things that really matter to patients - the

outcome of their healthcare, and · Empower and liberate clinicians to innovate, with the freedom to focus on improving

healthcare services. With this vision now in statute, this paper sets out a framework on how Islington Clinical Commissioning Group (ICCG) will use health intelligence to help drive these changes and create a healthcare economy that provides a high quality, safe, effective and efficient health and social care experience for Islington patients. Good quality information is at the heart of organisational intelligence. Information can be broadly divided into three main functions:-

1. to provide the evidence base for good managerial and clinical decision making e.g. setting priorities across the health and social care economy and informing patient choices and decisions

2. to ensure that the Clinical Commissioning Group (CCG) is able to deliver appropriate levels of governance, hold its providers accountable and in turn, provide assurance to the bodies to which it is accountable – the NHS Commissioning Board and the population of Islington

3. to enable ‘research’1 through forensic (deep dive) analysis to drive improvement, innovation and transformation for specific areas of health and social care service delivery

These correlate to the delegated requirements for CCGs in exercising their functions, to:

· act with a view to securing continuous improvement in quality of services, and in outcomes

· have regard to the need to reduce inequalities between patients access to and outcomes from health services

· promote the involvement of patients, their carers and representatives in decisions about the provision of health services to them

· promote innovation in the provision of health services · act with a view to securing integration in the provision of health services, and the

provision of health and social care services where the CCG considers that this would improve the quality of the services or reduce inequalities between patients in outcomes and access to services.

1 ‘Research’ is used to establish or confirm facts, reaffirm the results of previous work, solve new or existing problems, support theorems, or develop new ones

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The NHS reforms herald new structures, organisations and dispersal of resources and new prospects to use information to help develop outstanding clinical leadership and patient engagement. With this, is a need for a new approach to delivering high quality information - to inform the new commissioning structures and processes, ensure clinicians and managers have the information they need at the time they need it; to inform the internal performance management of ICCG to achieve continuous improvement, spark innovation and to meet the requirements of the new NHS Commissioning Board (NCB) performance framework which will assure them ICCG is meeting and surpassing contractual standards of service delivery, patient quality and performance. Information currently used tends towards ‘macro’ level assessment, whereas patient based information will need to be not only more readily available to clinicians but relevant to their patient populations and therefore accuracy and data quality needs to improve. The information will increasingly focus on specific patients, their journey along pathways and the health outcomes achieved, on a personal as well as a population level. The information should support patient risk stratification and integrated care and assist in decisions that support the shift in care away from hospital settings. This open new challenges and opportunities regarding the sharing of patient information between organisations. We will need to ensure we have systems in place to report on quality and safety issues to ensure we gain early insight in to when services fail and put in place rectification strategies. With our patients being at the heart of every decision, key to this strategy, will be finding ways to capture and report information regarding the patients’ experience of their journey and feeding that into the service planning and commissioning cycles. Information on services and outcomes will be fed back to inform patient choice through evidenced based dialogue with their clinicians and through other media and the CCG Website. The CCG will increasingly integrate information to ensure we have a ‘balanced’ view of Islington’s health and social care economy as a whole as part of our internal assurance framework. In this way we will be able to understand more readily the impact of our decision making. Performance monitoring and management should cover those areas of change that impact most in the delivery of our objectives and ensure we are a highly performing organisation with a grip on our internal functions and well-being and to meet the demands of the new Performance Framework from the NHSCB.

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Figure 1: Key Areas of ICCG Performance Management It will require us to use intelligence form a variety of sources to set strategy and inform new commissioning plans. We will use information to measure how relationships and processes change in order to deliver our aims and how the patient experience is enhanced by the changes we introduce. Techniques such as patient perception questionnaires and re-use of the 360 degree stakeholder evaluation used in the Authorisation process should be used. We will work closely with Public Health to inform our strategic commissioning intentions and Needs assessment and in liaison understand the longer term impact on the health of the Islington population as a result of our commissioning, the implementation of Integrated care programmes and delivery of Local Enhanced Service (LES) initiatives. Intelligence should include activity and financial information around our contract performance, related to GP Practice populations, patient and service outcomes (including National KPIs and Outcomes), QIPP savings and our investment programme, quality and safety aspects, as well as understanding the impact of our prevention strategies. Our organisational well-being will be aligned to the organisation maintaining and exceeding performance against the Authorisation domains, our financial health and our processes. Our competence as commissioners will also be reflected by the success of the relationships we maintain with the Commissioning Support Unit (CSU) and other key partners as well as the internal and external processes we develop and early attention to securing a robust set of KPIs to monitor the CSU SLA will be important to the future functioning of the health economy. We will aim to use intelligence from both ‘soft’ and hard’ sources like patient, partner and GP feedback and ensure good contextual analysis using information from Public Health. While not exhaustive, this strategy sets out the structures and processes required to rise to the new challenges, maintain a grip on organisational performance and support risk management. The flexible and cost effective infrastructure proposed will enable ICCG to respond to new requirements as it matures and grows and place more resources towards

Impact of commissioning

& financial decisions

Organisational Well Being

Relationships

Internal and external

Processes

Innovation

Service, Quality and Individual

Outcomes

Islington CCG

Patient satisfaction &

choice

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the patient services as the cost of the back office requirement for information and analytics reduces. 2. The Aims of the Performance and Information strategy Successful organisations are typically ones that invest time and resources in the acquisition and delivery of good information to become ‘intelligent organisations’. Islington CCG will create a health intelligence system through its Performance and Information Strategy to ensure that timely, accurate and appropriate information is available to relevant staff that will:

· Inform how the CCG delivers services by understanding about the health (and social) care needs and wants of patients and their experience of the services they use

· Support Needs assessment covering the health and well-being of the whole population Provide knowledge of ‘ Health in Islington’ , - data, knowledge and surveillance information, population health profiles, from Public Health to shape the Joint Strategic Health Needs Assessment (JSNA) and other planning documents and to understand gaps in service, the outcomes and impact of commissioning decisions and service transformations on the health and well-being of the population of Islington

· Ensure there exists an appropriate assurance framework to serve external performance management and compliance regimes and any other regulatory requirements

· Ensure a firm grip on the finances of the CCG and ensure we develop and achieve sound Investment plans, create informed budgets based on sound financial information and monitor the financial impact of our decisions.

· Inform on priorities to direct resources, ensuring that the CCG achieves ‘Value for Money’ in its commissioning and through the monitoring and management of the Service Level Agreement (SLA) with the Commissioning Support Unit (CSU)

· Inform planning and commissioning to enable continuous improvement through o Information on provider performance against contracted activity and cost,

quality and safety standards o the provision of performance information and trend analysis in key areas of

service delivery delivering service and financial planning models for Acute, Mental Health, Community and other Any Qualified Provider (AQP) contracts

· Monitor contracts, providing assurance on contract compliance against financial, quality and activity targets and standards, while exposing areas of poor performance for remediation

· Assess, inform and monitor commissioning decisions aimed at delivering improved outcomes across the health system, reporting on the impact and success of decommissioning (e.g. POLCE), shifts in care from secondary to community settings, Disinvestment (e.g. Reduced New to Follow up ratios, stretch contract targets) recovery plans (e.g. Whittington ED performance) and implementation of Payment by Results (PbR) initiatives (e.g. implementation of new Maternity Tariffs, Mental Health PbR)

· Ensure that the QIPP programme is in line with local priorities and is being effectively delivered within budget and agreed timelines

· Inform the development , outcomes and impact of Integrated Care initiatives

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· Facilitate innovation by presenting ‘deep dive’ information that gets to the root of service delivery issues and provides an evidence base for service transformation, and metrics to adjudge the effectiveness of those changes following implementation

· Enable the setting and monitoring of stretching CQUINs, KPIs and Quality Indicator targets within the contracts which can be monitored to improve standards, set against ICCG plans

· Monitoring quality indicators and standards outside of those specified in contracts · Support the benchmarking of ICCG services against the ‘Best performers’ to help

drive up the standards and quality of care · Enable GPs to understand their performance to enable individual, evidence based

Practice service changes or as part of a matrix of service developments across the borough.

· Use the new Calculating Quality Reporting Service (CQRS) to calculate achievements and payments on quality services delivered by GP services, including Quality and Outcomes Framework (QOF), nationally commissioned enhanced services and services commissioned locally that go beyond the National GP contract.

· Provide information to support Medicines Management and enhance Prescribing practices

· Support GPs to focus resources by understanding those patients who carry the highest risk of consuming high levels of resource through risk stratification techniques

· Ensure information is available to Practices to support their developmental needs and the strategic needs of the practice(2 way accountability)

· Inform and monitor the delivery of the objectives and health outcomes established in the Health and Well-being (HWB) strategy, Joint Commissioning , CSP plans and informing the London Quality Surveillance Network

· Enable the CCG to provide assurance of overall performance to North Central London (NCL) cluster during the Transition and thereafter, the NHS Commissioning Board

· Enable the CCG to provide assurance to the population of Islington by publishing relevant information on our Web site and other media, on our performance as local Commissioners

· Communicate the outcome of new initiatives to stakeholders · Provide appropriate information to the population of Islington that supports choices,

provides information that can influence changes to the way people live their lives and enables a culture of ‘no decision about me without me’2

· To monitor the use of patient focused systems such as Choose and Book and 111 Directory of Services

· Inform the development of annual reporting, special investigations, business cases and consultation documents and support communications to key stakeholders on the CCG contribution to the Health and Well-being strategy3

· Assess the performance of the CCG in relation to its peers through Benchmarking techniques to assist in identifying best practice and potential quality and efficiency gains

2 The Power of Information: Putting all of us in control of the health and care information we need. Department of Health, May 2012 3 The CCG has a legal obligation to review the extent of the CCG’s contribution to the delivery of the local joint health and wellbeing strategy

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· Assure compliance with regulation and statutory requirements a, such as implementation of best practice/ NICE guidance

· Provide information in relation the National Outcomes Framework to help monitor our progress and strive for continuous improvement

To achieve this, information will need to be sourced from a range of partner organisations including Public Health, the Commissioning Support Unit (currently NCL), Local Authority, London Ambulance Services, Providers in Mental Health, Acute and Community Services (including new Providers moving into the market), Healthwatch (currently LINk) and local Voluntary Groups and General Practitioners. 3. Key Principles In delivering a Performance and Information Strategy, we acknowledge some key principles to underpin it. Others may well emerge as the CCG matures.

· All information used to effect commissioning and changes in behaviour, decisions or outcome should always be related to information derived from our patients (and/or their carers) to ensure we put our patients in the heart of everything we do, so patient stories or narratives, information on patient feedback and experience should always form part of our analysis to provide a patient centred ‘whole picture’

· Primary Information should reflect individual patient journeys along a range of pathways in health and social care settings

· Information should be used to stimulate action whenever possible – if it does not, we should not waste resources in collecting, analysing and deliberating on it

· Monitoring reports should provide a commentary about what actions need to be taken and update on what progress has been made against previously identified actions

· We will not only focus on clinical and service outcomes, we will endeavour to measure the Impact of decisions on the population of Islington and so assess the success of our Aims

· All decision making bodies and individuals should have access to all the information necessary to make robust and enduring decisions in a timely manner

· Reports with data and quantitative information should also always be accompanied by commentary and qualitative information to provide context/intelligence

· Data should be derived from the same sources and used by all, to create ‘a single version of the truth’.

· ICCG will do everything within the letter and spirit of legislation and guidance, and in particular adhere to the highest possible information governance standards

4. Proposed Approach We recognise that in a changing landscape, we will still need some time to fully develop our plans around Performance and Information. Indeed, the assurance framework set by the NHS Commissioning Board is still to be finalised; so this strategy sets out our current thinking. The NHS reforms will enable different approaches to health and social care delivery, so it follows that our information requirements, as a CCG will differ. Our Performance and Information strategy should be ambitious, leading edge and unafraid to articulate that ICCG proposes to deliver results based on its sophisticated use of information and health

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intelligence. The strategy should underpin ICCG as a recognised ‘Centre of Excellence’ in the commissioning and delivery of patient focused healthcare to a well informed, proactive population who are in control of their health and healthcare. We will be flexible and adaptive to external and internal organisational changes and learning that will emerge on our journey towards becoming a high functioning CCG. It will set a framework for the different healthcare market that is emerging and enable ICCG to deliver a credible, achievable, affordable and measurable Commissioning Strategy Plan (CSP) in response to the changing commissioning backdrop. During the transition period to end of March 2013, the Performance and Information (P&I) function will be developed so that relevant information is available to individual staff and various planning and governance groups at the time they need it, in a format that is appropriate to support them in the delivery of their various functions and tasks. The CCG have therefore invested in a Board level post during this period to deliver the necessary technology, structures and processes that will not form part of the staffing structure after March 2013. The potential to cut a rich volume of data in different ways will be considerable. Information will be available to truly understand demand and match provision accordingly. ICCG should be able to forecast unscheduled need on an individual and population basis and make provision to meet these needs in imaginative and cost effective ways. Linked with social marketing techniques and through engaging patients in healthcare design, ICCG will ensure the best, most cost effective use of services is made. It is not atypical to see ‘data rich and information poor’ organisations where there are bulky sets of ‘management packs’ gathering dust. A typical reason is that information lacks relevance and completeness. Therefore the ICCG P&I strategy will be based on a robust analysis of information requirements to provide the decision making bodies with the timely and sufficient information they need.

The strategy will be delivered in phases; Initially working towards creating ‘an intelligent organisation’ to support the delivery of our aims and objectives for health and social care, then increasingly moving towards providing information to support Patient choices in line with the results of the Governments consultation on Information4 There is an imperative throughout the development of the Performance and Information Strategy to ensure the necessary Information Governance requirements are in place and strictly observed.

5. The technical framework 5.1 Data collection and Storage Data can be described as Information in raw or unorganised form. Currently, the key data providers are NCL. As they move towards becoming the Commissioning Support Unit (CSU) they should maintain a responsibility to derive good quality data from Providers, either directly or from the Department of Health’s Information Centre Secondary Uses Service (SUS), store it safely and securely and supply it to their Information/Analytics

4 Liberating the NHS: An information Revolution: A consultation proposal. Department of Health, Oct 2010

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function. ICCG will establish a robust Service Level Agreement (SLA) with the CSU to provide a range of services to support the realisation of the P&I aims. The ICCG P&I team also store data from SUS (PbR Inpatient spells, Outpatients and Accident and Emergency) and Service Level Agreement Management (SLAM) information in a local data warehouse. This warehouse also holds information on Prescribing to support medicines management and holds local community (GPwSI etc) data on ENT, Dermatology and Diabetes, Practice list sizes by 5 year age bands and sex (quarterly updated), Quality and Outcomes Framework (QOF) annual metrics and InHealth Diagnostics data. Also in development is data on Choose and Book and the CCG is about to receive raw data from Mental Health and Community services Providers via NCL/CSU. A pivotal data source is from GP systems and work is underway to ensure that the necessary primary care information is derived to support Risk Stratification and Integrated Care and which will enable the CCG to track patient journeys in primary, community and secondary care settings. Increasingly, data will be available from Local Authority sources. There is no reason that as NCL moves towards becoming the CSU, that they should not house the ICCG data warehouse and even share or amalgamate it as a data source in future. 5.2 Delivering Information Data that has been verified and is specific, organised for a purpose and presented within a context which gives meaning and relevance can be described as information. Information can also be non-data derived and is usually described as ‘knowledge’, derived from experience. Both elements are needed for Health Intelligence. Although this may sound pedantic, within the context of the CCG P&I strategy, it is important as it relates to the principle of ensuring we look at the ‘whole picture’ and use collective information to understand the impact of decisions across the health economy and distribute resources accordingly. NCL /CSU currently provide the CCG with a range of information from their Information and Performance teams which cover contract activity and financial performance and performance of Providers against National Key Performance Indicators (KPIs). At present it predominantly loaded to reflect Acute Provider performance and we will work with NCL to expand the delivery of information, particularly in relation to supporting the delivery of community and mental health contracts and contracts relating to other areas of delegated responsibility (elderly, children, learning disabilities etc). A key piece of work will be aimed at ensuring the CSU are able to report on the CCGs local targets derived from local commissioning initiatives and Health and Well Being objectives. Additional Information is derived from Public Health which will be delivered under SLA with an identified ‘Core offer’ which will be developed and managed through the AD of Performance and Information. Public Health provides the CCG with information on Primary care related targets such as immunisation, cytology uptake etc, information on the ‘health of the population’ and GP Profiles as well as ‘deep dive ‘reviews and outcome based analysis of population needs which are highly valued and play a significant role in shaping ICCG commissioning intentions. Information is sent to the Local Authority (LA) directly from Providers to monitor jointly commissioned contracts and further work is being undertaken in respect of capturing and

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using information relating to LA services. In particular, ICCG and LA are developing information flows to support the delivery and monitoring of integrated care. We are able to use data in our CCG warehouse to produce a range of information reports in relation to the requirements outlined in section 1, using an On Line Analytical Processing (OLAP) tool which is called ‘Analyser’. This is available to all CCG staff and Islington GPs and is currently used in varying degrees. We aim that this tool will be delivered to the desktops of key decision makers and planners and will deliver training to key CCG managers, GPs and other users to support their needs for information - while recognising that this may be a significant challenge for some users. However, this ‘self service’ approach to extracting information will offer the most cost effective way of delivering a significant amount of information to the CCG and enable a lean information analytics team to support the delivery of other information requirements such as ‘deep dive’ analysis and ad hoc reports. The system will enable significant automation and allow the analysts to pull down updated Board and Committee reports. The CCG is about to launch regular monthly reports to be available to GPs and/or Practice Managers, either in paper format or electronically via Analyser. This information will support GPs to develop their Practices and be the foundation of the Board Link visits between Practices and ICCG which will commence in October 2012.

Public Health

Figure Two: Levels of Information required for ICCG

Patients

GPs

Islington Localities

GP Practices

Islington CCG

Cluster/London-wide

ICCG/GPs

Commissioning Support Unit

London Borough of Islington

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5.3 Information Analysis Information and raw data can be cut in different ways to form different views or make linkages and correlations that may have not been previously established. This level of analysis is often referred to as ‘forensic’ or ‘deep dive’ analyses and employs a range of analytical and statistical analysis techniques. It can be vital in establishing the root cause of changes in performance and informing commissioning and resource allocation priorities, particularly if aligned with information on population needs assessment and other Public Health information. Public Health already provides an outstanding analytic service across a range of topics and further work to align this work to our future needs will be undertaken. ICCG are currently working with Public Health to enable their information, in particular information to support PH LES’, to be available through Analyser to GPs. Strategically, using information from a range of different sources to create a richer source of intelligence will enable greater depth and complex analysis. The CCG P&I function will increasingly move towards the provision of this type of work, using the CSS to deliver more ‘routine reporting’. There is a proposal in the CSU structure to have an ‘outreach post’ for each CCG and it is envisaged this work will also be ideally suited to this role. (See Section 6) To achieve this deeper level of understanding, the ultimate aim will be to provide information that reflects the balance of services across the health and social care landscape and creates a picture of the ‘health’ of the economy as a whole. By using a ‘whole systems’ approach we can ensure that actions in one area are not adversely affecting another and track the move of services from secondary to community and primary care settings. This will be hugely important for the successful delivery of Integrated Care and to maintain financial viability of the Providers. A whole economy approach to information will support the development of financial information to embrace ‘whole life costing’ where the price over time takes precedence over looking at immediate costs and will inform our strategic planning and this will developed further as we develop financial information reporting. In addition to providing information as the evidence base for good decision making, a second function lies in the use of information for assurance and performance management purposes; to ensure that ICCG is able to deliver appropriate levels of governance, hold its providers accountable and in turn, provide assurance to the bodies to which it is accountable – the NHS Commissioning Board and, importantly, the population of Islington. For this, a range of Scorecards and dashboard are being established to present information appropriate to the level of assurance required and which are easy to interpret. There is now an established Board level report with a scorecard and dashboard, and dashboards to support the Quality and Governance Committee. This is currently being re-designed to provide an integrated report, encompassing financial, contracting & quality performance reporting. Further work is being undertaken to provide assurance mechanism for the Finance and Performance Committee. In addition a set of metrics are being established through a Task to Finish group to support the delivery and performance management of Integrated care which support the IC Board and its operational/development groups. A ‘Storyboard’ is being developed to support the Patient and Public Participation Group which will inform the CCG of performance and be available to patients and the Public. This work will be extended to provide information to inform

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choices about their own health and healthcare. An exercise to ensure the Service Improvement Group (SIG) has the decision support information it needs has commenced. Initially Boards, committees and groups should have a wide range of information (metrics, indicators and outcome measures. But over time, consideration should be made towards ‘exception reporting’ once confidence in the data and performance grows. Still to be established is the Assurance and planning framework for NHSCB and work will continue to ensure ICCG is able to respond to the requirements of this process and influence its development. We would aim that information does not need to be specifically derived for this purpose, but is a by product of the existing internal reporting processes. Currently NCL as a Proto NCB provide a partially completed template which is completed at the CCG and used to support an Integrated Performance Management review meeting each month.

6. CCG P&I Staffing The future CCG P&I staffing is based on an AD of Performance and Information (Band 8c) accountable to the Chief Finance Officer and with close links to the Director of Commissioning. This post will coordinate the function and be responsible for future development and delivery of the framework, manage the day to day work of an out posted information analyst from the CSU, manage the relationship with the Public Health informatics department as well as working closely with the information, health intelligence and performance resources provided through the CSU. They will drive as much valuable output from the CSU as is practical. There is also a substantive Information Analyst (Band 7) in post. Two interim system developers are in post until March 2013 to ensure the self service system (Analyser) is in place. The CCG needs will become further established and insight will emerge relating to the efficacy and effectiveness of services received from the CSU. With the emphasis also on ‘self-service’ to staff, the CCG should continuously review the balance of internal and external resourcing to ensure cost efficiency. A support and maintenance contract for Analyser will need to be put in place to ensure this facility remains available to ICCG staff and GP members and nominated Partners, such as LB Islington and Camden Public Health. In addition to developing Analyser and automating the scorecards and dashboards, P&I will make available a library of pre-prepared reports, which will be regularly updated. An initial key role of the AD will be ensuring performance information is available to GPs on a regular basis and to support Board Link visits. 7. Data Quality If the quality of the data used is poor, then the wrong interpretation and conclusions could be made, so data quality (DQ) is a key component to any high performing intelligence function and will continue to be a priority for the work of the ICCG P&I function. There is a

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recognition that DQ should improve. A process has been set up with the CSU to identify and log key DQ issues and ensure they are dealt with by the Providers through the Contract Technical Groups. It will also ensure that DQ issues are captured for inclusion in the data quality development plans set out in Schedule 14B of the Provider contracts. 8. Establishing Measures Because of the importance of this area, a short explanation of this work is useful. Regulatory guidelines have traditionally dictated critical areas of performance. The reforms have impacted significantly on this and put at the heart of health and social care, the HWB strategy and with it, the ability of CCGs to set their own local priorities; creating a different framework for measuring performance. Although we will still need to respond to nationally set targets and requirements of compliance frameworks, in future will increasingly set our own measures and information requirements. The measures we establish as a CCG will reveal the success of our ambitions, as articulated in the various strategy documents developed, both as a CCG and as part of the wider health and social care economy. Health and Wellbeing boards will use JSNAs and joint HWB strategies to set and measure outcomes for the local community; but they will also be able to align these local priorities with the National Outcomes Frameworks for the NHS, public health and adult social care. We can therefore be bold and innovative in how we approach the development of our performance management framework. While sharing good practice and learning from other CCGS, we should also aim to be leading edge in London. Establishing ‘Impact Measures’ and ‘Measures of innovation’ are examples of how we would do this. We also have an opportunity to consider how commissioning of services related to wider health determinants such as housing, education or lifestyle behaviours can be more closely integrated with commissioning of health and social care services – and this will also affect the way our strategy pans out. 9. Information for Patients The ultimate vision of the Governments proposed ‘Information Revolution’ is to provide a framework where patients will have complete and easy electronic access enabling more choice and control and be in charge of making decisions about their care.

- their own health information from cradle to grave - the information they need to make informed decisions about their health & care

providers - the information they need to make informed decisions about their care

Islington Clinical Commissioning Group will engage patients and the public on an ongoing basis when undertaking commissioning responsibilities. In turn the CCG will support its constituent practices by working closely with the patients and local communities they serve, including through Local Involvement Networks (Healthwatch), locality patient participation groups and community partners. From this, we will aim to be a front runner in realising this ambition, providing GPs with information on service performance, to support Choose and Book discussions and providing information to patients, not only on our performance as a CCG but on the performance of our commissioned Providers. We will provide clear and

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comprehensive signposting information to Patients even if legislative responsibilities lay with other Health and Social care organisations. 10. Concluding remarks We have begun to set up the process of delivering information and healthcare intelligence to enable the allocation of the right resources, at the right time, in the right areas. The development of the NHS Commissioning Performance Framework will impact on the deliverables from the P&I function and as the CCG transitions from an emerging organisation to one of maturity, its needs and requirements for different types of decision support and performance management information may also change. We will increasingly use more benchmarking information for supporting decisions, in promoting good practice and driving efficiencies and service improvements and this will play a significant part in delivering intelligence. The implementation of this framework is therefore a journey which will be articulated more fully in future documents and in actions as the ICCG develops. Jacky Kutner Interim Director of Performance and Information October 2012

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Integrated Quality, Finance and Performance Report

Period ending 31 October 2012 LEAD DIRECTOR: Alison Blair, Chief Officer AUTHORS: Jacky Kutner, Interim Director of Performance and Information

Ahmet Koray, Chief Finance Officer Sophie Lusby, Programme Director – Authorisation and QIPP Paul Sinden, Director of Commissioning Martin Machray, Director of Quality and Integrated Governance

CONTACT DETAILS:

[email protected] Katie McInerney, PA to Jacky Kutner, 020 7527 1361 [email protected]

SUMMARY: This Integrated Performance report reflects the CCG performance against a number of key indicators. The report sets out the financial position and overall performance of Islington CCG for the period ending 31 October 2012. Overall, Islington CCG is performing satisfactorily for the period ending 31 October 2012. SUPPORTING PAPERS: Appendix 5.1a: - Financial Performance Appendix 5.1b: Islington Clinical Commissioning Group Dashboard Cycle #8 2012 Appendix 5.1c: Islington Clinical Commissioning Group Scorecard. Key Performance Indicators - Board Monitoring Report - Cycle #8 October 2012 KEY: LMC: Local Medical Committee QIPP: Quality, Innovation, Productivity and Prevention UCLH: University College London Hospital NA: Non-applicable TBC: To be confirmed



· NOTE the contents of this report

GOVERNANCE:

Members with voting rights Members without voting rights Dr Gillian Greenhough

Chair

Marian Harrington

Local Authority Representative


Gerry McMullan



Joint Vice Chairs (Clinical)

Robbie Bunt LMC Representative





Dr Rathini Ratnavel













Dr Mo Akmal


Objective(s) / Plans supported by this paper: This paper provides an overview of the performance of services relating to Islington registered population. It encapsulates all Islington CCG’s key objectives and plans. Audit Trail: (Details of the groups or committees that have received the paper including dates) NHS North Central London Cluster receives a report which details the same information which is used to underpin the monthly Integrated Performance Review meeting with NHS North Central London (NHS Commissioning Board from November 2012). Various elements of this paper have been discussed at the three main Governing Body Committees, as appropriate.

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Patient & Public Involvement (PPI): CCG Performance in this area is addressed in this paper Equality Impact Assessment: None specific Risks: This report is one element used to monitor the CCG against its top three risks Resource Implications: None specific

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Introduction This report is the second to be presented in the new integrated format to the Governing Body and it will be continuously improved based on feedback in the coming months. Overall, Islington Clinical Commissioning Group is performing satisfactorily for the period ending 31 October 2012. 1. Financial Position – Summary

1.1 At the end of October 2012 (Month 7), Islington’s financial position:

· Recorded an in-month surplus of £3m, £2.2m above plan (see Appendix A). · Increased the cumulative surplus to £11.3m, £6m above the £5.3m plan

surplus (see Appendix A).

· The forecast outturn based on performance over the first seven months of the year and after considering risks and opportunities, is a £16.7m surplus. This is a further change against the planned surplus (£9.1m) and the revised forecast presented three months ago (£13.2m).

· The improvement in the forecast is being driven by the projected

performance of acute expenditure against planned levels and underspends on operating costs.

· Delegated budgets recorded a £628k underspend this month and are

forecast to be £4.9m underspent by the year-end (see Appendix A).

· QIPP savings of £645k were delivered this month. For the first seven months of the year, £4.7m of savings have been achieved and the forecast remains to achieve £9.1m for the year.

· Our run-rate is currently a £1.5m surplus per month, 4% of resource limit.

1.2 In-month performance was £2.2m under budget as a result of:

· Reversing accruals that are no longer required for Public Health non-commissioning costs (£1.4m).

· Acute contracts continue to underspend against plan (£426k this month and

£1.4m cumulatively) with performance at the Royal Free and Bart’s and the London being the two main contributors. The Bart’s & the London position is being driven by underspends on critical care bed costs (£1.2m).

· Non-acute budgets relating to mental health and community services were

underspent by £81k and £202k respectively.

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1.3 The table below summaries the current position, with a more detailed analysis provided in Appendix A. Month Year-to-End (YTD) Variance Variance Rating Budget Actual Variance Variance Rating £k % £k £k £k % Revenue Resource Limit 0 0.0% GREEN (276,649) (276,649) 0 0.0% GREEN

Acute & Integrated Care 426 2.0% GREEN 142,412 141,057 1,355 1.0% GREEN

Non Acute 202 2.3% GREEN 56,327 55,584 743 1.3% GREEN CCG delegated budgets Total 628 2.1% GREEN 198,738 196,640 2,098 1.1% GREEN

NCB shadow budgets - Primary Care

(7) (0.1)% AMBER 50,676 50,459 217 0.4% GREEN

Public Health 44 5.9% GREEN 5,268 5,219 49 0.9% GREEN

Operating Costs 1,397 50.6% GREEN 15,361 13,051 2,310 15.0% GREEN Other (QIPP, Reserves and contingencies)

186 100.0% GREEN 1,304 0 1,304 100.0% GREEN

Total Expenditure 2,249 5.4% GREEN 271,348 265,369 5,979 2.2% GREEN

Net Surplus 2,249 297.3% GREEN 5,300 11,279 5,979 2.2% GREEN

2. Acute and Integrated Care Expenditure

2.1 The overall acute category of expenditure improved by £426k this month, with both inner and outer sector contracts recording positive variances of £127k and £319k respectively. These were offset by overspends against the cost of Service Level Agreement excluded items (drugs and devices) and non-contracted activity, i.e. where Islington registered patient activity was delivered by providers we do not have contracts with.

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2.2 The table below shows the in-sector position by provider. All contracts except UCLH, Moorfields and Barnet and Chase Farm are underspent, with the Royal Free the most significant (£846k). IN SECTOR

BC

F

GO

SH

ME

H

NM

ID

RFR

EE

RN

OH

WH

ITT

(AC

UTE

)

WH

ITT

(ICO

)

UC

LH

IN S

ECTO

R

TOTA

L

£000's Plan 236 1,940 1,908 720 10,004 707 38,261 23,494 44,342 121,614

Projected Outturn 277 1,780 2,227 571 9,178 616 38,129 23,285 44,625 120,688

Cap & Collar 0 0 0 (149) 20 0 (132) 0 (262)

Adjusted Outturn 277 1,780 2,227 720 9,159 616 38,261 23,285 44,625 120,950

Variance (41) 160 (319) 0 846 91 0 209 (282) 663

% Variance (17%) 8% (17%) 0% 8% 13% 0% 1% (1%) 1%

2.2 The positive out-of-sector variance of £980k is due to lower than planned expenditure with the Bart’s & the London (£1.2m) contract and in the main, activity associated with critical care access. This activity is very high cost, low volume and extremely variable and any underspend should be considered with risk.

OUT OF SECTOR

BA

RTS

CH

ELW

ES

T

GS

TT

HO

ME

RTO

N

IMP

ER

IAL

KIN

GS

NW

LH

R

BR

OM

PTO

N

ST

GE

OR

GE

S

R M

AR

SD

EN

OX

FOR

D

OU

T O

F SE

CTO

R

TOTA

L

£000's Plan 5,936 604 1,220 2,458 1,022 286 130 338 111 165 50 12,321 Projected Outturn 4,752 736 1,338 2,271 1,113 210 111 414 140 203 54 11,341

Cap & Collar 0 0 0 0 0 0 0 0 0 0 0 0

Adjusted Outturn 4,752 736 1,338 2,271 1,113 210 111 414 140 203 54 11,341

Variance 1,184 (132) (118) 187 (91) 77 19 (75) (28) (38) (4) 980

% Variance 20% (22%) (10%) 8% (9%) 27% 14% (22%) (25%) (23%) (8%) 8%

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3. Operating Plan for 2012/13 – QIPP and Investment 3.1 Table 1 below provides an update on savings delivered through the QIPP plan for 2012/13:

Table 1: QIPP Performance QIPP Plan Actual Variance £000 £000 £000 Acute 4,041 3,377 -664 Primary Care 300 225 -75 Primary Care Medicines Management 1,186 1,400 +214 New Pathways of Care 1,197 668 -529 Mental Health & Joint Commissioning 1,907 1,907 0 Adults & Older People 860 860 0 Children 101 101 0 Prevention 0 0 0 QIPP Stretch (acute activity) 3,861 612 -3,249 Total 13,452 9,150 -4,302

Table One: Islington CCG QIPP plan for 2012/13 3.2 At month seven the QIPP plan is forecast to underachieve by £4.3m, compared to £2.1m at month six, with slippage accruing from:

· A £2m change in the QIPP target to reflect the outcome of the UCLH contract,

in addition to the £1.2m shortfall reported at month six

· Implementation of the policy on procedures of limited clinical effectiveness (PoLCE), although predicted savings have increased to £337k from £150k

· Primary care contracts across general practice, dentistry, optometry and

community pharmacy, with London First methodology yielding less savings on list accuracy than anticipated

· Referral management and the introduction of new pathways of care as an

alternative to acute referral. 3.3 Slippage in these areas is partially offset by an over recovery of savings for Primary Care Medicines Management. Further recovery may accrue from Continuing Care with the underspend against budget reported in month seven accounts not yet reflected in year end savings. 3.4. The month seven forecast savings at £9.2m, is marginally less than the £9.4m reported at month six.

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3.5. Table 2 provides a summary of the sources and application of QIPP investments in 2012/13:

Table 2: Investment Progress Investments Plan Actual Variance £000 £000 £000 Recurrent 8,400 6,500 -1,900 Non-recurrent 4,000 800 -3,200 Primary Care Development 1,800 1,800 0 Total 14,200 9,100 5,100

Table 2: Summary of the sources and application of QIPP investments in 2012/13: 3.6 The forecast outturn reported in Table 2 is as per the report to the September 2012 Governing Body, with a £1.9m forecast under spend on recurrent investment funds and a £3.2m forecast under spend of the £4m non-recurrent funds released from brought forward surplus. 3.7 Actions being undertaken to reduce the forecast under spends on both the recurrent and non-recurrent investment sources include:

· Expanding community capacity at Whittington Health to align with the requirements of the Primary Care and Integrated Care Strategy, with investment focussing on rapid response, community geriatrician capacity, and community in-reach into acute services

· The accelerated roll-out of EMIS Web into general practice by December 2012, compared to the original timetable of December 2013

· Bringing forward investment priorities from 2013/14 into 2012/13

· Identification of non-recurrent investment options in 2012/13.

3.7 Non-recurrent investment opportunities identified for 2012/13 were reported to the November 2012 Finance & Performance Committee, and a report for sign-off will be submitted to the December 2012 Committee meeting.

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4. Financial Risks and Opportunities 4.1 After taking account of known factors, the estimate of financial risk or opportunity facing Islington CCG over and above the current forecast is a fully mitigated position, i.e. risks of £7m have mitigations of £7m identified against them.

Current Estimate

£’000 Risks Additional QIPP target within UCLH contract 2,000 Acute contracts delivered to plan, i.e. no forecast underspends (incl. critical care beds) 2,300 Further 20% QIPP slippage against current forecast 1,800 Continuing care retrospective claims 1,000

Total risks 7,100 Mitigations Potential budget surplus (non-acute) 1,000 Slippage on investments remains (but £3.2m of non-recurrent assumed spent) 1,900 Slippage on primary care investment programme (from £6m total budget) 1,000 Unallocated reserves 3,100

Total opportunities 7,000 Net Risk or Opportunity 0

5. Feedback from last Integrated Performance Review of Islington CCG with NHS North Central London 5.1 The review meeting for November between NHS North Central London (NCL) and the CCG was held on 7th November. It was recommended that a root cause review was undertaken in relation to the 4 hour wait targets at both Whittington and UCLH hospitals, and the C-Diff cumulative performance which has been requested of the Commissioning Support Unit (CSU.) 5.2 The next meeting is with the NHS Commissioning Board and is scheduled to take place on 29th November. This is to be an Assurance and Development meeting, arranged with Anne Rainsberry and her Commissioning Board senior team where a presentation has been requested. 5.3 The purpose of this initial meeting is to develop a common understanding of the CCG’s position in relation to delivery (performance, finance, QIPP etc), authorisation and strategic issues. 6. Performance against Key Indicators and Local Priorities

6.1 This section focuses on the key performance issues for the period ending 31 October 2012 and represents cycle #8 of the year. The time frames for the information are indicated throughout in the commentary. The most up to date figures

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are used where available, although some of these remain subject to validation. This month, the Governing Body is meeting before the most up to date information has been fully supplied by North Central Cluster (NCL). Further verbal updates may be given at the meeting.

7. Key Performance Attainments this Period 7.1 Diagnostic Waits over 6 weeks: This target is to achieve fewer than 1% of patients waiting over 6 weeks for diagnostic tests. The performance has improved to a reported ‘green’ position of 0.34% in October. Islington CCG will continue to carefully monitor the position. 7.2 New Birth visits, though still not performing to the desired level of visits within 14 days, have considerably improved from 68% in July to 79% in August.

7.3 Maternity access within 12 weeks 6 days at the Whittington Integrated Care Organisation, moved from 89.7% in August to 96.6% in September. Note this measure is an indicator only and does not fully address the issue of late bookings which is captured in the national measure which picks up both bookings and births – the latest indicator for this is Q4 11/12 – 83.52% against a 90% threshold. 7.4 Cancer waits performance remains above the threshold for all measures except the 2 week wait breast symptomatic target (91.5% - Amber)

7.5 The number of GPs making a contribution to child protection case conferences for October 2012 is 86%, rising from 83% last month. This is significantly higher than elsewhere in London. An audit of the quality of reports has been completed and will be available shortly.

8. Areas of Performance for Improvement The following performance areas are indicated as needing further improvement: 8.1 The overall A&E 4 hour wait was reported as 93.80% for October and continues to give serious concern. At week ending 18th November, UCLH had a performance of 93.77% and Whittington Hospital, 94.15%. All other NCL trusts had met the 95% threshold apart from UCLH and the Whittington.

8.2 UCLH are reporting on-going pressures in what is now the 8th consecutive week of underperformance on the 95% threshold. The trust continue to focus efforts on recovering performance on the 4 hour wait threshold and has implemented the Acute Tower Improvement Plan which is being driven by a CEO chaired group currently meeting three times a week (Mondays, Wednesdays, Fridays) to review actions and performance.

8.3 Whittington Health has reported that the majority of breaches (70%) took place Monday to Wednesday last week mainly due to waits for specialist opinion, delays in A&E assessment and overall bed capacity issues.

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Exception reports have been received from both trusts. 8.2 Improving Access to Psychological Therapies (IAPT). Although the figures are not updated this please note that an action plan has been agreed with Camden & Islington Foundation Trust and a full written report has been delivered to the Finance and Performance Committee. 8.3 A Mixed Sex Accommodation (MSA) breach was reported in October. 8.4 Podiatry and Physiotherapy waits continue to give concern. These have been introduced into the scorecard for the first time this month. At present, the average waits are 6 weeks for Podiatry and 13 weeks for Physiotherapy. Discussions are being held with Whittington ICO regarding their failure to reach the required maximum 6 week wait and a rectification plan is to be produced.

Graph One: Average number of weeks wait for Physiotherapy – Whittington ICO 2012/13 8.5 Infection Control: C Diff and MRSA: The table below shows the current performance of our two major providers. 36 C.diff cases have been reported by UCLH on the HPA database, which is above the year to date plan of 32 cases for this stage of the year. There is an agreed C.diff reduction strategy and implementation/delivery plan including work on anti-microbial stewardship and environmental vapour cleaning being implemented by the Trust. This was discussed at the last UCLH Infection Control Committee and shared with the NHS NCL IC and performance teams. It has also been reviewed at the monthly clinical quality review group meeting in November. 8.6 UCLH has reported the largest number of hospital acquired cases within Islington this year and as a Trust is above year to date trajectory for acquisition. The UCLH infection control team are reporting to their Board monthly on actions to reduce further acquisition. At this stage of the year last year there were 29 cases reported for Islington who reported 47 cases by the end of the year against an annual threshold of 65. We are advised that we are not observing something significantly different from last year’s picture in terms of actual reported number of cases. Anti-microbial stewardship is key to reducing the incidence of C.diff and the main learning for any provider will be around prudent prescribing and the Trust are fully committed to implementing the agreed actions.

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ACUTE TRUSTS HCAI UPDATE 1ST APRIL 2012 – 30TH SEPTEMBER 2012

Acute Trust MRSA Bacteraemia

2012 - 2013 C.difficile

2012 - 2013 Objective Reported Objective Reported

Whittington 1 1 20 7

9. Authorisation 9.1 The CCG is entering the final stages of the authorisation process. At the end of October 2012, the NHSCB convened a ‘Conditions Panel’ to consider the Site Visit Report and draft conditions for the CCG based directly on the remaining red radio buttons that were agreed by the assessment panel.

9.2 The CCG was pleased to note that the draft conditions presented to them were in the five areas that had already been identified in the feedback from the assessment panel on the day. As part of the process the CCG was now invited to respond to these conditions. In regards to four of the five conditions, the NHSCB advised the CCG that additional evidence could now be accepted and asked that this be provided, alongside a ‘considered response’. This would be discussed at the Authorisation Sub Committee of the NHSCB on 5th December 2012. The submission was made within the deadline on 19th November 2012.

9.3 The expectation is that the Authorisation Sub Committee will accept this new evidence and we will be left with one remaining condition, competency 5.1A, relating to CCG Collaboration, for discharge in the New Year. Whilst there is no detailed process outlined as yet the indications are that the NHSCB will perform a review of remaining conditions in March 2013 across the country. We confidently expect the condition to discharge itself in preparation for the planning round over December 2012 as we move into the contracting and implementation phase of our collaborative plans across North Central London. 10. Patient Related Performance Monitoring 10.1 Work continues on developing a Patient and Public Participation (PPP) ‘storyboard’ that will capture both qualitative and quantitative information, including patient stories. This was discussed at the PPP working group on 22 November 2012 and a draft document is in the process of being drawn up for consultation. 11. GP Performance 11.1 This is a new section to the report this month and will be expanded next month following further discussion at the Governing Body meeting. It is proposed, the initial

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information will focus on general information; the number of first Out Patient appointments, Accident and Emergency attendances and planned and unplanned activity each month. 11.2 From January 2012, Islington GPs will be sent information concerning their individual activity to assist in their performance management.

12. Next Steps – Performance Management · Further work will be undertaken to further improve the reporting of more timely

information and the presentation to Board. Work continues to identify increasing numbers of KPIs and set up the relevant data sources.

· The Performance and Information Strategy went the Finance and Performance Committee in November and will be on the December Board Meeting Agenda

· Presentations and Training sessions for Analyser, the CCGs on line ‘self-service’ reporting tool have taken place in November and further training and demonstrations arranged for December.

· A process has been put in place so that monthly GP information reports can be automatically generated. These have been used to support the GP Board link visits and will commence being sent out on a monthly basis in January 2013. Copies will also be available on Analyser, the CCG on line information system.

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APPENDIX 5.1a – Islington CCG detailed year-to-date actual and full year financial position Period Ending 31 October 2012 (Month 7)

Month Year-to-date (YTD) Full Year Budget Actual Variance Rating Budget Actual Variance Rating Budget Forecast Variance Rating £k £k £k % £k £k £k % £k £k £k %

Revenue Resource Limit (42,545) (42,545) 0 0.0% GREEN (276,649) (276,649) 0 0.0% GREEN (491,994) (491,994) 0 0.0% GREEN

CCG Delegated Budgets

Acute & Integrated Care NHS SLA - In Sector

18,734 18,607 127 0.7% GREEN 121,713 120,950 763 0.6% GREEN 208,695 207,518 1,177 0.6% GREEN

Acute & Integrated Care NHS SLA - Out of Sector

1,901 1,582 319 16.8% GREEN 12,321 11,341 980 8.0% GREEN 21,069 19,221 1,848 8.8% GREEN

SLA Exclusions 141 284 (143) (101.9)% RED 1,305 1,831 (525) (40.3)% RED 1,725 2,709 (984) (57.0)% RED

Acute - Readmissions & Threshold

165 65 100 60.7% GREEN 1,152 946 206 17.9% GREEN 1,976 1,621 355 18.0% GREEN

Acute Demand Reserve 32 0 32 100.0% GREEN 225 0 225 100.0% GREEN 452 0 452 100.0% GREEN

Acute LAS & In Health 674 683 (9) (1.3)% RED 4,715 4,779 (64) (1.3)% RED 8,084 8,193 (109) (1.3)% RED

Non Contracted Activity (173) (173) 0 (0.0)% AMBER 980 1,209 (229) (23.4)% RED 1,679 2,137 (458) (27.3)% RED

Acute & Integrated Care Total 21,474 21,048 426 2.0% GREEN 142,412 141,057 1,355 1.0% GREEN 243,680 241,399 2,281 0.9% GREEN

Mental Health 3,701 3,619 81 2.2% GREEN 24,224 23,826 398 1.6% GREEN 41,527 40,527 1,000 2.4% GREEN

Older People 409 373 36 8.8% GREEN 2,901 2,865 36 1.2% GREEN 4,973 4,911 62 1.2% GREEN

Learning Disabilities 272 272 0 0.0% GREEN 2,007 2,007 0 0.0% GREEN 3,441 3,441 0 0.0% GREEN

Physical Disabilities 63 59 3 5.0% GREEN 438 390 48 11.0% GREEN 751 668 83 11.1% GREEN

Children’s Services 50 68 (18) (36.6)% RED 522 500 22 4.2% GREEN 894 856 38 4.2% GREEN

Continuing Care 632 597 35 5.5% GREEN 4,423 4,109 314 7.1% GREEN 7,582 7,044 538 7.1% GREEN

End of Life care 82 82 0 0.0% GREEN 561 561 0 0.0% GREEN 962 962 0 0.0% GREEN

Community Services 901 699 202 22.4% GREEN 5,602 5,537 65 1.2% GREEN 9,603 9,496 107 1.1% GREEN

CCG Investments 0 0 0 0.0% GREEN 0 0 0 0.0% GREEN 7,500 6,500 1,000 13.3% GREEN

Prescribing 2,100 2,240 (140) (6.7)% RED 14,699 14,839 (140) (1.0)% AMBER 25,198 25,439 (241) (1.0)% AMBER

Primary Care Investment Strategy 570 567 3 0.6% GREEN 950 950 (0) (0.0)% AMBER 6,053 6,053 0 0.0% GREEN

Non Acute Total 8,778 8,576 202 2.3% GREEN 56,327 55,584 743 1.3% GREEN 108,485 105,898 2,587 2.4% GREEN

CCG delegated budgets Total 30,252 29,624 628 2.1% GREEN 198,738 196,640 2,098 1.1% GREEN 352,165 347,297 4,868 1.4% GREEN

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Primary Care - Medical 2,388 2,238 151 6.3% GREEN 16,719 16,607 112 0.7% GREEN 30,062 30,111 (49) (0.2)% AMBER

Primary Care - Pharmacy 431 558 (128) (29.6)% RED 3,015 3,143 (128) (4.2)% RED 5,169 5,388 (219) (4.2)% RED

Primary Care - Ophthalmic 128 170 (42) (32.8)% RED 896 916 (20) (2.2)% RED 1,536 1,570 (34) (2.2)% RED

Primary Care - Dental 633 559 75 11.8% GREEN 4,432 4,107 325 7.3% GREEN 7,599 7,291 308 4.1% GREEN

Specialist Commissioning 2,777 2,839 (63) (2.3)% RED 19,439 19,511 (72) (0.4)% AMBER 33,323 33,471 (148) (0.4)% AMBER

Prisons 1,481 1,481 0 0.0% GREEN 6,175 6,175 0 0.0% GREEN 10,586 10,586 0 0.0% GREEN

NCB shadow budgets Total 7,838 7,845 (7) (0.1)% AMBER 50,676 50,459 217 0.4% GREEN 88,274 88,416 (142) (0.2)% AMBER

Sexual health 99 55 44 44.7% GREEN 691 641 49 7.2% GREEN 1,184 1,184 0 0.0% GREEN

Substance Misuse 654 654 0 0.0% GREEN 4,578 4,578 0 0.0% GREEN 7,848 7,848 0 0.0% GREEN

Public Health Total 753 709 44 5.9% GREEN 5,268 5,219 49 0.9% GREEN 9,031 9,031 0 0 GREEN

Total Commissioning Expenditure 38,843 38,178 665 1.7% GREEN 254,683 252,318 2,365 0.9% GREEN 449,470 444,744 4,726 1.1% GREEN

Borough costs 357 500 (143) (39.9)% RED 2,499 2,310 189 7.6% GREEN 4,510 4,510 0 0.0% GREEN

Commissioning support costs 1,293 1,247 46 3.5% GREEN 6,377 5,812 565 8.9% GREEN 12,296 12,096 200 1.6% GREEN

Public health non commissioning costs 619 (747) 1,366 220.7% GREEN 3,889 1,994 1,895 48.7% GREEN 6,790 5,790 1,000 14.7% GREEN

Estates income (279) (285) 5 (2.0)% RED (1,954) (1,992) 38 (2.0)% RED (3,349) (3,349) 0 0.0% GREEN

Estates expenditure 682 538 144 21.1% GREEN 3,930 4,161 (231) (5.9)% RED 6,723 7,107 (384) (5.7)% RED

Capital charges 88 110 (21) (23.8)% RED 619 767 (148) (23.8)% RED 1,061 1,211 (150) (14.1)% RED

Operating Costs Total 2,760 1,362 1,397 50.6% GREEN 15,361 13,051 2,310 15.0% GREEN 28,032 27,366 666 2.4% GREEN

Reserves (0) 0 (0) 100.0% GREEN 0 0 0 100.0% GREEN 3,172 3,172 0 0.0% GREEN

Contingency 186 0 186 100.0% GREEN 1,304 0 1,304 100.0% GREEN 2,236 0 2,236 100.0% GREEN

Reserves and contingencies Total 186 0 186 100.0% GREEN 1,304 0 1,304 100.0% GREEN 5,407 3,172 2,236 41.3% GREEN

Total Expenditure 41,789 39,540 2,249 5.4% GREEN 271,348 265,369 5,979 2.2% GREEN 482,909 475,281 7,628 1.6% GREEN

Risk Adjusted Surplus / (Deficit) 756 3,005 2,249 297.3% GREEN 5,300 11,279 5,979 2.2% GREEN 9,085 16,713 7,628 1.6% GREEN

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Appendix 5.1cOverall Performance Assessment

Overall Organisational Well Being previous currentFinancial Position

Investment PlansSurplusDelegated BudgetsQIPP PerformanceRun Rate

Risk StatusAuthorisation - Adherence to MilestonesGovernance

Key Performance Indicators (better/good) ↑New Birth VisitsDiagnostic WaitsCancer waits - overallMaternity Access (Whittington)Other key indicators

Key Performance Indicators (worse/poor) ↓

4 hour wait in A&EPhysiotherapy WaitsOther targets previously in this section - being closely monitored

Local Outcomes *Health Visiting Safeguarding : GP Participation in case conferencesPatient Experience*Infection ControlHealth ChecksOther Local Outcomes*

RAG Ratings for the above:

* still in development - subjective view where no data ExcellentGood

Satisfactory/AdequatePoor

Key Performance

Indicators

Local Outcomes

Islington CCG Board Dashboard - Month 7 2012

Contract Delivery

Service Delivery/Quality &

Safety

Overall Performance

Overall Financial StatusFinancial, Risk,

Authorisation

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MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Public Health Intelligence Profile: Mental Health (Psychotic disorders) LEAD DIRECTOR: Penny Bevan, Interim Director of Public Health AUTHOR: Public Health CONTACT DETAILS:

Dalina Vekinis, Senior Public Health Information Analyst, [email protected]

SUMMARY: Islington’s Public Health profile on psychotic disorders describes the trends and patters in the prevalence of diagnosed psychotic disorders in people aged 18 and over in Islington. It uses data from Islington’s GP Public Health dataset to show information on prevalence, demographics, long term conditions, recording of risk factors and care plans. Recommendations and key messages are provided to highlight areas for improvement. SUPPORTING PAPERS: App 5.2a: Public Health Intelligence Profile: Mental Health (Psychotic disorders) RECOMMENDED ACTION: The Governing Body is asked to:

· NOTE the recommendations of the profile: o To ensure care pathways related to psychotics disorders take long term

conditions and lifestyle factors in to account o Improve monitoring of lifestyle and risk factors o Document care plans

· CONSIDER the ways in which these recommendations can be implemented across Islington.

GOVERNANCE:














Dr Sabin Khan Salaried GP


representative Deborah Snook Practice Manager

representative







Dr Mo Akmal


Objective(s) / Plans supported by this paper: This profile supports the Joint Commissioning Strategy work on Mental Health conditions, as well as other key mental health promotion initiatives around equal access to services. Audit Trail: Review was sought from PH Assistant Directors, PH Strategists, Senior Joint Commissioning Manager for Mental Health and Continuing Healthcare, and the Mental Health lead for Islington CCG. The final report was disseminated via email to key members of the CCG and via the GP Bulletin to all GP practices. Patient & Public Involvement (PPI): Not applicable Equality Impact Assessment: Not applicable Risks: Not applicable Resource Implications: There are likely to be resource implications associated with implementation of the report recommendations but these would need to be considered as separate business cases. Next Steps: See profile for more information on key recommendations to be discussed by key groups and actions put in place.

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ISLINGTON PROFILEPUBLIC HEALTH INTELLIGENCE

MENTAL HEALTHPsychotic Disorders

November 2012

Appendix: 5.2aICCG GB - 113

CONTENTS1. Overview and recommendations 2

2. Key messages 2

3. GP PH dataset and case definition 4

4. How to use these analysis 5

5. Psychotic disorder analysis

About this profile

PURPOSEThis public health intelligence profile describes the trends and patterns in the prevalence ofdiagnosed psychotic disorders in people aged 18 and over in Islington.

This work will support and inform: joint commissioners and public health teams, and Islington’s clinical commissioning group; individual general practices in Islington mental health trusts community and voluntary sector

This profile can be found on our intranet:http://nww.islington.nhs.uk/pages/level2page.asp?id=1060&L1=1

1

5. Psychotic disorder analysis

- Prevalence of diagnosed psychotic disorders 6

- Breakdown of psychotic disorder diagnoses by demographic factors 14

- Psychotic disorders and long term conditions 22

- Data recording and risk factor screening 26

- Care plans and review 34

6. Data sources & methods 37

FURTHER INFORMATION AND FEEDBACK

This profile was created by Claire Tiffany (Public Health Information Officer) with input from BaljinderHeer (Public Health Strategist), Jonathan O’Sullivan (Assistant Director Public Health), George Howard(Senior Joint Commissioning Manager for Mental Health and Continuing Healthcare) and SharonBennett (Mental Health and Medicines Management lead for Islington Clinical Commissioning Group). Itwas reviewed by Dalina Vekinis (Senior Public Health Information Analyst) and Dr Sarah Dougan(Senior Public Health Manager: Health Intelligence & Needs Assessment).

For further information, please contact Dalina Vekinis.

Email: [email protected] Tel: 020 7527 1237

We would also very much welcome your comments on these profiles and how they could bettersuit your individual or practice requirements, so please do contact us with your ideas.

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Recommendations and key messages

OVERVIEW & RECOMMENDATIONS

1. Ensure care pathways related to psychotic disorders, take long term conditions and lifestylefactors in to account. People with psychotic disorders are at higher risk of physical ill-health thanthe general population. Within Islington higher rates of obesity and smoking are seen in people withpsychotic disorders compared to the general population. An unhealthy lifestyle contributes to poorerhealth outcomes. Developing specific pathways for care that focus on lifestyle changes andpreventing and managing long term conditions will help provide better health outcomes.

2. Improve monitoring of lifestyle and risk factors. Up to half of patients who have a psychoticdisorder are seen only in a primary care setting. For these patients, it is important that the primarycare team takes responsibility for carrying out reviews focussing on lifestyle (e.g. smoking) and riskfactors (e.g. blood pressure). People with psychotic disorders in Islington are more likely to havesmoking status, alcohol consumption and BMI recorded than the general population. They are alsomore likely to have a record of blood pressure in the past 15 months. There is, however, still room forimprovement, particularly for recording alcohol consumption which is missing for 26% of people withpsychotic disorders.

3. Documented care plans. Around 250 (9%) of eligible people with a psychotic disorder in Islingtondid not have a comprehensive care plan documented. This is slightly more than the national average(7%).

KEY MESSAGES

2

KEY MESSAGES

Prevalence of diagnosed psychotic disorders in context In 2010/11 there were 3,152 people diagnosed with a psychotic disorder registered with Islington GP

practices. Islington’s crude prevalence (1.5%) was the highest in England, and significantly higherthan the London and England averages.

Around 20% of people aged 18 and over diagnosed with a psychotic disorder in Islington have abipolar disorder. The remaining 80% are diagnosed with psychoses (including schizophrenia).

Breakdown of Islington prevalence There were fewer than five people aged under 18 recorded with a diagnosis of a psychotic disorder

in Islington. The majority of the analysis in this report therefore focuses on adults aged 18 and over.

The number of adults with a psychotic disorder varies by practice, from 12 to over 180 registeredwith St John’s Way Medical Centre. Adjusted for the age structure of the population, the prevalenceof psychotic disorders within Islingotn is significantly higher than expected for three practices andsignificantly lower for eight. Prevalence is significantly higher than expected in the North locality, andsignificantly lower in the South East, reflecting local patterns of deprivation.

The average age of adults living with psychotic disorders in Islington is 47 years, with 34 years theaverage age at diagnosis. This means, on average, people diagnosed with a psychotic disorder havehad the diagnosis for 13 years. Around half of adults have had a diagnosis for more than 10 years,whilst a quarter have been diagnosed for less than 5 years.

Psychotic disorders affect a greater proportion of men than women aged 18 and over (1.9%compared to 1.4%). The prevalence of diagnosed psychotic disorders increases in people aged 35

ICCG GB - 115

Recommendations and key messages

KEY MESSAGES (cont)years and over, with 45-54 year olds experiencing the highest prevalence. Some minority ethnicgroups have a significantly higher prevalence of psychotic disorders (the highest is 4.1% among theBlack Caribbean community). Prevalence is also higher in the most deprived areas (2.2%) and areaswith the highest social housing density (3.1%).

There were 167 new diagnoses of psychotic disorders in 2010/11, equating to 9 in every 10,000people aged 18 and over being newly diagnosed. Using these figures, and the 2009/10 QOFprevalence figures, suggests that just over 100 people diagnosed with a psychotic disorder leftIslington or died in 2010/11.

Long term conditions People diagnosed with a psychotic disorder have a significantly higher prevalence of depression

(and chronic depression), hypertension, diabetes, chronic kidney disease, COPD, stroke/TIA,chronic liver disease and heart failure, when compared to Islington’s general population aged 18 andover. Compared to the general population, people with psychotic disorders are 4 times more likely tohave chronic depression (3 times as likely to have depression); 2.4 times more likely to havediabetes and 1.9 times more likely to have strokes/ TIAs.

Not surprisingly depression is the most commonly diagnosed long term condition among adults witha psychotic disorder. Of people diagnosed with a psychotic disorder, 34% (1,036) are also

3

a psychotic disorder. Of people diagnosed with a psychotic disorder, 34% (1,036) are alsodiagnosed with depression. This is followed by hypertension, diagnosed in 16% (478) of people withpsychotic disorders, chronic depression in 12% (369) and diabetes in 11% (337). A diagnosis ofchronic depression is more likely to follow a diagnosis of a psychotic disorder than to precede it.

In terms of the number of long term conditions, people with psychotic disorders experience similarcomorbidity to the general population with long term conditions.

Data recording and risk factor screening People with psychotic disorders are more likely to have their smoking status, alcohol consumption

and BMI recorded than the general population.

Where recorded, adults with psychotic disorders are significantly more likely to be smokers (42%compared to 25% of the general population) and significantly more likely to be obese (31%compared to 16% of the general population). People with psychoses (including schizophrenia) aresignificantly less likely to be drinkers (27%) than people with bipolar disorders (43%) and the generalpopulation (40%).

Levels of blood pressure recording are higher in people with psychotic disorders than the generalpopulation. There is wide variation in the recording of blood pressure across GP practices (45% to92%) with nine significantly lower than the Islington average.

Care plans and review Just under 10% (approximately 250) of people with a psychotic disorder did not have a

comprehensive care plan (QOF indicator MH06). A similar proportion, and number, did not have arecord of review in the previous 15 months (QOF indicator MH09).

ICCG GB - 116

GP PH dataset and case definition

Islington GP PH Dataset Much of the epidemiological analysis in this profile has been undertaken using an anonymised

patient-level dataset from GP practices in Islington, in agreement with local GPs and withgovernance from our multi disciplinary Health Intelligence Advisory Group.

The dataset includes key information on demographics (including language and country of birth),behavioural and clinical risk factors, key conditions, details on the control and management ofconditions, key medications, and interventions.

This unique resource means that for the first time in Islington, it is possible to undertake in depthepidemiological analysis of primary care data for public health purposes, strengthening evidencebased decision making within the borough at all levels. More information on the dataset can befound in the Annual Public Health Report 2011.

While Dr Desai’s practice closed in 2011/12, the practice is still included in this analysis to ensurepatients registered with the practice are not excluded from analysis. This ensures consistent use ofthe data as it stood at 31 March 2011.

Case definitions for psychotic disorder Specific codes extracted to determine a diagnosis of psychotic disorders aligned with those

published under mental health in the Quality and Outcomes Framework (QOF) guidance. Thesecan be found on the Primary Care Commissioning website: http://www.pcc-cic.org.uk

4

The mental health QOF includes read codes for schizophrenia, bipolar affective disorder and otherpyschoses (Table 1). Following consultation with the HIAG it was decided to report on (1)psychoses (including schizophrenia) and (2) bipolar disorders as schizophrenia may be under-diagnosed and instead coded as psychosis. Bipolar was well coded.

Table 1: QOF mental health read codes for psychoses (including schizophrenia) and bipolardisordersREAD CODES DISEASE / DESCRIPTIONPsychoses (including schizophrenia)E1124 Single major depressive episode, severe, with psychosisE1134 Recurrent major depressive episodes, severe, with psychosisE11y% exc E11y2 Other and unspecified manic-depressive psychosesE11z Other and unspecified affective psychosesE11z0 Unspecified affective psychoses NOSE11zz Other affective psychosis NOSE12% Paranoid statesE13% exc E135 Other nonorganic psychosesEu323 [X] Severe depressive episode with psychotic symptomsEu328 [X] Major depression, severe with psychotic symptomsEu333 [X] Recurrent depressive disorder, current episode severe with psychotic symptomsE10% Schizophrenic disordersE2122 Schizotypal personalityEu2% [X]Schizophrenia, schizotypal and delusional disordersBipolarE110% Manic disorder, single episodeE111% Recurrent manic episodesE114-E117z Bipolar Affective DisorderEu30% [X] Manic episodeEu31% [X] Bipolar affective disorder

[X] signifies a term from ICD-10 (as opposed to ICD-9)

ICCG GB - 117

How to use these analyses

It is important to bear in mind the following when looking at this profile (or any other public healthintelligence products):

– It is the variation that is importantIn this profile, it is the variation between Islington GP practices that should be the main point ofreflection rather than average achievement. It is the unexplained variation (defined as: variation inthe utilisation of health care services that cannot be explained by differences in patient populationsor patient preferences) as this can highlight areas for potential improvements. For example, it mayhighlight under- or over- use of some interventions and services, or it may identify the use of lowervalue or less effective activities.

The data alone cannot tell us whether or not there are good and valid reasons for the variation. Itonly highlights areas for further investigation and reflection. A perfectly valid outcome ofinvestigations is that the variation is as expected. However, to improve the quality of care andpopulation health outcomes in Islington, a better understanding of reasons behind the variation at aGP practice level with clear identification of areas for improvement is needed.

– Reaching 100% achievementThe graphs may show 100% on their y-axis (vertical) but there is no expectation that 100% will be(ever be) achieved for the vast majority of indicators. There will always be patients for whom theintervention is unsuitable and/or who do not wish to have the intervention. Again, it is about thevariation between different GP practices, not an expectation of 100% achievement.

5

Ideally, there would be benchmarking against the achievements in Islington with other deprivedLondon boroughs (ie. with similar health needs), to give an indication of realistic level of achievementfor specific indicators across the whole population and an Islington position, but these data are notcurrently available.

– Populations not individualsEpidemiology is about the health of the population, not the individual. In this profile this is either all ofIslington’s registered population or a GP practice population. It includes everyone registered on GPlists at the end of March/beginning of April 2011, whether they attend the practice regularly or not, ornever at all.

– Beware of small numbersSome of the graphs have small numbers in them. They have been left in so that all GP practices cansee what is happening in their practice (according to the data). In these cases, the wide 95%confidence intervals will signify the uncertainty around the percentages, but be careful wheninterpreting them.

– Problems with coding and/or data extractionThere were some specific problems with data extractions from some GP practices for particularvariables and these have been noted on the relevant graphs. If after review of the data, any GPpractices think there are other problems with coding or data extraction, we will investigate and willamend publications as appropriate: [email protected]

ICCG GB - 118

PREVALENCE OF DIAGNOSEDPSYCHOTIC DISORDERS

6

This section describes the prevalence of psychoticdisorders, split by psychoses (including schizophrenia)and bipolar disorders. With the exception of QOF datathe analysis is based on people aged 18 and over.

PSYCHOTIC DISORDERS

3,152 people in Islingtonwere recorded as beingdiagnosed with a psychoticdisorder in the 2010/11Quality and OutcomesFramework (QOF).

Islington has the highestprevalence (1.5%) ofpeople recorded as beingdiagnosed with a psychotic

London PCTs: crude prevalence (all ages)

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7

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ICCG GB - 119

A diagnosis of a psychoticdisorder was recorded for 1.6%(3,015) of people aged 18 andover with a GP in Islington.

Fewer than 5 people agedunder 18 had a diagnosis of apsychotic disorder recorded.

The majority, 2,479 (82%),were diagnosed withpsychoses (including

Islington: crude prevalence

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Prevalence of people diagnosedwith a psychotic disorder, splitby bipolar disorderand psychoses (includingschizophrenia), Islington'sregistered populationaged 18

and over, March2011

8

psychoses (includingschizophrenia). The remaining536 (18%) were diagnosed witha bipolar disorder.

More information on thesecategories is given in the GPPH dataset and case definitionsection (page 5).

Different methods of dataextraction resulted in 137 fewerpeople with a diagnosis of apsychotic disorder in theIslington GP PH datasetcompared to the QOF.

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Typeofpsychotic disorderNote:Numbers on bars indicate the number of people diagnosed with a psychotic disorderSource: Islington's GP PH dataset, 2011

Adjusted for the agestructure of the population,prevalence of psychoticdisorders in people aged18 and over varies by GPlocality.

The North GP locality has aprevalence ratiosignificantly higher than theIslington average, whilst

Islington localities: indirectly standardised ratio

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Indirectly standardised ratio ofpeople diagnosed with a psychotic disorder,by GP locality, Islington's registeredpopulation aged 18 and over, March 2011

Red bars = higher than averageBlue bars = no different to average

Green bars = lower than averageIslington average

9

Islington average, whilstthe prevalence ratio for theSouth East is significantlylower.

Variation between localitiesmay be due to differencesin populationcharacteristics, for exampledeprivation and housingetc., and/ or diagnosis andrecording practices.

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Notes:Numbers on bars indicate the number of people diagnosed with a psychotic disorderSource: Islington's GP PH dataset, 2011

ICCG GB - 120

Adjusted for the agestructure of the population,prevalence of psychoticdisorders varies by GPpractice.

Three practices have aprevalence ratiosignificantly higher than theIslington average. Eightpractices have significantly

Islington GP practices: indirectlystandardised ratio (psychotic disorder)

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Indirectly standardised ratio of people diagnosed with a psychotic disorder,by GP practice, Islington's registered populationaged 18 and over, March2011



10

practices have significantlylower prevalence.

Variation betweenpractices may be due todifferences in populationcharacteristics and/ ordiagnosis and recordingpractices.

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Three practices have aprevalence ratiosignificantly higher than theIslington average. Onepractice has a significantly

Islington GP practices: indirectlystandardised ratio (bipolar disorder)

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ICCG GB - 121

Adjusted for the agestructure of the population,prevalence of psychoses(including schizophrenia)varies by GP practice.

Five practices have aprevalence ratiosignificantly higher than theIslington average. Sixpractices have a

Islington GP practices: indirectly standardisedratio (psychoses, including schizophrenia)

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over, March 2011Red bars = higher than average

Blue bars = no different to averageGreen bars = lower than average

Islington average

12

practices have asignificantly lowerprevalence.


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The number of patientsregistered with a psychoticdisorder aged 18 and overvaries by practice, from 12to 186 at St John’s WayMedical Centre.

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Islington GP practices: numbers recorded

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Bipolar*Psychoses (including schizophrenia)

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schizophrenia) ranges from8 to 154 (St John’s WayMedical Centre), whilst thenumber registered with abipolar disorder rangesfrom less than 5 to 44 (TheMiller Practice).

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GP practice*5 practices (asterisked) have less than 5 people diagnosed with a bipolar disorder. The number displayed for these practices indicates the numberof people diagnosed with any psychotic disorder (i.e. the numbers for bipolar and psychoses (including schizophrenia) have been combined).Source: Islington's GP PH dataset, 2011

ICCG GB - 122

BREAKDOWN OF PSYCHOTIC DISORDERDIAGNOSES BY DEMOGRAPHICFACTORS

14

This section describes the demographic characteristicsof people with psychotic disorders in terms of age, sex,ethnicity, deprivation, MosaicTM group and socialhousing density.

FACTORS

Around a quarter (28%) ofpeople aged 18 and overwith a psychotic disorderwere diagnosed 4 yearsago or less (from March2011).

Around half (48%) havebeen diagnosed with apsychotic disorder for 10years or more.

Years since diagnosis

20%

25%

30%

35%

Perc

etna

geof

peop

lew

itha

psyc

hotic

diso

rder

Years since diagnosis in people diagnosed with a psychotic disorder, Islington'sregisteredpopulation aged 18 and over, March 2011

15

years or more. The average number of

years since diagnosisacross Islington is 13.

The average age atdiagnosis is 34 years.

835 727 470 315 212 156 3000%

5%

10%

15%

0-4 5-9 10-14 15-19 20-24 25-29 30+

Perc

etna

geof

peop

lew

itha

psyc

hotic

diso

rder

Years since diagnosisNote:Numbers on bars indicate the number of people diagnosed with a psychotic disorderSource: Islington's GP PH dataset, 2011

ICCG GB - 123

The prevalence ofpsychotic disordersincreases in people aged35 years and over, with thehighest prevalence (2.8%)seen in people aged 45-54years. The average age is47 years.

Overall, psychoticdisorders are more

Differences by age and sex

3%

4%

5%

Perc

enta

geof

peop

le

Prevalence ofpeople diagnosedwith a psychotic disorder by age and sex, Islington'sregisteredpopulation aged 18 and over, March 2011

MenWomen

16

disorders are moreprevalent in men (1.9%)than women (1.4%),particularly between theages of 18 to 44 years.

Women have statisticallysignificantly higherprevalence of psychoticdisorders between theages of 45 to 84 (comparedto all women), whilstprevalence is statisticallysignificantly higher in menbetween the ages of 35 to64.

58 325 462 406 202 124 61 16 1,65

4

38 208 297 322 220 166 80 30 1,36

1

0%

1%

2%

18-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ All (18+)

Perc

enta

geof

peop

le

Age groupNotes:Numbers on bars indicate the number of people diagnosed with a psychotic disorderSource: Islington's GP PH dataset, 2011

Rates of psychotic disorders aresignificantly higher in peoplewith their ethnicity recorded bytheir GP as Black Caribbean(4.1%), White & BlackCaribbean (3.8%), White &Black African (3.3%), OtherBlack (2.9%), White Irish (2.6%)and Black African (2.5%).

Rates are significantly lower forIndian (1.1%), Chinese (0.9%)

Differences by ethnic group

2%

3%

4%

5%

Perc

enta

geof

peop

le

Prevalence ofpeople diagnosedwith a psychotic disorder by detailedethnicgroup, Islington's registeredpopulation aged 18 and over, March 2011

17

Indian (1.1%), Chinese (0.9%)and Other (1.1%) ethnic groups.

A higher proportion of peoplewith a psychotic disorder haveethnicity recorded than thegeneral population aged 18 andover (85% compared to 80%).

200

60 42 107

168

188

18 1,13

2

11 32 41 39 416

26 24 55 456

3,01

5

0%

1%

Bla

ckC

arib

bean

Whi

te&

Bla

ckC

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bean

Whi

te&

Bla

ckA

frica

n

Oth

erB

lack

Whi

teIri

sh

Bla

ckA

frica

n

Whi

te&

Asi

an

Whi

teB

ritis

h

Pak

ista

ni

Oth

erM

ixed

Ban

glad

eshi

Oth

erA

sian

Oth

erW

hite

Indi

an

Chi

nese

Oth

er

Unk

now

n

All*

Perc

enta

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le

Ethnic group* includes those with ethnicity not known

Note:Numbers on bars indicate the number of people diagnosed with a psychotic disorderSource: Islington's GP PH dataset, 2011

ICCG GB - 124

The percentage of peoplewith a psychotic disorder isalmost 70% higher in themost deprived quintile(2.2%) compared to theleast (1.3%).

Differences by local deprivation

3%

4%

5%

Perc

enta

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peop

lew

itha

psyc

hotic

diso

rder

Prevalence ofpeople with a psychotic disorderby local deprivationquintile, Islington's registered and residentpopulation aged18 and over, March 2011

18

674 660 495 484 4450%

1%

2%

Most deprived 2 3 4 Least deprived

Perc

enta

geof

peop

lew

itha

psyc

hotic

diso

rder

Local deprivation quintile

Note: 257 people living outside Islington, or with no deprivation score, were not included. Numbers on bars indicate the number of peoplediagnosed with a psychotic disorder.Source: Islington's GP PH dataset, 2011

The prevalence of psychoticdisorders increases steadily withthe density of social housing.

Prevalence in areas with highsocial housing density (81-100%) is four times higher thanin areas with no social housing(3.1% compared to 0.8%).However, in terms of numbersmost adults with psychotic

Differences by density of social housing

3%

4%

5%

Perc

enta

geof

peop

lew

itha

psyc

hotic

diso

rder

Prevalence ofpeople with a psychotic disorder by social housing density, Islington'sregisteredand residentpopulationaged 18 and over, March2011

19

most adults with psychoticdisorders (1,475) live in mixedtenure areas.

It should be noted thatsupported housing for peoplewith psychotic disorders is allsocial housing, and this maypartly explain some of thedifference.

Further details regarding socialhousing density in Islington, andpsychotic disorders, areavailable in the Health Needsand Social Housing profile:http://nww.islington.nhs.uk/pages/level2page.asp?id=1034&L1=1.

242 701 774 569 4090%

1%

2%

0% 1-20% 21-40% 41-80% 81-100%

Perc

enta

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peop

lew

itha

psyc

hotic

diso

rder

Social housing densityNote:320 people either living outside Islington, or without a social housing density category, were not included. Numbers on bars indicate thenumber of people diagnosed with a psychotic disorder.Source: Islington's GP PH dataset, 2011

ICCG GB - 125

Prevalence of psychoticdisorders is significantlyhigher (2.1%) in peoplerenting flats in high densitysocial housing compared towell-educated city dwellers(1.3%) and other groups(1.7%).

Differences by MosaicTM group

3%

4%

5%

Perc

enta

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lew

itha

psyc

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diso

rder

Percentage of people with a psychotic disorder by Mosaic™group, Islington'sregisteredand residentpopulationaged 18 and over, March2011

20

1,483 977 2160%

1%

2%

N - People renting flats in high densitysocial housing

G - Well-educated city dwellers Other

Perc

enta

geof

peop

lew

itha

psyc

hotic

diso

rder

Mosaic™group

Note:339 people either living outside Islington, or without a Mosaic code, were not included. Numbers on bars indocate the number of peoplediagnosed with a psychotic disorder.Source: Experian MosaicTM, 2011; applied to Islington's GP PH dataset, 2011

36 people aged 18 and overwere newly diagnosed with abipolar disorder and 131 withpsychoses (includingschizophrenia) in 2010/11.

Men had a significantly higherincidence rate for psychoses(including schizophrenia)compared to women (10.6 and4.2 per 10,000 respectively).

There was no significant

New diagnoses by sex

10

15

Cru

dein

cide

ncer

ate

(per

10,0

00po

pula

tion)

Crude incidenceofpeople diagnosed with a psychotic disorder (patient diagnosedin2010/11), by sex, Islington's registered populationaged 18 years and over, March2011

21

There was no significantdifference between men andwomen’s incidence rate forbipolar disorders (1.6 and 2.3per 10,000), possibly due to thesmall numbers.

Combining the number of peoplerecorded with a psychoticdisorder in the 2009/10 and2010/11 QOF (3,092 and 3,152respectively) with the number ofnew diagnoses (above) we canestimate that around 107 peoplewith a diagnosis of a psychoticdisorder either left the area ordied during this time period.

14 22 91 400

5

Men Women Men Women

Bipolar disorders Psychoses (including schizophrenia)

Cru

dein

cide

ncer

ate

(per

10,0

00po

pula

tion)

Typeofpsychotic disorderNotes:Numbers on bars indicate the number of people diagnosed with a psychotic disorderSource: Islington's GP PH dataset, 2011

ICCG GB - 126

PSYCHOTIC DISORDERS AND LONGTERM CONDITIONS

22

This section looks at comorbidity, in terms of long termconditions, of people with psychotic disorders.

TERM CONDITIONS

The prevalence of 9 of the 12long term conditions shown inthe chart are significantlyhigher in people with psychoticdisorders compared to thegeneral population (cancer,coronary heart disease andatrial fibrillation showed nodifference).

Not surprisingly depression isthe most common long term

Long term conditions: crude prevalence

20%

30%

40%

50%

Perc

enta

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le

Prevalence of long term conditions among people diagnosed with a psychotic disordercomparedto Islington's registeredpopulation aged 18 and over, March 2011

23

the most common long termcondition (34%). This isfollowed by hypertension(16%), chronic depression(12%) and diabetes (11%).

Compared to the generalpopulation people withpsychotic disorders are:– 4 times more likely to have

chronic depression (3 timesas likely to have depression)

– 2.4 times more likely to havediabetes, and

– 1.9 times more likely to havestrokes/ TIAs.

0%

10%

Dep

ress

ion*

Hyp

erte

nsio

n

Chr

onic

depr

essi

on

Dia

bete

s

Chr

onic

kidn

eydi

seas

e

CO

PD

Can

cer

Stro

ke/T

IA

Cor

onar

yhe

artd

isea

se

Chr

onic

liver

dise

ase

Hea

rtfa

ilure

Atri

alfib

rilla

tion

Perc

enta

geof

peop

le

Long term conditionPsychoses (including schizophrenia) Bipolar disorder General population

Note:People may be counted twice due to comorbidities. Numbers of chronic depression will be underestimated because data were only availablefor 37/38 Islington practices.Source: Islington's GP PH dataset, 2011

* Includes chronic depression

ICCG GB - 127

1,036 people diagnosed witha psychotic disorder alsohave a diagnosis ofdepression. Of these 369have chronic depression (onan anti-depressant for two ormore years).

Hypertension has beendiagnosed for 478 peoplewith a psychotic disorder and

Long term conditions: numbers recorded

1,036

478369 337400

600

800

1,000

1,200

Num

bero

fpeo

ple

Number of other long term conditions in people diagnosed with a psychoticdisorder, Islington's registeredpopulation aged 18and over, March 2011

Bipolar disorder

Psychoses(including schizophrenia)

24

with a psychotic disorder anddiabetes has been diagnosedfor 337.

369 337

106 92 79 73 66 42 39 280

200

400

Dep

ress

ion*

Hyp

erte

nsio

n

Chr

onic

depr

essi

on

Dia

bete

s

Chr

onic

kidn

eydi

seas

e

CO

PD

Can

cer

Stro

ke/T

IA

Cor

onar

yhe

artd

isea

se

Chr

onic

liver

dise

ase

Hea

rtfa

ilure

Atri

alfib

rilla

tion

Num

bero

fpeo

ple

Long term condition* Includes chronic depressionNote:People may be counted twice due to comorbidities. Numbers of chronic depression will be underestimated because data were only availablefor 37/38 Islington practices.Source: Islington's GP PH dataset, 2011

When compared to thegeneral population with along term condition, peoplewith psychotic disordershave similar comorbidity interms of the number of longterm conditions (psychoticdisorder is counted as along term condition).

Comorbidity

716 117599 8,449

248 31 217 3,499

153 29 124 2,154

50%

75%

100%

Perc

enta

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peop

le

Percentage ofpeople diagnosedwith psychotic disorders, by number of long termconditions, comparedto Islington's registeredpopulation aged18 and over with a

diagnosed long term condition, March2011

25

1,898 359 1,539 21,1910%

25%

All psychotic disorders Bipolar disorder Psychoses(including schizophrenia)

General population

Perc

enta

geof

peop

le

1 condition 2 conditions 3 condition 4+ conditions

Note:Long term conditions include high blood pressure, chronic kidney disease, diabetes, CHD, Cancer, Stroke/ TIA, COPD, atrialfibrillation, dementia, chronic depression, psychotic disorders and chronic liver disease. Numbers on bars indicate the number of people diagnosedwith a psychotic disorder. For people with a psychotic disorder, the psychotic disorder is counted as one condition - i.e. 1,898 people have apsychotic disorder and no other long term condition.Source: Islington's GP PH dataset, 2011

ICCG GB - 128

DATA RECORDING AND RISK FACTORSCREENING

26

This section compares the smoking status, alcoholconsumption, body mass index and blood pressurerecording of people with psychotic disorders to thegeneral population.

SCREENING

People diagnosed withpsychotic disorders arealmost twice as likely to besmokers than the generalpopulation aged 18 andover (of those with asmoking status recorded).

42% of people diagnosedwith a bipolar disorder and47% with psychoses

Smoking status

60%

70%

80%

90%

100%

Perc

enta

geof

peop

le

Smoking status in people diagnosed with a psychotic disorder and with a smokingstatus recorded, compared to Islington's registered population, aged 18 and

over, March 2011

27

47% with psychoses(including schizophrenia)are smokers, compared to25% of the generalpopulation aged 18 andover.

2% of people with apsychotic disorder do nothave a smoking statusrecorded, significantly lessthan the general population(13%).

222 140 1711,155 487 8190%

10%

20%

30%

40%

50%

Smoker Ex-smoker Non-smoker

Perc

enta

geof

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Smoking statusBipolardisorders Psychoses (including schizophrenia) General population


ICCG GB - 129

The prevalence of smoking inpeople diagnosed with apsychotic disorder rangesfrom 30% to 65% across GPpractices, with an average of46% for Islington.

This compares to a range of16% to 32% and an averageof 25% among the generalpopulation aged 18 and over.

Islington GP practices: smokers

20%30%40%50%60%70%80%90%

100%

Perc

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smok

ers

Prevalence ofsmokers in people diagnosedwith a psychotic disorder and with asmoking status recorded, by GP practice, comparedto Islington's registered

population aged18 and over, March 2011

General populationIslington average (psychotic disorders)Islington average (general population)

28

population aged 18 and over. The prevalence is

significantly higher than theIslington average for peoplediagnosed with a psychoticdisorder for three practicesand significantly lower fortwo.

Only three practices havesimilar percentages ofsmokers in people diagnosedwith a psychotic disorder andthe general population.

0%10%

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GP practiceRed bars = higher than average Blue bars = no different to average Green bars = lower than average

Source: Islington's GP PH dataset, 2011

People diagnosed withpsychoses (includingschizophrenia) are lesslikely to be drinkers (27%)than people diagnosed witha bipolar disorder (43%)and the general populationaged 18 and over (40%).

26% of people with apsychotic disorder and

Alcohol consumption

50%

60%

70%

80%

90%

100%

Perc

enta

geof

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le

Alcohol consumption in people diagnosed with a psychotic disorder comparedtoIslington's registeredpopulation, aged 18 and over, March 2011

29

psychotic disorder and34% of the generalpopulation aged 18 andover do not have alcoholconsumption recorded.

232 169 135670 1,167 6420%

10%

20%

30%

40%

50%

Drinker Non-drinker Not known

Perc

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Alcohol consumptionBipolardisorders Psychoses(including schizophrenia) General population


ICCG GB - 130

People diagnosed with apsychotic disorder are almosttwice as likely to be obesecompared to the generalpopulation aged 18 and over(31% compared to 16%).

26% (130) of people diagnosedwith a bipolar disorder and 32%(727) of people with psychoses(including schizophrenia) areobese compared to 16% of the

Body Mass Index

50%

60%

70%

80%

90%

100%

Perc

enta

geof

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le

Percentage ofpeople diagnosedwith a psychotic disorder by BMI group, whererecorded, compared to Islington'sregistered population, aged 18 and over, March2011

30

obese compared to 16% of thegeneral population aged 18 andover.

People diagnosed withpsychoses (includingschizophrenia) are significantlymore likely to be underweightor overweight than the generalpopulation aged 18 and over.

8% of people with a psychoticdisorder and 17% of thegeneral population aged 18 andover do not have their BMIrecorded.

18215 136 130

62806 689 727

0%

10%

20%

30%

40%

50%

Underweight Healthy Overweight Obese

Perc

enta

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BMI groupBipolardisorders Psychoses (including schizophrenia) General population


The prevalence of obesityin people diagnosed with apsychotic disorder rangesfrom 22% to 54% acrossGP practices, with anaverage of 31% forIslington.

This compares to a rangefrom 10% to 28% and anaverage of 16% among the

Islington GP practices: Obesity

10%20%30%40%50%60%70%80%90%

100%

Perc

enta

geob

ese

Prevalence ofobesity in people diagnosed with a psychotic disorder and with a BMIrecorded, by GP practice, comparedto Islington's registeredpopulation aged 18 and

over, March 2011General populationIslington average (psychotic disorders)Islington average (general population)

31

average of 16% among thegeneral population aged 18and over.

Two practices havesignificantly higherprevalence than theIslington average, whilstone has a significantlylower prevalence.

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Note: 4 practices with <5 obese people diagnosed with a psychotic disorder not included (Dr Desai's Surgery, Dr Kateb & Brown Surgery, NewNorth Health Centre, Wedmore Gardens Surgery)Source: Islington's GP PH dataset, 2011

Red bars = higher than average Blue bars = no different to average Green bars = lower than average

ICCG GB - 131

The proportion of peoplewith a psychotic disorderwho had their bloodpressure recorded duringthe past 15 months, issignificantly higher than thegeneral population aged 18and over.

67% (323) of people with abipolar disorder and 73%

Blood pressure recording

60%

70%

80%

90%

100%

Perc

enta

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Blood pressurerecordingin people diagnosed with a psychotic disorder, compared toIslington's registeredpopulation, aged 18 and over, March 2011

32

bipolar disorder and 73%(1,681) of people withpsychoses (includingschizophrenia) had theirblood pressure recordedover the past 15 monthscompared to 50% of thegeneral population.2,004 323 1,681

0%

10%

20%

30%

40%

50%

All psychotic disorders Bipolar disorders Psychoses(including schizophrenia)

General population

Perc

enta

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peop

le


The percentage of peoplediagnosed with a psychoticdisorder who have had ablood pressure reading inthe past 15 months rangesfrom 45% to 92% acrossGP practices, with anaverage of 72% forIslington.

This compares to a range

Islington GP practices: blood pressurerecording

20%30%40%50%60%70%80%90%

100%

Perc

enta

geof

peop

le

Blood pressurerecordingin people diagnosed with a psychotic disorder, by GPpractice, comparedto Islington's registeredpopulation aged 18 and over, March 2011

General populationIslington average (psychotic disorders)Islington average (general population)

33

This compares to a rangefrom 40% to 71% and anaverage of 50% among thegeneral population aged 18and over.

Six practices havepercentages significantlyhigher than the Islingtonaverage, whilst nine have asignificantly lowerpercentage.

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Red bars = higher than average Blue bars = no different to average Green bars = lower than average

ICCG GB - 132

CARE PLANS AND REVIEW

34

This section presents two mental health QOF indicatorsat GP practice level. The remaining 2010/11 mentalhealth indicators are available via practice level QOFreports on the intranet:http://nww.islington.nhs.uk/pages/level2page.asp?id=825&L1=1

or by emailing: [email protected].

258 (9%) out of an eligible2,926 people with apsychotic disorder inIslington did not have acomprehensive care plandocumented in the records,agreed betweenindividuals, their familyand/or carers asappropriate.

Islington GP practices: care plans

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QOF MH06: Percentage ofpeople diagnosedwith a psychotic disorder who have acomprehensivecare plan document recorded, by GP practice, Islington'sregistered

population, all ages, 2010/2011Islington

35

The percentage of peoplewith a care plan variesacross GP practices inIslington from 69% to100%, with an average of91% for Islington.

Practices with the largestnumbers (rather thanpercentages) of peoplewho did not have a careplan were Ritchie StreetGroup Practice and StJohn's Way Medical Centre(22 people each).

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ICCG GB - 133

249 (9%) out of an eligible2,844 people with a psychoticdisorder in Islington did nothave their care reviewed inthe previous 15 months.

The percentage of peoplewith a psychotic disorder whohad their care reviewed in theprevious 15 months variesacross GP practices in

Islington GP practices: review of care

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population, all ages, 2010/2011Islington

36

across GP practices inIslington from 78% to 100%,with an average of 91% forIslington.

Practices with the largestnumbers (rather thanpercentages) of people whodid not have a care reviewwere Highbury GrangeMedical Centre (26 people)and Roman Way MedicalCentre (20 people).

Please note, this QOFindicator is no longer included(from 2011/12 onwards).

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ICCG GB - 134

Data sources & methods

Islington GP Dataset extractionMuch of the epidemiological analysis in this profile has been undertaken using an anonymised patient-level dataset from GP practices inIslington, in agreement with local GPs and with governance from our multi disciplinary Health Intelligence Advisory Group. This datasetincludes key information on demographics (including age and ethnicity), behavioural and clinical risk factors, key conditions, details onthe control and management of conditions. This unique resource means that for the first time in Islington, it is possible to undertake indepth epidemiological analysis of primary care data for public health purposes, strengthening evidence based decision making withinthe borough at all levels.

Population denominatorsIn calculating rates, the registered population was used as of March 2011. The practice list sizes were obtained from the Islington GPdataset (see above).

37

dataset (see above).

95% confidence intervalsPercentages and rates are reported with 95% CI. These give the range of values which quantify the imprecision in the estimate of thepercentage or rate. They are used to quantify the imprecision that results from random variation in the estimation of the value becauseevents (e.g. admissions) are influenced by the random occurrences that are inherent in life. They do not include imprecision resultingfrom systematic error (i.e. bias). By comparing the 95% CIs around estimates or a target, we can say whether statistically, there aredifferences or not in the estimates we are observing.

Indirectly standardised ratesThe indirectly standardised rate is the observed number of events, relative to the number of events that would be expected, if standardage-specific rates were applied to the particular observed population’s age structure. This enables the comparison of a population rate(e.g. that for a GP) with a standard rate, (e.g. that for the borough), taking into account differences in population age structures.

ICCG GB - 135

6

FURTHER INFORMATION & FEEDBACK

This profile has been created by Islington's Public Health Intelligence team. For further information pleasecontact Dalina Vekinis.

Email: [email protected], Tel: 020 7527 1237

We would also very much welcome your comments on these profiles and how they could bettersuit your individual or practice requirements, so please contact us with your ideas.

About Public Health IntelligencePublic health intelligence is a specialist area of public health. Trained analysts use a variety of statisticaland epidemiological methods to collate, analyse and interpret data to provide an evidence-base andinform decision-making at all levels. Islington’s Public Health Intelligence team undertake epidemiologicalanalysis on a wide range of data sources.

For those who have access to NHS Islington’s intranet, all of our profiles, as well as other data andoutputs van be accessed at: http://nww.islington.nhs.uk/pages/level1page.asp?id=489&L1=8.

ICCG GB - 136

MEETING: Islington Clinical Commissioning Group Governing Body DATE: Wednesday, 5 December 2012 TITLE: Report from Finance and Performance Group LEAD DIRECTOR: Anne Weyman, Chair of Finance and Performance Group AUTHOR: Ahmet Koray, Chief Finance officer CONTACT DETAILS:

[email protected]

SUMMARY: This report outlines the agenda items, discussion and decisions made by Performance and Finance Group at its meeting on 21 November 2012. SUPPORTING PAPERS: None. RECOMMENDED ACTION: The Governing Body is asked to:

· NOTE the activities of the Group; and

· NOTE the contents of this report and the decisions made by the Group.

GOVERNANCE:


Greenhough Chair

Marian



Gerry McMullan




Dr Sharon Bennett

Central Locality GP Representative




Information Dr Rathini Ratnavel






Deborah Snook Practice Manager


Representative Jennie Hurley Practice Nurse

Representative






Dr Mo Akmal


Objective(s) / Plans supported by this paper: This report relates to delivery of financial and performance governance arrangements. Audit Trail: The Governing Body reviews the activity of the group at each meeting after the committee meets. Patient & Public Involvement (PPI): There has been no patient and public involvement for this paper. Equality Impact Assessment: No Equality Impact Assessment is planned or has been undertaken for the report. Risks: This paper identifies risks arising from the review of finance and performance activity. Resource Implications: There are no direct resource implications for this paper, but plans to remain with budget, deliver investment plans and meet performance targets are within this paper. Next Steps: An update of investment plans to be presented to the next Finance and Performance Group and an action plan to be developed to address physiotherapy waiting times.

ICCG GB - 138

Page 1 of 2

1. Introduction

1.1. This report outlines the agenda items, discussion and decisions made by Performance and Finance Group at its meeting on 21 November 2012. 2. Finance & Performance Group

2.1. The table below summarises the agenda items, the discussions and agreed actions from the meeting as follows: Agenda item Summary of report and discussion Matters arising - physiotherapy waiting time

The issue of physiotherapy waiting times was discussed with concerned raised on the deteriorating position. The maximum waiting time the CCG expects is 6 weeks and this is being significantly breached. Decision: A further report and action plan has been requested by the Group.

CCG Finance Report

The latest position was presented including an update on provider contract performance. The change in forecast and the investment plan were discussed. Decision: A final investment plan for the current year to be presented to the next Group meeting. Action to include a discussion with Camden CCG and the Cluster DoF to share ideas on investments that can be made now that will result in longer-term benefits to Islington services.

Operating Plan update

The latest QIPP position was reported reflecting the additional savings target identified as a result of finalising the UCLH contract. The forecast remains to achieve savings of £9.1m, but this is now £4.3m adrift of target. The position is being mitigated by a similar level of slippage on investment schemes.

Contracts Performance

An update was provided by the Cluster Contracts Team with detail supporting the variances within the finance report.

Activity Report Activity performance for the period ending 31st August 2012 was presented. Key messages included GP first outpatient referrals and A&E attendances forecast to increase by the end of March 2013 when compared to last year, 2.4% and 6.4% respectively. Offsetting this was a forecast reduction in consultant to consultant referrals (5.5%).

ICCG GB - 139

Page 2 of 2

Developing a Performance and Information Strategy

A draft strategy was presented proposing the development of a health intelligence system to ensure that timely, accurate and appropriate information is available to all relevant staff. A consultation will be undertaken with partner organisations, patients and the public before a final draft is presented to the Governing Body for approval.

Intermediate Care - pooled budget arrangements

The S.75 pooled budget for intermediate care to be enhanced to allow a streamlining of management arrangements. An increase in the pooled budget by moving existing CCG budgets into the pooled fund. There is no additional financial impact on the CCG and further work will be undertaken to refine the proposal. The Group supported the principles of the proposal.

3. Conclusion

3.1. The Finance & Performance Group agreed the following actions:

· A further report and action plan on physiotherapy waiting times · A final investment plan for the current year to be developed for

approval at the next meeting of the Group.

3.2. The Governing Body is asked to:

· NOTE the activities of the Group · NOTE the contents of this report and the decisions made by the Group.

ICCG GB - 140

1

Minutes

Governance and Quality Group Tuesday, 30 October 2012

National Children’s Bureau, Wakley Street, London EC1V 8AJ Members Present: Sorrel Brookes Lay Member (Chair) Dr Sarah Dougan Senior Public Health Manager – Health Intelligence and Needs

Assessment Clare Henderson Assistant Director of Strategic Commissioning and Adult Services –

for items 1-8 Martin Machray Director of Quality and Integrated Governance Sabrina Rees Senior Commissioning Manager, Children’s Services – for items 1-11 Dr Karen Sennett Clinical Lead for Governance Imelda McLoughlin Patient Member Katy Amberley Patient Member In Attendance: Alison Blair Chief Officer Elaine Oxley Head of Safeguarding Adults, Islington Council – for item 11 Brenda Pratt Deputy Director, Contracts and Performance Management, NHS

North Central London – for items 1-7 Paul Sinden Interim Director of Commissioning – for items 1-7 Apologies: Dr Katie Coleman Joint Vice-Chair (Clinical) Jacky Kutner Interim Director of Performance and Information Louise Lingwood Assistant Director of Quality and Safety, NHS North Central London Minutes: Sharon Jackson Board Secretary

The agenda was taken out of sequence to accommodate those presenting reports. The order was: 1, 2, 3, 4, 5, 6, 7, 8, 11, 9, 10, 12, 13, 14

ICCG GB - 141

2

1. Apologies for Absence: Action 1.1 The apologies were noted as above. 1.2 The Chair welcomed everyone to the meeting and asked the group to introduce

themselves.

2. Declarations of Interest 2.1 There were no declarations of interest. 3. Minutes and Actions of the meeting held on 25 September 2012 3.1 The minutes were agreed as a true and accurate record of the meeting subject to

corrections to the spelling of Imelda McLoughlin and Katy Amberley.

3.2 The Chair led a review of the action log: · 09/12-2 – It was noted that a public health briefing on the registered

population had been circulated. It was further noted that the action had not been captured accurately however it was no longer relevant and could therefore be removed from the action log.

· 09/12-4 – Clare Henderson agreed to confirm if the checklist for family carers and volunteers for visits to patients in out of borough placements had been developed.

4 Matters Arising 4.1 There were no other matters arising. 5. Clinical Quality Review Group Report: Camden and Islington NHS

Foundation Trust

5.1 Martin Machray presented the report on behalf of Louise Lingwood and Dr Sharon

Bennett which provided an overview of discussions and issues raised at the Clinical Quality Review Group (CQRG) meetings in the last quarter.

5.2 It was noted that a key issue for the Trust was of integration and communications

between primary and community care. The Trust had restructured the management team and appointed Dr Colin Thome as the Director of Integrated Care. It was hoped that the new leadership would start to improve the communications between the sectors. The group noted that the report did not provide assurance on this matter and requested a report back on the Trust’s compliance with the communication requirements in the contract.

5.3 In regards to the serious incidents detailed in the report, Martin Machray advised

that there was no indication that procedure or clinical practice was the cause. The group asked that trends analysis be provided with the report to enable identification of issues.

5.4 Martin Machray reported that a concern notice had been issued for Stacey Street

Nursing Home which was operationally run by the Trust but Care Quality Commission (CQC) registration was with Family Mosaic at that time. An action plan to address the concerns was in place and was monitored by the joint commissioning team weekly. Clare Henderson noted that some of the actions remained on-going and would not be in place by the end of October as reported.

ICCG GB - 142

3

5.5 The group welcomed the increase in frequency of the CQRG meetings to six

weeks however it was noted that the future meetings dates in the minutes that had been provided as part of the report did not reflect that increase.

5.6 There was concern about the new structure following the reorganisation to a

single assessment site. Soft intelligence had indicated that first appointments were being done by GP Registrars and there was often not a consultant on site. Dr Karen Sennett agreed to raise the issue with Dr Kirschner, Consultant at Camden and Islington NHS Foundation Trust.

5.5 The Group NOTED the report. 5.6 ACTION 10/12-1: To provide a briefing on Camden and Islington NHS Foundation

Trust’s compliance with the communication requirements in the contract. PS

ACTION 10/12-2: To provide trends analysis with the CQRG report to enable identification of issues.

LL

ACTION 10/12-3: To ensure Camden and Islington NHS Foundation Trust CQRG meetings are scheduled at least every six weeks.

LL

ACTION 10/12-4: To raise the issue of first appointments in the new assessment site with Dr Kirschner.

KS

6. Clinical Quality Review Group Report: Whittington Health 6.1 Brenda Pratt presented the report which provided a view of the business of the

Clinical Quality Review Group (CQRG). Regular monthly meetings were held and there was a rotating agenda on themed issues such as cancer, service specifications, safeguarding, patient experience and the urgent care centre.

6.2 An area of concern for Whittington Health was the development of a performance

assurance framework for community services that was fit for purpose. There were two tiers to the framework; service line meetings led by the responsible commissioner for those services; and a consolidated schedule of key performance indicators (KPIs) broken down by service line which were in varying stages of development. An application had been submitted to the NHS North Central London Programme Office for additional project support to enable finalisation of the framework.

6.3 Brenda Pratt advised that detailed information had been requested from the Trust

about the issue with waiting times for muscolo-skeletal services (MSK) in regards to the ‘did not attend’ (DNA) profile and waiting times by team or service area.

6.4 The group discussed the issues with the recruitment of health visitors. The

majority of newly qualified health visitors at Whittington Health had been employed by Haringey due to a pay grade differential between the two boroughs. Brenda Pratt advised that the contracts team were charged with looking at potential recruitment incentive schemes and skill mix issues. It was noted that NHS London had advised that different grades such as health visitor assistants could not carry out visits. It was also noted that Islington had made provision for funding additional health visitors however this would not be available until the Trust had reached its establishment figure. It might be possible to release this funding for additional skill mix staff.

ICCG GB - 143

4

6.5 The group noted that there had been no GP attendance in the last quarter at the CQRG which was a concern as it was a major contract for Islington. It was also noted that there was still an issue with physiotherapy waiting times, contrary to the report. As per the previous item the group requested that context and trends analysis be provided for the serious incident reporting.

6.6 The Group:

· NOTED the contents of the report; and · SUPPORTED the development of an annual performance report from April

2013

ACTION 10/12-5: To confirm if Dr Anjan Chakraborty attended the October

Whittington Health CQRG meeting. MM

ACTION 10/12-6: To provide an update on the performance assurance framework as part of the next CQRG report in January and include trends analysis for serious incidents.

JG / BP

7. Quality in Contracting 7.1 Paul Sinden attended the meeting to give a briefing on quality in contracting and

advised that he would provide a written briefing for members to be circulated with minutes. He briefed the group on: the standard NHS contract; national and local performance indicators; productivity metrics; incentives including performance tariffs; Commissioning for Quality Indicators (CQUINs); annual quality accounts; the contracts premium; contract meetings; and the escalation process including rectification plans, performance notices and market testing.

7.2 There was a discussion about commissioning for quality. It was noted that staff

happiness was the biggest indicator of good patient care and the group supported the suggestion that this should be in all contracts for 2013/14.

7.3 Paul Sinden agreed to circulate the quality elements of the standard contract to

members to enable future discussions with Trusts. It was agreed that there was a need to discuss how best to use information from contractual meetings. It was suggested that senior members of provider organisations should be invited to attend the Governance and Quality Group to discuss particular areas of concern about quality and that attendance from provider organisations should be built in to the Annual Cycle of Business to present their quality accounts.

7.4 ACTION 10/12-7: To provide a briefing on quality in contracting to be circulated

with the minutes. PS

ACTION 10/12-8: To invite a senior member of Moorfields Eye Hospital NHS Trust to the December meeting of the Governance and Quality Group.

MM

ACTION 10/12-9: To build in to the Annual Cycle of Business a rolling programme of attendance from provider organisations to present quality accounts.

MM / SJ

8. Review of Governance Arrangements 8.1 Martin Machray introduced the first draft of the governance review for discussion

which provided a set of recommendations and questions to debate before the December meeting of the Governing Body.

ICCG GB - 144

5

8.2 The group made a number of suggestions: · The Integrated Care Programme Board should not be time limited and

should report in to the Service Improvement Group, and the committee diagram should be amended accordingly;

· It was necessary to articulate the responsibilities of the Service Improvement Group around the development and delivery of strategy. It was noted that it was possible that the Governing Body could delegate authority for certain functions;

· The Service Improvement Group should align with the Health and Wellbeing Board priorities;

· Consideration should be given to training and support for patient members to enable meaningful contribution to groups;

· The recommendation to review the constitution in 12 months should be explicit that it would be an opportunity to suggest or make amendments;

· The group supported the recommendation for less frequent Governing Body meetings and felt this should also be extended to committees. This recommendation did not fit under the membership / quorum section;

· It should be clear that the ‘transition period’ meant until the 1 April 2013; · The meaning of the sentence on ‘full membership of any CCG decision

making group should rest within the senior leadership of the CCG’ needed to be more explicit;

· The Chief Officer’s Report to the Governing Body should be used as a way to update members on CCG matters rather than the introduction of a regular briefing for members;

· The recommendation to promote full involvement and debate at seminars should not just be limited to clinicians.

· The Transformation Board had been set up to deliver the Whittington Health contract and needed one key relationship with the CCG. It was agreed that the terms of reference would need to be developed before this could be decided.

· Performance and quality were intrinsically linked so it may make more sense to have performance in with quality.

· Patient feedback is a critical part of quality and it needed to be clear how the committee would receive feedback including patient stories.

8.3 There was agreement that the discussion paper needed to outline the principles

of the review and should provide suggestions with the pro’s and con’s for each option. Martin Machray noted that the questions about patient and public involvement and the split of roles and responsibilities would be presented to the November Governing Body seminar.

8.4 The Group:

· NOTED the report; and · NOTED that the issues raised would be discussed at the Governing Body

seminar on 21 November 2012 and a final draft would be developed following this to be presented for adoption to the Governing Body.

9. Report on the NHS North Central London Quality Workshop

ICCG GB - 145

6

9.1 Martin Machray introduced the update on how work was progressing following the quality workshop and advised that the current NHS North Central London Quality and Safety Committee would meet twice more and stop in March 2013. The CCGs in the sector had agreed to establish a network meeting across at least five CCGs on a regular basis replacing some of the Quality Committee meetings. This would be led by Islington and a proposal was being developed.

9.2 The Group NOTED the progress made following the Quality Workshop. 10. NHS North Central London Serious Incident Investigation Report 10.1 Martin Machray presented the report for information and noted that the incident had

not occurred in Islington. It was also noted that there was no indication that the smears were inadequate. The report had previously been circulated but it was agreed to re-send it in the weekly email to GPs.

10.2 The Group AGREED that there should be a reminder sent to all GPs about the

scope of unregistered Health Care Assistants and that they were not allowed to undertake cervical screening.

10.3 ACTION 10/12-10: To arrange for the Serious Incident Report to be circulated as

part of the weekly email to GPs. MM

11. Safeguarding Adults Annual Review 11.1 Elaine Oxley joined the meeting to present the Safeguarding Adults Annual Review

and noted that the service was jointly funded by the London Borough of Islington and Islington PCT. Elaine Oxley outlined the key messages from the report which were:

· There had been an increase in safeguarding alerts of 15% in the last year due to a significant communications campaign.

· There had been a drop in conversion rates from safeguarding alerts to investigation which was thought to be due to inappropriate referrals. Training was being done with groups such as the police to address this.

· Independent audits, peer audits and internal audits were undertaken regularly. The safeguarding adult unit could also undertake an audit if requested by the Governance and Quality Group.

· A successful community conference had been held and the outcomes were being used to plan the strategy.

· There was to be new legislation on safeguarding adults which would make the Partnership Board a statutory body. An annual plan would be produced for April.

· GP referrals were low however training was being delivered. A quick guide had been developed for GPs which would be circulated.

11.2 In response to a question about if individuals were counted more than once, Elaine

Oxley advised that some were counted many times as they may have been victims of abuse on a number of occasions. It was noted that Sean McLaughlin was executive lead for safeguarding adults and Elaine Oxley was the responsible officer.

11.3 The Group NOTED the contents of the report and congratulated Elaine Oxley on a

very accessible and well written document.

12. Performance – Quality Dashboard

ICCG GB - 146

7

12.1 Martin Machray presented the report and noted that it did not yet include the data on health visiting which had been requested from Whittington Health. It was further noted that the report did not provide the thresholds of the calculations or the definitions as previously requested. Also, the group had requested that the health checks indicator be removed from patient experience.

12.2 The group NOTED the report. 12.3 ACTION 10/12-11: To liaise with Jacky Kutner about the requested improvements

to the performance report. MM

13. Any Other Business 13.1 There was none. 14. Date of Next Meeting 14.1 12:30pm, Tuesday, 27 November 2012 Meeting Room 2, National Children’s Bureau, 8 Wakley Street, London EC1V 7QE

ICCG GB - 147