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Page 1 Shropshire CCG Governing Body meeting Agenda 11 September 2019 William Farr House Mytton Oak Road Shrewsbury Shropshire SY3 8XL Tel: 01743 277595 E-mail: [email protected] A G E N D A The meeting is to be held in public to enable the public to observe the decision making process. Meeting Title Governing Body Meeting Date Wednesday 11 September 2019 Chair Dr Julian Povey Time 1.00pm Minute Taker Mrs Sandra Stackhouse Venue / Location Plymouth Suite Upper Meeting Room, First Floor, Ludlow Racecourse, Bromfield, Shropshire, SY8 2BT RESOLVE: A private Governing Body meeting will precede this where it will be resolved that representatives of the press and other members of the public be excluded having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (section 1(2) Public Bodies (Admission to Meetings) Act 1960). Dr Julian Povey, Chair Reference Agenda Item Presenter Time Paper GB-2019-09.108 Apologies Mr K Timmis, Dr S James Julian Povey 1.00 verbal GB-2019-09.109 Members’ Declaration of Interests Julian Povey 1.00 verbal GB-2019-09.110 Introductory Comments from the Chair Julian Povey 1.05 verbal GB-2019-09.111 Minutes of Previous Meeting Meeting held on 10 July 2019 Julian Povey 1.10 enclosure GB-2019-09.112 Matters Arising Julian Povey 1.15 enclosure GB-2019-09.113 Questions from Members of the Public Questions from members of the public will be accepted in writing 48 hours prior to the meeting and should be submitted by 12.00 noon Monday 9 September to: Dr Julian Povey, Clinical Chair, Shropshire CCG, Somerby Suite, William Farr House, Mytton Oak Road, Shrewsbury, SY3 8XL or via email: [email protected] Guidelines on submitting questions can be found at: http://www.shropshireccg.nhs.uk/get- involved/meetings-and-events/governing- body-meetings/ Julian Povey 1.20 verbal GB-2019-09.114 Clinical and Financial Reports Finance, Contracting Report incl. Quality, Innovation, Productivity & Prevention (QIPP) schemes Claire Skidmore 1.25 enclosure

Transcript of shropshireccg.nhs.uk · 2019-09-05 · Page 1 Shropshire CCG Governing Body meeting – Agenda 11...

Page 1 Shropshire CCG Governing Body meeting – Agenda 11 September 2019

William Farr House

Mytton Oak Road Shrewsbury Shropshire

SY3 8XL Tel: 01743 277595

E-mail: [email protected]

A G E N D A

The meeting is to be held in public to enable the public to observe the decision making process.

Meeting Title

Governing Body Meeting Date Wednesday 11 September 2019

Chair

Dr Julian Povey Time 1.00pm

Minute Taker

Mrs Sandra Stackhouse Venue / Location

Plymouth Suite Upper Meeting Room, First Floor, Ludlow Racecourse, Bromfield, Shropshire, SY8 2BT

RESOLVE: A private Governing Body meeting will precede this where it will be resolved that representatives of

the press and other members of the public be excluded having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (section 1(2) Public Bodies (Admission to Meetings) Act 1960).

Dr Julian Povey, Chair

Reference

Agenda Item Presenter Time Paper

GB-2019-09.108 Apologies Mr K Timmis, Dr S James

Julian Povey 1.00 verbal

GB-2019-09.109 Members’ Declaration of Interests

Julian Povey 1.00 verbal

GB-2019-09.110 Introductory Comments from the Chair

Julian Povey 1.05 verbal

GB-2019-09.111

Minutes of Previous Meeting

Meeting held on 10 July 2019

Julian Povey

1.10

enclosure

GB-2019-09.112

Matters Arising Julian Povey

1.15 enclosure

GB-2019-09.113 Questions from Members of the Public Questions from members of the public will be accepted in writing 48 hours prior to the meeting and should be submitted by 12.00 noon Monday 9 September to: Dr Julian Povey, Clinical Chair, Shropshire CCG, Somerby Suite, William Farr House, Mytton Oak Road, Shrewsbury, SY3 8XL or via email: [email protected] Guidelines on submitting questions can be found at: http://www.shropshireccg.nhs.uk/get-involved/meetings-and-events/governing-body-meetings/

Julian Povey 1.20 verbal

GB-2019-09.114

Clinical and Financial Reports Finance, Contracting Report incl. Quality, Innovation, Productivity & Prevention (QIPP) schemes

Claire Skidmore

1.25

enclosure

Page 2 Shropshire CCG Governing Body meeting – Agenda 11 September 2019

GB-2019-09.115

Corporate Performance Reports Quality Exception and Performance Report

Chris Morris/ Julie Davies

1.55

enclosure

BREAK 2.15

GB-2019-09.116

Learning Disabilities Mortality Review (LeDeR) Annual Report

Chris Morris

2.25

enclosure

GB-2019-09.117 GB-2019-09.118 GB-2019-09.119 GB-2019-09.120 GB-2019-09.121 GB-2019-09.122

Governance & Engagement Update on Future Strategic Commissioning Arrangements CCG Strategic Priorities Creation of a Remuneration Committees in Common Audit Committee – 28 August (summary) Healthwatch Report Results of the Integrated Assurance Framework

David Stout David Stout Sam Tilley Sarah Porter Lynn Cawley Julian Povey

2.35

2.45

2.55

3.05

3.15

3.20

enclosure enclosure enclosure enclosure enclosure enclosure

GB-2019-09.123 GB-2019-09.124 GB-2019-09.125 GB-2019-09.126 GB-2019-09.127 GB-2019-09.128 GB-2019-09.129 GB-2019-09.130

For Information Only/Exception Reporting Clinical Commissioning Committee – 19 June Finance & Performance Committee – 3 July & 7 August Primary Care Commissioning Committee – 5 June Quality Committee – 26 June & 31 July System A&E Delivery Board – 25 June & 23 July North Locality Board – 23 May Shrewsbury and Atcham Locality Board – 20 June South Locality Board – 2 May

Sarah Porter Kevin Morris Colin Stanford Meredith Vivian David Stout Mike Matthee Deborah Shepherd Matthew Bird

3.25 enclosures enclosures enclosure enclosures enclosures enclosure enclosure enclosure

GB-2019-09.131

Any Other Business

Julian Povey 3.30 verbal

Date of Next Meeting

Wednesday 13 November 2019, time and venue to be confirmed

A hearing loop system can be made available, upon prior request, to members of the public with hearing difficulties. Please contact the CCG at least 48 hours prior to the meeting at: [email protected]

Dr Julian Povey David Stout

Clinical Chair Accountable Officer

Page 1 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

Shropshire Clinical Commissioning Group

MINUTES OF THE SHROPSHIRE CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

HELD IN THE SOVEREIGN SUITE, SHREWSBURY TOWN FOOTBALL CLUB, OTELEY ROAD, SHREWSBURY, SY2 6ST

AT 1.30 PM ON WEDNESDAY 10 JULY 2019

Present Dr Julian Povey CCG Chair Dr Finola Lynch Deputy Clinical Chair Mr David Stout Accountable Officer Mrs Claire Skidmore Chief Finance Officer Dr Jessica Sokolov Medical Director Dr Stephen James GP Governing Body Member & Clinical Director Dr John Pepper GP Governing Body Member & Clinical Director Mr Kevin Morris GP Practice Governing Body Member Dr Deborah Shepherd Locality Chair, Shrewsbury & Atcham Locality Board Dr Matthew Bird Locality Chair, South Locality Board Dr Michael Matthee Joint Locality Chair, North Locality Board Dr Priya George GP Governing Body Member & Clinical Director Dr Alan Leaman Secondary Care Member Dr Julie Davies Director of Performance & Delivery Mrs Christine Morris Chief Nurse for Shropshire and Telford & Wrekin CCGs Mrs Nicky Wilde Director of Primary Care Mrs Sam Tilley Director of Corporate Affairs Mr Keith Timmis Lay Member – Governance and Audit (Vice Chair) Mrs Sarah Porter Lay Member – Transformation Mr Meredith Vivian Lay Member – Patient and Public Involvement Dr Colin Stanford Lay Member In Attendance Ms Rachel Robinson Director of Public Health, Shropshire Council Ms Lynn Cawley Healthwatch Shropshire – Observer Mrs Sandra Stackhouse Corporate Services Officer – Minute Taker 1.1 Dr Povey welcomed members, observers and the public to the Shropshire Clinical Commissioning

Group (CCG) Governing Body meeting being held in public.

1.2 A special welcome was extended to new Members of the Board: Mrs Christine Morris, Dr Colin Stanford and Ms Rachel Robinson.

Minute No. GB-2019-07.086 - Apologies 2.1 Apologies were noted from:

Mrs Gail Fortes-Mayer Director of Contracting & Planning

Minute No. GB-2019-07.087 - Declarations of Interests 3.1 Members had previously declared their interests, which were listed on the Governing Body Register of

Interests and was available to view on the CCG’s website at: http://www.shropshireccg.nhs.uk/about-us/conflicts-of-interest/ However, Members were asked to confirm any specific conflicts of interest that they had relating to the agenda items and these were noted as follows:

Ms Robinson declared that she was the new Director of Public Health and was an employee of Shropshire Council.

3.2 There were no other additional conflicts of interest noted.

Agenda Item - GB-2019-09.111

CCG Governing Body – 11.09.19

Page 2 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

Minute No. GB-2019-07.088 - Introductory Comments from the Chair 4.1 Attendees of the meeting were reminded that the meeting was being live streamed, which would be

available to view on YouTube. Should there be any technical difficulties with the wi-fi signal connection affecting the streaming process; a recording of the meeting would be uploaded onto the CCG’s website as soon as possible following the meeting.

Minute No. GB-2019-07.089 – Minutes of the Previous Meeting – 8 May 2019 5.1 The minutes of the previous meeting held on 8 May 2019 were presented and approved as a true and

an accurate record of the meeting.

RESOLVE: MEMBERS FORMALLY RECEIVED AND APPROVED as an accurate record the minutes of the meeting of Shropshire Clinical Commissioning Group (CCG) held on 8 May 2019.

Minute No. GB-2019-07.090 – Matters Arising from the Minutes of the Previous Meeting 6.1 It was noted that the actions from the previous meeting had been completed or included on the

agenda. The following updates on the matters arising were noted as follows:

a) GB-2019-05.067 – Quality Exception Report – Chief Clinical Information Officer (CCIO) role Mr Stout reported that a job description for the CCIO role had been developed and was being progressed.

b) GB-2019-05.074 – 360 Degree Stakeholder Survey

Mrs Tilley advised that the CCG had reviewed the stakeholder surveys undertaken over the last four years, which had shown that on the one occasion where follow up calls had been made to GP practices, there had been a better response rate. This information had been considered helpful for future planning, however, it had since been announced that the 360 Degree Stakeholder Survey would be discontinued and, therefore, the CCG would not be required to take part in the survey going forward.

Minute No. GB-2019-07.091 – Public Questions 7.1 Dr Povey advised that there had been no questions received from the public for this meeting. Clinical and Finance Reports Minute No. GB-2019-07.092 – Governing Body Assurance Framework (GBAF) 8.1 Mrs Tilley briefly talked through the updates included in the GBAF and cover paper, which had

included actions from the Governing Body meeting, held on 13 March 2019, which had been actioned. 8.2 The main point that was brought to the Governing Body’s attention was the reformatting of the

document following a recommendation from the CCG’s internal auditors. This change ensured a firmer process of identifying and tracking gaps in controls and assurances and actions demonstrating how they were mitigating those gaps. Once an action had been carried out and they were having a mitigating impact the action would be then transferred to the controls or assurances section where it would be noted as a current mitigation.

8.3 Following review of the document: Dr Povey pointed out that in Risks 1 and 2: 1/18 Finance and

72/16 Quality and Safety, the columns did not include indication arrows showing the level of risk compared to the previous GBAF. Re. Risk 1, Mr Stout asked that the risk be amended to read that the CCG fails to deliver its ‘plan’ and not its ‘control total’.

RESOLVE: THE GOVERNING BODY RECEIVED the GBAF and REVIEWED the detail of the risks and

highlighted the updates required. THE GOVERNING BODY also CONSIDERED the risks highlighted in the GBAF as it

conducts its business.

ACTION: Mrs Tilley to update the first two new risks on the GBAF to include the indication arrows in the assessment of risk column. Also to amend the first risk listed re. Finance to state that the CCG fails to deliver its ‘plan’ and not its ‘control total’.

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Minute No. GB-2019-07.093 – Finance and Contracting Report including Quality, Innovation, Productivity & Prevention (QIPP) schemes 9.1 Mrs Skidmore presented an update on the CCG’s finance and contracting position as detailed in the

Finance and Contracting Report to 31 May 2019 (Month 2), the key points of which to note were as follows:

9.2 Mrs Skidmore highlighted that there had been a major review of the CCG’s reporting style in readiness

for the new financial year. The CCG had already taken the step to combine the QIPP report into the Finance and Contracting Report. However, assurance was given that the Finance and Performance Committee still continued to take separate papers to review the detailed information, in particular, on the QIPP schemes. The new reporting style was an attempt to ensure information was presented to the Governing Body in the most effective way to aid decision-making and assurance.

9.3 Apologies were extended for an error in that paragraph 11 should have been omitted as it made reference to graphs that had not been included in the report. Members were asked to disregard this as it did not change the overall presentation.

9.4 The CCG had set a budget based on a financial plan for 2019/20 that did not meet its control total of £12.3m. The plan submitted showed a forecast deficit of £22.9m. NHSE had now written formally confirming their acceptance of the CCG’s planned position and a copy of the letter had been included with the papers for Members’ information. Although the letter set out a number of requirements of the CCG, it was considered helpful that there was a formal record that NHSE had accepted the CCG’s planned position.

9.5 Mrs Skidmore reported that the CCG was not on trajectory to meet its control total for the year with

Month 2 data showing a year to date overspend against plan of £2.1m. The CCG was experiencing significant cost pressures in the acute sector, particularly in musculoskeletal activity, ambulance conveyances, non-elective activity and a rapid increase in costs and activity in the mental health area of continuing healthcare.

9.6 The CCG continued to report that it could meet a planned deficit of £22.9m. However, this position

was dependent on significant QIPP delivery and success resulting from a number of management actions. Mrs Skidmore highlighted that an unmitigated risk of £5.1m was therefore now a very serious concern to the financial position. It was very early in the financial year and there had already been indications of overspend. As a system, work was continuing to investigate what had driven changes in hospital activity and any changes would be subsequently reflected in the position reported. The management team were working hard both internally and with partner organisations in the system at ways to control the position.

9.7 The CCG was currently reporting a forecast QIPP delivery of £18.4m against a plan of £19.8m. There

were a number of schemes that were not due to commence until later in the year and the management team were monitoring the plans to ensure the delivery trajectories remained on schedule.

9.8 Mr Morris reiterated that as Chair of the Finance and Performance Committee he shared the concerns

raised and, as discussed at the last Finance and Performance meeting, there was going to be a focus on some of those areas that were not performing particularly well, together with the CCG’s QIPP programmes, and there would be deep dives carried out on some of those areas. The next review would be around CHC followed by MSK. Hopefully this work would help develop an action plan.

9.9 Following points raised, Mrs Skidmore agreed to have the assumptions in the plans tested by

reviewing the data and graphs included in A-1A: Shrewsbury and Telford Hospital (SaTH) position, in particular, the A&E activity and costs. Similarly, in A-1B; Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH) position, to review the elective activity and cost and 1

st outpatients’ activity and cost.

9.10 Mr Stout commented that the presentation of the report had improved and it was clearer, however, it

had raised some questions. The CCG needed to have a clearer understanding of what assumptions had been included in the plans and had those assumptions been properly based. Mr Stout asked for rolling annual averages to be included in future reports to give a clearer perspective of activity over time.

9.11 Dr Leaman sought clarification about the nature and magnitude of the outstanding dispute with the Betsi Cadwaladr Health Board.

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9.12 Mrs Skidmore explained that the Health Board, which was governed by Welsh contracting rules, had amended its pricing arrangements but had not served sufficient notice according to English contracting rules. There had been a difference of opinion regarding the timing of the price changes, with discussions continuing last year, which had not been resolved by the end of the financial year. However, recently there had been positive conversations held with the Health Board working towards avoiding an arbitration position. The CCG was looking at a quantum for the contract for 2019/20 of approximately £5m, which was considered sizeable and was why the discussions had been difficult.

9.13 Dr Povey referred to the final bullet point in the letter received from NHS England (NHSE) where it stated: ‘The CCG should take all necessary actions to ensure that the Directions imposed on the CCG in 2016 are lifted as soon as practicable.’ It was pointed out that at the time when the CCG was placed in directions, there had been requirements for CCG to arrange a Capacity and Capability Review; develop a medium term financial plan; appoint a new Accountable Officer (AO) and a review of the senior management structure, which had all been completed. Dr Povey asked Mr Stout what further steps did the CCG need to take in order for directions to be lifted.

9.14 Mr Stout advised that it was his understanding that the bullet point referred to was included in all letters to CCGs that were under directions. It was believed that the Integrated Assurance Framework (IAF) rating the CCG expected to receive very soon was connected to directions also and it would be the decision of NHSE whether or not to lift the CCG’s directions.

9.15 Mr Timmis said that it was his understanding that the CCG had been waiting for NHSE to approve the CCG’s medium term financial plan and although this had been discussed over the last two years this had never been signed off. It was thought this was the reason for the delay in the CCG being lifted out of directions.

9.16 Mrs Skidmore confirmed that this had been discussed previously. By virtue of the fact that the system

plan needed to be submitted in the autumn there would be a point in time when the CCG could have that conversation with NHSE again although Mrs Skidmore was unsure whether that would resolve itself before the 31 March 2020. It was considered the best the CCG could do was to keep working to build its plan as it was already.

9.17 Mr Stout advised that connected to this was that by establishing a new single commissioning

organisation, the CCG would submit a medium term financial plan and a sign off of the new organisation would implicitly include the sign off of the collective deficit with Telford and Wrekin CCG leading to the financial plan.

9.18 Dr Povey thought the new presentation of the report was a positive change but there needed to be

more information on contracting especially as there were contracting challenges moving forward. It was also requested that risks should include stratification into worst and best case scenarios to provide a rationale.

9.19 Mr Stout agreed that there needed to be significantly more detail in the report, in part through the

Finance and Performance Committee especially as the year progressed and the risks became solidified and if the pressures seen in Month 2 continued.

9.20 Mrs Skidmore advised that other than the issue with the Betsi Cadwalldr Health Board already

discussed there was not anything of scale that was not picked up anywhere else in the reports through performance and quality at the present time. Mrs Skidmore would feedback the comments to the Finance Team to ensure the suggestions were included in future reports.

RESOLVE: THE GOVERNING BODY NOTED:

The financial position at Month 2 The financial challenge for 2019/20 and the urgency required around developing

further in-year QIPP plans The new report format and provided feedback.

ACTION: Mrs Skidmore to check assumptions in plans by reviewing the data and graphs included in A-1a: Shrewsbury and Telford Hospital Trust’s (SaTH) position, in particular, the A&E activity and costs. Similarly, in A-1b: Robert Jones and Agnes Hunt Orthopaedic Hospital’s (RJAH) position, to review the elective activity and cost and 1

st outpatients’ activity and cost. Mrs Skidmore also to

arrange for annual averages to be included in future reports. Mrs Skidmore to feedback Members’ comments on the report to the Finance Team and ensure that the request for further information is included in future reports.

Page 5 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

CORPORATE PERFORMANCE REPORTS

Minute No. GB-2019-07.094 – Quality Exception Report and Performance Report 10.1 Dr Julie Davies referred to the report circulated and explained that it was the first attempt to integrate

quality and performance reporting for the CCG and set out Shropshire CCG’s performance against all its key performance and quality indicators for Months 1 and 2 where available for 2019/20. Governing Body Members were asked for their feedback on the revised report, which would be incorporated into future versions.

10.2 Dr Davies highlighted the following key areas for the Governing Body to note, which included:

Cancer - The deterioration in cancer performance, in particular the 2 week RTT breast symptoms and the overall 2 week wait performance targets for the CCG, were not achieved in April and it was predicted the performance would deteriorate in May. The improvement plans continued to be monitored but breast radiologist capacity had continued to be an issue. Following the Planned Working Group meeting with Shrewsbury and Telford Hospital the previous week, it was expected an improvement in the service would be seen in June.

Urology – This area remained a risk despite the ongoing improvements in the urology pathway as a result of the joint working with University Hospital North Midlands (UHNM). The underlying consultant workforce capacity remained an issue, which was not just a Shropshire issue. NHSE/I’s Regional Director of Commissioning has set up a regional Urological Cancer Review Board, which the CCG and SaTH would attend.

10.3 Quality - Mrs Morris added that there was a process in place to oversee the 104 day waits. It was known that the vast majority of those related to patients whose pathway went through tertiary centres and the oversight of this was through the Quality Surveillance Group, chaired by NHSE. Conversations are held across the North Midlands region with Cancer Alliance representatives and with commissioners from UHNM to enable the CCG to have the cross challenge. The CCG had put in a challenge to ensure that Shropshire patients are not disadvantaged in their wait when they are being seen by providers outside of the county. Some assurances have been received but the CCG would continue to raise this matter. Although it had not been identified that there had been any significant harm to patients while they wait, it was not good from a patient experience perspective.

10.4 Dr Davies continued to highlight the updates on the following areas:

Improving Access to Psychological Therapies (IAPT) access – The increased target run rate of 22% in place for 2019/20 was not achieved in the first two months of the year but assurance had been given by the provider that this would improve in June. This was mainly due to the time taken to recruit additional staff.

A&E performance – The demand into the Emergency Departments continues to increase both in walk-ins and ambulance conveyances and remains above plan but along regional trends. An improvement in performance had been seen in the day time as staffing improves. Some pilots had been carried out with the Emergency Service Improvement Programme (ESIP) around implementing the national programme of same day emergency care, which has given some benefit at approximately 5%.

Ambulance handovers >30 mins and >1 hr – Improvements have been seen but the issues remain with significant volumes of ambulances attending either Emergency Departments. With a combination of the same day emergency care and improvements in systems and processes, there had been a gradual reduction in handover times.

Referral to Treatment (RTT) – The 18 week performance continued to be compromised as a result of emergency pressures and ongoing escalation into both sites Day Surgery Units. From the beginning of July an improvement had been seen with A&E medical patients no longer being escalated into the Day Surgery Unit at the Princess Royal Hospital (PRH)

Mental Health – The Midlands Partnership Foundation Trust (MPFT) have raised concerns about the issue of a backlog of children waiting for an assessment for Autistic Spectrum Disorders (ASD). Both CCGs have been meeting with the Trust on an urgent basis to try and find a solution and had agreed some investment, which has been prioritised to clear the long waits of over 12 months as quickly as possible. This issue was not particularly related to just Shropshire but a sustainable solution needed to be found.

10.5 Quality – Mrs Morris reported that most of the quality issues aligned to those issues highlighted by Dr

Davies and had been reported in the paper presented. In relation to ASD, MPFT had been asked to consider a harm performer perspective. Whilst the children were not necessarily going to come to

Page 6 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

harm through longer waits, their developmental issues needed to be fully considered and the Trust had been asked to identify any associated risk.

10.6 The Safe Today process has continued within SaTH, which on a daily basis, looks at staffing in the

two EDs ensuring that issues identified by the Care Quality Commission (CQC) and the actions that were put in place continued to be followed by the Trust. The issues are monitored through the Safety, Oversight and Assurance Group, which meets monthly and is chaired by NHS Improvement (NHSI) in SaTH, which is attended by Dr Sokolov, Mrs Morris and Healthwatch. NHSI had noted an upward trajectory in terms of the Trust delivering the Quality Improvement Plan, and as commissioners, the CCG was testing out the quality improvement plans through the Clinical Quality Review processes.

10.7 Dr Povey commented that he did agree that reducing the size of the reports was better but stressed

that the reports did need to provide sufficient information to provide assurance. Dr Povey referred to an action from the previous meeting, which had been to present the Learning Disabilities Mortality Review (LeDeR) Annual Report to the next meeting. Mrs Morris reported that the LeDeR report had been presented to the last Quality Committee meeting and would bring back to the next Governing Body meeting.

10.8 Dr Shepherd noted the performance data on children’s cancer, which had appeared to have fallen and

asked if there was more detail available. 10.9 Dr Davies advised that the CCG had requested more information from SaTH and had asked for a

meeting to discuss this further. There had been no particular concerns noted but a report had been requested to review if there were any underlying issues.

10.10 Dr Shepherd referred to the phrasing in paragraph 70, line 4, regarding the ASD Waiting List which

stated that: ‘It had been suggested that families of Children and Young People with attachment, emotional deregulation are pursuing a diagnosis when there is not ASD.” Dr Shepherd said she felt that the phrasing was inappropriate as it seemed to suggest that there was some blame on families pursuing a diagnosis. Dr Davies apologised for this and explained that this was not the intention and would arrange for better rewording of the sentence to reflect that this was not the case.

10.11 Dr Stanford referred to the statement in paragraph 26 that 64% (approximately two-thirds) of patients

with learning disabilities were not receiving annual health checks by the GPs, which was a very vulnerable group with worse outcomes than many other patient groups. Dr Stanford asked what schemes or actions were being taken to address this issue.

10.12 Dr Davies advised there was not a specific scheme at the present time. This area of work had been

discussed at the last Governing Body development meeting and had been identified as an issue and had been included in the CCG’s planning on priorities. It was hoped that closer working with Telford and Wrekin CCG would provide the extra capacity to review this area of work in the future.

10.13 Dr Lynch referred to the table included in paragraph 39, and highlighted the Shropshire mean wait

times and call category standards. Dr Povey explained that the contract was based on the provider’s regional data which affected Shropshire’s figures. The data had been recently challenged by the Health and Social Care Overview Scrutiny Committee and the Health and Wellbeing Board and more information on the long waiting times had been requested from WMAS.

10.14 Dr Pepper referred to the cancer 31 day wait statistics for patients where the subsequent treatment is

surgery and noted that the performance had declined. Dr Pepper asked if there was anything in particular in the system that had been an issue this year which might have affected the performance.

10.15 Dr Davies explained that the performance would have been impacted by the 2 week performance but

she had not been aware of anything in particular having been escalated and no cancer surgery had been cancelled.

10.16 Dr Pepper also referred to page 9 and queried the total stated (8997) for delays in ambulance

handover times of more than 30 minutes. It was explained that the data presented was English ambulance activity and not Welsh ambulance activity. The total of 8997 was the total for English activity for the previous year.

10.17 Dr Pepper made an observation about maternity smoking and that Shropshire was consistently above

the national average of 10.5%. It was highlighted that this came at the same time as some QIPP services in the county had been lost. Dr Pepper acknowledged that there was a service for pregnant women but considered there needed to be a service for pre-pregnant women.

Page 7 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

10.18 Mr Stout noted that the CCG, working with Shropshire Council, had managed to maintain the smoking and pregnancy service, which was what the specific statistic was relating to and that this was good news. In terms of the wider work, this was a short term solution and the CCG was looking at how it might address this in the longer term.

10.19 Mr Stout reported that in terms of the wider smoking cessation service position, the public health

budget had been reduced nationally which had affected the service at local level. In the longer term, as integrated care systems were developed, the use of collective resource would be deployed to provide services that would best meet the needs of the local population, which could include a smoking cessation service.

10.20 Ms Robinson added that Public Health was monitoring the services but it was in a really difficult

position as a result of the local authority being under significant financial pressures. Difficult decisions were being made and the decommissioning of services was being reviewed. Discussions were being held with Public Health England but it was a system wide issue which it was hoped would be worked on collectively. Ms Robinson would provide an update to the Clinical Commissioning Committee on the changes to some services that could be worked on jointly.

10.21 Dr Povey expressed disappointment at the breast cancer 2 week data of 41% and was surprised to

see the performance had worsened. Dr Davies advised that May’s data could show a further decline in performance.

10.22 Dr Povey further queried the status of the patients on the waiting list and whether there had been any

harm reported as a result of the delay. 10.23 Dr Davies advised that the latest update given at the last Planned Care Working Group meeting was

that the longest wait with 14 days being the target was 28 days. It had been reported the previous week this had been reduced to 21 days and Dr Davies was receiving a weekly update on the current position.

10.24 Dr Povey asked, in addition to working with a provider, what steps were taken if a provider was not

reaching a fundamental target. It was pointed out that there had been a similar issue last year and then there had been a trajectory when the provider had stated it was going to achieve the 14 day target.

10.25 Dr Davies explained the target had been achieved but then the Trust had lost capacity. The issue with

the lack of breast radiologists was not just a Shropshire issue, it was a national issue. The CCG followed the contractual processes and there were action plans in place but, particularly with the issues in Urology, this has been outside of the Trust’s control.

10.26 A strategic partnership with UHNM had been developed and Alison Tongue, the Regional Director of

Commissioning for NHSE/I had set up a Urological Cancer Review Board, which would be looking at the long-term provision of services. A needs assessment would be carried out for Urological cancer to gain an understanding of the workforce requirements and the diagnostic capability to meet the demand for services. Dr Davies added that one effect that had caused an increase in referrals was thought to have resulted in a number of promotional events run by voluntary and charity organisations, which although had good intentions, were targeting the lowest risk of the population, which was having an impact on the service.

10.27 Dr Povey queried why 12 hour trolley breaches were used as a marker for quality when after every

incident there appeared to be no harm caused to the patient. Dr Povey asked in how much detail were these cases analysed about whether there has been any harm to patients.

10.28 Mrs Morris agreed with this point and explained that the harm performer was carried out quite soon

after the 12 hour trolley breach. There would be a 72 hour review and then a short review of the impact on that patient. Sometimes it was later that the patient may get a harm incident, for example, they may develop a pressure ulcer that was caused by the long delay on the trolley but actually materialises later in time. The Governing Body was assured that instances were monitored through the Quality Oversight and the reporting process, however, currently there were no metrics to measure the patient experience element, which required monitoring.

10.29 Dr Povey referred to paragraph 61: Midwifery and the statement that the Midwife Led Unit (MLU) at

the RSH site had closed for essential building repair work that was in addition to the other freestanding MLUs being closed, which meant the service was offering a consultant unit alongside a maternity unit and home deliveries. To reduce the impact on patients Dr Povey asked what work was being done with providers about this until the renovation work had been completed at RSH.

Page 8 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

10.30 Mrs Morris reported that the Trust was managing the numbers of women presenting on a daily basis.

Assurance had been given that there was capacity at the Wrekin Unit to take all those women who wish to have a Midwife Led birth but it was believed that staffing was being flexed across the consultant unit and the MLU in The Wrekin and so was not an easy solution. There had been a slight increase to 1.8% in home births, which was still very low but was still an option to women and the midwives were encouraging more women to safely have home births where the level of risk is low. The level of Birth Before Arrival (BBA) had not changed but was being monitored on a monthly basis.

10.31 Mr Stout highlighted that the format of this report had been changed to incorporate the Quality and

Performance reports into a single integrated report, which would continue to develop. RESOLVE: THE GOVERNING BODY NOTED the contents of the report and the CCG actions

contained within to recover performance and quality in those areas which were currently below target. The Governing Body also provided feedback on the revised report which would be incorporated into future versions.

ACTION: Mrs Morris to arrange for the annual review of the Learning Disabilities Mortality Review (LeDeR) to be presented to the next Governing Body meeting including data and assurance. Dr Davies to arrange the rewording of sentence 5, paragraph 70, page 17 of the report to avoid any misinterpretation and to make clear that there was no suggestion of blame on patients’ families for pursuing a diagnosis for Autism Spectrum Disorder (ASD). Minute No. GB-2019-07.095 – Ambulance Demand Review 11.1 Dr Davies presented the report on the Ambulance Demand Review that had followed the last meeting,

which had looked at the analysis work undertaken by the new multi-stakeholder Ambulance Demand and Pathways Group to understand the increase in the ambulance rates.

11.2 It was reported that it was still difficult to understand any specific causes for the increase in demand

other than the increase in public demand in dialling 999 and the consequence of that in terms of an increase in conveyances. Research was continuing looking at this possible cause and whether there were other steps that could be taken to manage the demand differently. An action plan had been developed and Dr Davies talked through the updates on the key items in that plan which were:

WMAS Strategic Capacity Cell

Ambulance Care Co-Ordinator Test of Change

Refresh of the Directory of Services

Expanding the range of alternative community pathways

High Intensity User Service

Increasing the update of Minor Injury Units

Reducing ambulance handover delays. 11.3 Dr Lynch referred to paragraph 6 of the report and welcomed any initiative to ensure that the

ambulances were at the right place at the right time. However, Dr Lynch had been disappointed to find out about the work of the Strategic Capacity Cell via the Governing Body rather than through the Shropshire Care Closer to Home project. WMAS was a partner and each partner was invited at the end of the meeting to share any initiatives they were doing which may dovetail with the work of the group. The transformation programme had found that this service was having a noted impact which had limited alternatives to convey patients to A&E at the present time.

11.4 Dr Davies agreed and said the CCG needed to ensure that it had an understanding of the impact on

each service or initiative and that these services dovetailed together. WMAS was a partner and it did need to factor in the CCG’s work in its plans.

11.5 Dr Povey asked if there was a way to feedback to WMAS in November. Mr Stout agreed there was a

theme about how the CCG commissioned ambulance services given it was a regional service and there was an obvious risk that: (a) the CCG was not always present at the discussions, and (b) the rurality of the county was not always fully taken into account. It was agreed that the CCG would look into strengthening the way it interfaces with the regional commissioning discussions on the WMAS service to ensure the CCG’s concerns were taken into account.

11.6 Dr Sokolov referred to the additional analysis to determine if there was any causal relationship

between the change in the NHS111/GP Out of Hours (OOH) Integrated Urgent Care model and the increase in ambulance demand. In paragraph 4, it stated that analysis of the 7 months activity data

Page 9 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

since the new GP OOH model was introduced in October 2018 showed an average 2% disposition rate from GP OOH to a 999 ambulance which was lower than the average rate before the model change. Dr Sokolov asked if that was the full question because there was a concern or perception that patients could not access their GP and phoned 999 instead, which was considered not necessarily a direct impact from GPs because it was the patients that chose a different route by dialling 999.

11.7 Dr Davies agreed this was a possibility but the analysis that projected the activity before and after the

service change to NHS 111 suggested that there had not been a material impact. 11.8 Mr Stout advised that at the Health and Wellbeing Board meeting, it had been reported that

Shropshire’s use of ambulances per head of population was actually lower than other parts of the country and so discussions needed to bear in mind the wider context.

11.9 Dr Stanford referred to paragraph 14, on page 5, and reference to the High Intensity User Service and

said he had been surprised to see that the post had remained unfilled because someone had left the position. Dr Stanford asked if this potentially would have an impact on the response rate and costs in healthcare and to protect the post in case this happened again.

11.10 Dr Davies reported that Telford and Wrekin CCG had appointed someone but unfortunately the

person had withdrawn but Telford and Wrekin CCG did have a different solution now. The CCGs would need to discuss this further in order to protect this post to ensure there was coverage as it was a key role. It was also confirmed that support was included for the post.

RESOLVE: THE GOVERNING BODY NOTED the contents of the progress update report and

REQUESTED that further updates on progress against the action plan are taken to the Clinical Commissioning Committee on a quarterly basis with any further major issues coming back to the Governing Body.

ACTIONS: Dr Davies/The CCG to look into strengthening the way the CCG interfaces with the regional commissioning discussions on the WMAS service to ensure the CCG’s concerns are taken into account. Dr Davies to ensure further updates on progress against the action plan are taken to the Clinical Commissioning Committee (CCC) on a quarterly basis. Minute No. GB-2019-07.096 – West Midlands Quality Review Service (WMQRS) Report 12.1 Mrs Morris referred to the WMQRS report, which had been an independent review commissioned by

NHSE of Shropshire and Telford and Wrekin CCGs’ quality function following some issues raised across the providers last year. It was reported that this review had entailed a considerable amount of work collating documentary evidence around the key lines of enquiry that had been shared with the CCGs’ teams. This work had included interviews, telephone calls and discussions with 10 senior leaders from the West Midlands who had scrutinised the CCGs’ processes over a 2 day period.

12.2 The report presented showed good assurance of the quality functions across both CCGs, particularly

about the effective collaboration of the two quality teams and how resources were used. The areas identified for using best practice were: serious incidents (SIs), Looked After Children (LAC) and monitoring processes, which Mrs Morris said was testament to the teams who had worked hard on making improvements. The CCGs were also praised for their safeguarding approaches; the LeDeR programme; their quality functions in primary care and how the organisations used business intelligence.

12.3 There had been some areas highlighted for improvement, which had been mainly regarding

processes. The reviewer had suggested that the CCGs had a joint quality strategy and a joint escalation framework in place across the two teams. At the time, Shropshire CCG had an active quality strategy and Telford and Wrekin CCG had an active escalation framework and was now working as one interim quality team. It was planned to look at best practice across the country together with the work of both CCGs to develop a new suite of documents that formalised the quality monitoring work, which would also build in patient stories.

12.4 The providers had shared with the reviewers their good relationships with the CCG Quality Leads

although there were challenges but they were effective working relationships and the providers would welcome a single quality voice. Now that there was an interim structure in place, all the quality functions across all the services that the CCG commissioned were being reviewed. The quality leads had been realigned to cover this work and to reduce the duplication of work carried out previously

Page 10 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

across the two CCGs. This had also freed up some capacity to be able to look in more depth in some areas, for example, End of Life Care and Frailty.

12.5 Mrs Morris reported that the Quality Committee had reviewed this report at its last meeting at which it

had been agreed that the actions from the report around systems and processes, and documentation aligned with a joint team, would be presented to the Quality Committee’s September meeting for review and agreement.

12.6 Dr Povey said he considered the report was very positive overall and on behalf of the Governing Body

thanked Mrs Morris and Ms Dawn Clarke, (previously Shropshire CCG’s Director of Nursing, Quality and Safety), and their teams, for the work undertaken on behalf of Telford and Wrekin and Shropshire CCGs.

RESOLVE: THE GOVERNING BODY NOTED the contents of the report and also thanked Mrs Morris

and Ms Dawn Clarke, and their teams, for the work undertaken on behalf of Telford and Wrekin and Shropshire CCGs. THE GOVERNING BODY also AGREED that updates from the actions from the report would be presented to the Quality Committee’s September meeting.

Governance & Engagement

Minute No. GB-2019-07.097 – Future Strategic Commissioning Arrangements 13.1 Mr Stout referred to the paper circulated, which summarised the progress made to date on the

recommendations that had been approved at the last Governing Body meeting. 13.2 Following the decision at the last Governing Body meeting to proceed to put forward a proposition of

dissolving the two existing CCGs and forming a new single commissioning organisation across Shropshire, Telford and Wrekin, the appointment of an Accountable Officer to work across the two CCGs had been progressed. Dr Povey was working with Dr Jo Leahy, Chair of Telford & Wrekin CCG on leading the process and the interviews were scheduled for 23 July.

13.3 The work to submit the application for forming a new organisation was not insubstantial. NHSE had

developed a comprehensive and detailed set of key lines of enquiry and submissions that the CCG would need to make to support its proposition, which would need to be submitted by the end of September.

13.4 There was a considerable amount of work to be carried out with a number of checkpoint processes

with NHSE. The CCG had made clear to NHSE its objective to achieve the establishment of the new organisation by 1 April 2020 if possible. However, should this not be achievable, the CCG would proceed to implement the integrated management team by 1 April 2020 and would continue as two organisations with more shared governance than at present.

13.5 A small Programme Management Office (PMO) had now been established to support the work,

commissioned from the CSU. Alison Smith, Executive Lead Governance and Engagement, at Telford and Wrekin CCG was the Senior Responsible Officer (SRO) for this work across the two organisations. The CCG had also secured additional HR capacity from the Commissioning Support Unit (CSU) recognising that there would be considerable demand for managing change. Procurement had also commenced for Operational Development (OD) support for the engagement of staff, partners, and members on the design of the new organisation.

13.5 The CCG was already engaging with Members and Dr Povey and Mr Stout would be attending the

Locality Board meetings with Member practices, who were a key part of the decision-making on this process, to debate the rationale and to hear any concerns raised and ensure those issues were being addressed.

13.6 Dr Leaman asked if the Governing Body would be given an opportunity to make suggestions as to

how the new organisational structure should look. 13.7 Mr Stout advised that the OD work would include discussion with the Governing Body Members. The

intention was to build a new organisation taking into account the strengths of both CCGs and to consider what should be done differently if certain areas had not been successful. It was hoped the OD support would be in place by 1 August to support the future design of the new organisation during August and September. It would not be the last opportunity but it was felt important that there was a clear objective by the time the CCG made its submission at the end of September. The CCG would

Page 11 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

need to produce a new constitution for the new organisation, which would be permissive of change in the future to allow it to evolve quickly.

13.8 Mr Vivian queried whether estates were included in the work of any of the work streams. Mr Stout

advised that the physical office space for the new organisation would need to be resolved but it would not necessarily mean that there would be one base. However, it was recognised that Shropshire CCG’s current office space was suboptimal and there needed to be a long-term solution which was better than the current office space. Mrs Tilley was carrying out some preliminary work in relation to achieving a better long-term solution but this needed to be aligned with the new structure, staff numbers, etc. This work did not need to be finalised by 1 April 2020 as there could be a lead time to account for the agreement of leases, etc.

13.9 Mr Vivian also commented on the report that recruitment of the new Accountable Officer was

proceeding but that he had not seen any further information regarding the process, ie who was involved; what they were involved in; and what the arrangements were for interviewing, etc.

13.10 Dr Povey explained that the new organisation would be completely separate from the current CCGs.

In accordance with the Health and Social Care Act, there were clear roles that were required on the Board, which would include clinical representatives who worked in medical practices, an Accountable Officer (AO), Chief Finance Officer (CFO) and Lay Members. The CCG was also required to follow the advice of NHSE. It was the aim to try and appoint a new AO as soon as possible so the appointee would be able to lead the formation of the new organisation. The process was being led by Dr Leahy and Dr Povey jointly in conjunction with Fran Steele, Area Director, NHSE who would be on the interview panel alongside the two Chief Executives from the Local Authorities. As well as the interview panel there would be two stakeholder panels which would comprise of members of: Healthwatch, the CCG Governing Bodies, and partners. The panel would make a recommendation to NHSE, which would need to be signed off by Simon Stevens, Chief Executive, NHSE.

13.11 Dr Povey outlined the process explaining that once appointed, the new AO would become the joint AO

taking over the roles of the present AOs. The CCG was going through a process with membership support and would apply to NHSE for approval to create a new CCG. One of the first steps in the process would be to appoint a new Chair. Dr Povey described several further steps to be undertaken to transition the senior leadership into the new organisation.

13.12 It was agreed that Mr Stout would bring back this document to future Governing Body meetings and

development sessions to discuss updates. As the work progressed, it would need to be discussed at the Board Committees, for example, at the Audit Committee and Finance and Performance Committee meetings, as required. The work would also be taken through the relevant governance structures because not all of the work was the responsibility of the present CCG.

RESOLVE: THE GOVERNING BODY NOTED the progress made to date on creating a single strategic

commissioner for Shropshire and Telford and Wrekin. ACTION: Mr Stout to present an update at the next meeting. Minute No. GB-2019-07.098 – Audit Committee – 21 May & 26 June (summary) 14.1 Mr Timmis said he had taken the report of the Audit Committee meetings on 21 May and 26 June

2019 as read but highlighted the main points for the Governing Body to note:

Some very positive comments had been received from the external auditor about the Finance Department’s processes. Further improvements had been identified but the external auditor was confident that the CCG was progressing well with the new team in place.

The financial risk of some disputed balances had been highlighted, some of which had now materialised in the CCG’s finance position. Although this was not material to the accounts it was of significant importance, and the external auditor had stressed what they thought were the potential risks and the process the CCG and the new organisation needed to adopt going forward.

The Annual Audit letter, which had been attached as an appendix to the report, had been discussed. This was considered a clear summary of the external audit work undertaken during the year and reinforced previous messages to the Governing Body.

The external auditor had noted improvements to the continuing healthcare (CHC) processes compared to the previous year; however, further evidence was expected. Additional testing had been carried out, which had placed an onus on the CCG to adopt firmer arrangements with the Broadcare system and links between CHC and the Finance Department. Concerns would apply equally to patients as to finance as a lot of the work was about clarity of information flows also.

Page 12 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

An additional report had been requested from internal audit about contracting related finance arrangements which had raised some significant concerns. Mr Stout, Mr Timmis and Mr Morris had attended an internal meeting to gain assurance about the actions taking place, which had provided some assurance. However, an update was expected at the August Audit Committee meeting and further appropriate questions would be asked at future Finance and Performance Committee meetings to ensure that there were robust arrangements in place to provide sufficient information. It was highlighted that the points made had not been material to the accounts but a review was being undertaken to ensure that there was the certainty of the information provided; that there were firm processes in place in both departments; and that there was sufficient pace with the changes made.

14.2 Dr Povey noted the changes made and asked what steps had been taken to remedy the issues raised

in the report. 14.3 Mr Stout explained that the kinds of issues that had been highlighted were about ensuring clarity of

roles and responsibilities, where it had appeared there was uncertainty about individual roles and basic controls. As a result, staff had been supported in understanding their respective roles and responsibilities and were provided with a clear brief rather than by means of complex policies. The critical action was to ensure the reporting to the Finance and Performance Committee was clear and with sufficient detail to give assurance and to ensure the roles and responsibilities were clear to staff.

14.4 Mrs Skidmore added a further aspect in that the work had not just focussed on the finance and

contracting teams but the embeddedness of an understanding of the roles of responsibilities throughout the broader organisation. A programme of training would be launched at the staff briefing the next day for all budget managers, budget holders and all other interested staff, which would focus on levels of authority and responsibilities. There was quite a lot of work taking place within the contracts team already and would be strengthened by a new joint appointment of a senior leader within the team from the beginning of August who would be reviewing processes and procedures. The CCG had its own internal audit programme also to support that through the year and so there was a process of testing change where it was being implemented to ensure it was robust.

14.5 Dr Povey thanked Mr Timmis for the report noting there were many positives but also many

challenges. It was noted that the challenges were frustrating as they seemed to be the same year on year that had not been addressed.

14.6 Dr Povey brought Members’ attention to the e-learning training offered by the Healthcare Financial

Management Association (HFMA) and requested for the information about the training modules and a reminder about log-ins to be re-circulated to the Governing Body.

14.7 Mrs Skidmore apologised that the copy of the Annual Audit Letter included in the public papers was a

draft copy, which included paragraph 11, which the Finance Team was going to update and edit. Mrs Skidmore would arrange for the final version of the letter to be included in a revised set of Governing Body meeting papers to be available on the CCG’s website.

RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the results of the annual accounts

process and CONFIRMED they were content to wait for the results of the August Audit Committee to gain assurance on the operation of the CCG’s contracting and financial controls.

ACTIONS: Mrs Tilley to arrange to circulate to Governing Body Members information on the Health Financial Management Association (HFMA) e-learning training modules and further details on how to access the training. Mrs Skidmore to arrange for the final version of the Annual Audit Letter for Shropshire CCG to be included in a revised set of Governing Body meeting papers to be available on the CCG’s website. The hyperlink to be then forwarded to Governing Body Members for information. [Actioned 11/7/19.] FOR INFORMATION ONLY/EXCEPTION REPORTING Minute Nos. GB-2019-07.099 to GB-2019-07.106 15.1 The following minutes of the Governing Body Committees were received and noted for information

only:

Clinical Commissioning Committee – 17 April & 15 May 2019

Finance & Performance Committee – 3 April & 1 May 2019

Primary Care Commissioning Committee – 3 April 2019

Page 13 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

Quality Committee – 24 April & 29 May 2019

A&E Delivery Group – 23 April & 28 May 2019

North Locality Board – 28 March 2019

Shrewsbury & Atcham Locality Board – 11 April 2019

South Locality Board – 7 March

15.2 There were no points raised in relation to the minutes. RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the minutes as presented above. Minute No. GB-2019-07.107 – Any Other Business 16.1 Primary Care Networks (PCNs) – Mr Stout highlighted that there were now four Primary Care

Networks (PCNs) in place as directed by NHSE. The Groups meet every two months and the decision-making would be taken through the Primary Care Commissioning Committee. It was pointed out that the PCNs were in early form but were an important step in the NHS’ structure for the future.

16.2 Long Term Implementation Plan – Mr Stout reported that the Long-Term Plan Implementation

Guidance had now been published, which required every Sustainability and Transformation Partnership (STP) area to submit a long-term implementation plan by November. The CCG would, therefore, be working with partners in the STP on a collective implementation plan across the local system. The plan would interface quite significantly with the CCG’s specific commissioning intentions.

16.3 Mrs Skidmore advised that she had an 8-page summary of the NHS Long-Term Plan Implementation

Framework, which she would arrange to have circulated to Members for information. Included in the summary were links to additional information, should Members wish to read further background material.

16.4 Mr Vivian enquired about the process for developing the plan and asked if there would be an engagement exercise for the Governing Body to inform that.

16.5 Mr Stout explained that as the STP was a partnership and would have no statutory existence, the

submission of the plan was on behalf of all the organisations in the STP. At the end point there would be a requirement for the organisations to receive, endorse and sign-off the submission.

16.6 In the shorter term, the process for developing the CCG’s commissioning intentions would include a

development session with Governing Body Members. The CCG would need to ensure that work included the requirements of the long-term plan so that the CCG’s plan and the system’s plan were two separate entities. There needed to be a reiterative process in the partnership working where the contents of the plan was already being developed simultaneously and which needed to be consolidated into one plan for submission for the area. However, it was considered the degree and the effectiveness of partnership working had improved over recent months and the processes were stronger than previously, which would aid progression of the plan.

16.7 Mr Vivian further asked how the CCG could involve patients and the public in that work. 16.8 Mr Stout referred to the process for engagement of patients and the public that had been agreed and

was included in the development plans. The CCG needed to ensure that the work it was doing in a systems setting was in line with that ambition. The STP Communication and Engagement work stream was also developing its work to ensure that there was effective engagement in the development of those plans.

ACTION: Mrs Skidmore to arrange for the circulation of the summary of the NHS Long-Term Plan Implementation Framework to Governing Body Members for information. [Actioned 11/07/19.] DATE OF NEXT MEETING The next scheduled meeting of the CCG Governing Body is:

CCG Governing Body Meeting (open to the public) Wednesday 11 September 2019, at Ludlow Racecourse.

SIGNED ………………………………………………….. DATE …………………………………………

Page 14 Minutes of the CCG Governing Body Meeting – 10 July 2019 SCS Shropshire Clinical Commissiong Group

1

Actions from the Part I CCG Governing Body meeting held in public – 10 July 2019

Shropshire Clinical Commissioning Group

ACTIONS FROM THE CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING – 10 JULY 2019

Agenda Item Action Required By Whom By When Date Completed/ Comments

GB-2019-07.092 – Governing Body Assurance Framework (GBAF)

Mrs Tilley to update the first two new risks on the GBAF to include the indication arrows in the assessment of risk column. Also to amend the first risk re. Finance to state the CCG fails to deliver ‘its plan’ and not its ‘control total’.

Mrs Sam Tilley

Complete

11.07.19

GB-2019-07.093 – Finance and Contracting Report including Quality, Innovation, Productivity & Prevention (QIPP) schemes

Mrs Skidmore to check assumptions in plans by reviewing the data and graphs included in A-1a: Shrewsbury and Telford Hospital NHS Trust’s (SaTH) position, in particular, the A&E activity and cost. Similarly, in A-1b: Robert Jones and Agnes Hunt Orthopaedic Hospital’s (RJAH) position, to review the elective activity and cost and 1

st outpatients’ activity

and cost. Also to arrange for annual averages to be included in future reports. Mrs Skidmore to feedback Members’ comments on the report to the Finance Team and ensure that the request for further information is included in future reports.

Mrs Claire Skidmore

To be provided in reporting to the 7

th August Finance and

Performance Committee meeting

07.08.19

GB-2019-07.094 – Quality Exception and Performance Report

Mrs Morris to arrange for the annual review of the Learning Disabilities Mortality Review (LeDeR) to be presented to the next Governing Body meeting including data and assurance. Dr Davies to arrange the rewording of sentence 5 in paragraph 70, lines 4-6, page 17 of the report to avoid

Mrs Christine Morris Dr Julie Davies

September meeting – included on the agenda Immediately

11.07.19

2

Actions from the Part I CCG Governing Body meeting held in public – 10 July 2019

Agenda Item Action Required By Whom By When Date Completed/ Comments

any misinterpretation and to make clear that there was no suggestion of blame on patients’ families for pursuing a diagnosis for Autism Spectrum Disorder (ASD).

GB-2019-07.095 – Future Strategic Commissioning Arrangements

Mr Stout to present an update at the next meeting

Mr David Stout

September meeting – included on the agenda

11.07.19

GB-2019-07.097 – Ambulance Demand Deep Dive – Progress Update

Dr Davies to look into strengthening the way the CCG interfaces with the regional commissioners and other CCGs in discussions regarding contract negotiations with West Midlands Ambulance Service (WMAS) to ensure the CCG’s concerns are taken into account. Dr Davies to ensure further updates on progress against the action plan are taken to the Clinical Commissioning Committee (CCC) on a quarterly basis.

Dr Julie Davies/The CCG Dr Julie Davies

As soon as possible

GB-2019-07.098 – Audit Committee

Mrs Tilley to arrange to circulate to Governing Body Members information on the Health Financial Management Association (HFMA) e-learning training modules and further details on how to access the training. Mrs Skidmore to arrange for the final version of the Annual Audit Letter for Shropshire CCG to be included in a revised set of Governing Body meeting papers to be available on the CCG’s website. The hyperlink to the relevant website page to be then forwarded to Governing Body Members for information.

Mrs Sam Tilley/ Mrs Sandra Stackhouse Mrs Claire Skidmore/ Mrs Sandra Stackhouse

Complete Complete

18.07.19 11.07.19

3

Actions from the Part I CCG Governing Body meeting held in public – 10 July 2019

Agenda Item Action Required By Whom By When Date Completed/ Comments

GB-2019-07.107 – Any other business – NHS Long Term Plan Implementation Framework

Mrs Skidmore to arrange to circulate to Governing Body Members for information the summary of the NHS Long Term Plan Implementation Framework.

Mrs Claire Skidmore

Complete

11.07.19

1

Agenda item: GB-2019-09.114 Shropshire CCG Governing Body meeting: 11th September 2019

Title of the report: Financial Position Month 4, 2019/20

Responsible Director: Claire Skidmore – Chief Finance Officer

Author of the report: Laura Clare - Deputy Chief Finance Officer

Presenter: Claire Skidmore – Chief Finance Officer

Purpose of the report: The purpose of this report is to articulate the current financial position and to highlight any financial or contractual risks.

Key issues or points to note at 31st July 2019 (Month 4): At Month 4 the CCG is showing a year to date overspend of £5.25m against the submitted plan. Significant cost pressures are being seen in the acute sector particularly around Emergency and A&E activity both at the main acute provider and within smaller acute contracts. Musculoskeletal activity at RJAH continues to perform over plan and ambulance conveyances are above contract although this has slowed down since Month 2. The rapid increase in costs and activity within the Mental health area of Continuing Healthcare also continues. Current forecasts against the QIPP plan suggest an outturn of £17.5m (88% delivery). This includes the development of new schemes to replace those in the original plan that have been reassessed with a lower delivery trajectory. The current risk assessment of the total programme is £1.9m which is incorporated into the CCG’s reported risk position. This is an improvement on the £4m risk reported at month 3 and is reflected in part in the crystallisation of non-delivery into the position, as well as an improving confidence in previously reported high risk schemes. Despite best efforts, the risk adjusted position has deteriorated by £3.5m between months 3 and 4. This is predominantly driven by shifts in out of area contract outturn and high cost cases in both CHC and Mental Health. Hence this leaves the CCG with a reported position that contains £18.4m unmitigated risk. This means that if all risks materialise and assuming identified mitigations could be deployed, the CCG would miss hitting the financial plan by £18.4m (ie would deliver a £41.3m in year deficit). There is significant concern at the CCG that given the scale of the risks flagged at month 4 the planned deficit will be exceeded at year end. Current potential mitigations fall far short of the risks modelled. We continue to review and assess all forecast positions and to pursue options for reducing costs. Particular focus this month is on seeking joint commissioner opportunities with T&WCCG and also leveraging support from system partners to add pace to delivery of work that will reduce cost to the system. In spite of this, and recognising that some mitigations should be possible between now and March 2020, at this stage of the year it is difficult to see how such a scale of deviation from plan could be fully recovered. The CCG anticipates a further conversation with NHSE/I at a proposed escalation meeting in early September with respect to preparing for the Q2 reported position. A protocol for movement of reported position is expected from NHSE/I shortly which is expected to set out a requirement for the provision of a financial recovery plan and Board Assurance Statement to support the CCG’s case for changing the reported position in readiness for quarter end. The CCG recently met with NHSE/I as part of the Q1

2

system assurance meeting and feedback from this meeting was shared with the Finance and Performance Committee. The underlying position is presented with a working assumption that management actions designed to hit plan are likely to be non-recurrent in nature. As actions develop further this position will be reviewed.

Actions required by Governing Body Members: The Governing Body is asked to:

Note the financial position at Month 4

Note the financial challenge for 2019/20 and the urgency required around developing

mitigations to the risk of overspend

Note the anticipated protocol for amendment to reported position and the potential

requirement to sign off an assurance statement prior to Q2 figures being finalised.

3

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications No If yes, please provide details of additional resources required

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the clinical engagement

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes If yes how will this be mitigated

Un-mitigated risk signals that, if risks were to materialise, the CCG would not have sufficient financial cover to offset these. The fragility of the CCG’s finances should not be underestimated. The current position contains insufficient flexibility (contingency) to cover any unexpected expenditure arising before the end of the financial year. Any further unexpected expenditure will adversely affect our financial position over and above what is currently reported.

Below is a list of schedules appended to this report.

Appendix Content Appendix A A1 Acute Services

A2 Non Acute Services

A3 Primary Care Services

A4 Other

A5 Running Costs

A6 Better Care Fund

A7 QIPP

A8 Allocations

A9 Statement of Financial Position

Appendix B B1 Financial Summary Position B2 QIPP Detail

4

NHS Shropshire CCG

Governing Body Meeting- 11th September 2019

Financial Position Month 4 - 2019/20

Financial Performance Dashboard

1. The CCG’s overall performance at 2019/20 Month 4 against key financial objectives

is shown in Table 1 below:

Table 1: Performance against key financial objectives

Target/ Duty Target RAG

Control Total Deficit £12.3m deficit R

Performance against submitted plan

YTD- £5.2m deficit

R

Cash 1.25% monthly drawdown – 3.75% below

target in month

A

Better Payment Practice

>=95% G

Summary Financial Position

2. The CCG has a financial plan for 2019/20 that delivers a £22.9m deficit. This

is with a view to returning to in-year financial balance over time. When risks

and mitigations are applied to the CCG’s current position against this plan,

this results in an unmitigated risk of £18.4m suggesting that, if all risks and

mitigations materialise as reported, the CCG would exit the year with an in-

year deficit of £41.3m.

3. Table 2 outlines the financial position at Month 4 and further detail is provided at

Appendix B-1.

Table 2: Summary Financial Position at Month 4

4. At Month 4 the CCG is reporting a year to date deficit of £12.9m against a

submitted plan of £7.6m, a £5.2m YTD variance against plan. Significant cost

2019/20

Budget

Forecast

Outturn

Forecast

Variance

Budget Year

to Date

Actual

Year to

Date

Variance

year to

date

Net Risk Risk adjusted

forecast

variance

£000 £000 £000 £000 £000 £000 £'000 £'000

Total Resource Limit 471,240 471,240 0 156,530 156,530 0

Acute Services 232,216 245,306 13,090 77,118 81,927 4,809 100 13,190

Community Health Services 48,203 48,359 156 16,068 15,875 (192) 0 156

CHC, FNC & Special Placements 35,432 39,382 3,950 11,811 13,502 1,692 1,560 5,510

Mental Health Services 42,728 45,624 2,896 14,243 15,078 835 0 2,896

Primary Care Services 65,048 65,538 490 20,792 20,842 50 (800) (310)

Other 17,753 (2,829) (20,582) 6,806 4,859 (1,948) 17,561 (3,021)

Running Costs 6,610 6,610 0 2,203 2,213 10 0 0

Co-Commissioning 46,104 46,104 0 15,108 15,097 (11) 0 0

Total Expenditure 494,094 494,094 0 164,147 169,394 5,246 18,421 18,421

Deficit/(Surplus) 22,854 22,854 0 7,618 12,864 5,246 41,275

5

pressures are being seen in the acute sector particularly around Emergency and

A&E activity both at the main acute provider and within smaller acute contracts.

Musculoskeletal activity at RJAH continues to perform over plan and ambulance

conveyances are above contract although this has slowed down since Month 2.

The rapid increase in costs and activity within the Mental Health area of Continuing

Healthcare/Complex Care also continues in Month 4.

5. The bridge diagram below shows the difference between planned expenditure at

Month 4 and actual expenditure.

Graph 1: Month 4 Variance from Plan

6. The QIPP position is provided in detail at Appendix A and Appendix B-2. Current

forecasts suggest an outturn of £17.5m (88% delivery). This includes the

development of new schemes to replace those in the original plan that have been

reassessed with a lower delivery trajectory. The current risk assessment of the

total programme is £1.9m which is incorporated into the CCG’s reported risk

position. This is an improvement on the £4m risk reported at month 3 and is

reflected in part in the crystallisation of non-delivery in the position, as well as an

improving confidence in previously reported high risk schemes.

7. In order to deliver a £22.9m deficit in year, there would need to be a £17.6m reduction in expenditure between now and the end of the year. At month 3, management actions were shown against several different service headings where impact was assumed. For month 4, a decision has been taken to show this against one line in the ‘other’ section of our reporting in order to highlight the issue. The total value of this management action required is flagged as high risk and included in the financial risk assessment.

8. Current areas being urgently reviewed by management are outlined in the table below.

6

Table 3: Areas being urgently reviewed by management

Areas for urgent review and action

Addressing QIPP slippage to make good shortfall against plan

and general review of all expenditure lines

Review of all Non Elective expenditure and discussion with

SATH

Review of all Outpatient expenditure and discussion with SATH

and SCHT

Other Acute expenditure under review and challenged where

appropriate. Discussions with host commissioners to reduce

expenditure

CHC/Complex Case Review- reviewing core CHC and Mental

Health at individual case level

9. Progress against these actions is being discussed at the joint executive meeting on

a weekly basis.

10. There is significant concern at the CCG that given the scale of the risks flagged at month 4 the planned deficit will be exceeded at year end. Current potential mitigations fall far short of the risks modelled. We continue to review and assess all forecast positions and to pursue options for reducing costs. Particular focus this month is on seeking joint commissioner opportunities with T&WCCG and also leveraging support from system partners to add pace to delivery of work that will reduce cost to the system. In spite of this, and recognising that some mitigations should be possible between now and March 2020, at this stage of the year it is difficult to see how such a scale of deviation from plan could be fully recovered.

11. The CCG anticipates a further conversation with NHSE/I at a proposed escalation

meeting in early September with respect to preparing the Q2 reported position. A

protocol for movement of reported position is expected from NHSE/I shortly which is

expected to set out a requirement for the provision of a financial recovery plan and

Board Assurance Statement to support the CCG’s case for changing the reported

position prior to Q2. The CCG recently met with NHSE/I as part of the Q1 system

assurance meeting and feedback from this meeting was shared with the Finance

and Performance Committee.

12. The CCG is not currently eligible for Commissioner Sustainability Funding (CSF) as

it did not submit a financial plan that meets the NHS England required control total.

13. The CCG started the financial year with a cumulative deficit carried forward from

2018/19 of £76.6m, the submitted plan currently forecasts this to reach £99.5m by

the end of 2019/20 but if the risk adjusted position materialises as anticipated this

will be significantly higher.

Underlying Financial Position 14. The underlying position at Month 4 is shown below in Table 4 detailing each of the

non recurrent items within the position. This shows an underlying deficit of £42.6m.

This is a further deterioration since the position shown at Month 3 as the majority of

7

the overspend increases are deemed to be recurrent whilst actions to bring the YTD

position back into line with the plan by year end have been assumed to be non

recurrent in nature. As actions develop further this will be kept under review.

Table 4: Underlying Position at Month 4

Run Rate

15. The 2019/20 planned deficit is shown in Graph 2 below compared to the year to

date position extrapolated to the end of the year. The planned cashflow versus

actual position is also shown in Graph 3.

16. At Month 4 the CCG is showing a spend position that is £5.25m above the year to

date plan. The CCG is running at an average monthly deficit of approximately

£3.2m rather than the planned monthly deficit of £1.9m. If this rate of overspend

continued to the end of the year on a straight line basis the CCG would be £16m

away from the target. However, reserves/contingencies are phased into Month 12 to

offset some of the cost pressure and there are a number of assumptions around

QIPP delivery phasing.

£'000

Month 4 Forecast Position in ledger (in line with plan) 22,854 Deficit

Non Recurrent Items in Position:

ACUTE non recurrent prior year benefits 31

COMMUNITY non recurrent expenditure- consultancy 11-

MENTAL HEALTH non recurrent expenditure 177-

PRIMARY CARE- non recurrent benefits prescribing inc incentive scheme 414

CONTINUING HEALTHCARE- non recurrent expenditure- interims 315-

OTHER- non recurrent benefits- patient transport, 111 etc 247

RUNNING COSTS- non recurrent expenditure- OD work etc 151-

Use of contingency recurrently need to reinstate next year 2,104

Assumption that management action to meet plan is non recurrent 17,561

Underlying Position at Month 4 42,557 Deficit

8

Graph 2 : Run Rate- I& E Deficit

17. The green line in the graph above assumes that management action will deliver a

financial impact from December onwards in order to bring spend back in line with

plan. This is a very high risk assumption and is incorporated in the risk adjusted

position. The graph shows the extent of recovery that would be required in quarter 4

to deliver the CCG financial plan.

Graph 3 : Run Rate- Cash

18. The planned cash flow is shown in the graph compared to the current actual cash position. The CCG does not currently foresee any cash related problems linked to the projected overspend position. The finance team continue to manage cash carefully.

19. At month 4 the CCG spent less cash than originally forecast and was unable to meet its cash target of holding no more than 1.25% of its original drawdown at the end of the month, (achievement was 5% against the target). This was due to the receipt of income totalling £1.7m which was not anticipated in the original forecast. The majority of this income related to sales invoices raised to NHSE some time ago to recharge GP IT capital expenditure and is not a recurrent issue.

-

100,000

200,000

300,000

400,000

500,000

600,000

£'000

Run Rate- Cash

Planned cashflow

Actual Cashflow withstraight line forecast

9

Contract Position Summary 20. Month 3 SUS data is now available and Month 4 contract positions have been

calculated on this basis. Appendix A shows the detail around each of the contracts

below.

SATH- Shrewsbury and Telford Hospital

21. The Month 4 position for SATH shows a year to date overspend of £1.9m and a

forecast outturn of £5.1m overspend. The slowdown in run rate is due to

assumptions around QIPP delivery later in the year.

22. The main areas of overspend continue to be emergencies and A&E attendances.

23. Contract Performance Notices are currently open with SaTH for failure to achieve

the constitutional targets relating to A&E and Cancer. A deep dive report into the

drivers behind A&E attendances was provided at the last F& P meeting. A remedial

action plan for Cancer is discussed at Planned Care Working Group and there are

now bi-weekly calls with NHSE/I to discuss this.

RJAH- Robert Jones and Agnes Hunt

24. The RJAH contract is over performing by 553k year to date with a forecast outturn

of £2.5m overspend. The main areas of over performance are elective activity and

non pbr variable (the main overspend in this area is high cost drugs). This is a large

over performance at an early stage of the year.

25. The CCG is holding weekly meetings with RJAH to oversee management of the

over performance. The two main areas under discussion are:

Performance of SOOS

The Trust listing patients from follow up appointments.

26. Activity in June, and expected in the July monitoring will be significantly below plan

due to the Trust having issues in relation to their theatre utilisation in these months

with annual leave and sickness. RJAH are currently modelling their activity recovery

plan for the rest of the year and have agreed to do this in conjunction with the CCG

in order to manage the risk of future activity for the CCG being in excess of

previously agreed plan.

WMAS- West Midlands Ambulance Contract 27. The Month 4 position at WMAS is a year to date overspend of £137k and a forecast

overspend of £549k. The overspend is made up of over performance in activity and

handover delay charges. The forecast has come down significantly since Month 2

as over performance has decreased from 10.6% in April to 2.8% in May and then

remaining fairly steady at 3% over in June.

10

BCUHB - Betsi Cadwaladr University Health Board 28. The outstanding dispute between the CCG and BCUHB has now reached resolution

with a final settlement figure of £4.1m for 2018/19 being agreed by CFOs in August.

The CCG paid the outstanding balance to the provider during August.

29. The 2019/20 contract agreement is now in progress based on the English NHS

Standard Contract. Discussions are underway with BCUHB to agree amendments

required for the Welsh position. The CFO/DOF agreement included that pricing

abatement would be in place for 2019/20 at 80%. This is being factored into the

contract documentation for 2019/20.

Out of Area Acute Contracts 30. Out of Area Acute Contracts are showing signs of overheating at month 4. The main

providers with over performance at Month 4 are University Hospital North Midlands

(UHNM), Wye Valley and Royal Wolverhampton Hospitals. The majority of the

overspends at these trusts is in Emergencies. The CCG is also now seeing a

pattern of overspend coming through in Non Contracted Activity which has also

impacted on the forecast position this month.

31. The contract team are currently liaising with the host Commissioners to understand

the drivers of the over performance and whether or not they are expected to

continue into future months. In relation to the elective activity we are looking at

triangulating the waiting list and referrals to understand the expected activity in the

remaining months of the year.

Continuing Healthcare 32. Appendix A outlines the current position on continuing healthcare/complex care

(including mental health) which shows a YTD position of £2.6m overspend and a

forecast outturn of £6.7m overspend. At Month 4 we continue to see high levels of

expenditure particularly in Mental Health.

33. The CHC forecast assumes that management action is in place to reduce the

expenditure trend before year end in the form of CHC complex case reviews and a

review into Mental Health cases. This has been flagged as high risk and therefore

£1.5m can be found in the financial risk assessment.

QIPP Summary 34. As at Month 4, QIPP forecast delivery year to date is reported as a shortfall of

£351k. A forecast of £17.5m is modelled against a plan of £19.8m. This represents

an estimated under delivery of £2.3m at month 12. The QIPP position is provided in

detail at Appendix A and Appendix B-2.

35. Further to this, £1.9m has been identified as a risk of delivery and therefore if all

risks were to materialise, actual outturn delivery would be £15.6m.

11

36. A number of schemes are reliant on delivery by external partners and there are

concerns that capacity issues may impact on project delivery.

37. Project leads remain committed to containing and pulling back significant slippage

against plan where possible; focusing on delivery of schemes and continuing to

work closely with providers. The management team aims to recoup current forecast

slippage in the programme though acknowledges the challenge that this presents,

particularly given the limitations of current commissioner and provider capacity.

38. A joint CCG workshop was held at the beginning of August to consider existing

schemes and how these could be built upon whilst identifying any further

opportunities. This was facilitated by Attain and well attended by commissioners,

clinical leads, executive leads and support services such as BI & Finance. Key

Leads were identified across themed areas who have been asked to identify any

opportunities for stretch or streamlining of existing schemes and summarise any

barriers to delivery. An update from each of the leads was reviewed by the joint

executive team on 2nd September.

39. Further, at STP level, a small number of areas have been identified for ‘at pace’

review to identify where system ‘quick wins’ might be achieved. Non Elective,

Outpatients and Elective RTT were chosen and task and finish groups established

to oversee development of a plan and actions. CCG executives have been

engaged in these early discussions and in addition are also using the STP links with

MPFT to facilitate our work on Mental Health Complex Care.

40. Where variance from plan is found in actuals or forecast for year end this is

incorporated into the finance position and associated QIPP reporting. In addition to

this, schemes are risk assessed during the month and will continue to be reviewed

throughout the year. Where further risk is identified this is captured in the CCG’s

reported risk position. The level of FOT risk applied at month 4 has been

summarised below.

Table 5: QIPP Risk

41. The PMO, in collaboration with exec leads and project managers, have identified

two schemes that are deemed to be carrying a risk that the figures reported in the

Net Planned

Savings £000’s

Forecast

Delivery

£000’s

Risk Adjusted

Delivery

£000’s

Risk Of Delivery

£000’s

£19,815 £17,498 £15,598 £1,900

Scheme Name Net Planned

Savings

£000’s

Forecast

Delivery

£000’s

Confidence of

Delivery

£000’s

Risk of

Delivery

£000’s

CCtH – Admission

Avoidance

£1,000 £1,000 £600 £400

CHC Stretch Target £1,000 £2,000 £500 £1,500

Total Risk £1,900

12

overall position may not be achievable. For Care Closer to Home (CCtH) this is due

to delays experienced in the procurement of a provider for the admissions

avoidance scheme and for CHC stretch this is driven by a late start in year to the

development of a work plan and hence delivery of associated savings.

42. The following table details QIPP portfolio level risk. Scheme level delivery risk was

shared with the Finance and Performance Committee and discussed at it’s recent

meeting.

Table 6: QIPP Portfolio Risk

Area Brief Description of Risk RAG Mitigating Actions

Portfolio – Internal

Lack of overall capacity and capability to deliver the QIPP portfolio.

Commitment from Directors to manage project risk on an individual basis, identifying capacity and skills required where appropriate.

Joint working arrangements with Telford CCG developing throughout 2019/20.

(Finance and Quality departments are already working across both organisations).

Portfolio – External

Some schemes are reliant on delivery by external partners. Where there are capacity issues this may impact on the CCG’s position if timescales for delivery slip.

Continue to progress concerns through contracting and commissioning arrangements and escalation as appropriate to Strategic Commisisoning Boards, Executives and STP.

Financial Risk and Mitigation 43. The Month 4 financial submission to NHS England highlights unmitigated risk of

£18.4m. Detail around risks and mitigations are shown below in Graph 4.

44. The graph highlights the breakdown of risks and mitigations that takes the CCG

from a planned deficit of £22.9m to a risk adjusted deficit of £41.3m.

45. Despite best efforts, the risk adjusted position has deteriorated by £3.5m between

months 3 and 4.

13

Graph 4: Key risks and mitigations

Each of the risks and mitigations is described in Table 7. Table 7: Key risks and mitigations

Potential scenarios against submitted financial plan

46. Based on the risks and mitigations presented in Table 7, there are a number of

potential scenarios that could arise if the risks or mitigations materialise in year.

These are presented in Table 8 below.

Month 4 £'000

RISK RISK DESCRIPTION

QIPP Risk Latest risk assessment regarding QIPP delivery from scheme leads. 1,900

CHC

CCG assessment of likely risk associated with outstanding CHC case dispute 280

Other Management action required to address gap 17,561

Total 19,741

MITIGATIONS

STP QIPP Transformational QIPP schemes currently being pursued at STP level- likely impact on Shropshire CCG if successful -1100

CHC Potential benefit from negotiations around adult joint funding and potential release of prior year accrual -220

Total 1,320 -

Total Net risk 18,421

14

Table 8: Potential Scenarios

Scenario 1 Scenario 2 Scenario 3 Risks occur without any mitigations

Risk adjusted plan position- Risks and mitigations occur

Plan Position- Any risk arising is fully mitigated.

£42.6m deficit ‘worst case’

£41.3m deficit ‘most likely’

£22.9m deficit ‘best case’

47. The current assessment of the CCG’s position would indicate that the risk adjusted

plan (Scenario 2) is the most likely outturn scenario. Management action will reduce

the risk adjusted position and this is currently being modelled, however given the

scale of recovery required to pull expenditure back to planned levels by the end of

the year, the ‘best case’ scenario above is not deemed to be possible.

Conclusion 48. As described above the CCG is continuing to experience significant cost pressures

at Month 4, particularly in the areas of acute contracts and continuing and complex

healthcare.

49. There is significant concern that given the scale of the risks flagged at month 4 the

planned deficit will be exceeded at year end. Current potential mitigations fall far

short of the risks modelled. We continue to review and assess all forecast positions

and to pursue options for reducing costs. Particular focus this month is on seeking

joint commissioner opportunities with T&WCCG and also leveraging support from

system partners to add pace to delivery of work that will reduce cost to the system.

50. In spite of this, and recognising that some mitigations should be possible between

now and March 2020, at this stage of the year it is difficult to see how such a scale

of deviation from plan could be fully recovered.

1. Appendix A

1

Contents page Ref Description Page no. A-1 Acute Services 2-8 A-2 Non Acute Services 9-13 A-3 Primary Care Services 14 A-4 Other 15 A-5 Running Cost Allowance 16 A-6 Better Care Fund 17 A-7 QIPP Position 18 A-8 Allocations 19 A-9 Statement of Financial Position 20

A-1 Acute Services

KEY MESSAGES

At Month 4 the CCG is currently reporting an over

performance of £4.8m YTD. This is primarily being driven

by SaTH and Out of Area (OOA) providers.

The forecast for the year is just over £13m above plan.

Run rate slows in the second half of the year due to QIPPs

that are starting in the latter part of the year.

The forecast in this area has deteriorated since last month

due to the transfer of an assumption around management

action into the ‘other’ section. Assumptions will only be

moved into expenditure categories once there is sufficient

confidence in delivery.

2

The risk adjusted forecast includes QIPP risk around Care closer to home

and assumed mitigation around STP QIPP schemes in relation to elective

care.

The main drivers of over performance are:

- Emergency admissions and A&E attendances at SATH

- Elective musculoskeletal activity at RJAH.

- Emergency activity in the Out of Area contracts.

The graph below shows the emergency activity trend for the top 5

providers:

Emergencies at top 5 providers:

2019/20 Budget

£'000

Forecast

Outturn £'000

Forecast

Variance £'000

Budget Year to

Date £'000

Actual Year to

Date £'000

Variance Year

to Date £'000

Net Risk

£'000

Risk

adjusted

forecast

variance

£'000

SaTH 149,892 155,018 5,126 49,827 51,738 1,911 5,126

RJAH 32,673 35,221 2,548 10,810 11,364 554 2,548

WMAS 14,616 15,165 549 4,817 4,954 137 549

NCAs & Other 35,035 39,902 4,867 11,663 13,871 2,208 100 4,967

Total Acute Services 232,216 245,306 13,090 77,118 81,927 4,808 100 13,190

A-1a SaTH

3

Shrewsbury and Telford Hospital Trust

Shropshire CCG Position at Month 4 - Finance (Per Month 3 SATH Monitoring)

PODYtd Cost Plan

£

Ytd Cost Actual

£

Ytd Cost

Variance

£

Cost Variance as %

of Total Cost

Variance

2019-20 Cost

Plan

£

2019-20 Cost

FOT

£

FOT Cost

Variance £

FOT percentage

Variance above

Plan

Day Case 5,293,029 5,516,278 223,249 4.2% 16,284,975 16,972,119 687,144 4.2%

Elective 2,437,460 2,156,757 (280,703) (11.5%) 6,847,723 6,059,219 (788,504) (11.5%)

Emergency 20,265,681 22,305,860 2,040,179 10.1% 61,576,687 67,774,924 6,198,237 10.1%

Non Elective Other 2,059,740 1,902,966 (156,774) (7.6%) 6,371,825 5,886,855 (484,970) (7.6%)

Critical Care 915,296 995,173 79,877 8.7% 2,745,861 2,825,738 79,877 2.9%

Outpatient Firsts 3,319,066 3,424,371 105,305 3.2% 9,731,420 10,040,277 308,857 3.2%

Outpatient Follow Ups 2,539,534 2,487,110 (52,424) (2.1%) 7,631,711 7,474,187 (157,524) (2.1%)

Outpatient Procedures 2,328,523 2,310,673 (17,850) (0.8%) 7,114,656 7,060,161 (54,495) (0.8%)

Accident and Emergency 3,532,250 3,855,290 323,040 9.1% 10,424,707 11,377,908 953,201 9.1%

Non PBR Variable 7,545,805 7,206,475 (339,330) (4.5%) 22,813,281 21,940,584 (872,697) (3.8%)

Non PBR Block 543,648 543,648 (0) (0.0%) 1,630,944 1,630,943 (1) (0.0%)

CQUIN 592,940 615,787 22,847 3.9% 1,778,820 1,847,361 68,541 3.9%

Blended Payment Rebate 0 (1,465,481) (1,465,481) 0.0% 0 (4,533,445) (4,533,445) 0.0%

MRET/Readmissions (1,718,594) 0 1,718,594 (100.0%) (5,217,000) 0 5,217,000 (100.0%)

Total 49,654,378 51,854,907 2,200,529 4.4% 149,735,610 156,356,830 6,621,220 4.4%

Prisoners 52,303 53,114 811 156,585 156,585 0

QIPP - COPD Admissions 0 0 0 0 (285,314) (285,314)

QIPP - Ex-Tel 0 0 0 0 (190,919) (190,919)

QIPP - Heart Failure 0 0 0 0 (374,412) (374,412)

QIPP - HISU 0 0 0 0 (120,000) (120,000)

CDU Adjustment 0 (169,569) (169,569) 0 (524,559) (524,559)

Phasing Correction 120,175 0 (120,175) 0 0 0

Total Over/(Under) performance 49,826,855 51,738,452 1,911,596 3.8% 149,892,195 155,018,211 5,126,016 3.4%

Ytd Plan v Actual (£) FOT 2019-20 Plan v Actual (£)

A-1a SaTH

4

SaTH Emergency Activity Activity continues to be significantly above plan at month 3 YTD however month 3 is slightly lower than the average over performance of the first two months. The drivers of the over performance are the same as previous months with these being Respiratory Medicine, Trauma & Orthopaedics and General Medicine.

SaTH A&E Activity Whilst activity and finance continues to over perform YTD, June continues the trend of May of only over performing by a few percentage points as opposed to April’s 14%.

A-1b RJAH

5

Robert Jones and Agnes Hunt Hospital Trust

Shropshire CCG Position at Month 4 - Finance (Per Month 3 RJAH Monitoring)

POD

Ytd Cost

Plan

£

Ytd Cost

Actual

£

Ytd Cost

Variance

£

Cost Variance

as % of Total

Cost Variance

2019-20 Cost

Plan

£

2019-20 Cost

FOT

£

FOT Cost

Variance

£

FOT

percentage

Variance

above PlanDay Case 1,703,078 1,750,063 46,985 2.8% 5,149,986 5,687,753 537,767 10.4%Elective 3,617,598 4,126,494 508,897 14.1% 10,939,355 12,961,723 2,022,368 18.5%Non Elective Other 351,782 449,071 97,289 27.7% 1,063,764 1,258,343 194,579 18.3%Regular Admissions 186,698 197,232 10,534 5.6% 564,562 596,415 31,853 5.6%Outpatient Firsts 816,742 832,417 15,675 1.9% 2,469,768 2,663,267 193,499 7.8%Outpatient Follow Ups 1,274,481 1,266,020 (8,461) (0.7%) 3,853,938 4,024,903 170,965 4.4%Outpatient Procedures 381,365 365,617 (15,748) (4.1%) 1,153,220 1,105,600 (47,620) (4.1%)Non PBR Variable 1,403,742 1,512,161 108,419 7.7% 4,228,852 4,554,911 326,060 7.7%Non PBR Block 950,492 950,492 (0) (0.0%) 2,874,219 2,874,219 (0) (0.0%)CQUIN 124,235 129,119 4,884 3.9% 375,677 398,445 22,768 6.1%Total 10,810,212 11,578,686 768,474 7.1% 32,673,340 36,125,580 3,452,240 10.6%

Riskshare 0 (214,755) (214,755) 0 (904,610) (904,610)

Challenges 0 (17,620) (17,620) 0 (17,620) (17,620)

Total position 10,810,212 11,363,932 553,719 5.1% 32,673,340 35,220,969 2,547,629 7.8%

Ytd Plan v Actual (£) FOT 2019-20 Plan v Actual (£)

A-1b RJAH

6

RJaH Daycase Activity We have seen a dip in activity in June which has brought the activity more in line with plan, this however is related to more clinical staff not being at work whether this is annual leave or sickness. Work is continuing with the Trust to align the activity trajectories with the agreed plan.

RJaH Elective Activity Within the Elective POD we are still seeing over performance in June however this has reduced significantly due to the reasons outlined above, again the CCG is working with the Trust to make sure the activity is in line with the contracted levels.

A-1c West Midlands Ambulance

7

Activity in June has followed May’s trend being at approximately 3% over plan compared to April’s 11%. This has therefore slightly improved the forecast position. YTD there seems to be a slight increase in the percentage of patients who have been conveyed to hospital as opposed to just being seen which has resulted in additional expenditure at the Hospitals. Progress is also being made with SaTH to employ a member of staff on a pilot basis to make sure that the ambulance PIN number is recorded at handover which should help the CCG reduce their handover charge figures as we are currently forecasting over £300k (£200k in plan, £100k overspend) in relation to this area.

M4 M12

4,687,807 M4 Plan 14,227,706 M12 Plan

233,160 OP M3 + M4 Exp 805,032 FOT OP

24,696 HandChanges 106,908 HandChanges

6,968 Non Comp 24,403 Non Comp

4,952,631 M4 Position 15,164,049 M12 Position

1,070 Prior Year 1,070 Prior Year

76,614 CAS (SWBCCG) 229,843 CAS (SWBCCG)

5,030,315 M3 Position Final 15,394,962 M12 Position Final

14,845,560 Annual Plan

549,402 Variance

39,120- FOT Movement

Month 4 Shropshire

A-1d NCA and Others

8

2019/20 Budget

£'000

Forecast

Outturn £'000

Forecast

Variance £'000

Budget Year to

Date £'000

Actual Year to

Date £'000

Variance Year

to Date £'000

Other Acute Contracts 27,368 31,394 4,026 9,136 11,163 2,027

Acute NCA's 3,734 4,602 868 1,215 1,445 229

Acute Special Placements 22 22 0 7 4 (3)

Winter Resilience 2,030 2,030 0 678 677 (1)

Future Fit 230 230 0 77 65 (12)

STP 175 190 15 58 58 (0)

Acute services - Other 357 362 5 119 118 (2)

High Cost Drugs 533 533 0 178 178 0

Acute Services Team 586 539 (47) 195 164 (31)

NCA & Others 35,035 39,902 4,867 11,663 13,871 2,208

The two main drivers of the over-performance, both YTD and forecast outturn are ‘Other acute contracts’ and ‘NCAs’ Other Acute Contracts is the main driver of the over performance accounting for approximately 83% of the forecast overspend. The main drivers in this area are as follows • University Hospitals of North Midlands- Forecasting an over-performance of £985k based on a significant increase in emergency

activity as well as a couple of high cost patients • Wye Valley Trust – Forecasting an over-performance of £388k due to an over-performance primarily driven by emergency activity. • Slippage in QIPP of £1.9m which is primarily made up of Care Closer to Home £2m (which is partially mitigated by lower

investment in the community section) and VBC/MSK expected savings which should be appearing in the expenditure of the Trusts. (£250k and £231k respectively)

• Prior Year cost pressure of £111k. This was primarily driven by Royal Wolverhampton Trust which came in £115k higher than expected due to a much higher than expected month 12.

For NCAs, we have only received two complete months worth of data and as such with the nature of the area there is risk of some fluctuation in the earlier part of the year however from the data to date we have not seen the reduction in spend we were currently hoping for. Analysis is currently being undertaken in this area to understand if the increase in activity is due to a shift in market share or if the total quantum is increasing and if so which areas these relate to.

A-2 Non Acute Services

Key Messages • The Non Acute Services position at Month 4 shows a £2,335k YTD overspend and £7,002k forecast overspend. The majority of

this overspend relates to significant over performance in terms of both activity and cost in relation to Continuing and Complex Healthcare – under both the core CHC budget line and Mental Health (£2.5m of the £2.9m MH overspend relates to CHC). Further information on the overspend and mitigating actions is provided on the CHC slide.

• Information regarding the Shropshire Community Health NHS Trust (SCHT) and Midlands Partnership NHS Foundation Trust (MPFT) contracts are provided on the following slides. The SCHT positon is £92k underspent year to date and forecast to breakeven. The MPFT position is a year to date overspend of £66k and forecast overspend of £382k mainly due to Psychiatric Intensive Care Unit (PICU) over performance.

• Work continues to develop the price activity matrix with both Shropshire Community Trust and Midlands Partnership Foundation Trust (MPFT).

• The Community forecast overspend of £156k includes overspends in ophthalmology (£423k) and pain management (£105k). An urgent meeting is arranged to agree an action plan to address the overspend in ophthalmology and an action plan is also required for pain management. These overspends are partially offset by slippage in care closer to home investment - it is envisaged that the full investment will not be required and the forecast includes an underspend of £400k.

• The CCG is planning to meet the Mental Health Investment Standard in 2019/20 which means that Mental Health spend will have increased in line (or more) with CCG allocation growth.

9

2019/20 Budget

£'000

Forecast

Outturn £'000

Forecast

Variance £'000

Budget Year to

Date £'000

Actual Year to

Date £'000

Variance Year

to Date £'000

Net Risk

£'000

Risk Adjusted

Forecast

Variance £'000

Community 48,203 48,359 156 16,068 15,875 (192) 0 156

Mental Health 42,728 45,624 2,896 14,243 15,078 835 0 2,896

Continuing Care 35,432 39,382 3,950 11,811 13,502 1,692 1,560 5,510

Total Non Acute Services 126,363 133,365 7,002 42,121 44,456 2,335 1,560 8,562

A-2a Shropshire Community Trust

10

The YTD position for the SCHT (Main Contract) is £92k underspent based on the latest monitoring (month 3), which shows under performance against Payment by Results (PbR) outpatient activity. The current forecast is breakeven which is unchanged from last month, on the basis the PbR variance could be seasonal, and is being impacted by current capacity shortfalls. The trend will be monitored over the coming months through the Contract Review Meetings (CRMs). A summary of the activity performance for June year to date is shown in the table opposite. In addition to the under performance against hospital outpatient activity, there is significant under performance against community equipment activity (commissioned on a ‘block’ arrangement which means the cost is fixed). The contract value includes a £350k QIPP target and the forecast position of breakeven assumes full delivery. There is a 50:50 risk share in place hence the CCG’s exposure to non delivery is £175k at worst. A working group is set up to consider QIPP opportunities and a number are being assessed for viability. There is a separate contract for Out of Hours which is at an agreed fixed value, and therefore is reported as breakeven, for year to date and forecast.

M3 M3 M3

Summary Activity Activity Variance

Plan Actual

Hospital

Imaging 2,320 2,485 165

Inpatients 471 476 5

MIU 7,062 7,008 (54)

Outpatients 3,951 2,965 (986)

Community

Community 92,177 94,552 2,375

Equipment 48,614 32,197 (16,417)

2019/20 Budget Forecast Forecast Budget Year Actual Year Variance Year

Outturn Variance To Date To Date To Date

£'000 £'000 £'000 £'000 £'000 £'000

Main Contract 40,553 40,553 0 13,518 13,426 (92)

Out of Hours 3,150 3,150 0 1,050 1,050 0

Total SCHT 43,703 43,703 0 14,568 14,476 (92)

A-2b Midlands Partnership Foundation Trust

11

The YTD position for the MPFT (Main Contract) is £22k overspent based on the latest monitoring (month 3), which shows over performance against Psychiatric Intensive Care Unit (PICU). The forecast has deteriorated to an overspend of £250k compared to breakeven last month. This is based on a continuation of the pressures in PICU, estimated using historical and current patient information. This position shows the annual PICU days have been used in 4 months. An urgent meeting will take place with Business Intelligence (BI) to understand if this increase in local costs could be partly/ fully offset by a decrease in out of area costs which fall in the Non Contracted Activity (NCA) budget. The NCA forecast is currently assumed to be breakeven. The 0-25 EHWS YTD and forecast overspend relates to an inflationary dispute and estimated charges which are required to address all over 12 months waiters with Autism Spectrum Disorder (ASD). The CCG has prepared an offer to settle the inflationary dispute and resolution is anticipated during September.

The activity under the main contract is above as at month 3 (June). The over performance against PbR Non Admitted Care is mainly due to dementia activity which is being addressed through the Dementia Tariff Subgroup set up to review alternative currencies and propose mitigations to over performance. A group has also been set up to review alternative currencies for IAPT. As reported previously the contract is subject to caps/ collars and marginal rates which effectively make it a block contract except for Psychiatric Intensive Care Unit (PICU) activity.

2019/20 Budget Forecast Forecast Budget Year Actual Year Variance Year

Outturn Variance To Date To Date To Date

£'000 £'000 £'000 £'000 £'000 £'000

Main Contract 30,362 30,612 250 10,121 10,143 22

0-25 Emotional Health & Wellbeing 2,874 3,006 132 958 1,002 44

Total MPFT 33,236 33,618 382 11,079 11,145 66

M3 M3 M3

Summary Activity Activity Variance

Plan Actual

MH PbR Admitted Care 5,465 5,464 (1)

MH PbR Non Admitted Care 325,010 414,677 89,667

MH Non PbR 8,687 6,624 (2,063)

Specialist and Family Care 485 437 (48)

LD Services 2,094 1,904 (190)

A-2c Continuing Healthcare/ Complex Care

12

At Month 4 the position across both core CHC and Mental Health shows a YTD overspend of £2.6m and a forecast overspend of £6.7m. The

forecast includes an assumption around QIPP scheme delivery.

A-2c Continuing Healthcare/ Complex Care

13

The main drivers of the increase in reported over spend include:

1. An amendment to forecasting methodology this month to accommodate deficiencies identified in the way data in Broadcare

feeds financial forecasts.

2. Reflection of additional spend due to the identification of a backlog of reviews. This backlog causes difficulties with accurate

forecasting. The CHC team have taken steps to remove the backlog.

3. Receipt of an updated schedule of intended recharges from Shropshire Council related to Children’s Joint Funded cases which

details costs relating to a number of new patients for which no package cost is currently included in Broadcare. These have

been accrued for (£240K) but the team will be investigating the validity of these intended recharges.

4. The over spend above assumes that the CHC team will achieve a significant level of QIPP. There is a significant risk to delivery

in this areas which is included in the CCG’s risk assessment of QIPP.

5. Urgent action is underway to review all cases and address problems that have emerged with backlog. Further, a financial review

exercise has also been commissioned from Liaison which may identify overpayments that could be recouped.

A-3 Primary Care Services

14

Key Messages:

Primary Care Delegated Commissioning

The CCG submitted a delegated commissioning

expenditure plan that is £1.5m higher than the ring

fenced allocation. i.e. the delegated commissioning

area is contributing £1.5m towards the CCG overall

deficit this year.

At Month 4 there is a small overall underspend. Within

this however is an overspend on dispensing of £122k,

offset by underspends in Other GP services of £77k

linked to prior year Locum savings, and smaller

savings linked to Enhanced services and Premises

charges.

Prescribing

The latest data available relates to M2 and is still

limited with regards to spotting trends. The YTD

position reflects the £250k benefit b/f from 18/19, and a

current year (M1-2) overspend of £310K. The risk

adjusted position shows a current assumption of £800k

benefit from STP medicines management schemes.

Primary Care Other

The main variances in this section are as follows:

• An overspend in Primary care commissioning

schemes of £96k YTD & £257k forecast, linked to

activity pressures.

• A overspend YTD in Oxygen related to a Prior Year

adjustment and the forecast reflects a new QIPP

scheme introduced in M3

• The Prescribing Incentives saving relates to the

18/19 scheme, now that all payments have been

made.

• Underspend in P.C. Team relating to vacancies

• A forecast overspend in P.C IT which reflects an

unexpected hardware commitment due later in the

year.

Primary Care Delegated Commissioning

Opening

Budget 19/20 Annual Budget

M4 YTD

Budget

M4 YTD

Actual

M4 YTD

Variance

Forecast

Outturn

Forecast

Variance Net risk

Risk

adjusted

forecast

variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

General Practice - GMS 29,237 28,692 9,564 9,568 4 28,692 0 0

General Practice - PMS 375 375 125 125 0 375 0 0

General Practice - APMS 1,216 1,216 405 403 (2) 1,216 0 0

Enhanced Services 1,782 2,368 557 526 (31) 2,257 (111) (111)

QOF 4,439 4,439 1,036 1,052 16 4,455 16 16

Premises cost reimbursements 5,420 5,420 2,169 2,130 (39) 5,382 (38) (38)

Dispensing 2,508 2,508 787 909 122 2,718 210 210

Other - GP Services 1,071 1,071 461 384 (77) 994 (77) (77)

Net Reserves 56 15 4 0 (4) 15 0 0

Co Commissioning Total 46,104 46,104 15,108 15,097 (11) 46,104 0 0

Other Primary Care Commissioning

£'000 £'000 £'000 £'000 £'000 £'000 £'000

Prescribing 49,603 49,432 15,682 15,797 115 49,661 229 (800) (571)

Out Of Hours 3,150 3,150 1,050 1,050 0 3,150 0 0

Enhanced Services 2,696 5,568 1,754 1,754 0 5,568 0 0

Primary Care Other

- Central Drugs 1,257 1,257 419 438 19 1,257 0 0

- Oxygen 604 605 202 221 19 574 (31) (31)

- Primary Care Commissioning Schemes 1,414 1,414 471 567 96 1,671 257 257

- Hospice Drugs 75 75 25 33 8 85 10 10

- Prescribing Incentives 315 315 105 (32) (137) 178 (137) (137)

- Care Home Advanced Scheme 230 230 77 77 0 230 0 0

- Primary Care Team 1,935 1,845 615 545 (70) 1,820 (25) (25)

- Primary Care IT 978 1,157 392 392 0 1,344 187 187

- Primary Care Reserves 242 0 0 0 0 0 0 0

Primary Care Other Total 7,050 6,898 2,306 2,241 (65) 7,159 261 261

Total Other Primary Care Commissioning 62,499 65,048 20,792 20,842 50 65,538 490 (800) (310)

GRAND TOTAL 108,603 111,152 35,900 35,939 39 111,642 490 (800) (310)

A-4 Other

15

Key Messages • The overall position on ‘other’ is a £1.9m underspend year to date and a £20.6m underspend in the forecast. This underspend

position relates to the release of the £2.1m contingency reserve in Month 12 and around £17.6m further management action that

would be required to bring the position back to plan, (reflected in the commissioning reserve line). This management action has

previously been shown against several different service headings but this is now reported against one line in order to highlight the

scale of the issue. This is currently flagged in its entirety as at high risk and included in the financial risk assessment.

• The underspend on Patient Transport reflects reduced activity levels a one-off prior year benefit of £70k.

• Reablement is forecast to overspend due to two patients with complex care packages which were not known at the time of setting

the budget. One is a new patient and the other is an existing patient whose care package has become more complex.

2019/20 Budget

£'000

Forecast

Outturn £'000

Forecast

Variance £'000

Budget Year to

Date £'000

Actual Year to

Date £'000

Variance Year

to Date £'000

Net Risk

£'000

Risk adjusted

forecast

variance

£'000

Patient Transport 3,301 3,121 (180) 1,100 1,318 218 (180)

NHS 111 984 1,064 80 328 289 (39) 80

Referral Assessment Service Team 423 413 (10) 141 123 (17) (10)

Community & Care Co-ordinators 370 370 0 123 123 0 0

NHS Property Services 225 225 0 75 75 (0) 0

Quality Premium Programme 0 0 0 0 0 0 0

Better Care Fund 7,779 7,779 0 2,593 2,593 0 0

Reablement 557 845 288 186 266 80 288

Other 210 211 1 70 70 (0) 1

Commissioning Reserve 1,800 (16,857) (18,657) 2,190 0 (2,190) 17,561 (1,096)

0.5% Contingency 2,104 0 (2,104) 0 0 0 (2,104)

Other Total 17,753 (2,829) (20,582) 6,806 4,859 (1,948) 17,561 (3,021)

A-5 Running Cost Allowance

16

Key Messages • The CCG has a separate allocation for the running costs of the organisation (non clinical posts/support), which equates to £6.6m. • At Month 4 the running cost forecast is break-even which assumes full achievement of the in year QIPP of £225k. We are working

with Budget Holders to mitigate this risk through vacancy savings and monitoring our discretionary spend in order to meet our target allocation.

• The M4 year to date position includes underspends due to vacancies. However, the residual year to date unachieved QIPP of £75k produces an overall overspend position of £10k.

• For 2020/21 the CCG will have a much lower running cost budget of £5,835k and we are working on plans with Telford and Wrekin CCG in order to address this.

There are 14 interim staff in post as at month 4, of which 8 are covering posts within CHC. The forecast outturn assumes this will reduce through the year with no additional interims currently planned to be appointed post month 4.

Forecast

Outturn £'000% Actual Year to

Date £'000%

403 57% 260 57%

306 43% 196 43%

709 455

Cost of Agency/Interim Staff

Programme Costs

Running Costs

Total

2019/20 Budget

£'000

Forecast

Outturn £'000

Forecast

Variance £'000

Budget Year to

Date £'000

Actual Year to

Date £'000

Variance Year

to Date £'000

Corporate Costs 3,693 3,836 143 1,231 1,200 (31)

Service Planning 767 754 (13) 256 297 41

Commissioning & Contracting 735 665 (70) 245 202 (42)

Strategy & Service Redesign 352 332 (20) 117 110 (7)

Finance 803 788 (15) 268 261 (7)

Governance 200 200 0 67 69 2

Nursing & Quality 193 206 13 64 74 10

Corporate Reserves 91 (171) (262) 31 0 (31)

Running Costs QIPP (225) 0 225 (75) 0 75

Running Cost Total 6,609 6,610 1 2,203 2,213 10

A-6 Better Care Fund (BCF)

17

Funding Breakdown: £

CCG Funded - Minimum 12,241,704

LA Funded via CCG 7,779,300

20,021,004

Additional LA Funding, seperately allocated to the funds above

LA Contribution 5,456,282

i BCF 8,288,253

13,744,535

Total Joint CCG / LA Fund 33,765,539

Note

These budget figures are in line with 18/19 and

currently only estimates, as awaiting details of the

actual 19/20 allocations

The BCF is currently showing a small

underspend year to date but it is early in

the year and data is limited, therefore the

forecast position is currently break even.

Annual Y ear to Y ear to Y ear to Y ear end Y ear end

Summary Statement Date Date Date Forecast Forecast

Budget Budget E xpenditure V ariance E xpenditure V ariance

£ £ £ £ £ £

P revention P rogramme

Care Navigation / Co Ordination 735,828 245,276 243,182 2,094- 735,828 -

Carers Services 2,540 847 - 847- 2,540 -

T otal P revention P rogramme738,368 246,123 243,182 2,941- 738,368 0

Admissions Avoidance

Assistive Technologies 1,646,474 548,825 537,697 11,128- 1,646,474 -

Care Navigation / Co Ordination 649,175 216,392 216,392 - 649,175 -

Enablers for Intergration 3,666,234 1,222,078 1,222,078 - 3,666,234 -

Healthcare services to Care Homess 245,465 81,822 76,667 5,155- 245,465 -

Intermediate Care Services 3,171,187 1,057,062 1,015,550 41,512- 3,171,187 -

Personailised Healthcare at Home 331,501 110,500 90,692 19,808- 331,501 -

T otal Admissions Avoidance9,710,036 3,236,679 3,159,076 77,603- 9,710,036 0

E arly S upportive Discharge

Integrated Care Plannning 1,793,300 597,767 597,767 - 1,793,300 -

T otal E arly S upportive Discharge1,793,300 597,767 597,767 - 1,793,300 0

Other

SCCG funded LA expenditure7,779,300 2,593,100 2,593,100 - 7,779,300 -

LA Funding expenditure5,456,282 1,818,761 1,818,761 - 5,456,282 -

i BCF8,288,253 2,762,751 2,762,751 - 8,288,253 -

T otal E arly S upportive Discharge21,523,835 7,174,612 7,174,612 - 21,523,835 0

Grand T otal: 33,765,539 11,255,180 11,174,636 (80,544) 33,765,539 0

The information above details the 2019/20 QIPP Plan and position as at Month 4. The CCG is currently forecasting to deliver £17.5m of QIPP against a target of £19.8m (88%)

Key messages

• QIPP is forecast to under deliver by £2.3m at month 12. • A further risk of £1.9m has been set against Forecast Delivery • It is essential that the CCG continue to generate and develop additional cost savings • Regular meetings continue to be held led by Executive leads to provide scrutiny and challenge • Milestones and KPIs are being monitored by the PMO to ensure issues are escalated to the

QIPP Programme Board • A joint workshop between Telford & Wrekin and Shropshire CCGs was held on Friday 2nd

August 2019 which considered further opportunities to identify savings in year and leads have been identified to work on rapid identification of opportunities.

It is essential that the CCG continues to generate and develop additional cost saving initiatives across the organisation as well as focusing on joint opportunities with Telford and Wrekin CCG as well as opportunities at a system wide level. Further detail is provided at Appendix B-2.

QIPP Position

2019/20 Plan Month 4 YTD Forecast

Risk QIPP Position M4 Gross Investment Net Plan Actual Variance Revised Forecast

Variance from Plan

%Variance from Plan

Category of Spend £000's £000's £000's £000's £000's £000's % Achieved £000's £000's %

Acute Services 10,959 1,773 9,186 1,793 1,270 -523 71% 6,361 -2,825 69% 400

Continuing Care 2,871 87 2,784 684 652 -32 95% 3,507 724 126% 1500

Contracting 3,138 0 3,138 1,046 1,046 0 100% 3,138 0 100% 0

Corporate Services 1,000 0 1,000 333 34 -299 10% 1,000 0 100% 0

Primary Care 4,397 691 3,706 1,179 1,681 503 143% 3,491 -215 94% 0

Total 22,365 2,550 19,815 5,035 4,684 -351 93% 17,498 -2,317 88% 1900

18

A- 8 Allocations

19

The CCG allocations at Month 4 are shown below:

Recurrent

Non

Recurrent Total

£000 £000 £000

Cummulative Allocations up to Month 3 466,659 2,983 469,642

Month 4 allocation adjustments:

19/20 upfront FTA proposal - Shropshire TCP 1,260 1,260

Offender Health secondarfy care allocation - 1st tranche 78 78

GPFV - STP Funding - Workforce Training Hubs 85 85

GPFV - STP Funding - Fellowships Core Offer 77 77

GPFV - STP Funding - Fellowships Aspiring Leaders 98 98

Total In-Year Resources 2019/20 466,659 4,581 471,240

Return of Cumulative Deficit (76,726) (76,726)

Total Cumulative Resources 2019/20 466,659 (72,145) 394,514

A-9 Statement of Financial Position The table below illustrates the CCGs Statement of Financial Position or Balance Sheet at month 4.

20

JUN-19 JUL-19 Movement

PPE 113,571 (166) (113,737)

Accumulated Depreciation 113,571 0 (113,571)

Net PPE 0 (166) (166)

Intangible Assets 0 0 0

Intangible Assets Depreciation 0 0 0

Net Intangible Assets 0 0 0

Investment Property 0 0 0

Non-Current Assets Held for Sale 0 0 0

Non-Current Financial Assets 0 0 0

Other Receivables Non-Current 0 0 0

Total Other Non-Current Assets 0 0 0

Non-Current Assets 0 (166) (166)

Cash 380,892 1,884,355 1,503,463

Accounts Receivable 3,547,177 3,919,494 372,317

Inventory 0 0 0

Investments 0 0 0

Other Current Assets 3,928,069 5,803,850 1,875,781

Current Assets 3,928,069 5,803,850 1,875,781

TOTAL ASSETS 3,928,069 5,803,684 1,875,615

Accounts Payable 36,277,162 36,315,938 38,776

Accrued Liabilities 0 0 0

Short Term Borrowing 0 0 0

Current Liabilities 36,277,162 36,315,938 38,776

Non-Current Payables 0 0 0

Non-Current Borrowing 0 0 0

Other Liabilities 0 0 0

Long Term Liabilities 0 0 0

General Fund 0 0 0

Share Capital 0 0 0

Revaluation Reserve 0 0 0

Donated Assets Reserve 0 0 0

Government Grants Reserve 0 0 0

Other Reserves 0 0 0

Retained Earnings incl. In Year (32,349,093) (30,512,254) 1,836,839

Total Taxpayers Equity (32,349,093) (30,512,254) 1,836,839

TOTAL EQUITY + LIABILITIES 3,928,069 5,803,684 1,875,615

Note that the negative balance on

PPE is a coding error and will be

corrected at month 5

Appendix B-1

Shropshire CCG2019/20 Financial Summary Position as at Month 4

Recurrent

Budget

Non Recurrent

Budget

Annual

Budget

Budget Year to

Date - month 4

Actual Year to Date -

month 4

Variance Year

to Date -

month 4

Forecast

Outturn

Outturn

Variance

£000 £000 £000 £000 £000 £000 £000 £000

RESOURCES

Recurrent Allocation 415,479 4,581 420,060 139,806 139,806 0 420,060 0

Deficit Brought Forward (76,726) (76,726) (25,575) (25,575) 0 (76,726) 0

Co-Commissioning Allocation 44,570 44,570 14,520 14,520 0 44,570 0

Running Costs Allocation 6,610 6,610 2,203 2,203 0 6,610 0

Total resource limit 466,659 (72,145) 394,514 130,954 130,954 0 394,514 0

EXPENDITURE

Acute Services

Shrewsbury and Telford Hospitals NHS Trust 149,892 149,892 49,827 51,738 1,912 155,018 5,126

Robert Jones and Agnes Hunt FT 32,673 32,673 10,810 11,364 554 35,221 2,548

West Midlands Ambulance Service Contract 14,616 14,616 4,817 4,954 137 15,165 549

Other Acute Contracts 27,368 27,368 9,136 11,163 2,027 31,394 4,026

Acute NCA's 3,734 3,734 1,215 1,445 229 4,602 868

Acute Special Placements 22 22 7 4 (3) 22 0

Winter Resilience 2,030 2,030 678 677 (1) 2,030 0

Future Fit 230 230 77 65 (12) 230 0

STP 175 175 58 58 (0) 190 15

Acute services - Other 357 357 119 118 (2) 362 5

High Cost Drugs 533 533 178 178 0 533 0

Acute Services Team 586 586 195 164 (31) 539 (47)

Acute Reserves 0 0 0 0 0 0 0

Acute Services Total 232,216 0 232,216 77,118 81,927 4,809 245,306 13,090

Community Health Services

Shropshire Community Trust 40,553 40,553 13,518 13,426 (92) 40,553 0

Other Community Services 5,338 5,338 1,779 1,711 (68) 5,534 196

Palliative Care 2,312 2,312 771 738 (33) 2,272 (40)

Care closer to home reserve 0 0 0 0 0 0 0

Community Health Services Total 48,203 0 48,203 16,068 15,875 (192) 48,359 156

Continuing Healthcare

Complex Care 26,359 0 26,359 8,787 10,672 1,885 31,313 4,954

Funded Nursing Care 7,940 0 7,940 2,647 2,361 (286) 6,898 (1,042)

Complex Care Team 1,133 0 1,133 378 470 92 1,171 38

Continuing Care Reserves 0 0 0 0 0 0 0 0

Continuing Healthcare Total 35,432 0 35,432 11,811 13,502 1,692 39,382 3,950

Mental Health Services

Midland Partnership FT 33,236 0 33,236 11,079 11,144 66 33,618 382

Other NHS Mental Health Contracts (315) 0 (315) (105) (187) (82) (315) 0

Mental Health NCA's 1,253 0 1,253 418 418 0 1,253 0

Mental Health Special Placements 0 0 0 0 0 0 0 0

Mental Health - Winter Resilience 0 0 0 0 0 0 0 0

Mental Health - Other 1,727 177 1,904 635 587 (48) 1,910 6

Mental Health - TCP 55 0 55 18 18 0 54 (1)

S117 Placements 6,595 0 6,595 2,198 3,098 900 9,104 2,509

Mental Health Reserves 0 0 0 0 0 0 0 0

Mental Health Services Total 42,551 177 42,728 14,243 15,078 835 45,624 2,896

Primary Care Services

Prescribing 49,432 0 49,432 15,682 15,797 115 49,661 229

Central Drugs 1,257 0 1,257 419 438 19 1,257 0

Oxygen 605 0 605 202 221 20 574 (31)

Enhanced Services 2,696 2,872 5,568 1,754 1,754 0 5,568 0

Out Of Hours 3,150 0 3,150 1,050 1,050 0 3,150 0

Primary Care Commissioning Schemes (Dermatology) 1,414 0 1,414 471 567 96 1,671 257

Hospice Drugs 75 0 75 25 33 8 85 10

Prescribing Incentives 315 0 315 105 (32) (137) 178 (137)

Care Home Advanced Scheme 230 0 230 77 77 (0) 230 0

Primary Care Team 1,845 0 1,845 615 545 (70) 1,820 (25)

Primary Care IT 1,157 0 1,157 393 393 0 1,344 187

Primary Care Reserves 0 0 0 0 0 0 0 0

Primary Care Services Total 62,176 2,872 65,048 20,792 20,842 50 65,538 490

Other

Patient Transport 3,301 0 3,301 1,100 1,318 218 3,121 (180)

NHS 111 984 0 984 328 289 (39) 1,064 80

Referral Assessment Service Team 423 0 423 141 123 (17) 413 (10)

Community & Care Co-ordinators 370 0 370 123 123 0 370 0

NHS Property Services 225 0 225 75 75 (0) 225 0

Quality Premium Programme 0 0 0 0 0 0 0 0

Better Care Fund 7,779 0 7,779 2,593 2,593 0 7,779 0

Legacy 0 0 0 0 0 0 0 0

Non Recurrent Solutions 0 0 0 0 0 0 0 0

Shropshire Intervention Framework 0 0 0 0 0 0 0 0

Reablement 557 0 557 186 266 80 845 288

Other 210 0 210 70 70 (0) 211 1

Other Total 13,849 0 13,849 4,617 4,859 242 14,028 179

Reserves

Commissioning Reserve 268 1,532 1,800 2,190 0 (2,190) (16,857) (18,657)

0 0 0 0 0 0 0 0 0

0.5% Non Recurrent Reserve 0 0 0 0 0 0 0 0

0.5% Contingency 2,104 0 2,104 0 0 0 0 (2,104)

CHC Risk Pool Contribution 0 0 0 0 0 0 0 0

CHC Interim Support 0 0 0 0 0 0 0 0

Anticipated Allocation 0 0 0 0 0 0 0 0

Reserves Total 2,372 1,532 3,904 2,190 0 (2,190) (16,857) (20,761)

Running Costs

Corporate Costs 3,693 0 3,693 1,231 1,200 (31) 3,836 143

Service Planning 767 0 767 256 297 41 754 (13)

Commissioning & Contracting 735 0 735 245 202 (42) 665 (70)

Strategy & Service Redesign 352 0 352 117 110 (7) 332 (20)

Finance 803 0 803 268 261 (7) 788 (15)

Governance 200 0 200 67 69 2 200 0

Nursing & Quality 193 0 193 64 74 10 206 13

Corporate Reserves (133) 0 (133) (44) 0 44 (171) (38)

Running Cost Total 6,610 0 6,610 2,203 2,213 10 6,610 0

0 45,873 0 45,873 15,031 15,097 66 46,089 216

0 231 0 231 77 0 (77) 15 (216)

Co Commissioning Total 46,104 0 46,104 15,108 15,097 (11) 46,104 0

Total Expenditure 489,513 4,581 494,094 164,147 169,394 5,247 494,094 0

Budget (Surplus)/Deficit 22,854 76,726 99,580 33,193 38,439 5,246 99,580 0

Total Resource Limit 466,659 4,581 394,514 130,954 130,954 0 394,514 0

Total Expenditure 489,513 4,581 494,094 164,147 169,394 5,247 494,094 0

Budget (Surplus)/Deficit 22,854 76,726 99,580 33,193 38,439 5,247 99,580 0

Deficit Brought Forward (76,726) (25,575) (25,575) (76,726) 0

In Year (Surplus)/Deficit 22,854 7,618 12,864 5,247 22,854 0

2019/20 2019/20 2019/20

Appendix B-2

Shropshire CCG2019/20 QIPP Month 4

Budget Area QIPP Scheme

Gross

Savings Investment Net Savings

M4 YTD

Plan

M4 YTD

Actual

M4

Variance

Forecast

Delivery M4

Variance

from

Plan M4

Forecast

Variance

from

Plan % Risk

Acute Services Additional VBC 250 0 250 83 257 173 423 173 169%Autism and Aspergers Provision 20 0 20 0 0 0 20 0 100%Category 1 PLCV Activity 35 0 35 12 13 1 35 0 100%Commissioning Stretch 0 0 0 0 0 0 0 0 0%COPD Admissions 656 0 656 73 0 -73 285 -371 43%Dermatology Commissioning Options 42 0 42 14 14 0 42 0 100%Ex-Tel (Investment) 0 133 -133 -15 0 15 -33 100 25%Ex-Tel (SaTH) 764 0 764 85 0 -85 191 -573 25%Fracture Liasion Service 115 220 -105 -35 0 35 -105 0 100%Frailty front door 420 420 0 0 0 0 0 0 0%Heart Failure 374 0 374 42 0 -42 374 0 100%HISU 120 0 120 13 13 0 120 0 100%Home Oxygen Assessment and Review Service 51 0 51 6 0 -6 55 4 107%Home Oxygen Service (National) 0 0 0 0 0 0 47 47 0%MSK Service Redesign EL other 232 0 232 77 0 -77 155 -77 67%MSK Service Redesign DC Other 44 0 44 15 0 -15 29 -15 67%MSK Service Redesign DC RJAH 305 0 305 102 25 -76 25 -279 8%MSK Service Redesign DC SaTH 94 0 94 31 51 20 94 0 100%MSK Service Redesign EL RJAH 2,043 0 2,043 681 458 -223 1,875 -168 92%MSK Service Redesign EL SaTH 255 0 255 85 155 70 255 0 100%MSK Service Redesign OPFA RJAH 98 0 98 33 18 -14 98 0 100%MSK Service Redesign OPFU RJAH 22 0 22 7 8 1 22 0 100%RTT Relaxed Target 770 0 770 257 257 0 770 0 100%SCHT (Contract 1) inc APCS 350 0 350 117 0 -117 350 0 100%Shropshire Care Closer to Home (Admissions

Avoidance) 1,000 0 1,000 0 0 0 1,000 0 100% 400

Shropshire Care Closer to Home (Demonstrator Sites) 2,900 0 2,900 111 0 -111 833 -2,067 29%Shropshire Care Closer to Home (Investment) 0 1,000 -1,000 0 0 0 -600 400 60%

Acute Services Total 10,959 1,773 9,186 1,793 1,271 -522 6,361 -2,825 69% 400

Continuing Care Service CHC Additional 0 0 0 0 0 0 0 0 0%CHC AQP 329 0 329 66 0 -66 0 -329 0%CHC Stretch Target 1,000 0 1,000 200 0 -200 2,000 1,000 200% 1,500Childrens Placements 500 0 500 100 173 73 500 0 100%Collaborative Commissioning 300 0 300 100 0 -100 0 -300 0%Mental Health Out of Area (Commissioning) 290 87 203 68 0 -68 203 0 100%Mental Health Out of Area (Cygnet) 0 0 0 0 12 12 36 36 100%Review Programme 452 0 452 151 467 316 768 316 170%

Continuing Care Services Total 2,871 87 2,784 684 652 -32 3,507 724 126% 1,500

Contracting Mental Health Rebasing of the Contract 600 0 600 200 200 0 600 0 100%OOH Service 757 0 757 252 252 0 757 0 100%RJAH Contract 852 0 852 284 284 0 852 0 100%SaTH Contract 623 0 623 208 208 0 623 0 100%SCHT (Contract 2) 306 0 306 102 102 0 306 0 100%

Contracting Services Total 3,138 0 3,138 1,046 1,046 0 3,138 0 100% 0

Corporate Services Running Costs Review in year 225 0 225 75 34 -75 225 0 100%Corporate Services Running Costs Review towards 20% 775 0 775 258 0 -258 775 0 100%

Corporate Services Total 1,000 0 1,000 333 34 -299 1,000 0 100% 0

Primary Care Appliances (Stoma) 40 22 18 6 25 19 46 28 256%Appliances (Wound) 180 0 180 60 0 -60 40 -140 22%Biosimilars (RJAH) 431 0 431 144 218 74 467 36 108%Biosimilars (SaTH) 386 0 386 129 194 65 418 32 108%Care Home Prescribing 440 24 416 139 306 167 416 0 100%Co-Commissioning Efficiences 216 0 216 72 72 0 216 0 100%Diabetes 150 47 103 34 12 -22 103 0 100%DOLVs 100 0 100 33 88 55 100 0 100%Drug Switches 300 0 300 100 198 98 300 0 100%Prescribing Stretch Target 133 0 133 44 0 -44 133 0 100%Prescription Ordering Direct (POD) 1,030 578 452 151 235 84 452 0 100%Respiratory 220 20 200 67 76 9 200 0 100%Scriptswitch 500 0 500 167 239 72 500 0 100%Self-Care (OTC) 100 0 100 33 19 -14 100 0 100%Self-Care (OTC) NHSE Stretch 170 0 170 0 0 0 0 -170 0%

Primary Care Services Total 4,397 691 3,706 1,179 1,681 503 3,491 -215 94% 0

Grand Total 22,365 2,550 19,815 5,035 4,684 -351 17,498 -2,317 88% 1,900

Plan Month 4 YTD Forecast

1

2019/20

Agenda item: GB-2019-09.115 CCG Governing Body meeting: 11.09.19

Title of the report:

Governing Body SCCG Performance & Quality Report 2019/20

Responsible Director:

Julie Davies, Director of Performance & Delivery Chris Morris, Chief Nurse

Author of the report:

Charles Millar, Head of Planning, Performance and Contracting Helen Bayley, Strategic Lead for Quality & Care Improvement Team

Presenter:

Julie Davies, Director of Performance & Delivery

Purpose of the report: To update the governing body on the CCGs key quality and performance matters for 2019/20 against the key performance & quality indicators that the CCG is held accountable for with NHS England. This overview provides assurance on performance achievement against targets/standards at CCG, the quality of our commissioned services at provider level as appropriate, and the delivery and contractual actions in place to address areas of poor performance & quality.

Key issues or points to note: The attached report is a further iteration of our integrated quality and performance reporting for the CCG and sets out Shropshire CCG’s performance against all its key performance & quality indicators for Month 3 and 4 where available for 2019/20. Governing Body members are therefore asked for their feedback on the revised report which will be incorporated into future versions. They key standards that were not met YTD for SCCG are :- 62 day RTT 2wk wait (Breast) 2wk wait from GP referral A&E 4hr target Ambulance handovers >30mins and >1hr RTT

The 62day RTT, 2wk Breast symptoms and overall 2wk wait performance targets for the CCG were not achieved. The improvement plans continue to be closely monitored but breast radiologist capacity has continued to be an issue although it is increasing slowly. This has shown the expected improvement in June and is expected to continue to improve in July and August. The overall trajectory for the recovery of 85% 62day RTT

2

target remains on track for October 19. Urology remains a risk within this despite ongoing improvements in elements of the surgical pathways as a result of the joint working with UHNM, the underlying consultant workforce capacity issues remain. Bi -weekly calls remain in place with NHSE to also monitor delivery against these plans and provide support as required. The CCGs overall cancer performance is also affected by out of county providers particularly Royal Wolverhampton and UHNM and this is continually progressed through the corresponding lead commissioners via our contract team with support as required from NHSI & NHSE. The increased IAPT access target run rate of 22% in place for 2019/20 was achieved in June and July. This is now expected to continue to achieve for the remainder of the year. A&E performance having shown signs of in May fell back in June but recovered > 73% in July. Demand for Shropshire remains above plan YTD but seems to be along regional trends. Workforce levels and systems and processes remain the key underlying issues although both are showing signs of improvement which is being reflected in the recent performance. There was 1x 12hr trolley wait in April and the harm pro-forma has been received and assurance gained that although the patient experience was poor the patient affected did not suffer any harm. Both > 1hr and >30mins ambulance handover delays have continued to improve in June and July particularly the >1hr. Work continues between SATH and WMAS to further improve ambulance handovers via monthly meetings chaired by the CCG. The CCG has continued to fail the RTT target YTD as a result of emergency pressures and ongoing escalation into both sites Day Surgery Units. The recovery of this target is being reviewed as The Trust are looking to secure additional Vanguard capacity to protect elective capacity during the winter and a revised recovery trajectory is being brought back to the Planned Care Working Group in October. The CCG had 0 over 52 wk waiters at the end of June and the look forward is also positive. This continues to be monitored weekly by the CCG for its patients across all providers to continue to minimize any >52 wk breaches. Workforce remains the key quality concern at SaTH and the heavy dependency on agency staff, recent nursing recruitment drives in India have been successful. There has also been some improvement in recruitment of Middle Grade Doctors although levels at PRH remain an issue. The CQC report form the unannounced visit in April was published on 2nd August. The Trust has stated they have actioned all issues identified and tis is presented to the System Oversight and Assurance Group. Last month it was reported that MPFT had raised concerns regarding the size have identified non –recurrent funding to bring down the waiting list and a new model for the sustainable delivery of this service for the future has been developed across the system and is going through the respective CCG governance processes in September.

Actions required by Governing Body Members: The Governing Body is asked to NOTE the contents of the report and the CCG actions contained within to recover performance & quality in those areas which are currently below target and to provide feedback on the revised report which will be incorporated into future versions.

3

Monitoring form

Agenda Item: GB-2019-09.115

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications Yes/ No If yes, please provide details of additional resources required

2 Health inequalities Yes/ No The action taken by the CCG to deliver all its constitutional targets will address

any health inequalities currently present in the areas the performance targets are not being met.

3 Human Rights, equality and diversity requirements Yes/ No If yes, please provide details of the effect upon these requirements

4 Clinical engagement Yes/ No If yes, please provide details of the clinical engagement

5 Patient and public engagement Yes/ No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes/ No The CCG would fail to get its full Quality Premium Payment if it fails any of its key

performance premium indicators.

GOVERNING BODY

PERFORMANCE AND QUALITY REPORT

September 2019

1 INTRODUCTION

1.1 This performance and quality report provides an overview of the key performance

indicators (KPIs) that the CCG is held accountable for with NHS England during

2019/20. Many of these are part of the CCG’s Improvement and Assessment

Framework (IAF) for 2019/20.

1.2 The monthly data reported is for June 2019 and July 2019 where data is available.

1.3 Some of the CCG Improvement and Assessment Framework indicators have been

updated where new data has been made available.

1.4 The overview provides assurance on performance achievement against

targets/standards at CCG and provider level as appropriate, and the delivery of

actions in place to mitigate.

1.5 The narrative includes details of the reasons for non-achievement of the standards and the actions in place to mitigate the risks.

1.6 Where key standards were not achieved in 2018/19, trajectories have been set as part of the Sustainability & Transformation Fund (STF), in the 2019/20 planning round. For Robert Jones & Agnes Hunt Hospital and Shrewsbury & Telford Hospital Trust, these included;

A&E 4 Hour Wait

18 Weeks RTT Incompletes

Cancer 62 days wait

Page | 1

2 EXECUTIVE SUMMARY

Shropshire CCG No of Indicators

GREEN RED

Current Month

Previous Month

Current Month

Previous Month

Cancer 8

4 3 4 5

Elective Access

Urgent & Emergency Care

12

4 5 8 7

Mental Health 5 4 5

Learning Disability 4

n/a n/a n/a n/a

Maternity 4

n/a n/a n/a n/a

Dementia 1 1 1 0 0

Primary Medical Care and Elective Access

4

2 2 2 2

NHS Continuing Healthcare

3

2 2 1 1

Page | 2

3 CANCER

3.1 As at June2019, performance for the cancer indicators is as follows:

Page | 3

Cancer:

Key Performance Headlines Risks and Issues Actions to Address

Performance on 14 day Breast symptomatic rates has improved

marginally but remains low due to capacity issues. Recovery of

performance is not expected until later in the year but a further slight

improvement is projected for next month.

Daily and weekly assurance and escalation meetings have been

introduced to manage patient treatment lists as effectively as

possible.

Additional booking staff are scheduled to commence in the two

week wait service in July.

Recent analysis shows that 82% of referrals to the Breast

Service are discharged at first outpatient appointment.

Additional diagnostic capacity is being secured which is intended

to accelerate the recovery trajectory which is showing signs of

having bottomed out.

Overall 14 day wait performance –

Staffing capacity remains a problem in relation to a number of tumour

sites and in Diagnostic support.

Improvement plans are in place for all tumour sites. Recruitment

initiatives are being progressed but there are some time gaps

before new appointments will be in place.

SaTH are working with Health Harmonie (Dermatology) to

improve first outpatient appointment scheduling and take up.

Capacity for Urological cancer treatments continues to be an issue both

locally and regionally. Capacity issues in diagnostic support are also

impacting on performance though cancer work is prioritised.

Additional clinics are scheduled where possible and booking

office staff liaise with patients to encourage uptake of earliest

appointments.

The Prostate pathway has been revised and additional capacity

for diagnostics enabled through appointment of additional locum.

All patient choosing robotic surgery are being transferred to

UHNM

Page | 4

The 62day performance deteriorated in June 73.6%, against May’s

performance 76.6%. The current projected recovery dates received as

part of the tumour site improvement plans show all tumour sites

cumulatively delivering 85% from July 2019. Patient choice remains an

issue impacting on performance

Improvement plans are in place for all tumour sites. These

include closer monitoring of PTL list, additional MDT processes

and process and pathway improvements.

The Lung cancer pathway is being reviewed as part of the move

to the National Optimal Lung pathway.

The cancer dashboard also details 3 further indicators, which are all

reported on an annual basis. The indicators are; diagnosis at early

stage 1&2 which has fallen to 49.2% , one year survival which has

increased to 72.4% and cancer patient experience which remains at

8.9. Baselines and the latest position are shown. The patient

experience RAG rating is based on a survey where patients are rating

their care (excellent or very good).

Key Quality Risks and Issues

Cancer Breaches – in May 2019 (latest available validated quality

figures) 4 patients waited more than 104 days for their cancer

treatment: 1 colorectal, 2 were urology, 1 upper GI. Causes of the delay

in the main include patient choice and delayed diagnostics

Harm pro-formas are awaited from the clinician/ operational

team responsible for each individual patient.

3.2 The performance at SaTH by tumour site for June 2019 is detailed below compared with the national average where possible. At tumour level,

local numbers are small in comparison to national values and consequently more prone to the variability inherent with rates based on small

numbers. Significant work is being progressed with the Cancer Alliance on tumour pathways for Lung, Breast, Upper GI and Colorectal as part of

the move towards adoption of national optimal pathways.

Page | 5

2 week performance 62 day performance

Tumour Site SaTH National Comparison SaTH National Comparison

Breast 15.3% 84.2% Worse 76.9% 88.6% Worse Childrens cancer 75.0% 91.3% Worse

Gynaecological 95.3% 91.1% Better

Haematological 92.9% 95.0% Worse

Head & Neck 97.1% 93.5% Better

LGI 95.3% 88.4% Better 65.7% 64.7% Better Lung 88.9% 94.9% Worse 28.6% 68.4% Worse Skin 92.4% 90.9% Better 92.0% 95.5% Worse

Testicular 100% 97.0% Better UGI 90.2% 91.6% Worse 61.9% N/A Urological 94.4% 94.8% Similar 68.0% 69.1% Worse

Page | 6

4 MENTAL HEALTH

Mental Health:

Key Performance Headlines Risks and Issues Actions to Address

IAPT performance improved to 2.3% in July. This is the second

consecutive month that MPFT have achieved the monthly target, and

provides a good start toward achievement of the annualised rate of

22% by the end of the financial year. This is as a result of additional

CCG investment. The recovery rate was above the 50% target level

with a value of 52.4% in July.

Plans are being developed to provide a more integrated MH

service between Shropshire and T&W CCGs.

Page | 7

As at Q1, 2019/20, 99.1% patients on CPA were followed up within

7days against the 95% standard.

As at the end of June the CCG is achieving 80% against a target of

50%. The numbers of cases each month is small, so month on month

percentage achievement is subject to variability due to small numbers

Progress continues to be made with implementing the agreed

Improvement plan for the Under 25 services and fortnightly reporting

against this continues to be in place. Latest data for the service

indicates that a high proportion (>40%) of referrals being deemed as

inappropriate, insufficient information or did not attend or wish to

proceed.

Additional staff training is being progressed but additional

recruitment is likely to remain a challenge for the Trust for the

foreseeable future

Key Quality Risks and Issues The MPFT CQC report was published on 5th July 2019. The overall

rating of the Trust remains ‘Good’. The ‘Effective’ domain has been

identified as requiring improvement. A number of requirement notices

have been issues by CQC.

The Trust are working on the required service improvement

plans, which are being reviewed by CQRM, with added

assurance being sought through attendance of site visits.

Page | 8

5 LEARNING DISABILITIES (LD) Dementia and Maternity

5.1 There are three indicators relating to LD. For maternity, three out of the four maternity indicator positions are reported annually. There

are three indicators in the dashboard, with data now populated. These show the CCG in the middle range of the national distribution.

Page | 9

Learning Disabilities:

Key Performance Headlines Risks and Issues Actions to Address

Learning Disabilities At Q4, 2018/19, the rate for reliance on specialist inpatient care for people with

a learning disability and/or autism was reported as 62 per 1m population

A joint LD strategy is being developed across the STP footprint aimed at ensuring reduction in unwarranted variation in services and outcomes

The proportion of people with a learning disability on the GP register receiving

an annual health check is 64% (2017/18). The CCG has performed above the

England average of 51.4%

Completeness of the GP Learning Disability Register – the CCG performs

slightly higher than the England average

Maternity Maternal smoking at time of delivery is reported on a quarterly basis. Q3

(13.9%) showed a slight reduction against Q2 2018/19 performance.

Dementia Dementia diagnosis continues to perform above the national standard, July

2019 achievement was 70.8%

The percentage of patients diagnosed with dementia whose care plan has

been reviewed in a face-to-face review in the preceding 12 months, was 80%

for Shropshire CCG, with the England average being 77.5% (2017/18).

Key Quality Risk and Issues

Oak House is now closed. All patients are having their respite needs met by

local care providers with support from the team. Management of change and

Service specification for new service in development is to be complete by October. Pathways and training to be developed during Q3 with full implementation of service in

Page | 10

recruitment for therapy staff is in progress. Q4.

There is currently no joint strategy for LD and ASD. The first meeting has been held and agreed to move

forward with an all age LD and ASD strategy across

Shropshire, Telford and Wrekin within the next 6 months.

The current waiting list for of children waiting for autistic spectrum disorder

assessments had been raised as an issue by the provider

Both CCGs have agreed some non-recurrent funding to ensure the waiting list is reduced and a new model for the sustainable delivery of this service for the future has been developed across the system and is going through the respective CCG governance processes in September.

The current Deprivation Of Liberty Safeguards are being replaced. The

relevant Act received Royal Assent in May and is to be implemented on the 1st

October 2020. Previously a Hospital or a care home in which a Deprivation Of

Liberty (DOL) occurred would apply to the Council as Supervisory Body to

assess and approve the DOL. Now either a NHS Hospital (for in-patients) or

the LA/CCG will be the Responsible Body (RB) if they are funding a community

care for any person 16+ or a Care Home package for any person aged 18+.

The CCG may therefore be the responsible body and will have important new

statutory responsibilities. The CCG will have to decide if it wishes to undertake

certain new roles such as appointing Approved Mental Capacity Professionals

to scrutinise cases when people are objecting to their care or treatment and the

CCG is funding it. Similarly NHS Trusts will become their own Responsible

Body.

An implementation group for Shropshire and Telford has been created called STING (Shropshire & Telford Implementation Network Group). A paper is being submitted to Board in September

Key Performance Risks and Issues

Key Performance Risks and Issues

Page | 11

6 URGENT AND EMERGENCY CARE -

6.1 A&E Performance and Ambulance Handover Delays

URGENT AND EMERGENCY CARE:

Key Performance Headlines Risks and Issues Actions to Address

The SaTH A&E 4 Hour Wait target has not been achieved and is

reported as 71.1% in June and 73.2% in July. This is below the

target trajectory.

The action plan agreed through the A&E Delivery Board has identified 6

key action areas:

Ambulance Demand

Page | 12

Frailty

ED Systems & Processes

Same Day Emergency Care

Home First – Pathway Zero

Integrated Discharge Management

Workforce limitations continue to be the key problem for SaTH. Recruitment initiatives have shown some success but capacity at

middle grade doctor level remains a key issue particularly at PRH.

International recruitment initiatives have been positive with the first

cohort of staff from this expected to commence in December. Additional

analysis has shown that increased ambulance arrivals, particularly for

patients aged over 75, is a key factor in A&E activity. Potential ways to

alleviate conveyances are being explored including changes to the out

of Hours service to encourage clinicians to provide increased local shift

coverage to act as an alternative to conveyance where possible. There

is also some limited provision of an experienced community nurse into

the CAS service to facilitate community care opportunities

The numbers of Stranded patients appears has remained relatively

stable but the number of Super Stranded patients (>21days LOS)

remains above expectations

Delayed Transfers of Care remain very low in SaTH and SCHT

indicating good working processes with the local authorities to facilitate

discharges. The priority action areas were reviewed jointly with ECIST,

SaTH and the CCGs and progress with ED systems and processes

changes is being reviewed with ECIST at the end of August. Plans for

implementing the SDEC model, including reviews of pathways with

external partners, are being progressed but are highly impacted by

workforce capacity.

Ambulance handover delays (over 60mins) have reduced

significantly in July 19 against the levels reported in April 19

Ambulance improvement plans are in place with SaTH and are showing

positive impacts on reducing handover delays

Page | 13

NHS111 activity appears to have stabilised into a more regular

pattern with activity peaks associated with key holiday periods. For

the CCG in June the rate of disposition of the calls to the ambulance

service and to ED were 14.1% and 6.8% respectively which are at

the upper end of the usual range of values over the last 6 months.

Key Quality Risk and Issues

The CQC Report for SaTH from the follow up inspection in April

2019 was published 2nd August. The Trust has stated they had

actioned all issues identified.

Actions are presented to the System Oversight and Assurance Group (SOAG) monthly and to the CQRMs.

Actions were agreed by the task and finish group to develop a suite

of patient safety, clinical effectiveness and patient experience

metrics for a weekly ED risk report for SaTH.

The metrics is still under review in order to ensure the level of risk is clearly reported within the Trust and to the CCG. Weekly risk reports will feed into a comprehensive risk report for review at each CQRM

Workforce limitations continue to be the key problem for SaTH, with

the level of nursing vacancies remaining a significant concern.

An STP work stream looking at workforce is in progress. Recruitment

drives in India continue with 50 nurses confirming acceptance of posts.

It is likely to be March before the required training has been completed.

The Trust is working with all local universities to improve system wide

recruitment but this will also take time to embed in order to have an

impact of the level of vacancies. Further detail on agency staff numbers

and block bookings has been requested and to be reported at CQRm

on a monthly basis.

There was 1 x 12 hour trolley waits reported in A&E at SaTH in July. The harm pro-forma indicated that the patient came to no harm as a

result of the delay.

The local out of Hours service via Shropdoc, 95.23% of base and

home visit shifts were filled during May which was a significant

improvement on the April shift fill. Coverage of GP shifts at was 96%

Shropdoc provided the following on-going mitigation: UCP shift fill has

improved dramatically, still a few still in training, but this will soon taper

off. Salaried GP advert has now gone live. GP shift fill steady.

Page | 14

6.2 Ambulance Response Times, Crew Clear and Delayed transfers of care

Ambulance Response Times, Crew Clear and Delayed transfers of care

Key Performance Headlines Risks and Issues Actions to Address

and for UCPs 95%. No GP shifts for NHS 111 CAS were covered.

Page | 15

The CCG achieved the standards for the Category 4 calls in July but, failed the

standards for category 2 and 3 calls for the second consecutive month

Performance issues are raised regularly with the Regional

lead commissioner

DTOC (SaTH) – In June 2019, the number of delayed days was 1.6% of

occupied bed days. This is ahead of the 3.5% target at SaTH. The RJAH

deteriorated slightly to 4.3%, though this figure includes complex spinal

patients. At SCHT, the June value remained at 1.1%. The SaTH and SCHT

values are amongst the best performers in England

RJAH are working on improvement plans relating to

Delayed Discharges

Key Quality Risk and Issues

Delayed Discharges remain an issue at RJAH. It has been said that bed

challenges within the Trust impact on acute spinal patients awaiting admission.

ECIST revisited the Trust recently.

The Trust are currently formulating an action plan from

suggestions made by ECIST and have agreed to share

when complete

s

Page | 16

7 Primary Medical Care, Community Services and Elective Access

Indicator Description

Late

st

Ba

selin

e

Po

siti

on

Ou

ttu

rn/S

tan

dar

d

Stan

dar

d/

Targ

et Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Patient Experience of GP Services 201883.8%

England

Last time you had a general practice appointment, how good

was the healthcare professional at giving you enough time

87%

England

(Good)

Last time you had a general practice appointment, how good

was the healthcare professional at listening to you

89%

England

(Good)

Last time you had a general practice appointment, how good

was the healthcare professional at treating you with care and

concern

87%

England

(Good)

How would you describe your experience of your GP Practice

83%

England

(Good)

Overall, how would you describe your experience of making

an appointment?

67%

England

(Good)

Were you satisfied with the type of appointment offered?

74%

England

(Good)

Primary care access - proportion of population benefitting

from extended access servicesMar-19

99.85%

(England)50% 49% 49% 51% 51% 51% 100% 100% 100% 100% 100% 100%

Primary care workforce Sept 20181.05

(England)

Count of total investment in primary care transformation

made by CCGs compared with £3 head commitment made in

the General Practice Forward View

Qtr 2 2018Green

(England)

Indicator Description

Late

st B

ase

line

Po

siti

on

Ou

ttu

rn/S

tan

d

ard

Stan

dar

d/T

arg

et

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

RTT - incompletes (CCG) 2018/19 91.0% 92% 89.7% 90.2% 89.9%

RTT - incompletes (SaTH) 2018/19 92.3% 92% 87.5% 87.8% 87.0%

RTT - incompletes (RJAH) 2018/19 89.8% 92% 87.5% 87.2% 86.6%

No. of 52 Week Waiters (CCG) 2018/19 56 0 0 0 0

Diagnostic Test Waiting Time < 6 weeks (CCG) 2018/19 0.9% 1% 1.2% 1.3% 0.9%

Diagnostic Test Waiting Time < 6 weeks (SaTH) 2018/19 0.3% 1% 0.8% 0.7% 0.5%

Diagnostic Test Waiting Time < 6 weeks (RJAH) 2018/19 1.0% 1% 2.4% 2.9% 1.7%

Cancelled Operations - no. of patients re-admitted within 28

days (SaTH)2018/19 5

Zero

Tolerance

Cancelled Operations - no. of patients re-admitted within 28

days (ShropCom)2018/19 2

Zero

Tolerance

Cancelled Operations - no. of patients re-admitted within 28

days (RJAH)2018/19 1

Zero

Tolerance

Pri

mar

y M

ed

ical

Car

e

92% Good

92% Good

92% Good

88% Good

1.19

(September 2018)

Green

88.6%

74% Good

2019 GP

Patient

Survey

79% Good

Elec

tive

Acc

ess

2

0

1

Page | 17

Primary Medical Care, Community Services and Elective Access

Key Performance Headlines Risks and Issues Actions to Address

Access to, and satisfaction with, Primary care services

continues to be rated highly by Shropshire patients and

compares well with the overall England position.

Extended access at weekends and evenings was introduced from the 1st

of October and is reported to be operating smoothly.

Comparing the CCG with others in nationally published data,

continues to show the Shropshire practices, in general, are

rated at the positive end of the national spectrum on almost all

available measures.

The CCG failed to achieve the RTT 18 week performance

(incompletes) in June (89.9%).

Recovery plans are monitored at the Planned care Working Groups but

are subject to continued revisions due to ongoing escalation into the Day

Surgery Units at both acute sites. SaTH failed to achieve their overall RTT target in June at

87.0%. This is largely due to the overspill from emergency

cases limiting elective capacity and capacity limitations in

outpatients. RJAH reported 90.6% overall in June, failing to

achieve the target

SaTH are planning additional bed capacity for the winter months which

is planned to protect some elective capacity.

At the end of June there were 0 x 52 week waiters reported for

the CCG.

CCGs are also monitored on the overall numbers on the

Incomplete Waits list to remain at the March 2019 level. This

has increased in June to 21,116 against a target of 19,284.

The increase is largely at RJAH and at other providers (in part

The CCG is working with SaTH and RJAH to understand factors behind

the increase and develop appropriate mitigating actions

Page | 18

due to additional providers starting to submit RTT data

nationally). The numbers at SaTH have remained relatively

stable since April Performance against the 99% standard for waiting time for a

Diagnostic Test was achieved by the CCG in June with a level

of 99.1%.

Cancelled Operations – both SaTH and SCHT failed the target

in Q4, SaTH reported 4 cancelled operations and SCHT

reported 1 cancelled operation.

Any patient safety issues relating to cancelled operations are managed

through the contractual quality processes.

Key Quality Risk and Issues

The first pilot quality assurance visit using the newly revised QA tool has been undertaken. The aim of the visit was to provide support and triangulate assurance with Quality and Care Improvement of practices which can be used as improvement cycles in preparation for CQC annual regulatory reviews and potential inspections. The practice representatives provided positive feedback and valuable input into the development of the quality assurance template.

Alignment of the quality support offer within primary care is in progress across the STP footprint.

The Primary Care Team is sourcing an alternative complex wound care service in the Wem and Prees area through the new Primary Care Network.

Expressions of interest were submitted by Friday 16 August 2019 and is following due process.

The national primary care commissioning team has announced that they expect all CCGs to have created a system for GP remuneration for either attending or providing reports for Child Protection conferences. They have also suggested that the scheme extends to adult safeguarding. This is due to

Both CCGs have been discussing how to further scope the likely impact. A comprehensive paper written by the lead for Children’s Safeguarding will be submitted at Board level for decision making

Page | 19

difficulties noted at a national level regarding GP engagement and information sharing with child protection work.

Shropshire and Telford and Wrekin have been accepted to be part of the first Midlands Region Frailty Collaborative programme. The programme will take place over the next 4 months and will be intense in order to be ready to support winter pressures.

The Frailty Collaborative working group has been formed with representation across commissioners and providers. Project implementation and delivery will be supported by the Emergency Care Intensive support team.

Ongoing development of the Enhanced Health in Care Homes (EHiCH) is progressing.

Governance arrangements have been clarified

The implementation of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment) has been led by the EOL/ReSPECT group. ReSPECT replaces the current DNACPR process on the 1st November, 2019 throughout the footprint of the STP. It has distinct advantages over the scheme it replaces. It is transferrable and includes further information about advanced care/ end of life planning and builds on national research and consultation.

The group is working with Shropshire Partners In Care who won the contract to deliver the training needed by all front line staff. GP input is vital and the group have been discussing primary care engagement. NHS Trusts are members of the group and there have been special projects to ensure care home engagement. Ensuring STP wide coverage of the ReSPECT process is the key risk going forward as no new DNACPR forms are to be used after the 31st October, 2019. The ReSPECT group are addressing this.

SCHT received a Good overall CQC inspection report with good for all individual domains. New roles such as memory and well-being worker and falls prevention work have had the positive impact on the wards in the Community Hospitals. A number of concerns have been raised by GP’s in relation to SCHT Community Team and criteria for accepting referrals.

The National Early Warning Score (NEWS) 2 has been adopted on the

wards within community hospitals. Meetings are taking place between the trust, commissioners and quality

team to monitor and review care and to ensure accurate service

specifications are in place.

Concerns raised over the last twelve months in relation to Looked After Children’s Services (LAC) are showing signs of improvement. Concerns have been raised previously regarding the back log

Clearer process and systems are in place for monitoring and reporting to

ensure accurate reflection of the status of health assessments for LAC is

in place. Health passports are now being offered to LAC though uptake of having

Page | 20

in Shropshire of Statutory Health Passports.

a passport remains low The SCHT’s Looked After Children Health Team continues to work with

the CCG on implementing quality health assessment. Improved reporting

on the dashboard has been presented at CQRM.

8 NHS Continuing Health Care and HCAIs

9 Recommendation

The Governing Body is asked to NOTE the contents of the report and the CCG actions contained within to recover performance in those areas

which are currently below target.

Agenda item – GB-2019-09.116

CCG Governing Body – 11.09.19

1

Title of the report:

LeDeR annual update report

Responsible Director:

Mrs Christine Morris, Chief Nurse working across NHS Shropshire and NHS Telford and Wrekin CCGs

Author of the report:

Helen Bayley, Strategic Lead Nurse for Quality

Presenter:

Helen Bayley, Strategic Lead Nurse for Quality

Purpose of the report: To provide an update of the LeDeR programme and its aim to reduce health inequalities and support services by embedding the learning from the LeDeR reviews across Telford & Wrekin and Shropshire.

Key issues or points to note: The reduction of the premature mortality of people with a learning disability has been identified as one of the four main priorities for the NHS for the next 10 years. The Learning Disabilities Mortality Review (LeDeR) programme is a national project to review the deaths of all patients with Learning Disabilities. 49 deaths have been notified since the programme started in June 2017. 29 deaths of Shropshire patients with Learning Disabilities were reported to the LeDeR programme, between April 2017 and March 2019. Of these, 16 patients died in Hospital (1 in Birmingham), 12 died in their usual place of residence i.e. either a care home or their own private home. The causes of death, and the learning from the reviews, are predominantly in line with national feedback from the LeDeR programme. Two of the reviews were graded as excellent care. 10 reviews have been graded as good care. One identified as having some gaps in care but did not contribute to the death and one was it was considered following the review that gaps in care may have contributed to the death. This case went to coroner’s inquest with the learning shared across the Trusts. Shropshire/ Telford and Wrekin remain one of the best performing CCGs nationally, having a low number of unallocated cases, and a high number of completed cases.

Actions required by Quality Committee Members: To receive and note the content of the provider quality exception report.

Agenda item – GB-2019-09.116

CCG Governing Body – 11.09.19

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LeDeR Annual update report

April 2018 – March 2019

LEARNING DISABILITY MORTALITY REVIEW (LEDER) PROGRAMME

Shropshire, Telford and Wrekin

1.0 Executive Summary:

The Learning Disabilities Mortality Review (LeDeR) programme is a national project to review the deaths of all patients with Learning Disabilities. The programme was established to support local areas to review the deaths of people with learning disabilities, identify learning from those deaths, and take forward the learning into service improvement initiatives. The programme is led by the University of Bristol, and commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England. This is a joint health and social care project, involving healthcare providers across the health economy, Local Authority and CCG’s. During 2018/2019, 29 deaths of patients with Learning Disabilities were reported to the LeDeR programme, Shropshire, Telford & Wrekin. 17 patients were from Shropshire and 12 T&W. 2.0 Review process:

LeDeR reviews are not investigations of care but aim to develop learning and improve care. The focus of the reviews is to:

• Identify potentially avoidable factors that may have contributed to a person’s death. • Identify differences in health and social care delivery across England and ways of improving

services to prevent early deaths of people with learning disabilities. • Develop plans of action that will guide necessary changes in health and social care services

in order to reduce premature deaths of people with learning disabilities For each death, there is an initial review. Someone who knew the person well, such as a family member, is invited to contribute his or her views and is a fundamental part of the review. The reviewer will also look at relevant case notes relating to the person who has died, and will make contact with relevant organisations/ agencies to discuss cases and access notes if required. This involves the range of agencies that have been supporting the person who has died, (e.g. health and social care staff). The review looks at three levels of care: • a) Initial diagnosis and management of the condition • b) Ongoing management of the condition from initial diagnosis to critical illness • c) Management and care received during final illness 3.0 National Picture:

From 1st July 2016-31st December 2018, 4,302 ‘in scope’ deaths have been notified to the programme. In 2018, this was approximately 86% of the estimated number of deaths of people with learning disabilities in England each year. One in 10 (10%) included a multi-agency review.

Agenda item – GB-2019-09.116

CCG Governing Body – 11.09.19

3

The median age at death for people with learning disabilities (aged 4 years and over) who died from in year was 59 years. For males it was 60 years; for females 59 years. 38% of the deaths were still waiting to be allocated to a reviewer, indicating continuing and Significant problems with the timeliness with which reviews of deaths take place nationally. Of the deaths of children (aged 4-17 years), 42% were from BAME groups. None of the children deaths locally were BAEM. A quarter (25%) of people from BAME groups had profound and multiple learning disabilities, twice the proportion (11%) of white British ethnicity. All deaths locally were white British. There was a rise in deaths through autumn and early winter. Over a third (37%) of people who died from aspiration pneumonia did so between Octobers – December. The proportion of people with learning disabilities dying in hospital was 62%; in the general population it is 46%. In the 2016/2017 64% of deaths were in hospital. Reviewers felt that the majority (79%) of DNACPR orders were appropriate, and correctly completed And followed. However, 19 reviews reported that the term ‘learning disabilities’ or ‘Down’s syndrome’ was given as the rationale for the DNACPR order. This has not been the case on any of the local DNACPR orders. The most common individual causes of death • Pneumonia • Sepsis • Aspiration Pneumonia 4.0 Local Findings:

Locally 29 deaths have been notified to the LeDeR programme, between April 2017 and March 2019.within 2018/19. Fourteen of these reviews have been completed; quality assured by the LAC’s and submitted to the LeDeR team in Bristol. Of these, 16 patients died in Hospital (1 in Birmingham) and 12 died in their usual place of residence i.e. either a care home or their own private home. One of the notifications was withdrawn due to the patient not meeting the LeDeR eligibility of an LD diagnosis. Age of death: 3 of the 29 deaths were in the 4-25 age group; 9/29 deaths were in the 26-55 age group; 4/29 were aged 56-65 and 13/29 were aged 65 plus (4 aged 80+ and 7 aged 70+). This makes the mean age of deaths 58 years. 18 of the deaths were males, (the mean age 60years) and 11 females (mean age 56 years). The cause of death most commonly reported were: generalised pneumonia (6); Heart Disease (5); Respiratory failure (4); Sepsis (4); Aspiration Pneumonia (3); multi-organ failure (2); Batton disease (1); Volvulus (1). Three cases are still to be confirmed. Grading of Care: Two of these reviews were graded with a score of one (excellent care). Ten reviews have been graded as a score of 2 which indicates (good care). One was graded as 4 (some gaps in care but did not contribute to the death),

Agenda item – GB-2019-09.116

CCG Governing Body – 11.09.19

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One was graded as a six (gaps in care which may have contributed to the death). This case went to coroner’s inquest with the learning has been shared via the steering group across the Trusts. The key learning from this case is identified below: • Use of the LD passport - All patients with LD should carry or have easy access to an LD

passport to share with health care staff. • Referral for LD specialist support - Staff within emergency care service should familiarise

themselves with the contact information of their local Community Learning Disabilities Team. Awareness that a referral can be made to the CLDT where the named nurse has any concerns

• Assessment of pain - references were made to the patient having pain. The hospital need to utilise tools to assess pain in patients with a learning disability. The trust are now looking at non-verbal aids for communication; EASY READ pain management literature.

• No specific pathway or adjustment for emergency care of patients with LD. ED requires a specific care pathway/protocol for identifying and caring for patients with a learning disability.

• Admission and discharge pre-planning - The CCG and the trust are reviewing the contract and commissioning arrangements of the hospital LD liaison nurses.

The most commonly reported gaps in practice of the other reviews were: • Delays in diagnosing and treating illness. • The quality of health and social care received by the person. • Delayed discharge from hospital. • Delayed recognition of approaching end-of-life. • The coordination of care. • Information sharing. • Transition planning for those moving from children’s to adults’ services. • Policies for specialist referral. • Staff resources and skills. This learning has been shared with providers but further assurance is required as to how these recommendations are being actioned at an operational level. One notification was withdrawn from the process as it was decided during the initial review that the patient did not have a learning disability. There is variance across the county in how General Practices code people with a learning disability. The LeDeR Programme uses the definition included in the ‘Valuing People’, the 2001 White Paper on the health and social care of people with learning disabilities which states: ‘Learning disability includes the presence of significantly reduced ability to understand new or complex information to learn new skills (impaired intelligence), with reduced ability to cope independently (impaired social functioning), which started before adulthood, with a lasting effect on development. Good Practice has been cited in many of the reviews. The main themes are in relation to:

• Strong, effective inter-agency working. • Person-centred care. • End-of-life care. • The provision of ‘reasonable adjustments’

This report will be shared with the four main providers at CQRM. Work is ongoing through the steering group to ensure the actions required are implemented.

Agenda item – GB-2019-09.116

CCG Governing Body – 11.09.19

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5.0 NHSE Assurances: There are 2 key priorities for LeDeR as a programme across the Midland and East

1. Improving the rate at which reviews are assigned 2. Improving the length of time which it takes for the reviews to be completed 3. Ensuring action is taken to address the recommendations emerging from completed reviews.

Shropshire/ Telford and Wrekin remain the highest performing footprint in Midlands and East, having the lowest number of unallocated cases. Shropshire/ T&W are also in the top three nationally of allocated cases. 61% of reviews notified have since the onset of the programme in June 2017 have been completed This also makes the footprint one of the best performing CCG’s in regards to completed cases. Currently there are 9 reviews that have taken over 6 months to be completed. NHSE have requested further information on the cause of the delays. In the main this is due to awaiting information and other investigations or police enquiry to be completed. The LACs continue to support the reviewers. Medical Examiners to be asked to raise and discuss with clinicians any instances of unconscious bias they or families identify e.g. in recording ‘learning disabilities’ as the rationale for DNACPR orders or where it is described as the cause of death. The Department of Health and Social Care and NHS England to support national mortality review programmes to work with ‘Ask, Listen, Do’ and jointly develop and share guidelines that provide a routine opportunity for any family to raise any concerns about their relative’s death. It is also to be noted that the national team have asked the Shropshire Local Area Contacts (LAC’s) to provide support to other CCG’s who have challenges in establishing systems and process to embed LeDeR into practice. 5.0 Recommendations to committees:

TCP Board/ Safeguarding Board/ Q and PPQ are asked to:

1. Receive and acknowledge the key points identified in this report.

2. To note that the capacity of reviewers may become a concern if the number of notifications continues to rise.

3. To note that further assurances are requested from providers regarding the implementation

of learning and improvement to ensure robust processes are in place to address the gaps identified and improve care for people with learning difficulties.

1

Agenda item: GB-2019-09.117 Shropshire CCG Governing Body meeting: 11.09.19

Title of the report:

Single Strategic Commissioner for Shropshire & Telford &

Wrekin – Update Report

Responsible Director:

David Stout, Accountable Officer, Shropshire CCG

David Evans, Accountable Officer, Telford & Wrekin CCG

Author of the report:

Sam Tilley, Director of Corporate Affairs, Shropshire CCG

Alison Smith, Executive Lead Governance & Engagement,

Telford & Wrekin CCG

Presenter:

David Stout, Accountable Officer, Shropshire CCG

David Evans, Accountable Officer, Telford & Wrekin CCG

Purpose of the report: The purpose of this report is to provide an update on progress towards creating a single strategic commissioner across Shropshire and Telford and Wrekin.

Key issues or points to note: The Report highlights the progress made to date on the key recommendations that were approved at the last Governing Body meeting.

Actions required by Governing Body Members:

note the progress made to date on creating a single strategic commissioner for Shropshire, Telford and Wrekin; and

note the risks outlined.

2

Monitoring form

Agenda Item: GB-2019-09.117

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications Yes Future working arrangements will impact on future resources required by the

CCG’s

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No The CCG will be undertaking an EIA on the CCG workforce and also on its

population of the programme proposal.

4 Clinical engagement Yes Clinical engagement will be key in moving forward with and shaping future

working arrangements

5 Patient and public engagement Yes Public engagement will form part of the Communications and Engagement Plan

for the programme. The Communications and Engagement Plan for the programme is attached as appendix 1 to the report.

6 Risk to financial and clinical sustainability Yes Future working arrangements are a key consideration in the financial and clinical sustainability of the CCG’s going forwards

3

NHS Shropshire CCG Governing Board Meeting 11th September 2019

Single Strategic Commissioner for Shropshire, Telford & Wrekin – Update

Report

David Stout, Accountable Officer, Shropshire CCG

David Evans, Accountable Officer, Telford & Wrekin CCG

Introduction

1. At its Board meeting held on 15th May 2019, the Governing Board agreed to;

Support the dissolution of both CCGs and the formation of a single strategic commissioning organisation for the Shropshire, Telford & Wrekin footprint.

The early recruitment of a single Accountable Officer and the early integration of management teams.

Support a timetable for the formation of the single strategic commissioning organisation by April 2020.

Support the development of a Programme Management Office to oversee the programme.

2. This report seeks to provide the Govern Board with a further update on progress with the agreed recommendations above.

Report

3. Accountable Officer Recruitment

The recruitment to a single Accountable Officer role has been completed and a

recommendation of a preferred candidate has been made to NHS England. There is

no prescribed timeline for NHS England to respond, however we expect a response

in early September.

4. Organisational Development Partner The CCGs have secured support from Deloitte as an organisational Development (OD) Partner to help facilitate at pace engagement with the membership of both CCGs, staff and key stakeholders to help inform the development and vision of a new single strategic commissioner. Some engagement discussions had already been initiated by the Chairs of the CCGs and Accountable Officers in July, acknowledging that an OD partner would not be able to commence until early August. Therefore some discussions have already taken place with the respective membership of each CCG through Locality Meetings

4

for Shropshire and the Practice Forum for Telford and Wrekin and with Directors and Executive Leads from both organisations. Briefings have also been provided to both Health and Wellbeing Boards and the Joint health Overview and Scrutiny Panel. Work supported by Deloitte started on 8th August with discussions with both CCG Governing Bodies, CCG membership, local authorities and staff within the CCGs. Plans are also in place to engage with ICS partners, senior managers in the CCGs, CCG staff and Healthwatch in the coming weeks. The Deloitte work has been structured into two phases, the first being initial engagement to help inform the case for change, high level operating model and initial Organisational Development (OD) Plan which all form key documentary evidence for application to NHS England on 30th September. This will then be followed by a second phase which will be to deliver the OD plan agreed from 30th September through to 31st March 2020. 5. Oversight Group and Workstreams The CCGs have convened a Joint Executive Group, composed of the Directors and Executive leads from both CCGs and chaired by the Accountable Officers, which is meeting weekly to provide the necessary oversight to the programme and to ensure project timelines are adhered to and risks are identified and mitigated where possible. The Joint Executive Group is supported by a PMO team to ensure that the project timelines and interdependencies are sufficiently managed. In addition to this, the programme has also established 5 workstreams to undertake the detailed work required to prepare for creation of a single strategic commissioner. The workstreams have been focussed on producing first drafts of the evidence required for application submission on 30th September which were submitted to NHS England on 19th August, in preparation for a pre application meeting scheduled on 5th September with NHS England. As this report was written prior to this pre application meeting taking place, Accountable Officers will update Governing Bodies verbally on the outcome of this meeting.

Functionality – this will include engagement with members and stakeholders, determine the new operating model for the single strategic commissioner and respective documents that will support this model.

The workstream has produced a first draft of a Commissioning Strategy, Primary Care Strategy and a case for change document which are both being dynamically informed by the OD engagement taking place. Work is being undertaken to produce a Quality Strategy, Benefits Realisation Plan and Procurement Strategy, with plans in place to deliver these to the required standard by 30th September. Key risks at this stage include; not enough discussion has taken place to help inform an operating model which in turn will provide the foundation for much

5

of the Commissioning Strategy, Case for Change, Benefits Realisation Plan and future governance structure. This is however planned but not yet delivered. The Commissioning Strategy also has to be based on the Long Term Plan for the Shropshire health system which will not be fully developed until November 2019.

Communications and Engagement – to provide oversight of the development of a Communications and Engagement Strategy for the new CCG and to develop and oversee the delivery of a communications and engagement plan for the project itself, across all stakeholders.

A Communications and Engagement plan has been developed and is attached as appendix 1 for information. The plan includes all key stakeholders, staff, CCG membership, senior managers, public and key patient groups. Delivery of the plan has already commenced. A Communications and Engagement Strategy for the new single strategic commissioner has been developed and submitted on 19th August in preparation for the pre application meeting on 5th September. This is not fully completed as key areas of the strategy that described engagement at a local level has yet to be determined as this will be informed by the OD discussions planned by yet to be delivered fully. The work stream has also taken advice on the level of equality impact assessment (EIA) that would be required to support this proposal. The advice has highlighted that the application process for NHS England requires an EIA of the proposal on the workforce of both CCGs. In addition, although the proposal is a structural change to the CCGs and has no immediate impact on the populations both CCGs serve, the CCGs have been advised to undertake an EIA of the proposal on the populations of Shropshire, Telford and Wrekin. As a result the CCGs have commissioned from Arden and GEM CSU Equality Impact Assessments on both the workforce of both CCGs and of the populations the CCGs serve. The key risks at this stage are; that not enough discussion has taken place to help inform an operating model which in turn will provide the basis for describing engagement at a local level in the Communications and Engagement Strategy and that we have a very short timescale to deliver the project engagement plan and EIA work.

Finance - to provide oversight of the development of the Medium Term Financial Plan for the new CCG and to plan for the creation of a new financial ledger for the new CCG.

The work stream has produced a first draft of a Medium Term Financial Plan (MTFP) for the new CCG and has undertaken a piece of work to compare Standing Financial Instructions of both CCGs as required by the application criteria.

6

The key risk at this stage is that the MTFP requires alignment with the STP financial model which is not due to be completed until the end of September.

HR - to provide oversight of the management of change process that both CCGs will be required to run in order to identify staff who will transfer into the new legal entity.

This work stream has been focussed to date on the recruitment process for the Accountable Officer across both CCGs. In addition some preparatory work has been continuing on ensuring job descriptions for existing staff are up to date. Key risks are around delays in commencement of management of change process due to any further delays in appointing an Accountable Officer.

Governance - to provide oversight of the development of a new corporate governance framework, constitution and governance processes for the new CCG. Delivery of a Constitution and governance structure is scheduled for after 30th

September in line with requirements from NHS England.

The key risk at this stage is that OD discussions do not produce outcomes to

support the design of a high level governance structure that will be required to

produce a draft Constitution and Governance Handbook.

6. Project timeline

The high level timeline is as follows:

14th May 2019

Governing Bodies agree to support proposal to apply

for dissolution of existing CCGs and creation of a new

single strategic commissioner.

June Creation of a project overview group – Joint Executive

Group

Creation of 5 work streams and confirmation of work

stream and sub work stream leads

Confirmation of deliverables for each work stream

against NHS England application criteria and inter

dependencies

1st July

By 30th July

By 8th August

PMO in place – produce programme plan

Additional technical HR support in place – begin

planning for Accountable Officer recruitment

Procure OD partner

Accountable Officer recruitment process completed

Recommendation to NHS England on preferred

candidate for Accountable Officer

7

1st August

19th August

OD partner in place

Deadline for submission for pre-application evidence

5th September

w/c 16th September

w/c 23rd September

27th September

Pre application meeting with NHS England

Membership support for application

Governing Body support for application

Final application and evidence submission to NHS

England

3rd October Make application to NHS SBS to create a new ledger

18th October NHS England Regional Management Team to make

recommendation on status of application to national

team.

29th October NHS England Statutory Committee to consider

application

21st November Application to NHS Digital for new organisational code

made if application is successful.

21st January National team notify Government Banking Services

27th February Draft Constitution prepared and submitted to NHS

England for review and approval

5th March Staff transfer schemes and grant of merger documents

to be signed off

6th March Letter to existing CCGs regarding dissolution

31st March` New CCG established.

The PMO reports to the Joint Executive Group weekly and currently the project is

delivering against target, but it should be emphasised that the timeline that the CCGs

are working to is very challenging, with the greatest risk to delivery of the project that

there will not be sufficient time, in the first instance, to produce an application and

supporting evidence to the standard required by NHS England to ensure it is

successful.

Recommendations The Governance Board is asked to:

note the progress made to date on creating a single strategic commissioner for Shropshire and Telford and Wrekin; and

note the risks outlined.

NHS Shropshire CCG and NHS Telford and Wrekin CCG Single Strategic Commissioner Transition Communications and Engagement Plan Outline of the Plan This is a working document setting out the planned communications and engagement to support the transition to one single strategic commissioner and the dissolution of Shropshire CCG and Telford & Wrekin CCG. Aims To create understanding of the transition and how it will be delivered whilst at the same time giving reassurances to patients and key stakeholders, with particular reference to the CCG’s respective staff, to ensure they are involved and feel involved in the process. Objectives

Offer the opportunity for feedback and two-way dialogue on the transition to our stakeholders from across the whole County.

Provide accurate, timely information tailored to an audience’s particular needs with appropriate messaging.

Provide a planned programme of engagement to reach across stakeholders including GP practices, partners, staff, patients and the public.

Ensure participation from the GP membership and their support for the transition.

Support as smooth as possible the transition for the CCG’s respective staff by utilising and co-ordinating engagement opportunities.

Demonstrate how feedback has been considered and, if appropriate, used. Approach – special considerations The key consideration is that all activity is co-ordinated and is always presented as a joint approach from the two respective CCGs. Timing is a critical factor with the delivery submission date of September 30th and then a live date of 1st April 2020. Already activity has been underway on a drip feed approach timed around the Governance.

Engagement and Communications Activity to date – an overview Board Engagement With NHS England (NHSE) support, Shropshire and Telford and Wrekin CCGs carried out separate facilitated sessions with their governing bodies late 2018 and then held a joint session early in 2019, to begin exploring the appetite for and mechanisms required for closer working. Discussions included both options of closer working:

informal working using joint management and collaborative mechanisms, whilst still retaining two statutory bodies, and

the alternative of dissolving the two CCGs and creating one new strategic commissioning organisation with one governing body, one management team and one governance structure.

These sessions were positively received and resulted in a commitment to explore this further. In light of this, papers were presented to both CCG’s governing bodies initially in March and then a final proposal in May 2019. This resulted in both Boards approving the dissolution of the existing CCGs and the formation of a new single strategic commissioning organisation across the whole Shropshire footprint. Board Announcement Engagement activity started early to co-ordinate with the first public Board paper to announce the intention in May 2019. This was delivered through a co-ordinated advance staff briefing delivered by each respective AO in face-to-face team meetings. This was further supplemented by stakeholder briefings to all partners across the health and social care economy as well as planned media releases. GP Practice Membership With GP practice membership there have been visits across the Shropshire CCG membership network meetings and for Telford and Wrekin membership through attendance at two Practice Forum meetings in June and July 2019. These were completed by the respective Chairs and AOs for each organisation to personally update them and assess reactions and initial feedback. The feedback received from the meetings was mixed and further tailored engagement is being planned. A standing open offer for further engagement has been given to all practices should they have any further questions. Executive Team Engagement Both executive teams were brought together with a facilitator to start to discuss what the potential benefits of creating a new CCG could be in order to undertake some preparatory discussions prior to the OD partner being commissioned. The outcomes of this session were shared with the OD partner when they started their contract. Staff Engagement Both CCGs have internal communication mechanisms, but a priority needs to be a co-ordinated approach. Principally, this relates to verbal team briefs as Shropshire CCG holds a face-to-face team brief once a month, whereby Telford & Wrekin CCG holds a weekly huddle at the start of each week. There is clearly a need to align any news announcements on the transition so they are co-ordinated across both CCGs.

Monthly staff newsletters also run shared content on the transition as well as staff announcements issued electronically for more time-sensitive updates. A staff Q&A has been developed and is being reviewed weekly with both organisations capturing questions via team meetings and designated ‘post boxes’ to allow anonymous questions to be submitted. All questions are presented to the weekly Joint Executive Meeting where they are reviewed. The signed off responses are then provided back to the Communications and Engagement Team to update the master copy who issue the revised version to all staff in a co-ordinated manner across both CCGs. Stakeholder engagement Accountable Officers and Chairs have attended and presented an overview of the proposal to the two local authority Health and Wellbeing Boards in July 2019 and to the Joint Health Overview and Scrutiny Committee for both local authorities in June 2019. The Accountable Officers have also met with the LMC and have meetings planned with Healthwatch. Communication and Engagement Channels Steps are now being made, where possible, to align channels to ensure that messages are co-ordinated and delivered in a timely manners across both CCGs, particularly with regard to staff messaging/engagement activity. This plan initially focusses on internal staff comms and engagement.

Staff newsletters Both CCGs produce a monthly staff newsletter – details included in the activity calendar appendix 1.

Staff face-to-face staff briefings At Telford & Wrekin CCG there is a staff huddle on Monday mornings hosted by AO David Evans, but in his absence Chris Morris/Jon Cooke. This is a quick, informal update for staff on news/events of the last week or up-coming. Staff can ask questions or share information with colleagues.

Staff briefings Shropshire CCG has a planned monthly programme of staff briefings with updates from the AO and Chair to all staff. This is scheduled for one hour and is mandatory that staff attend unless required at essential meetings. Informal in nature but there is an agenda with agreed presentations and guest speakers. Usually includes an interactive activity with staff as part of engagement. Telford & Wrekin CCG has no current regular agreed meetings as these are held on an ad hoc basis usually when there is something specific to discuss with staff i.e single organisation. This is usually hosted in the staff rest room by the AO and Chair, depending on the subject nature.

Shared files Telford & Wrekin CCG Staff/GP member intranet - information can be uploaded on a daily basis. Shropshire CCG does not have an intranet, but has a dedicated corporate documents section on its shared drive which all staff can access. This is managed by the CCG’s Communications and Engagement Team.

GP newsletter

Telford & Wrekin CCG has a monthly GP newsletter to subscribed GPs and Practice managers. Shropshire CCG has a weekly practice bulletin which is aimed at GPs and all practice staff. This is produced in-house with copy and layout every Thursday and Friday, with an issue day every Monday.

GP and Practice engagement There are opportunities to have direct engagement with practices through their regular group meeting which are organised slightly differently in the two CCG areas:

Telford & Wrekin CCG GP Practices hold a Forum. These are held on the third Tuesday of every month, except in August and

December, from 1.30pm. A new Chair is due to be appointed and one GP from each practice and the

practice member attends. The agenda is set by Karen Ball at T&W CCG - it gets full very quickly so

anything which needs to go on the agenda needs to be sent a.s.a.p. Papers go out the week before the meeting.

Shropshire CCG holds Locality Meetings

These are held on a monthly basis with the exception of August and October (protected learning time). Shrewsbury & Atcham Locality – third Thursday every month, pm meeting North Locality – fourth Thursday every month, pm meeting South Locality – six weekly cycle, on a Wed/Thurs from 3.30pm – 7pm

For each of the Locality Meetings above it is possible to be considered for an agenda item and in the first instance contact is required with SCCG’s locality managers to discuss.

Note: For the purposes of this project the two respective CCG’s are using existing corporate e-mail accounts to capture any feedback Stakeholder Mapping – to be revised The scope of the plan covers the pre-engagement completed to date and future engagement required with the following stakeholders:

o CCG Practice membership o CCG Staff o Local Medical Committee o Any specific boards o Health & Wellbeing Boards o NHS Provider Chief Executives o Local Authority Directors of Adult Care o Local Authority Directors of Children’s Services o Elected Representatives o Joint Health Overview & Scrutiny Committees for Shropshire Council

and Telford and Wrekin Council o Healthwatch: Shropshire and Telford and Wrekin o NHS England/NHS Improvement

o MPs o Patients and the public, via:

FT Governors & memberships PPG Chairs and members Lay and Patient Reference Groups General public messaging

Key Messages (to be refined)

The proposal is that the existing CCGs are dissolved to create a new statutory body that will become a single strategic commissioner across the whole footprint of Shropshire, Telford and Wrekin. The OD engagement discussions are at a very early stage, however the working assumptions made from these discussions to date on the case for change are:

• Potential to break down barriers and create genuinely integrated pathways that are better for patients and improve outcomes.

• A single set of commissioning and decision making processes should mean:

reduced variation in outcomes and access to services across the county,

greater influence with providers, better use of clinical and managerial time on the things that

count, reduced duplication and potential financial efficiencies as

required by NHS England. • Enables strategic commissioning of quality services that are financially

sustainable. • Enables the health system to create a new integrated care system that

prioritises healthcare transformation. • It is the national direction of travel to have a single CCG (strategic

commissioner) for each Integrated Care System (ICS) footprint across the country.

• The CCGs have a unique opportunity to design the future single CCG that we wish to see.

Governance

Sign off protocols Sign off will be by Accountable Officers for communications related to stakeholders and staff, with sign off for membership by Chairs of the CCG.

Due to holiday periods where annual leave may not allow this sign off

procedure, then planning for sign off should take place well in advance.

Reporting

Reporting of feedback, planned communications and other related information

or risks will be to the PMO to include in the weekly update report to the Joint

Executive Group.

Activity Plan

Background & Pre-engagement The two CCGS have an ambition and intention to dissolve in order to create a new single strategic commissioner organisation. The Strategic Outline Case was taken through Governing Body discussions on 12/13th March 2019. This direction was agreed by the two CCG Governing Bodies on 14/15th May 2019. Approach

The approach focusses internally on the staff within the CCGs and externally with

key stakeholders

Internal Stakeholders

The Executives for each area act as the main advocates for the change during the pre-merger process and then post merger.

Two staff meetings are held to explore the advantages and dis-advantages of merger along with any concerns raised prior to application and a whole staff meeting held pre 31/2/20 for staff.

Regular individual directorate meetings are held, with the merger as a statutory agenda item.

A regular specific newsletter item is sent to staff on any merger updates.

A staff survey is undertaken regularly for views.

A regular frequently asked questions is sent to staff.

Senior Management Team meetings have a set agenda item on the transition and creation of a single strategic commissioning organisation.

Regular HR sessions are held for staff to ask questions

External

CCG CEO, 2 x Chairs, GB clinical leads, the CCG Chairs to act as main advocates for change during engagement period.

Utilise existing CCG place, education and network meetings where available to engage with CCG membership.

Utilising existing strategic sessions/Boards to take opportunity to consult with key stakeholders.

With an approach of co-production hold a series of engagement events through the life cycle of the project with key stakeholders. The initial meeting would be an opportunity to highlight any issues, concerns or risks as well as identifying what has worked well in the current CCGs and what could be changed. This would then move on to what the new organisation could look like and how it would interact with stakeholders along with further updates and engagement as required.

Secure support from LMC.

Secure agreement from the membership with a face-to-face vote at the Membership Forum for GP Practices in Telford & Wrekin CCG and an electronic vote for GP Practices from Shropshire CCG.

Survey to be delivered for patients, members of the public, staff and stakeholders to capture wider feedback – this will be based on the questions given to practices in the face-to-face vote and the electronic survey.

Additional information – the findings from the survey will be used to help inform

and develop further engagement activity and will be supplemented by a planned

Equality Impact Assessment, which has recently been commissioned.

Two CCG Governing Bodies/membership/stakeholders

Activity Timescale 2019 Strategic Outline Case discussions at CCG Governing Bodies &

with NHS England

Engagement

2019 Activity Timescale

Action By

w/c 1 July Governing Bodies and Executives to map out benefits realisation with clear strategic narrative on why merger. Include dis-benefits and mitigations

AS

w/c 1 July Map engagement opportunities with stakeholders for work during July/August. Align CEO and Chairs to these sessions.

AS/ST

w/c 1 July Map engagement opportunities for CEO and Chairs at existing primary care forums, including network, education, place alliance meetings.

Pre-membership forum

During engagement period Align managers to support discussions and get agenda time as required.

AS/ST

w/c 1 July Agree internal governance on decision making and map GB decision points (plan may need amendment accordingly).

PMO – programme plan

w/c 8 July Draft Engagement document

AH

w/c 8 July Governing Body meetings to agree strategic paper ST/AS

w/c 8 July Invite to Membership Forums to be held in August and again in September

AS/ST

w/c 15 July Information to HOSC chairs to brief on background AS

w/c 15 July Finalise plans for launch of engagement, including views collation method, promotional materials, media handling, social media calendar.

AH

w/c 22July Finalise engagement documentation and fulfilment/distribution methods.

AH

22 Jul – 22 Aug Attendance at existing stakeholder meetings for pre-engagement

HWBB x 2

JHOSC

June and July 2019

w/c 22 July NHS England Sense Check meeting.

AS

w/c 22 July Finalise membership voting process ST/AS

DATE OF GP Membership meetings

Membership Forum – Shropshire ST

w/c 05/08/19 Draft Strategic Narrative Paper from AOs shared with GBs

Deloitte/ST/AS

w/c tbc Present to Local Authorities Deloitte/AOs/Chairs

w/c 05/08 Discuss merger proposal with Healthwatch Shropshire/Telford and Wrekin

AOs

w/c 13/08 Membership forum - Telford Deloitte/ST/AS w/c 02/09 Membership forum – Shropshire if required Deloitte/ST/AS w/c 12/09 Membership forum – Telford Deloitte/ST/AS w/c 02/09 Draft public questionnaire (based on BSOL&

Derbyshire) AH

w/c 02/09 Review engagement document draft AH

w/c 02/09 Prep Survey Questions for GP membership

Prep Survey Questions for Public/stakeholders

w/c09/09 Layout and load two surveys with supporting comms and messaging

AH

w/c02/09 Develop template for engagement questionnaire AH

TBA Launch Public Engagement online – 2 websites and social media

AH

TBA Upload copy & Survey link to 2 CCG websites AH

On-going Launch stakeholder engagement –

ICS partners

Health & Wellbeing Board

NHS Provider Chief Executives

Local Authority Directors of Adult Care

Local Authority Directors of Children’s Services

LMC

Elected Representatives

Health Overview & Scrutiny Committees for TBA

NHS England/NHS Improvement

PPGs

General Public

AH

w/c 09/09 Develop drip feed of updates for practice vote AH

TBA Record votes (Support or Oppose) AH

TBA Closure of stakeholder engagement

AH

Collate stakeholder responses and develop decision engagement report documenting feedback form all stakeholders including membership.

AH

TBA Decision/recommendation made following engagement

Chairs

NHS England Panel Meeting AS

w/c 17/9 Governing Body Decision on Submission – meeting in common

AS/ST

GP membership receive outcome of engagement and GB decision on options

AS/ST/AH

w/c 24/9 Update report emailed to HOSCs, HWBB and Healthwatch

AH

w/c 24/9 Share engagement feedback and decision with stakeholders

AH

Key:

Complete

In progress

Pending

Feedback mechanism and reporting In order to demonstrate what feedback has been provided and how it will be used, a feedback capture template and log has been developed (see appendix 2 and 3). Feedback from each engagement opportunity will be captured in the template and then transposed across to the tracker which will be used to identify themes. From this an engagement report on the proposal will be published to allow the governing bodies and membership of the CCGs to determine what mitigation can be put in place to address the feedback received.

Engagement Activity Plan - Appendix 1

Activity Date Stakeholder Status

Staff Briefing across both CCGs – face-to-face

3 June Staff – both CCG

Complete

Presentation on NHSE directive to reduce workforce by 20% and single organisation

April 16 T&W GPs Complete

Report from the CCG Board presented to GPS

May 21 GPs T&W Complete

Roundtable discussion June 18 TBA – Sharon at T&W

Complete

Launch of AO recruitment – e-shot

21 June Staff - both CCGs

Complete

Staff announcement – update on HOSC – e-shot

25 June Staff – both CCGs

Complete

Staff announcement AO update

26 June Staff - both CCGs

Complete

Staff FAQs 1 July Staff - both CCGs

SCCG Staff Briefing 11 July SCCG staff Complete

Staff FAQs 16 July Staff – both CCGs

Complete

Dr Leahy presentation 16 July GPs Complete

Staff FAQs 22 July Staff – both CCGs

Complete

SCCG Staff newsletter 26 July Staff Complete

SCCG GP Newsletter update

29 July GP members

Complete

Update on AO recruitment 2 August Staff – both CCGs

Complete

Staff FAQ 6 August Staff – both CCGs

Complete

Note: Staff FAQs on a weekly basis, every Tuesday, subject to any questions being received

SCCG Staff Briefing 19 August SCCG staff

SCCG Staff newsletter Last week August

SCCG staff

T&W Staff Newsletter/GP Monthly newsletter

Deadline 21 August

T&W staff

SCCG Staff Briefing 25 September SCCG staff

SCCG Staff newsletter Last week September

SCCG staff

T&W Staff Newsletter/GP Monthly newsletter

Deadline 25 September

T&W staff

SCCG Staff Briefing 31 October SCCG staff

SCCG Staff newsletter Last week October

SCCG staff

T&W Staff Newsletter/GP Monthly newsletter

Deadline 23 October

T&W staff

SCCG Staff Briefing 18 November SCCG staff

SCCG Staff newsletter Last week November

SCCG staff

T&W Staff Newsletter/GP Monthly newsletter

Deadline 20 November

T&W staff

SCCG Staff Briefing 12 December SCCG staff

SCCG Staff newsletter Mid- December SCCG staff

T&W Staff Newsletter/GP Monthly newsletter

Deadline 18 December

T&W staff

Appendix 2 Communications and Engagement Capture Form

Single Strategic Commissioner/Group

Attended Feedback Form Date Location Who from

CCG Attended

Group Name

Equalities Group

No of People

Feedback:

Appendix 3 Feedback Log and Theme Analysis

See separate Excel Spreadsheet.

1

Agenda item: GB-2019-09.118 Shropshire CCG Governing Body: 11.09.19

Title of the report:

Shropshire CCG Strategic Priorities Update

Responsible Director:

David Stout – Accountable Officer

Author of the report:

Sam Tilley – Director of Corporate Affairs

Presenter:

David Stout – Accountable Officer

Purpose of the report: To update the Governing Body on progress in relation to the Strategic priorities for Shropshire

CCG during 2019/20

Key issues or points to note: In June 2019 Shropshire CCG’s Governing Body undertook a development session focused on

agreeing a set of strategic priorities for delivery during 2019/20. The priority areas set out below

were selected from a longlist of options generated at the development session by Governing

Body members and then put to a vote to create a shortlist.

Development of a single strategic commissioning organisation across Shropshire,

Telford & Wrekin

Urgent & emergency care

Primary Care

Mental health & learning disabilities

Planned Care

Cancer

The short list was formally adopted by the Governing Body at its confidential meeting in August

2019 and it was agreed that regular updates would be brought back to each Governing body

meeting to demonstrate progress in delivery.

The Governing Body also discussed the development of a set of key performance indicators

(KPIs) to accompany the strategic priorities. Although this work can still be undertaken it is

likely that this work will now be subsumed into the work to create a single strategic

commissioning organisation and given the point in the year the Governing Members may feel

the current reporting method is sufficient.

2

Actions required by Governing Body Members:

The Governing Body is asked to:

Note the progress against the CCG’s strategic priorities

Agree whether the current reporting method is sufficient until such time that the new

single strategic commissioner is created or whether a set of KPIs should be developed

for the remainder of 2019/20.

3

Monitoring form Agenda Item: GB-2019-09.118

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications No If yes, please provide details of the effect upon these requirements

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the effect upon these requirements

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability No If yes how will this be mitigated

Shropshire CCG Strategic Priorities Update Tracker – September 2019

Priority Action Update (as at 1 September 2019)

Development of a single strategic commissioning organisation across Shropshire, Telford & Wrekin We have recognised the importance of moving to a single strategic commissioning organisation across the STP area as a key means of delivering our overall ambitions, with an aim of achieving that by April 2020.

Develop a transformation plan to deliver a new CCG and ensure that we support staff through the change

Lead: David Stout Transformation plan underway. Documents to support application to NHSE near completion. HR and PMO support secured from MLCSU and Organisational Development support secured from Deloitte. Sessions run with both Governing Bodies separately and jointly and with staff from both CCGs. Current plans on track for single CCG by April 2020 but dependent on NHSE and membership approval later in September.

Urgent & emergency care We continue to face increasing pressures on the urgent & emergency care system. It is essential that we address these pressures through our care closer to home programme to improve the quality of care and to deliver commitments we have made as part of the Future Fit programme.

Support the system wide development of the co-ordination of a comprehensive community offer with an innovative integrated front door

Lead: Jess Sokolov The CCG continues to support the development of Urgent Treatment Centres at both A and E sites. Streaming is in place on both sites 24/7, with the CCG supporting cross site learning. The Urgent Care commissioning lead is working with the system Urgent Care director to monitor the impact on patient flow of a new assessment pathway for acute GP referrals, following June’s Start of Change week. The CCG continues to progress Admission Avoidance procurement for this winter, the wider Care Closer to Home work (reported elsewhere), and continues to offer support and challenge around the system readiness to move to the LTP vision of place based care.

Primary Care GPs and practice teams provide vital services for patients. They are at the heart of our communities and we recognise the importance of having good access to the full range of primary care services, not only to a GP practice but to the full range of Primary Care Providers.

Use innovation and work in collaboration with NHS England as the commissioner of community pharmacy, dentistry and opticians to ensure improved patient access to all areas of primary care, which in turn will reduce the pressure on the wider health

Lead: Nicky Wilde Discussions have taken place with NHS England as commissioners for community pharmacy, dentistry and optometry to discuss potential collaboration in delivery of wider Primary Care Services A meeting with the Local Pharmaceutical Committee Chair has taken place specifically around the new Pharmacy contract to commence April 2020 and the links to the wider delivery of the Long Term Plan. Outline paper drafted for the October Primary Care

Commissioning Committee.

Mental health & learning disabilities In line with delivering the mental health long term plan, we are committed to meeting the mental health investment standard.

Prioritise the management of mental health crisis and improve follow up for those who present in crisis

Lead: Julie Davies Mental health crisis was chosen as a priority across the system as well as by SCCG Governing Body given the demand on the Section 136 Suite (444 admissions in 2018 with 23% conversion rate to inpatient care) and the large numbers of people in contact with MH services who present to A&E urgent care. Since July the CCG has been successful in securing additional recurrent monies to strengthen the crisis care pathways across STW including: additional Band 5 staff for the Crisis Home Treatment Team, commencement of Street Triage with registered staff working with West Mercia Police and new service development of crisis cafes with Shropshire Sanctuary and Designs in Mind covering six evenings per week between 5-11pm. The NHS Plan identifies children’s crisis as a priority area for future investment and the CCGs are reviewing the offer to children and young people, as well as undertaking a deep dive into pathways into A&E for people in contact with MH services. The latter is significant given that the total number of the mental health services population (8% of total Shropshire Telford and Wrekin – STW population) utilise 18% of A&E attendances. The same 8% MH population also use 14% of all diagnostic examinations. A recent report into mental health and physical health across the STP identified that Shropshire and Telford & Wrekin STP could potentially save up to £412k in A&E attendances and up to £12.0m in inpatient care, by reducing mental health service users hospital activity to the same current levels of the rest of the population, in subgroups which may be amenable to change. This requires further work and business case development to take forward future changes to service models.

Planned Care We have a wide programme of transformation of planned care services set out in the operating plan. Within that programme, one specific priority given the scale of the opportunity to deliver significant quality and value for money improvements is the transformation of MSK services (including the existing SOOs/TEMS services, pain management, rheumatology and metabolic bone disease).

Develop a single integrated model of care of MSK services across Shropshire, Telford & Wrekin that requires more integrated provision

Lead: Julie Davies This priority is being taken forward via the MSK transformation Board. The aim is for the single model to be defined and agreed by the end of September. This is being developed through a clinically led design group. To date this work is on track to meet the end of September deadline subject to agreement at the September Transformation Board on the 5th Sept.

Cancer We recognise that there are particular challenges in delivering some cancer pathways in Shropshire, Telford & Wrekin given workforce issues for our local providers and access issues for our patients.

Work with providers to address access and workforce issues by developing wider alliances with bigger hospitals

Lead: Gail Fortes Mayer Work is underway on a number of fronts to ensure there are sustainable cancer services for STW. There is a dedicated cancer workforce group at an STP and wide (staffordshire) level. The cancer strategy group are reviewing critical cancer pathways that require a networked service approach. Urology has been the first cancer pathway that this model has been explored with UHNM. Oher cancer sites are likely to be those where technology, skills sets, service interdependency require surgery or other treatment modalities to be performed at a tertiary centre. The STW STP is working as part of the West Midlands Cancer Alliance to progress work on networked diagnostics, rapid diagnostic centres and technology driven solutions to ensure that if SaTH does not provide an enhanced level of care, STW patients have equitable access to such services.

Agenda item: GB-2019-09.119

Shropshire CCG Governing Body meeting: 11.09.19

Title of the report:

Creation of a Remuneration Committees in Common for

Telford and Wrekin and Shropshire CCGs

Responsible Director:

David Stout, Accountable Officer, Shropshire CCG

Dave Evans, Accountable Officer, Telford & Wrekin CCG

Author of the report:

Sam Tilley, Director of Corporate Affairs, Shropshire CCG

Alison Smith, Executive Lead Governance & Engagement,

Telford & Wrekin CCG

Presenter:

Sam Tilley, Director of Corporate Affairs, Shropshire CCG

Purpose of the report:

The purpose of this report is to propose to the Governing Body the implementation of a Remuneration

Commitees in Common to aid and align decision making in the preparation for the transition to a Single

Strategic Commissioning Organisation.

Key issues or points to note:

Shropshire and Telford and Wrekin CCGs are undertaking a range of work in order to establish a Single Strategic Commissioning Organisation by April 2020. As part of this work it is proposed that an early move to a Remuneration Committees in Common would be beneficial in supporting decision making and robust governance to the work programme. The creation of a Committees in Common will ensure transparency, alignment and consistency in the approach to remuneration of future senior staff

Actions required by Governing Body Members:

The Governing Body is asked to:

Approve the creation of Remuneration Committees in Common between NHS Shropshire CCG and NHS Telford and Wrekin CCG for the purpose of supporting the process and decision

making associated with the transition to a single strategic commissioning organisation

based on the parameters set out in this paper

Monitoring form

Agenda Item: GB-2019-09.119

Does this report and its recommendations have implications and impact with

regard to the following:

1 Additional staffing or financial resource implications

Yes The remuneration of future senior staff may impact on the future resources of the

single strategic commissioning organisation and the outgoing CCGs

2 Health inequalities

No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements

No If yes, please provide details of the effect upon these requirements

4 Clinical engagement

No If yes, please provide details of the effect upon these requirements

5 Patient and public engagement

No If yes, please provide details of the effect upon these requirements

6 Risk to financial and clinical sustainability

Yes Future working arrangements are a key consideration in the financial and clinical

sustainability of the single strategic commissioning organisation and the outgoing

CCGs

Committees in Common Terms of Reference

Remuneration Committee

Authors:

Sam Tilley, Director of Corporate Affairs, Shropshire CCG

Alison Smith, Executive lead, Governance and Engagement, Telford & Wrekin CCG

Executive Summary and Actions Required

1 Shropshire and Telford and Wrekin CCGs are undertaking a range of work in order to establish a single strategic commissioning organisation by April 2020. As part of this work it has been agreed that an early move to a Remuneration Committees in Common would be beneficial in supporting decision making and robust governance to the work programme.

2 To this end this paper sets out the context of adopting a Committees in Common (CiC) approach and attaches a set of Committees in Common Terms of Reference for adoption.

Context

3 The two CCGs have a range of options available to them in making a decisions together;

Joint working group – each CCG would create a joint working group. This group would not have the authority to make decisions directly and so would refer to each CCG governing body for ratification of all decisions.

Delegation to an individual – paragraph 3(3) of Schedule 1A of the NHS Act 2006 permits CCGs to delegate responsibilities to any member or employee. Therefore the CCGs could delegate to a designated qualifying person the function of approving or agreeing decisions on its behalf.

Committees in Common – CCGs are permitted to delegate to a committee or sub-committee of the CCG. If this committee meets at the same time, in the same location as other committees from another CCG it is referred to as committees in common. It is the place and time that meetings are held that is in common, rather than the committees themselves.

The New Model Constitution Guidance (February 2019) stipulates that Remuneration and Audit Committees cannot be held as a joint committee

The following matrix demonstrates the advantages and disadvantages for each model:

Joint working group

Delegation to individual

Committees in Common

Advantages CCGs retain control Allows all parties to hear all view points

CCGs retain control Decision making streamlined – no need to ratify

CCGs retain control Decision making streamlined – no need to ratify Reduces administrative burden Allows fuller discussion and debate but without need to convene full Board composition.

Disadvantages CCGs may make different decisions Lengthens decision making as ratification required

Exposes one individual to criticism Does not allow fuller discussion and debate.

CCGs may make different decisions

Proposal

4 On balance it is proposed that the CCGs adopt a CiC model to make simultaneous resolutions regarding remuneration matters in relation to the transition to a single commissioning organisation. This model allows each CCG to retain control, whilst still managing the risk of either CCG making a different decision to the other. The model also has the advantage of including a mix of committee member’s experience and knowledge, whilst supporting streamlined decision making. It is also more time efficient, which is of particular benefit given the transition timetable.

5 In order for a CiC to operate consistently with the legal framework, several requirements must be met:

Each committee must have its own agenda, although they may be identical.

Each committee must take its own decisions and these must be recorded in its own minutes.

As there is more than one committee, the committees should be referred to as “committees in common” or “committees meeting in common” and not a “committee in common”.

It must be technically possible for each committee in the arrangement to reach a different decision although this will be unlikely.

There must be clear terms of reference for each committee and clear reporting lines back to each CCG.

6 The Governing Body is asked to note that the Remuneration Committee Terms of

Reference forms part of the Constitution for each CCG in line with NHS England Guidance. To make changes to the Remuneration Committee Terms of reference would require an application to NHS England to amend the Constitutions which could be lengthy. It is therefore proposed that a practical approach is adopted that allows a Committees in Common approach to be taken whilst not requiring changes to constitutional arrangements at this time.

7 It is suggested that for committees in common to run smoothly, where possible, each committee needs to have the same agenda. Only one discussion takes place about each agenda item and then each committee makes its own decision. In addition for operational purposes it is recommended that the CiC has a Convenor who acts as an overall chair to ensure the CiC runs as intended.

8 There are some differences between the SCCG and T&WCCG Remuneration Committees Terms of reference that need to be addressed in utilising the CiC approach:

a) Currently Shropshire CCG’s Remuneration Committee has decision making authority delegated from its Governing Body, whereas Telford & Wrekin CCG makes recommendations only to the Governing Body for approval. Shropshire CCG is an outlier in this matter, with most CCGs adopting the same position as T&W CCG. This was highlighted to SCCG by NHSE during a recent refresh of the SCCG Constitution and at this time SCCG agreed to review its Remuneration Committee Terms of reference with a view to bringing them in line with the norm (and NHSE requirements) over the subsequent 12 month period. It is therefore suggested as a result of the future direction of travel and to aid a Committees in Common arrangement in support of the transition, that Shropshire CCG refer any decisions made to its Governing body for approval in the intervening period until one organisation is created.

b) In the matter of Lay Member remuneration again there is difference between the two sets of Terms of Reference. Shropshire CCG enlist different membership (CCG Chair, Secondary Care Doctor and Accountable Officer) to make decisions on Lay Member remuneration, whereas Telford & Wrekin Remuneration Committee defer this to the Governing Body for consideration. It is therefore proposed that this continues to be the case for Telford & Wrekin and that for Shropshire there is an additional item added to the end of the agenda for this purpose, as required, which is attended by the appropriate members and that any decision is then referred to the Governing Body for approval.

9 Venue of meeting – It is proposed that meetings will alternate between a venue in Telford & Wrekin and Shropshire

10 Chairing arrangements – Each committee currently has a Chair. For the purposes of the Remuneration Committees in Common the overall Chair (acting as the Committees in Common Convenor) will be determined by the venue of the meeting. i.e. when a meeting is held in Telford & Wrekin the Chair of the Telford & Wrekin Remuneration Committee will also assume the role of Convenor and vice versa.

11 Membership will remain as set out in each of the CCG’s current Terms of Reference

12 Attached as appendix A is the draft terms of reference for the Committees in Common process. The Governing Body is asked to consider the paper and approve the creation of the Committees in Common process for the Remuneration Committee, noting that no changes have been made to the individual Remuneration Committee Terms of Reference.

Recommendations

The Governing Body is asked to:

Approve the creation of Remuneration Committees in Common between NHS Shropshire CCG and NHS Telford and Wrekin CCG for the purpose of supporting the process and decision making associated with the transition to a single strategic commissioning organisation based on the parameters set out in this paper

Appendix A

Shropshire and Telford & Wrekin Remuneration Committees in Common

Terms of Reference

Committees in Common Framework

CCG Governing Bodies are permitted to create Committees in Common for the purpose of conducting business in common. If this committee meets at the same time, in the same location as other committees (from other CCGs) it is referred to as committees in common. It is the place and time that meetings are held that is in common rather than the committees themselves that makes them common. In order for committee meetings in common to operate consistently with the legal framework, several requirements must be met:

Each committee must have its own terms of reference with clear lines of accountability back to each CCG

Each committee must have its own agenda, although they may be identical

Each committee must take its own decisions and these must be recorded in its own minutes

One set of minutes will be produced by the administrator with separate action logs for each committee

Note that there is more than one committee. The committees should be referred to as “committees in common” or “committees meeting in common” and not “a committee in common”

It must be technically possible for each committee in the arrangement to reach a different decision/ make a different recommendation although the intention is that a consensus would usually be reached

For committees in common to run smoothly, each committee needs to have the same agenda. Only one discussion takes place about each agenda item and then each committee makes its own decision. Each CCG retains individual accountability for any decisions/recommendations/actions taken on behalf of their local population. Establishment of the Committee’s in Common

The Governing Bodies of Shropshire CCG and Telford & Wrekin CCG have agreed to establish a Remuneration Committees in Common. They shall meet together as the Remuneration Committees in Common (RCiC). The RCiC will meet at the same time, at the same table to consider remuneration matters in line with the parameters set out below. 1. The Venue of the meeting will alternate between a location in Shropshire and a location

in Telford & Wrekin

2. Each committee with retain its Chair. However the CiC will have single a Convenor who acts as an overall chair to ensure the CiC runs as intended. The Convenor for the Committees in Common will be the host Chair determined by the location of the meeting

3. Telford & Wrekin Remuneration will make recommendations regarding remuneration matters to its Governance Board. Shropshire remuneration Committee will make descisions in relation to remuneration matters and will refer these to its Governing Body for ratification.

4. In the matter of Lay member remuneration Telford & Wrekin Committee will refer this mater to its Governance Board. Shropshire Remuneration Committee will make decisions regarding lay member remuneration which will be referred to its Governing Body for ratification. These decisions will be reached via a separate agenda item scheduled at the end of the main meeting using separate membership as set out in its Terms of Reference

5. Membership of each committee meeting as a Committees in Common will be as set out in each of the CCG’s Remuneration Committee Terms of Reference below

Telford & Wrekin Remuneration Committee (Operating under a Committees in Common arrangement

with NHS Shropshire CCG)

Terms of Reference

1. Introduction The remuneration committee (the committee) is established in accordance with NHS Telford and Wrekin Clinical Commissioning Group’s Constitution, standing orders and scheme of delegation. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the committee and shall have effect as if incorporated into the clinical commissioning group’s constitution and standing orders.

2. Membership

The committee shall be appointed by the Clinical Commissioning Group from amongst its Governance Board members.

The following are members of the committee:

Chair of the CCG

3 lay members

Only members of the committee have the right to attend committee meetings. Other individuals such as the accountable officer, any HR lead and external advisers may be invited to attend for all or part of any meeting as and when appropriate, however, should not be in attendance for discussions about their own remuneration and terms of service.

The chair will be the Lay Member for Governance. In the event of the chair of the remuneration committee being unable to attend all or part of the meeting, he or she will nominate a replacement from within the membership to deputise for that meeting.

In the event of the Committee not being quorate due to a conflict of interest, the Committee may, in accordance with clause 8.4.10 of the Constitution and in order to ensure that the relevant meeting is quorate, invite an additional and temporary member or members to attend.

3. Secretary Secretarial support for the panel will be provided by the lead human resources officer. Their role will be to support the chair in the management of remuneration business and for drawing the committee’s attention to best practice, national guidance and other relevant documents, as appropriate.

4. Quorum

The committee’s quorum will include 2 of the members listed in section 2 above.

In exceptional circumstances and where agreed with the Chair prior to the meeting, members of the Remuneration Committee may participate in meetings by telephone, by use of video conferencing facilities and/or webcam where such facilities are available. Participation in a meeting in any of these manners shall be deemed to constitute presence in person at the meeting.

5. Frequency and notice of meetings The committee will meet as required, but at least once per year and meetings will be called by the chair of the CCG giving at least 5 working days notice.

Draft minutes will be produced by the minute taker within 10 days of the meeting and circulated to members of the committee for comment within 5 days. The chair will then sign them within 5 days.

Full minutes of the Remuneration Committee will be sent in confidence to members and those in attendance at the Committee.

6. Remit and responsibilities of the committee The committee shall make recommendations to the clinical commissioning group governance board on determinations about pay and remuneration for employees of the clinical commissioning group and people who provide services to the clinical commissioning group and allowances under any pension scheme it might establish as an alternative to the NHS pension scheme.

In addition the following have also been delegated to the committee by the clinical commissioning group governance board:

recommends to the Clinical Commissioning Group Governance Board the financial arrangements for termination of employment, including the terms of any compensation packages and other contractual terms excluding ill health and normal retirement for all employees.

Recommends to the Clinical Commissioning Group Governance Board business cases for staff who wish to retire and then return to employment by the CCG that have been considered and recommended by the Executive team.

recommends to the Clinical Commissioning Group Governance Board the remuneration and conditions of service of the senior team;

reviewing the performance of the Accountable Officer and other senior team members and recommending annual salary awards, if appropriate;

the committee will recommend to the Clinical Commissioning Group Governance Board, the financial arrangements for termination of employment, including the terms of any compensation packages and other contractual terms excluding ill health and normal retirement for all employees;

it will consider the severance payments of the Accountable Officer and other senior staff, and recommend seeking HM Treasury approval as appropriate in accordance with the guidance “Managing Public Money” (HM Treasury.gov.uk);

it will be responsible for identifying and nominating for the approval of the Clinical Commissioning Group Governance Board/or group candidates to fill non-member practice places on the Clinical Commissioning Group Governance Board.

7. Relationship with the Governance Board

The lead human resource officer will prepare reports from the remuneration Committee which will be presented to the Governance Board annually. The reports will include the main items discussed and decisions made by the Committee. The Reports will not include specific detail relating to individuals or the deliberations of the Committee.

8. Policy and best practice

The committee will apply best practice in the decision making processes it will follow, seeking independent advice where required and ensuring that decisions are based upon clear and transparent criteria.

9. Conduct of the committee

The committee is expected to conduct its business in accordance with any national guidance and relevant codes of conduct / good governance practice.

Members of the committee are expected to declare conflicts of interest as set out in the constitution.

Annually the committee will review its own performance, membership and terms of reference. Any resulting changes to the terms of reference should be approved by the CCG Governance Board.

Date to be reviewed: September annually

Governing Body Remuneration Committee

(Operating under a Committees in Common arrangement with NHS Telford & Wrekin CCG)

Terms of Reference

Introduction

1. The Remuneration Committee (The Committee) is established in accordance with the Shropshire Clinical Commissioning Group’s (CCG) Constitution, Standing Orders and Scheme of Delegation. These Terms of Reference (TOR) set out the membership, remit, responsibilities and reporting arrangements of the committee and shall have effect as if incorporated into the CCG’s Constitution and Standing Orders.

Membership

2. The Committee membership shall consist of all the Governing Body Lay Members appointed by the CCG. The Committee shall be chaired by the Lay Member with the lead role in overseeing governance issues; he or she will also chair the Audit Committee.

3. In the event that the Chair cannot attend all or part of the meeting one of the other Lay Members shall act as Chair. All members have voting rights and a proposal shall be carried if there is majority agreement. In the event of a tied vote, the Chair shall have a casting vote.

4. The Accountable Officer shall attend meetings of the Committee in an advisory capacity and be present for all discussions other than those directly involving them. A duly appointed qualified Human Resources (HR) Adviser shall also attend all meetings and shall be present for all discussions.

5. For issues impacting the remuneration of the Accountable Officer they will be absented from that section of the meeting, and any proposals should be presented by the CCG Clinical Chair or CCG Deputy Clinical Chair in the absence of the former.

Secretary

6. Secretarial support shall be provided to support the Chair in the management of the Committee’s business.

Quorum

7. The quorum shall be 2 Lay Members.

Remuneration of Lay Members

8. For any matters regarding the remuneration of Lay Members of the Governing Body the membership of the Committee shall be:

CCG Clinical Chair

Governing Body Secondary Care Member

Accountable Officer

9. If the CCG Clinical Chair cannot attend then the CCG Deputy Clinical Chair shall deputise. The quoracy requirement for meetings held with this membership shall be that at least two members will be present, at least one of whom must be the CCG Clinical Chair or CCG Deputy Clinical Chair.

Frequency of Meetings

10. Meetings shall be held at least once a year and more frequently as required for the effective conduct of business.

Remit and Responsibilities of the Committee

11. The Committee shall make determinations about pay and remuneration for employees of the CCG, people who provide services to the CCG and allowances under any pension scheme it might establish as an alternative to the NHS pension scheme. In doing so the Committee will seek assurance from the Chief Finance Officer or Accountable Officer that decisions made by the Committee take into consideration the financial envelope within which the CCG is managed. This shall include:

a) Determining the remuneration and conditions of service of the Executive team

and any other managerial appointment that is not subject to the Agenda For Change framework.

b) Considering severance payments of the Accountable Officer and other senior staff, seeking HM Treasury approval as appropriate.

Relationship with the Governing Body

12. The Remuneration Committee is a committee of the Governing Body. The Chair shall report to the Governing Body at least annually on the proceedings of the Committee and draw to the attention of the Governing Body any issues that require disclosure or executive action.

13. A summary of each Remuneration Committee meeting and the decisions made, should be presented to the following Governing Body meeting held in public.

Policy and Best Practice

14. The Committee shall apply best practice in conducting its business. For example, the Committee shall:

a) Comply with disclosure requirements for remuneration. b) Where appropriate, seek independent advice about remuneration for individuals. c) Ensure that decisions are based on clear and transparent criteria. d) Act in accordance with national guidelines and relevant codes of conduct and

good governance practice.

15. The Committee shall have full authority to commission any reports or surveys it deems necessary to help it fulfill its remit.

Review

16. The Committee shall review its own performance, membership and Terms of Reference at least annually. Any change shall be ratified by the Governing Body.

1

Agenda item: GB-2019-09.120 Shropshire CCG Governing Body meeting: 10 July 2019

Title of the report:

Report from Audit Committee 28 August 2019

Responsible Director:

Sam Tilley, Director of Corporate Affairs

Author of the report:

Keith Timmis, Lay Member – Audit & Governance

Presenter:

Keith Timmis, Lay Member – Audit & Governance

Purpose of the report: To highlight to the Governing Body key issues arising from the 28 August

2019 Audit Committee meeting and to agree any actions that result.

Key issues or points to note:

1. The Committee received an update on the changes to finance and contract arrangements, in particular as they affect our smaller providers.

2. Internal audit reported on our arrangements for budget setting and concluded there was “moderate” assurance.

3. Progress is being made on improving arrangements for CHC. 4. External audit are completing a review of mental health spending.

Actions required by Governing Body Members:

Note the content of the report.

2

Monitoring form Agenda Item: GB-2019-09.120

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications No If yes, please provide details of additional resources required

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the clinical engagement

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes If yes how will this be mitigated

Urgent action is in progress to improve the operation of contracting and associated financial controls. This is vital to ensure we control our expenditure and report the financial forecast accurately. The Committee will review the situation at its August meeting.

3

NHS Shropshire CCG Audit Committee Report 28 August 2019

Keith Timmis: Lay Member – Audit & Governance Matters arising 1 Progress has been made on all the outstanding actions from previous

Committee meetings.

Governance issues from other sources 2 CHC remains a key issue that is regularly discussed at the Quality and

Finance & Performance Committees.

Contracting and finance arrangements 3 The outstanding dispute with the 2018/19 activity with Betsi Cadwalladr UHB

has been settled and discussions on the contract arrangements for 2019/20 are expected to conclude by the end of September. Improvements to arrangements in the finance and contract teams are underway. The Committee concluded that satisfactory progress has been made so far, but reassurance for the Finance & Performance Committee will come from a review of the operation of the arrangements over the rest of the financial year.

Internal audit 4 We received a follow-up report on the arrangements for reviewing serious

incidents. Progress is being made with a focus on merging approaches with Telford and Wrekin as the two teams come together.

5 CHC progress is being made and the timeline for action is realistic and comprehensive. Recruitment is hoping to cover the current level of vacancies that are occupied by interim staff at present. The Committee was satisfied with the progress to date and the plans for the future. Regular updates will be sent to the Quality and Finance & Performance Committees, so the Audit Committee is happy to wait for the next Internal Audit report.

6 Internal audit presented their report on budget setting. Their overall conclusion is the system has “moderate” assurance.

External audit 7 External audit are currently working on the special review of mental health

expenditure. This is a new review required by Government to demonstrate CCGs are meeting the commitment to increase spending on mental health.

Counter Fraud 8 We received an update on counter fraud work. The annual plan is progressing

as expected. One investigation has been passed to the national team and we asked the counter fraud specialist to ask them to give us updates as their work progresses.

Other matters 9 The Committee also briefly considered what arrangements might apply in

advance of the potential move to a new CCG for Shropshire and Telford & Wrekin.

Next meeting 19 The next Audit Committee meeting is 30 October 2019.

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Agenda item: GB-2019-09.121 Shropshire CCG Governing Body meeting: 11.09.2019

Title of the report:

Healthwatch Shropshire: Highlights May – August 2019

Responsible Director:

Lynn Cawley (Chief Officer)

Author of the report:

Lynn Cawley (Chief Officer)

Presenter:

Lynn Cawley (Chief Officer)

Purpose of the report: The purpose of the report is to update the CCG Governing Body on the activities and impact of Healthwatch Shropshire.

Key issues or points to note: Healthwatch Shropshire remains a four-day service following our budget cut from April 2018. We have now filled all our posts, albeit on reduced hours. The team continues to work to meet all our statutory functions and key priorities for 2019-20. Since we last reported to the SCCG Governing Body we have completed two large pieces of public engagement and published our reports:

Maternity Mental Health – findings to be included in a national report by Healthwatch England

STP Long Term Plan Engagement Report – findings to be included in the ST&W STP Long Term Plan

Our Community Engagement and Communications Officer is working to reach a broader spectrum of the population, including working people and young people up to 25.

Actions required by Governing Body Members: The Governing Body is asked to note the contents of this report.

2

Monitoring form Agenda Item: GB-2019-09.121

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications Yes/No If yes, please provide details of additional resources required

2 Health inequalities Yes/No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements Yes/No If yes, please provide details of the effect upon these requirements

4 Clinical engagement Yes/No If yes, please provide details of the clinical engagement

5 Patient and public engagement Yes/No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes/No If yes how will this be mitigated

1

NHS Shropshire Clinical Commissioning Group

Shropshire CCG Governing Body meeting 11th September 2019

Healthwatch Shropshire: Activities May - August 2019

Lynn Cawley, Chief Officer, Healthwatch Shropshire

Introduction Gathering and understanding people’s experiences of using local services is fundamental to informing the activities of Healthwatch Shropshire (HWS). As well as continuing to deliver on our statutory functions, our priorities for 2019-20 are:

1. Mental health and well-being, e.g. 0-25 services, quality of dementia care in care homes

2. Adult social care, e.g. partnership work around discharge and care at home 3. Primary Care, e.g. access, technology and shared care records, out-of-hours 4. Prevention and Social Prescribing, e.g. community resilience

Our Annual Report for 2018-19 was published in June: http://healthwatchshropshire.co.uk/sites/default/files/hws_trustee_report_financial_statements_ye_310319_signed.pdf Report 1. Intelligence

1.1 Hot Topics

0-25 Emotional Health and Wellbeing Service - This Hot Topic ran October - December 2018. We received 47 comments, the majority of which were overwhelmingly negative. We shared our ‘Spotlight report on Bee-U’ with MPFT and invited them to comment on the report and recommendations. This was received 10th May 2019 and the report published on our website. MPFT have asked us to repeat this piece of work next year.

January – July 2019 our Hot Topics were replaced by focused calls for comments regarding the projects being undertaken at the request of Healthwatch England on maternity mental health and the NHS Long Term Plan.

End of Life / Palliative Care – This Hot Topic is running from August to the end of September. HWS had already considered the value of this being the subject of a Hot Topic in order to find out more about people’s experiences of end of life and palliative care services. When approached by the CCG to ask if we could help to gather feedback from people about their experience of palliative care following a change of out-of-hours provision it was agreed that a Hot Topic would be a softer approaching to gathering this feedback than a targeted questionnaire. We are due to share our initial feedback with SCHT week beginning 16th September. We will publish a Spotlight report in due course highlighting our findings and this will be shared with the relevant working groups of the Sustainability and Transformation Partnership (STP).

2

Mid-September – November 2019 the focus of the Hot Topic is expected to be access to appointments, in particular primary care appointments.

1.2 Maternity Mental Health (Peri-natal Mental Health) Following our Hot Topic on Peri-natal Mental Health in September 2018, we were selected by Healthwatch England as one of five local Healthwatch to conduct wider engagement to inform their national report on Maternity Mental Health. This project was undertaken January – March 2019 and our report was published 24th June 2019. Our findings were shared with the Local Maternity System and Healthwatch Telford & Wrekin were asked to complete a similar piece of work. Healthwatch England’s report is currently being drafted and is expected to be published August / September 2019. http://healthwatchshropshire.co.uk/sites/default/files/uploads/Healthwatch_Shropshire_Report_Maternity_Mental_Health_2019.pdf 1.3 STP Long Term Plan Following the publication of the NHS Long Term Plan in January 2019, NHS England asked all local Healthwatch to give people the opportunity to have their say on how the national plan should be delivered locally. HWS were the coordinating Healthwatch working with Healthwatch Telford and Wrekin across the Shropshire, Telford & Wrekin Sustainability and Transformation Partnership footprint to complete a range of public engagement activities between March and May 2019. In total, we heard 641 views (376 in Shropshire, 265 in Telford & Wrekin). Our report was published 15th July 2019 and we are continuing to highlight our findings and recommendations at meetings across the STP regarding the local long-term plan. http://healthwatchshropshire.co.uk/sites/default/files/uploads/HWS,HWT&W_What_would_you_do_report.pdf 2 Communications and engagement 2.1 Update on engagement activities Since Jayne Morris, our Community Engagement and Communications Officer (CECO) took up the post on 11th December following a period without an Engagement Officer we have seen a steady increase in engagement activities.

3

As well as promoting and conducting engagement around the current Hot Topic, the CECO is building links with:

Local industry to help us to reach working people

Mental health services, including MPFT and Shropshire Council, to help us reach those people with experiences of using a range of mental health services

Education (secondary schools, colleges and the University Centre) to reach young people so we can find out their views on health and well-being provision

2.2 HWS previously reported that we had been commissioned by Healthy Lives to undertake a piece of engagement to explore the barriers people might face to engaging with Social Prescribing. This report was published in March 2019. Shropshire Council’s Healthy Lives have shared the report and our findings at a regional and national level with the Social Prescribing National Network and NHS England to be added to their websites.

http://healthwatchshropshire.co.uk/sites/default/files/hws_report_for_sp-_exploring_barriers_280319_v3.pdf 2.3 Our work on the STP Long Term Plan is ongoing as we continue to attend a range of meetings across the STP to highlight the importance of public engagement and reiterate our findings from our engagement on the STP Long Term Plan. We continue to support the work of Care Closer to Home and are members of the STP Communications and Engagement work stream where we presented the findings of our Long Term Plan engagement on 3rd July 2019. To-date we have been invited to attend meetings regarding:

The All-age Mental Health Strategy

The Learning Disability and Autism Strategy

The Primary Care Strategy

The Hospital Transformation Plan (Future-Fit)

A&E Delivery Board (on-going) 2.4 HWS continue to be involved in the Maternity Voices Partnership (MVP) and Local Maternity System (LMS) and Midwife Led Unit Review (Transforming Midwifery Care) Programme Boards and have shared our Maternity Mental Health report with all organisations involved. The CECO is attending a Public Health Conference 12th September with a focus on Maternity Mental Health to present our findings more widely. We have attended workshops around the MLU Review and been invited to feedback on the consultation document when it has been drafted. We have offered to support this consultation to give the public an opportunity to share their thoughts with an independent organisation in the same way we did during Future Fit. 3 Enter & View

3.1 Staffing and capacity Alli Sangster-Wall joined us as the new Enter & View Officer and IHCAS Coordinator 1st May 2019.

4

Since January 2019 HWS has had 14 enquiries from potential volunteers. To date one of these has completed their Enter & View training. We are continuing to meet with all applicants and arrange their induction / training as soon as possible. We currently have 10 Enter & View Authorised Representatives (ARs - volunteers who have been trained and DBS checked). Visits are conducted by teams of 2-3 ARs and the frequency of visits depends on the availability of ARs to form a team. 3.2 Visits and reports We have completed a programme of visits to eight care homes across the county that are registered with the CQC as providing some level of dementia care. As well as gathering feedback from residents and their visitors, we spoke to staff to learn more about the care they provide and looked at how ‘Dementia Friendly’ the environment was. We also selected homes that have achieved the ‘Gold Standard Framework for End of Life care’ to try and understand what this means for residents and their families. The individual reports for all homes visited have been published:

Churchill House Nursing and Residential Home

Danesford Grange Care Home

Four Rivers Nursing Home

Coton Hill House

Hinstock Manor Residential Care Home

Stretton Hall Nursing Home

Alexandra House

The Uplands at Oxon We are planning to publish a summary report of our findings from these visits in September 2019. All published Enter & View Reports are available on our website at: http://www.healthwatchshropshire.co.uk/enter-view-reports-0

5 You Said We Did We have not published a ‘You Said We Did’ during this period. We have been exploring a number of issues and raised several questions formally, but there has not been an outcome we have been in a position to report. The pieces of work we have completed and the reports published demonstrate our activity. We are assured by the responses received to our findings and recommendations that these will be taken into account during the planning, design and development of a range of services including Social Prescribing, Perinatal Mental Health, the 0-25 Emotional Health and Well-being Service and the STP Long Term Plan. Summary and Conclusion HWS remains a four-day service and now has a full staff team. We continue to undertake our statutory activities, address our key priorities and raise the profile of HWS. Recommendations The Governing Body is asked to note the contents of this report.

1

Agenda item: GB-2019.09.122 CCG Governing Body: 11.09.19

Title of the report:

Shropshire CCG Improvement and Assessment Framework

Results 2018/19

Responsible Director:

David Stout – Accountable Officer

Author of the report:

Sam Tilley – Director of Corporate Affairs

Presenter:

Julian Povey – CCG Chair

Purpose of the report: To update the Governing Body on the outcome of the CCG’s annual Improvement and

Assessment Framework results for 2018/18

Key issues or points to note: In July 2019 the CCG received its annual Improvement and Assessment Framework outcome

letters from NHS England for the 2018/19 period. This included a separate assessment

outcome relating to Patient and Public Participation in Commissioning Health and Care.

These letters are attached for information. However, the results are recorded as follows:

Overall assessment rating – Inadequate (downgraded from Requires Improvement in

2017/18)

Patient and Public Participation in Commissioning Health and Care rating – Green

(upgraded from amber in 2017/18)

The Governing body is asked to note the results of the assessments and to discuss any

relevant actions required.

Actions required by Governing Body Members:

The Governing Body is asked to:

The Governing body is asked to note the results of the assessments and to discuss any

relevant actions required

2

Monitoring form Agenda Item: GB-2019.09.122

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications No If yes, please provide details of the effect upon these requirements

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the effect upon these requirements

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability No If yes how will this be mitigated

Publishing Approval Reference 000697

Dear Accountable Officer

Compliance with statutory guidance on patient and public participation in commissioning health and care: the CCG Improvement and Assessment Framework (IAF) Patient and Community Engagement Indicator

As you will know, under the National Health Service Act 2006 (as amended by the Health and Social Care Act 2012), CCGs have a statutory duty to involve the public in commissioning (section 14Z2). In addition to meeting statutory responsibilities, effective patient and public participation helps CCGs to commission services that meet the needs of local communities and tackle health inequalities. NHS England has a legal duty (section 14Z16) to assess how well each CCG has discharged its public involvement duty (section 14Z2), as well as a commitment to supporting continuous improvement in public participation. A robust, and improvement focused, process of national assessment has been now been carried out for 2018/19 to reach final RAGG* ratings and scores for individual CCGs. I am writing to inform you that the final RAGG* rating and score for 2018/19 for your CCG following the national assessment and moderation process are as follows:

NHS Shropshire CCG

Domain A Domain B Domain C Domain D Domain E Final Score

Final RAGG*

3 1 3 3 2 12 GREEN

If you are the Chief Officer of more than one CCG you will receive a separate email notifying you of the assessment outcome for each relevant CCG. Please see section 3.4 of the Guidance for CCGs for information about the scoring approach for the indicator. All RAGG* ratings and scores are final and will be published

Public Participation Team

Experience, Participation and Equalities

Directorate of Nursing

NHS England and NHS Improvement

Quarry House Quarry Hill

Leeds LS2 7UE

Telephone: 0113 825 0861

Email address: [email protected]

Date

as part of the Q4 2018/19 CCG Improvement and Assessment Framework Dashboard and on the MyNHS site.

Supporting improvement We know that CCGs are keen to continue their improvement journeys. To support this, we have gathered many examples of excellent practice and will share these with CCGs and other system partners over the course of the year. The process has highlighted just how much work has been happening across the country to develop even better approaches to engaging with people and communities, and this is something we want to support people to share and learn from. Over the coming months we will:

- send each CCG a detailed assessment summary, focusing on those criteria that were identified as requiring improvement following 2018/19 assessments, to guide your improvement work;

- share the many examples of good practice identified as part of the 2018/19 assessments as well as signposting CCGs to other resources;

- organise a series of webinars focusing on domains which scored least highly in 2018/19 assessments, co-delivered by CCGs who are doing well in these areas;

- offer each CCG that has rated Amber in 2018/19 a one to one improvement and support session (either by telephone, webinar or in person);

- work with our regional NHS England and Improvement colleagues on activities to further support improvement.

We would be grateful if you could share this letter with relevant colleagues in your CCG, including engagement, participation and communications teams, your PPI Lay Member and, where appropriate, with your CSU. If you have any queries please contact my team at [email protected] Yours sincerely

Olivia Butterworth Head of Public Participation Experience, Participation and Equalities, Directorate of Nursing NHS England and Improvement

NHS England and NHS Improvement

David Stout Accountable Officer Shropshire CCG William Farr House Site Mytton Oak Road Shrewsbury SY3 8XL

Dear David, Re: 2018/19 CCG annual assessments

The CCG annual assessment for 2018/19 provides each CCG with a headline

assessment against the indicators in the CCG Improvement and Assessment

Framework (CCG IAF). The headline assessments have been confirmed by NHS

England’s Statutory Committee.

This letter provides your annual assessment, as well as a summary of any areas of

strength and where improvement is needed as discussed at our year-end review

(Annex A).

Detail of the methodology used to reach the overall assessment for 2018/19 can be

found at Annex B. The categorisation of the headline rating is either Outstanding,

Good, Requires Improvement or Inadequate.

The 2018/19 headline rating for Shropshire CCG is Inadequate

Fran Steele Director of Strategic Transformation

North Midlands locality Cardinal Square

10 Nottingham Road Derby

DE1 3QT

T: 0300 123 2620 E: [email protected]

W: www.england.nhs.uk and www.improvement.nhs.uk

9th July 2019

All CCGs assessed as inadequate at year-end will be subject NHS England’s special

measures regime, the Directions currently in place for your CCG will remain in

conjunction with special measures. I will write separately about the requirements that

will be underpinned by the special measures regime.

The 2018/19 annual assessments will be published on the Commissioning Regulation

pages of the NHS England website in July. At the same time they will be published on

the MyNHS section of the NHS Choices website. The Q4 IAF dashboard will be issued

with year- end ratings in July.

Although the 2019 IAF assessment will be a transitional year for oversight

arrangements, the CCG annual assessment process remains a familiar one. I look

forward to working with you and continuing to support your CCG in improving

healthcare for your local population and system.

I would ask that you please treat your headline rating in confidence until NHS

England has published the annual assessment report on its website. This rating

remains draft until formal release. Please let me know if there is anything in this letter

that you would like to follow up on.

Yours sincerely

Fran Steele

Director of Strategic Transformation, North Midlands locality

NHS England and NHS Improvement

Annex A – 2018/19 Summary Shropshire CCG - IAF Review

Key Areas of Strength / Areas of Good Practice NHS England (NHSE) acknowledges the overall progress the CCG has made towards

improving RTT waiting list position and reduction of RTT long waiters. However,

overall RTT performance has slightly deteriorated recently with this being driven by

winter pressures and an overall beds deficit at SaTH.

Whilst there has been no deterioration in the CCG mental health performance

standards there remains concern around the achievement of the IAPT access

standard, the delays in progressing the revised service model and the funding of the

provision.

Given the context of rising demand and greater than planned increase in non-elective

activity throughout winter it is important to acknowledge the specific achievement of

the CCG and its partners around the maintained improvement in the standard for

reducing delayed transfer of care (DToC), and the associated matrix of stranded and

super stranded patients.

The CCG has unfortunately failed to fully implement a number of its QiPP schemes

and it has been subject to a significant number of in year cost pressures, in particular

for CHC. This has resulted in the CCG failing to deliver its deficit control total by

approximately £5 million.

The CCG has set out and demonstrated the progress that has been made during

2018/19 across a range of initiatives including further development and refinement of

its Out of Hospital model of care. This latter programme being a key building block

toward the delivery of a new model of care to support Future Fit and the development

of place-based commissioning.

NHSE note the decision of the Future Fit Joint Committee to support the proposal to commission a new clinical model of acute care and acknowledge the work and role of the CCG in reaching this position. Key Areas of Challenge The CCG is facing a significant financial challenge, to manage this it will be required

to review its approach to contracting and service provision. It has identified several

key areas that provide saving efficiencies / opportunities over the medium term,

however, the CCG will need to work collaboratively across a number of approaches

including risk share, reward share agreements, and shared saving opportunities.

Considering the wider Better Care indicators and acknowledging the complexity of the

reporting lag often associated with these, it is recognised that the CCG are managing

to meet the performance standards for several areas with the trend for six of these

indicators on a downward trajectory. Within our review you referred to a number of

programmes of work being undertaken in partnership with external partners to improve

these indicators.

During 2018/19 the CCG has continued to work to improve its performance for its

Better Care indicators, and in particular those where a joint approach with Telford &

Wrekin CCG or through a partnership structure has been beneficial.

Performance against the key indicator of A&E (4hr standard) remains a significant

challenge for the CCG and its delivery partners. It is important that NHSE continues

to raise its concerns around the lack of a single prioritised system plan for the local

health economy that is supported by robust arrangements to ensure its delivery. It is

recognised that because of the various support offers and through Regional

escalation, there are multiple recommendations / actions which are currently

competing with each other. Looking forward, NHSE is keen to clarify the internal and

external actions that the system will take to ensure a demonstrable improvement in

this standard for 2019/20.

Key area of improvement - 2019/20

In reviewing its 2019/20 QIPP programme, the CCG should:

• Engage its Right Care Delivery Partner to maximise the opportunities identified through the data led system opportunity analysis work

• Continue to collaborate and align its transformational commissioning programmes with Telford & Wrekin CCG

• Continue to progress its more strategic approach to commissioning, generating clear timescales and accountability frameworks to ensure robust delivery of its planning assumptions.

A number of commissioning programme areas need to extend their planning horizon and would benefit from a long term ‘road map’ that describes how they will move from the current operational / tactical approaches, to delivery of the CCG longer term model of care and support any changes in commissioning and provider architecture, aligned to the local delivery of the NHS long term plan.

Whilst good progress is being made in it’s proposed out of hospital model of care, this programme needs to be progressed as quickly as is practical to ensure its clinical model and assumption align to Future Fit.

Development Needs and Agreed Actions The Shropshire & Telford and Wrekin STP is at a crucial junction, as it moves from a single set of organisations working within a common geography to a single system with a common approach to its commissioning of services that meet the needs of the local population. The CCG must continue to develop its role and influence in informing and shaping the formation of a strategic commissioning function and associate Integrated Care system (ICS). The CCG needs to continue to support the clinical leaders in the STP/ local health economy to ensure quality and safety is considered throughout the STP work streams.

The CCG and its partners need to accelerate the work to refine its new models of care and their introduction, to support the establishment of clinical and financial sustainable provision that capitalise on the opportunities within primary care and is aligned to the STP.

Agreed actions

1. The CCG must continue to improve the level of achievement for its constitutional standards and rigorously manage the performance of all its providers throughout 2019/20.

2. Working through the A&E Delivery Board and its subgroups focus on working to improve the performance standards for urgent care including A&E 4 hr standard and ambulance handovers.

3. To continue to strengthen QiPP delivery and assurance processes ensuring

delivery in 2019/20.

4. To continue to review and monitor the service provision for its new commissioned OOH service, dementia pathway and CYP (0-25years) Mental Health service to ensure that any risks are identified, appropriately managed, mitigated and reported.

5. To consider setting a number of interim measures to provide assurance that

demonstrable improvements are taking place for its priority Better Care indicators.

6. To fully contribute to the programmes of work that will lead to the establishment

of a new strategic commissioning function and ICS.

7. Urgent care and winter planning - actions to be agree following the winter review

Conditions/Directions/Special Measures

• To provide a completed capacity & capability review and resulting action plan

• Notify board of any exec and next tier appointments

• To develop a commissioning Strategy, medium-term financial and organisational development plan in line with CCG Merger application timescales.

Annex B – Overall assessment methodology

NHS England’s annual performance assessment of CCGs 2018/19 1. The CCG IAF comprises 58 indicators selected to track and assess variation

across policy areas covering performance, delivery, outcomes, finance and leadership. Assessments have been derived using an algorithmic approach informed by statistical best practice; NHS England’s executives have applied operational judgement to determine the thresholds that place CCGs into one of four overall performance categories.

Step 1: indicator selection

2. A number of the indicators were included in the 2018/19 IAF on the basis that they were of high policy importance, but with a recognition that further development of data flows and indicator methodologies may be required during the year. By the end of the year, there were three indicators that were excluded as there was no data available for the measures: Percentage of deaths with three or more emergency admissions in last three months of life, Cardiometabolic assessment in mental health environments and Children and young people’s mental health services transformation.

Step 2: indicator banding

3. For each CCG, the remaining indicator values are calculated. For each indicator, the distance from a set point is calculated. This set point is either a national standard, where one exists for the indicator (for example in the NHS Constitution); or, where there is no standard, typically the CCG’s value is compared to the national average value.

4. Indicator values are converted to standardised scores (‘z-scores’), which allows

us to assess each CCG’s deviation from expected values on a common basis. CCGs with outlying values (good and bad) can then be identified in a consistent way. This method is widely accepted as best practice in the derivation of assessment ratings, and is adopted elsewhere in NHS England and by the CQC, among others. 1

5. Each indicator value for each CCG is assigned to a band, typically three bands

of 0 (worst), 2 (best) or 1 (in between).2

Step 3: weighting

6. Application of weightings allows the relatively greater importance of certain components (i.e. indicators) of the IAF to be recognised and for them to be given greater prominence in the rating calculation.

1 Spiegelhalter et al. (2012) Statistical Methods for healthcare regulation: rating, screening and surveillance 2 For a small number of indicators, more than 3 score levels are available, for example, the leadership indicator has four bands of assessment.

7. Weightings have been determined by NHS England, in consultation with operational and finance leads from across the organisation, and signal the significance we place on good leadership and financial management to the commissioner system:

• Performance and outcomes measures: 50%;

• Quality of leadership: 25%; and,

• Finance management: 25% 8. These weightings are applied to the individual indicator bandings for each CCG

to derive an overall weighted average score (out of 2).

Step 4: setting of rating thresholds

9. Each CCG’s weighted score out of 2 is plotted in ascending order to show the relative distribution across CCGs. Scoring thresholds can then be set in order to assign CCGs to one of the four overall assessment categories.

10. If a CCG is performing relatively well overall, their weighted score would be

expected to be greater than 1. If every indicator value for every CCG were within a mid-range of values, not significantly different from its set reference point, each indicator for that CCG would be scored as 1, resulting in an average (mean) weighted score of 1. This therefore represents an intuitive point around which to draw the line between ‘good’ and ‘requires improvement’.

11. In examining the 2018/19 scoring distribution, there was a natural break at 1.45,

and a perceptible change in the slope of the scores above this point. This therefore had face validity as a threshold and was selected as the break point between ‘good’ and ‘outstanding’.

12. NHS England’s executives have then applied operational judgement to determine the thresholds that place CCGs into the ‘inadequate’. A CCG is rated as ‘inadequate’ if it has been rated red in both quality of leadership and financial management.

13. This model is also shown visually below:

Figure 1: Worked example

Anytown CCG has:

- Quality of leadership rating of “Green” (equivalent to a banded score of 1.33) - Finance management rating of “Green” (equivalent to banded score of 2) - For the remaining 53 indicators, the total score is 49.5. - These scores are divided through by their denominator and weighted to

produce an overall domain weighted score:

(1.33

1) × 25% + (

2

1) × 25% + (

49.5

53) × 50% = 𝟏. 𝟑

1

Agenda item: GB-2019-09.123

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

Clinical Commissioning Committee

Date of Meeting:

11 and 19 June 2019

Chair:

Sarah Porter Lay Member

Key issues or points to note:

Care Closer to Home: Approved concepts of Phase 3 Models of Care to enable Programme

Team to undertake a robust 3 month Impact Assessment

SEND: Agreed for a draft refreshed strategy to be produced

Transforming Midwifery Care: Following discussion around Option Appraisals approved the

process of taking forward to both Governing Bodies the Programme Board’s recommendations

for proposed maternity hub locations and timeline for next steps

Actions required by Governing Body Members:

For information.

MINUTES OF SHROPSHIRE CLINICAL COMMISSIONING COMMITTEE (CCC) MEETING HELD

IN ROOM K2 AT 9.00AM ON WEDNESDAY 19 JUNE 2019

Present: Mrs Sarah Porter (Chair) Lay Member for Transformation Mrs Claire Skidmore Chief Finance Officer, Deputy Accountable Officer Dr Deborah Shepherd Shrewsbury & Atcham Locality Chair Dr John Pepper GP Board Member Mrs Chris Morris Director of Nursing & Quality Dr Katy Lewis North Locality Chair Dr Alan Leaman Secondary Care Consultant Dr Matthew Bird South Locality Chair Dr Jessica Sokolov Medical Director Mr Meredith Vivian Lay Member for Patient & Public Involvement Mrs Lisa Wicks Deputy Director of Performance and Delivery Mrs Elizabeth Walker Head of Medicines Management Mrs T Attfield Personal Assistant (Minute taker) In Attendance: Mr Barrie Reis-Seymour (Agenda item 19/6/061 – Shropshire Care Closer to Home) (Agenda item 19/6/065) – Community Equipment Specification) Mrs Hazel Malcolm (Agenda item 19/6/062 – SEND Update) (Agenda item 19/6/063 – Severndale Update) Mrs Cathy Davis (Agenda item 19/6/064 – 0-25 Action Plan Closure/Lessons Learnt) (Agenda item 19/6/066 – AHD Adults across Shropshire/T&W) Mrs Michele Rowland-Jones (Agenda item 19/6/067 – Treatment pathway for Plaque Psoriasis) (Agenda item 19/6/068 – Medicines Management Policy Reviews) Mrs Fiona Ellis (Agenda item 19/6/070) – Transforming Midwifery Care in Shropshire, Telford and Wrekin: Options Appraisal Report) Apologies: Mr David Stout Accountable Officer Dr Julie Davies Director of Performance & Delivery Mr Kevin Morris GP Practice Manager Board Representative Mrs Nicky Wilde Director of Primary Care Dr Finola Lynch GP Board Member Dr Priya George GP Board Member Dr Julian Povey CCG Chair Mrs Gail Fortes-Mayer Director of Contracting & Planning CCC-19/6/058 Apologies 1.0 Apologies were noted as above. CCC-19/6/059 Members’ Declarations of Interest 2.0 Mrs Porter requested that attendees declared any potential conflicts of interest regarding the

Committee Agenda. There were no declarations.

CCC-19/6/060 Minutes/Actions of Previous Meeting 15.05.19 & Matters Arising 3.0 The minutes of the previous meeting were discussed and agreed as a true record with the

exception of the following points:

Paragraph 4.3 – Mrs Skidmore advised that the sentence containing “Mr Reis-Seymour advised that the IT Risk Stratification would be presented to Audit … should read “the Risk Stratification Policy would be presented to the Audit Committee. Dr Pepper advised that in paragraph 8.3. the first sentence should read differently with reference to the level of assurance that all health checks had been made. Dr Pepper agreed to send wording to amend within the May minutes.

3.1 The CCC Action Tracker was discussed and updated as appropriate.

Agenda Item – GB-2019-09.123 CCG Governing Body – 11.09.19

Matters Arising - CCC Working Group Update

3.2 Ms Wicks highlighted key points discussed at the CCC Working Group on 11 June:

Audiology –The specification was discussed and would be presented to the CCC in July.

Back Pain Pathway – Pathway required minor changes and would then be presented to the CCC in July

Respect - Discussions were held around the implications but the steer from the group was to push this forward. It was agreed that this initiative needed to be project managed by the STP Programme Office and a recommendation was made by the Working Group to recruit a Project Manager. Paper will now be amended and ready for July CCC. Following discussions with regard to the timeline it was agreed that this needed to be taken to Governing Body in July as an information paper and then also to CCC in July.

Oak House – Closing 30 June – Telford patients had already been assessed and moved. Shropshire patients had been assessed with the majority going to Condover. Finances were just being finalised/agreeing spilt with Local Authority. Final paper would be presented to Execs next week around any financial risks. Discussions were held around patients being transferred and whether they would be receiving like for like provision of care. Following discussion it was agreed that the committee required assurance on how the needs of the patients will be met and it was agreed that a paper would be brought back to CCC.

SOOS Referral Form – presented for sign off and was agreed so would now be brought to CCC.

Headache Pathway – discussions held and was agreed to go back through Working Group before bringing to CCC.

ACTION: Back Pain Pathway paper to be brought to July CCC

Respect Paper to be brought to July CCC ACTION: It was agreed that additional paper around provision resulting from the closure of Oak House would be brought back to CCC to offer the committee assurance

CCC-19/6/061 Shropshire Care Closer to Home Update 4.0 Ms Wicks gave a verbal update with regard to the Shropshire Care Closer to Home

Demonstrator Sites and advised that were currently in week three of “going live” in all 8 sites and informed that these were around case management and risk stratification.

4.1 Mr Reis-Seymour highlighted that the MDTs had been put in place and informed that case

management teams were made up of Shropshire Council, Community Trust and MPFT and were pulling in the support of the voluntary care sector when required. Positive feedback had been received from most GP Practices and he said that teams were motivated about collaborative working. The team were currently finalising a GP myth busting email that would be circulated this week to ensure clarity around the operational process.

4.2 Challenges around IT and data issues had meant that the electronic Risk Stratification

process had been unable to run until 30 June which had delayed the full risk stratification of patient lists which meant that teams were currently manually working with existing caseloads of patients. Mr Reis-Seymour commented that the main learning coming out was that the Community Trust did not seem to be able properly staff the signed off version of the model and felt that they were only delivering around 70% of the developed model. The Community Trust were intending to recruit a central co-ordinator/case manager but were presently using Community Matrons. This generated a risk as they would be compromising their clinical responsibilities and it had been identified as a broad workforce issue and would be escalated to the Programme Board to discuss the way forward and then to the Strategic Leadership group if it was felt necessary

ACTION: A risk was noted around the Community Trust managing the signed off

version and that it had been identified as a workforce issue that was being escalated to the Programme Board and then the Strategic Leadership group if then felt necessary

4.3 Discussion took place around system readiness to implement the model, and work to

understand this further is ongoing. 4.4 Robust evaluation criteria had been agreed and evaluation of the data would start at the end

of December over a 3 month period, which would look at the activity and performance impact, taking into account all differential factors of all practices, and adding softer intelligence through patient experience of the service.

4.5 Mr Vivien asked as well as collecting patient experience through the demonstrator sites if

there would be any other patient experience controlled measure within the other sites. It was agreed that this was an important element and was required for comparison and Mr Reis-Seymour agreed to collect data using the same metrics.

ACTION: Mr Reis-Seymour agreed to collect other patient experience from additional

sites using the same metrics as the demonstrator sites. CCC-19/6/062 SEND Update 5.0 Mrs Hazel Malcolm presented an update on the implementation of SEND and advised that

the paper highlighted progress made over the last quarter and asked members to approve the recommendations in preparation for a potential Ofsted/CQC inspection in the Autumn Term 2019.

5.1 Mrs Malcolm advised that there were approx. 6,500 pupils within the County with special

educational needs and of those only 1,500 actually had an educational and healthcare plan. The last quarter had shown some improvements i.e. started to progress joint commissioning process and the framework and statement had been agreed at the SEND Board last week. Key achievements during the first quarter where noted.

Mrs Malcolm highlighted the areas identified that required further development – action plan been produced around key areas:

performance data

CaMHS – parents concerned around waiting times – provided assurance that Steve Trenchard is leading across organisation to look at transformation plan and how SEND is embedded into the CAMHS transformation plan.

Personal budgets – working with LA to clarify how will manage personal budgets going forward.

5.2 Following discussions it was noted that within the Action Plan there were 9 areas rated red

but it was hoped before the inspection took place that number would be improved and moved from up red. Dr Lewis said that on the action plan there are a few areas in red that had no progress/update against them. Mrs Malcolm noted that these areas needed to have clear action against them.

5.3 It was agreed that the draft refreshed strategy would be brought to CCC in September

before going out to public consultation. Committee members noted and approved recommendations Action: Refreshed strategy to be brought back to the September CCC meeting CCC-19/6/063 Severndale Update 6.0 Mrs Malcolm gave a brief update of the current situation of the nursing provision at

Severndale Academy and highlighted the work undertaken with the Local Authority and Shropshire Community Health Trust to clarify the provision of health services to children and young people at Severndate Academy

6.1 It was noted that potentially children were not accessing school because the healthcare

provision was not on site for them to attend so one of the objectives had been to get to a better place by September. The revised model outlined what the healthcare provision should be and how this would be delivered to enable the children to access school. Various meetings had taken place with both the school and the wider group of stakeholders to develop an action plan and the outcome was that there was now commitment from the school to train TAs as this would relieve some of the work pressures on the community nursing team. There was also commitment to continue to work closely with parents. The three cases of children with continuing healthcare that also have educational healthcare plans will be reviewed to ensure that there is clarification across all partners.

6.2. Dr Sokolov informed that when the paper was brought previously to CCC there had been

concern that because of the nervousness of Severndale around training their staff, children were being prevented from attending school, and asked if the CCG were now confident that this had been dealt with and that there were now no health barriers to children attending Severndale. Mrs Malcolm advised that the Head still had a few anxieties but had agreed to carry out review on the 3 children and the Provider had sent them a draft training plan and that they would also be monitoring the competencies of the TAs.

6.3 Dr Sokolov said that in terms of monitoring the development of the training programme in

ensuring that those children can attend school, an update should be presented to Quality to keep sight of any risks. It was agreed that a paper should be taken to Quality around October/November time. Action: paper around monitoring the development of the training programme to be taken through Quality Committee to mitigate any risks in October/November

CCC-19/6/064 0-25 Action Plan Closure and Lessons Learnt 7.0 Mrs Davis advised that the presented report provided an overview of the work that had been

completed as part of the 0-25 year Health and Emotional Wellbeing BeeU service action plan and that it made a number of recommendations regarding the next steps to follow the action plan to continue to develop the 0-25 service offer to CYP.

7.1 Key points to note were:

Addressing the use of medication for CYP and the relevant health checks

Establishing a Stepped Care delivery model and an operating framework that used the principles of THRIVE.

7.2 Mrs Davis summarised that the original service specification had been very ambitious

around the KPIs and management and had been a clear model/way to deliver the service. The service was now at a point of having a clear model and was developing a way to clearly manage this and was also working on communications to ensure that all stakeholders understood the new model going forward. There were now only a couple of areas around the delivery of service that requires addressing –

Neuro developmental pathway

Re-write the contract/specifications to ensure underpinning management in place 7.3 Ms Wicks asked to ensure that the numbers and data were correct under Learning Lessons

Recommendation 12.9 - “move quickly regarding ASD waiting times” as she thought numbers for Shropshire seemed low. Mrs Davis informed members of the difficulty she had experienced in obtaining prevalence but said that she thought numbers were correct and were split proportionally as you would expect but said that the other concern was that ASD often had features that looked like attachment disorder and for parents was a very hard concept to grasp, so was now working at looking at this in schools as how to reframe this, so had to consider this in wider cohort for attachment disorder to ensure flowed through correctly. Members expressed concern and said need to change recommendation around waiting times as needed to capture wider areas as stated.

7.4 It was noted that the within the recommendation the Committee had been asked to note the

recommendations but Mrs Davis confirmed that the Committee were asked to sign off/support the development.

It was noted that one of the recommendations was to support fully the implementation of the recommendation from the Leaning Lessons event but members expressed that they still had concerns as a committee. Mrs Davis asked if she changed recommendation to say” The key recommendation is to continue the work to ensure the BeeU service transformation continues and the neuro-developmental pathways are addressed, including assuring that the data and management of the service is addressed”, if this would ease concerns. Dr Pepper said yes but would also need to include that the service was developed with a plan of catch up for those that are waiting. Members agreed.

Following discussions it was agreed that Mrs Davis would amend recommendations and re-submit to members before approval.

It was also noted that members would support on the basis that this would be within existing resources and this should be outlined within the paper.

ACTION: Mrs Davis to amend paper/recommendations incorporating all comments and re-submit to members for approval

CCC-19/6/065 Community Equipment Specification 8.0 Mr Reis-Seymour advised that the service specification had been approved in principle in

March by the Committee pending confirmation of the agreed KPI’s and reporting requirements that underpinned the service.

8.1 The Commissioning team had now developed a more comprehensive list of reporting

requirements but the contract developed currently had only the 3 standard reporting lines with the aspiration of moving towards a more enhanced level of reporting during the year ahead. The Committee were asked to note the background to the Community Equipment Service and standard lines of reporting and agree to the proposed enhanced levels soft reporting to work towards during 2019/20.

8.2 Mrs Porter asked about timescales. Ms Wicks advised that the Community Trust were going

to give access to their data warehouse and explained that once had access they should be able to draw down the required data but concern was expressed that currently still did not have access so timescale was dependent on obtaining the information. Mrs Skidmore said that when started to work on contracting round for next year would take into account, based on early evidence, whether need to serve notice and would need to keep this and would then be in a position to escalate if not they were not forthcoming with the data.

8.3 Dr Shepherd expressed concern over only having the 3 indicators and asked why the CCG

were being granted access and asked why the Community Trust would not be providing the CCG with the data not just granted access for us to extract it as it was already delayed. Ms Wicks advised that through the contract they had had to complete a freedom of information request and then still did not obtain data as they did not physically have the system at that time to be able to report the data. It was stated that there was a need to go through the process to reach a point going forward whether to hold to account or go out to procurement.

8.4 Dr Leaman asked if it could be noted that in the new contract a better service was required

which included operating on a Saturday morning. Mrs Skidmore advised that this could be passed on through the commissioning intentions process for consideration. Members asked if the Committee could feed in requests to the commissioning process. Mrs Skidmore to task Dr Davies with determining the process by which both the CCC and Governing Body can feed into the commissioning intentions list for 2020/21.

Action: Ms Wicks to pass on comments/requests through the commissioning intentions process for the new contract next year. Action: Mrs Skidmore to take paper to Executive Team with regard to request to be part of the feeding in process for commissioning intensions.

Members agreed recommendations CCC-19/6/066 ADHD Adults across Shropshire and Telford and Wrekin 8.0 Mrs Davis advised members that the paper was being presented to acknowledge the

extension of the present contract and agree that a market engagement exercise is completed based upon that the most appropriate joint procurement process.

8.1 Mrs Skidmore asked if she was confident that there was sufficient time to turn procurement

around when there would be a market engagement exercise first and whether the procurement was aware in their programme of work to deliver to the timescales. Mrs Davis said that she would need to clarify with procurement but thought timescale was tight but was possible to carry out within the timeframe.

8.2 Dr Shepherd highlighted that in the report under key issues or points it stated that the service

specification was to provide a local ADHD service for Telford and Wrekin CCG only and needed to also say Shropshire CCG.

Following discussions it was agreed to support the recommendation to progress but need to note that concerns were expressed around the tight timeline and that a procurement timeline needed to be produced. If timelines changed which then impacted on the service then it was agreed would need to bring back to CCC.

CCC-19/6/067 Treatment Pathway for Plaque Psoriasis 9.0 Mrs Rowland-Jones advised that there were two new TAs and members were asked to review

the amendments made to the treatment pathway following the approval by NICE of Certolizumab and Tidrakizumab for the treatment of plaque psoriasis and to approve it for use. Members endorsed the amendments to the treatment pathway.

CCC-19/6/068 Medicines Management Policy Reviews 10.0 Mrs Rowland-Jones presented the report and explained that this was to inform members of

existing NHS Shropshire CCG commissioning policies which had been made into joint policies with Telford and Wrekin CCG and explained that titles, headers, footers and review dates had been amended accordingly. The Committee were asked to note the commissioning policies listed within the paper.

Committee members had no questions and noted the policies listed

CCC-19/6/069 Funding Requests – Patient needing Pleurex Drains 11.0 Ms Wicks advised that a number of requests had been presented to the Commissioning team

as previously these had incorrectly been put through Individually Funding Panel because there was a clinical decision that needed to be made. Mrs Walker had now taken over IFRs and was only putting through exceptional cases so a high number of requests were now coming through to the commissioning team of the requests that are not provided either as main commissioner services, part of CHC or were not IFR or VBC rejections. She explained that the paper presented was the first of the requests coming through CCC for a decision on how to take forward. Ms Wicks advised that at the Executive Team meeting it was agreed that a policy was required on how these requests would be considered and had only presented the report as an example. Members were asked how they thought this should go forward.

11.1 Following discussions it was agreed that the policy once developed would be brought back to

the CCC to ensure the detail was correct and then following the process within the policy could then decide whether there was a better place for the decisions of the funding requests to sit but it was felt that could not discuss presented case until there was a robust process/policy in place.

Action: Funding Request Policy to be brought back through CCC once written

CCC-19/6/070 Transforming Midwifery Care in Shropshire, Telford and Wrekin: Options

Appraisal Report 12.0 Mrs Ellis handed out a slide pack to members and Dr Sokolov explained to the Committee as

to what they were being asked to agree with the paper. She explained that there was joint board development session taking place and that the output of the programme board would be considered there prior to the Governing Boards individual sign off. It was important that the report also went through CCC governance so this was why was being presented to CCC and members were asked to note the contents of the report; approve the process of the options appraisal; approve the additional process to gain assurance with regard to travel and transport and then to approve taking the outcome/recommendations from the Programme Board to the joint board session. Following the joint Board session this would then be developed for taking to individual Governing Bodies for sign off. Dr Sokolov reiterated that the Committee were only being asked to note the report and approve the process.

12.1 Dr Sokolov took members through the presentation on access Impact Assessment and

Location of Maternity Hubs and highlighted that the recommendations from the Programme Board was that, even though there was a marginal variation between 3 hubs and 4 hubs in terms of benefit, that 4 hubs would mean a slight cost increase and would require additional staffing, so a 3 hub model had been recommended. The recommendation was that the 3 hubs would be in South Telford, South Shropshire and North Shropshire. She informed that impact activity of the new service model would be routinely analysed and consideration given to introducing additional hubs should activity levels and outcome data indicate a need. Routine antenatal and postnatal care as well as home births would continue to be available in all localities.

12.2 Mrs Ellis summarised that the proposed 3 hub model would be in addition to Wrekin and

Shrewsbury MLUs which would also act as hubs for 12 hours per day. She explained that they would be open 24 hours per day, 7 days a week for births and MLU activities. Access data through the options appraisal had backed up the evidence that the current MLUs were not in the right place. The only negative impact would be Oswestry as this would not have an MLU but would still have all routine ante-natal and post-natal care and home births, but women would need to access scans from their nearest hub. Dr Sokolov informed that the Oswestry activity last year was only 52 deliveries in the Oswestry MLU and an average of 106 women went across to Wrexham.

12.3 Dr Bird asked why two hubs would be in located in Telford and why did it not look at Telford

South amalgamating into Wrekin as he felt this would be challenged from women in Oswestry/Bridgnorth. Mrs Ellis advised that this was decided and based on terms of population and need. Mrs Ellis said if looked at one large hub serving all women then this would need to be long term plan if going to be considered. Mrs Morris said that from the data it was clear that there was a specific need for two hubs in Telford, and also that there had to be mitigation due to the decision of future fit of moving Women’s and Children to Shrewsbury. It was noted that the hubs would also offer a more comprehensive community based service that would also link in to prevention work and family support and that over time this would be built up. Dr Bird asked if women could choose which hub they wished to use. Dr Sokolov said that the community hubs would be much more flexible and would be around patient choice. The hub locations proposed should bring services closer to more women across the County.

12.4 Mrs Ellis advised that informative sessions would need to take place in all areas to all staff to

avoid negativity.

Following discussions the Committee noted the outcome of the Access and Transport Impact Assessment and the Programme’s Board’s recommendations to the proposed locations of the maternity hubs and the timeline for the next steps and approved the process of taking this forward through Governing Bodies. It was also noted that informative sessions in all areas would need to take place to avoid negativity.

CCC-19/6/071 Any Other Business There were no other items of any other business. Date of Next Meeting The next meeting of the Clinical Commissioning Committee will be held on Wednesday 17 July 2019 at 9.00am in Meeting Room B, William Farr House.

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Agenda item: GB-2019-09.124

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

Finance and Performance Committee

Date of Meeting:

3rd July 2019 and 7th August 2019

Chair:

Kevin Morris

Key issues or points to note:

MSK QIPP not delivering as much QIPP as we had hoped for.

CHC a great deal of work was being undertaken to get to a true picture of the CHC spend. This

could well take a number of months to complete this work. This continues to pose a risk to our

financial and performance delivery.

On-going work is being done to provide assurances around QIPP are being undertaken.

However, the committee was concerned that the current slippage would not be addressed. A

robust discussion was had in relation to realistic forecasts.

Draft Financial Recovery Plan is being monitored monthly by the committee.

Actions required by Governing Body Members: To note concerns raised regarding our QIPP and financial position and the monitoring of this

over the coming months.

CHC to provided F&P committee with monthly progress reports on actions related to improved

performance. A new dashboard of information will be presented of activity and performance

information to F&P committee for oversight and assurance.

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Agenda Item: GB-2019-09.124 CCG Governing Body – 11.09.19

Shropshire Clinical Commissioning Group

MINUTES OF THE FINANCE & PERFORMANCE COMMITTEE

HELD IN MEETING ROOM B, WILLIAM FARR HOUSE, SHREWSBURY, SY3 8XL ON WEDNESDAY 3 JULY 2019 AT 1.30PM

Present Mr Kevin Morris (Chair) GP Practice Board Representative Mr Keith Timmis Lay Member – Governance & Audit Ms Laura Clare Deputy Chief Finance Officer Dr Julie Davies Director of Performance & Delivery Dr Michael Matthee North Locality Chair Ms Sarah Porter Lay Member – Transformation Ms Kate Owen Joint PMO Mr Meredith Vivian Lay Member – Patient & Public Engagement In Attendance Mrs Faye Harrison PA/Minute Taker Apologies Mrs Claire Skidmore Chief Finance Officer Mrs Gail Fortes-Mayer Director of Contracting FPC-2019.07.060 - Apologies

1.1 Apologies were noted as above although it was hoped that Claire Skidmore may be

available to attend towards the end of the meeting.

FPC-2019.07.061 - Members’ Declaration of Interests 2.1 There were no declarations of interest. FPC-2019.07.062 - Minutes of Previous Meeting held on 1 May 2019 3.1 The Minutes from the meeting held on 1 May 2019 were agreed as a true and

accurate record. FPC-2019.07.063 - Matters Arising/ Action Tracker 4.1 The Action Tracker was reviewed and updated accordingly. 4.2 Key points raised were as follows:

FPC-2019.05.045 – Quality Impact Assessments Mrs. Skidmore to provide an update on Quality Impact Assessments graded as

moderate to high in June FPC. Ms Owen confirmed that this had been completed for all schemes and there were no

high risk issues

FPC-2019.05.045 – Local Authority Mrs. Owen to provide an update on the meeting with the Local Authority from the

25th April 2019 in June FPC. Ms Owen updated that she had spoken with the Commissioner who confirmed there

was no longer any issues with the running of the Local Authority meeting. Terms of Reference are currently being reviewed by the Joint Nurse Executive.

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FPC-2019.05.045 – Mental Health Mrs. Skidmore to provide an update on the cross subsidisation in respect to community and the mental health contract in June FPC. Ms Clare updated that the original amount was £1.5m but this is now at £600,000; this is included in both Telford and Shropshire’s plan.

FPC-2019.05.046 – Cross Border Dr. Davies to feed back in June FPC any recommendations from the cross border network meeting on 10th May. Dr Davies gave the feedback that the issue had now been resolved.

FPC-2019.07.064 - Quality, Innovation, Productivity & Prevention (QIPP) Report 5.1 Ms Owen highlighted the key points of the report with regards to the QIPP year end

forecast. She commented that although some of the schemes have slipped work is on going in order to stretch the targets for schemes which are currently high risk and yet to be worked up. A series of pipeline schemes are being reviewed and worked on at the moment.

5.2 A joint workshop has been arranged with Telford & Wrekin to try and identify further

saving schemes. Concern was raised over this workshop and the timescale of the exercise. The on going risk around outpatients at SaTH was briefly discussed; this can be picked up further at the QIPP Board.

5.3 Discussion was held around MSK and RJAH over performance. Some small

schemes in Paediatrics are being worked up and are awaiting turnaround from Business Intelligence (BI).

5.4 CHC was discussed and it was agreed that a report would be requested from Chris

Morris to be brought to the next committee detailing the business cases which need to be completed and the figured required.

Action: Report on CHC to be requested from Chris Morris for the August

Committee 5.5 Workforce capacity was discussed and how this will be factored in to the QIPP

projections when transforming to a Single Strategic Commissioning Board. It was confirmed that this had not yet been factored although it is recorded on the Risk Log. There will be 20% less resource next year however some areas will not be affected.

5.6 The QIPP Programme Board was discussed and whether it was appropriate for Mr

Morris to chair both the QIPP Programme Board and Finance and Performance Committee and it was agreed that as the QIPP Meeting was not a formal sub-committee of the Board there wasn’t an issue.

5.7 Mr Timmis raised concern around the figures for Month 2 and how far behind they

currently are. RJAH are not delivering and he felt this is something which needed to be highlighted to the Governing Body.

5.8 Corporate savings was discussed and Ms Clare confirmed that in the 2019/20 plan

there is £1m of recurrent savings which are off set with a non-recurrent reserve. More detail regarding this was requested to be added to the report for next month.

Action: More detail to be added to the QIPP report around the £1m recurrent

savings which are off set with a non-recurrent reserve.

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5.9 Members felt that it may be more beneficial to concentrate on the larger schemes

which will make larger savings which will also help with workforce capacity moving forward. RAG ratings will also need to be looked at.

FPC-2019.07.065 – PMO Governance Report 6.1 The Terms of Reference were discussed and the minor amendments agreed. It was

also agreed to change the wording of who will chair the meeting to ‘Non-Exec Chair’ rather than ‘GB Lay Member Chair’. Claire Skidmore would remain as deputy chair.

6.2 It was agreed to work towards joint meetings with Telford and Wrekin. 6.3 Ms Owen highlighted the flow chart detailed within the report which explained the

QIPP functions and how it works. It will be shared with all departments via the Project Leads to highlight the process to staff so that they are aware at which stage they will be required to get involved.

FPC-2019.07.066 – Draft Financial Recovery Plan 7.1 It was agreed to move this item towards the end of the meeting in case Claire

Skidmore was able to attend. Monthly Monitoring for Finance and Performance FPC-2019.07.067 – Finance & Contracting Report 8.1 Ms Clare talked members through the new format of the report and requested

feedback. Members commented that the report was much more user friendly. 8.2 She confirmed that the Month 2 figures were not as hoped with a £2.1m overspend

due to the main areas of cost pressures which include MSK, Ambulance conveyances, CHC particularly Mental Health and Emergencies in the acute sector. The same cost pressures are being seen in Telford and they are also significantly overspent.

8.3 At this stage of the year it is reported that the plan of £22.9m will be met. An

unmitigated risk of £5.1m is being flagged to NHS England. Ms Clare highlighted the run rate graph to members. There is a contingency reserve phased into Month 12 as per NHSE guidance.

8.4 The £4m of high risk QIPP was also highlighted to members as well as on going work

around the management action factored in to CHC Mental Health for both CCG’s. Investigations are on going.

8.5 Ms Clare explained that more detail is available in the appendices on specific

contracts and categories of spends. Appendix B contains a letter from NHSE regarding a Primary Care shortfall however since then a letter from Fran Steele has been received confirming we will not be measured against the control total. It needed to be made clear that the control total has not changed.

8.6 Staffing levels for the next 9 months will need to be looked at.

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8.7 The Betsi issue was discussed and Ms Clare confirmed that Mrs Skidmore had a booked call later today. It is hoped that there will be a resolution by the end of the week.

8.8 It was felt that it would be useful to include an STP section within the report going

forward and also to include the allocated savings into the QIPP report. 8.9 The £350,000 QIPP regarding the Community Trust was discussed and concern was

raised this this would not deliver. Dr Davies confirmed this this was accepted in the contract and they initially identified £80,000 revised work around outpatients. A letter was sent to them detailing options for further work and it was agreed at the SCB to hold further discussions around the data.

8.10 The breakeven forecast for Primary Care against the revised plan was discussed.

Ms Clare explained the delegated allocation to members and stated that this year it hadn’t been able to stay within the allocation. A submitted plan requests to spend £1.5m more than the ring-fenced allocation which will be reported as breakeven. It was felt the paragraph needed re-wording to make the situation clearer.

8.11 The creditors list was discussed and it was felt that the Betsi amount appeared

confusing. Ms Clare confirmed that as there is an on going dispute it is difficult to pinpoint figures. A further breakdown would be requested.

8.12 Mr Morris discussed the bullet points in the letter from Fran Steele as this could be

interpreted in different ways. It was felt that they were referring to the QIPP’s not being contractualised. Further discussion was held around this issue as it can be confusing it was agreed to add further detail to the report going forward.

8.13 With regards to the Ambulance contract Dr Davies asked whether the Regional

Contractors were managing the contract and Ms Clare agreed to chase this up with the Contracting Team.

Action: Ms Clare to chase up whether the Regional Contractors were managing

the Ambulance Contract. FPC-2019.07.068 – Performance Report 9.1 Dr Davies updated that starter change work has begun around ambulance handovers

and a 41% improvement has been seen. Work is on going through the A&E Delivery Group looking at how to maintain the performance levels. There has been an issue around PIN numbers and when they are stopping the clock; support from NHSEI is being received.

9.2 RTT has been massively affected due to the escalation of the day surgery unit. 9.3 Despite RJAH achieving for us they haven’t managed to achieve overall due to their

planned Consultant leave and have been asked to look at this in order to maintain. 9.4 52 week waits are still in a good position however there is still some anxiousness

around the Out of Area Providers. There has been a ‘blip’ around diagnostics due to some issues at RJAH with MRI and ultrasound.

9.5 Dr Davies reported that despite the poor position around A&E in April things have

improved throughout May and June due to the Same Day Emergency Care (SDEC)

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which gives around a 5% improvement in performance with minimal breeches throughout the day. It is hoped this will continue.

9.6 Benefits are starting to be seen at SaTH due to their commitment around nursing

workforce. The workforce team have committed to having a regular representative at A&E Delivery Group from the end of July.

9.7 Discharges and DTOC remain to be the best in the region. 9.8 A significant dip has been seen in the 2 week cancer waits because of the issues

around breast symptoms and radiology. There have also been some short term issues around dermatology and the sub-contractors. With regards to the 62 day performance it is hoped that this will be achieved from October onwards. Further discussion was held and concern raised around the on going issues around cancer.

9.9 The issues around Urology have been escalated and there is a Regional Meeting on

11 July to look at this and offer support. 9.10 Discussion was held around what should be done with the information in the report to

move the situations forward and it was felt that challenge should be put back in via the A&E Delivery Group as well as keeping on top of the on going workforce issues. Timescales should also be factored in.

9.11 The ShropDoc Out of Hours Contract Review was discussed as it was thought that

this was supposed of happened after 6 months but hasn’t. Telford and Wrekin are the lead commissioners on this issue and it was agreed that Ms Clare would chase this up with Jon Cooke.

Action: Ms Clare to chase up response from Jon Cooke with regards to the

ShropDoc Out of Hours Contract. FPC-2019.07.066 – Draft Financial Recovery Plan 10.1 In Mrs Skidmore’s absence Ms Clare talked members through the plan highlighting

that this is still in draft form. 10.2 A version of the plan went to Board around 18 months ago and was signed off; an

update was required by NHSE by summer 2019. The Long Term Plan Implementation Framework came out recently which requires the STP to submit a 5 year strategic plan by September.

10.3 Ms Clare highlighted the key points of the report to members and explained how

things would work going forward. The plan is currently just for Shropshire CCG but a joint plan will be worked on going forward.

10.4 Feedback has already been received from NHSE and David Stout and Ms Clare

would welcome feedback from the Committee. 10.5 The following feedback was received:

Slide 3 – wording needs to be changed on the quote regarding ambitious assumption of delivery and challenging QIPP

Slide 3 – also requires changing of the word ‘surplus’

Slide 5 – clear actions required

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Slide 8 – the increase in the elderly population rate (above the age of 65 is well above the national average) needs to be mentioned as services will need to adapt in line with the increase.

Transformation needs to be the key focus of the plan to turn the finance round and it was felt that this was missed from the document. More detail around delivery of the schemes is also needed. It would need to be sufficient and plausible enough to turn the finances around.

Narrative needs to be more precise

The triggers for rurality need to be understood

The deprivation index should be included as part of the rurality issues

QIPP assumptions need to be worked on

The document wasn’t hard hitting enough – need to be more confident about the facts

The solution needs to be greater than the problem with more detail

Future Fit was not included – need to mention the delays

Robust contract management needs to be shown with relating financial issues

Risks to be highlighted

Embedded systems and financial control are key

Need to look at the overall message FPC-2019.07.069 – Key Messages to the Governing Body 11.1 The key messages for the Governing Body were noted as follows: Public Meeting

QIPP Savings

MSK – Month 2 not delivering to the level of requirement

7% away from plan as of Month 2 in the figures

CHC report required

Ambulance over 10% - needs investigation

QIPP in contracts does not mean savings

Part 2 Board

MTP – feedback for Draft Recovery Plan FPC-2019.07.070 - Any Other Business 12.1 Members discussed the timing of the committee as it was felt the current timing is not

ideal. Numerous possibilities were talked about and it was agreed to move the meeting from September onwards. The possibility of swapping the times with Quality Committee was felt to be the best option. Aligning the meeting with Telford & Wrekin was also discussed.

Action: Mrs Skidmore/Mrs Harrison to look at the timing of the meeting and

send out new dates. Date and Time of Next Meeting Wednesday 7 August 2019 1.30pm – 3.30pm, Room B, William Farr House

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Agenda Item – GB-2019-09.124 CCG Governing Body – 11.09.19

Shropshire Clinical Commissioning Group

MINUTES OF THE FINANCE & PERFORMANCE COMMITTEE

HELD IN MEETING ROOM B, WILLIAM FARR HOUSE, SHREWSBURY, SY3 8XL ON WEDNESDAY 7 AUGUST 2019 AT 1.30PM

Present Mr Kevin Morris (Chair) GP Practice Board Representative Mrs Claire Skidmore Chief Finance Officer Mr Keith Timmis Lay Member – Governance & Audit Dr Julie Davies Director of Performance & Delivery Dr Michael Matthee North Locality Chair Ms Sarah Porter Lay Member – Transformation Ms Kate Owen Joint PMO Mr Meredith Vivian Lay Member – Patient & Public Engagement Apologies Mrs Laura Clare Deputy Chief Finance Officer Mrs Gail Fortes-Mayer Director of Contracting & Planning In Attendance Mrs Chris Morris Executive Chief Nurse Mr Charles Millar Head of Planning Performance and Contracting As no minute taker was available the Committee was recorded and transcribed back following the meeting. FPC-2019.08.071 - Apologies

1.1 Apologies were noted as above.

FPC-2019.08.072 - Members’ Declaration of Interests 2.1 Mr Morris informed members that he would hand over the chairing of the meeting to

Mr Timmis for agenda items relating to CHC as his wife, Mrs Chris Morris is the Executive Chief Nurse.

FPC-2019.08.073 - Minutes of Previous Meeting held on 3 July 2019 3.1 The Minutes from the meeting held on 3 July 2019 were discussed and the following

amendments were required:

Paragraph 5.2 should read ‘The on going risk around outpatients at SaTH was briefly discussed’

It was clarified that BI was the acronym for Business Intelligence Paragraph 10.5 needed a couple of amendments to the bullet points around slide 8 and transformation.

The 5th Bullet Point on page 6 should read deprivation FPC-2019.08.074 - Matters Arising/ Action Tracker 4.1 The Action Tracker was discussed and updated as appropriate. The following

updates were given:

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FPC-2019.05.046 – Quality Premium Dr. Davies to provide an update on the Quality Premium payment in June FPC Dr Davies updated that she has a summary of the position for last year but the challenge is that NHS England have updated that there won’t be a final assessment until the Autumn and it is thought that the Quality Premium may have been dropped for 2019/20 as no requirements have been received. The assessment based on May’s data will be circulated following the meeting. FPC-2019.07.067 – Finance & Contracting Report Ms Clare to chase up whether the Regional Contractors were managing the Ambulance Contract Mrs Skidmore updated that Sandwell and West Birmingham CCG are the Lead Commissioners and will be managing the contracts. This can be discussed further at a later date if required. FPC-2019.07.068 – Performance Report Ms Clare to chase up response from Jon Cooke with regards to the ShropDoc Out of Hours Contract A meeting has taken place to review the current situation; further update would be brought to the next meeting.

FPC-2019.08.075 - Quality, Innovation, Productivity & Prevention (QIPP) Report

Mrs Chris Morris joined the meeting 5.1 Mrs Skidmore informed members that at Month 3 it is reported that the QIPP delivery

will fall slightly short of the overall plan. It was worth noting that although the number had been brought down it hasn’t stopped the on going work to look at further recovery within existing schemes or other opportunities.

5.2 A significant risk assessment of £4m has been brought against the position to look at

where some of the schemes are heading. If all of the risk materialises and no mitigations found then the programme delivery would be £14.4m at the end of the year.

5.3 Mrs Skidmore updated on the recent Opportunities Session which took place where

joint working with Telford was undertaken to produce a single list of schemes. This will be taken to Exec Team for further discussion on Monday 12 August. It will be key to assign one Lead across the system to alleviate duplication and ease workload.

5.4 Ms Owen drew members attention to the summary from paragraph 8 onwards in the

report and explained some of the detail. Dr Davies expanded on the RJAH issue and informed members that a draft standing operating procedure for how they manage their watchful waits and their timely discharge patients should be available later this week.

5.5 Dr Davies went on to update that improving the clinical triage within SOOS is being

worked on along with location tracking which is proving challenging. Weekly calls are taking place.

5.6 Ms Owen reported that some emerging risks had been highlighted around Shropshire

Care Closer to Home and a revised forecast has been produced. Dr Davies commented that there is also risk around MSK and implementation. Further

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discussion was held around these risks and Dr Davies provided more detail as requested.

5.7 Discussion was held around the Financial Recovery Plan and the concern around

getting the STP to deliver and whether the issues should be escalated. Mrs Skidmore felt that things are starting to move forward however not at the pace which is required.

5.8 Mrs Skidmore reported that it has been agreed that an Executive Summit will take

place in September with ShropCom to consolidate views and agree how best to move forward.

5.9 Dr Matthee raised concern that had been discussed at Locality Meetings that things

don’t seem to be moving on and no penalties are received when actions and targets aren’t completed. It was commented that the pressure is now being outed through the Senior Leadership Group and some of the other STP Forums. Work is on going to force the issue. Mr Timmis highlighted his concern further to members. Mrs Skidmore suggested that an STP representative could come to the Board Meeting to discuss any issues. Further discussion was held around the best way to move this issue forward.

5.10 Another risk is around CHC Stretch Targets update would be given in the CHC

update. 5.11 Mr Morris felt that the current understanding of QIPP and Delivery was being lost and

further explanation and work was required. It was commented that the summary within the report needed firming up. Concern was raised that the some of the schemes are not much further forward than they were 6 months ago and he felt concerned at this. Mr Morris would be raising this issue at Governing Body in his over view. Members discussed this in more detail and how it was best to move the issues forward so that more assurance can be given. The process going forward once agreed, would need better explanation. This away forward was agreed.

5.12 Dr Davies commented that she felt more confidence this year as there is a shared

commitment to achieve transformation and being held to account for it. This will help to turn round the financial position.

FPC-2019.08.076 – CHC Report 6.1 Mr Morris handed over the chair responsibility to Mr Timmis. 6.2 Mr Timmis informed members that the report had already been to Quality Committee

and would also be going to Audit Committee in the following weeks as there are different aspects to the report which need to be discussed accordingly at each Committee. Each Committee would require assurance about how to move forward.

6.3 Mr Timmis began by commenting that it would be key to be realistic about what is

achievable and ensure that figures are manageable although it was noted that this would take time.

6.4 Mrs Morris talked through the paper with members and highlighted the key points.

She reported that there are 8 lines of QIPP which equal £2.7m however she felt there are only 3 ways in which to reduce the bottom line within CHC.

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6.5 Mrs Morris informed members that in order to make savings it would be important ensure the National Framework is robustly applied and costs are managed once they’ve been agreed, working closely with the Local Authority and other providers. All the cases currently on the books will need to be reviewed to determine whether the care packages are appropriate for the level of health need of the patient.

6.6 The plan is to get the processes up to speed so that patient flow is managed

appropriately and no backlog is created. 6.7 Mrs Morris talked to the members about Cygnet Healthcare Provider which is on of

the schemes who has signed up the CCG for a volume discount, however this will need to be looked into in more detail as when comparing costs with Telford their rate is the same without discount.

6.8 Mrs Morris went on to discuss Out of Area Commissioning. There is a boundary

between what is being commissioned by the CCG for the care of Mental Health patients and what is being commissioned for individual patients with Mental Health issues. Mrs Morris has a meeting with Cathy Riley from the Mental Health Trust to look at why the changes in process have occurred. Mrs Morris reported that there has been a growth of 40 cases from April to August and this also needs to be looked into.

6.9 The Collaborative Commissioning QIPP Scheme is about how the CCG work with the

Local Authority and a brokerage provision is being put into place to manage the market. This will start in September although the impact will not be seen straight away.

6.10 With regards to Children’s Placements Mrs Morris explained that this is about Looked

After Children who are placed in residential care or out of county. There are 43 children who are currently in receipt of high cost care packages. The children who come into county are not paid for by the CCG. A review scheme is in place. We are currently on track to hit the savings target for this scheme. There is concern around the lack of a Children’s Commissioner which is being investigated.

6.11 There is limited information available around Hospice at Home however Mrs Morris

reported that she is currently in the process of trying to understand the service specification and funding for this scheme. Mrs Morris will meet with their Chief Executive next week. There is a contract in place for Hospice provision but this specific domiciliary care falls outside of that and there are currently no costing for this.

6.12 The final QIPP scheme is around the review programme which is a success story as

it is currently way above trajectory. Clear direction to staff as well as additional capacity has helped this succeed.

6.13 Mrs Morris discussed the dashboard with members, talking through each section and

explaining how cause and effect can be measured. This is a live dashboard which is currently being worked on by each team. Mrs Morris confirmed that each month an updated dashboard would be presented to the Committee for both Finance and Performance elements.

6.14 Mrs Morris went on to highlight the Action Plan to members and reported that she

hoped that it would take around 3 months to ascertain what is achievable and what is not.

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6.15 Comments and actions have been received from both Internal and External Audit colleagues and this will be presented to the Audit Committee later this month. It is expected to take approximately 2 years to turn this around.

6.16 Mrs Skidmore commented that from a Financial Recovery point of view the

turnaround time is slightly worrying however it is understandable and it will need to be made clear in the forecasting that the assumptions line up adequately.

6.17 Mrs Skidmore drew members attention to the appeals paper and commented that

she felt that value could be estimated and that someone within the Finance Team would look in to this.

ACTION: Update on CHC to be brought to Finance & Performance Committee on

a monthly basis 6.18 With regards to Workforce Issues Mrs Morris explained that the Teams from

Shropshire and Telford & Wrekin has been brought together into one team and the benefits are beginning to be seen with clear Strategic and Clinical Leadership.

6.19 A revised structure has been taken to the Executive Team Meeting and a reduction in

the number of interims has produced a large cost saving with a further saving of £180,000 once all posts are recruited to substantively. 7 posts are currently out to advert.

6.20 Mr Timmis handed back the Chairing of the meeting to Mr Morris FPC-2019.08.077 – Post Month 3 Review of Drivers of Increased Emergency Activity 7.1 Dr Davies highlighted the key points within the report. There are currently 2 different

views across the 2 sites. The main driver at RSH is over 75’s via 999 calls and ambulance whereas at PRH this is Paediatrics and General Medicine increases.

7.2 Next steps and actions include challenging providers to understand the issues

whether it is workforce or systems and process which need to be addressed. 7.3 Dr Davies highlighted that Ambulance Service support would be required to help

prevent conveyances and she was concerned that currently no support is being received and also that there is no Senior Level representation. This has been raised with NHSE/NHSI in anticipation of the Emergency Care Escalation Meeting tomorrow.

7.4 Discussion was held regarding the statistics for activity in the report and the logic

around this when making comparisons. The population within County was also discussed as this may contribute to the impact and how this would need to be factored in moving forward. Social factors and how Shropshire Care Closer to Home could be used was also discussed

7.5 Dr Davies drew members attention to the piece of analysis around Care Homes and

the increase in A&E attendances and admissions recently. This information has been passed onto the Local Authority for further discussion as the Care Home impact is currently around 10% of demand.

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FPC-2019.08.078 – Update on Progress with Financial Recovery Plan 8.1 Mrs Skidmore updated members that the Plan is very much a work in progress

particularly in terms of the content and format. It is currently a working draft. She reported that there is currently not as much pressure from NHSE to see the final document however they are being kept in the loop with all developments.

8.2 Mrs Skidmore highlighted the 2 main issues which are a refresh of the growth

assumptions and the development of the system in terms of transformation. Discussions with providers will be required around the broader transformation pieces. It will be key to get a grip on the system and process managing the contracts.

8.3 Each of the new clusters in the new Governance of the STP have been tasked with a

refresh of the current programmes of work that are on going and the impact that it will have. In order to put a financial model together activity numbers will be required therefore the clusters will be encouraged to provide these estimates. This will influence the QIPP numbers.

8.4 Dr Davies is starting to create the Commissioning Strategy and it will be key to align

the content and the language. 8.5 Now that Shropshire CCG are moving towards a Single Strategic Commissioner

everything within the current plan will be used as a basis for a single recovery plan. It is required that the combined plan is 70% complete by the assurance check point in September to make the judgment about whether the plan will go live.

8.6 There is a timeline for the STP Long Term Plan with the numbers for internal review

being ready for the end of August then through September the System Plan will be in place.

8.7 Mr Timmis highlighted all the serious concerns which had been raised around

delivering the Recovery Plan and the issues with delivery and progress made. Mrs Skidmore would escalate the concerns to the Accountable Officer. Further discussion was held around the concerns and how to address these in order to move forward.

8.8 Mrs Skidmore highlighted to members that although the Plan reports hitting the

position at Year End there is still serious concern around this. Monthly Monitoring for Finance and Performance FPC-2019.08.079 – Finance & Contracting Report 9.1 Mrs Skidmore reported that the 2 key drivers for the problems in the position still

remain acute and CHC. There is over performance with non-elective, A&E and Ambulance Service. Although the main focus is on SaTH the Out of County providers also need to be included in particular UHNM.

9.2 The issue with RJAH continues and despite the fact that there was some slippage

built into Month 3 there is confidence that this issue won’t become any worse. However as the risk share arrangement wasn’t reviewed at Month 3 this will be worked on ready for the Month 4 report.

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9.3 With regards to the ShropCom QIPP which is built into contract, this has also been risk assessed as there currently isn’t a full programme of work. ShropCom have provided commitment to drive this forward.

9.4 CHC still remains the area of most concern although Mrs Morris has a good grip on

the Service now. There are still staffing and backlog issues which are on going. There is an increase in both the number of patients and the cost of the packages.

9.5 Mrs Skidmore confirmed that the July cash numbers had caused problems as there

was an in month lump sum of Primary Care funds however this will balance out in next month’s figures.

9.6 Following a query from Mr Morris; Mrs Skidmore reported that they were currently in

a position to hold acute providers to account around the contracts. The Contracting Team have a new Deputy Contracting Manager who will be looking at this in more detail.

FPC-2019.08.080 – Performance Report 10.1 Dr Davies reported that the ability to do anything about the Ambulance issues is

limited however there is an opportunity to state strategic intent potentially around how the Ambulance Service is commissioned to have more of a focus on rural communities.

10.2 Ambulance handovers are improving and there is a good action plan in place

although there is an unrealistic trajectory to eliminate over 30 minute handovers by March 2020 which we need to be looked at.

10.3 With regards to RTT this is a consequence of the urgent care pressures. There was

a reduction in the escalation into DSU in July. As a request for the Financial Recovery and Assurance the impact of not recovering will be included in the modelling going forward. A Quality Assessment will also be requested. This has also been flagged at the Systems Meeting to ensure it doesn’t drop off the radar.

10.4 There was a problem in April and May with diagnostics however this has now

recovered. 10.5 There is an escalation meeting with regards to A&E tomorrow. There have been

some issues with complex discharges and levels have not been consistent. 10.6 It is expected that there will be a ‘blip’ with DTOC for July because of a complex

patient and ensuring the right level of care is given. 10.7 There was dreadful performance around Cancer in May although capacity

improvement is now coming in. From a Quality perspective it has been confirmed that the 62 day treatment target has not been breached.

10.8 there have been many issues around Urology and this has been linked into the

Regional position and is being taken forward by Alison Tonge. 10.9 111 and Out of Hours continue to be consistent with an increase in non-elective

activity. There seems to be a potential issue coinciding with October last year which is when the new Contract was awarded. This is being investigated by Gail Fortes-Mayer.

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10.10 It is hoped that ShropDoc will improve fulfilling their rota obligations. FPC-2019.08.081 – Finance & Performance Committee Terms of Reference 11.1 Mr Morris reported that the changes discussed at the last meeting had been made

and therefore this was for information only. FPC-2019.08.082 – Key Messages to the Governing Body 12.1 Key messages to be taken to the Governing Body include:

On going work to provide assurances is being undertaken

Progress is being made with CHC – timeline to be reinforced at Board

Draft Financial Recovery Plan is being monitored monthly FPC-2019.08.083 - Any Other Business 13.1 There were no items of Any Other Business discussed. Date and Time of Next Meeting Wednesday 28 August 11.30am – 12.30pm in K2, WFH

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Agenda item: GB-2019-09.125

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

Primary Care Commissioning Committee

Date of Meeting:

5th June 2019

Chair:

Dr Colin Stanford

Key issues or points to note:

1. STP Primary Care Strategy Operational Progress Report.

Mrs Wilde told the committee that with regard to Primary Care Networks (PCNs) a meeting had

taken place across the STP but that agreement had not been reached across all Shropshire GP Practices. The CCG is working with Practices to resolve this situation.

2. Finance Plan Report.

Mrs Skidmore reported that in the light of mandated national changes the allocation for Shropshire

was reduced by £1.5 Million. The CCG has reported to NHS England that this figure is contributing to the CCG's overarching deficit.

3. Shifnal Premises Development Full Business Case.

Dr Stanford summarised a letter received from the Chair of the Shifnal and Priorslee Patient

Participation group in support of the development. After presentations from The Practice and the developer and after further discussion the Committee approved the Full Business Case.

4. Riverside Medical Practice Final Business Case

Presentations by Dr Harwood, Dr Hodson, Tracey Willocks (Practice Manager) and Mr Tim Smith of Shropshire Council informed the discussion and the Committee approved the Final Business Case.

Actions required by Governing Body Members:

None

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Shropshire Clinical Commissioning Group

MINUTES OF THE PRIMARY CARE COMMISSIONING COMMITTEE (PCCC) HELD IN ROOM K2, WILLIAM FARR HOUSE, SHREWSBURY AT 10.00 AM ON

WEDNESDAY 5 JUNE 2019

Present Dr Colin Stanford External GP Member (Chair) Mr Keith Timmis Lay Member, Performance Mr Meredith Vivian Lay Member, Patient & Public Involvement Mrs Nicky Wilde Director of Primary Care Mrs Claire Skidmore Chief Finance Officer Mrs Sam Tilley Director of Corporate Affairs Mrs Sarah Porter Lay Member Dr Deborah Shepherd GP Member, Shrewsbury & Atcham Locality Chair Mrs Amanda Alamanos NHS England Primary Care Lead, Shropshire & Telford Mr Steve Ellis Head of Primary Care Mrs Vanessa Barrett Healthwatch Shropshire Ms Andrea Harper Communications & Engagement Officer Cllr. Lee Chapman Shropshire Council In Attendance Mrs Chris Billingham Personal Assistant, Minute Taker Apologies Mr David Stout Accountable Officer, Shropshire CCG Mr Kevin Morris Practice Member Representative Mrs Christine Morris Chief Nurse Dr Stephen James GP Member Dr Jessica Sokolov Medical Director Dr Finola Lynch GP Member Mrs Rebecca Woods Head of Primary Care for Shropshire and Staffordshire, NHS England PCCC-2019-06.034 - Apologies Apologies received were recorded as above. Dr Stanford welcomed Mrs Marion Law and representatives of Shifnal & Priorslee Patient Participation Group to the meeting. PCCC-2019-06.035 - Members’ Declaration of Interests There were no declarations of interest. PCCC-2019-06.036 – Minutes of Previous Part 1 Meeting held on 3 April 2019 and Matters Arising The Minutes of the previous Part 1 meeting held on 3 April 2019 were agreed as an accurate record provided the following amendments are noted:- Mrs Laura Clare is Deputy Chief Finance Officer and not Assistant Chief Finance Officer as stated. Page 4; Paragraph 2: Reference to “Shropshire and Telford & Wrekin CCG” should read “Shropshire and Telford & Wrekin CCGs”. Page 6; Paragraph 9: Reference to an error in the Co-Commissioning Delegated allocation is not accurate and should read “Every CCG was notified of a change to the allocation”.

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PCCC-2019-06.037 – Public Questions No questions were received from the public. Dr Stanford referred to the letter received from the Chair of the Shifnal & Priorslee Patient Participation Group which had already been discussed in the Part 2 meeting. The letter addressed the background to the Shifnal Surgery case, the difficulties with transport experienced by patients in travelling to the surgery at Priorslee, and supported the case for a new build in Shifnal itself on the Haughton Road site. PCCC-2019-06.038 – STP Primary Care Strategy Operational Progress Report The purpose of Mrs Wilde’s report was to provide Primary Care Commissioning Committee with a report setting out progress with delivering the Shropshire and Telford & Wrekin STP Primary Care Strategy. Committee was aware that the STP Primary Care Strategy had been signed off several months previously. In the past, Committee had received GP Forward View updates. However, as elements of GP Forward View are contained within the Strategy paper, a decision was taken not to continue with those updates but ensure that all information is contained within the Strategy update. The same paper was submitted to Telford & Wrekin Primary Care Committee.

5 of the programmes are rated as “Green” which indicates that all actions are on target

4 of the programmes are rated as “Amber” which indicates that there are certain issues against which the CCG are having to take mitigating action

No areas have currently been identified as “Red”

Mrs Wilde referred to the area of the report which referred to Primary Care Networks (PCNs) and advised Committee that a meeting had taken place across the whole of the STP. Invitations to attend were extended to Community Providers, Telford & Wrekin CCG and Shropshire CCG to review applications for the Primary Care Network. All of the Practices across the whole of Shropshire and Telford & Wrekin submitted applications, and all of Telford’s applications were approved. However, Shropshire was not able to formally approve any of their applications because one of the applications which covered the area of north east Shropshire across Market Drayton and Hodnet did not meet the criteria. The CCG is currently working with all Practices in the surrounding potential PCNs to try and encourage conversations with other Practices in order to achieve a solution. When this situation is resolved, all of Shropshire CCG’s applications can be formally approved. Committee will receive a separate paper at today’s meeting around IT. In future this will also be incorporated into the strategy update report. Mr Timmis raised a query around finance information being missed from the report. It was agreed that the template used for the updates would be amended to include a finance section. Mr Timmis also queried why workforce had been rated as Green given some of the concerns discussed by the Committee over the last 12 months. Mrs Wilde advised that the Green rating applied to whether or not the CCG was on target with actions and the overall trajectory is still being managed and being delivered. However, the wider risk on the Committee Risk Register remained Amber for workforce. The template will be updated to ensure that this is reflected correctly for future meetings. Mr Timmis referred to cuts made by the Council to Public Health funding, and believed that the CCG must ensure that there is no perverse incentive on the CCG to replace funding that was previously the responsibility of the Local Authority.

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Mrs Wilde confirmed that she was happy to add a Finance element onto each of the individual workstreams. Further discussion took place regarding the wording around risk assessments and quality concerns not being addressed by GP Practices. Dr Shepherd believed that the vast majority of GP Practices would be unlikely to refuse to address quality issues and queried that risk rating which was the same as other more serious identified risks. ACTION: Mrs Wilde to update the reporting template to include finance and clarity around Risk Mr Vivian queried the timeline for sign-off of the PCN process. Mrs Wilde confirmed that the CCG received Network applications by 15 May 2019. The CCG then had to evaluate those applications and respond to Practices by the end of May, which was done. June has been set aside to address any issues to enable all networks to go live on 1stJuly. As of today, the CCG are still not in a position to provide sign off and confirm that all criteria have been met. The CCG is currently liaising with NHS England to seek guidance as to the process if the application is resubmitted and still does not meet the criteria. Mrs Wilde has formally emailed all Clinical Directors and Lead Managers of the surrounding networks asking them to assist. The Committee noted the content of the report and agreed to the setting up of a cross-CCG working group to ensure delivery across all 9 work programmes. Mrs Wilde has recommended to Telford & Wrekin CCG that the cross-CCG Working Group should become the STP Project Board. The STP Board would comprise Primary Care Leads from both organisations, the Primary Care Committee Chairs of both organisations, a representative of NHS England, and the Director of the STP. The Terms of Reference may require to be slightly amended, but attempting to manage nine programmes of work across two organisations is becoming unmanageable without one body overseeing the process. PCCC-2019-06.039 – Primary Care IT Mr Ellis reviewed Mrs Spencer’s report, the purpose of which was to update Primary Care Commissioning Committee (PCCC) on the development of IT in GP Practices across Shropshire and how IT supports the future delivery of Primary Care strategy. Key issues or points to note were:-

PCCC has received updates on some of the Primary Care IT projects via the GP Forward View (GPFV) update reports.

Updates have only been provided if a project is part of NHS England's Estates and Technology Transformation Fund (ETTF) and therefore part of the GPFV.

To enable PCCC to have a wider awareness of how all of the IT projects within Primary Care support the delivery of the Primary Care Strategy, Committee need to be informed of all IT projects.

Mrs Spencer’s report provided a summary of recent projects delivered and the work programme for 2019/20. Future updates will be provided as part of the Primary Care Strategy operational progress reports.

The Primary Care team had been reviewing governance arrangements and had highlighted that the IT working group did not report directly through a governance process, so in future it would be included in the Primary Care Strategy updated report. The paper presented today is to set the scene for future updates. Mrs Skidmore commented that it is important to understand where IT sits in the STP, as the CCG has responsibilities to Primary Care to ensure the supply of the best equipment possible. However, systems must be compatible with other healthcare systems. Mrs Spencer’s main priorities are:-

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Migration to the Health and Social Care Network

Refresh of the hardware used in GP practices Discussion followed regarding funding of the project and Mrs Skidmore advised the Committee of very complicated rules around the financing of such projects. Capital expenditure sits on NHS England’s balance sheet and not the CCG’s balance sheet. However, some of the software and data management tools sit within the CCG’s revenue budget and the Finance team is currently finding ways of presenting this. ACTION: Mrs Skidmore to include information relating to IT funding in future Finance Reports submitted to the August Committee. The Committee noted the contents of Mrs Spencer’s report and agreed that the work programmes will deliver the required outcomes. PCCC-2019-06.040 – 2019/20 Finance Plan Report The purpose of Mrs Skidmore’s report was to inform Primary Care Committee of:-

The 2018/19 month 12 final position

The proposed budget allocation for 2019/20 financial year

The updated Five Year Forecast Position Key issues or points to note were:-

The final 2018/19 position for the Co-commissioning budget was a small non recurrent surplus of £286k.

The submitted financial plan for 2019/20 shows that the CCG is forecasting to exceed its allocation by £1.5m.

The underlying cost pressure in future years is detailed in the five year financial plan. Mrs Skidmore’s report reviewed the situation in 2018/19 in order to provide a formal record of how Shropshire CCG exited that financial year. The remainder of her report looks forward to 2019/20 and then considered the five year outlook for the delegated budget itself. In 2018/19 the CCG had a small non-recurrent surplus of £286k. No other feedback was received from the Auditors and the accounts were signed off to reflect those figures. Mrs Skidmore referred to the position for 2019/20 and referred to the impact of the changes, mandated on a national level, which saw the CCG’s allocation being reduced by £1.5m. The two core reductions were for Indemnity, and an adjustment to the allocation to reflect the fact that allocations were set on an estimated value of the GMS rate per patient which was lower in the final settlement, therefore CCGs nationally had the difference taken away as it was assumed that they should not need it. This deduction is compounded by a series of commitments within the Plan that the CCG must fund, including the payments to enable the CCG to establish Primary Care Networks and its contribution towards the Clinical Directors’ Forum. Every CCG in the country has been subject to the same adjustments and some have written individually to express their concerns regarding the additional pressure on their budgets. The Finance Plan includes details of the pressure that the £1.5m reduction on the allocation is placing on the CCG. It has been made very clear in all of the CCG’s reporting to NHS England that this figure contributes to the CCG’s overarching deficit. The CCG has updated the 5 year planning model, but there is concern that allocations may still be subject to change. Difficulties are being experienced in forecasting spend accurately as it is not yet known what the target will be in terms of spend related to the Five Year Plan.

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Mrs Skidmore wished to emphasise that the position being reported is before any assumptions are made on the Five Year Plan requirements. Mrs Skidmore invited questions, and Mr Timmis commented that very little of the budget for this is actually controllable. The message conveyed to the Governing Body has been that in Years 3, 4 and 5 the financial situation it is going to get much harder and care must be taken when providing the Governing Body with figures. Finally, Mr Timmis queried whether the figures contained within the table in the report were based on decisions that have been made regarding premises. Mrs Skidmore confirmed that the table in her report did include the recommendations in the Estates papers being presented to Committee today. Any further premises decisions made going forward would need careful consideration given the financial position. Mr Timmis expressed concern with the uncertainty of figures and impact of the Five Year View and asked that future presentation of the plan made the position clear, particularly with regard to estimates or uncertainty. Mrs Wilde and Mrs Skidmore both agreed that the majority of this budget is nationally mandated and reduction of spend would only be achieved if some of the Practices decided not to deliver elements of their contract which would impact on patient care. Mrs Skidmore asked the Committee to bear in mind that contingency was contained within the budget. The contingency currently offsets the QIPP requirement provided it is not required for anything else in year. Dr Stanford referred to the control of prescribing and dispensing costs. Mrs Wilde advised that a QIPP of just over £4m is in place for Medicines Management for this coming financial year and plans are in place to deliver that. The Committee noted the contents of the report. PCCC-2019-06.041 – Primary Care Risk Register The purpose of Mr Ellis’s report was to provide Primary Care Commissioning Committee with an update to the Risk Register for discussion and approval. Key points to note were:-

The reports are received every four months and the report had been re-numbered to reflect the fact that it now represented 2019/20.

The Register had been updated following comments received at Primary Care Committee in February.

The two Risk Registers – one for Delegated and one for Non Delegated – have been combined into one document.

The Committee agreed that references to Ms Dawn Clarke should now be replaced with Mrs Christine Morris’s name. The Committee noted the contents of Mr Ellis’s report. PCCC-2019-06.042 – Shifnal Premises Development Full Business Case Dr Stanford welcomed to the meeting Mr Ashley Seymour from Assura, Dr Shore, and Ms Louise Linning, Acting Practice Manager, Shifnal & Priorslee Practice. The purpose of the report submitted to Committee was to outline the amendments made to the Full Business Case (in the form of an Addendum) to address the deferral made by PCCC in February for the development of new premises for Shifnal & Priorslee Medical Practice.

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Key issues or points to note were:-

PCCC considered the Full Business Case (FBC) at its meeting on 6th February. A decision

was deferred due to the need for further work to take place in a range of areas. Considerable

work has taken place and is presented for decision at this meeting in an Addendum document.

A new building will result in a significant increase in rent of £151,047 including VAT, plus an

increase in rates on an already pressurised CCG budget.

There is time limitation on the availability of ETTF monies allocated to this scheme which

should be considered.

The options for Committee to consider are:-

Approve the request in full

Approve the request in part

Decline the application and request that the Practice provide a revised plan to support

redevelopment of their existing premises

A representative of the developers – Assura - gave a presentation on the Addendum and the

Business Case. Key points were:-

The current sub-standard premises are placing a constraint on services that can be provided

from that base

The Practice has a patient list which is consistently growing year on year, an ageing

population, and is the only Practice in Shifnal

Massive growth in housing developments has been seen over the last few years in Shifnal

An allocated site has been identified for a new Primary Care Centre with space to expand in the

future should this be necessary. Completion would be January 2021.

Louise Linning, Acting Manager for Shifnal & Priorslee Medical Practice, expanded on several areas

highlighted within the Addendum which would impact positively on patient care and allow the

Practice to act as hosts to a wider community, e.g. Community Teams, Safeguarding Teams, Social

Care services, etc.

Access and size risks at the current premises were reviewed. As the ageing population grows, the

current building will not cope with demand during the hours that the allied professions work. The

current surgery is 98% full 2 days per week.

Mrs Wilde asked whether agreement had been reached that the GP partners would hold the lease

for the building. Dr Shore confirmed that the GP partners will hold the lease, subject to any

assignment at a future point to an alternative party to safeguard patient care.

Mr Timmis observed that the information within the paper appeared to be very much focused on

Shifnal without taking account of the needs of patients across the whole of the area. As the scheme

moves forward, due consideration must be taken of the needs of all the patients in the area and how

they are best served. Mr Timmis expressed his support for the paper and all recommendations

contained within it.

Discussion followed regarding the needs of the population of Shifnal and ease of access to the

proposed Priorslee building. 30% of patients required mobility assistance, there was a lack of

public transport, and a lack of footpaths for patients who may wish to walk to the Priorslee surgery.

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Mr Ellis requested approval by Committee of the revenue funding for lease of the building,

and also approval of the Business Case.

He also requested Committee approval of the request for capital funding contained within the

Business Case. The recommendation is that the CCG funds the Stamp Duty, Land Tax and

GP Legal Fees.

Mrs Skidmore advised the Committee that modelling assumptions had been included in the budget

and this would not place any further burden to the budget position. However, she asked the

Committee to note that the additional request for capital would be an additional cost to the plan as

there is no budget for this funding, although her understanding was that these costs will not become

due for some time and can be planned for in the budget. Mr Ellis confirmed that this funding will

become payable on completion.

The Committee approved the Full Business Case and the request for funding as outlined above.

PCCC-2019-06.043 – Riverside Medical Practice Final Business Case The Committee welcomed representatives of Riverside Medical Practice - Dr Sarah Harwood, Dr Simon Hodson, and Ms Tracey Willocks, Practice Manager. Mr Tim Smith from Shropshire Council was also in attendance. The purpose of the report was to provide Committee with the Full Business Case for a new Primary Care Centre for Riverside Medical Practice, following approval of an Outline Business Case in August 2018. The Full Business Case was attached to the paper, together with proposed plans and Shropshire Council’s financial business case. Committee were specifically asked to note the impact this will have on CCG Finances from April 2020 as outlined in Section 9. Dr Harwood provided a brief history of the current situation, stating that patient numbers had dipped slightly over several years from 12,500 to 10,000, largely due to the uncertainty over premises. However, patient numbers are now increasing. The current premises are in a state of disrepair and are not fit for purpose. Building of the new premises is progressing well and once they are complete, the current premises will be vacated allowing the Local Authority to continue with their plans for Shrewsbury Town Centre. Mr Smith confirmed that all the figures contained within the Business Case had been checked by the Finance Director of Shropshire Council and the District Valuer. Discussions had also taken place with Officers of the CCG and Shropshire Council. The project is on target. Mrs Alamanos confirmed that discussions had taken place with the District Valuer regarding parking provision and the figure now presented to Committee was inclusive of 22 car parking spaces and provision of an ambulance “pull in” which was not previously included. Mrs Wilde thanked all parties involved for their hard work and confirmed that the Primary Care Directorate is supporting the Business Case. Mrs Skidmore confirmed that certain assumptions had already been made around finances for this project in future modelling. She will also ensure that provision is made for the capital funding in the future. As requested, the Committee approved:-

the Full Business Case for the development of the new premises for Riverside Medical

Practice on The Tannery Site in Shrewsbury Town Centre;

Agenda Item - GB-2019-09.125

CCG Governing Body – 11.09.19

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the funding of £224,160 including VAT for the recurrent costs of the lease, plus £34,650

including VAT for the recurrent costs of the car parking spaces of the development in line

with Section 9.2 of this Business Case. Taking into account the existing Notional Rent, this

equates to a total increase of £211,410 on the CCG Revenue budget.

funding for the one-off capital costs for SDLT & GP Legal costs only, totalling £48,000 including

VAT outlined in Section 9.3. PCCC-2019-06.044 – NHS England Update Mrs Alamanos had provided Mrs Wilde with a confidential NHS England Update which was for information of the Part 2 meeting only. ACTION: Mrs Wilde to circulate the NHSE Update to Part 2 members only. PCCC-2019-06.045 – Cycle of Business (for information only) Mr Ellis provided a verbal update and requested the Committee’s view of the Operational Plan. Reports or Business Cases will be brought to Committee by exception. The highlight report – which is the Operational Plan – would provide an overview and should any areas require to be expanded upon, that information would be submitted as a separate paper, e.g. when the Primary Care Networks are confirmed. The Committee suggested that an annual overview should be brought to Committee to review all topics and once a year a “deep dive” should be carried out on all issues reviewed throughout the year. The next “deep dive” is scheduled for the August Committee. PCCC-2019-06.046 – Review of Audit Recommendations The purpose of Mrs Wilde’s report, which had been circulated for information only, was:-

To confirm to Primary Care Commissioning Committee that actions from the internal audit undertaken in February 2018 are complete

To inform Primary Care Commissioning Committee of a non-delegated Primary Care Audit Outcome for completeness

To inform Primary Care Commissioning Committee of the delegated internal audits for 2019/20 to be undertaken in Quarter 4

The Committee noted the contents of the report. PCCC-2019-06.047 – Any Other Business There was no other business. PCCC-2019-06.048 – Date of Next Meeting The next meeting will take place on Wednesday 7 August 2019, commencing at 10.00 a.m. in K2, William Farr House.

Agenda Item - GB-2019-09.125

CCG Governing Body – 11.09.19

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1

Agenda item: GB-2019-09.126

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

Quality Committee

Date of Meeting:

26 June 2019

Chair:

Meredith Vivian, Lay Member, Patient and Public Involvement

Key issues or points to note:

Significant workforce pressures across SaTH impacting on quality and statutory targets. Over

70 nurses recently recruited from India to alleviate nursing pressure and reliance on Bank and

agency staff.

SaTH Chief Executive left on 20 June.

Concern growing over the increasing time taken to assess children with potential ASD.

Shrewsbury MLU closed for building work; mothers offered birthing at Telford MLU,

Consultant-led or home births.

Guidance and supportive materials were received from the Medicines Management

Department:

- Medicine review of care home residents;

- Shropshire CCG Memorandum of Understanding GP practice agreement;

- Guide to repeat prescribing.

The Committee considered the materials and supported their circulation but requested that

Chris Morris, Chief Nurse for Shropshire, should seek clarification where such material should

best be signed off in the future.

Transforming Care Partnership had seen recent staff departures amongst key personnel;

back-filling these roles may lead to pressure within the Directorate. Pressure continues in

finding appropriate placements for the more complex and challenging patients from secure to

community settings; the CCG has been placed on ‘red’ by NHS England and must now report

on a monthly basis.

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The Committee heard that there continues to be concerns over Continuing Healthcare and its

management: staffing needs reviewing, levels of overturned cases after review remain high,

and timescales for assessment and decision-making are too long. Work is underway to review

the entire system.

Actions required by Governing Body Members:

To note.

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Shropshire Clinical Commissioning Group

MINUTES OF THE QUALITY COMMITTEE

HELD IN ROOM B, WILLIAM FARR HOUSE

AT 2.00PM ON WEDNESDAY 26 JUNE 2019

Present Mr Meredith Vivian Lay Member – Patient & Public Involvement (Chair) Mr Keith Timmis Lay Member Mrs Christine Morris Chief Nurse Dr Alan Leaman Secondary Care Consultant Ms Lynn Cawley Chief Officer, Healthwatch Shropshire Mrs Chris Billingham Personal Assistant; Minute Taker

QC-2019-6.078 (Agenda Item 1) - Apologies Mr Vivian welcomed members and those in attendance to the meeting. Apologies were received from Dr Julie Davies, Dr Jessica Sokolov, Dr Finola Lynch, Mrs Gail Fortes-Mayer, Mrs Sarah Porter, and Ms Sam Bunyan. QC-2019-6.079 (Agenda Item 2) - Members’ Declaration of Interests There were no declarations of interest. QC-2019-6.080 (Agenda Item 3) – Minutes/Actions of Previous Meeting held on 29 May 2019 and Action Log The minutes of the previous meeting held on 29 May 2019 were reviewed and approved, provided the following amendment is noted:- Page 4 – Healthwatch Ms Cawley referred to Paragraph 1 and advised that Healthwatch had been asked to repeat their work on Bee U 0-25 Emotional Health & Wellbeing Service by MPFT, and not Shropcom as stated in the Minutes. The Action Tracker was reviewed and updated as appropriate. QC-2019-6.081 (Agenda Item 4) – Quality Exception Report The purpose of the report was to provide assurance to the Governing Body that processes are in place to monitor quality indicators and escalate and ensure remedial action is in place where poor performance is identified. Key issues or points to note were:-

Staffing levels remain a concern across Shropshire and Telford Hospitals

The ‘Safe Today’ report is being reviewed to provide greater assurance

CQC report following their visit in April is still awaited

SaTH’s Chief Executive left his post on 20.06.19

Concerns regarding the increasing waiting list for children with ASD to be seen by MPFT A new Interim Chief Executive has been recruited for SaTH and will commence in post at the end of July. A new Interim Director of Nursing and two Associate Directors are now in post. Over 70 nurses have been recruited from India who will commence employment during the next six months. This will reduce the dependency on Bank and Agency staff. The Chair of the NHSEI Assurance Group is satisfied that progress is being made. ACTION: Mrs Morris to include in her Exception Report going forward a copy of the paper she prepares each month to update Telford Quality Committee following the NHSEI Assurance Group meeting.

Agenda Item – GB-2019-09.126

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The Shrewsbury MLU has been closed due to building issues and women are being offered the opportunity to deliver their babies in the MLU at Telford, the Consultant unit, or to opt for a home birth. Attempts are being made to increase the number of Midwife-led births. Dr Leaman queried this information and Mrs Morris replied that the Better Births document, which is a national driver, requires CCGs to increase the number of Midwife-led births as that improves outcomes for women and babies. ACTION: Mrs Morris to meet with Dr Leaman outside of the meeting to update him on the work of the local Maternity system. The outcome of the Ockenden Review of Maternity services commissioned by the Secretary of State is awaited, but is not expected for several months. The report following the CQC visit to the Trust in April is still awaited. Mr Vivian referred to Paragraph 7 on Page 3 of Ms Bayley’s report which made reference to the setting up of a Task & Finish group and requested clarification of membership. Mrs Morris advised that those involved in the group would include Dr Sokolov (Medical Director), Mrs Old (Urgent Care Director), herself, and the Trust’s operational lead for Emergency Department (ED). Mr Vivian referred to Paragraph 14 and the reference to an erroneous diagnosis of ASD having an effect on waiting lists. Mrs Morris stated that the Mental Health Trust are advising the CCG that over 50% of the referrals they receive each month for children and young people are related to a need for diagnosis of ASD or ADHD. Mrs Beck is working with schools, as there is a desire from teachers to look at which referrals are appropriate to enter the system. This work is ongoing. QC-2019-6.082 (Agenda Item 5) – QRS Final Report Letter This review was carried out because NHS England required assurance that quality processes were robust, given the challenges that currently exist in our system. The outcome of the report on the two CCGs was positive and David Stout, Shropshire CCG’s Accountable Officer, wished this to be placed on the Agenda of Part 1 of the Governing Body meeting. Learning points within the document will be reviewed and this will be brought back to Quality Committee in September. The Committee approved this item being placed on the Agenda of the Governing Body. QC-2019-6.083 (Agenda Item 6) – Healthwatch Ms Cawley provided a verbal update to the meeting, as follows:- Healthwatch has completed the Peri-Natal Mental Health Report which, for clarity, has been renamed the Maternity Mental Health Report. The report is in line with the overarching work that Healthwatch England are carrying out relating to Maternity Mental Health and has been shared with the Local Maternity Systems (LMS) for comment. This feeds into a much bigger piece of work by NHS England and Healthwatch England on the STP Long Term Plan. Healthwatch Shropshire have coordinated this piece of work with Healthwatch Telford & Wrekin and engaged with over 600 people to obtain their views on how improvements could be made to their experience of using the NHS. This has been sent to the STP in draft form and feedback is awaited. Ms Cawley was contacted by NHS England asking Healthwatch Shropshire to contribute to a Serious Incident Network Event for the West Midlands, and supply a patient story. Mr Peter Jeffries, Associate Director of Quality, Governance & Risk at SaTH had requested a meeting in July to discuss how the Trust engages with families. Mrs Blay, Patient Safety & Quality Co-Ordinator, will be invited to attend this meeting. QC-2019-6.084 (Agenda Item 7) – Medicines Optimisation Strategy Quality Update Medicine Review of Care Home Residents – Guidelines and Resource Pack The purpose of the report compiled by Dr Catherine Lowe, Clinical Lead – Care Homes, was to gain the Committee’s approval for the guidance to be used in GP Practices within Shropshire. Key issues or points to note were:-

The number of medicines taken by patients rises with age and this can increase significantly for those living in care homes as they tend to be frailer with several co-morbidities.

Prescribing for frail people who live in care homes can often be challenging due to the many variables that must be considered.

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The guidelines are designed to provide the prescriber with a succinct overview of the key elements of medicine review.

Dr Lowe provided the Committee with the background to her guidelines, advising the Committee that she had been involved in delivering GP training on medicine review, an area which is coming increasingly to the fore. Feedback from that training was a desire for more resources and information on the process of reviewing medicines of our frail and older community, which resulted in her compiling the Guidelines and resource pack. Discussion followed and Committee members expressed doubt as to whether Quality Committee was the correct forum to approve the Guidelines. The Committee queried whether the guidelines should be directed towards Clinical Commissioning Committee. Mrs Morris was of the opinion that the reports should be submitted to Primary Care Committee as there is a clear overlap between the CCG function and the Primary Care oversight. ACTION: Mrs Morris to discuss the best forum for Medicines Management reports with Ms Michell-Harding. The remaining reports submitted by Medicines Management were drawn to the attention of the Committee as follows:-

Shropshire CCG Memorandum of Understanding GP Practice Agreement

GP Practice Agreement

Shropshire CCG Guide to Repeat Prescribing

Shropshire CCG Medication Review Guidance

Repeat Prescribing Guidelines The Committee received the documents and supported their use in the manner described. QC-2019-6.085 (Agenda Item 8) – Transforming Care including LEDER Transforming Care Ms Bayley’s report provided Committee with a brief overview of the programme and lessons learned over the past three years in relation to:

Ensuring the safe repatriation of individuals with learning disabilities who may present as a risk to themselves and/or others back into the community, within the challenges of the timeframes set out nationally.

Ensuring that monitoring processes are robust to aid prevention of people in the community at risk of admission going into hospital

Working with commissioners/ housing and other work streams on the service developments required to meet the agenda for current and future individuals requiring such care

Key issues or points to note were:-

The TCP Care Coordinator left in January and the TCP Operational Lead left in March. Capacity to take this work forward was agreed by the four partners and is in place. However this additional requirement has the potential to impact on other areas of CCG working.

On target reduction of NHSE patients from secure hospital (24 in 2017 12 in March 2019).

Off trajectory for CCG patients (5 in 2017 to 9 in March 2019).

Monthly multi agency dynamic risk register review meetings occur in both Local Authority areas.

A comprehensive Workforce Plan has been developed and submitted to NHS England which is aligned to the Shropshire Sustainability and Transformation Partnership (STP) workforce planning priorities.

Children and Young People Focus Group has focused on review and delivery of an ASD pathway. Work has been undertaken across the system - including working with parents and carers - to understand what support is available and required.

Discussion followed around staffing and resource issues and the difficulties involved in finding appropriate placements for the more complex and challenging patients within the community. The CCG is over its trajectory for CCG patients, partly because it is on trajectory for NHS England patients. As a result of being off trajectory, the CCG has been placed on Red Alert by NHS England and now provides them with monthly assurances and participates in weekly calls in order to provide a higher level of assurance around plans for care. Mr Vivian queried whether the figure of £990k referred to in Paragraph 6.3 of Ms Bayley’s report was recurring and Ms Bayley confirmed that it was not. The allocation for 2019/20 is not yet known.

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LeDeR The Committee received and noted the contents of Ms Bayley’s report, the purpose of which was to provide an update of the LeDeR programme and its aim to reduce health inequalities and support services by embedding the learning from the LeDeR reviews across Telford & Wrekin and Shropshire. Key issues or points to note were:-

The reduction of the premature mortality of people with a learning disability has been identified as one of the four main priorities for the NHS for the next 10 years. The Learning Disabilities Mortality Review (LeDeR) programme is a national project to review the deaths of all patients with Learning Disabilities. 49 deaths have been notified since the programme started in June 2017.

29 deaths of Shropshire patients with Learning Disabilities were reported to the LeDeR programme between April 2017 and March 2019. Of these, 16 patients died in hospital (1 in Birmingham), and 12 died in their usual place of residence i.e. either a care home or their own private home.

The causes of death and the learning from the reviews is predominantly in line with national feedback from the LeDeR programme.

Two of the reviews were graded as excellent care. Ten reviews have been graded as good care. One was identified as having some gaps in care but did not contribute to the death, and in one case it was considered following the review that gaps in care may have contributed to the death. This case went to Coroner’s inquest with the learning shared across the Trusts.

Shropshire / Telford and Wrekin remain one of the best performing CCG’s nationally, having a low number of unallocated cases, and a high number of completed cases.

The Committee had no questions regarding Ms Bayley’s report, and the Chair thanked her for her update on the LeDeR programme.

QC-2019-6.086 (Agenda Item 9) – Continuing Healthcare (CHC) and Complex Care The purpose of the report was to provide an update to the Quality Committee (QC) about the current CHC appeals and to note the specific areas highlighted within the report. Committee members were asked to note the contents of the report and consider the recommendation for additional resource. Points to note were:- Shropshire

There are currently 88 outstanding CHC appeals in Shropshire. The conversion rate over the last few years of

decisions being overturned upon appeal is approximately 15%. It should, therefore, be forecast that

approximately 13 decisions will be overturned. Due to the varying timeframe of appeals and also package cost it

is not possible to accurately forecast likely financial impact.

Telford and Wrekin

There are currently 9 outstanding CHC appeals in Telford and Wrekin. The conversion rate over the last few

years of decisions being overturned upon appeal is approximately 10%. It should, therefore, be forecast that

approximately 1 decision will be overturned. Due to the varying timeframe of appeals and also package cost it is

not possible to accurately forecast likely financial impact.

Additional staffing and resource will be considered as part of the future team plans and the potential future plans

to become a single organisation.

The data revealed that there are a large number of cases being overturned by the local independent review panel

and our external panel which provides some assurance to the Committee that the correct decisions are being

made. There is a backlog in Shropshire which must be addressed as it carries a financial risk. Mrs Morris has

asked the Finance team to analyse the funding from overturned cases and utilize that figure to enable forecasting

of financial risks and provide a basis for making an accruals decision.

Resources and workforce across the Complex Care Teams of Shropshire and Telford and Wrekin are being

reviewed. Mrs Morris will take a paper to the next Executive Team to outline how to address demand in relation

to retrospective cases and appeals. A system is now in place to log appeals as they are received.

Mr Timmis requested a quality check of certain figures contained within the report if they were to provide the

basis of a financial assessment.

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Going forward, Mrs Morris will bring to the Committee anything which is pertinent for assurance purposes.

QC-2019-6.087 (Agenda Item 10) – Quarterly Safeguarding Children Report Mrs Braun, Designated Nurse for Looked After Children, attended Quality Committee on behalf of Mr Coan who

was on annual leave.

The purpose of Mr Coan’s report was to provide an update to the Quality Committee [QC] about the functioning of the CCG’s statutory responsibility to safeguard children and Looked After Children, and to note the specific areas highlighted within the report. Key issues and points to note were:-

Work in relation to the Joint Targeted Area Inspection continues. A gap was identified during the JTAI in relation to substance misuse and support for children who may misuse substances and have mental health issues. A worker with mental health qualifications who is supported by Midlands Partnership Foundation Trust (MPFT) has been appointed to Addactions – a drug and alcohol addiction charity - to address this gap.

Changes have been made to the original plan to merge the Child Death Overview Panel (CDOP) with Hereford and Worcester CCG. Telford & Wrekin and Shropshire will continue to have one CDOP, but will share themes and trends with the other CDOP panel. This process now falls short of the suggestions by the Government’s national guidance around CDOP panels. This was discussed with NHSEI who recognize that Shropshire CCG falls under the 60 deaths per year threshold. However, due to the CCG’s rural nature this could be accepted by the national panel, although the national team may still wish us to join with another CDOP. Hereford and Worcester are in a similar position. The recommendation was submitted on 24 June and confirmation is awaited from the National CDOP panel as to whether it is acceptable.

A new Strategic Partnership Board has been established which has oversight of the existing Adults and Children Safeguarding Boards. Existing Boards will become forums for sharing information and will no longer have decision making responsibilities.

Shropshire CCG are on schedule to meet the target of 20% of Health Passports being delivered, which is the

national average.

The Committee noted the changes to configuration of the Safeguarding Boards and CDOP panel, which may change the level of information being presented to Quality Committee in the future. Updates on this will be provided when the new arrangements are established.

QC-2019-6.088 (Agenda Item 11) – Points to Escalate to CCG Board

There were no points to escalate to the Governing Body.

QC-2019-6.089 (Agenda Item 12) – Any Other Business Dr Leaman queried whether drafting Guidelines was the function of the CCG. Discussion followed and

Mr Timmis stated that this could be a legitimate mechanism in promoting quality. However, there is an issue in

that there is no obvious Committee structure to monitor and review processes.

Mrs Morris commented that the CCG is the owner of the Medicines budget, and the guidelines will enable it to

have a level of control over prescribing in the community. She believed that this was standard practice but will

obtain clarity on this point in order to avoid duplication of effort.

ACTION: Mrs Morris to obtain clarity on drafting of Commissioning Guidelines by the CCG.

QC-2019-6.090 (Agenda Item 13) – Date and Time of Next Meeting The next meeting will take place on Wednesday 31 July 2019 at 2.00 p.m. in Meeting Room B, William Farr House.

1

Agenda item: GB-2019-09.126

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

Quality Committee

Date of Meeting:

31 July 2019

Chair:

Meredith Vivian, Lay Member, Patient and Public Involvement

Key issues or points to note:

In 2016 NHS England issued a framework to support the development of ‘Enhanced Care for

Care Homes’. The CCG, working with all health and social care partners, has developed a

Shropshire-wide strategy for delivery comprising: enhanced primary care support; MDT support;

rehabilitation and re-ablement; high quality ‘end of life’ and dementia care; joined-up

commissioning across health and social care; workforce development; data, IT and technology.

Work to progress continuous improvement across the seven standards will be reported on a

quarterly basis.

New Safeguarding Board arrangements are being put in place. The new Board is the

responsibility of CCG, Police and Local Authority equally.

Refreshed arrangements have been put in place to establish robust management of

Continuing Healthcare including closer monitoring of high-cost packages; responding to

recommendations of auditors (to report to next Audit Committee); assessment of historical

cases; CCG funding of only the healthcare element of cases. Future reporting to QC should

include details of: appeals, backlogs, reviews, complaints and lessons learned.

Actions required by Governing Body Members:

To note.

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Shropshire Clinical Commissioning Group

MINUTES OF THE QUALITY COMMITTEE

HELD IN ROOM B, WILLIAM FARR HOUSE

AT 2.00PM ON WEDNESDAY 31 JULY 2019

Present Mr Keith Timmis Lay Member for Audit & Governance (Chair) Mrs Sarah Porter Lay Member for Transformation Mrs Christine Morris Chief Nurse Dr Julie Davies Director of Performance & Delivery Dr Alan Leaman Secondary Care Consultant Ms Lynn Cawley Chief Officer, Healthwatch Shropshire Ms Samantha Bunyan Head of Quality (Part Meeting Only) Mrs Chris Billingham Personal Assistant; Minute Taker

QC-2019-7.091 (Agenda Item 1) - Apologies Mr Timmis welcomed members to the meeting. Apologies were received from Mr Meredith Vivian, Dr Jessica Sokolov, Dr Finola Lynch, and Mrs Gail Fortes-Mayer. QC-2019-7.092 (Agenda Item 2) - Members’ Declaration of Interests There were no declarations of interest. QC-2019-7.093 (Agenda Item 3) – Minutes/Actions of Previous Meeting held on 26 June 2019 and Action Log The minutes of the previous meeting held on 26 June 2019 were reviewed and approved, provided the following amendment is noted:- Page 5 – Any Other Business Dr Leaman referred to Paragraph 1 of this item which stated that “Dr Leaman queried whether drafting Commissioning Guidelines was the function of the CCG”. He wished this to be amended to read “Dr Leaman queried whether drafting Guidelines was the function of the CCG”. The Action Tracker was reviewed and updated as appropriate. QC-2019-7.094 (Agenda Item 4) – Commissioning Requirement for the Enhanced Care Home Framework Dr Davies referred to the paper which was submitted to the Clinical Commissioning Working Group which she intended to circulate to Committee members for information. Dr Davies proposed that she and Alison Massey should provide an update to Quality Committee on a quarterly basis. A framework was issued by NHS England in 2016 regarding Enhanced Care for Care Homes in which there were seven care elements:-

Enhanced Primary Care support

Multi-disciplinary team support

Rehabilitation and re-ablement

High quality End of Life and Dementia care

Joining up commissioning collaboration between Health and Social Care

Workforce Development

Data, IT and Technology Within the framework there were 48 standards within the 7 headings.

Agenda Item – GB-2019-09.126

CCG Governing Body – 11.09.19

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A recent audit across Shropshire Telford & Wrekin revealed that the combined organisation is Green on 24 of the standards, Amber on 13, and Red on 7. Additional information is required on 4 of the standards before a rating can be confirmed. The Working Group had supported the establishment of a system-wide Care Home Working Group to co-ordinate the work streams which would be led by Alison Massey. Shropshire has in place a Care Home Advanced Service which is an enhanced service for Primary Care. Shropshire CCG and the Local Authority have agreed to carry out a joint Local Authority and NHS review of that service in order to consistently meet the standards contained within the framework. A Care Home Dashboard will be developed in order to monitor Care Home emergency admissions which will monitor such admissions by Care Home, length of stay, readmissions within 30 days, and deaths in hospital via Care Home, in order to identify trends and areas for improvement. The CQC has issued data for Shropshire Telford & Wrekin relating to Care Home domiciliary care, A&E performance, A&E attendance and admissions, etc. As at Q3 2018/19 both CCGs had exceeded both their comparator group and the national average for the first time. Dr Davies has asked the local Business Improvement team to replicate the data source for Q1 which will be used to inform the Care Home Dashboard. Dr Davies’ paper will be submitted to Clinical Commissioning Committee in August. ACTION: Dr Davies to provide Quality Committee with quarterly updates on the Enhanced Care Home Framework. Dr Davies to circulate the paper submitted to Clinical Commissioning Working Group regarding the Enhanced Care Home Framework QC-2019-7.095 (Agenda Item 5) – Provider Exception Report Ms Bunyan’s Exception Report was taken as read. The purpose of the report was to provide assurance to the Committee that processes are in place to monitor quality indicators and escalate and ensure remedial action is in place where poor performance is identified. Key points of the report were:-

Urological and breast cancer waits remain a concern

Staffing levels remain a concern across Shropshire and Telford Hospitals

Safe today report system has been reviewed to provide greater assurance

CQC report following visit in April is still awaited

An estates and clinical task and finish group are meeting to scope and assess potential locations for the MLU

A Commissioning solution for the ADHD assessment waiting list is in progress Shrewsbury and Telford Hospitals NHS Trust (SaTH) Mrs Porter referred to Paragraph 4 of the Executive Summary and expressed her concern that “significant concerns” had been identified on the Neo Natal Ward regarding cleanliness, laundering of baby linen and expressed breast milk. Ms Bunyan advised that Mrs Kidson will receive updates at the Infection Prevention & Control Committee. A return visit by NHS England and NHS Improvement will take place in October. NHS Improvement have carried out a follow-up review since the original visit and, following remedial actions taken by the hospital, are now satisfied. The Action Plan is being monitored via CQRM. Dr Davies referred to Paragraph 6 and asked the Committee to note that the issue is not breast cancer, but the symptomatic breast. She asked the Committee to be assured that although there are delays in the ‘appointment within 14 days’ criteria and appointments are currently around 20 days, no-one is failing the 62 day target in breast cancer. The issue with appointments relates to Radiographer and Radiologist capacity. Mrs Porter queried the information contained within Paragraph 13 regarding the Safe Today Review. Mrs Morris advised the Committee that, in view of issues experienced, a decision was taken to review the trigger tool for the calls. The Emergency Care and Intensive Support Team have a trigger tool that is used in other places and it was agreed with the Trust that this tool would be considered in order to establish whether it was more sensitive to fluctuations in workforce and risk issues within the Emergency Departments. The Trust were to send the tool to Mrs Morris but it has not yet been received by her. Processes should have been put in place by 1 August 2019 but this target will now not be achieved. Once received, a process will be implemented whereby that trigger tool is used to provide both a weekly report and a comprehensive monthly report that is submitted to the Quality Review meeting to review and utilize them in the management of risk.

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Mr Timmis expressed the view that the main concern of Quality Committee would be the accuracy of the information being provided by SaTH in view of past issues. Dr Leaman referred to Paragraph 10 of the Executive Summary to the report which stated that only 58% of staff have completed basic paediatric life support. Ms Bunyan advised that the figure relates to anyone who has completed paediatric life support as part of their mandatory training. However, the data that is received is not broken down into departments or staff groups. An update is expected mid-month as it has been acknowledged that the data was not at all helpful. A nurse who is trained in Advanced Paediatric Life Support is on duty in an Emergency Department every shift, but the data provided to the CCG was not detailed enough to provide assurance in any other area. ACTION: A report to be submitted to the August Quality Committee by Ms Bunyan regarding improved collection of Paediatric Life Support data. Primary Care Dr Leaman queried the figures stated in Paragraph 29 relating to the rate for Primary Care utilization of appointments, which included extended access. A follow up report will be submitted to Primary Care Committee. Robert Jones Agnes Hunt Orthopaedic Hospital NHS Foundation Trust The Committee noted that reference in Paragraph 25 to the Emergency Care Intensive Support Team visiting Robert Jones and Agnes Hunt Orthopaedic Hospital should in fact be the Elective Care Intensive Support Team. Midlands Foundation Partnership Trust Discussion took place regarding Appraisal Rates as outlined in Paragraph 26 and Mr Timmis requested information relating to appraisal rates –v- targets. Mrs Morris advised that the targets are 95% with a fluctuation across departments and teams. The lowest target is around 75%. The Trust has a live dashboard from which they provide the CCG with a snapshot. This can be used to provide more information to the next Committee, and also to update the Committee on a monthly basis. The Committee referred to Paragraph 28 and requested information relating to the timescale for 0-25 ADHD assessments. Ms Bunyan believed that the waiting list had been reviewed and those who had been waiting for more than a year will be offered urgent appointments. A new service has been commissioned which will deal with the backlog. QC-2019-7.096 (Agenda Item 6) – Adult & Children’s Safeguarding Q1 – New Safeguarding Board Arrangements Mr Coan’s report was taken as read. In 2018 the CCG were advised of changes to the manner in which Safeguarding Boards operated. Under the new system there had to be equal partnership between health, police and the Local Authority. Previously, the Local Authority was the Lead. A Shropshire Safeguarding Partnership is being established which will consist of the Chief Nurse, Shropshire CCG; the Director of Children’s and Adult Services of the Local Authority; and the Chief Police Officer for Shropshire. The same is happening in Telford. Quality Committee noted the changes to configuration of the safeguarding arrangements. QC-2019-7.097 (Agenda Item 7) – Healthwatch Ms Cawley referred to the Maternity Mental Health report compiled by Healthwatch which was discussed at the previous Committee meeting and has now been published. Healthwatch have now published their STP Long Term Plan report and have received assurance that feedback received from the public will be incorporated in the STP Long Term Plan. As a result of a request by the CCG for Healthwatch to be involved in the review of the Shropdoc 111 work, their latest “hot topic” is End of Life and Palliative Care. Healthwatch were initially asked to carry out a survey but did not have the capacity - nor the skills and experience in their staff and volunteers - to have some very challenging conversations. However, members of the public can contact Healthwatch if they wish to share their experience. Healthwatch representatives attended the Serious Incident Network event where the new Patient Safety Strategy was discussed. NHS England are arranging to speak to all Healthwatch organisations in that network about how Healthwatch Shropshire might be involved in the implementation of the framework for patient safety.

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QC-2019-7.098 (Agenda Item 8) – Continuing Healthcare (CHC) and Complex Care The purpose of the report was to provide an update to the Quality Committee on risks identified and progress made in the area of Continuing Healthcare (CHC) and Complex Care service delivery since 20 May 2019. Management of the CHC and complex care provision has been a challenge for some time as a result of a number

of factors:

Changing Executive leadership

Changing Service Managers

Considerable clinical vacancies covered by agency staff

Poor staff morale

Financial overspend, governance issues and legacy issues

Lack of systems and processes

Non-compliance with NHSE targets of 28 days from assessment to decision and implementation of

personal health budget trajectory

Limited assurances from External and Internal Auditors

In a short period of time following a stocktake, clear actions have been taken to progress the challenges

described. Plans will be shared with relevant Committees over the next two months and a monitoring process

with variance reporting put in place. Other actions taken include:-

Processes are now in place to monitor spend on high cost care packages and ensure that individuals

concerned receive the correct care.

Addressing actions requested by the Auditors. This information will be submitted to the next Audit

Committee.

A monitoring process to manage historical decision making which has previously been in excess of the

CCG’s requirements. This may be challenged by the Local Authority. Going forward, the CCG will

fund only the health needs of new patients, which will be identified during initial assessment. Cases

already in the system will be challenged during a programme of review which has been implemented for

existing cases.

Key areas upon which the Committee would wish to receive updates going forward are appeals, backlogs,

reviews, complaints and lessons learned.

QC-2019-7.099(Agenda Item 9) – Points to Escalate to CCG Board

The situation at PRH overnight which had received press coverage

Complex Care: to appraise the Board of the stocktake carried out by Mrs Morris, sensitivities with the

Local Authority, and the significant risks involved with this service currently.

QC-2019-7.100 (Agenda Item 10) – Any Other Business

Dr Davies referred to the Provider Exception Report and the winter planning process and suggested that the

CCG should set an expectation earlier with Providers for flu immunization. Immunization of staff must be a

priority.

ACTION: Mrs Morris to place Flu’ Immunization on the CQRM Agenda.

QC-2019-7.101 (Agenda Item 13) – Date and Time of Next Meeting The next meeting will take place on Wednesday 28 August 2019 at 2.00 p.m. in Meeting Room B, William Farr House.

Agenda Item – GB-2019-09.127a CCG Governing Body – 11.09.19

System A&E Delivery Board Notes & Actions

Meeting Title

A&E Delivery Board Date 25 June 2019

Chair

Dave Evans Time 14:30 – 16:30

Venue / Location

Venue Aldridge Room, Halesfield

Attendee’s

Present: Dave Evans (Chair) Claire Old Julie Davies Pete Mason Paul Shirley Lynn Cawley David Stout Bev Tabernacle Jess Sokolov Jayne Knott (note taker)

Dial in attendees: Paul Baylis (until 3.30pm) Andy Begley Nigel Lee

Apologies: Clive Jones: Jan Ditheridge: Simon Wright: Fran Beck: Amanda Edwards: Jonathan Bletcher

1. Minutes/Actions from previous meeting 28.5.19 Minutes of the previous meeting were approved as an accurate record. Actions:

1. Both CCG’s going out to tender for UTC offer: Request has gone in and it was thought there would be no issues.

2. Update Bed Bridge: No letter has been received from Simon Wright, Simon has now left the Trust so Bev Tabernacle will pick this issue up (regarding CDU assessment unit) Commissioners and SaTH to get together before next delivery board to pull something together. Update at next meeting.

3. SaTH Workforce update: Victoria Rankin to give detailed update at A&E Delivery Group on 2 July. This is needed before the next escalation meeting.

4. Integrated Discharge teams: Accommodation for the Integrated discharge team had been identified, Simon Wright said that wasn’t possible but would look at what else could be done. Dave Evans will pick this up with Bev Tabernacle as SW has now left the Trust.

5. SaTH2Home: Second meeting of this group has now taken place. It was thought that this piece of work would take longer than originally thought. We need to understand what the risk is if SaTH2Home goes and local authorities don’t pick it up. Update at delivery group, then to board.

6. Demand model- ward 35: It was thought that this had been brought forward to open in October. There was a concern on how this ward would be staffed. Pete Mason thought it would be a therapy led ward, this plan hadn’t been agreed internally as the last space utilisation meeting was cancelled Clarification needed on SaTH’s intentions for ward 35 asap. Bev Tabernacle to update A&E delivery group 2 July. Community beds – not managed effectively. SaTH bed management is being radically changed. Today interviews are being held for more DLN’s. Need to revisit service of IV

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Therapies. Exec on-call at weekends from Commissioners need to challenge if there are community beds on the 12 mid-day call, and challenge when the patients will be identified for those beds and when will they be moved, and ask for an update by 15:00/16:00hr. Any issues to be relayed to the Exec on-call at SaTH. Dave Evans to send communication out to all of the on-call from the Commissioning team.

7. Powys Bed issues: Scheduled calls being cancelled by Powys, Andy Begley to check on update.

8. Emergency care dashboard: Julie Davies to update next meeting.

2. Demand and Capacity: Final iteration of the dynamic bed model. Issue around the bed numbers, which there will be an update at the next delivery group on the 2 July and discuss what the options are. Julie Davies made a plea to SaTH that they have one person to own this work. Nigel Lee to write to Edwin Borman. Need dedicated resource. This needs to be closed down by next week (5 July) and the dynamic bed model sorted. Dave Evans also commented that he wants all actions to be completed by the next meeting, if not he wants a clear understanding as to why they haven’t.

3. Winter Plan development: System wide event before w/c 21 July, Claire Old to work out what the date will be due to Boards etc. Dave Evans asked if the planning event could be brought forward a week so the timing is right to bring something back to the next board. Demand and Capacity will be done based on the mitigated schemes. The system winter plan to be agreed by the A&E delivery group early August, then take to August board for agreement, and then recommendations are made to all boards. 30 August draft plan is taken to NHSI&E. Final sign off 30 September due to dates of boards. The plans will be in place with a clear timetable of schemes for introduction to meet winter demand. System wide 5 Year plan -needs to finished by October. Revisit Future Fit in September? The starting point for the plan is the activity assumptions built into Future Fit, once they have been revised. Need clarity on what is going to be produced. Liaise with all groups. STP UEC development plan - the first iteration needs submitting by 5 July, actions were discussed. Identify leads to populate template ready to meet the submission:

Integrated urgent care/Urgent treatment centre – Julie Davies/Fran Beck

Ambulance – Fran Beck, with the opportunity to be supported by Paul Devlin and Jenny Sears Brown.

Hospitals – SDEC– Nigel Lee - Reducing LoS – Tanya Miles/Andy Begley

Digital – Rob Gray? (invite to SAEDG) Plan to go to Lauren Leverton, Claire Old to pull it together then to board members for info. This needs to be a realistic clear plan on what can be achieved.

4. Urgent care stocktake meeting: This letter has already gone to SAED Group and the actions have been allocated from the letter. Dave Evans asked for update at the next group meeting 2 July. Metrics – now shared with NHSE/I CDU criteria – NL/CA in discussions Recruitment plan – NL to update PRH Frailty 5 days – CO to take to Frailty board 26.6.19 Use of HALOS – Agreement received today on what is to be monitored. Trial to run for 3 months, then evaluate. There was some confusion over this. ToC event Shropcom & WMAS – start 1 July Work with GP practices in Telford – This is being worked on Demand avoidance pathways – out to procurement JDa to update Improving demand avoidance pathways in Telford – Teams are out working with practices in Wellington to refer to rapid response. Update 30 bed gap at PRH – NL updated Board on work already in hand Criteria led discharge – NL to refresh with Arne Rose. Changes to staffing and processes at SaTH – NL said work was in hand Respect forms – No implementation plan yet, although commitment made.

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IT Systems for EDs – NHS digital to visit SaTH 26.6.19 BI relating to Urgent care – Peter Fryer – offer of support. Claire to email SAED group members as a reminder that updates needed for the 2 July.

5. STP UEC Transformation plans letter: Discussed earlier on the agenda

6. Chairing this Board going forward: Dave Evans suggested that Paula Clark (new interim CEO SaTH) may want to be the new Chair of this board. Dave happy to Chair meanwhile, although he does chair SAED group also. Bev Tabernacle will speak to Paula next week.

7. Urgent Care Dashboard: Demand continues to be high for ambulance and walk-ins. What is happening to cause peaks. Element of variants in Clinical conditions. Above plan on super stranded across both sites. Discuss and agree what we understand are the key influences. Is the stranded and super stranded numbers person dependant? Is the hypothesis correct? Update at next SAED group meeting 2.7.19.

8. Frailty Collaborative letter: Ian Sturgess is leading this for Pauline Phillip. Ian has been working with the system on stranded patient work for 12 months and is very keen that we form the part of the first collaborative so he can continue working with us on the Frailty component. It was said that Frailty should be the next ToC. Claire has had discussions with Fran Beck and Finola Lynch about which staff should be going to the collaborative. Concentration would be on frailty at the front door, and frailty 72 hours and the transfer into the deep in patient bed as a start of change process. Do we want to be in the first wave? And who are the 8-10 people that are going to go? 3 from Acute, 2-Commissioners, 2-Community, 2-Local Authority, 1-WMAS. Claire to register an interest and put names forward and notification will be 8 July.

9. Acute Medicine/SDEC update and next steps A start of chance week has taken place and a redesign of the ambulatory care into the SDEC. The assessment of patients for admission rather than admitting people directly and there is an assessment area in both sites which have also been linked into short stay. The challenge is staffing these areas, need to be open longer than 9am-5pm, the metrics are being worked out at the moment as it had only finished at PRH on Friday. Virginia Mason have been involved, and the sustainability will be the test. ACP and nursing have had good involvement. Arne Rose is the HiC lead for SDEC. NHS plan requires us to go from 1/5 of SDEC to 1/3. The analysis will go to the internal SaTH urgent care group on a Thursday morning and then to the SAEDG either on the 2 July or 16 July then to board.

10. AOB: Dave Evans to speak to Jan Ditheridge regarding therapy integration anticipated with Shropcom. Need to progress Out of Hospital work. Bev Tabernacle and Dave Evans to meet with Steve Gregory to push forward.

4

Summary of Actions

Action required Owner By when

1. Updated Bed Bridge –. No letter has been received from Simon Wright, Simon has now left the Trust so Bev Tabernacle will pick this issue up (regarding CDU assessment unit) Commissioners and SaTH to get together before next delivery board to pull something together. Update at next meeting.

Bev Tabernacle 23.7.19

2. Integrated discharge teams: Dave Evans will pick this up with Bev Tabernacle as SW has now left the Trust.

Dave Evans/ Bev Tabernacle

23.7.19

3. SaTH2Home: Second meeting of this group has now taken place. It was thought that this piece of work would take longer than originally thought. We need to understand what the risk is if SaTH2Home goes and local authorities don’t pick it up. Update at delivery group, then to board.

Fran Beck 23.7.19

4. Powys LA bed issues - Still challenges with Powys LA around capacity of domiciliary care, which has now been escalated to the Welsh assembly government. Adam Greenough and Tanya Miles to have a conversation about how things are done in Shropshire. Andy Begley to check with Tanya on update.

Tanya Miles 23.7.19

5. Emergency care dashboard - Charles Millar to add A&E trajectory to the dashboard – add trend lines and variants. Julie to update at next Board

Charles Millar/ Julie Davies

23.7.19

6. Urgent Care stocktake letter/actions: This letter has already gone to SAED Group and the actions have been allocated from the letter. Claire to email SAED group members as a reminder that updates needed for the 2 July.

Claire Old 23.7.19

7. Chairing this Board going forward: Bev Tabernacle to speak with Paula Clark about being the new Chair of future meetings

Bev Tabernacle 23.7.19

8. AOB: Dave Evans to speak to Jan Ditheridge regarding therapy integration anticipated with Shropcom. Need to progress Out of Hospital work. Bev Tabernacle and Dave Evans to meet with Steve Gregory to push forward.

Dave Evans Bev Tabernacle Steve Gregory

23.7.19

Agenda Item – GB-2019-09.127b CCG Governing Body – 11.09.19

System A&E Delivery Board

Notes & Actions

Meeting Title

A&E Delivery Board Date 23 July 2019

Chair

David Stout Time 14:30 – 16:30

Venue / Location

Venue Seminar room 2, SECC

Attendee’s

Present:

David Stout (Chair) Accountable officer SCCG Claire Old Urgent Care Director Pete Mason NHSE & I Fran Beck Exec lead for Commissioning, T&W CCG Mark Docherty Director WMAS Emma Pyrah Head of In Hospital, SCCG Steve Gregory Director of Nursing and Ops, Shropcom Paula Clark Interim Chief Executive SaTH Nigel Lee Chief Operating Officer SaTH Nicky Jacques Chief Officer SPIC Tanya Miles Deputy Director, of Adult Social Care, Shrops LA Terry Harte Healthwatch, Shropshire Laura Baker Healthwatch, T&W Gill Harrill STP Jayne Knott STP

Dial in attendees: No-one present

1.Apologies: Andy Begley: Clive Jones: Clive Wright: Jess Sokolov: Jan Ditheridge: Julie Davies: Dave Evans: Mark Brandreth.

2. Minutes/Actions from previous meeting 25/6/19 - Minutes of the previous meeting were approved as an accurate record. Actions:

1. Update bed bridge – To be discussed on today’s agenda. 2. Integrated discharge teams – Nigel Lee to pick up this action with both LA’s. 3. SaTH2Home – To be discussed on today’s agenda 4. Powys LA bed issues – Tanya Miles has a telephone call scheduled for 26 July, then

feedback at next Board. 5. Emergency care dashboard – To be discussed on today’s agenda. 6. Urgent care stocktake letter/actions – To be discussed on today’s agenda. 7. Chairing this Board going forward – To be discussed on today’s agenda. 8. AOB – Steve Gregory and Nigel Lee to meet outside of this meeting. Action closed.

3. CDU Assessment: Accommodation – new fit for purpose accommodation at PRH. Interim solution at RSH.

2

Estates teams have done initial assessments. Usage – what is the usage and how can this be improved. The usage is being monitored on a weekly basis. Deployment – for both sites to man the CDU 24/7, which won’t happen until October. Payment – how is the CDU being paid for? How does the financial challenge get resolved? Need to get commissioning, contracting and finance colleagues to help resolve the issues. Emma Pyrah and Fran Beck to facilitate this and report back to this Board in September with the resolution or outstanding problems why it hasn’t been resolved.

4. Emergency Care Dashboard: Needs further discussion within delivery group due to many changes. Needs to run parallel with the winter plan. Proposition back to Board in September. Dashboard ‘Guardian’ Claire Old? Revisit distribution list for dashboard? Live dashboard?

5. Demand and Capacity: Nigel Lee presented an update. Short stay capacity is excluded, although there are assumptions that take this into account. Chris Green from ECIST has been asked to run the model on short stay to make sure we have the assumptions right. Report back to this Board with a model.

6. SaTH2Home: Fran Beck presented an update to the Board, and went through the recommendations from the group. There was some discussion on LoS. Need to plan the trajectory’s, Telford needs further work. Trajectory back to next Board. Paula Clark suggested changing wording on slide 20, replace ‘knock on effect’

7. Shropshire UEC Escalation letter (10 July) Allocated Officers to all of the actions and this is now progressing.

8. Winter Plan update from the workshop: Plan on target, workshop well attended. No representation from WMAS or T&W LA. Pete Mason requested support at meetings from WMAS. Plan update at Board in August.

9. System Frailty Collaborative update: We were successful getting on the Frailty Collaborative, this is clinically led. First meeting was held yesterday 22 July. Chair is Jess Sokolov. It had been decided at this meeting to concentrate on the In Hospital Frailty model. It was asked where the recommendations etc are to be reported up too and to ensure that there is system sign-up. This is a 90 day programme. This will go through the STP process.

10. Action plan for demand management (draft): Fran Beck presented an update to the Board.

11. Clarification of staffing plan and project plan for opening Ward 35: A discharge area that could take patients from 7.30am was a good idea Therapy led ward? How to relocate DAART Detailed plan. Challenge is that the capacity is needed so need to get it open. Nigel Lee to share therapy update with Emma Pyrah. Steve Gregory/Nigel Lee to meet and discuss.

12. SaTH Workforce gaps: No update on the wider workforce gap. Workforce Deputy to be

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invited to the next A&E delivery group to provide update.

13. Chairing the Board going forward: The Board agreed that they were happy for Dave Evans to carry on chairing this Board going forward. Need to decide who chairs the A&E Delivery group, Dave Evans does this at present.

14. AOB: No AOB

Summary of Actions

Action required Owner By when

1. Updated Bed Bridge (CDU) –. how is the CDU being paid for? How does the financial challenge get resolved? Need to get commissioning, contracting and finance colleagues to help resolve the issues. Emma Pyrah and Fran Beck to facilitate this and report back to this Board in September with the resolution or outstanding problems why it hasn’t been resolved.

Fran Beck/ Emma Pyrah

24.9.19

2. Integrated Discharge Teams: Dave Evans to pick up with Bev Tabernacle now Simon Wright has left the Trust. No update yet. Nigel Lee to pick this up with both LA’s.

Nigel Lee 27.8.19

3. SaTH2Home: Need to plan the trajectory’s, Further work needed for Telford. Trajectory back to next Board.

Fran Beck 27.8.19

4. Powys LA bed issues – Telephone call scheduled this Friday 26 July. Tanya Miles to update next Board.

Tanya Miles 27.8.19

5. Emergency Care Dashboard: Needs further discussion within delivery group due to many changes. Needs to run parallel with the winter plan. Proposition back to Board in September. Dashboard ‘Guardian’ Claire Old? Revisit distribution list for dashboard?

Claire Old 24.9.19

6. Clarification of staffing plan and project plan for opening Ward 35: A discharge area that could take patients from 7.30am was a good idea. Therapy led ward? How to relocate DAART Nigel Lee to share therapy update with Emma Pyrah. Steve Gregory/Nigel Lee to meet and discuss. Therapy update for agenda at next A&E delivery group.

Nigel Lee/ Steve Gregory

27.8.19

1

Agenda item: GB-2019-09.128

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

North Locality Committee meeting

Date of Meeting:

Thursday 23 May 2019

Chair:

Dr Michael Matthee

Key issues or points to note:

CCG Financial Position

o Presented by Claire Skidmore

o Clarity re. finances

Improving Access to Psychological Therapies

o Concern re. provision

o It was felt that there was a gap in provision, which the Primary Care Liaison Nurse had

previously held

Care Coordination Centre – feedback on performance and ideas for development and

improvement

Midwife prescribing – not always being done

Minor Eye Conditions Service (MECS)

Actions required by Governing Body Members: None

Agenda Item – GB-2019-09.128 CCG Governing Body – 11.09.19

North Locality Board Meeting – 23 May 2019 Page 1

Member Name Practice Attendance

Dr Adam Booth Baschurch – Prescott Surgery Apologies

Nicolas Storey Baschurch – Prescott Surgery Attended

Dr Tim Lyttle Churchmere Medical Group Apologies

Jenny Davies Churchmere Medical Group Apologies

Dr Geoffrey Davies Clive Medical Practice Apologies

Dr Angela Ayers Clive Medical Practice Apologies

Zoe Bishop Clive Medical Practice Apologies

Dr Naresh Raichura Hodnet Medical Centre Attended

Christine Charlesworth Hodnet Medical Centre Attended

Dr Jonathan Davis Knockin Medical Centre Attended

Mary Herbert Knockin Medical Centre Apologies

Dr Mike Matthee (Joint Chair) Market Drayton – Drayton Medical Practice Attended

Michele Matthee Market Drayton – Drayton Medical Practice Attended

Dr Santiago Eslava Oswestry - Cambrian Medical Centre Apologies

Kevin Morris Oswestry - Cambrian Medical Centre Attended

Dr Stefan Lachowicz Oswestry – The Caxton Surgery Attended

James Bradbury Oswestry – The Caxton Surgery Attended

Dr Yvonne Vibhishanan Oswestry - Plas Ffynnon Medical Centre Attended

Sarah Williams Oswestry - Plas Ffynnon Medical Centre Attended

Dr Alistair C W Clark Shawbury Medical Practice Apologies

Joanne Clark Shawbury Medical Practice Apologies

Dr Catherine Rogers Wem & Prees Medical Practice Attended

Richard Birkenhead Wem & Prees Medical Practice Apologies

Dr Katy Lewis (Joint Chair) Westbury Medical Centre Apologies

Helen Bowkett Westbury Medical Centre Apologies

Dr Ruth Clayton Whitchurch – Dodington Surgery Attended

Elaine Ashley Whitchurch – Dodington Surgery Attended

In Attendance Organisation/Role Attendance

Dr Julian Povey CCG Chair Apologies

David Stout CCG Accountable Officer Apologies

Nicky Wilde CCG Director of Primary Care Attended

Janet Gittins CCG North Locality Manager Attended

Heather Clark (Minutes) CCG Personal Assistant Attended

Claire Skidmore [Item 7] CCG Chief Finance Officer Attended

Cathy Davis [Item 8] CCG Mental Health Lead Attended

Anne O’Shea [Item 8] IAPT Service Lead Attended

Emma Pyrah [Item 9] CCG Head of In Hospital Attended

Fiona Smith [Item 9] Shropdoc Clinical Service Manager Attended

Claire Timmins [Item 9] Shropdoc Director of Operations Attended

Minutes of the

North Locality Board Meeting

Thursday 23 May 2019

Drayton Medical Practice

Agenda Item – GB-2019-09.128 CCG Governing Body – 11.09.19

North Locality Board Meeting – 23 May 2019 Page 2

Minute No NLB-2019-05.048 [Item 1] - Welcome & Apologies

1.1 Dr Michael Matthee welcomed those present for attending; apologies were recorded as above. Minute No NLB-2019-05.049 [Item 2] - Members’ Declarations of Interests

2.1 There were no further interests declared for items included on this meeting’s agenda.

ACTION: For Members who had not already completed a Declaration of Interests form or were

due to fill in a new form, they were requested to complete and sign a form and send it to

Heather Clark as soon as possible.

Minute No NLB-2019-05.050 [Item 3] - Minutes of Meeting held on 28 March 2019 and Actions 3.1 The minutes of the meeting held on 28 March 2019 were approved as an accurate record of the

meeting and were signed by the Chairs. 3.2 Minute No NLB-2018-10.092 – The action for Dr Katy Lewis to chase consultant re discussion on heart

failure and AF was deferred to the next meeting as Dr Lewis had given apologies. 3.3 Minute No NLB-2019-02.024 - Maternity Audit – Discussion took place about the results from the audit

on notifications of pregnancy; it was agreed that the notifications received were not very good or clear. Janet Gittins advised that this had been reported and the team were working on improving the notifications. Mrs Gittins asked Members to check the figures on the audit and to send any comments to her. Dr Matthee also asked if further information could be provided about the automatic notification system. Concern was raised about the wording in the audit which stated that notifications were sent in a “timely manner” and Members wanted a more specific timeframe to show them how many days it takes for notifications to be sent.

ACTION: Members to check audit figures and send comments to Janet Gittins. Janet to get

more information about the automatic notification system and a more specific timeframe for

notifications to be sent.

3.4 Minute No NLB-2019-02.023 – Right Care Data Pack – Dr Matthee stated that it was hoped that a consultant would be available to attend the May meeting but she was not available. Heather Clark advised that she had been in touch with the respiratory consultants’ secretaries from SATH (The Shrewsbury and Telford Hospital Trust) and Dr Lewis would be speaking to one of them the following week to see if they can attend in July.

3.5 Minute No NLB-2019-03.039 and Minute No NLB-2019-03.040 – Heart Failure and Pain Management

– Janet Gittins advised that Dr Lewis had met with the lead commissioner to give them the feedback from the discussions that took place at the locality meeting in March.

Minute No NLB-2019-05.051 [Item 4] - Matters Arising 4.1 No further matters were raised. Minute No NLB-2019-05.052 [Item 5] – CCG and Locality Update

5.1 The Locality Update paper was circulated to Members prior to the meeting for information; there were no further questions asked about this.

Minute No NLB-2019-05.053 [Item 6] – Introduction of New Accountable Officer

6.1 David Stout sent his apologies and therefore this item was postponed to the next meeting in July. Minute No NLB-2019-05.054 [Item 7] – CCG Financial Position 7.1 Claire Skidmore, Chief Finance Officer, attended the meeting to give an update to Members about the

CCG financial position; a presentation was circulated to members prior to the meeting. Mrs Skidmore

explained that the CCG spends approx. £470m a year across a wide range of services and historically,

Agenda Item – GB-2019-09.128 CCG Governing Body – 11.09.19

North Locality Board Meeting – 23 May 2019 Page 3

and especially in the past three years, the CCG had been accumulating quite a significant deficit

position. The control total or “allowable deficit” for the CCG in 2018/19 was a deficit position of

£13.3m; at year-end the CCG exceeded this by approx. £5m. This deficit added to the accumulated

deficit gives a total of approx. £80m. Mrs Skidmore added that she hoped that in about three years’

time the CCG would be in a position where it could spend within the control total and start paying off

some of the historic debt.

7.2 Claire Skidmore advised that the control total set by NHS England for 2019/20 is £12.3m and the plan

that had been submitted showed that the CCG is forecasting to deliver a £23.8m deficit in 2019/20;

this is £11.5m away from the control total. If the CCG were to meet the control total in 2019/20 it would

have to save £30m which is 7% of the total budget; nowhere in the country has managed to find this

amount of savings. This position is dependent on the CCG delivering £19.5m of QIPP (Quality

Innovation Productivity and Prevention) savings. Due to risk associated with the QIPP plan there is

also net risk in the plan of £4.6m, which gives a total risk adjusted deficit forecast for 2019/20 of

£28.4m. The QIPP savings include a rolling programme of schemes such as MSK (Musculoskeletal)

and Care Closer to Home. In 2019/20 there will be a lot of work to do in Continuing Healthcare (CHC)

reviewing package prices, and also looking at other areas of the system to see if failings in the

community services are manifesting in costs for CHC that could potentially be avoided. The

prescribing team will also be working on prescribing spend and working closely with practices.

7.3 Claire Skidmore asked Members to let their Locality Manager or Locality Chairs know if they could

think of any other ideas to improve services, reduce waste or make savings. One member suggested

looking at prescribing in secondary care as well as in primary care. Nicky Wilde advised that the joint

formulary was almost at a point of being signed off and it was contracted so that penalties could be

invoked if necessary. She added that there was also more joint work ongoing with Telford and Wrekin

CCG on prescribing policies.

Minute No NLB-2019-05.055 [Item 8] – IAPT (Improving Access to Psychological Therapies)

8.1 Cathy Davis, CCG Mental Health Lead and Anne O’Shea, IAPT Service Lead attended the meeting to talk about the IAPT service and what it offers; a presentation was circulated to Members prior to the meeting. Ms O’Shea explained that the service offered NICE guidance recommended treatment and that patients who were seen were very happy with the service. Ms Davis advised that capacity at the service had been increased so that the team could work towards meeting the 18 week target set by NHS England. She confirmed that the team did monitor effectiveness and were above the national average.

8.2 Discussion took place about the gap between the first telephone call from the service to when the

patient is actually seen or starts treatment, as a lot of patients go back to their GPs as they feel it is easier to be seen. Members felt that some patients needed some hand-holding and extra help but Ms O’Shea advised that there was no evidence to show that this worked or made people better. She explained that most patients receive a first telephone call where they are assessed and given some ‘homework’ to do before their next session, at the second treatment session they are evaluated and the next step of treatment is determined. All patients are given an allocated therapist and phone number to call if they decline between treatment sessions. Ms O’Shea advised that if a patent comes back to the practice, to ask the patient if they have spoken to their allocated therapist first. The number for the service and named therapist should be on the initial letter that is sent and also copied to the GP; Anne O’Shea advised that if this was not happening to let her know.

8.3 Dr Clayton stated that one of her patients was told that they could not access the IAPT service as they

couldn’t use the telephone. Ms O’Shea advised that this was not right and the service does offer some face to face assessments for people that cannot use phones, there are over 30 of these available per month.

8.4 Anne O’Shea agreed with Members that a long wait was not helpful and advised that 10 years ago

IAPT was bolted on to another service that already had a 2 year waiting list. The service had now received additional funding from the CCG and in the next year there should be improvements, especially for people who need one to one treatment. Ms O’Shea added that in the past patients were

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North Locality Board Meeting – 23 May 2019 Page 4

given a choice of which treatment option they would prefer and most would choose one to one treatment which added to the waiting list. Now this is only given to those who really needed it and the team were working on advising patients of the most appropriate treatment for them. Ms O’Shea also mentioned that if someone was referred to IAPT and the team assess them as not appropriate for the service they would be referred on to the most appropriate service, and should not be referred back to the GP.

8.5 Members discussed Primary Care Liaison Workers who in the past could see patients within two

weeks; they were told that when these workers were gone these patients could be sent to IAPT instead. Members did state that they were happy with what IAPT offered and what the service does for patients when they are seen, and that patients report being happy with the treatment. There was agreement that there was a need for help for the cohort of people in the middle where IAPT is not quite enough but they are also not appropriate for a community service. Anne O’Shea also clarified that if patients were referred to the CMHT (Community Mental Health Team), they would assess the patient and refer to IAPT if they were not appropriate for CMHT. She added that urgency is outside the scope of IAPT and that evidence shows that people are happy to talk on the phone, the team only hear back from people who don’t attend or don’t complete their homework.

8.6 Anne O’Shea advised that there was self-referral information available on the IAPT website. There

was also a new system called SilverCloud which is an online interactive intervention with a therapist; patients have to be referred to the IAPT service in order to use this. The team are waiting for updated leaflets which will have information about SilverCloud on them.

8.7 Anne O’Shea explained that the team would be more than happy to fast track people if GPs felt there

was a need for a quicker assessment, and these patients could be assessed within a 1-2 week timeframe. Anne advised Members to make it clear on referrals if an urgent assessment would be needed. She thought that it would be better for GPs to make referrals for these patients rather than advising the patient to self-refer, as the patient may ring in and not mention anything about urgency, and therefore would be treated as a normal referral. Anne advised that new practitioners would be in place by August or September 2019 to give the team more capacity.

8.8 Cathy Davis offered to come back to the meeting to explain what is available for people outside of the

IAPT service. She added that she was currently looking at this and where patients can go in a crisis. This should take a few months to complete and therefore Cathy agreed to come back to the locality meeting in September with further information.

ACTIONS: Cathy Davis to come back to the locality meeting in September to give feedback

about what services are available outside of the IAPT service.

Minute No NLB-2019-05.056 [Item 9] – Care Co-ordination Centre (CCC) 9.1 Fiona Smith, Clinical Service Manager for Shropdoc, advised that the CCC take about 200 calls per

day with peak times of 11am-1pm and 4pm-6pm, and that 43% of the workload comes through these times. Some of the challenges the CCC face are when trying to get through to SATH and also calls back to GP practices. An escalation policy had been designed about how to manage calls at peak times; this states that if the service cannot speak to a clinician straight away they will be asking if they can call back in 30 minutes. There is also work ongoing with SATH about how to get through to them quicker, with a test of change week planned for June 2019.

9.2 Ms Smith explained that when the KPIs (Key Performance Indicators) were set up they were about

issues with getting through to the service and speaking to clinicians. The team are working on an EMIS template that can be filled in quickly and sent straight to the team instead of GPs waiting on the phone to speak to someone. The team may need to speak to the GP for more information depending what is on the form or if more complex information is needed. The team also need to work on a system to provide feedback to GPs following referral. Ms Smith advised that the team would need to look at an easier way to get information back from GPs if needed as they have struggled to get through in the past. Nicky Wilde advised that all practices should have a dedicated professional line. Ms Smith also noted that if a referral was sent at the end of the day the CCC team may need a number to call the GP back e.g. mobile number if the practice is closed or if the GP is going out to complete home visits. Fiona advised that there would be a pilot of the EMIS template and the template would be ready for 3

rd

June 2019.

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North Locality Board Meeting – 23 May 2019 Page 5

9.3 Kevin Morris stated that he couldn’t remember getting any other advice back from the CCC other than

to admit a patient. Fiona Smith explained that part of the service was to help to prevent admissions and use community services, Emma Pyrah added that 70% of calls taken do go through acute services. There was general agreement from Members that they were happy with the service once they get through on the phone and it was just the waiting times that needed to be improved.

Minute No NLB-2019-05.057 [Item 10] – Primary Care Update 10.1 The Primary Care update paper was circulated to Members prior to the meeting; there were no further

questions raised about this. Minute No NLB-2019-05.058 [Item 11] – Commissioning Update 11.1 The Commissioning update paper was circulated to Members prior to the meeting; there were no

further questions raised about this. Minute No NLB-2019-05.059 [Item 12] – Locality Assurance Framework 12.1 The Locality Assurance Framework was circulated to Members prior to the meeting for information, it

was decided that this did not have to be on the agenda again as the only item on the framework was now resolved.

Minute No NLB-2019-05.060 [Item 13] – Guidance for Locality Board Meetings 13.1 The Guidance for Locality Board Meetings was circulated to Members prior to the meeting for

information; there were no further questions asked about this. Minute No NLB-2019-05.061 [Item 14] – Any Other Business 14.1 Midwives prescribing – A discussion took place about midwives and what they were able to hand out

to patients e.g. folic acid and iron. Nicky Wilde advised she would ask Liz Walker from the Medicines Management Team for clarification. The Head of Midwifery had been told that GPs could not prescribe, but the midwives were not aware of this and have been sending patients to their GPs.

ACTION: Nicky Wilde/Janet Gittins to clarify with Liz Walker what midwives can prescribe, and

send a letter from Liz Walker to the Trust and copy to the GP Practices.

14.2 Pre-Op Assessments – Members stated that GPs had been asked to complete pre-op assessments over the phone when legally they were not covered to do this. Discussion took place about this and it was confirmed that legally it should only be the person completing the operation who signs the consent form. Nicky Wilde asked for any live examples to be sent to Janet Gittins. It was also noted that GPs could be unaware of some these patients if they are being referred to Health Care Assistants directly.

ACTION: Members to send to Janet Gittins live examples of pre-op assessments being sent to

GPs to complete.

14.3 Phlebotomy at Whitchurch – Whitchurch patients have complained about being turned away from the phlebotomy service in Whitchurch once the service had reached capacity of 40. Elaine Ashley advised that this was discussed when an audit took place recently and it was discovered that not all patients seen by the service were Whitchurch patients, some even came from Malpas which is not in the Shropshire CCG area. Dodington Surgery has been doing bloods in surgery on top of this. Janet Gittins explained that this had been raised with commissioners and would be discussed at the contract meeting the following week.

14.4 Pathway for Stoke Patients Re-admission – Dr Clayton advised that she had a patient who had a lung

lobectomy and was supposed to go back for a review appointment to have results discussed and re-dressing. The appointment was cancelled as the results had not come back and the patient was told to go to their GP surgery for the dressing to be changed. At the surgery it was found that the patient had a post-operative infection and Dr Clayton spent an hour trying to get the patient re-admitted to Stoke. Dr Clayton ended up sending the patient to A&E at Stoke and they were admitted for 10 days. Dr

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Clayton wrote to the consultant following this and he said she should have called his secretary about this. Dr Matthee advised he was not surprised about this as there had been a move around of departments at Stoke and if he refers patients there they usually end up advising the patient to go through A&E.

14.5 MECS (Minor Eye Conditions Service) – Dr Vibhishanan asked about MECS which was previously

known as PEARS (Primary Eye-care Assessment and Referral Service). She saw a patient that had been booked in as an emergency appointment as the patient was told to see their GP by MECS; this was because they could not offer an appointment to the patient within 48 hours. The patient who was sent to the surgery would have been fine to wait a bit longer to be seen by MECS. Dr Vibhishanan asked what the point of the service was if it diverted patients back to their GP if they could not be seen within 48 hours. Nicky Wilde advised that originally there were a certain amount of services in place and that this was estimated to increase over time; though it had been found that there were not many opticians willing to pick this up; the commissioners will be looking at this again to find a solution.

Minute No NLB-2019-05.062 [Item 15] - Date of Next Meeting 15.1 The next meeting will take place on: Thursday 18 July 2019 at The Venue at Park Hall, Oswestry

commencing at 2.30pm. A provider session will take place before the Locality Board from 1.30 – 2.30pm.

Future Meeting Dates

Wednesday 26 June 2019 (PLT)

Thursday 18 July 2019, The Venue at Park Hall, Oswestry

Thursday 26 September 2019, Drayton Medical Practice, Market Drayton

Thursday 24 October 2019 (PLT)

Thursday 28 November 2019, The Venue at Park Hall, Oswestry

Signed: …………………………………............ Date: ….........................…………. Dr Michael Matthee, Joint North Locality Chair Signed: …………………………………............ Date: ….........................…………. Dr Katy Lewis, Joint North Locality Chair

1

Agenda item: GB-2019-09.129

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

Shrewsbury and Atcham Locality Committee meeting

Date of Meeting:

20th June 2019

Chair:

Dr Deborah Shepherd

Key issues or points to note:

Locality Chair’s update, including information on the updated Locality Committee meeting

guidance, and on the confirmed decision to dissolve Shropshire and Telford & Wrekin CCGs to

form a new single strategic commissioning organisation

Hot topics from members – suggestions for high risk drug monitoring systems; SaTH access to

summary care records; continuing issues with public health nursing team; primary care

networks; suggestions for future meeting topics.

Care Coordination Centre – feedback on performance and ideas for development and

improvement

IAPT – update and feedback on the service

Discussion and comments on proposed pathway for managing reviews of children prescribed

medication for mental health issues

Brief review of Rightcare data and planning for detailed clinical review in next meeting

Actions required by Governing Body Members: None

Agenda Item – GB-2019-09.129 CCG Governing Body – 11.09.19

Shrewsbury & Atcham Locality Board Minutes – 20 June 2019 Page 1 of 7

Member Name Practice Attendance

Dr D Shepherd (Chair) CCG Locality Chair & Locum GP Attended

Dr J Pepper Belvidere Attended

Caroline Davis Belvidere Attended

Dr M Fallon Claremont Bank Attended

Jane Read Claremont Bank Attended

Dr E Baines Marden Attended

Zoe George Marden Attended

Dr Julia Visick Marysville Attended

Izzy Culliss Marysville Attended

Dr Sarah Watton Mytton Oak Apologies

Adrian Kirsop Mytton Oak Apologies

Dr R Bland Pontesbury Attended

Heather Brown Pontesbury Attended

Dr H Bale Radbrook Green Attended

Angela Treherne Radbrook Green Apologies

Dr P Rwezaura Riverside Attended

Tracy Willocks (Vice Chair) Riverside Attended

Dr D Martin Severn Fields Apologies

Tim Bellett Severn Fields Apologies

Dr L Davis South Hermitage Attended

Caroline Brown South Hermitage Attended

Dr E Jutsum The Beeches Apologies

Kim Richards The Beeches Attended

Jo Beason Whitehall Attended

Dr K McCormack Worthen Apologies

Cheryl Brierley Worthen Attended

In Attendance Organisation/Role Attendance

Dr Julian Povey CCG Chair Apologies

David Stout CCG Accountable Officer Apologies

Nicky Wilde CCG Director of Primary Care Attended

Jenny Stevenson CCG Locality Manager Attended

Heather Clark (Minute Taker)

CCG Personal Assistant Attended

Emma Pyrah CCG Head of In Hospital [Item 5] Attended

Fiona Smith Shropdoc Clinical Service Manager [Item 5] Attended

Claire Timmins Shropdoc Director of Operations [Item 5] Attended

Cathy Davis CCG Mental Health Commissioning Lead [Item 6] Attended

Anne O’Shea MPFT IAPT Service Lead [Item 6] Attended

Clare Michell-Harding CCG Senior Project Lead Pharmacist [Item 7] Apologies

Carrie Jenkins CCG Locality Pharmacist [Item 7] Attended

Gail Fortes-Mayer CCG Director of Contracting and Planning [Item 8] Apologies

Minutes of the

Shrewsbury & Atcham Locality Board Meeting

Thursday 20 June 2019

Board Meeting Room, Severn Fields Health Village, Sundorne Road, Shrewsbury, SY1 4RQ

Agenda Item – GB-2019-09.129 CCG Governing Body – 11.09.19

Shrewsbury & Atcham Locality Board Minutes – 20 June 2019 Page 2 of 7

Minute No S&ALB-2019-06.063: Item 1 - Welcome & Apologies

1.1 Dr Deborah Shepherd, Locality Chair, welcomed and thanked Members for attending and introductions were made. Apologies were noted as above.

1.2 Dr Shepherd welcomed Carrie Jenkins, the new Shrewsbury and Atcham Locality Pharmacist. Minute No S&ALB-2019-06.064: Item 2 – Members’ Declarations of Interests

2.1 Members were reminded of the governance requirement to submit annually a new completed and signed declaration of interest form, copies of which were tabled. There were no further interests declared for items included on the agenda.

ACTION: Members were reminded to submit a new completed and signed declaration of interest form if required and return to Miss Heather Clark. ([email protected])

Minute No S&ALB-2019-06.065: Item 3 – Locality Chair Update 3.1 Locality Board Meeting Guidance - Dr Shepherd advised that the guidance for locality meetings had

been formalised and sent to Members. She added that the guidance explains the format of meetings and emphasises the commissioning focus of the meetings. Dr Shepherd asked Members to let her know if they had any comments about the guidance.

3.2 Terms of Reference - At the last meeting Members discussed changes to the terms of reference. Dr

Shepherd advised that the Locality Chairs did meet to discuss making changes, but in view of the changes upcoming to the CCG it was not felt appropriate to formally change anything now as the terms of reference would need to be looked at again when the new organisation was formed. Dr Shepherd advised that she had made a note of the things that Members wanted to change so that this could be looked at in the future. She added that one thing that was agreed and had changed was the patient representation part of the meetings. A review of patient involvement at the CCG had taken place and a paper went to the Governing Body meeting last month. It was agreed that patient representatives were not needed at Locality meetings as they are meetings of the GP Membership, and that patient involvement in CCG commissioning decisions would be achieved via other mechanisms. She thanked the Shrewsbury patient representatives for their contributions over the past years of their attendance at the meetings.

3.3 Single Strategic Commissioning Organisation - Dr Shepherd stated that the Governing Bodies of

Shropshire CCG and Telford and Wrekin CCG had both approved the dissolution of the two CCGs in order to create a new Single Strategic Commissioning Organisation. The plan was to achieve this by April 2020; if this deadline cannot be met it will be April 2021. Dr Shepherd explained that work had begun to appoint a joint Accountable Officer for the new organisation and adverts for this role would be out soon. There would also need to be Membership involvement and this would be discussed at future meetings. Dr Fallon asked whether Locality Board meetings would continue in the new organisation; Dr Shepherd advised that this would need to be agreed going forward and that it would be a good idea for Members to start thinking about what they would like to see in the new organisation. The first stage in the process would be to recruit a new Accountable Officer and they would then appoint the Executive Team; the Executive Team and Membership would then work out the form of the new organisation. Members would be regularly updated and consulted as matters progress.

3.4 Planned Care Work - Dr Shepherd advised that she had taken on some planned care work along with Dr

Katy Lewis from the North Locality. This had been working well creating a greater link between localities and planned care, and they had been able to influence and feed information back directly. Dr Shepherd advised that issues that were previously raised by Members regarding cardiology had already been discussed at the Planned Care Working Group, and changes had been made in cardiology around workforce issues and also making sure the Advice and Guidance Service was covered on a daily basis by a consultant.

3.5 Public Health - At the last meeting the cuts in Public Health services were discussed, Dr Shepherd

advised that the new Director of Public Health would be attending the locality meeting in September so that this can be discussed in more detail.

3.6 Riverside Premises - Dr Shepherd expressed congratulations to Riverside Medical Practice as the

business case for their new premises had been approved.

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3.7 SATH - It was stated that Simon Wright had resigned as Chief Executive of The Shrewsbury and Telford Hospital NHS Trust (SATH) and there would be an interim Chief Executive in place until a new one is recruited.

3.8 July Locality Meeting - It was confirmed that the July Locality meeting would be an informal meeting and

would not be minuted; with a mainly clinical focus most likely looking at paediatric respiratory data. It was also agreed that invitations would be sent to the Perinatal Mental Health Service who had expressed a wish to come to the meeting, there would also be a presentation about the PINCER prescribing tool.

Minute No S&ALB-2019-06.066: Item 4 – Open Discussion – “Hot Topics” from Practices

4.1 High Risk Drug Monitoring System - Dr Fallon asked about DMARDs (Disease-Modifying Anti-rheumatic Drugs) and stated that he was aware that Darwin were looking at a drug monitoring system for high risk drugs and asked if this was something the CCG could commission for all practices. Carrie Jenkins stated that the Medicines Management Team had been looking at a system called Eclipse and this could possibly be something that could be funded centrally. She advised that she would look into this and send something out to Members.

ACTION: Carrie Jenkins to look into Eclipse system and send further information out to Members.

4.2 SATH Access to Summary Care Records - A discussion took place about adding information such as

Advanced Directives and DNAR (Do Not Attempt Resuscitation) forms to the Enriched Summary Care Records (eSCR) as the Resus Lead at SATH stated that if patients do not carry these on them at all times then SATH would not know about them. Most doctors at the hospital do not have smartcards, which means they cannot access the eSCR. Doctors therefore would not know if a patient has DNAR instructions unless they carried a copy with them at all times.

ACTION: Jenny Stevenson/Deborah Shepherd to discuss issue around SATH access to Summary Care Records with IT Lead, Commissioners and Contracting team.

4.3 Public Health Nursing Team - It was raised that the Public Health Nursing team were not attending

practice meetings on a quarterly basis as agreed in a previous meeting. Members requested that if the team could not commit to attending these meetings that they would need confirmation of this in writing for CQC records.

ACTION: Jenny Stevenson to contact the Public Health Nursing Team about attendance at practice meetings.

4.4 Primary Care Networks – A discussion took place about Primary Care Networks. Nicky Wilde advised

that there were issues in the North and South West, with the South West issues being signed off recently. The North was close to being finalised and was hoped to be signed off the following week. It was confirmed that all practices in Shropshire CCG were joining a Primary Care Network. Nicky Wilde suggested that practices work towards a start date of 1

st July 2019, though this would need to be

confirmed officially by NHS England. 4.5 September Locality Meeting - Dr Shepherd asked for any suggestions for the next locality meeting in

September. The following suggestions were made by Members:

Update from the BeeU Service as Members were still receiving poor feedback about the service.

Dr Fallon asked about Elvanse (Lisdexamfetamine) which is a stimulant drug for patients with ADHD (Attention-Deficit Disorder/Hyperactivity Disorder). He wanted to know the referral criteria for the service run by Dr Mohammed at Battlefield. Dr Shepherd advised she was aware the service was being recommissioned. Carrie Jenkins added that there was a shared care agreement in place for children and was aware that something was in development in the adult pathway for ADHD.

Communication between primary and secondary care, such as digital signatures, written prescriptions, quicker and smarter ways of working, information sharing (such as DNAR).

Members discussed the differences in the locality meetings, with the North Locality having a separate provider section, and the South Locality sometimes meeting after the main commissioning meeting when needed. It was agreed to try the same format as the North Locality for the next meeting in September, with a separate provider section before the commissioning meeting.

ACTION: Jenny Stevenson/Deborah Shepherd to consider the best way to address the topics suggested by Members. Members to send any suggested topics for the September provider section to Jenny Stevenson and Deborah Shepherd.

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Minute No S&ALB-2019-06.067: Item 5 – Care Co-ordination Centre 5.1 Fiona Smith and Claire Timmins from ShropDoc and Emma Pyrah from the CCG attended the meeting to

talk about the Care Co-ordination Centre (CCC). Emma Pyrah explained that a new contract had been put in place from 1

st October 2018 and details of this were in the briefing paper provided. She added that

this was the first time the CCC had a specification with Key Performance Indicators (KPIs) in place and feedback on the performance metrics were welcomed.

5.2 Fiona Smith talked about the challenges faced by the service. The CCC take around 200 calls a day with

areas of peak demand between 11am-1pm and 4pm-6pm where the team get 43% of their calls. Some of the KPIs in place are about how quickly calls are answered (within 60 seconds) and how long it takes to speak to a clinician (within 5 minutes). Fiona explained that these KPIs were harder to achieve at peak times, and the team also have challenges getting through to the hospital which could sometimes take 20-30 minutes.

5.3 Fiona Smith advised that the team were working on an EMIS template which could be sent to the CCC

by a GP instead of having to wait on the phone, this would be via email to a secure email address. A dedicated team member would monitor emails, separately from those taking phone calls, to ensure timely receipt and action. It was agreed that prompt confirmation would need to be sent back to the GP to confirm receipt and also with detail about what had happened with the referral. Claire Timmins added that some GPs had already been given an option of a call back from the CCC within 30 minutes during peak times, so they do not have to wait on the phone; she advised that this had worked well so far. Fiona Smith explained that the team did have an escalation policy that was in use, and could give an indication of how long GPs are likely to be waiting to speak to a clinician when they call CCC by advising how many calls are being dealt with ahead of theirs (exact timings could not be provided as it would depend how long it would take to deal with those already in the queue).

5.4 Members felt that once they had made a decision and the referral had been accepted by CCC, there was

no need for the Site Manager to triage referrals again as they did not change or add anything and this increased delays. Emma Pyrah advised that there was a lot of work ongoing at SATH around how activity flows through the front door in AMU and other areas.

ACTION: CCG to feedback request from Members that further triage of accepted referrals by site manager are to be stopped.

5.5 Further discussion took place about the proposed EMIS template. Claire Timmins explained that the

team would need sufficient detail on the template so that the CCC would not need to call the GP back, and added that most of the template would be self-populating. It was suggested that KPIs could be changed to measure the time it took for an acknowledgement email to be sent from CCC. Claire Timmins advised that the team would like to pilot the form in a small and large surgery; Marden, Marysville and Belvidere practices expressed interest in this. It was also commented that if the CCC had access to EMIS it would make the sharing of information easier. Nicky Wilde advised that there would be a lot of changes happening in the next 6-12 months looking at IT systems and interfaces between systems; the timeline for achieving this was not known. It was confirmed that the EMIS template would be an extra option for referrals and that GPs could still phone in to CCC if needed, for example if on home visits.

ACTION: CCG to work with ShropDoc on exploring option of giving CCC access to EMIS.

Minute No S&ALB-2019-06.068: Item 6 – IAPT (Improving Access to Psychological Therapies) 6.1 Cathy Davis, CCG Mental Health Commissioning Lead and Anne O’Shea, IAPT Service Lead attended

the meeting to give an update and overview of the IAPT service. The presentation included information about:

Staff

Waiting times

Team areas

Referral routes and assessment

Stepped Care Model

Treatment Options: SilverCloud, CBT (Cognitive Behavioural Therapy), Counselling, Think Good

Feel Good, Anger Management, EMDR (Eye Movement Desensitisation and Reprocessing), ACT

(Acceptance and Commitment Therapy), IPT (Interpersonal Therapy), Couples Therapy

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6.2 Ms O’Shea explained that the team were looking for more venues in which to see patients and asked

Members to get in touch if they could offer a room in their practice. The team would need a sound proof

room with a couple of chairs and table, preferably with a facility for some kind of reception area.

ACTION: Members to contact Anne O’Shea if they were able to offer a room in their practice for IAPT team therapy sessions.

6.3 Anne O’Shea advised that the team now had data going back to 2010 and could now look at trends and

performance. Anne explained that in Shropshire there had been a massive rise in PTSD (Post-Traumatic

Stress Disorder). She added that the team were working on an expansion project and there is a target for

25% of the population identified as being likely to suffer from depression and anxiety to have accessed

the service by 2020/21. The IAPT team are going through a recruitment drive currently with new

practitioners hoped to be in place by August or September 2019.

6.4 Discussion took place about EMDR and the long waiting list for this and what was offered to patients

while they were waiting. Anne O’Shea advised that this treatment had been very popular and the team

only had a small number of therapists qualified in EMDR, some of whom had retired. Ten therapists were

now receiving training for this which would be completed at the end of the year; it was expected that the

waiting time would then reduce.

6.5 Members stated that it would be useful to know information about waiting list delays and alternatives so

they could discuss this with their patients, as feedback from patients can be negative when they cannot

access the therapy they need straight away. Anne O’Shea advised that previously the team used to send

a bulletin around with this kind of information but it was stopped, this could be started again if useful.

Members advised that it would be useful to know about waiting times and figures such as how many

patients complete their course of treatment. Ms O’Shea advised that these figures were available and the

team did currently provide monthly reports, she added that approximately 50-60% of patients complete

their treatment with IAPT; waiting list times can fluctuate due to demand in different therapies.

6.6 Ms O’Shea advised that there were now various supported online intervention modules on a system

called SilverCloud; patients need to be referred to IAPT to get access to this system. It was confirmed

that there were exclusions for referrals to IAPT such as eating disorders but that the team would signpost

these referrals to the relevant team and would not send these referrals back to the GP. The same would

be for patients who require treatment from a Clinical Psychologist; the IAPT team would refer them on to

secondary care. It was confirmed that written referrals from GPs to IAPT would be accepted if it was felt

more information was needed.

ACTION: Cathy Davis to clarify commissioning arrangements for and access to Clinical Psychologists as GP experience is that they are difficult to access.

6.7 Members asked about patients that are too anxious for a phone call assessment and whether this could

be discussed through email instead. Anne O’Shea advised that this could be done, usually there is a

phone assessment but face to face assessments could also be offered if needed. She explained that

there were approximately 20-30 face to face assessments available per month. The team find that the

majority of people would talk to the team after they have had some kind of initial contact with them. If

face to face assessments were needed it was asked that Members make this clear on referrals.

6.8 Discussion took place about letters that were sent out following initial assessments which ask the GP to

monitor risk while the patient is waiting for their therapy to start. It was agreed that the wording of these

letters would be changed. Patients have allocated therapists in the IAPT team and are told to contact

them if they have any issues while they are waiting for therapy. The IAPT team would only expect the GP

to check on the patient if they happened to come to see them for something else. Anne O’Shea agreed

that it would be good for the IAPT team to have a standard way of communicating and it was agreed that

it would be best to write a letter to the patient and copy in the GP so they were aware of what has been

agreed and who the allocated therapist is. If GPs had any specific queries or issues regarding patients it

was advised that they could contact Anne O’Shea directly to investigate.

ACTION: Jenny Stevenson to circulate Anne O’Shea’s email address to Members

Agenda Item – GB-2019-09.129 CCG Governing Body – 11.09.19

Shrewsbury & Atcham Locality Board Minutes – 20 June 2019 Page 6 of 7

Jenny Stevenson to contact Anne O’Shea re electronic copies of the self-referral leaflets and send out to Members once received.

Minute No S&ALB-2019-06.069: Item 7 – Medicines Management 0-25 Discussion/Pathway Development

7.1 Carrie Jenkins advised that a pathway had been proposed for identifying and managing patients

previously under the care of CAMHS (Child and Adolescent Mental Health Services) who were still being prescribed certain mental health drugs by their GP, and who were not under the care of the new MPFT (Midlands Partnership NHS Foundation Trust) BeeU service. Dr Shepherd added that this was the last stage of identifying all children being prescribed mental health drugs and ensuring they have had appropriate physical health checks and follow up. The searches were now in place and ready to be run for this last cohort of patients, and the proposal was about how to manage them once identified. The patients from the previous searches (for those children whose care had transferred to MPFT) had now all been reviewed and had physical health checks, no problems or concerns had arisen from this.

7.2 It was explained that the proposed pathway would be discussed with all localities to gather comments

and concerns, clarification would then come out for information following this. The following clarifications and comments were made:

The pathway refers specifically to children and young people who were previously under the care of, and prescribed for by the old CAMHS service provided by SSSFT (South Staffordshire and Shropshire Healthcare NHS Foundation Trust).

Clarity was needed for out of area patients that come into Shropshire on certain drugs - it was confirmed that for Looked After Children (LAC) a pathway had been agreed and was in place for MPFT to see these patients.

There was a typing error in the “Clinical criteria for MPFT management” box which states “MFPT”.

The heading of the pathway needed to be clarified as to what the pathway is for and which drugs were included.

It was confirmed that the Medicines Management team could run the six monthly searches once practice permission is granted, and could offer support to practices with the process.

If a patient was under MPFT with no up to date ESCA (Essential Shared Care Agreement) in place, the patient would wait for their next planned review with MPFT to have a new ESCA issued and checks done. If the review was a long time away the GP could ask for the review to be brought forward if there were concerns.

If the patient was not under MPFT, the GP would review the patient as part of their medication review and check they have had the appropriate physical checks and consider if they need to be referred back to MPFT.

MPFT should manage all patients on antipsychotics, not just depot, and ADHD drugs.

Current patients under MPFT with an ESCA – MPFT are to complete annual reviews and share information with GP; any additional monitoring needing to be done by the GP should be specified in the ESCA. It was confirmed that while on medication the patient would remain under the care of MPFT, once stabilised they would have annual reviews with MPFT but the prescribing would pass to the GP, under the ESCA, if the GP was happy to do so.

Patients who are cared for out of area but registered with a Shropshire practice would have to follow the pathway of the out of area CCG/Trust.

All MPFT ESCAs had been agreed in January 2019 by the Area Prescribing Committee and it was agreed that a link to these would be circulated to Members.

Old ESCAs with SSSFT were no longer current and needed to be reissued by MPFT.

ACTION: Jenny Stevenson to circulate pathway discussion comments following the meeting along with a link to current ESCAs. Medicines Management Team to confirm pathway once they had attended all locality meetings.

Minute No S&ALB-2019-06.070: Item 8 – Locality RightCare Data – progress since last meeting and

planning for July

8.1 Members looked at Right Care data for cardiology that had been shared prior to the meeting. Dr

Shepherd explained that last time Members looked at high level data and requested more detailed data. It was agreed that the level of data provided was too detailed and needed to be summarised to help interpret the data and highlight the issues. Dr Pepper suggested approaching the best performing CCGs to see what they were doing differently.

ACTION: Summary of data to be put together and presented at the July locality meeting, focusing on paediatric respiratory.

Agenda Item – GB-2019-09.129 CCG Governing Body – 11.09.19

Shrewsbury & Atcham Locality Board Minutes – 20 June 2019 Page 7 of 7

Minute No S&ALB-2019-06.071: Item 9 – Minutes of Meeting held on 11 April 2019 and Actions 9.1 The minutes of the meeting held on 11 April 2019 were agreed as a true and accurate record of the

meeting and were signed by the Chair. 9.2 All actions from the previous meeting were completed with updates provided by Jenny Stevenson as

follows:

Minute No S&ALB-2019-04.050 Public Health Services – Rachel Robinson, new Director of Public Health, will be attending the locality meeting in September.

Minute No S&ALB-2019-04.052 Right Care – Gail Fortes-Mayer will be attending the July locality meeting for a discussion around the data for paediatric respiratory.

Minute No S&ALB-2019-04.061 MECS (Minor Eye Conditions Service) – Members asked for an electronic MECS leaflet to be circulated.

ACTION: Electronic copy of MECS leaflet to be circulated.

Minute No S&ALB-2019-06.072: Item 10 – Matters Arising 10.1 No items were raised for this agenda item. Minute No S&ALB-2019-06.073: Item 11 – Primary Care Update

11.1 The monthly Primary Care Update had been circulated to Members prior to the meeting and there were

no further questions about this. Minute No S&ALB-2019-06.074: Item 12 – Commissioning Update

12.1 The monthly Commissioning Update had been circulated to Members prior to the meeting and there were no further questions about this.

Minute No S&ALB-2019-06.075: Item 13 – Any Other Business

13.1 No items were raised for this agenda item.

Minute No S&ALB-2019-06.076: Item 14 - Date and Time of Next Meeting

16.1 The next meeting will be held on Thursday 18 July 2019 in Severn Fields Health Village commencing

at 2.00pm. It was explained that this meeting would be an informal clinical meeting to look at data on respiratory conditions, specifically paediatric asthma. Dr Shepherd advised that the relevant people would be invited to discuss the PINCER tool and the Perinatal Mental Health Team as agreed earlier in the meeting.

16.2 The next formal meeting will be held on Thursday 19 September 2019 in Severn Fields Health Village,

Sundorne Road, Shrewsbury, SY1 4RQ commencing at 2.00pm. 16.3 Further 2019 meeting dates:

Tuesday 9 July – PLT Thursday 18 July August meeting cancelled Thursday 19 September Thursday 17 October - PLT Thursday 21 November

Thursday 19 December

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

Dr Deborah Shepherd, Locality Chair

Agenda item: GB-2019-09.130

Shropshire CCG Governing Body meeting: 11 September 2019

Committee Meeting Summary Sheet

Name of Committee:

South Locality Board Meeting

Date of Meeting:

02/05/2019

Chair:

Dr Matthew Bird

Key issues or points to note: CCG Chair Update – The new Accountable Officer for Shropshire CCG, David Stout, was introduced to the Locality Members. Dr Povey explained that Shropshire CCG and Telford and Wrekin CCG would be proposing the dissolution of the two CCGs to create a new CCG. If this was agreed by the two Governing Bodies the CCGs would aim to create a new single strategic organisation from 1st April 2020. Locality Chair Update – Locality Chairs had been working on guidance for the locality meetings to share with Members and attendees/presenters at the meetings. Locality meetings in the future would be streamlined with less topics for discussion. Concerns were raised about the decision made by Shropshire Council to stop the help to slim and smoking cessation services. CCG Finance – Laura Clare, Deputy Chief Finance Officer, attended the meeting to give an update about the CCG financial position and discuss QIPP schemes. Concern was raised about delayed payments to practices for the extended access service. IAPT Update – Cathy Davies, CCG Mental Health Lead, and Anne O’Shea, IAPT Service Lead attended the meeting to give an update and overview of the IAPT service. Members raised concerns about the capacity of the IAPT team and long waiting times for patients. It was confirmed that the team had been given additional funding for more counsellors that would be starting soon. Medicines Management – Members talked about respiratory and pain prescribing topics, and agreed that it was unfortunate there was no longer an opioid addiction service as it was useful to patients. The Medicines Management team advised they would be completing an audit to see how many patients were affected and would be looking at how existing services could link into this. There would be more information available at the next PLT session. Social Prescribing – Penny Bason, STP Programme Manager, Katy Warren and Cathy Levy, Social Prescribing Leads from Shropshire Council attended the meeting to give a presentation about social prescribing. It was acknowledged that the service was very useful and there had been a decrease of a third of GP appointments for the patients referred to the Social Prescribers.

Referral Issues – Members raised concerns about dermatology referrals and cross border issues with RAS referrals. It was agreed that some kind of referral protocol was needed to show what can be offered to patients.

Actions required by Governing Body Members:

No actions required

Agenda Item – GB-2019-09.130 CCG Governing Body – 11.09.19

South Locality Board Minutes – 2 May 2019 Page 1

Name Practice/Organisation Signature

Dr Matthew Bird (Chair) Albrighton Attended

Val Eastup Albrighton Attended

Dr Dale Abbotts Alveley Attended

Lindsey Clark Alveley Attended

Dr Adrian Penney Bishop’s Castle Apologies

Dr Paul Gardner Bishop’s Castle Attended

Sarah Bevan Bishop’s Castle Apologies

Dr Stuart Wright Bridgnorth Attended

Sandra Sutton Bridgnorth Attended

Dr Mathai Babu Broseley Attended

Nina Wakenell Broseley Attended

Dr Bill Bassett Brown Clee Attended

Vicki Brassington Brown Clee Apologies

Dr Alex Chamberlain Church Stretton Attended

Emma Kay Church Stretton Attended

Dr Paul Thompson Cleobury Mortimer Attended

Mark Dodds Cleobury Mortimer Attended

Dr Juliet Bennett Clun Attended Peter Allen Clun Attended Dr David Appleby Craven Arms Attended Susan Mellor-Palmer Craven Arms Attended Dr Shailendra Allen Highley Attended

Sudhanshu Consul Highley Attended

Dr Catherine Beanland Ludlow – Portcullis Apologies

Rachel Shields Ludlow – Portcullis Attended

Dr Graham Cook Ludlow - Station Drive Attended

Dr Jennie Bailey Much Wenlock & Cressage Attended

Sarah Hope Much Wenlock & Cressage Apologies

Dr Philip Leigh Shifnal & Priorslee Apologies

Theresa Dolman Shifnal & Priorslee Attended

Sylvia Pledger PPG South East Attended

Mary Eminson PPG Clun Attended

Colin Kelcey PPG Clun Attended

Dr Julian Povey CCG Clinical Chair Attended

David Stout CCG Accountable Officer Attended

Nicky Wilde CCG Director of Primary Care Apologies

Dr Julie Davies CCG Director of Performance and Delivery Apologies

Tom Brettell CCG South Locality Manager Attended

Heather Clark (Minute Taker) CCG Personal Assistant Attended

Clare Michell-Harding CCG Senior Project Lead Pharmacist Attended Shola Olowosale CCG Locality Pharmacist Attended Dr Finola Lynch CCG GP Governing Body Member & Vice-Chair Attended

Laura Clare CCG Deputy Chief Finance Officer Attended

Cathy Davies CCG Commissioning and Redesign Lead (Mental Health) Attended

Anne O’Shea IAPT Service Lead Attended

Emma Pyrah CCG Head of In Hospital Apologies

Penny Bason STP Programme Manager Attended

Katy Warren Social Prescribing Project Lead Attended

Cathy Levy Social Prescribing Project Lead Attended

Minutes of the

South Locality Board Meeting

Thursday 2 May 2019

Bridgnorth Medical Practice

Agenda Item – GB-2019-09.130 CCG Governing Body – 11.09.19

South Locality Board Minutes – 2 May 2019 Page 2

Minute No SLB-2019-05.046: Item 1 – Welcome & Apologies 1.1 Dr Matthew Bird, Locality Chair, welcomed and thanked Members for attending and introductions were

made.

1.2 Apologies received were recorded as above.

Minute No SLB-2019-05.047: Item 2 – Members’ Declaration of Interests

2.1 Members were reminded of the requirement to complete a new Declaration of Interests form annually. No new declarations of interest were made.

ACTION: For those Members who had not already submitted a new Declaration of Interests form they were requested to complete and sign and forward or hand to Miss Clark. ([email protected])

Minute No SLB-2019-05.048: Item 3 – Minutes of Formal Meeting held on 7 March 2019 3.1 The minutes of the meeting held on 7 March 2019 were agreed as a true and accurate record and were

signed by the Chair.

Minute No SLB-2019-05.049: Item 4 – Matters Arising

4.1 Minute No SLB-2019-03.039 – Patient Group Representatives – Dr Bird advised that there had been some progress made on this but that the role of patients was still to be decided, and the CCG was working on a more effective and streamlined approach to patient involvement.

4.2 Minute No SLB-2019-03.040 – Referral Issues – Dr Povey advised that he had not received details from

Dr Beanland about the rejected two week rule referrals. Rachel Shields advised that this had been reported on Datix with one being an administrative problem regarding referrals to Hereford. Dr Povey advised that this would now go through the normal complaints procedure which the CCG was currently refreshing.

Minute No SLB-2019-05.050: Item 5 – Introduction of New Accountable Officer 5.1 Dr Bird introduced David Stout who joined Shropshire CCG on 1

st April 2019 as the interim Accountable

Officer. David explained that he had most recently worked with the CCGs in Central London and South West London for 2-3 years. He had also spent a year in Cumbria which had similarities to Shropshire due to rurality and workforce challenges. David was also a PCT Chief Executive for 6 years in London, and worked for 6 years for the NHS Confederation. David stated he was keen to get out and meet CCG Members but could not promise to attend every meeting.

Minute No SLB-2019-05.051: Item 6 – CCG Chair’s Update 6.1 Dr Julian Povey advised that the CCG held a meeting the previous day to inform staff about a paper that

would be presented to the CCG Governing Body meeting on 8th May 2019. The paper explains that

Shropshire CCG and Telford and Wrekin CCG are proposing the dissolution of both CCGs to create one new CCG organisation. The paper would not be signed off until it had been to both CCG Governing Body meetings. Dr Povey explained that NHS England and NHS Improvement had recently released guidance for this process with deadlines and timeframes. The guidance states that if CCGs can submit an application by 30

th September they can work towards starting a new organisation from 1

st April the

following year if the application is approved. The proposal going to both CCG Boards states that this would be the preferred option and that the new organisation would commence on 1

st April 2020. If this is

not possible within the timeframes the CCGs will work towards a single management team across both CCGs and would work towards a new organisation from 1

st April 2021.

6.2 Dr Povey explained that the process to create a new CCG would involve setting up a PMO office to work

on the process and legal side of the proposal, and there would be union, HR and staff involvement. The proposal also states that the CCGs would go out to appoint a single Accountable Office to cover both CCGs as soon as possible, and this would go through the normal process of advertisement and appointment. Dr Povey advised that until a process was in place with a PMO team and HR advice sought there was not much more information at this time.

Agenda Item – GB-2019-09.130 CCG Governing Body – 11.09.19

South Locality Board Minutes – 2 May 2019 Page 3

6.3 Dr Allen asked if the process to come to this decision had been an easy one. Dr Povey explained that the CCG had met with Telford and Wrekin CCG and both had issued a statement of intent for joint working. If the proposal is supported by both Boards it would be important to note that this would be a new organisation and not one merging with another. Dr Povey added that it was his understanding that the Telford and Wrekin CCG Board supported the proposal but that it would need to be approved at their Governing Body meeting first. Dr Povey explained that the NHS Long Term Plan gives a direction towards ICSs (Integrated Care Systems) and the need to have a single commissioner per ICS. There is also a target of 20% reduction in running costs by all CCGs by 1

st April 2020; this would only be

achievable if CCGs worked together more closely. Mr Stout added that this was not a Shropshire specific thing and was happening everywhere across the country.

Minute No SLB-2019-05.052: Item 7 – Locality Chair’s Update 7.1 Locality Board Guidance - Dr Matthew Bird explained that Dr Deborah Shepherd, Chair of Shrewsbury

and Atcham Locality had been leading on developing guidance for Locality Board meetings and this would be shared with practices soon. He added that there had been confusion around the meetings with them being used to share information with Members as providers and not as commissioners. The idea that had been raised would be to streamline the agendas with two main topics per meeting for a better and more effective discussion; at least one of the items would have a clinical focus. A question was asked about problems with service provision and whether these should be reported through the locality meetings. Dr Povey advised that yes this could be bought to the meetings to be discussed; but that the meetings were not for other services to come to talk to Members as providers. He added that with the formation of Primary Care Networks (PCNs) and ICSs that the membership and structure of the meetings may need to be reviewed again in the future.

7.2 Help to Slim and Smoking Cessation Services - A short discussion took place about the decision made

by Shropshire Council to stop the help to slim and smoking cessation services. Dr Bird advised that these services were funded by the council and it was their decision to remove funding, he was not aware of any replacement services. Dr Povey added that the CCG had highlighted that this was not the best plan and Public Health England were aware of this, but there was a problem in funding the services due to the public health grant being reduced. Dr Povey explained that prevention services were not in the CCG budget but that the NHS Long Term Plan implies that prevention may come back to the NHS or may be a role for PCNs. David Stout advised that he had met with the new Public Health Director, Rachel Robinson, and there was a commitment from the Local Authority to look again at smoking in pregnancy services; conversations were ongoing about whether this part of the service could be maintained. The help to slim and smoking cessation services will stop taking referrals in June 2019.

Minute No SLB-2019-05.053: Item 8 – CCG Financial Position 8.1 Laura Clare, Deputy Chief Finance Officer, attended the meeting to give an update to Members about

the CCG financial position. A presentation was circulated to members prior to the meeting. Mrs Clare explained that at 2018/19 year-end the CCG had a total deficit of £17m; this was £5m above the control total set by NHS England of £12m. The CCG did manage to deliver £16m of savings which included key schemes such as prescribing, contractual challenges with hospitals and frequent flyers. The total cumulative deficit at year-end was £76m.

8.2 The control total or “allowable deficit” set by NHS England for 2019/20 is £12.3m and the plan that had

been submitted showed that the CCG is forecasting to deliver a £23.8m deficit in 2019/20; this is £11.5m away from the control total. This position is dependent on the CCG delivering £19.5m of QIPP (Quality Innovation Productivity and Prevention) savings. Due to risk associated with the QIPP plan there is also net risk in the plan of £4.6m, which gives a total risk adjusted deficit forecast for 2019/20 of £28.4m.

8.3 A question was asked about differences between CCGs and Local Authorities that cannot run a deficit.

David Stout explained that the consequences were different for CCGs and Local Authorities; he added that to be in deficit is technically against the law as the CCG would be breaching its statutory duty and the CCG was already under direction. If Local Authorities were in deficit administrators would be bought in. He stated that the most extreme thing to happen would be decisions being forced on the Governing Body about what the CCG could and could not fund. Mr Stout advised that something similar took place in South East London with a regime to drive through service reconfiguration, and the decisions made were not very popular with the local community and didn’t work well. He added that the position the CCG was in was serious and the CCG does have to do something about it.

8.4 Dr Allen asked which QIPP schemes were successful in the last year. Dr Povey advised that the

Governing Body papers would be made public the following day and the information about QIPP

Agenda Item – GB-2019-09.130 CCG Governing Body – 11.09.19

South Locality Board Minutes – 2 May 2019 Page 4

schemes were in these. In 2018/19 the CCG achieved 80% of QIPP schemes. Dr Povey stated that he was grateful for the help and contribution of Members to achieve this and also patients, public, providers and staff. He added that in the future when ICSs are formed there would be a system budget and control total.

8.5 David Stout explained that the plan for 2019/20 which had been submitted by the CCG had a high

percentage of spend, but that if the CCG had a plan that balanced the books it would require a percentage of cuts that had not been achieved in other areas. Mrs Clare added that in the North Midlands area, the only other CCG with a larger deficit than Shropshire was Staffordshire; there were also patches in London with significant problems.

8.6 Dr Stuart Wright asked if the CCG deficit made an impact in paying providers for services as he was

struggling to get payment for extended access services. Tom Brettell advised that the payments were due the following week and it was acknowledged that communication about this had been poor. Dr Povey advised that the NHS had targets for the amount of invoices that are paid within 30 days and that the CCG were performing well on this; he thought that something had gone wrong with internal processes, but that this was not due to a cash flow problem. Dr Wright stated that he would need assurances that the next invoice he submitted would be paid on time. Laura Clare advised that she would look into this problem.

ACTION: Laura Clare to look into invoice/payment problems for extended access services.

Minute No SLB-2019-05.054: Item 9 – IAPT (Improving Access to Psychological Therapies) 9.1 Cathy Davies, CCG Mental Health Lead and Anne O’Shea, IAPT Service Lead attended the meeting to

give an update and overview of the IAPT service. The presentation included information about:

Staff

Waiting times

Team areas

Referrals routes and assessment

Stepped Care Model

Treatment Options: SilverCloud, CBT (Cognitive Behavioural Therapy), Counselling, Think Good

Feel Good, Anger Management, EMDR (Eye Movement Desensitisation and Reprocessing), ACT

(Acceptance and Commitment Therapy), IPT (Interpersonal Therapy), Couples Therapy

ACTION: Heather Clark to send out IAPT presentation to Members. 9.2 Ms O’Shea confirmed that usually the first session was a telephone call but this did also include a

treatment element. Patients are given ‘homework’ to do and things to read before the next phone call a couple of weeks later. If patients haven’t completed the homework they will be asked for the reasons why. The second phase of treatment does sometimes go over the 18 week target at the moment. The IAPT team are looking for spaces to utilise in practices for these sessions. The team are also able to help people with learning disabilities and will assess the level of their problem to see if a face to face appointment is needed rather than a phone call.

9.3 A discussion took place about EMDR and contraindications to treatment which included undisclosed drug

use, certain medications, heart problems or pregnancy. Dr Bailey stated that it would make more sense for the practitioner who provides the EMDR treatment to ask the patient if there were any contraindications, or to send a list to GPs that could be checked. Anne O’Shea advised that often the team will not ask the GP for this information and to bear in mind that practitioners have no medical training. This was an exception and generally speaking not much gets in the way of the EMDR treatment, the team would not be transferring responsibility but just asking for advice. There are only one or two cases a year across the county.

9.4 Dr Allen asked if SilverCloud could be offered to patients directly. Anne O’Shea advised that patients

needed to be entered onto the IAPTus system so that the team can record the activity and measurement score, and advised Members to email the team if patients were interested in using SilverCloud. Dr Allen asked if Members could be shown the SilverCloud system if they wanted to see it. Ms O’Shea advised that she could send account log in details for Members to have a look at the modules available.

ACTION: Anne O’Shea to send out a link and account log in details to SilverCloud so that Members can look at this.

Agenda Item – GB-2019-09.130 CCG Governing Body – 11.09.19

South Locality Board Minutes – 2 May 2019 Page 5

9.5 Dr Bailey stated that Members had concerns about capacity in the IAPT service and had experiences of

patients waiting a long time for treatment; at the last meeting this was discussed due to the withdrawal of practice counsellors. Anne O’Shea explained that the IAPT team had been given additional funding for further counsellors, and had gone through the recruitment process; the new counsellors would start to work for the team once they have worked their notice periods. She added that this would give the team extra capacity and they would do everything they could to bring the waiting list down. Part of this would be to not offer the service that patients are asking for but instead the service they need. In the past patients were given choices and asked for 1:1 counselling and would then have to wait a very long time. The team hoped that over the next 6 months to a year things would settle down and capacity would no longer be a problem.

9.6 Dr Bird asked about the Practice Counsellor’s waiting lists and how the patients on these lists would be

slotted in to make the waiting time fair for all. Anne O’Shea advised that these patients had been sent opt in letters to ensure they still wanted to access the service. Some had already opted in, been assessed and had their first treatment session and were now on a waiting list until the new practitioners and counsellors that had been recruited can see them. Some patients have opted out but now have the IAPT team details if they wish to access this service again in the future. The patients on the waiting list will be picked up in the order in which they have opted in to the service. If they have already been assessed by the team and sent to their practice for counselling these patients will be seen as a priority. So far the team had found this to be very successful and have had no complaints.

9.7 Susan Mellor-Palmer asked how many hours or days would be allocated to each practice. Anne O’Shea

explained that this was still to be worked out and the team would need to look at the sizes of practices and demographics, but that the service would be a supply and demand service rather than each practice having a set number of hours allocated.

Minute No SLB-2019-05.055: Item 10 – Prescribing Update 10.1 Shola Olowosale, South Locality Pharmacist, attended the meeting to give an update from the Medicines

Management Team. Electronic copies of the presentation had been circulated prior to the meeting and hard copies were tabled at the meeting. The update covered the following points:

Pain – opioid prescribing rates, available support and future plans

Respiratory – right care data, asthma opportunities, available support and future plans

CCG Prescribing Development Scheme – antimicrobial stewardship, restricted medicines, OTC

medicines

10.2 Discussion took place about the service that was previously part of the substance misuse team for opioid addiction; it was agreed that the service was useful to patients and that it was unfortunate that it no longer existed. Clare Michell-Harding advised that an audit would be taking place to see how many patients are affected by this; the team would also be looking at existing services to see how they can link into this. Part of the PLT will be to signpost to local services that can be used. Dr Bird reminded everyone to sign up to the PLT so that the CCG would be aware how many people would be attending.

Minute No SLB-2019-05.056: Item 11 – Social Prescribing 11.1 Penny Bason, STP Programme Manager, Katy Warren and Cathy Levy, Social Prescribing Project Leads

from Shropshire Council, attended the meeting to give a presentation about Social Prescribing in Shropshire. The presentation covered details about:

Shropshire’s Model

Eligibility

PAM (Patient Activation Measure) Profiles

Social Prescribing in South Locality

Findings of Evaluation

National Social Prescribing Network findings

PCN Offer

11.2 Dr Stuart Wright stated that the project was very positive and he had seen a positive change in patients, especially in the pre-diabetic group that were identified for the project. The Social Prescriber also works well with the Care Co-ordinator as they cover slightly different patient groups. There was a good turn out to the launch event from organisations all over the district, including voluntary sector groups.

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11.3 Sylvia Pledger asked about the weight control and stop smoking services and how Social Prescribers would be affected once these services have been stopped. Penny Bason advised that the team were working with the National Diabetes Prevention Programme for weight management support, and that they did not provide a weight management programme but they provided support. The team recognised that this was a big issue and understood how much patients valued the service.

11.4 A question was asked about what was next following the pilot. Cathy Levy explained that there was now

NHS England funding for link workers, and that Social Prescribing will be open to PCNs to see what they would want and how they would like to take this forward. The pathways had already been developed through the pilot and it was hoped that people would access the support now it was available. The team advised that they also had access to more data and information if needed.

11.5 Dr Finola Lynch advised that she had read the evaluation and could see an improvement in patient

activation, there was a willingness to take part and there had been significant weight loss. There had also been a decrease of a third of GP appointments for the patients that had been referred.

Minute No SLB-2019-05.057: Item 12 – Care Co-Ordination Centre 12.1 Apologies were received from Emma Pyrah and the Shropdoc team, it was agreed the item should be

deferred to the next meeting.

ACTION: Heather Clark to rearrange Care Co-ordination Centre item to a future meeting. Minute No SLB-2019-05.058: Item 13 – Patient Group Representatives 13.1 Mrs Pledger advised that she had no updates. Minute No SLB-2019-05.059: Item 14 – South Locality Bank Account 14.1 Dr Bird explained that when he started the South Locality Chair role he was given details about a locality

bank account. Following enquiries it appeared that when the CCG was formed the South Locality opted to be responsible for its own budget for meeting attendance, and a surplus arose due to not all practices attending every meeting. Dr Bird stated that he was keen to close the account and the simplest way to do this would be to give this money back to the CCG for the PLT (Protected Learning Time) fund for all localities. Dr Penney was consulted about this due to being involved historically and advised that he thought the money had been ring-fenced for education for the South Locality. Some Members agreed that the money should be given back to the CCG, and some Members thought that Dr Penney would prefer the money to be made available for South Locality training only and should be asked for his opinion first. It was agreed that Dr Bird would speak further to Dr Penney about the suggestion that had been made to give the money back to the CCG.

ACTION: Dr Bird to speak to Dr Penney about the locality bank account.

Minute No SLB-2019-05.060: Item 15 – Primary Care Update 15.1 An update paper was circulated prior to the meeting and there were no further questions about this. Minute No SLB-2019-05.061: Item 16 – Commissioning Update 16.1 An update paper was circulated prior to the meeting and there were no further questions about this. Minute No SLB-2019-05.062: Item 17 – Any Other Business 17.1 Members Roles at Locality Meetings - Dr Thompson stated that sometimes he was confused about

Members roles at the locality meetings and that it would be useful on the agenda to have one line to explain what Members need to do e.g. item for discussion/information/approval. It was also raised that the Medicines Management updates didn’t fit in with the commissioning meeting and are usually provider focused. Dr Povey advised that these updates were being changed to have more of a commissioning focus. Dr Babu added that the updates were usually duplication of data that had already been sent out to practices. Dr Povey stated that if the proposal to create a new CCG is agreed, the format of the meetings would need to be reviewed; there would also be PCNs in the future too which may affect these decisions.

Agenda Item – GB-2019-09.130 CCG Governing Body – 11.09.19

South Locality Board Minutes – 2 May 2019 Page 7

17.2 Hearing Services – It was raised that the outside clinic had lost their contract for domiciliary hearing services and patients were being discharged with a request to their GP to generate another referral. Dr Povey advised that this would need to be discussed with the relevant commissioner.

ACTION: Tom Brettell to discuss hearing services with relevant commissioner and send email out to Members with information following this.

17.3 Dermatology – Dr Babu asked about Dermatology; Dr Povey advised that this was a hospital sub-

contract. SATH sub-contracted two week referrals to Health Harmony, the community contract went out to tender and the St Michaels skin clinic now had the contract for this. Dr Bailey stated that she had received a letter from Health Harmony about a two week referral seen in the community clinic; the letter stated that the patient needed a skin graft and the consultant couldn’t do this in the community and therefore needed a new two week referral into secondary care. Dr Povey advised that this was wrong and was a pathway problem with the provider that needed to be looked into; it should also be reported on Datix.

ACTION: Tom Brettell to look into issues with dermatology two week referrals.

17.4 RAS (Referral Assessment Service) - Discussion took place about patients who would like to attend a

service out of area, for example Hereford, and have been told by RAS that they cannot accept out of county referrals. Dr Povey advised that these patients must go through the Shropshire community interface first due to national policy and this was the same for Dermatology and MSK, at the next stage they would be given a choice of where to go. It was agreed by all that communication needed to be better and there needed to be some kind of referral protocol to show what can be offered to patients.

ACTION: Tom Brettell and Dr Matthew Bird to look into issue regarding a clear referral protocol.

Minute No SLB-2019-05.063: Item 18 – Date and Time of Next Meetings 18.1 The next formal meeting will take place on: Thursday 11 July 2019 at Mayfair Centre, Church Stretton

at 3.30pm. 18.2 Dates of future meetings:

Wednesday 15 May 2019 PLT Tuesday 2 July 2019 PLT Thursday 11 July 2019 Mayfair Centre, Church Stretton Wednesday 4 September 2019 Bridgnorth Medical Practice Thursday 3 October 2019 PLT Wednesday 6 November 2019 Bridgnorth Medical Practice Thursday 9 January 2020 Mayfair Centre, Church Stretton Wednesday 5 February 2020 Bridgnorth Medical Practice Thursday 5 March 2020 Mayfair Centre, Church Stretton

Signed: ………………………………………….. Date: ……………………… Dr Matthew Bird, Locality Chair