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AGENDA

Reporting Period 2013-14

REPORTING GROUP TITLE

NHS South Cheshire CCG Extraordinary & Formal Governing Body Date / Time Venue Chair Meeting No.

Thursday 27th March 2014, 14:15 – 17:15

PLC Conference Centre, Reaseheath College, Nantwich CH5 6DF

Dr Andrew Wilson 7

No. Business Subject Topic Lead Time

Slot Reports/ Verbal

7.1 7.1.1 Welcome & Apologies for Absence Chair 14:15 Verbal

7.2 7.2.1 Patient’s Story E Leigh 14:20 Verbal/Film

7.3 Committee Management 7.3.1 Minutes of the meeting held on

Thursday 6 February 2014 Chair 14:35 Attached

7.4 Financial & Contract Management

7.4.1 Finance Report L Risk L Risk

14:40 15:00

Attached Attached 7.4.2 2014 / 15 Budgets

7.5 Governance 7.5.1 Risk Management Strategy L Risk 15:20 Attached

7.5.2 Corporate Risk Register Update L Risk 15:30 Attached

7.6 Business

7.6.1

Locality Reports • Nantwich • SMASH • Crewe

A London M Tate

15:40 Attached

7.6.2 CCG 2 Year Operational Plan - Final J Vitta 15:45 Attached

7.6.3 Annual Report J Vitta 16:00 Attached

7.6.4 Learning Disability Update J Thorley 16:15 Attached

7.6.5 Better Care Fund Submission G Kilminster 16:20 Attached

7.6.6 Refreshed Health & Wellbeing Strategy G Kilminster 16:35 Attached

7.6.7 Primary Care Update A Best 16:50 Attached

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Agenda NHS South Cheshire Clinical Commissioning Group: NHS South Cheshire Governing Body – 2014-03-27

7.7 Quality & Performance

7.7.1 Quality Report S Cooke 16:55 Attached

7.7.2 NHS Performance Outcome Measure 2013-14 – Reporting Period Ending Jan-14

L Risk 17:05 Attached

7.8

Operational Management & Regulatory Updates

7.8.1

Committee Minutes: • Quality & Performance

Committee • Governance & Audit

Committee

S Cooke G Bruce

17:15 Attached

7.9 Any Other Business

7.9.1

The next meeting is scheduled to take place on Thursday, 5 June 2014 at 14:00, venue YMCA Conference Centre, Crewe

17:20 Verbal

CIRCULATION LIST

MEETING SCHEDULE

2013-14 Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar

Date 05-06-14 07-08-14 02-10-14 04-12-14 05-02-15

Time 14:00 14:00 14:00 14:00 15:00

Venue Crewe Nantwich Middlewich Nantwich TBC

Name Organisation Membership Category Committee Quorum

Dr Andrew Wilson NHS South Cheshire CCG Clinical Professional

The committee will be quorate when one lay member, three clinical

members and one executive are present

Dr Andrew Hudson NHS South Cheshire CCG Clinical Professional Dr Annabel London NHS South Cheshire CCG Clinical Professional Dr Michael Tate NHS South Cheshire CCG Clinical Professional Dr Andrew Spooner NHS South Cheshire CCG Clinical Professional Graham Bruce NHS South Cheshire CCG Lay Member John Clough NHS South Cheshire CCG Lay Member Diane Noble NHS South Cheshire CCG Lay Member Dr Heather Grimbaldeston Cheshire East Council Director of Public Health, Cheshire East Dr Robert Pugh NHS South Cheshire CCG Secondary Care representative Judith Thorley NHS South Cheshire CCG Executive Nurse Simon Whitehouse NHS SC/VR CCGs Chief Officer Fiona Field NHS South Cheshire CCG Director of Partnerships & Governance Lynda Risk NHS SC/VR CCGs Chief Finance Officer Attendees

Jo Vitta NHS SC/VR CCGs Governance & Business All Meetings Wendy Jeffries NHSC SC CCG Office Administrator All meetings

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Prepared By: Wendy Jeffries NHS SC CCG – [Governing Body Meeting] – 2014-02-06

Date/Time Venue


Ref Discussion and Action Points Whom When

Committee Management

6.1.1 Apologies for Absence

A Wilson welcomed the Members of the Governing Body to the meeting.

There were three members of the Public in attendance at the meeting.

There were no Apologies for today’s meeting.

MEMBERSHIP

Present Name Organisation Title Committee Quorum Dr Andrew Wilson NHS South Cheshire CCG Chair

A meeting will be quorate if, one lay

representative, three clinical

representatives and one executive

are present.

Graham Bruce NHS South Cheshire CCG Lay Representative – Governance & Audit

John Clough NHS South Cheshire CCG Lay Representative – Governance & Audit

Fiona Field NHS South Cheshire CCG Director of Partnerships & Governance

Dr Heather Grimbaldeston Cheshire East Council, Director of Public Health, Cheshire

East Dr Annabel London NHS South Cheshire CCG Locality Lead – Nantwich & Rural Diane Noble NHS South Cheshire CCG Lay Representative - PPI Dr Robert Pugh NHS South Cheshire CCG Secondary Care Representative Lynda Risk NHS South Cheshire &

NHS Vale Royal CCGs Chief Finance Officer

Dr Andrew Spooner NHS South Cheshire CCG Commissioning Lead Dr Mike Tate NHS South Cheshire CCG Locality Lead – S.M.A.S.H Dr Andrew Hudson NHS South Cheshire CCG Locality Lead - Crewe Judith Thorley NHS South Cheshire CCG Executive Nurse Simon Whitehouse NHS South Cheshire &

NHS Vale Royal CCGs Chief Officer

Attendees J Vitta NHS South Cheshire &

NHS Vale Royal CCGs Business Manager

Sue Cooke NHS South Cheshire & NHS Vale Royal CCGs Quality Manager

Amanda Best NHS South Cheshire & NHS Vale Royal CCGs Service Delivery Manager

Minute Taker Wendy Jeffries NHS South Cheshire CCG PA to Dr Andrew Wilson, NHS

South Cheshire CCG Clinical Chair

Chair: Dr Andrew Wilson

NHS South Cheshire CCG Formal Governing Body Meeting

The Olive Grove Conference Centre,

Regents Park, Nantwich

6th February 2014 14:00

Meeting No: Six Reporting Period 2013-14

MINUTES

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6.1.2 Minutes of the last meeting and matters arising The minutes of the NHS South Cheshire CCG Governing Body meeting

held on Thursday 5 December 2013 had been circulated with the agenda.

The minutes of the meeting were approved as a correct record.

NHS South Cheshire CCG Governing Body:

• Approved the minutes from the NHS South Cheshire CCG Governing Body meeting held on 5th December 2013.

6.2 Governance

6.2.1 Strategic Goals

A short report had been circulated with the Agenda confirming the

proposed revised Strategic Objectives for NHS South Cheshire CCG that

align with the five National outcomes (tabled at the meeting) as defined in

the NHS England Planning Guidance.

1) Prevent people from dying prematurely.

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

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

4) Ensuring that people have a positive experience of care.

5) Treating and caring for people in a safe environment and protecting

them from avoidable harm.

This proposal had been discussed with South Cheshire Membership

Council in January and had been agreed as a sensible and clear way

forward.

F Field reported that by adopting the five domains as the South Cheshire

CCG strategic objectives, we will be able to target our local work to

achieve measureable progress towards local and National outcomes and it

would give a clear “line of sight” between pieces of work and achieving our

objectives. It will also enable the Governing Body and Membership

Council to challenge why and how work is prioritised by the CCG.

The Governing Body accepted the five strategic objectives but commented

that more detail was required to show how these objectives would be

achieved through work programmes.

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After discussion, it was suggested and agreed that a highlight summary at

the beginning of each domain would give a good picture for understanding

of how we would achieve the objective. The first draft showing this

information will come back to the Governing Body in the future.


• Agreed to note the contents of the report; and

• Accept the redefined Strategic Goals

F Feb/Mar 2014

6.2.2 Assurance Framework Update L Risk reported on the Assurance Framework Update report which was

circulated with the agenda. The purpose of the report is to provide the

Governing Body with a progress report on the risk entries graded 12 and

above

L Risk went on to explain that the new dashboard identifies and gives an

overview of all risks to the CCG. The dashboard had been taken at the

Governance and Audit Committee recently where good discussions had

taken place with the realisation that some risks had to be accepted.

Clarification on the vascular surgery/pathway risk would be taken outside

the meeting as more information was required. The Governing Body

thought that a ‘highlight’ report showing key risks would be beneficial to

future meetings, enabling a risk appetite to set risk levels and to give

essential clarification.


• Agreed to note the contents of the risk management arrangements, in particular new risks identified during the reporting period; risks which are being recommended for closure; risks reviewed with recommendations to de-escalate existing score.

• Requested that a highlight report outlining background information and the progress of mitigating actions for each major risk was included in future risk reports.

` LR

Mar 2014

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6.3 Business

6.3.1 Chief Officer’s Report The Chief Officer’s report had been circulated with the agenda in advance

of the meeting and provided the Governing Body with an overview of

important Clinical Commissioning Group business:

• An overview of the recently published NHS England Planning

guidance.

• A Summary of the Assurance Framework Checkpoint 2 meeting with

NHS England Area team:

• CSU Policy Review Consultation

• Recruitment

• Breast Screening review.

• CSU correspondence to staff regarding a potential merger with Greater

Manchester CSU and CSU understanding efficiency review.

• Technology review.

• Primary Care Strategy


• Noted the contents of the report.

6.3.2 Locality Reports for: Nantwich & Rural, Sandbach, Middlewich, Alsager, Scholar Green, Haslington & Crewe

The Locality report had been circulated with the agenda in advance of the

meeting.

A London gave an overview of the report highlighting that work has

commenced on the CQUIN process in the Nantwich Locality. This is

having positive results in developing six pathways for primary care to move

services out of an acute hospital setting and into a Community Primary

Care setting.

A Hudson reported that Public Health is looking at targeted needs in

Crewe so resources and additional services can be focussed on improving

outcomes for people in Crewe.

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• Noted the content of the report summarising the work of each programme.

6.3.3 CCG Draft 2 Year Operational Plan A copy of the CCG Draft 2-year Operational Plan had been circulated with

the agenda in advance of the meeting.

J Vitta reiterated that the planning guidance had come out before

Christmas and has set out ambitious challenges for the NHS to look at

longer term planning over 5 and 2 years. The Governing Body were asked

for comments and feedback on the Draft Plan.

Prior to this meeting, a Stakeholder event had been held to share the Draft

Plan. The theme had been how to quickly transform services across

health and social care, reducing pressure and activity services and

resources whilst integrating services around the patient/person. Feedback

from the event and from Governing Body members, will be incorporated in

to a Second Draft Plan for the March Governing Body meeting; final sign

off will be in April.

S Whitehouse stated that this is a real challenge to develop a 5 year

Strategic Plan at the same time as a 2 year Operational Plan. This is an

NHS England requirement for all CCG’s.

The 5 year Plan is not solely a CCG plan as it needs to be owned and

signed off by all partners to show they are in agreement.

The Chairman stated that it would be helpful if we add a narrative

describing the changes we would want for our citizens that challenges our

work.

The financial plan which is at an early stage was discussed; we must show

a balanced position although this is a challenge for us and our partners.

The Better Care Fund that supports the Connecting Care 5 year strategic

plan will identify resources to be shared between health and social care

during 2014/15 and 2015/16 and this will need to be signed off at the

Health & Well Being Board as well as by SCCCG Governing Body.

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S Whitehouse expressed thanks to both J Vitta and F Field for the work

they had undertaken on a tight timescale.


• Reviewed the draft 2 year Operational Plan and provided initial comments and feedback for final submission.

6.3.4 Local Enhanced Services The report had been circulated with the agenda in advance of the meeting.

The role of Chair was handed over to Graham Bruce (Lay Member

and Deputy Chair) from Dr Andrew Wilson due to potential of Conflict of Interest. The other GP’s on the Governing Body did not take part in the debate due to potential conflict of interest.

A Best updated the Governing Body on the review of Enhanced Services

which has commenced with participating practices an in-depth review of

the specification has started. Communication with NHS England has given

a clarification agreement and their support to enable the majority of

services to have contracts extended for 14/15, and give the CCG and NHS

England more time to specify the services we would want to commission.

An update is to be given to the Governing Body at the July meeting.

NHS South Cheshire CCG Governing Body (excluding GP Members):

• Noted the contents of the report, and

• Approved the recommendations: 1. Based on the preliminary findings and advice from the NHS

England Area Team, the CCG are recommending to waiver the option to undergo any procurement exercise by April 2014 for each of the LES arrangements detailed above.

2. The CCG recommends to the Governing Body the approval to transfer current commissioned services across onto a Standard NHS Contract for 2014/15. This transfer will require full Service specifications to be written for all LES to be fit for purpose with robust service description, delivery requirements, KPIs, performance management, payment processes and aligned to current NICE and other relevant guidance.

AB

July 2014

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3. The CCG recommends that Spirometry is not carried forward

as a LES, due to the overlap with core General Medical Services.

4. The CCG would also like to postpone any recommendation regarding future commissioning decisions around Dermatology and Counselling services pending further quantitate and qualitative analysis of currently commissioned services. A further decision will be made before end of March 2014.

5. This approach will allow the CCG to ensure that a timely and detailed review will be undertaken during 2014/15 to determine future enhanced commissioned services that meet the specific needs of the CCG, supporting the operational plan, Primary Care strategy and targeting needs of the local population.

6.3.5 NHS England Additional Winter Funding 2013-14 The report had been circulated with the agenda in advance of the meeting.

S Whitehouse gave a summary to the Governing Body explaining that

before Christmas, SCCCG were given an allocation of winter pressure

money with the mandate that this would be managed through the Urgent

Care Board. A bidding process was quickly established to score and

prioritise local schemes to reduce pressure on A&E at MCHfT and support

patients at home. The report gave a high level summary of the process

undertaken and gave assurance to Governing Body members on how this

resource was used.

The Urgent Care Board has now become the Urgent Case Working Group

(multi agency) to review the schemes and provide assurance as well as

steer the transformation of urgent care services locally.


• Noted the contents of the report.

6.4 Quality & Performance

6.4.1 Quality Report The Quality report was circulated with the agenda, note that the data is up

to December 2013.

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S Cooke introduced the report and highlighted the following points:

• The AQuA mortality review in to MCHfT had commenced with a report

expected in April 2014.

• A ‘never’ event from back in May 2013 had been investigated by

MCHfT with a report expected before April and before the new theatres

are operational as the event had involved theatre processes.

• CCG Quality leads are currently involved in investigating three further

never events in Quarter 3, (details to follow). The Quality team were

asked to explain what the term ‘never’ event means for Governing

Body members.

• It was asked that the ‘Friends & Family’ test indicator be shown in a

more informative way. It was also suggested that the ‘Friends &

Family test’ be a future agenda item on the Informal Governing Body

agenda to help understand results and metrics.

• The Quality team are asked to show National benchmarks in the

Quality report to compose our local performance.


• Noted the position update relating to clinical quality and patient safety from main providers, Mid Cheshire Hospitals Foundation Trust, Cheshire and Wirral Partnership Foundation Trust, East Cheshire NHS Trust Community Services and BMI South Cheshire Hospital.

SEC SEC SEC

Mar 2014 Mar 2014 Mar 2014

6.4.2 Advancing Quality Funding The Advancing Quality Funding report had been circulated with the

agenda in advance of the meeting.

S Cooke gave an overview of the report stating that Advancing Quality

Alliance are a North West organisation we are currently members; the

Quality & Performance Committee was wanting to ask the Governing Body

to make a decision regarding renewal of the subscription.

The Quality & Performance Committee had concerns as to whether

membership was good value for money as the data is always six months in

arrears. It is noted that this Alliance is a membership organisation, not a

commercial one.

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After discussion, the Governing Body proposed a one year agreement with

a mandate for a six month investigation in which the CCG work closely

with Advancing Quality Alliance. The Quality & Performance Committee

are to bring a paper back to the Governing Body recommending whether

to sign up for a further two years once the investigative work is completed.


• Noted the content of the report;

• Made the decision to propose a one year subscription with mandate that a further decision be made in six months with regards the renewal of the subscription to the Advancing Quality Programme in 2014/15.

SEC July 2014

6.4.3 Quality & Safeguarding Strategy J Thorley gave an overview on the report that was circulated with the

Agenda prior to the meeting.

The Governing Body were asked to comment on the contents of the

strategy: it was agreed that the Diagram (p202 of 285) be shown in a more

engaging format.

The Governing Body supported quality and safeguarding as a continuance

across the whole system. Poor quality often becomes a safeguarding

issue. The next steps are to hold engagement events for shared

understanding across the CCG, patients, public and providers.

J Thorley proposed that a patient story should come to future Governing

Body formal meetings, they have a powerful impact and help CCG

understanding of how the patient experience relates to the work we are

doing. The Governing Body were keen to adopt and agreed this approach.

It asked that the stories, where possible, were relevant to the meeting

content, add value and relate to the five strategic objectives.


• Approved the contents of the Quality and Safeguarding Strategy.

• Approved ‘patient stories’ coming to the Governing Body as part of the Quality report to give further opportunity for learning and challenge.

JT

June 2014

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6.4.4 Ambulance Services (Planned & Emergency) Update Report January 2014 The paper was circulated with the agenda before the meeting and gave an

update regarding the current ambulance commissioning arrangements and

performance of the North West Ambulance Services (NWAS), Planned

Transfer Service (PTS) and Paramedic Emergency Service (PES).

FF presented the report explaining the type of services provided, how calls

are triaged and the different categories of calls.

The Governing Body asked for more detail on the Cheshire targets and

why we no longer have a local target to see how the local figures would

relate to the regional performance figures.

Further work was requested to develop a local target through the Cheshire

wide NWAS group.


• Acknowledged the Local Governance arrangements with neighbouring CCG’s.

• Noted that performance is being effectively managed and monitored through the Living Well Programme Board.

ADDED comments were:

• Governing Body would like to suggest that the local improvement target be developed for our CCG.

• The Governing Body requested a definitive answer as to whether we are able to exercise choice of emergency ambulance provider for our area CCG.

FF FF

Feb 2014 March 2014

6.4.5 Delivering the National Nursing & Care Strategy J Thorley gave an overview on the report that was circulated with the

Agenda prior to the meeting.

The Governing Body’s attention was drawn to the six action areas (the 6

C’s):

• Helping people to stay independent, maximising well-being and

improving health outcomes;

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• Working with people to provide a positive experience of care;

• Delivering high quality care and measuring the impact of care’

• Building and strengthening leadership’

• Ensuring the right staff, with the right skills, are in the right place’

• Supporting positive staff experience.

J Thorley was pleased to announce that a South Cheshire Practice Nurse

Membership Council had been set up in late 2013, delivering compassion

in practice, better practice and having a stronger voice into the Governing

Body.

The Practice Nurse Membership Council have, through Trish Vickers,

established a Leadership Programme for Practice Nurses, solely aimed for

Practice Nurses; at a National level, this has gained interest from the

Department of Health and Jane Cummings as Director and Nursing.

It was suggested that the Governing Body use the 6 C’s to ‘sense check’

decision making and for a small task and finish group to be set up to see

how this aligns with our objectives and values.

The Governing Body commended the great work that Judi and Trish have

done and agreed to the task and finish group.

J Thorley was asked to bring a highlight report with regards Delivering the

National Nursing & Care Strategy to future Governing Body meetings.


• Noted the Practice Nurse Membership Council;

• Approved the development of a Leadership programme for Practice

Nurses;

• Agreed to adopt the 6 C’s as a ‘sense check’ for decision making

JT/FF JT

March 2014 March 2014

6.5 Financial & Contract Management

6.5.1 Finance Report

L Risk gave a summary of the Finance report which was circulated with the

agenda and key points are summarised below:

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• A controlled total of 1.9M agreed by the Area Team to carry over to the

next year, 2014/15.

• Drew attention to ‘Better Payments Practice Code’ whereby CCG pay

all invoices promptly within 30 days.

• Regarding the ‘Better Care Fund’: discussions are taking place with

East Cheshire Council to identify spending to reduce care in Secondary

settings and increase support to Community and Primary Care settings.

The Better Care Fund plan first draft has to be completed by 14

February 2014 to support the 5 year Connecting Care strategic plan.

Detailed financial and activity costing is taking place before final

submission in June 2014. The Better Care Fund plan is due to be

available in June with a draft going to the Programme Board.

S Whitehouse gave thanks to LR and the finance team for the work they

have done over the last twelve months. He went on to explain that the

reason for the increase in the control total budget was because the CCG

had applied a “brake” on investment during the year. This included the lack

of clarity around specialist commissioning movement of monies outside

CCG control. Our financial position is now better than we anticipated but it

has not allowed us to invest in year due to the latest of the financial

certainty.


• noted the CCG is now reporting a forecast surplus of £1.9 million (current control total £1 million), dialogue with the Area Team (NHS England) is taking place to secure the carry forward of this surplus into 2014/15; and

• noted Mid Cheshire Hospitals over performance of £1.8 million (with a risk range of £1.6 million to £2.5million); and

• noted the additional winter pressures funding of £1.088 million; and

• noted the current uncommitted resources of £1.2 million available to cover the further risks identified; and

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• noted the CCG has now been issued with its allocations for 2014/15 and 15/16; and

• noted the Better Care Fund to be identified from CCG resource in 2015/16 is £10.481 million; and

• noted the initial 5 year planning gap (financial challenge) based on initial planning assumptions, aimed at the delivery of the NHS challenge to deliver a further £30 billion savings over the next 5 year period; and

• noted the summary of the initial draft Budgets for 2014/15;and

• noted the summary of the initial 2 year operational plans for 2014/15 and 15/16.

ADDED decision/comments:

• Adopt prompt 30 day ‘Better Payments Practice Code’.

6.6 Operational Management & Regulatory Updates

6.6.1 Minutes of Statutory Meetings

• Quality & Performance Committee

• Governance & Audit Committee

It was reported that a process is now in place for both South Cheshire

CCG and Vale Royal CCG to hold a Joint Governance & Audit meeting

from April 2014 onwards.


• Noted the Quality and Performance Committee minutes 28th November 2013.

• Noted the Governance & Audit Committee minutes 28th November 2013.

6.7 Any Other Business

6.7.1

Winterbourne View Concordat Progress Report A verbal update summary on progress in the implementation of the

Winterbourne View Concordat programme was given by J Thorley:

This programme sets out to transform services for vulnerable people who

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have behaviours viewed as challenging, ensuring that these people no

longer live inappropriately in hospitals but receive the care and support

they need closer to home and in line with best practice.

The Winterbourne View Concordat set out specific actions to be

undertaken by health and social care commissioners and in June 2013 the

action to “review the care of all those included on the register and agree a

care plan for each individual based on their and their family’s needs” was

100% complete.

A meeting is scheduled for 7.2.14 to progress necessary actions.

A formal paper will be presented at a future Governing Body meeting,

Date and Time of next meeting

The next NHS South Cheshire CCG Governing Body meeting will be an

end of year Extraordinary meeting held in public on Thursday, 27th March 2014, at 14:15 hours at the PLC Conference Centre, Reaseheath College,

Nantwich, Cheshire CW5 6DF.

JT

Mar 2014

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Prepared By : Sue Lowe, Senior Finance Officer NHS South Cheshire CCG Governing Body

REPORT

Reporting Period 2013-14 REPORTING GROUP TITLE

NHS South Cheshire Governing Body REPORT TITLE DATE/TIME AGENDA ITEM

Finance Report for NHS South Cheshire CCG

27 March 2014 1415-1700 7.4.1

PURPOSE OF REPORT The purpose of this report is to provide the Governing Body with the financial position for Month 11; 2013/14. This report is based on the current financial information available to the CCG and reports the required financial targets specified by the NHS England and the CCG constitution.

Report Prepared By: Sue Lowe Senior Finance Officer Governing Body Lead: Lynda Risk Chief Finance Officer

STATE HOW THIS PAPER LINKS TO THE NHS SCCCG VISION, AIMS & VALUES & GOALS

The paper shows how the NHS South Cheshire CCG will apply its financial resources in 2013/14 to support its vision, aims and values. GOALS 2013-14

Building Services around the needs of the patient; Building Services based on the needs of the patient’s community; Using the patient’s registered practice as the hub for service delivery and

the monitoring of patient health and health journeys; Breaking down barriers between Health & Social Care Separate disease based health services Primary and Secondary Care

Use of education and constructive profession challenge to improve quality; Use patients to inform and introduce challenge at all levels of service provision.

VISION

To maximise health and wellbeing and minimise health and inequalities, informed by local voices and delivered in partnership.

RECOMMENDATIONS

The SCCCG Governing Body are asked to: a) note the CCG continues to report a forecast surplus of £1.9

million (current control total £1 million), dialogue with the Area Team (NHS England) has taken place to secure the carry forward of this surplus into 2014/15; and

b) note Mid Cheshire Hospitals over performance of £2.3 million; and

c) note the contract settlement with Cheshire & Wirral Partnership Foundation Trust at a cost of £0.6 million; and

d) note the remaining uncertainties around the impact of legacy transactions relating to Central & Eastern Cheshire PCT, clarifying/final guidance relating to provisions and partially guidance remain outstanding; and

e) note the current uncommitted resources of £0.3 million available to cover the further risks identified; and

f) note the next stage Financial Plan submission with be 4th April 2014.

ACTION REQUIRED DECISION: Approval Assurance

EQUALITY: Impact Assessed

COMMUNICATION: Disclose on Website

RISKS: Issues outlined

RESOURCES: Issues outlined

Yes Yes

No

No

Yes

Yes

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1.0 Introduction 1.1 This report sets out the Financial Position for 2013/14, as at month 11, for NHS South Cheshire

CCG. This report follows the previous formal Governing Body report of 6th February 2013. 2.0 Financial Overview 2.1 Financial Overview 2013/14 2.1.1 The CCGs estimated resource at Month 11 is £199,596 (previously reported £198.722

million) including running costs of £4.260 million (£25 per head of population). The main increase in the resource is due to the transfer of £0.859 million from the Area Team (NHS England) relating to a change in the definition of responsibility for high cost drugs, this is to be included in Mid Cheshire Hospitals contract.

2.1.2 The forecast surplus is £1.935 million as previously reported. This will bring the CCG back to

the original plan. Dialogue has taken place with the Area Team (NHS England) to secure the carry forward of any potential increased surplus to 2014/15.

2.1.3 The three key risks for the delivery of the 2013/14 position are secondary care over

performance and partially completed spells, with the level of over performance at Mid Cheshire Hospitals giving the greatest cause for concern, continuing health care assessments relating to the Learning Disability Pool, and also, the possible impact of transactions relating to Central & Eastern Cheshire PCT being allocated against CCG resources, final guidance from NHS England remains outstanding. The risks are considered in more detail later in the report.

2.1.4 Following the current contract adjustments, there is a forecast budget shortfall of £4.506

million (previously reported £4.806 million). However, based on current data the forecast position at month 11, considering the forecast (over)/underspends, results in an adjusted forecast general reserve of £0.305 million (previously reported at £1.282 million).

See Table 1 below:-

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Table 1

Forecast position Forecast Month 9

Forecast Month 11

£000 £000 Budgetary Shortfall Month 9 (4806) (4,806) Specialised Commissioning Drugs (MCHT) 250 Ambulance Services 50 Budgetary Shortfall month 11 (4,806) (4506) Forecast(overspends)/underspends month 11 Acute & Community Contracts (3,835) (4,643) Continuing Care Services (561) (267) Other Contracts 2,218 1,845 Running Costs 800 820 Prescribing Savings 1,771 1,361 Delays in the Investment Programme 2,020 2,020 Release of Contingency 0.5% 968 968 Headroom 2% (not invested 2.6million) 3,287 3,287 Release of Earmarked reserves 355 355 Release of general reserve to deliver increased

(935) (935)

Adjusted General Reserve (detail Appendix 2 ) 1,282 305

MEMO Shortfall from forecast surplus 0

0 2.2 Financial overview 14/15 2.2.1 The CCG is currently producing its Budget Book for 2014/15 and this will be presented separately

to this report, and will include the steps taken to address the planning gap of circa £11 million, to enable the delivery of the planned surplus in 14/15 of £2.043 million.

3.0 Key financial risks 3.1 The key financial risks are detailed in the corporate risk register and will need to be monitored

closely as we move through the remainder of this year into next year. Table 2 below summarises the entries made on the risk register, these have been included to aid understanding of the finance report, the full risks can be found on the corporate risk register and also within the Audit and Governance Report.

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Table 2

Risk Title as per corporate Risk Register Risk Rating Year Risk 1 allocations & top slices low 2013/14 0-£1 million

2 public health allocation Low 2013/14 -2014/15 0-£1 million

3 specialised commissioning Medium 2013/14- 2014/15 0- £2 million

4 over performance and contract settlement High 2013/14 0-£5 million 5 financial Systems Low 2013/14 Audit risk

6 QIPP Low 2013/14 Reported as delivered

7 continuing care back log of applications & restitution claims Medium

2013/14 & 14/15 0-£1 million

8 mental health- payment by results Medium 2014/15 future costs value unknown

9 Audlem & Wrenbury allocation closed Closed 0-0.5million

10 continuing care applications (including Learning Disability) Medium

2013/14& 2014/15 0-£1 million

11 Forecast surplus and control total Medium 2013/14 -2014/15 0-£2 million

12 Integration Agenda within existing resource 2015/16 Medium 2015/16 0- £10million

3.2 The highest risk for the current year is secondary care over performance. Mid Cheshire Hospitals

is currently forecast to overspend by £2.3 million.

3.3 The CCG will also need to finalise the impact of the remaining contract settlements for East Cheshire Trust.

3.4 The CCG will be required to account for partially completed spells at the year end and is required to reflect the figures supplied by its NHS providers. The amount at the close of the previous year was £1.116 million; guidance has now been received as to the mechanics of transferring this legacy balance on to the CCG ledger; however some risk will remain until this transfer is actually transacted. This transfer will be required to offset/reduce the new close of year partially completed spells balance.

3.5 The CCG will be required to account for restitution claims which arose after the formation of the

CCG, currently forecast at nil. However there remains a risk that the CCG may be required to include costs that relate to the predecessor organisation. Guidance has now been issued that indicates the legacy provisions will be accounted for by NHS England in 2013/14; however it is unclear where the statutory responsibility lies, national discussions continue and we await final clarity from NHS England.

3.6 The Learning Disability service is operated under a pooled arrangement with Cheshire East

Council and is forecast to overspend by £0.3 million (as previously reported). However, East Cheshire Council has indicated that a number of clients within the pool will require continuing health care reviews (financial risk circa £0.5million). The CCG is in discussion with East Cheshire Council and East Cheshire CCG as to the future of the existing Pooled arrangements in 2014/15, it is likely the pool arrangement will cease this financial year. This risk is included on the corporate risk register.

20 of 371

3.7 As part of the integration planning the CCG has agreed in principle with partners a number of services and their associated budgets which will be held in a pooled budget in 2015/16 under the proposed governance of the Connecting Care Board. The fund, known as the Better Care Fund (BCF), may cause a potential shortfall in 15/16 where the proposed transformational activities are not in place or do not deliver the level of savings required across the BCF footprint.

4.0 Financial Position 2013/14 4.1 CCG Summary Expenditure 4.1.1 The CCGs expenditure is required to remain within its resource limit, currently forecast at £199.596.

It was previously recommended that the forecast surplus is increased to £1.9 million. Dialogue has taken place with the Area Team to secure the carry forward of any potential increased surplus into 2014/15. A summary position can be seen below in table 3:-

(Note a detailed version of this summary can be found in Appendix 3). Table 3

Summary of Planned Expenditure

£000

To

tal

Budg

et

£000

Ye

ar to

Dat

e Bu

dget

£000

Ye

ar to

Dat

e Ex

pend

iture

£000

Ye

ar to

Dat

e Va

rianc

e

£000

Ye

ar

Fore

cast

O

uttu

rn

£000

Ye

ar

varia

nce

Total NHS Provider

139,387

126,682

131,593

(4,911)

143,775

(4,388)

Total Non NHS Contracts

3,045

2,792

3,013 (221)

3,300 (255)

Other Contracts

10,606

9,723

7,973

1,750

8,761

1,845

Continuing Care Services

10,321 9,461 9,662 (201) 10,588 (267)

Prescribing 28,853

26,448

25,196

1,252

27,492 1,361

Running Costs 4,260 3,906 3,207 699 3,440 820

Earmarked & General Reserves

2,124

3,035

-

3,035

305

1,819

Total Forecast Expenditure

198,596

182,047

180,644

1,403

197,661

935

Surplus budget 1,000 917 - 917

- 1,000

Total 199,596 182,964 180,644 2,320 197,661 1,935 21 of 371

4.1.2 A summary CCG position, against the control total of £1 million, can be seen in Table 4

below (forecast resource £199.596 million less planned expenditure of £198.596 million). The forecast recurrent position is reduced by the release of circa £2.8 million of planned non recurrent expenditure from the 2% headroom budget to support the CCG recurrent risks.

Table 4

Summary Illustrative underlying position

Recurrent Non

Recurrent

Total £000 £000 £000 Total Planned Resource

195,706

3,890

199,596

Total Planned Expenditure (190,835) (7,761) (198,596) Planned Surplus Revised (Control total ) 4,871 (3,871) 1,000 % of resource(plan) 2.5% (2.0)% 0.5% Forecast position (based on month 11) 2,793 (0,858) 1,935

% of resource (forecast) 1.4% ( 0.4)% 1.0% 4.2 Acute & community contracts (NHS and Non NHS), forecast overspent £4.643 million

(previously reported £3.835 million overspent)

4.2.1 The NHS acute and community contracts are forecast to overspend by £4.388 million (previously reported £3.570 million) and non NHS contracts forecast to overspend by £0.255 million (previously reported £0.265 million). The contracts showing the major variances or risks are detailed further below:-

4.2.2 Mid Cheshire Hospitals FT is the CCG’s largest contract, the current contract value is £87.425

million (previously reported £86.566 million). The increase in the contract value is as a result of a transfer from NHS England of £0.859 million for the high cost drugs that the CCG is responsible for, following the review of the definitions. At month 11 the forecast over performance is £2.342 million, this being based on January data (previously reported at £1.828 million). Non elective admissions continue below plan at £1.3 million, however elective admissions have continued to show an increase, over performing by £3.6 million. There remains a risk of further movement. This over performance includes over performance relating to high cost drugs, which have now been transferred to the CCG from NHS England.

A graphical illustration of the contract and data can be seen at Appendix 1.

4.2.3 The University Hospitals of North Staffordshire (UHNS) budget has previously been increased by £1 million to include vascular activity which is primarily as a result of the specialty not being included in the original contract offer. This contract adjustment is being finalised at £0.764 million. In addition there is also significant over performance £0.489 million (previously reported at £0.624million).

4.2.4 East Cheshire Community contract has contract items to be confirmed, these include therapy

services, community accommodation and continence services and these are reflected in the financial position as pending budget amendments.

4.2.5 Cheshire and Wirral Partnership Trust contract discussions have now been finalised and is

included in the reported position. The settlement has caused an additional cost of £0.600 million and has been included in the CCG financial position.

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4.3 Prescribing; forecast under spend £1.361million (previously reported £1.771 million underspend)

4.3.1 At month 11 the forecast out turn is £27.492 million (previously reported at £27.082 million), this is

£1.361 million under spent compared to the budget of £28.853 million. The full underspend has been released into the CCGs financial position to cover pressures in other areas. The forecast for GP Practices are indicated to us by the Prescription Pricing Division (PPD) and this report includes those forecasts.

A summary can be seen in Table 5 below: Table 5

Summary of Prescribing Budgets

Annual Budget

Year to Date

Budget

Year to Date

Expenditure

Year to Date

variance

Year Forecast Outturn

Year Forecast variance

£000 £000 £000 £000 £000 £000

GP Prescribing 25,254

23,149 23,995 (846)

26,176 (922) Other prescribers 368 337 55 282 60 308 Non GP Budgets 1,092

1,001 1,146 (145)

1,256 (164)

Contingency 2,139

1,961 - 1,961

- 2,139 Total 28,853

26,448 25,196 1,252

27,492 1,361

5.0 Risk Management 4.1 The CCG will need to plan appropriately to manage in year financial risk. Table 6 below shows a

range of scenario forecast out-turns; these will continue to be refined as the year draws to a close. The CCG will need to manage these risks to deliver the required surplus.

A more detailed Assessment of risks can be seen in the Audit and Governance Report. Financial risks are included on the corporate risk register.

Table 6 Summary Plan Position

£000

W

orst

£0

00

Prob

able

£0

00

Best

£000

M

onth

11

Fore

cast

Total NHS & Non NHS Provider Contracts (5,000) (4,643) (4,400) -

(4,643)

Other Contracts including & Health Care at Home, Learning Disabilities

1,845

1,845

2,000

1,845 Continuing Care Services (800) (267) (267) (267)

Prescribing 1,231

1,361 1,500 1,361 Running Costs 750 820 900 820 Earmarked & General Reserves 1,819 1,819 1,819 1,819 Control total 1,000 1,000 1,000 1,000 Allocations - - - - Total scenario surplus/(deficit) 845 1,935 2,552 1,935 Surplus -Control Total 1,000 1,000

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6.0 Financial position 2014/15

6.1 The draft financial plan was submitted to NHS England in line with the required deadline on 14th February 2014. The final two year financial plan is due on 4th April (following the contract negotiations), and final 5 year financial plan is to be supplied on 20th June 2014.

6.2 The CCG is currently producing its Budget Book for 2014/15 and this will be presented separately to

this report, this will include the steps taken to address the planning gap of circa £11 million, this to enable the delivery of the planned surplus in 14/15 of £2.043 million.

7.0 Recommendations 7.1 That the Governing Body notes that the CCG continues to forecast a surplus of £1.9 million (current

control total £1 million), dialogue with the Area Team has taken place to secure the carry forward of this potential underspend into 2014/15 ; and

7.2 That the Governing Body note Mid Cheshire Hospitals over performance of £2.3 million (further over

performance remaining a risk to the CCGs forecast surplus); and 7.3 That the Governing Body note the contract settlement for Cheshire & Wirral Partnership Foundation

Trust at a cost of £0.6 million; and 7.4 That the Governing Body notes the continuing uncertainty around the impact of transactions relating to

the Central & Eastern Cheshire PCT, clarifying/final guidance relating to provisions and partially completed spells guidance remain outstanding; and

7.5 That the Governing Body note the current uncommitted resources are £0.305 million, to manage the

remaining risks to the CCG in 2013/14 (previously reported 1.282 million); and 7.6 That the Governing Body notes the next stage financial plan submission will be 4th April 2014.

Lynda Risk Chief Finance Officer

27th March 2014 24 of 371

Appendix 1

Mid Cheshire Hospitals NHS Foundation Trust

Penalties Total £'000s

Application of contract Penalties 259

Point of Delivery Full Year

Plan Activity Full Year

Plan £'000s

Mth 10 Actual£'000s

Forecast £'000s

Forecast (over spend)/

underspend £'000s

Accident & Emergency Attendances 42 3,969 3,293 3,945 24Direct Access 1,238 3,367 2,905 3,480 (113)Elective 18 15,931 14,742 17,661 (1,730)High Cost Drugs 2 1,380 1,527 1,829 (449)Maternity 32 6,595 5,589 6,695 (100)Non Elective 21 29,231 23,329 27,947 1,284Other 13 11,076 8,933 10,721 365Outpatient - First Attendance 35 5,279 4,554 5,456 (177)Outpatient - Follow Up Attendance 68 6,829 6,159 7,378 (548)Outpatient Procedures 14 2,301 2,365 2,833 (531)Unbundled Radiology 16 1,467 1,531 1,834 (366)Total 1,498 87,426 74,925 89,778 (2,342)

Contract Plan £'000s

Non ElectiveElectiveOtherOutpatient - Follow Up AttendanceOutpatient - First Attendance

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Appendix 2

NonRecurrent

Summary General Reserve Recurrent Total£000 £000 £000

Total in Plan 1,582 1,777 3,359Month 1 Movements

Specialised Commissioning CWW (8,239) (8,239)Oral Surgery Reversed 1,210 1,210Other Allocation Pending Adjustments (355) (355)Budget changes mainly as a result of Contract offers

(936) (936)

Total Revised Month 1 (6,383) 1,422 (4,961)Month 2 Movements NHS England Baseline Transfer (not yet finalised)

(1,006) (1,006)

Budget changes mainly as a result of Contract Finalisation

1,072 1,072

Control total movement(£1,935-£935) 935 935Return of Surplus 2012/13 adjustment 9 9Month 3 Movements University Hospital North Staffs (1,000) (1,000)East Cheshire Community -Entral feeds (180) (180)East Cheshire Community -Therapies(shortfall not in reserves)

(16) (16)

Warrington & Halton (9) (9)Total General Reserve Deficit Month 3 (6,516) 1,360 (5,156)Month 4 Movements East Cheshire Community -Entral feeds 180 (180) 0East Cheshire Community -Therapies(shortfall not in reserves)

16 (16) 0

East Cheshire Community -Contract value (4) (4)GP Care Homes Scheme - Aging well (105) (105)PTS - NWAS contract variation (50) (50)Dementia Nurse -Aging well (32) (32)72 Hour Phone Call Scheme -Aging Well (32) (32)Intermediate Care review GP attendance -Aging Well

(25) (25)

Specialised Commissioning CWW- rebase mth 4 estimated

(900) (900)

Total General Reserve Deficit Month 4 (7,224) 920 (6,304)MCHT Contract alignment (37) (37)Removal or Rehab from SSOTO Contract 184 184Sub Total General Reserve Deficit month 5 (7,077) 920 (6,157)Release of Legacy top slice- freed up 3,028 3,028Total General Reserve Deficit Month 5 (4,049) 920 (3,129)Specialised Commissioning CWW- rebase allocation adjustment month 6

(504) (504)

Return of Surplus 2012/13 adjustment 6 6Total General Reserve Deficit Month 6 & 7 (4,553) 926 (3,627)Specialised Commissioning Drugs (MCHT) (250) (250)Therapy Services Contract issue(ECT) (800) (800)Community Accommodation (ECT) (135) (135)Continence service (ECT) (230) (230)Potential adjustment to increase forecast surplus

(935) (935)

Total General Reserve Deficit Month 8 (5,718) (259) (5,977)University hospital North Staffs contract finalisation(vascular)

236 236

Potential adjustment to increase forecast surplus

935 935

Total General Reserve Deficit Month 9 (5,482) 676 (4,806)Specialised Commissioning Drugs (MCHT) 250 250Total General Reserve Deficit month 10 (5,482) 926 (4,556)PTS - NWAS contract variation 50 50Total General Reserve Deficit month 11 (5,482) 976 (4,506)Forecast Corrective ActionsInvestment Programme Slippage 1,950 70 2,020Contingency 0.5% - released 968 968Headroom 2% (removal of additional 0investment) 3,287 3,287Earmarked Reserves - released 355 355Potential adjustment to increase forecast surplus

(935) (935)

Sub Total Corrective Action 6,205 (510) 5,695Total General Reserve Month 11 723 416 1,139Forecast (Overspends)/UnderspendsAcute & community Contracts (4,643) (4,643)Other Contracts & Earmarked reserves 1,845 1,845Continuing Care Services (267) (267)Prescribing 1,361 1,361Running Costs 870 870Total Forecast (overspends)/underspends (1,704) 870 (834)Total Adjusted General Reserve Mth 11 (overspend)/underspend

(981) 1,286 305

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Appendix 3 Summary of all Budgets

Rec Non Rec Total PLAN Movement Revised Budget

Year to Date Budget

Year to Date

Actual

Year to Date

Variance

Year Forecast Outturn

Type Budget Heading £000 £000 £000 £000 £000 £000 £000 £000 £000

Allocation Baseline - confirmed 193,566 0 193,566 0 193,566 193,566Allocation Baseline Running Cost Allowance 4,260 4,260 0 4,260 4,260Pending Baseline - pending - oral surgery 0 0 0 0 0 0Pending Baseline - pending - VPN Transfer 0 0 0 0 0Allocation Baseline - pending - Audlem & Wrenbury Transfer 8,406 8,406 0 8,406 8,406Allocation Baseline - pending - 1% PCT Surplus 1,928 1,928 0 1,928 1,928Allocation Specialised Commissioning CWW (8,239) (8,239) 0 (8,239) (8,239)Pending Non Elective Thresold(held in Earmarked Reserves ) 0 0 0 0 0Pending Exempt Overseas(held in Earmarked Reserves) 0 0 0 0 0Allocation Baseline allocation adjustment (1,006) (1,006) 0 (1,006) (1,006)Allocation National Enhanced Services Trf to CCG from NHS E (LES 109 109 0 109 109Allocation Minor ailment Scheme Trf to CCG from NHS E 14 14 0 14 14Allocation Specialised Commissioning CWW Rebasing mth 4 (1,404) (1,404) 0 (1,404) (1,404)Allocation Winter pressures (targeted to MCHT) 1,088 1,088 0 1,088 1,088Allocation Specialised Drugs MCHT 859 859 0 859 859Allocation Non running Costs- Planning Patient Public engagement 10 10 0 10 10Allocation Funding for personal health budget rollout 20 20 0 20 20Allocation Spec Comm adjustment paediatric burns (area team) (alder hey c (15) (15) 0 (15) (15)

0

196,712 2,884 199,596 0 199,596 0 0 0 199,596

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Rec Non Rec Total Plan Movement Revised Budget

Year to Date Budget

Year to Date Actual

Year to Date

Variance

Year Forecast

Outturn

Year Forecast Variance

RED Amber Green

Type

Workstream

Budget Heading £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Acute LW Aintree Hospitals FT 175 0 175 0 175 160 184 (24) 199 (24) Amber Acute SW Alderhey 549 (15) 534 0 534 490 600 (110) 654 (120) Red Acute SW Central Manchester University Hospital FT 660 0 660 0 660 605 869 (264) 949 (289) Red Acute LW Christies FT 0 0 0 0 0 0 0 0 0 0 n/aAcute LW Clatterbridge Centre for Oncology FT 0 0 0 0 0 0 0 0 0 0 n/aAcute LW Countess of Chester FT 525 0 525 0 525 461 389 72 431 94 GreenAcute SW East Cheshire NHS Trust (Acute) 952 0 952 0 952 873 1,202 (329) 1,297 (345) Red Acute SW Liverpool Women's Foundation NHS Trust 120 0 120 0 120 110 87 23 95 25 GreenAcute LW Mid Cheshire Hospitals FT 86,502 923 87,425 0 87,425 80,140 82,286 (2,146) 89,767 (2,342) Red Acute LW Winter Pressures (MCHT) 1,088 1,088 0 1,088 997 997 0 1,088 0 GreenAcute LW Specialised Drugs(MCHT) 0 0 0 0 0 0 GreenAcute LW NCA 2,505 0 2,505 0 2,505 2,296 2,070 226 2,253 252 GreenAcute LW Contract Exclusions 0 0 0 0 0 0 0 0 0 0 n/aAcute LW Pennine Acute NHS Trust - Acute 0 0 0 0 0 0 0 0 0 0 n/aAcute LW Pennine Care Foundation NHS Trust 0 0 0 0 0 (0) 0 (0) 0 0 n/aAcute LW Robert Jones and Agnes Hunt FT 2,014 0 2,014 0 2,014 1,846 1,955 (109) 2,125 (111) Red Acute LW Royal Liverpool & Broadgreen NHS Trust 614 0 614 0 614 563 670 (107) 730 (116) Red Acute LW Salford Royal NHS FT 243 0 243 0 243 223 370 (147) 399 (156) Red Acute LW St Helens & Knowsley NHS Trust 115 0 115 0 115 105 202 (97) 218 (103) Red Acute LW Stockport NHS FT 187 0 187 0 187 171 326 (155) 353 (166) Red Acute LW Trafford Healthcare NHS Trust 0 0 0 0 0 0 0 0 0 0 n/aAcute LW University Hospital of North Staffs NHS Trust 7,442 0 7,442 0 7,442 6,822 7,218 (396) 7,931 (489) Red Acute LW University Hospital of South Manchester NHS FT 981 0 981 0 981 899 910 (11) 991 (10) Amber Acute LW Warrington & Halton Foundation NHS Trust 200 0 200 0 200 183 162 21 180 20 GreenAcute LW Wigan, Wrightington & Leigh NHS FT 110 0 110 0 110 101 162 (61) 119 (9) Amber Acute LW Wirral University Teaching Hospitals NHS FT 155 0 155 0 155 142 98 44 108 47 GreenAmbulance LW North West Ambulance Service 5,700 0 5,700 0 5,700 5,225 5,335 (110) 5,899 (199) Red Ambulance LW Collaborative Commissioning 28 (28) 33 (33) Amber Ambulance LW NHS 111 101 (101) 101 (101) Red Community SW East Cheshire NHS Trust (Community) 12,825 780 13,605 1,165 14,770 12,471 13,279 (808) 14,486 284 GreenMH LW Staffordshire & Stoke on Trent Partnership NHS Trust 539 0 539 0 539 493 671 (178) 732 (193) Red MH LW Cheshire & Wirral Partnership FT 13,997 (1,823) 12,174 0 12,174 11,160 11,296 (136) 12,499 (325) Red MH LW Earmarked 0 0 0 0 0 0 GreenCommunity LW North Staffs Combined Healthcare NHS Trust 159 0 159 0 159 146 126 20 138 21 Green

Total NHS Contracts 137,269 953 138,222 1,165 139,387 126,682 131,593 (4,911) 143,775 (4,388) Red

28 of 371


Year to Date Budget

Year to Date Actual

Year to Date

Variance

Year Forecast

Outturn


RED Amber Green

Type

Workstream

Budget Heading £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Non NHS SW British Pregnancy Advisory Service (BPAS) 42 0 42 0 42 39 71 (32) 77 (35) Amber Non NHS LW Hospice - St Lukes 343 0 343 0 343 314 316 (2) 344 (1) Amber Non NHS AW Pain Management (PBC) 145 0 145 0 145 133 161 (28) 176 (31) Amber Non NHS LW Practice Nurse Training (PBC) 2 0 2 0 2 2 0 2 2 0 GreenNon NHS SW Vasectomy - Ashfields (PBC) 68 0 68 0 68 82 74 8 59 9 GreenNon NHS SW Vasectomy - Nantwich (PBC) 21 0 21 0 21 0 4 (4) 25 (4) Amber Non NHS SW Epilepsy Service - David Lewis Centre (PBC) 0 0 0 0 0 0 0 0 0 0 n/aNon NHS LW Audiology (PBC) 129 0 129 0 129 118 408 (290) 451 (322) Red Non NHS LW Carpel Tunnel & Minor Surgery (PBC) 19 0 19 0 19 17 5 12 10 9 GreenNon NHS LW Spire Cheshire 37 0 37 0 37 34 41 (7) 44 (7) Amber Non NHS LW BMI South Cheshire 1,272 0 1,272 0 1,272 1,166 1,635 (469) 1,784 (512) Red Non NHS AW Bespoke Care Panel (BCP) 524 0 524 0 524 480 135 345 150 374 GreenNon NHS AW Eye Care Services 55 0 55 0 55 50 75 (25) 82 (27) Amber Non NHS LW Patient Transport Services(SRCL) 160 0 160 0 160 147 88 59 96 64 GreenNon NHS LW Trauma Centre(earmarked) 114 0 114 0 114 105 0 105 0 114 GreenNon NHS Corp HV Family Nurse Practioners(earmarked) 114 0 114 0 114 105 0 105 0 114 Green

Total Non NHS Contracts 3,045 0 3,045 0 3,045 2,792 3,013 (221) 3,300 (255) Red

LA Corp LD Pool 1,374 1,823 3,197 0 3,197 2,931 3,163 (232) 3,450 (253) Red LA AW Grants 727 0 727 0 727 666 636 30 694 33 GreenLA AW Joint Equipment 216 0 216 0 216 198 250 (52) 272 (56) Amber

Total LA Contracts 2,317 1,823 4,140 0 4,140 3,795 4,049 (254) 4,416 (276) Red

NHS/LA AW Reablement 1,094 25 1,119 0 1,119 1,026 1,092 (66) 1,201 (82) Amber NHS AW Readmissions(reserve) 483 0 483 0 483 443 0 443 0 483 Green

Total Ring-Fenced Budget 1,577 25 1,602 0 1,602 1,469 1,092 377 1,201 401

29 of 371


Year to Date Budget

Year to Date Actual

Year to Date

Variance

Year Forecast

Outturn


RED Amber Green

Type

Workstream

Budget Heading £000 £000 £000 £000 £000 £000 £000 £000 £000 £000

Non NHS LW Healthcare at Home 1,166 0 1,166 0 1,166 1,069 632 437 689 477 GreenNon NHS Corp CITC 7,507 0 7,507 0 7,507 6,881 7,152 (271) 7,880 (373) Red Non NHS Corp NHS Funded Care 2,521 0 2,521 0 2,521 2,311 2,510 (199) 2,708 (187) Red Non NHS Corp Prescribing 28,817 36 28,853 0 28,853 26,448 25,196 1,252 27,492 1,361 GreenNon NHS Corp Non Running Costs 1,009 30 1,039 0 1,039 952 1,144 (192) 1,263 (224) Red Non NHS Corp Programme expenditure(CIDS) 0 30 30 0 30 27 12 15 30 0 GreenNon NHS Corp ICT LHC (reserve) 306 0 306 0 306 281 186 95 203 103 GreenNon NHS LW LES/LeQof 1,410 105 1,515 0 1,515 1,389 780 609 875 640 GreenNon NHS Corp Provisions 293 0 293 0 293 269 0 269 0 293 GreenNon NHS Corp Depreciation & Capital Costs 352 0 352 0 352 323 78 245 84 268 GreenNon NHS LW Audlem & Wrenbury 456 0 456 0 456 418 0 418 0 456 Green

Total Other Contracts 43,837 201 44,038 0 44,038 40,368 37,690 2,678 41,224 2,814

Sub Total 188,045 3,002 191,047 1,165 192,212 175,106 177,437 (2,331) 193,916 (1,704)

Reserve Corp 1% Recurrent Surplus Reserve 1,935 (935) 1,000 0 1,000 917 917 1,935 (935) Red Reserve Corp 0.5% Risk Reserve 968 0 968 0 968 887 887 0 968 GreenReserve Corp 2% Headroom Reserve 3,871 (3,871) 0 0 0 0 0 GreenReserve Corp 2% Headroom Reserve 3,287 3,287 0 3,287 3,013 3,013 0 3,287 GreenReserve Corp CIDS 1,950 70 2,020 0 2,020 1,852 1,852 0 2,020 GreenRunning Cost Corp Running Costs 4,260 4,260 0 4,260 3,906 3,207 699 3,440 820 Green

Sub Totals 12,984 (1,449) 11,535 0 11,535 10,575 3,207 7,368 5,375 6,160

Total CCG Budgets 201,029 1,553 202,582 1,165 203,747 185,681 180,644 5,037 199,291 4,456

Reserve Corp Reserves (Uncommitted) (4,317) 976 (3,341) (1,165) (4,506) (3,042) 0 (3,042) 305 (4,811) Red Reserve Corp Reserves (Earmarked) 0 355 355 0 355 325 0 325 0 355 Green

Total CCG Budgets 196,712 2,884 199,596 0 199,596 182,964 180,644 2,320 199,596 0

30 of 371

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32 of 371

Prepared By : Sue Lowe, Senior Finance Officer NHS South Cheshire CCG Governing Body

REPORT



Finance Report for NHS South Cheshire CCG 27th March 2014

14:00hrs 7.4.2

PURPOSE OF REPORT The purpose of this report is to provide the Governing Body with the Budget Book for 2014/15. This report is based on the current financial information available to the CCG and reports the required financial targets specified by the NHS England and the CCG constitution.


The paper shows how the NHS South Cheshire CCG will apply its financial resources in 2014/15 to support its vision, aims and values.

Report Prepared By: Sue Lowe Senior Finance Officer Governing Body Lead: Lynda Risk Chief Finance Officer

GOALS 2013-14




VISION


RECOMMENDATIONS

The SCCCG Governing Body are asked to:

• note the content of the NHS South Cheshire CCG and NHS Vale Royal CCG Commissioning Executive report, appendix 1 ; and

• approve the CCG budget book for 2014/15, summarised in table 3 & 4 (full budget book tabled due to size); and

• approve the steps taken to address the budgetary shortfall of £5.5 million, and to consider the remaining shortfall £0.953 million; and

• note the risks identified for 2014/15 and nil uncommitted reserves to manage the risks to the CCG in 2014/15.






Yes Yes

No

No

Yes

Yes

33 of 371

1.0 Introduction 1.1 This report sets out the budgets for 2014/15 for NHS South Cheshire CCG.

2.0 Included in this report

2.1 Report to NHS South Cheshire CCG and NHS Vale Royal CCG Clinical Commissioning Executive; Appendix 1

2.2 CCG Budget Book summarised in table 3 & 4 (full draft budget book tabled due to size)

2.3 Recommended adjustments/actions to bridge the budgetary gap of £5.5 million, with

remaining shortfall £0.953 million. 3.0 Financial Overview 2014/15

3.1 The CCG is required to achieve a surplus of £2.020 million which is 1% of the CCG recurrent resource as required by NHS England financial framework.

3.2 The CCG budget book shows a budgetary shortfall of £5.5 million. The CCG initial

plans had previously highlighted a planning gap of £11 million. The plan submission of the 14th February had considered how the planning gap could be addressed by the release of the 2.5% headroom and all other reserves, to enable the delivery a 1% surplus of £2.020 million in 2014/15, however there remained an unaddressed shortfall of £4 million in this initial plan.

3.3 The current budgetary shortfall of £5.5 million is recommended to be addressed as outlined

in Table 1 below. :- Table 1

Addressing the budgetary shortfall

Recurrent £000

Non recurrent £000

Total

£000

Budget Book – budgetary shortfall (2,397) (3,103) (5,500) Contract negotiation – Mid Cheshire Hospitals 1,787 - 1,787 Reduce target surplus from 1% to 0.5% 1,000 1,000 Prescribing (reduce growth from 6% to 4%) 500 500 Reduce earmarked reserves- remove Community 7 day working)

460 460

Reduce earmarked reserves Psychiatric & memory service (75%)

300 300

CHC (contracts and complexity negotiations) 500 500 Slippage of commissioning intentions investments (nil of £1.457m)

- - -

Targeting of elective admissions (thresholds)

- - - Remaining budgetary shortfall 1,150 (2,103) (953)

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3.4 This action will leave the CCG exposed to significant risk in 14/15, including the risks of contract settlement, these risks will need to be monitored closely and corrective action will need to be taken as required. A summary can be seen in Table 2 below

Table 2

Risk Rating Year Risk 1 Allocations & top slices low 2014/15 0-£1 million 2 Return of surplus from 2013/14- 2014/15 Low 2014/15 0-£1 million 3 Specialised commissioning Medium 2014/15 0- £2 million 4 Over performance and contract settlement High 2014/15 0-£3 million 5 NHS Property Services (national Gap) medium 2014/15 0-£0.75million 6 QIPP Medium 2014/15 0-£1.5 million

7

Continuing Health Care new restitution claims, and risk of further contribution to the national legacy risk pool Medium 2014/15 0-£1 million

8 GP IT budgets from NHS England insufficient transfer to cover cost Medium 2014/15 0-£0.5 million

9 Mental Health –Payments by Results low 2015/16

Future costs value unknown

10 Continuing Health Care applications (including learning disability) Medium

2013/14& 2014/15 0-£1 million

11 Delivery of forecast surplus and control total High 2014/15 0-£2 million

12 Integration Agenda within existing resource 2015/16 Medium 2015/16 0- £10million

3.5 The CCG will be required to contribute to the national legacy restitution risk pool of £0.767 million, and will also be required to account for any new claims that arise in 2014/15, however it is unclear where the statutory responsibility lies, national discussions continue and we await final clarity from NHS England. This amount has been included in the CCG budgets.

3.6 The CCG may have to contribute to the national shortfall relating to NHS Property Services,

no value has been earmarked in the CCG budgets for this unknown amount; however the risk is noted in the CCG risk table above.

4.0 Detailed Budgets 2014/15 4.1 CCG Summary Budget 4.1.1 A summary CCG position, against the control total of £2.020 million, can be seen in Table 4

below (forecast resource £203.662 million less planned expenditure of £207.142 million).

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Table 3

Summary Position

Recurrent Non

Recurrent

Total £000 £000 £000 Total Planned Resource

201,720

1,942

203,662

Total Planned Expenditure (204,117) (3,025) (207,142) Addressing the gap (Budgetary

2,397 3,103 5,500

Planned Surplus - 2,020 2,020 % of resource(plan) - 1% 1%

4.2 CCG Summary Expenditure Budgets 4.2.1 The CCGs expenditure is required to remain within its resource limit, currently forecast

at £203.662 million. A summary of the position can be seen below in table 4:- Table 4

Summary of Planned Expenditure

£000

To

tal

Dra

ft Bu

dget

Boo

k

£000

Ad

dres

sing

th

e Bu

dget

ary

Gap

£000

Rev

ised

Pla

n

Total NHS Provider Contracts 146,403 (1,787) 144,616 Total Non NHS Contracts

2,876 2,876

Other Contracts

6,349 6,349

Primary Care 988 988

Continuing Care Services

11,877 (500) 11,377 Prescribing

29,630 (500) 29,130

Running costs (Programme) 1,620 1,620

Running Costs 4,238 4,238

Earmarked Reserves 1,705 (760) 945

Commissioning intentions 1,457 -

1,457

Budgetary gap (5,500) 4,547 (953) Total Forecast Expenditure

201,643 1,000 202,643 Surplus Budget 2,020 (1,000) 1,020

Total 203,663 - 203,663 36 of 371

REPORT


South Cheshire and Vale Royal Clinical Commissioning Executive REPORT TITLE AGENDA ITEM

14/15 Budget Book 20th March 2014

PURPOSE OF REPORT

The purpose of this report is to

• Appraise the Clinical Commissioning Executive (CCE) of the current budgetary position of the NHS South Cheshire and NHS Vale Royal CCGs for 14/15

• To allow the CCE to review the possible funding options

• To allow the CCE to provide advice to the Governing Bodies on the adoption of the CCG Budgets for 2014/15 and options available to bridge the current funding gap.

AUTHOR Lynda Risk Chief Finance Officer Sue Lowe Senior Finance Officer


The paper shows how the NHS South Cheshire CCG and NHS Vale Royal CCG propose to apply their financial resources in 2014/15 to support their vision, aims and values.

GOVERNING BODY LEAD(s) Lynda Risk Chief Finance Officer

The CCE is asked to :-

• Discuss the assumptions made so far in obtaining the proposed 14/15 budget

• Assess the options for reducing the current funding

gap in both CCGs

• To provide advice to the VR and SC Governing Bodies in respect of bridging the funding gap






Yes Yes

No

No

yes

yes

Appendix 1

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1. Summary

The information in this report outlines:-

• The budget setting process which has been undertaken • The key risks which have been funded and those which remain uncovered. • The assumptions made in arriving at the budgeted figures • The key investments proposed. • The resulting budget deficit for each CCG, NHS South Cheshire CCG £5.5m and NHS Vale Royal CCG

£2.9m.

The Clinical Commissioning Executive (CCE) is requested to review the possible funding options and to provide advice to the South Cheshire and the Vale Royal Governing Bodies on the adoption of the CCG Budgets for 2014/15 and options available to bridge the current funding gap.

2. Background

The CCG has to produce each year a budget book to be agreed by the Governing Body which outlines where the CCG intends to spend its resources over the next twelve months in order to commission services for the CCG population.

The 14/15 budget book supports the 2 year operational and 5 year strategic plans and will be used in year to monitor the CCG’s financial performance.

In 13/14 both CCGs are predicting a surplus position (NHS Vale Royal CCG £3.2m and NHS South Cheshire CCG £1.9m) and deliver their 1% control total.

3. Developing the 14/15 Budget Book

The Budget Books have been developed in the following way:-

• The plan from 13/14 was taken and uplifted to fund the 13/14 outturn as predicted at month 9. This represents a basis from which to start any assessment of 14/15.

• The outturn was assessed to identify if there are any recurrent/non recurrent items which have varied the 13/14 position but which will not occur in 14/15

• Each budget was taken and discussed with the relevant budget manager and finance support to assess the potential growth or reduction in 14/15 in comparison to 13/14, based on historic trends where they existed, knowledge of potential risks in 14/15 or national/peer comparison and guidelines.

• For Commissioning Intentions a review of all of the projects and their potential funding/savings was carried out with service development managers.

Appendix 1

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4. Key Risks Funded

The key risks which have been funded within the budgets are:

• Elective growth in Mid Cheshire, this has been a key item in the over performance in both CCGs in 13/14 (SCCCG £3.6m and VRCCG £2.3m) and there is no indication of a decrease in the level of activity.

• National guidance has indicated the requirement to create a national risk pool relating to CHC restitution cases which relate to the Central and Eastern Cheshire Primary Care Trust. Whilst the liability relates to a previous NHS body the CCGs are being directed to contribute to a fund to support this cost.

• It has been indicated nationally that the Prescribing budget should be increased by between 4-7% on outturn

• Continuing Health Care, NHS Funded Care and Complex Cases for Learning Disabilities and Mental Health continue to be a pressure as the number of patients and their acuity increases. There is a key risk in relation to the potential dissolution of the Learning Disabilities Pool with East Cheshire Council.

5. Uncovered Risks

There are a number of uncovered risks which are not included in the budgets currently due to the uncertainty of the financial impact. The key risks are:

• Primary Care ICT funding is being transferred back to the CCGs in 14/15 the level of the funding and associated expenditure is currently unconfirmed

• Property services charges for unoccupied buildings via NHS Property Services, whilst there have been initial discussions with NHS Property Services in relation to this issue it is unclear what the precise impact maybe although the charge initially quoted was circa £1m.

• There is only a small contingency available to the CCGs and this has been identified to cover already known potential risks. Effectively there is no contingency for future unidentified risks.

6. Investments

A number of investments have also been included within the current budgeted expenditure:-

• Commissioning intentions have been included within the budgets as notified by the Service Development Managers via the Program Boards. The details of the commissioning intentions are shown in Appendix 5 (VRCCG) and Appendix 6 (SCCCG) with the associated savings being shown in Appendix 7.

• The Innovation Fund has been created to encourage all our local providers to work together to develop integrated care. The providers included are the local Primary Care Federations, East Cheshire Trust, East Cheshire Council, Cheshire West and Chester Council and Mid Cheshire NHS Foundation Trust. This is a key part of the Connecting Care Strategy and forms part of the national mandate to develop services around practices the initial value of the fund across the SCCCG and VRCCG is £1.4m (approx. £4.66 per capita). Another £1.8m has also been included within the fund, this may be used in year for further investment in integration or used to support non elective performance above 13/14 outturn at MCHFT.

Appendix 1

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There are also three other investments which have been identified during recent discussions with Service Delivery Managers which were not previously noted. These are included in Earmarked Reserves-contingency: - Psychiatric Liaison Services, Dementia Services and 7 day working.

7. NHS South Cheshire CCG (SCCCG) Budget

The more detailed summary of the SCCCG Budget Book is shown in Appendix 2. The table below summarises the key changes from 13/14 forecast outturn at month 9 to the predicted budgets required in 14/15. The assumptions used indicate a deficit in 14/15 of £5.5m.

14/15 Plan with changes since 14/02/14

Forecast Out turn 13/14 (from month 9 finance Report)

Variance Outurn 13/14 versa plan with changes

Comments

£000 £000 £000Allocation 203,662 197,634 6,028 growth in allocation

NHS Contracts - Healthcare 146,403 143,433 2,970

includes £2.3m for MCHFT Based on £91,000k - option 1(excluding Area Team NR alloc for Drugs £759k).Tariff efficiency 4%( £3.5 m)ie circa 6.5% increase' less tariff cost 2.6% net increase 3.9% over outurn

Non NHS Contracts - Healthcare 2,876 2,876 0Innovation fund 2,180 0 2,180 Create Innovation fundIntegrated Working Initiative 4,169 4,077 92 Reinstate reablement to full budgetPrimary Care 988 988 0Continuing Healthcare 11,877 10,304 1,573 New National Risk Pool £767k,

Prescribing 29,630 27,734 1,896circa 6% uplift - could be reduced to 4%?, but out turn is expected to worsen

Other Programme Contracts 1,620 1,545 75Running Costs 4,238 3,460 778 Allocation as per national figures1% Recurrent Surplus Reserve 2,020 1,935 85 Reduction in Surplus to required 1%other 0 1,282 (1,282)Commissioning Intentions 1,457 0 1,457

Earmarked Reserves - contingency 1,705 0 1,705

LD 490k, 7 day working £460k, 355k Exempt overseas & NE penalty, Memory Services 200k, Psychiatric liason 200k.

Total Budgeted expenditure 209,163 197,634 8,367Deficit/Reserve (5,501) 0 (5,501)

Appendix 1

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8. NHS Vale Royal CCG (VRCCG)Budget

The more detailed summary of the VRCCG Budget Book is shown in Appendix 1. The table below summarises the key changes from 13/14 forecast outturn at month 9 to the predicted budgets required in 14/15. The assumptions used indicate a deficit in 14/15 of £2.9m. It should be noted that the additional surplus of £2m from 13/14 has not been included within the allocation for the CCG in 14/15. Although NHS England has agreed to return the monies to the CCG it has become apparent that the return of the additional surplus for all CCGs who have exceeded their control total will require the completion of a business case in order to secure the return of the funding. At this stage there is a high level of uncertainty around the process and the return of the funds.




Comments

£000 £000 £000Allocation 120,310 117,899 2,411 growth in allocation

NHS Contracts - Healthcare 81,188 80,372 816

£654k allocated to MCHFT Based on £48,400k (excluding Area Team NR alloc for Drugs 435k) Efficency 4% (£1.9m), circa 5.3% increase over outurn, less tariff cost 2.6%, net increase to contract 2.7%

Non NHS Contracts - Healthcare 2,195 2,149 46Innovation fund 1,205 0 1,205 Create Innovation fundIntegrated Working Initiative 4,447 4,128 319 Reinstate reablement to full budgetPrimary Care 631 691 (60)Continuing Healthcare 8,151 6,997 1,154 National Risk Reserve £654,000

Prescribing 17,862 16,498 1,364circa 6% uplift - could be reduced to 4%?, but out turn is expected to worsen

Other Programme Contracts 1,043 1,006 37Running Costs 2,403 2,040 363 Allocation as per national figures1% Recurrent Surplus Reserve 1,225 3,200 (1,975) Reduction in Surplus to required 1%other 285 0 285Commissioning Intentions 1,293 0 1,293

Earmarked Reserves - contingency 1,276 0 1,276

LD 500k, 7 day working £310k, 246k Exempt overseas & NE penalty Memory Services 110k, Psychiatric liason 110k.

Total Budgeted expenditure 120,635 117,081 3,554Deficit/Reserve (2,894) 818 (3,712)

Appendix 1

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9. Review and Options

All CCG Governing Bodies have to agree a balanced budget. Currently the budgets for both CCGs are in a deficit position. The CCE is being asked to review the options available to bridge the funding gap and advise the Governing Bodies.

The following options may be considered. This is not an exhaustive list and the items included are shown as examples and not a resolution to the issue.

• Review, prioritise and reduce all discretionary funding across all budgets • Remove investments and commissioning intentions • Reduce the level of growth allocated to key budgets where there is already a known risk associated with

growth in activity or acuity e.g. Continuing Health Care, Prescribing • Maintain a level of unidentified productivity savings in the budget • Reduce the control total in each CCG to 0.5%

All of the above will have an impact on the financial robustness of the CCG and will increase the risk of the CCG either not meeting its financial duties or not delivering its outcome measures. Each action would need to be considered and the associated risk identified.

Appendix 1

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Appendix 1

Vale Royal Initial Plan, options and comparisons to 2013/14 outurn A B C +B-C

Initial Plan 14/15 as submitted 14/02/14




Total Total Total Total

Type Budget Heading £000 £000 £000 £000

Allocation Alocation - Confirmed 114,263 114,263 114,263 - Allocation Return of Surplus assumption 3,199 1,199 1,196 3 Allocation running costs 2,403 2,403 2,440 37- Allocation Growth 2,445 2,445 2,445 Growth 2.1%

122,310 120,310 117,899 2,411



Acute Aintree Hospitals FT 236 236 234 2 Acute Alderhey Childrens Hospital FT 333 333 330 3 Acute Central Manchester University Hospital FT 774 774 770 4 Acute Countess of Chester FT 1,853 1,853 1,843 10 Acute East Cheshire NHS Trust (Acute) 400 553 398 155 contract offer 153k over initial plan. Offer £553Acute Liverpool Women's Foundation NHS Trust 119 119 119 -

Acute Mid Cheshire Hospitals FT 48,349 48,400 47,746 654

Based on £48,400 (excluding Area Team NR alloc for Drugs 435k) Efficency 4% (£1.9m), circa 5.3% increase over outurn, less tariff cost 2.6%, net increase to contract 2.7%

Acute Non Contract Activity 1,269 1,269 1,260 9 Acute Robert Jones and Agnus Hunt FT 461 461 458 3 Acute Royal Liverpool & Broadgreen NHS Trust 489 489 485 4 Acute Salford Royal NHS FT 203 203 202 1 Acute St Helens & Knowsley NHS Trust 166 166 166 - Acute Stockport NHS FT 219 219 218 1 Acute University Hospital of North Staffs NHS Trust 2,072 2,278 2,059 219 contract offer 206k over initial plan. Offer £2,278Acute University Hospital of South Manchester NHS FT 1,080 1,080 1,074 6 Acute Warrington & Halton Foundation NHS Trust 2,734 2,734 2,718 16 Acute Wigan, Wrightington & Leigh NHS FT 112 112 111 1 Acute Wirral University Teaching Hospitals NHS FT 149 149 148 1 Ambulance North West Ambulance Service(including 111) 3,283 3,283 3,211 72 Community East Cheshire NHS Trust (Community) 8,046 8,512 8,621 109- MH Staffordshire & Stoke on Trent Partnership NHS Trust 54 54 55 1- MH Cheshire & Wirral Partnership FT 7,911 7,911 8,146 235-

Total NHS Contracts - Healthcare 80,312 81,188 80,372 816

Appendix 1

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Appendix 1



Non NHS British Pregnancy Advisory Service 55 55 55 - Non NHS Audiology - Multiple Providers 184 184 138 46 Non NHS Pain Management - Interface Medical 90 90 90 - Non NHS Spire Cheshire 857 857 857 - Non NHS BMI South Cheshire 714 714 714 - Non NHS Bespoke Care Panel - Multiple Providers 136 136 136 - Non NHS Eye Care Services - A Needham 67 67 67 - Non NHS Patient Transport Services - SRCL 92 92 92 -

Total Non NHS Contracts - Healthcare 2,195 2,195 2,149 46

Int Learning Disability Services with Local Authority 2,800 2,800 2,800 - LD protected in 2013/14, but CWAC indicated risk of £0.5m(£0.5m in earmarked reserve)

Int Grants 628 628 628 - Int Joint Equipment 151 151 151 - Int Reablement 655 655 336 319 Reinstated to baseline - elements could be discretionary Int Hospice - St Lukes 213 213 213 - Int CCG Innovation Fund - 1,205 - 1,205 ( NE 641k,readmissions £274k,Tariff cwp£140k, ECT £150k)

Total Integrated Working Initiative 4,447 5,652 4,128 1,524

Primary Care Primary Care 631 631 691 60- Discretionary

Total Primary Care 631 631 691 60-

CHC Continuing Healthcare (incl Mental Health) 5,767 5,577 5,277 300 5% increase but very high risk of futher pressures CHC NHS Funded Care 1,920 1,920 1,720 200 10% increase but very high risk of further pressures CHC Continuing Healthcare Litigation Claims 381 654 - 654 New National Risk Pool £454k, plus 200k CCG own

Total Continuing Healthcare 8,068 8,151 6,997 1,154

Prescribing Prescribing 17,383 17,383 16,019 1,364 circa 6% uplift - could be reduced to 4%?, but out turn is expected to worsen

Prescribing Healthcare at Home 479 479 479 -

Total Prescribing 17,862 17,862 16,498 1,364

Appendix 1

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Appendix 1 Total Total Total Total


Non NHS Non Running Costs 783 798 826 28- Consultancy/agency staff discretionary Non NHS Community Information System 95 95 95 - Emmis Non NHS Provider - Cost of Capital 150 150 85 65 Legacy Provider Deprec, plus CCG own basedNon NHS CCG - Cost of Capital - - - -

Total Other Programme Contracts 1,028 1,043 1,006 37

Admin Running Costs 2,403 2,403 2,040 363 Consultancy/agency staff discretionary

Total Running Costs 2,403 2,403 2,040 363

Total CCG Budget 116,946 119,125 113,881 5,244

Reserve Readmissions 274 - - - Reserve 1% Recurrent Surplus Reserve 1,225 1,225 3,200 1,975- 1% target Reserve 0.5% Risk Reserve 285 285 - 285 Discretionary Reserve 2% Headroom Reserve - - - - Reserve 2% Headroom Reserve - - - - Reserve CIDS 1,784 1,293 - 1,293 Discretionary Reserve Uncommitted 740 2,894- 818 3,712- Shortfall from 1% surplus

Reserve Earmarked 1,056 1,276 - 1,276 LD 500k, 7 day working £310k, 246k Exempt overseas & NE penalty Memory Services 110k, Psychiatric liason 110k.

Total CCG Budget 5,364 1,185 4,018 2,833-

Appendix 1

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Appendix 2

South Cheshire Initial Plan, options and comparisons to 2013/14 outurn A B C +B-C

Initial Plan 14/15 as submitted 14/02/14






Allocation Baseline - confirmed 191,446 191,446 191,446 - Allocation Return of Surplus assumption 1,942 1,942 1,928 14 Allocation running costs 4,238 4,238 4,260 22- Allocation Growth 6,036 6,036 6,036 Growth 3.1 %

203,662 203,662 197,634 6,028



Acute Aintree Hospitals FT 200 200 199 1 Acute Alder Hey Childrens Hospital FT 648 648 644 4 Acute Central Manchester University Hospital FT 955 955 949 6 Acute Countess of Chester FT 433 433 431 2 Acute East Cheshire NHS Trust (Acute) 1,305 1,607 1,297 310 contract offer 302k over initial plan. Offer £1,607Acute Liverpool Women's Foundation NHS Trust 92 92 92 -

Acute Mid Cheshire Hospitals FT 90,166 91,000 88,666 2,334

Based on £91,000 - option 1(excluding Area Team NR alloc for Drugs £759k).Tariff efficiency 4%( £3.5 m)ie circa 6.5% increase' less tariff cost 2.6% net increase 3.9% over outurn

Acute Robert Jones and Agnes Hunt FT 2,208 2,208 2,196 12 Acute Royal Liverpool & Broadgreen NHS Trust 734 734 730 4 Acute Salford Royal NHS FT 236 236 234 2 Acute St Helens & Knowsley NHS Trust 177 177 176 1 Acute Stockport NHS FT 355 355 353 2 Acute University Hospital of North Staffs NHS Trust 8,112 8,248 8,066 182 contract offer 136k over initial plan. Offer £8,248Acute University Hospital of South Manchester NHS FT 997 997 991 6 Acute Warrington & Halton Foundation NHS Trust 178 178 177 1 Acute Wrightington Wigan & Leigh NHS FT 119 119 119 - Acute Wirral University Teaching Hospitals NHS FT 109 109 108 1 AmbulanceNorth West Ambulance Service 6,082 6,082 6,020 62 CommunityEast Cheshire NHS Trust (Community) 13,872 14,636 14,829 193- CommunityStaffordshire & Stoke on Trent Partnership NHS Trust 752 752 762 10- MH North Staffs Combined Healthcare NHS Trust 136 136 138 2- MH Cheshire & Wirral Partnership FT 14,120 14,120 13,889 231 NCA Non Contracted Activity 2,381 2,381 2,367 14

Total NHS Contracts - Healthcare 144,367 146,403 143,433 2,970

Appendix 1

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Appendix 2



Non NHS British Pregnancy Advisory Service 65 65 65 - Non NHS Pain Management - Interface Medical 193 193 193 - Non NHS Audiology - Multiple Providers 344 344 344 - Non NHS Spire Cheshire 44 44 44 - Non NHS BMI South Cheshire 1,815 1,815 1,815 - Non NHS Bespoke Care Panel - Multiple Providers 210 210 210 - Non NHS Eye Care Services - A Needham 82 82 82 - Non NHS Patient Transport Services - SRCL 123 123 123 -

Total Non NHS Contracts - Healthcare 2,876 2,876 2,876 -

Int Learning Disability Services 1,577 1,577 1,577 - Int Grants 800 800 694 106 Int Joint Equipment 255 255 255 - Int Reablement 1,194 1,194 1,208 14- Int Hospice - St Lukes 343 343 343 - Int CCG Innovation Fund - 2,180 - 2,180 ( NE 1197k,readmissions £483k,Tariff cwp£250k, ECT £250k)

Total Integrated Working Initiative 4,169 6,349 4,077 2,272

Non NHS Primary Care 988 988 988 - Discretionary

Total Primary Care 988 988 988 -

Non NHS Continuing Healthcare (incl Mental Health) 8,123 7,838 7,532 306 4% increase but very high risk of futher pressures Non NHS NHS Funded Care 2,972 2,972 2,772 200 7% increase but very high risk of futher pressures Non NHS Continuing Healthcare Litigation Claims 593 1,067 - 1,067 New National Risk Pool £767k, plus 300k CCG own

Total Continuing Healthcare 11,688 11,877 10,304 1,573

PrescribingPrescribing 28,978 28,978 27,082 1,896 circa 6% uplift - could be reduced to 4%?, but out turn is expected to worsen

PrescribingHealthcare at Home 652 652 652 -

Total Prescribing 29,630 29,630 27,734 1,896

Appendix 1

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Appendix 2 Appendix 1

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Appendix 3

Vale Royal Sub Analysis Primary Care

Practice Scheme Budget 14/15

Nationally Enhanced Services

Vale Royal Practices Anti - Coagulation 10,000

Vale Royal Practices Near Patient Testing 58,000

Local Quality Scheme

Vale Royal Practices Loca l Qual i ty Scheme 384,000

Care Homes Scheme

Vale Royal Practices Care Homes 72,000

Other Community contracts

Danebridge/Fi redale Counsel l ing Services 35,000

High St. Weaverlodge 15,000

Danebridge Vasectomy 55,000

Danebridge Inter-practice -

Vale Royal Practices Practice Nurse Tra ining 2,000

Sub Total - Primary Care 631,000

Appendix 1

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Appendix 4 South Cheshire Sub Analysis Primary Care

Practice Scheme Budget 14/15

National Enhanced Services

South Cheshire Practices Anti - Coagulation 27,000

South Cheshire Practices Near Patient Testing 75,000

South Cheshire Practices Spiromentry -

Local Quality Scheme

South Cheshire Practices Loca l Qual i ty Scheme 654,000

Care Home Scheme

South Cheshire Practices GP Care Homes 105,000

Other Community Contracts

Ashfields Counsel l ing 23,000

Ashfields Dermatology 18,000

South Cheshire Practices Contingency 5,000-

Nantwich Heal th Centre Vasectomy 23,000

Ashfields Vasectomy 56,000

South Cheshire Practices Minor Surgery 10,000

South Cheshire Practices Practice Nurse Tra ining 2,000

Sub Total - Primary Care 988,000

Appendix 1

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Appendix 5

Vale Royal Financial Summary of Commissioning IntentionsInitial Plan Slippage

Rec N Rec

Children & Young People with Disabilities - SE SW01 TM - - Altogether Better Programme SW02 TM - - Sub Total - -

Paediatric Pathways (0-5 Admissions) SW03 TM - 13 Children with LTC SW04 TM - 5 Complex and Chaotic Adolescents SW05 TM - - CAMHS Specification Review SW06 TM - - Neuro-Development Pathways SW07 TM - 5 Sub Total - 23

Community Services Redesign and Procureme SW08 SHPerinatal Mental Health SW09 TM - - Developmental Outcomes SW10 TM - - Sub Total - - Total Starting Well - 23

NHS 111 LW01 SMMERIT LW02 JB 21 15 Mental Health Tariff LW03 JBDevelop a CCG Level Learning Disabilities Stra LW04 JBWinterbourne View Register LW05 JBSub Total 21 15

24/7 Urgent Care LW06 SM 18

Stroke (Re-procurement) LW07 SC 222 8 -100Parkinson's LW08 SM 2 Inhaler Technique Training LW09 SMPhlebotomy LW10 SMDiabetes Education LW11 SM 19 5 Memory Services for Dementia LW12 JB 2 Review of Liaison Psychiatry Service LW13 JB 45 Adult Neurodevelopment Conditions LW14 JBIAPT Services LW15 JBIAPT Military Veterans LW16 JB 14 IAPT BSL LW17 JB 2 Diagnose Cancer Early LW18 TWHigh Quality Diagnosis and Treatment Pathwa LW19 TWChemotherapy Reform LW20 TWDementia/EOL LW21 TWEOL - Workforce Education and Practice Deve LW22 TW 90 8 EOL Advanced Care Planning LW23 TWCarer Support at EOL and into Bereavement LW24 TWSub Total 378 57

Comments

Assume slippage as service not implemented until 30 September 2014

Must Do's / Mandatory Plans

Roll Overs from 2013/14

Starting WellMust Do's / Mandatory Plans


Commissioning Intentions 2014/15

Living Well

Project Description Ref No.Project

Lead

Costs (£000)2014/15

Appendix 1

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Appendix 5

Initial Plan Slippage

Rec N Rec

Sub Total - -

Extended Practice Teams / Integrated Neighbo AW01 KW 391 0- 391- Intermediate Care Services Review AW02 PD - 3 Transitional Care / Intermediate Care Beds AW03 SI - 419 Community Intevention Beds AW04 SI - 208 GP Care Homes Scheme Review AW05 AP - 7 Wheelchair Service Review AW06 AP - - Community Equipment Services AW07 AP - - Choose Well AW08 EL - 4 Citizens Advice Bureau AW09 KW - 104 Vale Royal Care Homes Contract Review AW10 AW - -

Third Sector Grants AW11 APSection 256 Review AW12 SI - - Self Care Self Management AW13 JG - - Pain Management Service Review AW14 PD - -

Falls Service Review AW15 N/ASub Total 391 746

Physiotherapy Service Review AW15 PDSub Total - - Total Ageing Well 391 746 Grand Total 924 860 -491

funded via the Innovation fund

Comments


Lead

Costs (£000)2014/15

Service and Economic Review underway

This work is no longer going ahead - as per the october programme board

Options paper being submitted to Jan Programme Board



Ageing Well


Appendix 1

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Appendix 6

South Cheshire Financial Summary of Commissioning IntentionsIntial Plan Options Plan

Rec N Rec

Children & Young People with Disabilities - SEND Legislat SW01 TM - - Altogether Better Programme SW02 TM - - Sub Total - -

Paediatric Pathways (0-5 Admissions) SW03 TM - 17 Children with LTC SW04 TM - 5 Complex and Chaotic Adolescents SW05 TM - - CAMHS Specification Review SW06 TM - - Neuro-Development Pathways SW07 TM - 5 Sub Total - 27

Community Services Redesign and Procurement SW08 SHPerinatal Mental Health SW09 TM - - Developmental Outcomes SW10 TM - - Sub Total - - Total Starting Well - 27

NHS 111 LW01 SMMERIT LW02 JB 35 25 Mental Health Tariff LW03 JBDevelop a CCG Level Learning Disabilities Strategy LW04 JBWinterbourne View Register LW05 JBSub Total 35 25

24/7 Urgent Care LW06 SM 32

Stroke (Re-procurement) LW07 SC 471 17 -230Parkinson's LW08 SM 5 Inhaler Technique Training LW09 SMPhlebotomy LW10 SMDiabetes Education LW11 SM 33 9 Memory Services for Dementia LW12 JB 3 Review of Liaison Psychiatry Service LW13 JB 45 Adult Neurodevelopment Conditions LW14 JBIAPT Services LW15 JBIAPT Military Veterans LW16 JB 22 IAPT BSL LW17 JB 5 Diagnose Cancer Early LW18 TWHigh Quality Diagnosis and Treatment Pathways LW19 TWChemotherapy Reform LW20 TWDementia/EOL LW21 TWEOL - Workforce Education and Practice Development LW22 TW 145 17 EOL Advanced Care Planning LW23 TWCarer Support at EOL and into Bereavement LW24 TWSub Total 697 107

Knee Replacement LW25 SMRespiratory Project LW26 JK 36 Diagnostics LW27 SMSubstance Misuse (including Alcohol) LW28 JBImproving Mortality Rates for those with Learning Disabiliti LW29 JB 5 Formulary and Antibiotic Pharmacist LW30 JK 42 Community Pharmacy Minor Ailments Scheme LW31 JK 25 Challenging Behaviour LW32 JB 3 EPaCCS LW33 TW 9 28 Acute Oncology Community Extension LW34 TW 32 Personality Disorders LW35 JB 51 Physical Health Needs Mental Health LW36 JB 27 Sub Total 230 28 Total Living Well 963 160

Assume slippage as service not implemented until 30 September 2014




Starting WellMust Do's / Mandatory Plans



Living Well


Lead

Costs (£000)2014/15

Appendix 1

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Appendix 6 Intial Plan Options Plan

Rec N Rec

Sub Total - -

Extended Practice Teams / Integrated Neighbourhood Tea AW01 KW 531 0 531- Intermediate Care Services Review AW02 PD - 3 Transitional Care / Intermediate Care Beds AW03 SI - 1,160 1,160- Community Intevention Beds AW04 SI - 417 GP Care Homes Scheme Review AW05 AP - 7 Wheelchair Service Review AW06 AP - - Community Equipment Services AW07 AP - - Choose Well AW08 EL - 6 Citizens Advice Bureau AW09 KW - 104 Vale Royal Care Homes Contract Review AW10 AW - - Third Sector Grants AW11 APSection 256 Review AW12 SI - - Self Care Self Management AW13 JG - - Pain Management Service Review AW14 PD - -

Falls Service Review (project closed ) AW15 N/ASub Total 531 1,698

Physiotherapy Service Review AW15 PDSub Total - - Total Aging Well 531 1,698 Grand Total Commissioning Intentions 1,493 1,885 -1921

Service and Economic Review underway


Lead

Costs (£000)2014/15

funded via the Innovation fund

Funded via Reablement

Options paper being submitted to Jan Programme

This work is no longer going ahead - as per the october programme board



Ageing Well


Appendix 1

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Appendix 7

Vale Royal Qipp Schemes Plan (schemes with savings) Intial Plan

ProgramRec N Rec

Paediatric Pathways (0-5 Admissions) Starting Well SW03 0 11End of Life -Work force and Practice Development Living Well LW22 82 0End of Life Living Well LW34 75 0Acute Oncology Community Extension Living Well LW35 108 0Personality Disorders Living Well LW35 16 0Community Intevention Beds Aging Well AW04 0 261Respiratory Project Prescribing LW26 130 0Formulary and Antibiotic Pharmacist Prescribing LW30 43 0Community Pharmacy Minor Ailments Scheme Prescribing LW31 19 0

Total Qipp Schemes 472 272

Project Description Ref No.Savings (£000)

2014/15

South Cheshire Savings Plan

ProgramRec N Rec

Paediatric Pathways (0-5 Admissions) Starting Well SW03 0 17End of Life -Work force and Practice Development Living Well LW22 173 0End of Life Living Well LW34 113 0Acute Oncology Community Extension Living Well LW35 161 0Personality Disorders Living Well LW35 34 0Community Intevention Beds Aging Well AW04 0 461Respiratory Project Prescribing LW26 368 0Formulary and Antibiotic Pharmacist Prescribing LW30 69 0Community Pharmacy Minor Ailments Scheme Prescribing LW31 31 0

Total Qipp Schemes 949 478

Project Description Ref No.Savings (£000)

2014/15

Appendix 1

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Prepared By : Lisa Carr, Performance & Risk Manager NHS South Cheshire CCG Governing Body

REPORT



Risk Management Strategy – March 2014 27 March 2014

1415-1700 7.5.1

PURPOSE OF REPORT This paper provides the Governing Body with a copy of the revised Risk Management Strategy and Policy 2014-15. This document has been sense checked through a process of consultation with a number of key stakeholders and reviewed by the Governance & Audit Committee in January 2014, which was subjected to amendments. The strategy outlines the guidance and national drivers which require NHS organisations to develop and implement robust risk management systems. It sets out the responsibilities for strategic and operational risk management and describes the procedure to be used in identifying, analysing, evaluating and controlling risks to the delivery of strategic objectives. This document provides a framework to provide assurance that strategic and operational risks are being managed and support the organisation’s delivery of its strategic goals and statutory obligations.

Report Prepared By: Lisa Carr Performance & Risk Manager Governing Body Lead: Lynda Risk Chief Finance Officer

GOALS 2013-14




VISION


RECOMMENDATIONS

The SCCCG Governing Body are asked to: i) note the process followed to refresh the contents of the Risk

Management Strategy & Policy 2014-15; and ii) approve the Risk Management Strategy & Policy 2014-15 for

implementation as from 1st April 2014.






No Yes

No

No

No

No

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Risk Management Strategy & Policy This document is a joint corporate strategy & policy providing guidance on the reporting and monitoring arrangements in place relating to governance and operational risks associated with both NHS South Cheshire and NHS Vale Royal Clinical Commissioning Groups and their providers in the delivery of healthcare services for the commissioned population.

2014-15

Produced By: Performance & Risk Manager NHS South Cheshire & NHS Vale Royal Clinical Commissioning Groups

2014-15

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Document Configuration Document No.00/00

1 Author(s) Lisa Carr, Performance & Risk Manager

2 Clinical / Executive Leads Lynda Risk, Chief Finance Officer

3 Responsible Committee Governance & Audit Committee

4 Governing Body Ratification Date 00 / 00 / 00

5 Review Date Annual refresh from Ratification Date

6 Version 0.1 (Draft)

7 Distribution Channels Committee Paper / Intranet / Website [email protected] [email protected]

8 NHS Authorisation Domain 4.2.1

9 Related Internal Documents

• Commissioning / Operating Plans • Quality Strategy • Serious Untoward Incidents Policy • Complaints Policy and Procedures • Claims Handling Policy & Procedure • Safeguarding Children and Vulnerable Adults Policy • Business Continuity Policy • Whistleblowing Policy • Commissioning Plan • HR Policies and Procedures (Moving & Handling Policy, Violent &

Aggression Policy, Governance Information / Safeguarding / Equality & Diversity / Accident & Incident Reporting

10 Related External Documents

• Health & Social Care Act 2012 • HM Treasury Audit and Risk Assurance Committee Handbook

April 2013 • NHS Audit Committee Handbook 2011 published by Healthcare

Financial Management Association (FHMA)

Copyright © NHS South Cheshire Clinical Commissioning Group, 2013. All Rights Reserved.

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http://[email protected]/

http://[email protected]/

CONTENTS 1.0 Introduction

2.0 Purpose

3.0 Objectives

4.0 Scope

5.0 Responsibilities & Accountabilities - Committees

6.0 Responsibilities & Accountabilities - Individuals

7.0 Risk Management Process

8.0 Governing Body Assurance Framework

9.0 Legal Requirements

10.0 Risk Assessment Training

11.0 Monitoring & Evaluation Process

12.0

APPENDICES

A Organisation Structure & Assurance Reporting Tiers + Risk Flowchart

B Nolan’s Seven Principles of Conduct

C Guidance on Risk Identification, Rating and planning mitigating actions

D Risk Scoring Matrix

E Blank Risk Assessment Form

F Definitions & Abbreviations

G

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1. Introduction 1.1 This document has been developed using guidance stemming from the NHS Audit

Committee Handbook 2011 published by Healthcare Financial Management Association (FHMA) in association with the Department of Health (DH). Together with Health and Safety Executive’s (HSEs) risk assessment model which is supported by the National Patient Safety Agency (NPSA).

1.2 It also reflects the legal duty of care placed on the respective NHS South Cheshire

Clinical Commissioning Group (SCCCG) & NHS Vale Royal Clinical Commissioning Group (VRCCG), to assess risks which may impact upon the health and safety of employees and others, who may be affected by the “business”. [Health and Safety at Work Act 1974; Management of Health and Safety at Work Regulations 1999 (amended).]

1.3 Risk is usually portrayed as being negative; something with an unwanted consequence

that needs to be avoided at all cost. However, without a Risk Management Framework that supports responsible and well managed risk-taking the organisation would not be able to achieve its strategic goals. It is only by being creative that the CCG’s will meet the challenges facing the organisations, hence the need to strive to develop new and innovative ways of working, whilst firm in the knowledge of the potential risks that are involved. By embedding risk management into the organisation’s structure and culture, this will ultimately encourage its management and staff to identify, understand and manage risks, and learn how to accept the right risks. A notable difference in the organisation’s attitude towards risk must be achieved by the adoption of this Strategy and Policy.

2. Purpose 2.1 This document provides guidance to all Members, staff and key stakeholders on the

management of the governance and operational risks within the organisation. It aims to:

• set out respective responsibilities for strategic and operational risk management for the respective Governing Bodies and staff throughout the organisations; and

• describe the procedures to be used in identifying, analysing, evaluating and

controlling risks to the delivery of strategic objectives.

3. Objectives 3.1 The objectives of the SCCCG & VRCCG risk management strategy are to:

• minimise chances of adverse incidents, risks and complaints by effective risk identification, prioritisation, treatment and management;

• maintain a risk management framework, which provides assurance to the Governing Body that strategic and operational risks are being managed effectively;

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• maintain a cohesive approach to corporate governance and effectively manage risk management resources;

• ensure that risk management is an integral part of SCCCG & VRCCG culture; • maintain robust systems for addressing externally issued alerts; • minimise avoidable financial loss, or the cost of risk transfer through a robust financial

strategy.

3.2 In addition to the operational need for good risk management, there are external drivers which require organisations to develop and implement robust risk management systems. These include: • Health & Safety Legislation governs statutory responsibilities for all employers and

providers of services to the public. • The Care Quality Commission (CQC) – assesses the quality of health and social

care organisations through the requirements for registration. • The NHS Litigation Authority Risk Management Standards ensures that

organisations achieve the requirements for robust risk management in the NHS. It is expected that the CCG will not be required to show compliance with the NHSLA standards as a commissioning-only organisation. However, the CCG uses these standards as an exemplar of best practice for risk management.

• Data Protection requirements on the management and protection of personal

identifiable information and other requirements in relation to the safe storage of personal data.

• Governance Statement previously known as Statements of Internal Control relates

to the formal statement published with the annual account, which declares compliance within a framework of controls.

4. Scope 4.1 The Risk Management Strategy encompasses all types of risk inherent in the business

activities of the respective organisations. These can be broadly categorised as Change, Clinical, Financial, Governance, Information Technology, Legal and Compliance, Operations, People and Strategic (see Table 1 overleaf).

4.2 Whilst the CCG’s are not directly responsible for either risk management or health and

safety of the commissioned healthcare Providers, mechanisms are in place to ensure these organisations conform with contractual requirements to safeguard against risks having an adverse impact on patients care and meet the standards prescribed for NHS Care.

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Type Description

Change Risks stemming from programmes and projects that do not deliver the agreed benefits, on time and to budget

Financial Risks relating to the management and control of the finances of the organisation i.e. insufficient funding, poor budget management, mismanagement of assets and liabilities and failure to collect due revenue.

Governance

Risks relating to the establishment of an effective organisational structure with clear lines of authorities and accountabilities i.e. inappropriate decision-making & delegations of authorities; lack of appropriate tone and cohesiveness of Governing Body members & leadership.

Legal & Compliance

Risks concerning Health & Safety compliance, consumer protection, data protection and employment practices i.e. failure to comply with legislation and the management of complaints and claims.

Operations

Risks concerning the day-to-day running of the organisation in striving to deliver its objectives i.e. loss of staff, process failures, breaches in provider contractual arrangements; irretrievable breakdown of partnerships and ineffective management of internal change.

Information & Technology

Risks concerning the day-to-day running of the organisation in striving to deliver its objectives i.e. technical breakdown of systems, loss of hard or soft copy data, failure by providers to deliver services

People Risks relating to insufficient human capacity, capability and inappropriate staff behaviour which have an adverse impact on performance, productivity and organisational reputation.

Strategic

Risks relating to the long term strategic objectives of the organisation affected by external factors such as the economy, political environment, technology changes, legal & regulatory changes and changes in customer needs. These tend to be classified as significant risks and have a cross cutting impact on the whole organisation.

Quality & Performance

Risks arising from the commissioning, provision and delivery of healthcare inclusive of clinical errors and negligence.

Table 1

5. Responsibilities & Accountabilities - Committees 5.1 A key component of an effective risk management system is a clearly defined structure

that performs a number of functions (See appendix A):

• To make explicit the scheme of accountability; • To make explicit the lines of reporting; • To support the delivery of the organisations risk management objectives; • To reinforce the organisations commitment to commissioning safe and effective

health care services on behalf of the population of South Cheshire & Vale Royal.

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5.1.1 Governing Body

All members of the NHS SCCCG & NHS VRCCG Governing Bodies share responsibility for the success of the respective organisations, thereby have a duty to assure themselves that effective management of risk and compliance with relevant legislation is in place. In relation to risk management the respective Governing Bodies are responsible for: • identifying principal risks to the achievement of strategic objectives; • monitoring these via the Governing Body Assurance Framework; • providing leadership on the management of risk; • determining the risk appetite for the SCCCG & VRCCG; • ensuring the approach to risk management is consistently applied; • ensuring that assurances demonstrate that risk has been identified, assessed and all

reasonable steps taken to manage it effectively and appropriately; and • endorsing risk related disclosure documents.

5.1.2 Governance & Audit Committee

The Governance & Audit Committee is responsible for providing assurance to the Governing Body that the organisation has systems and processes in place to operate in a manner which demonstrates openness, probity and accountability. The CCG’s will ensure compliance with the Nolan Committee recommendations ‘Seven Principles of Conduct’ that should underpin the work of public authorities (See Appendix B). The Committee need to review the adequacy and effectiveness of: • all risk and control related disclosure statements (in particular the Annual

Governance Statement), prior to endorsement by the Governing Body; and • the underlying assurance processes that indicate the degree of achievement of

corporate objectives, the effectiveness of the management of principal risks and the appropriateness of disclosure documents;

• arrangements around Finance, Contracting and Performance including Quality,

Innovation, Productivity and Prevention (QiPP) and Cost Improvement Programmes

5.1.3 Joint Quality & Performance Committee The Joint Quality & Performance Committee is responsible for providing assurance to the Governing Body that the organisation has systems and processes in place to ensure the commissioning and delivery of good quality, safe clinical healthcare services via its providers.

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The Committee will be responsible for the co-ordination and prioritisation of resources to promote a robust culture of Clinical Governance across the whole health economy. It was also focus on engagement and communication with all healthcare providers to ensure the identification of associated clinical risk/s and to ensure plans in place to mitigate the risks, in so far as reasonably practicable. This includes the identification of operational processes to ensure that contracts are performance-managed by the Commissioners.

5.1.4 Other Committees Other Committees’ have been established by the Governing Body in order to focus on

specific areas which have a key relationship to risk management these include:

• Remuneration Committee • Partnership Board • Joint Health Inequalities Sub-Committee • Serious Incidents Committee • Programme Boards – Starting Well, Living Well & Ageing Well • Safeguarding Boards – Children & Adults • Medicines Management Committee

6. Responsibilities & Accountabilities - Individuals 6.1 Every member of staff has an individual responsibility for the management of risk and all

levels of management must understand and assist to implement the risk management strategy and policy.

6.1.1 Chief Officer (Accountable Officer)

As Accountable Officer, the Chief Officer holds the executive responsibility for Risk Management on behalf of the Governing Body as set out in the Accountable Officer Memorandum and as the Accounting Officer responsible according to statute. To fulfil this responsibility the Chief Officer will: • ensure that management processes fulfil the responsibilities for risk management as

set out in the Risk Management Strategy; • ensure that full support and commitment is provided and maintained in every activity

relating to risk management; • plan for adequate staffing, finances and other resources, to ensure the management

of those risks which may have an adverse impact on the staff, finances or stakeholders of the SCCCG & VRCCG;

• ensure an appropriate Governing Body Assurance Framework (GBAF) is prepared and regularly updated and receives appropriate consideration; and

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• ensure that an Annual Governance Statement, adequately reflecting the risk management issues within the SCCCG & VRCCG, is prepared and signed off each year.

6.1.2 Senior Management Team (Leadership) The Senior Management Team will keep the principal corporate risks under regular review. Nominated members of the Leadership will act as Senior Information Risk Owner (SIRO) for their respective areas of the business and will ensure that within their CCGs all risk management issues are coordinated, managed, monitored and reviewed including: • supporting the Governing Body members on the development of principal risk against

the defined strategic objectives; • ensuring that Corporate Risk Register or Risk logs are maintained and actively

managed within business functions or programme teams; • ensuring staff comply with all organisational policies and procedures; • leading the management of risk by devising short, medium and long-term strategies

to tackle identified risk, including the production of any action plans; • ensuring all staff fulfil their responsibility for risk management by identifying,

reporting, monitoring and managing risk; • recommending to the Performance & Risk Manager the raising and closing of

identified risks, using the Risk Register; • support the designated Caldicott Guardian in executing their duties on clinical risk

audits, evidence based medicine and national & local guideline in commissioned healthcare services;

• as a minimum requirement will undergo bi-annual training on the principles of Risk Management and Safeguarding procedures.

6.1.3 Internal Auditors

The internal auditors are responsible for agreeing (with the respective Governance & Audit Committees) a programme of audits which assess the exposures and adequacy of mitigation of the principal risks affecting the organisation. The priorities contained in the internal audit programme should reflect the risk evaluation, set out in the Governing Body Assurance Framework. The reports and advice produced by internal audit should inform the management of risk by business areas although responsibility remains with the relevant risk owners, as set out in the following paragraphs.

6.1.4 Performance & Risk Manager (Local Delivery) The Performance & Risk Manager will:

• co-ordinate and support the development of the Governing Body Assurance Framework (BAF) and provide updates in advance of each reported meeting;

• obtaining Leadership ratification of proposed changes to the Assurance Framework and Corporate Risk Register;

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• manage the emerging risk entries onto the Corporate Risk Register and scrutinise the controls and assurances in order to present to the respective committees;

• support programme boards in maintaining emerging risks onto their Programme Risk Logs;

6.1.5 All Staff (Programme Teams)

All members of staff are responsible for maintaining risk awareness, identifying and reporting risks as appropriate to their line manager. It is key that all staff: • ensure that appropriate Induction and Mandatory training is accessed by employees

and a record of attendance made on personal files to support and underpin safe systems of work.

• familiarise and comply with the policies and procedures of SCCCG & VRCCG; • accept personal responsibility for maintaining a safe working environment, which

includes being aware of their duty under the current legislation and regulations. • ensure that appropriate and effective risk management systems and processes are in

place; • undertake timely review of risk assessments and risk reduction action plans • monitor all identified risks, and escalate any high/extreme risks to the attention of the

relevant Governing Body Committee. • monitor standards of clinical performance where required; • take reasonable care of their own safety and all others that may be affected by the

organisations business activities; • report all incidents / accidents and near miss; • events ensuring compliance with the incident reporting policy.

7. Risk Management Process

7.1 The Risk Management Strategy and Policy should be referred to regarding the systematic identification and analysis of all risks. The risk management process follows the principles as set by the AS/NZS 4360, 1999 Risk Management. (Revised Ed. 2004).

7.1.1 Risks are identified through feedback from many sources, such as corporate

objectives, proactive risk assessments, incident reporting and trends, clinical audit data, complaints, legal claims, patient and public feedback, stakeholders / partnership feedback and internal and external assurance assessments.

7.1.3 For risk assessments, the organisation has adopted the Health and Safety Executive’s

(HSEs) risk assessment model which is supported by the National Patient Safety Agency (NPSA). This principle uses a numerical scale based on a 5 x 5 matrix, in accordance with guidance as fully detailed at Appendix C.

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7.2 Risk Identification & Evaluation: 7.2.1 Risk management is a requirement of identification on the likelihood of a risk occurring

followed by an evaluation on the impact the potential risk could have on the delivery of objectives and operational business activity. Assessments of risks are conducted through audits, workplace assessments and day-to-day business practice. Many risks will be identified and appropriate action taken before instances of harm or loss have occurred, these risks are currently held on a paper based system and will be working towards being recorded onto a project management system called ‘VERTO’.

7.2.2 Both SCCCG & VRCCG will also receive information on risks and hazards from a number of external sources including Confidential Enquiry reports; Department of Health; National Patient Safety Agency. On receipt of this information it is important that the receiving programme team/individual ensures that there are adequate controls in place to mitigate against risk to the business or workforce or population in which we serve.

7.2.3 New risks are constantly emerging and the identification of risk needs to be an on-going and proactive process. The Corporate Risk Register will enable all risks to be ranked and provide a structure for collation and making decisions about whether or how risks should be treated. The grid matrix below presents the scoring assessment relating to the likelihood x impact = potential risk score which is then ranked and transferred to the corporate risk register.

7.2.4 All risks which have an overall rating of Medium or High will be escalated onto the Corporate Risk Register / Assurance Framework to inform the Governing Body and its Governance and Audit Committee on the assurance that mitigating actions are being taken to eliminate the risk from escalating.

Catastrophic 5 5 10 15 20 25

Severe 4 4 8 12 16 20

Moderate 3 3 6 9 12 15

Minor 2 2 4 6 8 10

Negligible 1 1 2 3 4 5

1 2 3 4 5Likel ihood x Impact = Score

HighMediumLowVery Low

Rare

Unl

ikel

y

Poss

ible

Likel

y

Alm

ost C

erta

in

IMPA

CT /

CON

SEQ

UEN

CE

LIKELIHOOD

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7.3 Control of Risk

The following presents the Risk Appetite controls: Threat Responses:

CONTROL DEFINITION

AVOID Can the project/task be carried out a different way so the risk does not occur?

REDUCE Can action be taken to reduce the probability OR impact of the risk occurring?

ELIMINATE Can definitive action be taken to eliminate the risk?

TRANSFER The most common form of this isa third party taking on the responsibility for the threat i.e. insurance/contract clause.

ACCEPT If risk cannot be reduced, avoided or transferred then prepare & implement an action plan to minimise effects.

Opportunity Responses:

CONTROL DEFINITION

REALISATION Identify and seize an opportunity to ensure a potential improvement can be realised i.e. completing a project early and reduce costs

ENHANCEMENT Seizing and improving on an identified opportunity to enhance realisation i.e. financial gain due to early project completion and revenue generation due to deploying resources.

EXPLOITATION Identifying and seizing multiple benefits through exploiting changes to objectives or specifications whilst maintain desired outcome.

Risk Management Assurance Flow

High 15-25

Unacceptable level of risk exposure which requires immediate corrective action managed by Leadership team and pro-active review by Governing Body

Include on the Assurance Framework and report to Governing Body on monthly basis via Governance Report

Medium8-12

Unacceptable level of risk exposure which requires active monitoring and controls and pro-active reviews by Leadership Team.

Leadership team with decision on whether to include on Assurance Framework or ongoing assurance to Governance & Audit Committee, then Governing Body

Low4-6

Acceptable level of risk, manage by routine controls and pro-active reviews by Programme Boards

Assurance obtained through Programme Board meetings and identify appropriateness to report to Leadership/Governance & Audit

Very Low1-3

Acceptable level of risk, manage by routine controls, ongoing reviews at operational team level.

Assurance considered at Service team level.

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7.4 Review / Follow Up

7.4.1 As risks change over time and new ones emerge, actions taken to control the risks will need to be reviewed to ensure they are effective. The frequency of review will depend on the severity of the risk involved.

7.4.2 All risks will require an action plan. Action plans for all Moderate and High risks, which have been escalated onto the Corporate Risk Register / Assurance Framework will be monitored by the team/individual which has identified the risk; the Programme Boards, the Governance and Audit Committee and the respective SCCCG & VRCCG Governing Bodies. Where a risk has been identified in one area of CCG business and has the potential to occur elsewhere, lessons learned will be widely shared via the respective Programme Board meetings. Suggested timescales for reviewing the risk: It is the responsibility of the identified lead to monitor all their Risks regularly.

8. Governing Body Assurance Framework (GBAF) 8.1 The Governing Body Assurance Framework (GBAF) is a means of identifying and

quantifying strategic risks within the organisation and is the means by which the Governing Body monitors and controls the risks which may impact on the organisations capacity to achieve its objectives. These are captured on the Risk Return form example in Appendix D.

8.2 The GBAF identifies the principal objectives of the organisation and the principal risks

related to the delivery of these objectives. Key controls are made explicit together with the assurances on these controls. In addition, the Framework will identify linkages with inter-related areas of assurance.

8.3 The GBAF also provides a structure for the evidence to support the Annual

Governance Statement:

High 1 - 4 weeks Moderate 1 - 3 months

Low 3 - 6 months

Governing Body level (short and medium term)

STRATEGIC OBJECTIVES

Executive/SMT Level

PRINCIPAL OBJECTIVES

Identify & agreed risks inform the Assurance Framework

PRINCIPAL RISKS

Determined by each principal risk

KEY CONTROLS

Both internal & independent evidence that controls in place

ASSURANCE Ensure delivery of principal objective via control& assurance

ACTION PLANS

1

2

3 4 5 6

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9. Legal Requirements 9.1 Risk treatment plans may include actions to meet specific legal requirements. It is

possible that such actions may not need to be undertaken urgently, as the risk has been assessed and rated as “low”. However, NHS SCCCG & NHS VRCCG will seek to comply with any legal requirements at the earliest opportunity. These should be highlighted in the action plan. The deadlines for these actions will usually be less than 1 year.

9.2 The CCGs are members of the National Health Service Litigation Authority (NHSLA) Risk Management Scheme for Trusts. This gives access to the following schemes:

• Liabilities to Third Parties Scheme (LTPS). • Employer Liability (EL) Scheme. • Public Liability (PL) Scheme. • Properties Expenses Scheme (PES).

The above provide the organisation with the means to fund the cost of legal liabilities and property losses.

10. Risk Assessment Training 10.1 In order to ensure that all levels within NHS SCCCG & NHS VRCCG have sufficient

awareness of risk management and are competent to identify, assess and manage risk within their working environment and area of responsibility, risk assessment training will be made available at induction.

10.2 Senior Managers have the responsibility for ensuring that risk assessment training within

their areas of work is undertaken as part of the annual performance review process; that staff are able to access and attend the relevant training.

10.3 The Risk Manager will undertake periodic reviews of inconsistency to risk scoring and

spot checks on stated controls being adopted.

11. Monitoring & Evaluation Process 11.1 The respective CCG’s will monitor and review the performance of risk management and

the continuing suitability and effectiveness of the systems and processes in place to manage risk through:

i) The Governance & Audit Committee will receive reports outlining high level risks

assessed Significant (12 and above) insofar that they can provide assurance to the respective CCG Governing Bodies that the systems and processes are working effectively.

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ii) Internal Audit will provide comments on the effectiveness risk management processes and provide a view on the CCG’s annual statement of Internal Control as part of its Internal Audit Plan. This information will be presented to the Governance & Audit Committee on publication and to the Leadership team for the implementation of any recommendations.

11.2 The CCG recognises that effective risk management requires not only the mitigation of the risk ratings through effective management of all known risks, but also must be embedded through the continued development of the organisational learning culture. It is essential on transition that the CCG retains the ‘organisational memory’. The organisation will promote the lessons learnt from our risk management activities i.e., incident reporting, complaints management, litigation / claims and audits etc. through the reporting mechanisms to the Governing Body and relevant Committees / Groups.

11.3 Service and Departmental representatives on the respective Committees / Groups are then expected to cascade the information to staff via Service and Departmental meetings. The Risk Management will also cascade information via safety bulletins and training sessions. The CCG will share learning with our healthcare partners and where practicable and relevant, involve other stakeholders.

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Appendix A:

Governance & Audit Committees

Remuneration Committees

Joint Quality & Performance Committee

Starting Well Programme Board

Joint Health Inequalities Group

Joint Incidents & Complaints Group

Clinical Commissioning

Executive

Operational / Leadership

Team

GP Practices: • South Cheshire x 18 • Vale Royal x 12

CCGs Business Functions : • Commissioning Team • Practice Engagement Team • Local Delivery Team • Quality Team • Contract & Finance Team • Medicine Management • Safeguarding Team

South Cheshire & Vale Royal Health Partnership Board

Connecting Care

Living Well Programme Board

Ageing Well Programme Board

Assurance Controls

Joint Medicines Management Group

Assurance Controls

Locality Teams

Management Team

Membership x 2

• Council (SCCCG) • Assembly (VRCCG)

Governing Body x 2

• NHS South Cheshire CCG • NHS Vale Royal CCG

Strategic Planning / Assurance Controls

Cheshire West & Chester Council • Health & Wellbeing Board • Local Safeguarding Children Board • Local Safeguarding Adults Board • Children Trust

Assurance Controls

Assurance Controls

Commissioning Support Unit Team

Cheshire East Council • Health & Wellbeing Board • Local Safeguarding Children Board • Local Safeguarding Adults Board • Children Trust

Assurance Controls

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Is this a new • Project / Contract? • Member of Staff? • Procedure / Piece of Equipment? • Redesigned service? • Potential risk identified through

contract monitoring etc?

YES

NO

Has an assessment been carried out?

Carry out Risk Assessment and

record & forward to Senior Manager to

agree risk.

Is this risk rated Moderate or High after Controls have

been considered?

YES

Is this risk accepted by Leadership?

YES

NO

YES

NO

NO

Review and

update assessment

monthly

Manage risk within

programme team

• Forward risk to Risk Manager.

• Record entry onto Corporate Risk Register / GBAF.

• Monthly Monitoring at respective governance meetings groups

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Appendix B:

Nolan’s Seven Principles of Public Life

1 Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.

2 Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

3 Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

4 Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.

5 Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

6 Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

7 Leadership Holders of public office should promote and support these principles by leadership and example.

These principles apply to all aspects of public life. The Committee has set them out here for the benefit of all who serve the public in any way.

74 of 371

Appendix C: Risk Identification, Rating & Risk Action Plan

First Stage: Qualitative Measures of Risk (The Consequence or Impact) Level Consequence Examples of Descriptors

1 Almost None

• No injuries (No treatment/intervention required/given, no time off work) • Patient Safety Incident resulting in ‘no harm’ (including near miss event) • Insignificant impact upon service provision (Loss/interruption not exceeding 1 hour) • None or minimal financial loss/cost

2 Minor

• Minor injury or illness (First aid treatment, time off work not exceeding 3 days) • Patient Safety Incident resulting in ‘low harm’ (as defined by the NPSA) • Minor impact upon service provision (Loss/interruption not exceeding 8 hours) • Low financial loss/cost

3 Moderate

• Moderate Injury (Medical attention required, time of work 4 -14 days, RIDDOR) • Patient Safety Incident resulting in ‘moderate harm’ (as defined by the NPSA) • Small patient numbers affected • Moderate impact on service provision (Loss/interruption not exceeding 24 hours) • Moderate financial loss/cost

4 Major

• Major injuries/long term incapacity/disability (Time off work in excess of 14 days) • Patient Safety Incident resulting in ‘serious harm’ (as defined by the NPSA) • Major impact upon service provision (Cancellation of service or loss/Interruption not exceeding 1 week • Major financial loss/cost

5 Catastrophic

• Death/permanent injuries/irreversible health effects • Patient Safety Incident resulting in death or major permanent incapacity • Large numbers of patients affected • Catastrophic impact upon service provision (loss/Interruption exceeding 1 week/ or/permanent loss of a service or facility) • Huge financial loss/cost

Second Stage: Qualitative Measures of Risk (The Likelihood of Occurrence) Level Likelihood Examples of Descriptors

1 Rare This will probably never occur/recur - not expected to recur for years (Adequate level of control. E.g. effective policy, training, supervision etc. is in place)

2 Unlikely Not expected to happen/recur - not expected to occur more than annually Defined safe systems of work, occasional exposure etc.

3 Possible Might happen or recur - expected to occur at least monthly Poor supervision, non-secure controls etc.

4 Likely Will probably happen/recur - expected to occur at least weekly Poor training, lack of supervision or ineffective controls etc.

5 Almost Certain

Will undoubtedly happen / recur, - expected to occur at least daily No control measures, constant exposure etc.

75 of 371

Risk Identification Guidance

1 Identify the Risks

• Identify potential risk/s - what, where, when, why and how events could prevent, delay or degrade the achievement of the intended action/outcome.

2 Analyse the Risk/s

• Identify and evaluate existing controls. • Determine the consequence and likelihood and hence the risk rating. • Consider the potential consequences and how these could occur.

3 Evaluate the Risk/s

• (How bad and how often) and decide on the existing precautions (controls) and decide if there is a need for further precautions (controls)?

• Consider the balance between potential benefits and adverse outcomes. • This will enable decisions to be made in respect of the extent and nature

of actions required and about priorities.

4 List Controls These include : National Guidance, Local Policies & Strategies; Job Descriptions; Records of Meetings etc

76 of 371

Appendix D: Risk Scoring Matrix

1 2 3 4 5Rare Unlikely Possible Likely Almost Certain

FrequencyHow often might it/does it happen

This will probably never happen/recur

Do not expect it to happen/recur but it is possible it may do so

Might happen or recur occasionally

Will probably happen/recur but it is not a persisting

issue

Will undoubtedly happen/recur, possibly

frequently

1 2 3 4 5Negligble Unlikely Possible Likely Almost Certain

Dom

ain

Impact on the safety of patients, staff or public (physical/psychological harm)

* Minimal injury requiring no/minimal intervention or treatment.

* No time off work

* Minor injury or illness, requiring minor intervention

* Requiring time off work for >3 days

* Increase in length of hospital stay by 1-3 days

* Moderate injury requiring professional intervention

* Requiring time off work for 4-14 days

* Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident

* An event which impacts on a small number of patients

* Major injury leading to long-term incapacity/disability

* Requiring time off work for >14 days

* Increase in length of hospital stay by >15 days

* Mismanagement of patient care with long-term effects

* Incident leading to death

* Multiple permanent injuries or irreversible health effects

* An event which impacts on a large number of patients

The information in this Appendix is based on guidance issued by the National Patient Safety Agency (www.npsa.nhs.uk).

Table 1: Probability score (P) : What is the likelihood of the consequence occurring? The frequency-based score is appropriate in most circumstances and is easier to

Probability Score

Table 2: Impact score (I) : Choose domain for identified risk, work along the columns in same row to assess the severity of the risk to determine the consequence score

Impact Score

77 of 371


Dom

ain Service/business

interruption Environmental impact

* Loss/interruption of >1 hour

* Minimal or no impact on the environment

* Loss/interruption of >8 hours

* Minor impact on environment

* Loss/interruption of >1 day

* Moderate impact on environment

* Loss/interruption of >1 week

* Major impact on environment

* Permanent loss of service or facility

* Catastrophic impact on environment

Dom

ain Quality/complaints/aud

it

* Peripheral element of treatment or service suboptimal

* Informal complaint/inquiry

* Overall treatment or service suboptimal

* Formal complaint (stage 1)

* Local resolution

* Single failure to meet internal standards

* Minor implications for patient safety if unresolved

* Reduced performance rating if unresolved

* Treatment or service has significantly reduced effectiveness

* Formal complaint (stage 2) complaint

* Local resolution (with potential to go to independent review)

* Repeated failure to meet internal standards

* Major patient safety implications if findings are not acted on

* Non-compliance with national standards with significant risk to patients if unresolved

* Multiple complaints/ independent review

* Low performance rating

* Critical report

* Totally unacceptable level or quality of treatment/service

* Gross failure of patient safety if findings not acted on

* Inquest/ombudsman inquiry

* Gross failure to meet national standards

Impact Score

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Dom

ain

Human resources/ organisational development/staffing/ competence

* Short-term low staffing level that temporarily reduces service quality (< 1 day)

* Low staffing level that reduces the service quality

* Late delivery of key objective/ service due to lack of staff

* Unsafe staffing level or competence (>1 day)

* Low staff morale

* Poor staff attendance for mandatory/key training

* Uncertain delivery of key objective/service due to lack of staff

* Unsafe staffing level or competence (>5 days)

*Loss of key staff Very low staff morale

* No staff attending mandatory/ key training

* Non-delivery of key objective/service due to lack of staff

* Ongoing unsafe staffing levels or competence Loss of several key staff

* No staff attending mandatory training /key training on an ongoing basis

Dom

ain

Statutory duty/ inspections

* No or minimal impact or breech of guidance/ statutory duty

* Breach of statutory legislation

* Reduced performance rating if unresolved

* Single breach in statutory duty

* Challenging external recommendations/ improvement notice

* Enforcement action Multiple breaches in statutory duty

* Improvement notices Low performance rating

* Critical report

* Multiple breaches in statutory duty

* Prosecution

* Complete systems change required

* Zero performance rating

Impact Score

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Dom

ain

Adverse publicity/ reputation

* Rumours

* Potential for public concern

* Local media coverage – short-term reduction in public confidence

* Elements of public expectation not being met

* Local media coverage – long-term reduction in public confidence

* National media coverage with <3 days service well below reasonable public expectation

* National media coverage with >3 days service well below reasonable public expectation

* MP concerned (questions in the House)

* Total loss of public confidence

Dom

ain Business objectives/

projects

* Insignificant cost increase/ schedule slippage

* <5 per cent over project budget

* Schedule slippage

* 5–10 per cent over project budget

* Schedule slippage

* Non-compliance with national 10–25 per cent over project budget

* Schedule slippage Key objectives not met

* Incident leading >25 per cent over project budget

* Schedule slippage Key objectives not met

Dom

ain

Financial, including claims

* Small loss Risk of claim remote

* Loss of 0.1–0.25 per cent of budget

* Claim less than £10,000

* Loss of 0.25–0.5 per cent of budget

* Claim(s) between £10,000 and £100,000

* Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget

* Claim(s) between £100,000 and £1 million

* Purchasers failing to pay on time

* Non-delivery of key objective/ Loss of >1 per cent of budget

* Failure to meet specification/ slippage Loss of contract / payment by results

* Claim(s) >£1 million

Impact Score

80 of 371

Appendix E : GBAF Template & Risk Return Form

2013

-14 PROGRAMME: Organisational Effectiveness Owner:

Jo Vitta Business Manager

RIS

K

Failure to meaningfully engage with staff stakeholders and patients resulting in poor decisions and outcomes

Risk Ranking Reviewed Date: 00/00/2013 Review Date : 00/00/00

Control Tick Avoid

Reduce Eliminate Transfer

Accept

Risk Type Tick Political

Legal Clinical

Technology Customer Needs

Rationale for Current SCORE :

Rating L x C = Level Initial: 3 4 12 Current: 3 4 12

Opened Date 01-03-13 Target Date 01-09-13 Closure Date

The governing body are aware of significant activity taking place in communicating with partner organisations, but have minimal assurances on the success of this activity.

Rationale for RISK APPETITE : Meaningful communications with stakeholders are key to the success of the CCG.

CONTROLS (What are we currently doing about the risk?) MITGATING ACTIONS (What have we done/what more should we do? • Annual Plan • Review findings from national Stakeholder Surveys • Press & Media Feedback • Customer Relationship Systems (Complaints & Comments) • Webpages – NHS Choices / PALS

• Communication & Engagement Strategy being refreshed and to be presented to the Governing body for ratification on 00-00-2013.

• Communication Policies/Guidance

ASSURANCES (How do we know if things are having a positive impact?) GAPS IN ASSURANCE (What additional assurances should we seek? • Review of communication and engagement plan at Governing Body. • Programme Boards routinely receive feedback from stakeholders via press,

surveys and complaints process.

• Training on the development of Press Releases and communication interaction. • Training on staging Focus Groups and conducting survey analysis.

ACTI

ON

PL

AN

Assigned to Action Detail Progress-to-Date Due Date

Almost Certain 5 5 10 15 20 25

Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x Impact = ScoreVery LowLowMediumHigh

Negli

gible

Min

or

Mod

erat

e

Seve

re

Cata

stro

phic

LIKEL

IHOO

D

IMPACT / CONSEQUENCE

81 of 371

APPENDIX F : Definitions & Abbreviations Level Definition Examples of Descriptors

Hazard

A hazard is something (e.g. an object, a property of a substance, a situation or set of circumstances or an activity) that can cause adverse effects.

Risks to Commissioning Business Plan, Concerns identified about a provider service have been identified. (i.e. trends of incidents / complaints / serious untoward incidents; not achieving required performance outcomes )

Risk

A risk is the probability [likelihood] that a hazard will actually cause its adverse effects, together with a measure of the effect [consequence]. It is a two-part concept and you have to have both parts to make sense of it. Likelihoods can be expressed as probabilities.

Risks to Commissioning Business Plan x number of patients (likelihood) have complained (effect) because they have not been able to access a commissioned service. (hazard) OR Commissioned service will not / has not been able (likelihood) to meet targets (effect) due to financial pressures.

Control Measures

Any actions/ procedures that are already in place, which eliminate, manage, control or mitigate any identified risks / hazards.

Risk Treatment

This involves the selection and implementation of appropriate options and action plans to mitigate or eliminate the risk. Risk Treatments should be implemented within realistic deadlines relevant to the risk. I.e. an Extreme risk will require more immediate action than a risk rated Low.

SMART

Action plans, which aim to mitigate the effects of risks should be all of the below to ensure ownership. • S = Suitable • M = Measurable • A = Achievable • R = Realistic • T = Timed

(SFAIRP) So far as is reasonably practicable

Both of these terms relate to the term “reasonably practicable. This involves weighing a risk against the trouble, time and money needed to control it. Thus, ALARP describes the level to which we expect to see workplace (health and safety) risks controlled. Risks to achieving the Strategic Plan should also be reduced to this lowest level or until “acceptable”.

(ALARP) As low as is reasonably practicable

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Acceptable Risk

This involves making an informed decision to accept the identified consequences and likelihood.

Risk Register

This is a log of all Directorate Risks.

Risks rated High or Extreme form part of the Assurance Framework, which is monitored monthly by the Board through the Healthcare Governance and Risk Group, Leadership Team and Governance and Audit Committee.

Monitor

To check, supervise, observe critically or record the progress of the proposed treatment Action Plan on a regular basis in order to identify change.

Review

To check that the risk is still valid and that the situation / circumstances under which the assessment was first made is still valid. If there are any changes then these should be reflected in the assessment and appropriate changes made.

83 of 371

Prepared By : Lisa Carr, Performance & Risk Manager NHS South Cheshire CCG Governing Body

REPORT



Risk Assurance – March 2014 27 March 2014

1415-1700 7.5.2

PURPOSE OF REPORT This paper provides the Governing Body with a progress report on the risk entries graded 12 and above stemming from the Corporate Risk Register. It provides details on new risks identified during the last reporting period, those risks being recommended for closure or score readjustment, together with comprehensive details of the controls and assurances and mitigating actions. This report follows the guidance stemming from the NHS Audit Committee Handbook 2011 published by the Healthcare Financial Management Association (HFMA) in association with the Department of Health. It is a mandatory requirement that NHS organisations have in place mechanisms for the management of strategic and operational risks. Contents of the report have been reviewed by the Governance & Audit Committee held on 27 March 2014.

Report Prepared By: Lisa Carr Performance & Risk Manager Governing Body Lead: Lynda Risk Chief Finance Officer

This document provides a framework to provide assurance that strategic and operational risks are being managed and support the organisation’s delivery of its strategic goals and statutory obligations.

GOALS 2013-14




VISION


RECOMMENDATIONS


i) note the contents of the report summarising the risk management arrangements, in particular that there are 21 live risk entries of which twelve are ranked 12 & above. One new risk entry CR2013-37 has been added and no risks were retired or escalated/de-escalated during the reporting period.






No Yes

No

No

No

No

84 of 371

Date / Time Agenda Item

EXECUTIVE LEAD(s)

i)

ii)

9.2.210.2.2

ACTIONS REQUIRED: Please Indicate Yes/No

STRATEGIC RELEVANCE: Please state link to CCG’s goals

This report sets out the work being made to ensure the management of risk through its controls and mitigating actions and in turn enable the CCG work towards its strategic goals and objectives.

RECOMMENDATIONS

The Governance & Audit Committee is asked to:-

note the contents of the report summarising the risk management arrangements, in particular new risks identified during the report period, risks which are being recommended for closure; risks reviewed with recommendations to de-escalate existing score.

note there are 21 live risk entries of which 12 are ranked 12 & above. One new risk entry CR2013-37 has been entered since the last reporting period and no risks identified to be retired or escalation requirements.

VRCCG Governance & AuditSCCCG Governance & Audit

25-03-1427-03-141.00pm

Bevan HouseNantwich

PURPOSE OF REPORT AUTHOR

This paper provides the Governance & Audit Committee with a progress report on the risk entries graded 12 and above stemming from the Corporate Risk Register. It provides details on new risks identified during the last reporting period, those risks being recommeded for closure or score readjustment, together with comprehensive details of the controls and assurances and mitigating actions.

This report follows the guidance stemming from the NHS Audit Committee Handbook 2011 published by the Healthcare Financial Management Association (HFMA) in association with the Department of Health. It is a mandatory requirement that NHS organisations have in place mechanisms for the management of strategic and operational risks.

There is a total of 21 live risks, 12 of which are ranked 12 and above. There has been 1 new risk added since the last reporting period CR2013-37 Risk Scored 8. There are no risks identified for descalation or retiring from the system.

Lisa Carr Performance & Risk Manager

Contributors : Service Delivery ManagersClinical Project ManagersContract & Finance ManagersQuality Team

Lynda RiskChief Finance Officer


REPORT TOPIC

Risk Assurance Update - March 2014Committee Venue

Yes No No Yes

REPORT

Assurance Decision Discussion Information

85 of 371

Mar-11 CR -2013-02 Continuing HealthcareClinical /

Operationalx

Feb- 14 De-

escalatedFrom 3 x 3 = 9 / To 3 x 2 = 6

Mar-11 CR - 2013-04 Clinical RiskOperational /

performancex

01/01/2014

Retired

Closed due to robust processes in

place. 2 x 2 = 4

Feb-12 CR - 2013-06 CCG Authorisation Operational xMar-14

Live EntryRanked 2 x 3 = 6

Feb-12 CR - 2013-07 Communications Operational x16/10/2013

Retired

New appointments made and in

post. Ranked 2 x 2 = 4

Mar-11 CR - 2013-01 ECT Community Business Unit Change / Financial xMar-14

Live Entry

No change to score rating

4 x 3 = 12

Aug-13 CR -2013-25 Personal Health Budgets Operational xMar-14

Live Entry

No change to score rating.

4 x 4 = 16

Mar-11 CR - 2013-03 Risk Management Operational xMar-14

Live Entry

No change to score rating.

2 x 2 = 4

Sep-12 CR - 2013-08 Altogether Better Change / Financial xAug-13 De-

escalatedFrom 4 x 4 = 16 To 2 x 2 = 4

Dec-12 CR - 2013-10 Bespoke Care - IFR Process Change xOct-13

EscalatedFrom 3 x 2 = 6 To 2 x 5 = 10

Aug-13 CR -2013-24 CSU SLA Management Operational xMar-14

Live

To review Internal Audit findings

Dec-13. 4 x 4 = 16

note

there are

21 live risk

Dashboard

Risk Entries to Corporate Register 2013-14NHS SOUTH CHESHIRE & NHS VALE ROYAL CCGs

Entry

Date

Entry

DateRisk No.

Sig

nific

ant =

9-1

2

Mod

erat

e =

5-8

Cor

pora

te

CONTROLRISK TYPE

Risk Owner Risk Title Category

RISK DETAILS

Governance &

Partnership Director

SCCCG

Fiona Field

REGISTER(s)RISK RATING

Risk

AppetiteCommentary

Low

= 1

-4

GOVERNANCE

Chief Finance Officer

SCCCG/VRCCG

Lynda Risk

Sta

rting

Wel

l

Livi

ng W

ell

Age

ing

Wel

l

Maj

or =

15-

25

Status

86 of 371

Dashboard


Entry

Date

Entry

DateRisk No.

Sig

nific

ant =

9-1

2

Mod

erat

e =

5-8

Cor

pora

te

CONTROLRISK TYPE


RISK DETAILS


Risk

AppetiteCommentary

Low

= 1

-4

GOVERNANCE

Sta

rting

Wel

l

Livi

ng W

ell

Age

ing

Wel

l

Maj

or =

15-

25

Status

Jun-13 CR - 2013-12Nice Guidance for IVF Treatment

Cycles

Financial /

Reputationalx x

Nov-13 De-

escalated

G&A advised to re-open and re-

score from 16 to 3 x 2 = 6

Mar-13 CR - 2013-14 1 1 1Clinical /

Operationalx x

Jan-14

Live entry

Score 3 x 3 = 9 being monitored via

Living Well Programme

Jun-13 CR - 2013-16 OOHsClinical /

Operationalx x

Feb-14

Live Entry

De-escalate from 16 to 3 x 3 = 9

Monitor via Living well Board

Jun-13 CR - 2013-15 Mortality @ MCHfT Clinical Quality x xMar-14

Live Entry

Await findings from AQUA Review in

Apr-14. 4 x 4 = 16

Oct-13 CR - 2013-28 MCHfT Emergency Dept 4hr Target Performance x xFeb-14

Live Entry



Oct-13 CR - 2013-28MCHfT Emergency Department 4hr

Target

Clinical /

Operational

Feb-14

Live Entry



Oct-13 CR - 2013-29Performance & Contract

Management @ MCHfTPerformance x x

Jan-14

Live Entry

Score 3 x 3 = 9 being monitored via


Jan-13 CR - 2013-30 Vascular Service ChangesClinical /

Operationalx x

Mar-14

Live Entry4 x 4 = 16

Feb-14 CR - 2013-36Learning Disabilities - Winterbourne

View Concordat

Clinical /

Operationalx x

Mar-14

Live Entry4 x 3 = 12

Service Delivery

Manager(s)


Julia Burgess / Sue

Milne / Tracey Wright /

Sue Cooke

Service Delivery

Manager

Starting Well

Programme

Tracey Matthews

87 of 371

Dashboard


Entry

Date

Entry

DateRisk No.

Sig

nific

ant =

9-1

2

Mod

erat

e =

5-8

Cor

pora

te

CONTROLRISK TYPE


RISK DETAILS


Risk

AppetiteCommentary

Low

= 1

-4

GOVERNANCE

Sta

rting

Wel

l

Livi

ng W

ell

Age

ing

Wel

l

Maj

or =

15-

25

Status

Oct-12 CR - 2013-09Development of Neighbourhood

TeamsChange x x

Sep-13

Retired

Redefine risks held on Ageing Well

Log

Jun-13 CR - 2013-17Capacity of Workforce for ageing

Well ProgrammeOperational x x

Nov-13

Retired

Closed due to new appointments

being made.

Jul-13 CR - 2013-18 Integrated Health & Social CareClinical Quality /

Operationalx x

Sept-13

Retired

Redefined risks entries in Ageing

Programme log.

Jul-13 CR - 2013-19 NHS Social Care Allocations Political x xMar-14

Live Entry

Improvements made from CEC.

Awaiting CWaC. 3 x 4 = 12

Jul-13 CR -2013-20 Configuration of INT in Northwich Operational x x18-11-14

RetiredProgramme Board approved closure

Jul-13 CR - 2013-21 Integrated Team Project GroupChange/

Operationalx x

Jan-14

Retired

Overall of Project Structure.

Descalated from 12 to 6.

Aug-13 CR - 2013-22 Northwich 3 EngagementChange/

Operationalx x

14-10-13

RetiredEngagement Plan implemented

Aug-13 CR - 2013-23Business Case - Investment &

SavingsStrategic / Change x x

14-10-13

Retired

Workshop findings changed

mandate.

Aug-13 CR- 2013-26Transitional Care / Community

Intervention Beds Operational x x

Jan-14

Retired

Procurement completed and service

now operational.

Service Delivery

Manager

Ageing Well

Programme

John Turton

88 of 371

Dashboard


Entry

Date

Entry

DateRisk No.

Sig

nific

ant =

9-1

2

Mod

erat

e =

5-8

Cor

pora

te

CONTROLRISK TYPE


RISK DETAILS


Risk

AppetiteCommentary

Low

= 1

-4

GOVERNANCE

Sta

rting

Wel

l

Livi

ng W

ell

Age

ing

Wel

l

Maj

or =

15-

25

Status

Oct-11 CR - 2013-05 EMIS Integration Operational xMar-2014

Live EntryScored 3 x 4 = 12

Mar-13 CR - 2013-11Professional Concerns Process

Mechanism

Operational/

Clinicalx

16-09-13

Retired

Quality Team & CSU monitoring

BAU

Jun-13 CR - 2013-13Personal Confidential Data

Guidance Update

Financial / Clinical

Qualityx

Mar-2014


Oct-13 CR - 2013 -27Local Enhanced Services (LES)

Review

Clinical /

Operationalx

Dec-13 De-

escalated

From 4 x 4 = 16 to 3 x 3 = 9. De-

escalated to 2 x 3 = 6

Sep-13 CR - 2013-31 ICT Security Operational xMar-2014

Live EntryScore 5 x 4 = 20

Oct-13 CR - 2013-32Serious Concerns & Safeguarding

issues

Clinical /

Operationalx

Mar-2014

Live Entry

Work progressing to mitigate issues.

3 x 4 = 12

Oct-13 CR - 2013-33NICE TA 236, Acute Cononary

Syndromes CompliancePolitical / Clinical x

Mar-2014


Nov-13 CR - 2013-34CWP Contract 2013-14 implied

status not signed- off

Political /

Financialx

Mar-2014

Live EntryDescalated from 12 to 2 x 4 = 8

Jan-14 CR - 2013-35 Never Events @ MCHfT Clinical xMar-14


5 10 4 2 21Closed Risk Entry

Managed via Programme LogsTotal Live Corporate Entries

Service Delivery

Manager(s)

Corporate /Other

Programmes

Jo Vitta / Rachel

Smethurst / Amanda

Best / K Highfields / S

Cooke / Mark

Dickinson / Judith

Thorley / Steve Evans

89 of 371

Reporting Period : Feb-14

Executive Sponsor : Lynda Risk

Clinical Lead :Dr Andrew Wilson - SCCCG

Dr Jonathan Griffiths - VRCCG

Risk Manager : Lisa Carr

Strategies / Policies / Procedures Minutes / Reports / Data Results Controls / Assurances

Likelihood Impact Risk Score What measures being used to reduce risk? Sources of information to ascertain controls working? Identify areas of weakness in controls or

assurances and actions to be taken.L x I =

Risk

1

CR

-20

13

-01

SCC

CG

& V

RC

CG

ECT Community

Business Unit

There is a risk to the quality and

sustainability of community services, which

may be adversely affected by the wider

financial problems at ECT

01

-30

-11

(R

ef 4

)

T P

arke

r-P

ries

t

4 5 20

Hig

h

* Agreement to work with ECT to commission an

economic review of community services.

* CSU were commissioned in June 2012 to undertake a

community services review for South Cheshire and Vale

Royal.

* The proposed work for CSU to undertake a community

services review has been altered to take into account:

National best practice when commissioning outcomes;

community service models in areas that have already

implemented neighbourhood/practice teams; Quality

indicators for community services.

* Contract in place for ECT SC/VR are associates to this

contract.

* Contract & Quality meetings set up and held monthly

* An internal meeting with core staff tasked with the

delivery of the community review took place on 16

October 2013. By mid November a full project and

resource plan will be developed.

As @ Dec-13 a full project and resource plan has been

developed for the full duration of the 18 month project.

As @ Feb-14 agreement made and co-ordinating

contract across South Cheshire & Vale Royal.

* Project Team to be established to manage the

review.

* Apr-13 Economic Review was accepted by the

CCG and enacted through the contract.

* Jul-13 Quality Board 'Star Chamber' held with

Trust and Lay Members to review QIPP plans of

Trust.

* Aug-13 Executive meeting held to discuss future

of Trust and plans in respect of District Nursing in

particular.

* Oct-13 Letter sent to ECT indicating CCG

intentions regarding Neighbourhood

teams/Extended Practice Teams.

* Nov-13 Discussion of Nursing changes at ECT.

* Consideration is to be given as part of

project planning to ensure all three

programmes are engaged in the

development of new servie specifications.

* Both CCGs are keen to ensure that

14/15 contracts with existing providers

deliver quick wins to faclitate delivery of

the accountable care system adopted by

both CCGs. This is to be picked up

through the normal contracting round.

As @ Feb-14 outcomes and KPIs to be

developed.

4 x

3 =

12

19/0

3/20

14

NHS SOUTH CHESHIRE & NHS VALE ROYAL CCGs

CORPORATE RISK REGISTER 2013-14

* develop and maintain effective stakeholder & public engagement & partnership working* deliver clinical-led commissioning objectives through innovation service redesign* improve quality and safety of healthcare services with our providers* deliver compilance as a statutory organisation

LO

G N

o.

RISKS 2013-14CONTROLS ASSURANCES GAPS

Ris

k O

wne

r Time / Cost / Quality / Benefit /

Resource

Ris

k R

atin

g CU

RR

EN

T

SC

OR

E

UP

DA

TE

D

ID

Ref CCG Type Risk Title

PRINICPAL RISK INITIAL RISK SCORE

Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

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re

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T

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TE

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ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

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re

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EN

T

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OR

E

UP

DA

TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

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OO

D


5

CR

-20

13

-05

SCC

CG

& V

RC

CG

Op

erat

ion

al

EMIS IntegrationThe integration of EMIS web and other IT

systems and EMIS practice systems

01

-10

-11

(R

ef 1

1)

Kev

in H

igh

fiel

d

3 4 12

Hig

h

* The Programme Board to ensure the risk is managed

and solution is agreed acorss the CBU and Practice EMIS

systems

* MIAA Internal Audit Review 2012-13.

* ICT Strategy approved by respective Governing Bodies

* Service Delivery Manager - ICT Job Description

developed and appointment made in Aug-13

* Input from Chief Information Officer Clinical

lead from South cheshire to try to develop a

mutually agreed solution.

* Minutes & Reports from monthly ECT contract

Management Meetings

* New Service Delivery Manager - ICT to lead the

delivery of the ICT Strategy

* Discussed at Nov-13 ECT contract meeting.

* K Highfield has received ECT rollout plan

* Agreement on rollout expected Dec-13

* As @ Jan-14 A meeting took place in January 14

with the MD of Medical IG, CWP, East Cheshire

and Mid Cheshire, to discuss options of

integration of systems using the MIG and their

engagement with other key suppliers and

timescales.

* As @ Jan-14 there were two main

options of a portal and for complete

integration of systems, MIG will provide

costs by the end of Jan 14 for a joint

provision across the Cheshire Healthcare

area. A further meeting is arranged at the

end of Jan 14 with EMIS on their progress

on developing key integrations and

activations of supporting information

sharing.

* As @ Feb-14 The planned development

meeting with EMIS will now take place

25th February. * As @ Mar-14 The

planned development meeting with EMIS

was cancelled by EMIS, they have asked

to reschedule this on the 2nd April 2014.

This coincides with the activation of the

new GPSOC-R contract starting on the

first of April that brings in significant

changes to the Primary Care commercial

roadmap that EMIS will then support and

that NHS England will fund going forward.

3 x

4 =

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20/0

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Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

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Likel ihood x

Impact = Score

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Low

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TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

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ligib

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Min

or

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TE

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ID



Dat

e

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tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

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stro

phic

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LIH

OO

D


13

CR

-20

13

-13

SC&

VR

Fin

anci

al /

Clin

ical

Qu

alit

y

New Guidance

regarding

Personal

Confidential

Data

PCT was covered by the Section 251 within

the previous Health Act 2006 to receive,

hold and process patient identifiable data,

but the new Health and Social Care Act

2010 does not cover CCGs for this unless we

have explicit consent from the patient, or it

is being held and processed for direct care

purposes.

25

/06

/20

13

Kev

in H

igh

fiel

d

4 4 16

Hig

h

• 13-06-13 Publications Gateway Reference Number 168

letter issued to all CCGs confirming the current situation

• 13-06-13 CCG assigned Contract Lead

• 14-06-13 CCG Contract Lead attended a national

workshop In Leeds

• 20-06-13 Emails issued to all departments requesting

current data flows

• CSU & DMIC issued a data mapping template to the

CCG which is partially completed for submission end of

July 2013

• Letters drafted to inform all providers of the situation

• Assessment of current access to systems

* A spreadsheet has been created to collate all

the responses from the emails that have been

sent out regarding data flows.

* An area on the shared drive has been collated

where all emails and documents will be saved.

* As @ Jan-14 The Secretary of State for Health,

after receiving advice from the Confidentiality

Advisory Group (CAG), has approved NHS

England's application for a continuation of

Section 251 support for the transfer of data from

the Health and Social Care Information Centre

(HSCIC) to commissioning organisation

Accredited Safe Havens (CAG 2-03(a)/2013) until

October 2014.

* Once the current processes have been

assessed and altered where necessary we

need to consider what data is held from

previous years.

* Fieldwork to commence in Jul-13 for IG

Toolkit 2013-14 compliance evidence is

required and relates to the risk.

* As @ Sept-13 still awaiting guidance on

changes at centre.

* As @ Oct-13 still awaiting guidance on

changes at centre afrer additional Govt

review.

* As @ Nov-13 still awaiting guidance on

changes at centre after additional Govt

review.

* As @ Jan-14 the scope of the section

251 support has not changed and only

covers specific commissioning data

flowing from the HSCIC and its Data

Services For Commissioning Regional

Offices (DSCROs,) to commissioning

organisations who have obtained Stage 1

Accredited Safe Haven (ASH) status.

* As @ Feb-14 the scope of the section

251 support has not changed from Jan 14

update.

3 x

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ID



Dat

e

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tifi

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Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

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Neg

ligib

le

Min

or

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erat

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re

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15

CR

-20

13

-15

SC &

VR

Clin

ical

Qu

alit

y

Mortality at

MCHFT

Mortality rates are worse than expected on

national mortality measures.

14

.06

.13

Sue

Co

oke

4 4 16H

igh

* Monthly contract meetings and clinical quality and

patient safety review meeting.

* Monthly monitoring by Quality and Performance

Committee

As @ Oct-13 Escalated to Area Team through

Quality Surveillance Group awaiting outcome.

MCHfT, CCG's and CSU are working with the

National Information Centre to identify if patients

with 'zero length of stay' are being coded

appropriately. MCHft believe that these patients,

coded as assessments are not included in their

SHMI figures therefore increase the SHMI. MCHfT

are reclassifying these patients using the formula

from the National Infomation Centre and have

served notice on the CCG's that from April 2014

they will code these patients as short stay

admissions thereby decreasing their SHMI

As @ Nov-13 MCHfT has added this risk to their

Corporate Risk Register.

A joint clinical audit of patients with zero length

of stay will commence in Nov-13 and the findings

will be presented to Quality & Performance

Committee in Jan-14

Assurance required about the level of

clinical involvement and the depth of

investigation with regard to reducing

mortality. In October 2013 CCG's have

sent a letter to MCHfT asking for further

information about coding and how they

are addressing mortality rates in Divisions

that have higher than expected

deaths.Concern around date of AQuA

'deep dive' review. if date not expedited

then contingency plans are required. In

the next few weeks Dr foster Intelligence

will publish their annual report on

Hospital Standardised Mortality Ratio

(HSMR). mCHfT are likely to be outliers.

December 2013 - Dr Foster intelligence

mortality rate published - MCHFT outliers

January 2014 - AQuA mortality review

'deep dive' underway, final report to be

published in April 2014. CCG's involved

with process.

February 2014 - AQuA 'deep dive' review

still underway

March 2104 -AQuA 'deep dive' review

complete. Draft report out for comments.

Final report to be received in April 2014.

4 x

4 =

16

14-M

ar-1

4

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Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

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Low

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TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

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stro

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LIKE

LIH

OO

D


19

CR

-20

13

-19

SC C

CG

&V

R C

CG

s

Po

litic

al

NHS Social Care

Allocations

CCGs not seen delivery plan from LAs

(CWaCC and CEC) for the NHS Social Care

Allocations. CWaCC submitting a high level

paper to August Health and Wellbeing

Board. CEC currently undertaking 3

feasibility studies before committing

resource.

12

/07

/20

13

(A

W2

01

3-0

6)

Joh

n T

urt

on

4 3 12

Med

ium

Service Delivery Manager working with CEC and CWaCC

commissioners.

Emails and action notes of CEC and CWaCC

meetings.

13/09/13 - Meeting with Cheshire East 25th

September 2013 to discuss feasibility studies

relating to S256.

* Joint presentation being delivered to CWAC JCB

on initial proposals for ITF.

* As @ Jan-14 notes CEC meeting held in Dec-13

recieved. Quarterly performance report recieved

from CEC. Meetings for 2014/15 agreed with ECT

for assurance reporting.

* As @ Feb-14 Risk Return form issued to G&A

meeting.

* As @ Mar-14 following request by G&A

committee to escalate. Two draft letters have

been prepared by risk owner for Chief

Accountable Officer approve. Contents of final

letter being reviewed prior to circulation to

CWAC.

* Will escalate to Directors of Governance

and Partnerships if plans are not received

by end of July 2013. 11/08/13 -

* Escalated to Directors, for discussion at

Health and Wellbeing Boards.

* Meeting being arranged with Cheshire

West and Chester to take place.

* Meeting being arranged with Cheshire

West and Chester to take place by 14th

October.

* As @ Nov-13 no developments have

transpired since last reporting period.

there have been meetings and discussions

with CWAC but no further developments.

* Jan-14 Not recieved quarterly

performance report from CWaCC. CWaCC

have been emailed to request

performance report. CWaCC have been

asked to arrange quarterly performance

meetings.

3 x

4 =

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Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

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re

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T

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E

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TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

Cata

stro

phic

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LIH

OO

D


24

CR

-20

13

-24

NH

S SC

CC

G &

VR

CC

G

Op

erat

ion

al

CSU SLA

Management

CCG internal

capacity to

manage and

monitor

performance

Clarity on the CCG's internal process for

managing and monitoring the operational

delivery outputs from the CSU SLA to ensure

compilance is being attained to highest

standards and quality.

15

/08

/20

13

L R

isk

5 4 20

Hig

h

* Service Level Agreement Approved

* 141 KPIs identified and being used for performance

monitoring

* Monthly CSU monitoring meetings

* Establishment of internal monthly CSU feedback forms

* Attendance at Joint Commissioner & CSU Delivery &

Strategy Board

* Specific management meetings held for the following

CSU areas:-

-Continuing healthcare

-Contracts Data

-Performance

-Communications and engagement

-Information Governance

-FOI's,SUI's and Complaints

* Accountable Officer & Chief Finance Officer

attend monthly SLA meetings with CSU senior

management.

* Minutes & Reports from CSU monitoring

meeting

* Monthly Service Delivery & Performance Report

* CHC monthly meeting held

* BI Rapid Development Events held - CCG/CSU

action plan produced.

* As @ Jan-14 the HR Rapid Development Event

was held in Dec-13.

* MIAA Internal Audit carried our internal audit

review and findings being presented to the G&A

Committee in Jan-14

* As @ Feb-14 appointed external consultants for

review of CSU's SLA and KPIs

* As at Mar-14 Integral Healthcare undertaking

review of CSU services to report in April 2014.

* CCG needs to set up system to capture

the operational performance from each

of the CCG leads linked to the CSU

business areas in order to filter

information through to the SLA meetings

to be reviewed at an executive level.

* Need to pin point the governance

management for this SLA.

* At @ Sept-13 Too many KPIs being

monitored that are not specific or

relevant to performance.

* Internal reviewof performance and

requirements need to be undertaken.

*Develop contract management meetings

with HR support

* As @ Sept-13 G&A queried scoring and

consequently the decision to lower risk

score was taken from a 20 to 16.

* As @ Nov-13 HR Rapid Development

Event to be held.

4 x

4 =

16

19/0

3/20

14

25

CR

-20

13

-25

NH

S SC

CC

G &

VR

CC

G

Oep

rati

on

al

Personal Health

Budgets

Internal Audit Review Legacy Tracker has 5

recommendation entries (CEC048 to

CEC052). CSU via SLA provide full admin

support on PHB and unclear what actions

have been implemented to resolve the

outstanding recommendations by the CSU

leads.

15

/08

/20

13

T P

arke

r-P

ries

t

4 4 16

Hig

h

* Internal Audit Review Tracker Legacy document

* Covered via governance arrangements for CHC.

* 15-08-13 CCG Excutives and VRCCG Audit Chair

meet to review detail of legacy tracker.

* 17-08-13 VRCCG Audit Chair sent email to CSU

requesting a performance report on PHBs to the

G&A meeting in Sept-13 to present performance

information associated with number of PHBs,

assurances, outline safeguarding and financial

details

* 17-09-13 updated statement on PHB received

for G&A Committees to review.

* 28-01-14 additional update report presented to

G&A Committee

* As @ Feb-14 no updates to report

* Robust performance updates not being

regularly reported back to the CCG

relating to PHBs, no assurances provided

on quality impact of CSU service, clarity

on governance relating to safeguarding

and financial impacts

* As @ Nov-13 no change to current

position.

4 x

4 =

16

19/0

2/20

14

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Likely 4 4 8 12 16 20

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Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

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e

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re

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30

CR

-20

13

-30

NH

S SC

CC

G &

VR

CC

G

Clin

ical

/Op

erat

ion

al

Vascular Service

Changes

As of Dec 2012 Vale Royal CCG (VRCCG) and

South Cheshire CCG’s (SCCCG) ‘Trauma

Centre’ and ‘Vascular Centres’ were

relocated to North Staffordshire Hospital

from Mid Cheshire. The change in provider

was managed with the cooperation of both

Trusts and the Vascular Network; it will

ensure vascular patients requiring urgent or

emergency care receive the best care and

treatment delivering the best outcomes

from a specialist centre.

Prior to the change safety and cost issues

were raised relating to the risk of

emergency patients being transported to a

centre up to an additional 30 miles away

and not being stablised within 60 minutes.

01

.01

.13

Sue

Miln

e

4 4 16H

igh

Vascular network meetings are looking at:

1. Vascular (Surgical):

- AAA

- Stents

- Amputations

2. Stroke (Physician),:

- NICE = FAST positive must be thrombolysed within 4hrs

(approx. 3 per month)

- 9am to 9pm – all support available at MCHFT

- Stroke Nurse meets ambulance at front door of A&E

- Doppler used to evaluate if positive for Thrombolysis

for clot

- If positive treated in MCHFT

3. Cardiac / Primary PCI (Cardiologist)

- Paramedic assesses for MI and stabilised

- Patient conveyed direct to UHNS

4. Treatable MI (Surgical)

- Patient admitted to MCHFT

- Transfer to UHNS for planned procedure

- Return to MCHFT under Cardiologist

Current mitigating actions:

1. Surgical

- regular Vascular network and local working

group meetings with Community and acute input

- Improved communications between

organisations

- Sharing of procedures and processes

- UHNS involvement in discharge confernece calls

chaired by MCHFT

2. Stroke

- ED nurses being trained to fulfil role of stroke

nurse in ED between 9pm and 9am

- In negotiation with NWAS to improve

ambulance turnround for Stroke patients

requiring transfer from MCHFT for Thrombolysis

at UHNS

- Evaluation of compliance over last 12 months

being undertaken

3. Cardiac/PPCI

- In negotiation with NWAS to improve

ambulance availability patients requiring urgent

transfer from MCHFT to UHNS

- Evaluation of compliance over last 12 months

being undertaken

4. Treatable MI

- Review of activity and cost to be undertaken

- Impact on 2014/15 contract costs

- As @ 19th Feb above imformation is being

chased from the providers and responses will be

reported in March

1. Surgical

Issue: discharge back to local area

- Communication and distance adding

delays for discharge of patients

- Lack of understanding of Community

Services, Cheshire east and Cheshire West

and Chester processes and procedures

2. Stroke

Issue: 9pm to 9am

- Availability of stroke nurse at front door

- Availability of blue light ambulance from

MCHFT to UHNS

- NICE Compliance? Concerns OOHs

pathway taking over 4 hrs

3. Cardiac/PPCI

Issue: Ambulance without Paramedic

- Technicians unable to assess for MI

- ED assesses MI and stabilises

- Patient Transfer to UHNS

- Availability of blue light ambulance from

MCHFT to UHNS

4. Treatable MI

Issue: increase in activity

- Contract based on 12 per month

- Activity now approx. 60 per month

- NWAS asking for additional funding

16

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ar-1

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Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

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ligib

le

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or

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e

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31

CR

-20

13

-31

SCC

CG

& V

RC

CG

Op

erat

ion

al

ICT Security Risk

Our current computer operating systems of

Windows XP and Office 2003 will go out of

support from Microsoft on April 8, 2014 and

no further security patches will be release

by Microsoft after this date. This will affect

both CCG's and all GP Practices linked to

them.

16

/09

/20

13

Kev

in H

igh

fiel

d

5 4 20

Hig

h

A draft upgrade document has been prepared for

consideration by the CSU, there is understanding

between the CSU and the CCG's of what the

requirements are and the timescales that these need to

be implemented in, and the scope and impact to all

organisations. The project planning and resource

allocation is currently on hold by the CSU as there is

currently disagreement between NHS England and the

CSU as to who has the funding required to implement

this project. Following numerous conversations led by

Simon Whitehouse with both NHS England and the CSU

a further escalation email was sent by Simon W. on

19/10/2013 asking both the CSU and NHS England to

confirm their actual position on Primary Care funding

allocation going forward.

Statement from Microsoft Website current as of

21st October:

•Security & Compliance Risks: Unsupported and

unpatched environments are vulnerable to

security risks. This may result in an officially

recognized control failure by an internal or

external audit body, leading to suspension of

certifications, and/or public notification of the

organization’s inability to maintain its systems

and customer information.

•Lack of Independent Software Vendor (ISV) &

Hardware Manufacturers support: A recent

industry report from Gartner Research suggests

"many independent software vendors (ISVs) are

unlikely to support new versions of applications

on Windows XP in 2011; in 2012, it will become

common." And it may stifle access to hardware

innovation: Gartner Research further notes that

in 2012, most PC hardware manufacturers will

stop supporting Windows XP on the majority of

their new PC models.

As @ Mar-14 The Audit was completed

by the CSU enabling planning for

deployment on the weekend of Sat 15th

& 16th March 2014. Due to CSU identified

server issues this date was postponed

and a technical review has been taking

place. A fix for the underlying issue has

now been identified by 3rd line CSU

support which is planned to be tested

W/C 24th March. We are currently

awaiting the outcomes of this testing

before confirming a new date , potentially

5th & 6th April 2014 which will still

achieve the required date of end of life

support from 8th April. This new date and

future dates in April bring in additional

risk to the Finance people as they prepare

for financial year end.

5 x

4 =

20

20-M

ar-1

4

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Risk




LO

G N

o.


Ris

k O

wne


Resource

Ris

k R

atin

g CU

RR

EN

T

SC

OR

E

UP

DA

TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

Cata

stro

phic

LIKE

LIH

OO

D


32

CR

-20

13

-32

SCC

CG

& V

RC

CG

Clin

ical

/Op

erat

ion

al Serious Concerns

and Safeguarding

issues

communicated

between CHC

team and CCG

Leads

Failure to ensure effective, accurate and

timely communication of serious concerns

and safeguarding issues between CHC team,

CCG and leads for safeguarding and quality2

8/1

0/2

01

3

Jud

ith

Th

orl

ey

3 4 12

Med

ium

• Governing Body are aware of the numerous actions

underway with Cheshire East CCG, Cheshire East Council

and CQC to ensure information sharing. Confirmation of

expectations of robust informative reporting agreed

with CHC

• Monthly contract monitoring meeting CHC team and

MCHfT.

• Local quality surveillance meeting-information sharing

with Cheshire East (CE CCG)and South Cheshire CCG’s,

Cheshire East Council (CEC), and CQC.

• Director of Partnerships and Governance meet

regularly to exchange and compare

information/intelligence.

* Quarterly multi –agency meeting with LA,CQC, CCG

and CHC to share safeguarding intelligence to raise the

communications between partners.

* Quarterly forum held with GP’s and the Executive

Safeguarding Lead to review quality in nursing homes in

Eastern Cheshire.

* Quarterly assurance meetings with providers to

specifically review safeguarding processes

• More robust , informative and timely reports

from CHC team

• Longer term expect to see a reduced trend in

the number of safeguarding issues and

care/nursing homes on the safeguarding risk

register

* Jan-14 - work is being progressed but no

comprehensive update to report at this stage

* At @ Mar-14 Work is ongoing with bespoke

training for GP practices in adult safeguarding

alongside the unannounced inspections by the

CQC, where GP practices have non-conformities

support will be given by the Designated Nurse to

ensure they achieve the required outcome.

3 x

4 =

12

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ar-1

4

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Risk




LO

G N

o.


Ris

k O

wne


Resource

Ris

k R

atin

g CU

RR

EN

T

SC

OR

E

UP

DA

TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

Cata

stro

phic

LIKE

LIH

OO

D


33

CR

-20

13

-33

SCC

CG

& V

RC

CG

Po

litic

al /

Clin

ical

NICE TA 236,

Acute Coronary

Syndromes

Compliance

* Uncertainty whether the commissioned

Local (MCHfT) and Tertiary (UHNS) Acute

Trust Providers comply with NICE TA 236,

Acute Coronary Syndromes, issued in

October 2011. The expectation is that this

intervention is available to CCG residents

within 3 months of issue.

* There is a lack of an appropriate pathway

which is likely to affect access to the

intervention for the possibly eligible cohort

of patients. The impact is moderate as the

individual benefit is not guaranteed to be

substantial

28

/10

/20

13

Mar

k D

icki

nso

n

4 3 12

Med

ium

• Raised on several occasions at the local Joint Primary

and Secondary Care Medicines Committee (JMMC). A

pathway was proposed within the last 4 months but it

was not assessed as NICE compliant.

• The Committee continues to wait for a revised

pathway from the Trust Clinicians. Update expected on

19-2-2014

• Raised at the Quality & Performance Committee in Oct-

13 due to Trust failing to give clear indication that they

will be compliant

• Agreed matter to be raised at the subgroup meeting

and if there is no resolution at the formal Contract

meeting.

A resolution to the issue should be achieved by

early January 2014

* Dec-13 matter discussed at JMMC (18.12.13)

when Dr Paul Mann (PM) Cardiologist at MCHfT

attended. PM stated that Ticagrelor was on

MCHfT formulary and available should it be

requested. On-going discussions within

Cardiology regarding its position in treatment and

when it might be used. PM accepted that the

current ACS care pathway needed to be modified

and suggested a form of words.

* JMMC (15.1.14) was informed that the MCHfT

Cardiology dept wished to discuss the wording

further on 17.1.14 and JMMC would be informed

in due course. Current status is on-formulary but

is not clear to all clinicians on the current ACS

pathway when it may be appropriate to offer it.

* MMT not aware if matter being actively

reviewed at UHNS or has been raised formally

with them as a contracting matter. SC and VR are

Associates to their contract.

As @ Mar-14 not updates to report at this time.

• To see compliant pathway along with

audit that demonstrated implementation.

• This does not mean that the drug

should be used but it is available should it

be appropriate and if it is not used there

should be a documented rationale why it

was not clinically appropriate.

* It was agreed that (PM) would inform

JMMC of the final wording prior to the

next JMMC on 15.1.14.

* Dr Mark Dickinson (MD) will inform the

Contracting teams covering both MCHfT

and UHNS regarding this item on the risk

register. 4 x

3 =

12

20-M

ar-1

4

36

CR

2-1

3-3

6

SCC

CG

& V

RC

CG

Op

erat

ion

al &

Clin

ical

Learning

Disabilities -

Winterbourne

View Concordat

Both CCGs have identified that they will

only be partially compliant with

requirements set out in Transforming Care

that all current placements will be reviewed

and everyone in hospital inappropriately

will move to community based support as

quickly as possible, and no later than June

2014. There remains no alternative,

community based provision for people

currently placed out of area.

01

/02

/20

14

Julia

Bu

rges

s

4 3 12

Med

ium

* All current placements are regularly reviewed and a

small number of cases have been identified where

clients are unlikely to be transferred to a community

setting as this is considered clinically inappropriate.

Work to develop alternative provision has been initiated.

* Placements will continue to be reviewed

monthly and registers kept up to date, including

details of discharge planning.

* The Programme Board will receive regular

updates on progress with the development of

alternative models of provision.

* Governing Bodies appraised of

reputational risks in February and will

receive a further update in March 2014.

12

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Risk




LO

G N

o.


Ris

k O

wne


Resource

Ris

k R

atin

g CU

RR

EN

T

SC

OR

E

UP

DA

TE

D

ID



Dat

e

Idem

tifi

ed


Likely 4 4 8 12 16 20

Possible 3 3 6 9 12 15

Unlikely 2 2 4 6 8 10

Rare 1 1 2 3 4 5

1 2 3 4 5

Likel ihood x

Impact = Score

Very Low

Low

Medium

High

Neg

ligib

le

Min

or

Mod

erat

e

Seve

re

Cata

stro

phic

LIKE

LIH

OO

D


37

CR

2-1

3-3

7

SCC

CG

& V

RC

CG

Op

erat

ion

al

Standards of

Business

Conduct and

Declarations of

Interest Register

Limited assurance given following the

Internal Audit follow-up review of the NHS

Constitution relating to Conflicts of Interest

governance arrangements. No policy in

place and process system not fully

embedded. Hence not all CCG members,

lay members and staff adhering to

requirements. Incomplete Register of

Interests register.

12

/03

/20

14

Rac

hel

Sm

eth

urs

t

3 3 9

Med

ium

* NHS Constitution published and on website.

* Draft Standards of Business Conduct & Declaration of

Interest has been developed and presented to the G&A

Meeting in Jan-14.

* Declarations of Interest Register refreshed and

uploaded to website.

* Letters issued in March 2014 to all staff band 7+ and

Governing Body members to complete Declaration of

Interest Form.

* MIAA undertook follow-up audit in March 2014

and provided 'Limited Assurance'

* Task & Finish Group established in Feb-14 and

sense checked contents.

* Draft Standards to be reviewed and

approved by the respective Membership

Council/Assembly in April 2014.

*Ratification of the Standards by the

Governing Body in April/May 2014.

* Communicated and publish Standards

on website.

2 x

4 =

8

03/0

3/20

14

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RISK RETURN FORM – 2013-14

201

3-0

3

ORGANISATIONAL EFFECTIVENESS Owner: A

im

Commission safe high quality care in line with the NHS Mandate, NHS Constitution and National Guidance.

Ris

k

ICT Security issues due to end of life of Windows XP Operating System Support Date Last Reviewed: 20-03-14

Risk Type / Rating :

Risk Definition & Rationale for Current SCORE

Categorise Risk Type

High

Rating L x C = Level

Initial: 5 4 20

Current: 5 4 20

Opened Date 21-10-13

Target Date 08-04-14

Closure Date

The likelihood of this is confirmed by Microsoft in a formal statement released to the public and private sectors, with a clear date for end of their current product support.

The consequences could vary dependant on security attacks to our organisation from outside, although systems will continue to work as they do today.

CONTROLS (What are we currently doing about the risk?) MITGATING ACTIONS (What have we done/what more should we do?

CCGs have a draft deployment plan from the CSU

CCGs are informed of progress with funding situation on a weekly basis

CCGs have liaised with NHS England and CSU to escalate Primary Care budget issue

Escalation to both NHS England Director of Finance and NHS England Managing Director

Ensure regular escalations at Senior level and ICT Service Lead Informed of outcomes

ASSURANCES (How do we know if things are having a positive impact?) GAPS IN ASSURANCE (What additional assurances should we seek?

There are currently no assurances from NHS England or the CSU on who or when the release of funds to enable project start will be delivered.

CCG to confirm with CSU the cut-off date for starting the project to ensure it is delivered by April 8th 2014.

AC

TIO

N P

LAN

Assigned to Action Detail Progress-to-Date Due Date

Kevin Highfield To implement Windows 7 and Office 2010 across both CCG’s by 8th April 2014.

The required PC Desktop and Laptop Audit was completed as planned on 19th February 2014 by the CSU IT team, this enabled planning for deployment on the weekend of Sat 15th & 16th March 2014. Due to CSU identified server issues as part of the final testing cycle with the roaming profiles and the potential impact to end user data loss this date was postponed on Wed 13th March, this followed a discussion at a senior level with CCG and CSU of the risk associated. A full technical review has now taken place

5th Apr. 14

0

5

10

15

20

25

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Initial

Current

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RISK RETURN FORM – 2013-14

with CSU 3rd line support teams working with Microsoft to identify a fix for the underlying issue. The required fix has now been identified by 3rd line and is planned to be tested W/C 24th March. We now await the outcomes of this testing for the Server and Desktops supported before confirming a new date, potentially 5th & 6th April 2014. This date will still achieve the required target date of end of life support from Microsoft of 8th April. This new date and future dates in April bring in additional risk to the Finance people as which will need to be considered and a plan in place to mitigate this will be required.

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Prepared By : Practice Engagement Managers &Local Change Managers NHS South Cheshire CCG Governing Body

REPORT




Locality Report – March 2014 27 March 2014

1400-1715 7.6.1

PURPOSE OF REPORT This paper provides the Governing Body an update of work being undertaken by the South Cheshire Practice Engagement and Local Change Managers for 2013/14.

Report Prepared by: Becky Barber Tanya Jefcoate-Malam Cheryl Cooper Practice Engagement Managers & Local Change Managers

Governing Body Lead (s) Annabel London Locality Lead – Nantwich & Rural Mike Tate Locality Lead – S.M.A.S.H

GOALS 2013-14




VISION


RECOMMENDATIONS


i) Note the contents of the report.






No Yes

No

Yes

No

No

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REPORT TITLE

Locality Report –March 2014

CCG Overview The Primary Care CQUIN Working Party met in February 2014 to discuss proposals for the forthcoming scheme in 14/15. A number of suggestions were brought to the working party and the group scored these using the CCGs prioritisation tool. Following this the proposals were shared with the Membership Council in February 2014. The Membership requested the Working Party develop the Quality Scheme along the themes below:

• Primary Care Transformation, • Continue and develop this year’s over 75 year old review to include other vulnerable patients, • Significant Adverse Events including Drug Adverse Incidents – reporting of incidents by

practices, • Cancer/ePACCs - improving electronic documentation and co-ordination of care for patients.

The Working Party met in March 2014 and will report back to the March Membership Council. QP Work Practices continue to finalise their QP Work (a part of the GPs contract asking them to consider ideas for pathway improvement to reduce inappropriate Secondary Care activity). The ABPI Vascular Pathway has now been shared with all practices. The Unilateral Deafness/Tinnitus Pathway is now approved and will shortly be circulated. Education Two Education events have been held in February for all 18 practices in NHS South Cheshire CCG. The event for Practice Nurses was very well attended with around 63 nurses coming together to hear updates on:

• Infection Control • Nurse Prescribing • Wound Care

The event for GPs was also well attended with around 75 GPs coming together to hear updates on:

• Q&A Session with Dr Andrew Wilson regarding Transformation Agenda for Primary Care, building on the discussions at the December Summit for Primary Care

• The case for anti-coagulation in AF - the role of NOACs’. – Dr Nick Newall , Cardiologist at The Wirral University Teaching Hospital NHS Foundation Trust

• Community Outreach Librarian – Steve Collman, East Cheshire Trust • Diabetes Update – Dr Adrian Heald, MCHFT and Dr Mark Dickinson, Medicines Management

Team, NHS South Cheshire CCG • Gastro Update – Dr Ian London, MCHFT • Mental Capacity Act – Lawrence Tudin, SAS Daniels.

Remote Care Monitoring

A Working Party is now established to examine and consider options and implications for continuing with Tele Medicine in 2014/15.

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There are a number of options which will be considered and reported back to the Membership Council. Rope Green Practice continue to pilot the “Tunstall” project as a Tele Medicine solution. 10 Patients will be identified and requested to be involved in the pilot, the project overseen by the IT Team.

Diabetes Education

Funding is now in place for the planned Diabetes Education Programme for patients. Practices will shortly be able to refer patients into this new service.

GP Elective Referral Audit

All 18 practices in NHS South Cheshire have been participating in an Elective Referral Audit. This audit has been carried out by two GP peers in South Cheshire CGG. A template is completed at each practice to help the CCG identify unwarranted GP variation in referral patterns, education needs and best practice. NHS South Cheshire is also engaging with a qualified GP studying at Keele University to support the project. All practice audits will be completed by the 2nd of April and following this a full report will be provided to the Membership for consideration and next steps.

Data sets

A suite of data packs are being developed for all 18 practices in NHS South Cheshire CCG. This will include information that is both useful and intuitive to practices. Practices will be presented with high level practice data that aligns to demographics, prevalence and high level elective, non-elective and prescribing information. There will be a particular focus on Localities to reflect the differing health needs across NHS South Cheshire CCG. Atrial Fibrillation Project

The NHS South Cheshire CGG Primary Care Team and Medicine Management Team are developing a project led by clinicians to understand which quality improvement measures are available through primary and secondary prevention for patients with AF. Early identification of AF along with proactive education and management of AF patients can reduce the number of catastrophic strokes, reduce the length of time patients have to stay in hospital and also realise improved patient outcomes. Febrile Children Pathway

Earnswood Practice are participating in a 10 week pilot from the end of March to further support and develop the Febrile Children 0-4 pathway which has already been adopted by all 18 practices in NHS South Cheshire CCG as part of the QP work. Earnswood practice will be linking with the Out of Hours Children’s Community Nursing Service to support parents in managing their unwell child. The main focus is respiratory, gastro and febrile conditions. Locality Focus At the February Membership Council a discussion was held around the future format of locality meetings. Presently these meetings are held for one hour each month immediately prior to the Membership Meeting. The Membership wish to ensure that the locality meetings capture and focus on the health needs of the local population and it was agreed that a different way of working may be required to address this. In March all three localities are coming together to discuss and agree a plan for meetings in 2014/15.

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Prepared By : Jo Vitta, Business Manager NHS South Cheshire CCG Governing Body – 27-03-14 – FINAL Two Year Operational Plan 2014-16

REPORT




NHS South Cheshire CCG Two Year Operational Plan (2014-16) 27th March 1400-1715 7.6.2

PURPOSE OF REPORT The purpose of this report is to provide the Governing Body with a copy of the final Two Year Operational Plan (2014-16). The Plan has been drafted based on the Everyone Counts: Planning for Patients 2014/15 to 2018/19. The final Operational Plan will be submitted to NHS England on 4th April 2014.

AUTHOR Jo Vitta Business Manager EXECUTIVE LEAD Fiona Field Director of Governance & Partnerships

GOALS 2013-14




VISION


RECOMMENDATIONS

The SC CCG Governing Body are asked to:

1) To approve the final Two Year Operational Plan for submission to NHS England on the 4th April 2014.






Yes Yes

No

Yes

No

No

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REPORT TITLE

NHS South Cheshire CCG Two Year Operational Plan (2014-16)

1.0 Introduction

1.1 ‘Everyone Counts: Planning for Patients 2014/15 to 2018/19 sets out a bold framework within which commissioners will need to work with providers and partners in local government to develop strong, robust and ambitious five year plans to secure the continuity of sustainable high quality care for all.

2.0 Actions taken by the CCG in relation to the Operational Plan

2.1 A first draft was presented to Governing Body on the 6th February 2014 for comments which were subsequent followed up and action taken. Following this the draft plan was submitted to NHS England on 14th February 2014.

2.2 Following the production of a draft operational plan, the CCG held a successful

engagement event to share and engage with, informed members of the public, third sector organisations, provider trusts, partners and stakeholders. The event report can be viewed on the CCG website via the following link http://www.southcheshireccg.nhs.uk/news_items/6641-sharing-our-draft-operational-plans

2.3 Our draft Operational plan has also been shared with partners across the health and social

care landscape, including Cheshire East Council and the Health and Wellbeing Board. 2.4 Based on positive feedback on the draft Operational Plan from the NHS England Area

Team, an updated version is now presented in preparation for final submission to NHS England on 4th April 2014.

2.5 It is the intention of the CCG to now produce a public facing version of this document in

collaboration with members of the public. We will also be producing a specific easy read version, suitable for members of our communities who have learning disabilities and/or low literacy levels.

3.0 Recommendation

3.1 Governing Body is asked to:

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http://www.southcheshireccg.nhs.uk/news_items/6641-sharing-our-draft-operational-plans


• Note the updated version; and • Approve for final submission to NHS England.

113 of 371




NHS South Cheshire CCG Two Year Operational Plan (2014-16) 27th March 1400-1715 7.6.2

PURPOSE OF REPORT The purpose of this report is to provide the Governing Body with a copy of the final Two Year Operational Plan (2014-16). The Plan has been drafted based on the Everyone Counts: Planning for Patients 2014/15 to 2018/19. The final Operational Plan will be submitted to NHS England on 4th April 2014.

AUTHOR Jo Vitta Business Manager EXECUTIVE LEAD Fiona Field Director of Governance & Partnerships

GOALS 2013-14




VISION


RECOMMENDATIONS

The SC CCG Governing Body are asked to:

1) To approve the final Two Year Operational Plan for submission to NHS England on the 4th April 2014.






Yes Yes

No

Yes

No

No

114 of 371


REPORT TITLE

NHS South Cheshire CCG Two Year Operational Plan (2014-16)

1.0 Introduction

1.1 ‘Everyone Counts: Planning for Patients 2014/15 to 2018/19 sets out a bold framework within which commissioners will need to work with providers and partners in local government to develop strong, robust and ambitious five year plans to secure the continuity of sustainable high quality care for all.

2.0 Actions taken by the CCG in relation to the Operational Plan

2.1 A first draft was presented to Governing Body on the 6th February 2014 for comments which were subsequent followed up and action taken. Following this the draft plan was submitted to NHS England on 14th February 2014.

2.2 Following the production of a draft operational plan, the CCG held a successful

engagement event to share and engage with, informed members of the public, third sector organisations, provider trusts, partners and stakeholders. The event report can be viewed on the CCG website via the following link http://www.southcheshireccg.nhs.uk/news_items/6641-sharing-our-draft-operational-plans

2.3 Our draft Operational plan has also been shared with partners across the health and social

care landscape, including Cheshire East Council and the Health and Wellbeing Board. 2.4 Based on positive feedback on the draft Operational Plan from the NHS England Area

Team, an updated version is now presented in preparation for final submission to NHS England on 4th April 2014.

2.5 It is the intention of the CCG to now produce a public facing version of this document in

collaboration with members of the public. We will also be producing a specific easy read version, suitable for members of our communities who have learning disabilities and/or low literacy levels.

3.0 Recommendation

3.1 Governing Body is asked to:

• Note the updated version; and • Approve for final submission to NHS England.

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http://www.southcheshireccg.nhs.uk/news_items/6641-sharing-our-draft-operational-plans

2 Year Operational Plan 2014 - 2016

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2

CCG Information Reader Box Document Purpose For information CCG Website Link www.southcheshireccg.nhs.uk

Title NHS South Cheshire Clinical Commissioning Group

Year Operational Plan 2014-16 Author NHS South Cheshire Clinical Commissioning Group Publication Date April 2014 Target Audience NHS North of England, Local Area Team, CCG Shared Management

Team, NHS Trust Chief Executives, Directors of Nursing, Local Authority Chief Executives, Councillors, NHS Trust Board Chairs, Directors of Commissioning, PPG Chairs, CCG Membership Council, GPs, Healthwatch

Circulation List NHS North of England, Local Area Team, CCG Shared Management Team, NHS Trust Chief Executives, Directors of Nursing, Local Authority Chief Executives, Councillors, NHS Trust Board Chairs, Directors of Commissioning, PPG Chairs, CCG Membership Council, GPs, Healthwatch

Description The 2 Year Operational Plan of NHS South Cheshire Clinical Commissioning Group outlines its Strategic objectives and commissioning intentions for the next 2 years and the approach to improving the health outcomes and quality of care for its population.

Action Required N/A Timing N/A Contact Details NHS South Cheshire Clinical Commissioning Group

Bevan House Barony Court Nantwich Cheshire CW5 5QU T: 01270 275283 F: 01270 618392 Email: [email protected]

For recipients use

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http://www.southcheshireccg.nhs.uk/

mailto:[email protected]

3

Contents Section

Page

Number Foreword

4

1. Introduction

10

2. Who Are We?

13

3. Our Vision and Strategic Objectives

15

4. Central Cheshire Connecting Care – Our 5 Year Strategy (A modern model of integrated care)

17 - 22

5. Overview of Health Needs and Health Inequalities in South Cheshire

23 - 25

6. Delivering Improved Outcomes (Domains and ambitions) 28-65

6.1. Strategic Objectives: Domains and Ambitions 28 – 60 6.2. Strategic Objectives: Improving Health & Reducing Health

Inequalities 61

6.3. Strategic Objectives: Parity of Esteem (Physical and Mental Wellbeing

66

7. Our ‘Enablers’ to Transformation

71-85

7.1. Making a Difference – Engagement, Involvement and Communication

71

7.2. Wider Primary Care, Provided at Scale 77 7.3. Quality Premium 82 7.4. A Modern Model of Integrated Care 7.5. Access to highest quality urgent and emergency care 83 7.6. A Step Change in the productivity in elective care 84 7.7. Specialised services concentrated in centres of excellence 85

8. A Focus on the Essentials

85 - 110

8.1. Access 85 8.2. Quality, Safeguarding and Patient Safety 87 8.3. Innovation & Research 94 8.4. Information and Technology 95 8.5. Medicines Management 100 8.6. Procurement of Healthcare 102 8.7. Delivering Value 103

10. Key Trajectories

111

APPENDICIES • Glossary of Terms

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4

Foreword It is with great pleasure that I present the operational plan for NHS South Cheshire CCG. No plan is perfect and we do not claim that this one will be different! However, we do believe we have made important changes to how we approach our role as commissioners. I hope that readers find this plan to be “workmanlike”, to be a sensible analysis of what needs to change in our health service and where priorities should lie. I sincerely hope that it is clear that this document draws on a passionate drive to understand and improve our health services whilst honestly acknowledging the difficulties within it and the difficulties that lie in changing it. No plan is immune to change, nor should it be. However, we believe that the main pillars of this plan are those that our public and our partners will recognise and would wish to maintain and we look forward to working to improve the plan with them. Lastly, no plan is ever complete. On one level this plan makes no attempt to be complete. To pretend to have every answer in the face the financial challenges we have and the nature and extent of the changes needed to overcome this would be dishonest. We need to acknowledge where there are difficulties, and work with people using health services, and our partners, to overcome these problems. More fundamentally it may feel incomplete because part of the plan is to hand more of the responsibility for design and redesign of health services to those that work day in, day out, in the frontline services and those who day in, day out use those services. This way of working is outlined in the plan, inherent is outcome based commissioning and the concepts of accountable care systems and explicit in our desire to introduce quality improvement methodologies as core, day-to-day roles for all workers. But this way of working means that details of every change that will be made is not in the plan, as it is not yet decided and will not be until the teams on the ground have been formed and start their work. This can feel uncomfortable to those used to commissioning in a different way. Our role becomes one of systems manager, specifying outcomes with our population, ensuring that the environment of payment, incentive and contracts are aligned and then facilitating, encouraging and challenging. The challenge No informed person would doubt the challenge faced by both our health and social care systems. Our population lives with increasingly complex health needs, coupled with continual advancement of care options, means that each year more and more can be done for more people and that more money is needed. However, more and more money is not available and continual improvements can only be funded largely from being more efficient. Build Services around Patients/the Person Such efficiency savings are possible by building services around patients and their most significant needs. Services have grown up divided into health and social care, into physical or mental health, divided by the organisation that delivers them and restricted in scope by referral criteria, specifications or the requirements laid down central funding streams. Good people, working hard in such systems often fail to meet the needs of those they are trying to help. The patient, with their needs unmet tries again, apparently driving up demand. Cutting out this ‘failure demand’ is possible, and doing so provides better services for less money.

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Quality and Systems Improvement Methodologies Quality improvement methodologies are well-established, from the work of Dr W Edwards Deming to the contemporary work of Professor Don Berwick at the National Institute for Health Improvement in the USA, to more local examples like the work undertaken at Royal Bolton Acute Trust under the leadership of David Fillingham. This body of work, applied carefully to healthcare systems, improves care and improves efficiency when it is in the hands of clinicians and managers working on the front line. Our ambition is to implement it widely throughout our care systems However, our fragmented system with different organisations having different methods of payment, competing interests, different regulators and commissioners, lends itself poorly to applying these ways of working across organisations and the boundaries of care where much of the demand waste is generated. Our Solution Our plans essentially attempt to carve out a space, within our complex health and social care systems where services can be rebuilt with patients’ needs at their centre and within which improvement methodology can be consistently applied to improve the quality and efficiency of what is delivered. In order to do this we wish to contract multiple organisations together to deliver a common set of patient outcomes with payment based on capitation. The work mirrors strongly the Programme budgeting approach advocated by the right care movement and Professor Muir Grey. Accountable Care Systems and Accountable Care Teams - Commissioned for patient outcomes We are calling each, ‘carved out space’ an ‘Accountable Care System’. Each containing ‘accountable care teams’, responsible for delivering care on the ground to a defined population, but also the continuous improvement of the systems of care within which they work. To oversee the improvement of care systems, professionals are brought together from across health and social care and different care organisations on ‘Care Improvement Panels’. Such panels would, we propose, have strong patient representation and we would hope, local councillors representing their constituents. All members would be trained together in quality improvement methodologies. Via this mechanism the care teams become accountable to the users as Patient Accountable Care Teams. We hope to restore professional pride in the delivery of the highest quality. We know that mastery, self-determination and the ability to deliver the best are strong motivators for health and social care workers, both clinicians and managers. If the clinicians role is to change to include a responsibility to improve the systems of care, then managers roles will need to change to one of facilitation for clinicians in their new role, their focus moving from the achievement of targets to understanding what patients need and helping clinicians deliver it. Barbara Starfield and Principles of Efficient Healthcare Barbara Starfield identified that health systems that contained strong primary care teams delivered: continuity of care, person and not disease centred care, a solution for all common problems and the coordination of care if more complex or specialist care was required, and so therefore provided higher quality and more cost-effective healthcare. To build on this work, we wish to build our main ‘accountable care teams’ around primary care with a community focus and an explicit recognition of public health. We must work closely with

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our local authority colleagues with whom we would wish to have significant joint commissioning of such care systems. New Models of Care We need to develop new models of care, moving away from the medical or nursing model towards more person centred integrated models of care that recognise the importance of patient goals, care, carers and self-care, shared decision-making, health coaching, motivational support and move towards true partnerships with those who use services. We must recognise that sometimes, quite often, our population’s plea is “help me” not “fix me” but that we work in a system primarily designed to fix, where help can be an afterthought or missing altogether. Our new models must include a wider perspective, to include social elements and an understanding of the wider determinants of health. By delivering these efficiencies we safeguard the quality and availability of the highest tech, most specialist services that we all wish to see available to us. When the plea is “fix me”, we want that fix to be as effective, complete and timely as is possible. In other regards we wish to see more flexible specialist care, better able to support the work of the ‘accountable care teams’ and again more focused on patient goals. The principle of accountable care and service improvement methodologies can also be applied here and should be! I am very aware that not every section of the plan that is presented contains every aspect of these new ways of working and that not everything needed to deliver this new way is in this 2 year operational plan but will need to be developed in future plans. I hope that our focus on improving outcomes and on establishing changes that support a major shift in care delivery for the better can already be seen.

Dr Andrew Wilson GP, Ashfields Primary Care Centre GP Chair NHS South Cheshire CCG

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NHS South Cheshire Clinical Commissioning Group is a membership organisation comprising the following 18 practices: SMASH Locality (Sandbach, Middlewich, Alsager, Scholar Green, Haslington):

• Ashfields Primary Care Centre, Sandbach • The Acorns Surgery, Middlewich • Oaklands Medical Centre, Middlewich • Cedars Medical Centre, Alsager • Merepark Medical Centre, Alsager • Greenmoss Medical Centre, Scholar Green • Haslington Surgery, Haslington

Nantwich & Rural Locality:

• Audlem Medical Practice, Audlem • Kiltearn Medical Centre, Nantwich • Nantwich Health Centre, Nantwich • The Tudor Surgery, Nantwich • Wrenbury Medical Centre, Wrenbury

Crewe Locality:

• Delamere Practice, Crewe • Earnswood Medical Centre • Grosvenor Medical Centre, Crewe • Hungerford Medical Centre, Crewe • Millcroft Medical Centre, Crewe • Rope Green Medical Centre, Crewe

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Strategic Objectives 5 outcome domains

• Preventing people from dying prematurely • Enhancing quality of life for people with long-term conditions

• Helping people to recover from episodes of ill health or following injury • Ensuring that people have a positive experience of care

• Treating and caring for people in a safe environment and protecting them from avoidable harm + 7 outcome measures

+ Improving health, reducing health inequalities, parity of esteem

Delivering Transformational Service Models

Value

Commissioning for Transformation (with Clinical Leadership)

Vision: To maximise health and wellbeing and minimise health inequalities, informed by local voices and delivered in partnership

• New approach to ensuring that citizens are fully included in all aspects of service design and that patients are fully empowered in their own care

• Wider primary care, provided at scale • A modern model of integrated care • Access to the highest quality urgent and emergency care • A step-change in the productivity of elective care • Specialised services concentrated in centres of excellence

Access Quality Innovation

• Convenient for everyone

• NHS Constitution

• Value for money • Effectiveness • Efficiency • Procurement

• Supporting our staff to innovate

• Research

• Francis/Berwick • Patient Safety • Compassion in Practice • Staff Satisfaction • Seven Day working • Safeguarding

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1. Introduction The publication of The NHS belongs to the people – a call to action1 in July 2013 began a national discussion about the major transformational change that is required to ensure that the NHS responds to increasing pressures such as an ageing population, increasing prevalence of long term conditions, and rising healthcare costs. A Call to Action outlines the ‘case for change’ across the system and called on the public to get involved in shaping the future of their NHS service. Given the scale of the challenges we are facing within the NHS, we are moving away from incremental one year planning and instead developing bold and ambitious plans which cover the next five years, with the first two years mapped out in the form of this detailed operating plan. As a CCG we will work with local NHS Trusts and local government organisations to identify and communicate the larger footprint strategy within which they will sit. This will inform the five year strategic plan. As CCG sizes and local configurations differ, a larger unit of planning is required for the development of consistent and integrated long-term strategic plans. Our strategic planning will take a PAN-Cheshire approach, aligning to our main priorities regarding the integration of health and social care. We see this as crucial to enabling us to take a longer term, strategic perspective of the direction of travel across the health and social care landscape. We must develop and implement bold and transformative long-term strategies and plans to enable us to be financially sustainable and uphold safety and quality of patient care. Our two year operational plan is intended to inform local people, partners and staff about the healthcare services that will be commissioned during 2014-16 on behalf of the population (173,000) covered by NHS South Cheshire Clinical Commissioning Group (CCG). Underpinning the large amount of work represented in this plan is our commitment to ensure that our population receives high quality healthcare. Whilst each of the areas highlighted in this plan are important we always need to decide on the areas that we are going to focus on as a priority. We endeavour to do this in a transparent manner, involving patients, carers, local people, clinicians, voluntary organisations, local authorities and other interested parties. It is important that we are seen as a responsive organisation that listens and takes into account a wide range of perspectives but at the same time keeps its core principles central to commissioning decisions, valuing:

• self-care; • carers; • quality of personal care; • The family, community, voluntary and informal care structures.

We are committed to help improve the general health of the population, reduce health inequalities, ensure equitable access to healthcare and to work with our partners on the Health and Wellbeing Board and providers of care so that patients are treated with dignity and respect at all times. At the heart of our work as a clinically led commissioning organisation is the focus on improving

1 The NHS belongs to the people: a Call to action, July 2013, NHS England

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outcomes for our patients. We have therefore focussed our key actions on each of the 5 Domains of the NHS Outcomes Framework. Indeed these domains have now become our strategic objectives for 2014-16. We have identified local levels of ambition, based on evidence of local patient and public benefit, against a common set of indicators that place our duty to tackle health inequalities front and centre stage. This will ensure that we can clearly articulate the improvements we are aiming to deliver for patients across the 5 key areas:

Poorly Coordinated Care It surprises many people to discover that a very small portion of the UK population — approximately 5 per cent — accounts for nearly half of total spending on health care, while 20 per cent accounts for four-fifths of total spending. This relatively small slice of the population incurs such high costs because most of these individuals have complex medical problems. The problems include common but difficult-to-manage chronic diseases like diabetes and heart failure, as well as mental and behavioural health issues. Chronically ill people take more prescription drugs, undergo more tests and procedures, and are hospitalised more often than people in good health. But the costs for these patients increase dramatically when the care they receive is poorly coordinated i.e. when patients are referred by their GP to a specialist; move in and out of the hospital; and transition from the hospital to home care or a long-term care facility, often with poor oversight or communication between providers. Patients may undergo the same lab tests multiple times, they may get the wrong combination of medications, and serious conditions may get misdiagnosed. This not only leads to unnecessarily high costs but it also means poor care for the patients who most need help. Avoidable Hospital Readmissions One in five elderly patients discharged from hospitals in the UK ends up being readmitted within 30 days. Many of these readmissions could be prevented if hospitals, doctors, and community health programme worked together to assist patients who are returning home, moving on to a nursing home or rehabilitation facility. Discharged patients need clear instructions on how to care for themselves at home, as well as help in scheduling and keeping follow-up appointments, sticking to a prescribed medication plan, and making necessary lifestyle changes. The failure to provide genuine integrated care leaves most patients who suffer from long-term conditions with a patient pathway with gaps and frequent duplication of care. The experience for the

•Reducing the number of years of life lost from treatable conditions (e.g. including cancer, stroke, heart disease, respiratory disease and liver disease).

1 •Improving health related quality of life for people with

one or more long-term condition. 2 •Reducing the amount of time people spend avoidably

in hospital through better and more integrated care in the community, outside of hospital. 3 •Reducing the proportion of people reporting a very

poor experience of care. 4 •Making significant progress towards eliminating

avoidable deaths in our hospitals. 5

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http://www.chrt.org/publications/price-of-care/issue-brief-2010-08-health-care-cost-drivers/

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patient is, in some cases, so disjointed that the term ‘pathway’ cannot be applied in any real sense. It is the gaps in most patient pathways that lead to many of the health exacerbations that in turn lead to hospital beds that are filled with unnecessary emergencies. Therefore, one of the unplanned and unintended outcomes from this episodic approach to the patient experience is many more and longer stays in hospital. If we are to construct a patient centred future for the NHS, it will have to deliver genuinely integrated care, based around both the needs of patient groups (for example the frail elderly or children/adults with complex disabilities) and also based around the personal needs of individual patients within those groups. If we are to construct a sustainable future for the NHS, it will have to deliver genuinely integrated care, which provides powerful incentives to keep patients at home and out of hospital. To that end, the entire Health and Social Care Bill was amended to put a duty on all NHS bodies to promote integrated care. However, there are only a few examples of this policy being put into practice. If we look at the delivery of most care to most NHS patients, in most parts of the country, for most conditions, it remains traditional episodic and fragmented care. Outcome-based contracts for integrated care with an Accountable Lead Provider This is a different process from the traditional input/activity based contract that has been at the core of NHS commissioning. To get to a health care system that’s affordable yet provides high quality, we need to tackle the issues that have made things so expensive in the first place. It is the inefficiencies within the system as a whole that drive up fragmentation, and subsequently, cost. Accountable care systems - A new language is starting to emerge around outcomes and about population health in its entirety. This is the language describing both delivering and paying for patient care that is starting to take hold slowly. Typically, an accountable care system is a partnership between commissioners and a group of providers—primary care clinicians, community services, hospitals, specialists, rehabilitation centres, mental health services, social care and long-term care facilities - that agree to share responsibility, and sometimes the financial risk, for delivering quality health care to a population of patients. The accountable care system receives a payment through an outcomes based contract that covers the cost of providing all the care needed by these patients. In addition, the ‘system’ providers get to share in the savings if they meet cost and quality targets for their patients. On the flip side, providers that participate also agree to accept penalties if they go over budget or fail to deliver a quality service. We know for certain that more spending does not translate into better care or a better functioning health care system! So what does all this mean locally? Some of our really key programmes of work (community health services, Extended Practice Teams, urgent care review) are moving in a direction that starts to develop this system approach. The example below demonstrates the point:

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To support this direction of travel and respond to the very real cultural challenges, it is important to develop system improvement education and training across all staff working in health and social care.

2. Who Are We? We are NHS South Cheshire Clinical Commissioning Group and we exist to improve the health and healthcare of the local population. Our aim is to use the local knowledge of our GPs and their Practice teams to develop the way that health services are delivered and help our patients to make full use of the services that are available.

We are a membership organisation comprised of 18 member practices (listed on page 7). The pracitces cover a geographical area of Cheshire stretching from Nantwich in the south to Middlewich in the north. Crewe is the largest manufacturing town and much of the surrounding area is made up of smaller, rural market towns. The total registered population is 173,000,

The South Cheshire area falls entirely within the boundary of Cheshire East Council.

Close relationships exist between ourselves and NHS Vale Royal CCG, with whom we share a management team. We also working closely with NHS Eastern Cheshire CCG which lies to the east of our patch and with whom we share community health services and the Local Authority.

The acute general hospital, our main provider, is Mid Cheshire Hospital Foundation Trust (MCHFT), which is situated just outside Crewe. Mental health services are provided by Cheshire and Wirral Partnership Trust and East Cheshire Community Business Unit, which forms part of East Cheshire NHS Trust, provides community health services, such as district nursing, health visiting and therapy services

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We have responsibility for designing and commissioning local health services and will do this by commissioning or buying health and care services including:

• Elective hospital care • Rehabilitation care • Urgent and emergency care • Most community health services • Mental health and learning disability services

We work with patients and healthcare professionals and in partnership with local communities and local authorities. On our Governing Body, in addition to GPs, we have a registered nurse and a doctor who is a secondary care specialist. We are responsible for arranging emergency and urgent care services within our boundaries, and for commissioning services for any unregistered patients who live in our area. All GP practices have to belong to a Clinical Commissioning Group. Commissioning Support We receive Commissioning Support Services from Cheshire and Merseyside CSU. (CMCSU) Commissioning Support Units were set up as part of the recent Health and Social Care reforms to support CCGs and NHS England in undertaking their commissioning responsibilities and delivering the best possible outcomes for Patients. We work with the CSU as a key partner. There is a Service Level Agreement established between the CCGs and the CSU to manage the quality of the services that the CSU provides. The services that are provided to the CCG are:

• Technology Support (Information and Communication Technology) • Business Intelligence and Data Management

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• Process Centre and Governance Support (Management of Incidents, Complaints, Individual Funding Requests, Freedom of Information, Information Governance, Compliance and Assurance Claims)

• Communications Support including graphic and digital design • Human Resources Support • Organisational Design Support • Procurement advice and guidance • Continuing Healthcare, Complex Care and Clinical Quality

This support is developed through a locality model so that our services can be understood and accessed locally. Each of these functions has a locality lead. This partnership approach has been enhanced during 2013/14 by us and CSU sharing office space at Bevan House in Nantwich.

3. Our Vision and Strategic Objectives Our vision is:

To maximise health and wellbeing and minimise health inequalities, informed by local voices and delivered in partnership

We believe that our overarching priority is to improve quality of care and health outcomes for patients. Therefore we have set the five domains of the NHS Outcomes Framework as our Strategic Objectives. All our programmes of work and projects must align to each of the 5 Domains.

Vision CCG Strategic

Objectives 5 Domains

Local Context (JSNA)

Priorities for action Outcomes

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OUR VISION

To maximise health and wellbeing and minimise health inequalities, informed by local voices

and delivered in partnership OUR PRINCIPLES

Working to provide care ‘upstream’ (seeking prevention and avoiding crisis)

Focus care on patient goals and where appropriate, carer and family goals Building services around the patients’ needs

Championing quality in all its forms across all we do

OUR WAYS OF WORKING

Develop ‘Accountable Care Systems’ Locally • Put the patient at the centre of all commissioned services • Educate providers in accountable care system • Align workforces across health and social care • Explore new contracting options • Manage within a defined budget • Co-design with the public • Active support for self care, self management

Enhance local professional networks Co-produce metrics with public, patients and providers Shape commissioning of services with partners

OUR STRATEGIC OBJECTIVES Domain 1 Preventing people from dying prematurely

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

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

Domain 4 Ensuring that people have a positive experience of care

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

avoidable harm ORGANISATION WIDE OBJECTIVES

Good Governance - We will be a well-governed and adaptable organisation - with high standards of assurance, responsive to members and stakeholders in transforming services to meet future needs. Value for money - We will ensure resources are directed to maximise benefit to make the best use of public money. Engagement - We will embed meaningful and sustainable patient and member practice engagement into CCG decision making processes. Better communication and sharing of information - We will develop strong partnership working with our local authority partners to achieve shared outcomes and will also develop communication material in an accessible format

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4. Central Cheshire Connecting Care - Our 5 Year Strategy (A Modern Model of Integrated Care)

Integration and Pioneer Status in Cheshire It is widely accepted that there is a need to commission integrated care or, as patients and their carers would more likely call it, “joined up care”. The current model of care for patients is often a fragmented and disjointed one. It is driven by the fact that contracts, and an increasing drive towards specialism, means that organisational priorities can take preference over the needs of the patient. At the same time, we have a health and social care system that is unaffordable in the current climate. The ageing population means that demand for healthcare services will continue to increase. The current ‘episodic’ nature of care provision does not really meet the patients’ needs. Whilst individually patients and service users will often praise the service that they received at a specific time, there is an increasing theme “being heard” around improving the overall experience. Nationally the need to improve the integration of services has been recognised and there is a need for radical transformational change in the health and social care system, because the money that is available to meet the increasing health and social care needs of our population is not sustainable. Therefore we have to change what we are doing quickly before we can no longer afford healthcare for the population of South Cheshire. However this will not be easy and moving to a more coordinated system for patients whilst delivering control in the current system will be very challenging. In an attempt to try and learn more about this very real challenge nationally and assist in the delivery of transformational changes, implementation of new integrated care delivery models and new contracting models, it was agreed that some geographic areas should be supported to lead the way and go faster and for other areas to learn from them. Hence the national ‘Pioneers for Integrated Care’ programme was launched. The Government, NHS England, Monitor and the Local Government Association along with others, launched this initiative and asked for local areas to apply to become a ‘Pioneer Site’. At a local level this was something that we were really interested in. A submission was therefore made that covered both the Health & Well Being Board areas (one Health & Well Being Board for each Local Authority in Cheshire) and the 4 Cheshire CCGs (NHS South Cheshire, NHS Vale Royal, NHS Western Cheshire & NHS Eastern Cheshire). The application that was submitted was about recognising the 3 communities that exist in Cheshire and that the Pioneer Proposal would provide an overarching umbrella across these 3 communities. The local communities are important as they reflect patient flow and primary care provision. The strong history of partnership working in Cheshire was a key strength contributing to our success with our Cheshire wide partners in becoming one of the fourteen national ‘Integration Pioneer’ sites. Whilst the Pioneer proposal responds to the local challenges, it really focuses on the key themes being heard from patients about their overall experience:

• Being asked the same questions over and over again • Spending time ‘hanging’ between bits of the service

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• Having lots of people involved in their health care but not being really sure who is responsible for what and who is overall charge of their care

• Not really knowing what is going on • ‘Falling through the gaps’

Across the South Cheshire and Vale Royal footprint we have established a Partnership Board for our Connecting Care Programme. This Board has representation from commissioners (both CCGs, both Local Authorities & NHS England), and our main providers (Mid Cheshire Hospital Foundation Trust, East Cheshire Trust for community services, Cheshire and Wirral Partnership NHS Foundation Trust, North West Ambulance Service and Primary Care). It has the Chief Executive, Medical Director and/or lead Executive Director from all of these organisations sitting on it. The commitment to the Connecting Care Board is strong and the recent announcement that we are one of the Pioneer sites has helped to bring a real focus and energy to its work.

We are committed to delivering the National Voices narrative below: For the individual: ‘I can plan care with people who work together to understand me and my carer/s, allow me control and bring together services to achieve the outcomes important to me’.

(National Voices & Making it Real) Ours plans are ambitious and we will lead a programme of work to ensure that people within our local communities are empowered and supported to take responsibility for their own health and wellbeing. They will place less demand on more costly public services through the implementation of ground-breaking models of care and support based on: • integrated communities • integrated case management • integrated commissioning and • Integrated enablers to support these new ways of working.

Integration (Connecting Care) and the Better Care Fund

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We will only make good progress and improve ‘joined up care’ if we invest in services that help reduce the demand on secondary care. These services need to be community based and not just limited to health. Primary care, social care and community services are all needed to deliver care in a more coordinated manner if we are to tackle the rising secondary care demand. To support health and social care organisations to work more closely in local areas and to facilitate shared funding models, for 2014/15 a national ‘Better Care Fund’ (BCF) has been created. The fund has been created through the movement of existing grants and resources and it mandates the pooling of funds across health and social care that will fully come into effect in 2015/16. We will utilise this pooled fund to create a significant opportunity to transform the way that services are commissioning and delivered jointly across health and social care to support improved outcomes for our local populations. BCF truly supports the local impetus of our Connecting Care Programme. The 2 Health and Wellbeing Boards within Cheshire are leading this transformational change through a large-scale change programme with support from the national pioneer team. The Cheshire wide pioneer footprint encompasses a range of shared commitments and the following 3 core components based on local populations: • Central Cheshire (South Cheshire and Vale Royal) ‘Connecting Care’ programme • East Cheshire ‘Caring Together’ programme • West Cheshire ‘The West Cheshire Way’/’Altogether Better’.

Our Connecting Care Vision is “to ensure quality, personal, seamless support in a timely, efficient way to improve health and wellbeing”. To secure this vision, the Cheshire partners have given organisational and personal commitment to transform the health and social care system by: • Working much more closely together and in smarter ways to provide reliably, and without error,

all the care that will help people and ONLY the care that will help

o Putting the individual at the centre of all care – ‘no decision about me, without me’, improving their experience of care

o Assure quality by employing high quality, well trained staff with strong leadership and development skills

o Focusing on the multiple determinants of both physical and mental ill-health and creating innovative solutions across partners

o Creating more opportunities for and embedding cross organisational working that reduces duplication and achieves the best use of available resources

o Adding value to the lives of individuals and their families/carers and decommissioning care that does not add value

o Exploiting the use of new technologies to support independence, self-care and information sharing across partner organisations

• Building and strengthening community based services and support

o More care will be organised and delivered outside of traditional hospital settings, in local communities with closer collaboration across teams

o People will access services differently: with GP practices/Extended Practice Teams teams and community services

delivering care and support ‘closer to home’ with a smaller, more flexible community facing hospital delivering emergency and

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specialist care and regional specialist hospitals continuing to deliver specialist care, some of which

will be in the community setting o Traditional 5 day per week community services will be extended to offer support when

needed, 7 days per week o Care and support will be personalised, timely, responsive and seamless

• Developing our workforce and community assets to deliver new ways of working

o Empowering individuals at a local level to lead change and problem solve with full support from their colleagues

o Supporting people, their families/carers to take responsibility for their own wellbeing and make choices about their care based on their personal goals

o Offering education and training programmes tailored locally to support the implementation of new ways of working, self-care, local leadership, change management and quality improvement approaches. We are exploring a local academy approach to this programme.

o The most effective use is made of resources across health and social care, involving partnership working, joint commissioning, sharing of information, new contracting and funding approaches, exploiting new technologies and avoiding waste and unnecessary duplication. Again continuous quality improvement approaches are critical to this success.

Within the Connecting Care Board we have recognised that in order to deliver the transformational change, at pace, a more collaborative commissioning approach is required. Our discussions have resulted in an agreement to establish an ‘innovation fund’ (created through the tariff deflator), as an additional resource to and help support the changes required across secondary care, primary care, community and mental health provision and social care. This is a step change to the way we have worked previously and it is anticipated that through the Connecting Care Board, collaborative commissioning and the ‘innovation fund’, our providers of health and social care are supported to bring about the required transformational change and ultimate deliver the Connecting Care Vision.

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A Strategy for Transformation A strategy of 7 key integration health and social care outcomes have been established to ensure that all work stream activity and work plans are outcomes focused and driven. A large number of composite work plans are being delivered, or are in development, to achieve our integration outcomes and these are described within our programmes of work later in this document. The table below provides a summary of the Connecting Care Board priorities aligned to the ‘7 Integration Health and Social Care outcomes’ framework.

National Health And Social Care Outcomes

Framework

Local Connecting Care Programme Board Priorities

Communities that promote and support healthier living

Individuals and communities are able, motivated to and supported to look after and improve their health and wellbeing, resulting in more people being in good health or their best possible health for longer with reduced health inequalities.

Personalised care that supports self-management and independence and enhances quality of life

People with physical or mental Long Term Conditions, those with complex needs and the elderly frail are able to live as safely and independently as possible in the community. They will plan care with people who work together to achieve the outcomes important to them. Care will have a focus on prevention, self-management and independence and the individual will have control over their care and support.

Individuals will have positive experiences and outcomes

People have positive experiences of health, social care and support services, which help to maintain and improve their own health and wellbeing

Carers are supported People who provide unpaid care for others are supported, are consulted in decisions about the person they care for and they are able to maintain their own health and well-being and achieve quality of life

Services are safe People using health, social care and support services feel safe and secure, are safe-guarded from harm, have their dignity and human rights respected and are supported to plan ahead and have the freedom to manage risks the way that they wish

Empowered and engaged workforce and public

People who work in health, social care and community support/voluntary sector support are positive about their role, are supported to improve the care and support they provide and are empowered at a local level to lead change and develop new ways of working through continuous quality improvement approaches. Citizens are engaged in the shaping and development of health and care services and supported to make positive choices about their own health and wellbeing.

Effective resource use The most effective use is made of resources across health and social care, involving partnership working, joint commissioning, sharing of information, new contracting and funding approaches, exploiting new technologies and avoiding waste and unnecessary duplication.

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Joint Commissioning and Partnership Working We have been working with our partners from Eastern Cheshire CCG (ECCCG) and Cheshire East Council (CEC) to establish shared priorities for joint work over the next 2 years. These shared priorities support the Connecting Care transformational strategy and some will also form part of the Better Care Funding arrangements. The priorities cover children, adults and older people age groups with each commissioner organisation having taken part in a prioritisation process. They are:

• Early Help for Children – integration of children’s workforces (health, education, social care and VCFS)

• Domestic abuse • Community Services including Extended Practice Teams • Urgent Care/ Rapid Response/ Community Intervention/ Transitional/ Intermediate Care

Services as an alternative to hospital/ acute care • Community based stroke and rehabilitation services • Dementia - early detection, diagnosis and support services • CAHMS and transition to adult services • Primary mental health - early detection, diagnosis and support services • Supported self management of people with long term conditions including shared risk profiling

for early detection. Special Educational Needs (SEN) National changes through the Children and Families Bill 2013 are extending the support for young people up to the age of 25 with Special Educational Needs (SEN). These children and young people will have an education, health and care plan (EHC) that will support them outside of school age into further education and apprenticeships up to 25 years old. Parents and the young person will be more equal in the plan and potentially personal health budgets will be applicable in some cases. The CCG will need to work closely with Cheshire East Council to ensure a seamless transition into the new system. The changes to the commissioning of services has meant that some services that support children with SEN are now shared between the Public Health team within the council (school nursing) and special school support services – nursing and therapy services which is the CCGs responsibility. We are working closely with CEC through the Joint Commissioning Leadership Team to ensure joint commissioning of services is seamless and delivers targeted services with better health outcomes to children and young people with SEN. We are undertaking a review of all community services as commissioned through East Cheshire Trust (ECT) which currently includes the SEN support services through 2014-15.

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5. Overview of Health Needs and Health Inequalities in South Cheshire

Around 10.7% of our population across South Cheshire live in small areas (LSOAs) that are among the 20% most deprived areas in England. A further 15.6% live in the next most deprived fifth of areas in England. The map colours individual postcodes to illustrate geographical variations in deprivation. The areas of solid colour represent the towns, while areas with white spacing represent rural villages and rural communities. It shows that:

• Large parts of Crewe town are very deprived • Each of the four other main towns contain some deprived areas • All of the five main towns have a mix of very affluent areas as well as deprived areas • There is rural deprivation to the west and north of Nantwich, and from Sandbach to Alsager

The Annual Report of the Director of Public Health has highlighted the stark difference that living in deprivation makes to premature death, with a twofold difference in death rates between the most deprived and least deprived areas in South Cheshire. The Joint Strategic Needs Assessment shows that there are similar differences in the occurrence of many acute and chronic diseases, and also in many of the lifestyle factors that are known to cause disease in both children and adults. Within the area of the Crewe Local Area Partnership, there is a clear pattern of higher premature death rates among people experiencing higher levels of deprivation, whereas those who are less deprived have better health and a reduced risk of dying prematurely. The significantly worse health

Alsager

Sandbach

Nantwich

Crewe

Middlewich

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outcomes experienced by the people of Crewe adversely affect the average premature mortality rates for our population, and also for Cheshire East Council as a whole. The local variations are multi-factorial but are due in part to the health experience of people living in socioeconomically deprived areas. Local levels of socioeconomic deprivation affect early death rates in several possible ways. These include the health effects of material deprivation (e.g. through poorer housing, education and income), higher prevalence of harmful lifestyle behaviours (e.g. smoking and alcohol) and possibly reduced access to good quality healthcare. Directly Standardised Mortality Rates for All causes by deprivation quintile, Crewe LAP, aged under 75, Males & Females, 2009-11 provisional (using Mid2011 population estimates)

Where differences in health exist, are measured, deemed to be inappropriate, and can be reduced through the actions of GP practices or ourselves (either working alone or with partners), We can help to ensure that actions are targeted to all areas at a level that is appropriate to their needs. In so doing we will achieve maximum health gains within the available resources. Some of the areas that can be used for targeting initiatives in South Cheshire include:

• 25 electoral wards with an average population size of 6,800 • 24 middle level super output areas (MSOAs) with an average population size of 7,100 • 109 lower level super output areas (LSOAs) with an average population size of 1,600 • 18 general practices with an average population size of 9,500

Although many interventions will focus on populations defined by GP practices and/or the super output areas, we recognise the importance of ward level action and the role of elected Councillors as a force for change locally within the wards they represent. As already stated, the main towns across South Cheshire have communities that are affected by deprivation. Some areas of Crewe are in the 20% most deprived areas in England, and people’s lives

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are up to nine years shorter than in other parts of the town. The main causes of premature death in these areas are cancer, heart disease, stroke, respiratory and liver disease. Unhealthy lifestyles and harmful environments can lead to adverse health effects at each stage of people’s lives. Tobacco smoke is a major risk factor for poor health, and 25% of pregnant women in Crewe still smoke. In addition to the significant health hazards to babies and young children from being exposed to cigarette smoke, teenagers are at higher risk of becoming smokers if they live in a smoking household. In some areas of Crewe around a third of adults are smokers. These areas also have the highest rates of children admitted to hospital with respiratory problems. Most chronic respiratory disease in childhood is caused by repeated exposure to cigarette smoke, and we have over 1,120 children with chronic respiratory disease. Preventing respiratory ill-health in future generations of children is a key health need and one of our local priorities. General practices in South Cheshire provide care for over 40,000 patients with a chronic health condition, including 1,500 children. People with mental health problems have important but often hidden needs, and there are over 20,000 patients in South Cheshire with a history of depression, about forty percent higher than expected. There are high rates of excess mortality among adults with serious mental illness in Cheshire East. The risk of death in this group of people is over four times higher than in the general population. They need better detection and management of their risk factors by general practices working in partnership with local mental health services. Addressing mental illness is a key health need and one of our local priorities. Crewe has higher than average cancer death rates among both men and women, and in this town there are fewer than expected numbers of people who have survived cancer. This may relate to lung, upper gastrointestinal and colorectal cancers. The priority actions for us (in conjunction with Cheshire East Council and other partners) are to increase colorectal, breast and cervical screening, increase public awareness of cancer symptoms, encourage people to present early with symptoms to general practitioners, and strengthen specialist cancer referrals from general practices. Our registered population of 173,200 people is forecast to increase by 0.6% annually to 177,400 by 2015, and to 183,000 by 2020. The increase in the number of people over 75 in South Cheshire will be around fifty percent higher than is occurring nationally, increasing by 3.6% annually from 13,700 to 18,800 in 2020. Ageing populations have additional health and social care needs, and more people require support to remain independent and live at home. Some older people develop disabling sensory impairments including loss of hearing and loss of vision. Others may suffer from multiple chronic conditions. The number of people with dementia is increasing in South Cheshire, although more slowly than anticipated. In 2009/10, there were 925 people with dementia, which rose to 945 in 2010/11 and 984 in 2011/12. As fewer than 50% of patients with dementia are believed to be known to general practices, unrecognised dementia is becoming an important health need locally.

6. Delivering Improved Outcomes (and

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Ambitions) 6.1. Strategic Objectives: Domains and Ambitions

This Plan maps out how we will evolve and deliver the 5 year strategy over the first 2 years. It has been developed within the context of the NHS Outcomes Framework, the NHS Constitution and the Mandate set between the Department of Health and the NHS Commissioning Board. The overarching priority for us, as a CCG, is to improve the quality of care and health outcomes for patients. Key to delivering this is ensuring our plans are aligned to the five domains of the NHS Outcomes Framework, which is why we have adopted them as our main strategic objectives. The NHS Outcomes Framework 2014-16 sets out the outcomes and corresponding indicators that are used to hold us, as a commissioner, to account for improvements in health and wellbeing. The Framework describes the five main categories (domains) of better outcomes we aspire to deliver. To transform these five outcomes into measurable goals, we will also target action against the seven Ambitions defined by NHS England. Tackling health inequalities and being focused on advancing equality has also been a key component for us in developing its Commissioning Intentions for 2014-16. Each of the strategic objectives will address inequalities so that those most in need have the most to gain from the interventions we make. DOMAIN OUTCOME(s)

NHS ENGLAND (AMBITIONS)

•Prevent people from dying prematurely 1 •People with Long Term Conditions

(including mental illness) have the best possible quality of life 2

•Patients are able to recover quickly and successfully from episodes of ill-health and injury 3

•Patient have a positive experience of care 4

•Patient in our care are kept safe and protected from all avoidable harm 5

•Securing additional years of life for people with treatable mental and physical health conditions

i •Improving the health related quality

of life for people with long term conditions, including mental health conditions

ii •Reducing the amount of time people

spend avoidably in hospital through better and more integrated care in the community, outside of hospital

iii •Increasing the proportion of older

people living independently at home following discharge from hospital

iv •Increasing the number of people

having a positive experience of hospital care

v •Increasing the number of people with

mental and physical health conditions having a positive experience of care outside hospital, in general practice and in the community

vi •Making significant progress towards

eliminating avoidable deaths in our hospitals caused by problems in care

vii

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In developing our two year operational plan we have worked with our partners on the Health and Wellbeing Board, our provider organisations and the voluntary sector to consider the key challenges that together we need to address to make a real difference to the health and wellbeing of our communities over the coming years. Therefore during 2014-16 we aim to deliver a number of key Commissioning Intentions; all of which deliver key outcomes across the five CCG Strategic Objectives (NHS Outcome Domains) and key ambitions. Our Commissioning Intentions are aligned under three Strategic Programmes for NHS South Cheshire:

Starting Well Living Well Ageing Well These programmes also have to deliver core business around performance, contract management, risk management, quality improvement and assurance and financial probity. They also undertake partnership commissioning alongside other CCGs, local authorities and NHS England. This programme approach brings clarity to our work and projects and aligns with our Joint Health and Wellbeing Strategy. As members of the Health and Wellbeing Board with Cheshire East Council we have identified a set of joint priorities that we will address to make a real difference to the health and wellbeing of our community:

• Integration of teams (Extended Practice Teams) • Joint Carers Strategy • Joint equipment services • Prevention work with children and young people • Dementia Services • Integration of systems

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Strategic Objective 1:

Domain 1 Currently, England’s rates of premature death are worse than those in many other European countries for big killers like cancer, heart and liver disease. There are also significant inequalities between different communities and groups within England for both overall life expectancy as well as the quality of health people can expect to enjoy towards the end of their life (Source: NHS England). NHS South Cheshire CCG aims to prevent people from dying prematurely by promoting good health and discouraging decisions and behaviours that put health at risk. Where people do develop a condition, we aim to commission services that diagnose this early and manage it in the community so that it does not deteriorate. The main focuses on potential years of life lost, specifically around under 75’s mortality rate by:

• Reducing premature mortality from all major causes of death • Reducing premature deaths for severe mental illness • Reducing deaths in babies and young children • Reducing premature deaths in people with a learning disability (no CCG measure at

present) Our JSNA findings state: Any death under the age of 75 is considered to be a premature death. Each year in South Cheshire around 545 people die before their 75th birthday, and three quarters of these deaths are avoidable2. Around half of the deaths are occurring in the town of Crewe, where death rates for both men and women are significantly higher than in other parts of South Cheshire and are comparable to local authorities in the third highest decile for premature mortality in the country. Premature Mortality under 75, annual deaths and directly standardised rate/100,000 2009-11 Male deaths Male rate (CI) Female deaths Female rate (CI) Alsager 21 288 (220-368) 15 184 (134-247) Crewe 145 358 (326-392) 117 286 (258-317) Middlewich 20 277 (213-353) 19 260 (198-333) Nantwich 30 346 (279-423) 19 199 (149-258) Sandbach 31 276 (223-337) 23 188 (146-238) Rural areas of CCG 61 216 (185-249) 45 162 (136-192) South Cheshire CCG 308 300 (281-319) 238 225 (209-242) Source: Annual Report of the Director of Public Health 2012-2013 In the town of Crewe there is also a clear “North – South” divide, with higher death rates in the central and northern areas of the town. The highest rates of premature deaths are seen in the most deprived areas, and in some parts of Crewe female deaths are higher than among men. Focussing initiatives in Crewe would enable us to achieve early and significant success in this domain. Reducing premature deaths for severe mental illness (Parity of Esteem) We value mental health equally with physical health. There is significant evidence that links poor mental health with poor physical health, and poor physical health can lead to poor mental health. Mental health illness influences premature mortality in the following ways:

2 Avoidable deaths are those that would not have happened if appropriate medical and/or public health interventions had taken place to reduce a person’s risk of dying prematurely.

Preventing People from dying prematurely

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• People with schizophrenia and bipolar disorder die on average 20 years earlier than the general population, largely owing to physical health problems.

• People with mental disorder(s) smoke almost half of all tobacco consumed and account for almost half of all smoking-related deaths. Rates of smoking on in-patient mental health units are 70% compared to 21% in the general population. 3

• Depression doubles the risk of developing coronary heart disease • People with depression have a significantly worse survival rate from cancer and heart disease • People with two or more long-term physical illnesses have a seven-fold greater risk of

depression • Excessive consumption of alcohol is associated with higher levels of depressive and affective

problems, schizophrenia and personality disorders as well as with suicide and self-harm4 This highlights that many of the problems are circular. For example if you drink large amounts of alcohol you increase your risk of poor mental health. Poor mental health increases your risk of developing physical poor health. Physical illnesses can lead to poorer mental health which can in turn lead to an increased risk of premature mortality. By increasing the focus on mental health some of these issues can be addressed which will have knock on benefits for poor physical health and premature mortality rates.

Reducing premature deaths from cancer Crewe has a lower proportion of patients on practice cancer registers, which is related to historically high mortality amongst cancer patients in this town. Premature mortality from cancer in men is currently higher that the CCG average in Nantwich, Sandbach, Alsager and Crewe. In women there are higher rates in Crewe (where cancer mortality is higher than in men) and in Nantwich. Patients with cancer in 2010/11, under 75 directly standardised deaths/100,000 in 2009-11 Patients with

cancer (all ages) Proportion of

practice list size Male death

rate <75 (CI) Female death rate <75 (CI)

Alsager 324 2.6% 119 (78-174) 82 (50-124) Crewe 1,334 1.7% 113 (95-132) 124 (105-144) Middlewich 326 2.4% 102 (66-151) 100 (64-148) Nantwich 320 2.3% 141 (100-191) 115 (78-161) Sandbach 414 2.2% 121 (87-162) 85 (57-119) Rural areas of CCG 938 2.2% 101 (81-123) 72 (55-91) South Cheshire CCG 3,656 2.0% 112 (101-124) 100 (89-111) Source: Annual Report of the Director of Public Health 2012-2013 Local patterns of cancer give a good indication about where the CCG can focus action to improve lifestyle, screening, diagnosis and treatment. Looking at new cases of cancer in each town by tumour type for all ages for the six-year period from 2005 to 2010, the statistically significant outliers are:

• Crewe has high incidence and high mortality from lung cancer in both men and women • Middlewich has high incidence and high mortality from prostate cancer and lung cancer in men • Nantwich has high incidence and high mortality from breast cancer in women • Alsager has low incidence but high mortality from breast cancer in women • Nantwich has low incidence but high mortality from colorectal cancer in both men and women

Reducing premature deaths from cardiovascular disease While there have been significant improvements in the detection and recording of risk factors in primary care, more could be done to identify and effectively manage people with conditions which contribute to cardiovascular disease. Across South Cheshire there are an estimated 14,300 people with undiagnosed hypertension and a further 12,200 people who have hypertension that is diagnosed

3 ‘Living Well for Longer in Cheshire East’, The Annual Report of the Director of Public Health 2012-13 4 Royal College of Psychiatrists, 2010. No health without public mental health: the case for action

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but not sufficiently well controlled. The two figures together give an estimate of over 26,500 people whose high blood pressure is damaging their health and are directly leading to 51 avoidable heart attacks or strokes every year. Identification and Management of Hypertension, estimated numbers of patients, 2011/12 Diagnosed

hypertension Undiagnosed hypertension

Proportion undiagnosed

Undiagnosed and/or poorly

controlled hypertension

Heart attacks or

strokes that could be avoided

Alsager 2,229 985 31% 1,852 4 Crewe 11,005 6,240 36% 11,181 21 Middlewich 2,256 749 25% 1,741 3 Nantwich 2,403 1,030 30% 2,070 4 Sandbach 2,716 1,707 39% 3,003 6 Rural areas of CCG 7,024 3,589 34% 6,682 13 South Cheshire CCG 27,633 14,300 34% 26,529 51 Source: Annual Report of the Director of Public Health 2012-2013 There are also 915 high-risk patients with atrial fibrillation who are not receiving blood thinning (anticoagulation) treatment. Every year, an estimated 47 of them will have a stroke that could have been avoided if they had been prescribed effective blood thinning treatment. 2014-16 Areas of Action (Commissioning Intentions): We have identified a number of areas of action and key commissioning priorities to address the health needs identified, which support this Domain. Some of this actions/ Projects will need to be taken forward in partnership with our partners, such as public health, third sector, providers and other Clinical Commissioning Groups. The projects highlighted below are given as examples of work contributing towards this domain, but it’s important to note that they also contribute towards other domains (in brackets).

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Project and aims Outcome Milestones

Diagnose Cancer Early (D2,3,4) GP and practice nurse education focused on early detection of cancer particularly colorectal, lung and Upper GI cancers. Risk assessment and clinical guidance on early signs and symptoms to aid clinical management. Campaigns: national, local and targeted to raise awareness of early signs and symptoms of cancer. Age extension to cancer screening programmes and introduction of bowel scope.

Reduce the proportion of cancers that are diagnosed following an emergency presentation by 3% over three years. Cancer screening uptake to be in the top 20% compared to England. Cancers diagnosed at an earlier stage of disease progression – 20% of GP suspected referrals for cancer are diagnosed at an earlier stage over next three years (baseline in development). Reduction in premature mortality from cancer (under 75):- Reduce to 110 per 100,000 in 2 years (South Cheshire). Reduce to 140 per 100,000 in 2 years (Vale Royal).

• GP education – PLTs (March and May 2014) – workshop on early signs and symptoms prompting early diagnosis.

On-going: • clinical education on cancer • MacMillan Practice nurse

education course • Age extension to screening

programmes • National Campaigns • Introduction of bowel scope (May

2014) • Lung cancer pathway redesign

Learning Disabilities Mortality (D2,4) To improve mortality rates of those with learning disabilities by the following: Introduction of health equalities framework to measure individual health outcomes Promotion of health screening including national health screening programmes Improving health outcomes resulting from annual health checks Learning lessons from a cross organisational audit of deaths among the LD population

The key outcome for this work will be a reduction in avoidable mortality, improved quality of life for this population.

Introduce CQUIN – April 2014 Primary Care audit of health checks – June 2014 Audit of LD deaths – September 2014

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Enablers There are a number of areas of work that need to take place in order to ‘enable’ the delivery of the above projects and the overall delivery of the domain: Enabler Projects/Activity

Primary Care Innovation in Primary care to support improved outcomes for lung cancer.

At least 3% fewer strokes admitted to Acute/intermediate care, - as average for all practices, for each long term condition - hypertension, diabetes, AF; compared to March 2013. At least 3% fewer myocardial infarctions admitted to Acute services – as average for all practices; compared to March 2013 Targeted health inequalities interventions at community level that provide support and interventions where greatest need has been identified. i.e. improving cancer outcomes in Crewe.

Quality CCG Response Report to Francis (on-going action plans)

Information Technology Development of integration Disease registers - hospital disease registers will enable audit and research and provide better joined up care across boundaries as well as supporting detailed information needs and analysis on the causes of hospital admissions and allow us to target commissioning more effectively Cheshire Health Record – access to a (consenting) patient’s summary of their GP patient record. To provide partner health professionals up to date and accurate information that will enable more coordinated decision making about the treatment provided for the patient, which is also vital to the provision of coordinated and seamless services. Improved Data Sharing and Transparency - Working with colleagues and current / new partners to identify and plan for the delivery of integrations across Primary Care, community and Social care settings by connecting data and information across pathways, seamlessly integrating across organisations and systems

Communication and Engagement

Paediatric Pathway 0-5 • Understand what services are used and when. • Understand current patient/parent experience • Understand current patient flows • Understand what drives parent choices Integrated Neighbourhood Teams • Understand what drives patient choices • Understand what services are used and when – and how this can be

improved • Intermediate Care Services Review • To gather information on whether patients feel supported in returning to

their own home and whether the support they were given helped reduce admissions to care homes (following discharge from hospital) and helped reduce readmissions to hospital.

Transitional Care/ Community Intervention Beds (Winter 2013-14) • Understand patient experience in order to change, develop etc. • Identify gaps in current service • Understanding patient experience of returning home from hospital

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GP Care Homes Scheme • To engage with the GP’s and homes to learn, understand and develop the

new service spec. • To understand the patient experience and what are the benefits of the

scheme.

Medicines Management Maintain and develop the Local Health Economy Formulary including a work plan taking into account NICE Technology Appraisals programme, new product introductions and patent expiries Develop the capability of prescribing support software (Eclipse Live and Scriptswitch) to support improvements in patient safety

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Domain 2 Over a quarter of the population in England have a long term condition, and an increasing number of these have multiple conditions (the number with three or more is expected to increase from 1.9 million in 2008 to 2.9 million in 2018). People with long term health conditions use a significant proportion of health care services (50% of all GP appointments and 70% of days spent in hospital) and their care absorbs 70% of hospital and primary care budgets in England (Source: NHS England). We are committed to supporting people to be as independent and healthy as possible if they live with a long-term condition such as heart disease, asthma or depression, preventing any complications and the need to go into hospital. If they do need to be treated in hospital, we will support NHS provider services to work with social care and other services to ensure that people are supported to leave hospital and recover in the community. We will work to commission services that assist and help patients take charge of their care, supported by good quality primary care and continuity of care. It is also important to us that there is a parity of esteem for mental health. This domain focuses on the health related quality of life for people with long-term conditions:

• Ensuring people feel supported to manage their condition • Improving functional ability in people with long-term conditions • Reducing time spent in hospital by people with long-term conditions • Enhancing quality of life for carers, people with learning disabilities, mental illness and

people with dementia (no CCG measure at present) Our JSNA findings state: The Joint Strategic Needs Assessment and Annual Public Health Report have both drawn attention to the increased risk of hospital respiratory admissions among young children who live in areas that have high rates of adult smoking. Crewe has high rates of adult smoking and more pregnant women smoke at the time of delivery than the England average. Children in Crewe have higher rates of respiratory admissions and asthma than elsewhere in South Cheshire. We have acted quickly to look into the reasons why children are being admitted to hospital, and is working closely with the specialist children’s service at Mid Cheshire Hospitals Trust to develop alternatives to hospital admission and improve primary care clinical pathways for children with chronic respiratory disease and develop community-based alternatives in the early stages of the clinical pathway. Smokers with asthma have poorer control of their condition with a higher frequency of asthma attacks than non-smokers. Locally, emergency admissions to hospital for asthma seem to reflect this. We have significantly worse emergency admission rates (per 100 patients on the asthma register) compared to the England average (2.5% vs 1.8%). Compared to its peers within the ONS Cluster of Prospering Smaller Towns, South Cheshire CCG has the worst rates of emergency admission for asthma (55th out of 55). Management of respiratory disease, numbers of patients, 2011/12

Enhancing quality of life for people with long-term conditions

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14-19 year olds with asthma

14-19 year olds with asthma with smoking status

recorded

All patients with asthma and % with a review

recorded

All patients with COPD and % with a review

recorded

Alsager 25 21 (87%) 784 (79%) 248 (73%) Crewe 113 94 (83%) 4,588 (70%) 1,299 (77%) Middlewich 26 23 (89%) 851 (70%) 301 (81%) Nantwich 27 24 (87%) 851 (72%) 218 (81%) Sandbach 14 12 (84%) 1,211 (63%) 224 (83%) Rural areas of CCG 150 137 (91%) 2,602 (75%) 645 (81%) South Cheshire CCG 355 311 10,887 (71%) 2,935 (79%) Source: Annual Report of the Director of Public Health 2012-2013 The occurrence of dementia starts to increase over the age of 65. Dementia is most common in people in their eighties (10-20% affected) and nineties (30% affected). Women are about 30% more likely than men to develop dementia. Because more women live to a very old age, there are about twice as many women living with dementia than men. Early diagnosis and intervention is cost-effective, although these figures suggest that fewer than half of people with dementia in Cheshire East have received a formal diagnosis. The national benchmark rate for new referrals into a memory assessment service is 190 per 100,000 population per year, which means that memory assessment services in Cheshire East need to be able to see around 700 new patients each year. 450 patients were diagnosed with dementia in Cheshire East in 2010, and again in 2011. Prescriptions for antipsychotics in people newly diagnosed with dementia have also reduced from 12.5% in 2006 to 1.04% in 2011 (the national figure was 4.46% in 2011). This indicates that diagnosis is taking place much earlier. 2014-16 Areas of Action (Commissioning Intentions): Under this domain a number of key areas have been identified. These are actions/ Projects which will need to be taken forward (in some cases in partnership with our partners – public health, third sector, providers and other Clinical Commissioning Groups) in order to make an impact on improving outcomes.

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Extended Practice Teams (D1,3,4) Improve care for adults with one or more long-term conditions / complex needs by treating efficiently within community setting. To reduce fragmentation, duplication and communication between healthcare services. Care will be better co-ordinated around patient needs. Patients will be better informed and involved in their care.

• Reduction in admissions to hospital from baseline. • Reduction in the number of re-admissions. • Reduction in the number of admissions to long term care • Increased number of people dying in their referred place of

care. • Increase in number of patients that feel informed about their

care. • Increased number of people that have a positive experience

of care. • Increase in number of patients that feel able to manage their

condition. The core teams will include the following posts:

- General Practitioner - Care Coordinator (administrative support for the team) - Advanced Community Nurse - Community Nurse - Mental Health worker (health and wellbeing focus) - Social Worker - Wellbeing Practitioner (Third Sector)

Aligned to practices with a community focus, the teams will work together to re-design the way care is delivered for adults with multiple long term conditions/complex needs, so that patients’ needs are at the centre of everything the team does and collectively they are able to deliver a common set of patient outcomes.

Early adopters will be implemented during 2014/15. This will include the necessary IT Infrastructure. Full implementation will be aligned with the Community Services Review (March 2015) taking into consideration the learning from our early adopter sites.

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Paediatric Pathways 0-5 Admissions (D1,4,5) To reduce overall number of avoidable Paediatric 'Short Stay’ (<12 hours) Admissions. Develop alternative pathway to hospital admission for this cohort when appropriate.

Reduction in avoidable paediatric admissions to hospital for common childhood illnesses by 1% (at a practice level with the top 25% in the country where safe and appropriate) • Care closer to home • Improving the patient experience of children and young

people in healthcare settings • Improve the ability of 'Primary Care GP's' and 'Out of Hours'

to manage common paediatric self-limiting conditions in the community

• Change in parental behaviours with confidence of access to advice, guidance and management with GP or Community Nursing as first port of call (rather than directly accessing A&E)

To put in place a clear and robust care pathway and protocols for the management of the sick infant (what happens, by when and to what quality standard). To develop appropriate and accessible information for children, young people, their families and professionals in terms of making positive choices and the management of common childhood illness. Phase 1 – establish nurse home visiting scheme Phase 2 – Options appraisal and business case regarding an enhanced community provision for observation of children

Respiratory (D2,3,4) Build on the ‘Improving Inhaler Technique’ project and ‘Integrated Respiratory’ Teamwork to: Ensure compliance with NICE quality standards for COPD and asthma Deliver care close to home for patients with bronchiectasis. Reduce variation between practices and CCGs for respiratory admissions Improved consistency of provision of spirometry within general practice

Service Specifications updated Quality of primary care services through a primary care CQUIN or other contracting vehicle. Develop bronchiectasis service – community IV antibiotic and physiotherapy service is developed to reduce the number spells/ LOS for patients with bronchiectasis. Implement guide on spirometry – to improve the certainty of diagnosis and reduce variation between practitioners. Prevention of exacerbations of COPD

Audit current provision against NICE Quality Standards – June 2014 Establish Steering Group with clinical leadership and management support (as project links to planned care, urgent care, long term conditions and integrated care)– May 2014 Develop work programme (linking to existing work – improving inhaler technique project, review of asthma/COPD register, supporting early discharge) – July 2014

Children with LTC (D1,3,4,5) Improve care for children with long-term conditions Reduce avoidable admissions

Improved self-management, reduction in avoidable admissions/ LOS for children with LTC including use of inhalers. Introduction of self-care/self-management methodology Reduction in time spent in hospital by children and young people with Long Term Conditions Improved transition pathways for children with LTC (possible CQUIN)

Review local data – Within Q2 2014-15

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People feel supported to manage their condition Neuro-developmental Pathways (D4) To review existing pathways and ensure equity of access to diagnosis of autism and ADHD and on-going support Ensure local services reflect requirements of NICE guidance and prescribing (interdependency with CAMHS specification reviews – See Domain 4)

• As a ‘review’ the specific and measurable outcomes for this

area have yet to be defined. The outputs for this work already agreed:

• Recommendation as to the required changes in existing

multi-agency pathways. • NICE guidance benchmarking

• Mapping existing provision and pathways

– Qtr 1 2014 • Benchmarking data collated and review –

Qtr 1 2014 • Provider and user engagement – Qtr 2 &

3 • Report produced - Qtr 3

Adult Neuro-Developmental Conditions • Review of existing diagnostic pathways

and service capacity for adults with suspected ADHD.

• To ensure that services for adults with neurodevelopment conditions are able to meet current and future demand.

• Implementation of the autism strategy.

• improved quality of life for people with a long-term mental

health condition (CCG OIS) • Adults with ADHD and/or autism are able to receive an

accurate diagnosis • Appropriate follow-up is in place.

• Review of existing diagnostic pathways –

June 2014 • Staff and service user engagement –

July – Sept 2014

Memory Services for Dementia (D4) To review the current configuration and sustainability of memory services in the context of the rise in numbers with the condition. To develop shared care arrangements with secondary care to benefit of patients and their families. This will form part of an accountable care system linking into Extended Practice Teams.

Increased capacity in memory services, through a shift in activity from secondary to primary care. More timely access leads to earlier and more accurate diagnosis. Skilled primary care workforce Patients receive care closer to home. Enhance quality of life for people with dementia Improve dementia diagnosis rates - % target. Enhance quality of life for carers Improve the effectiveness of post- diagnostic care in sustaining. Improve the effectiveness of post- diagnostic care in sustaining independence and improving quality of life

Full business case presented in Feb 2014 Engagement with partners March – April 2014 Implementation from April 2014. Monthly highlight reports monthly to Living Well Programme Board.

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Commissioning of Personality Disorder (PD) Service (D3) To consider and commission models for future delivery of a personality disorder service based on best available evidence and best practice.

Establish a new service to: Reduce premature death of people with severe mental illness - % disorder. Ensuring people feel supported to manage their condition Enhancing quality of life for people with mental illness.

Pathway and service review April 2014- June 2014. Business case development August 2014 – October 2014. Implementation April 2015.

Military Veterans IAPT Service To commission an effective service this focuses on the needs of ex-service personnel, reservists, and their families.

• Decreased rates of re-admission for ex- service personnel • Improve recovery following talking therapies • Improve recovery from injuries and trauma • Increased access to psychological therapies for ex- service

personnel

Contract negotiations December 2013- January 2014. Commissioning and new contract commence April 2014. Quarterly monitoring.

Stroke Rehabilitation Pathway Procurement (1,3,4,5) To procure a specialist community rehabilitation team to work in conjunction with the acute provider, social care and the voluntary sector. The current stroke service has been reviewed and the commissioning team identified a gap in service provision relating to the stroke pathway. Our intention is to integrate the acute provision with community to ensure stroke survivors realise their full potential and improve quality of life.

Improved outcomes for stroke survivors and their families which will enable them to achieve their potential and improve their quality of life. Decrease length of stay in hospital. (Determined by individual patient need). Decrease the rate of readmission within 30 days by working within a multi-disciplinary team to address each stroke survivor’s individual support needs (health, social care and voluntary organisations, including carer support). E.g. supporting people to return to employment or activities of daily living. Improve patient access to the Community Stroke Rehabilitation Service by improving patient flow through the stroke unit, leading to earlier discharge by achieving 90% stay target. Reduction in acute bed days, working towards achieving the optimum length of stay of 19 days.

Full tender process to be complete by April 2014. Full implementation of new service by October 2014. The new service will be formally reviewed after the first 3 months following implementation in collaboration with the provider. This will also include service user and carer feedback to assure the CCG that the procured service does meet patient need, providing a quality service. This will be repeated on a quarterly basis as well as monthly meetings with the provider.

GP Care Homes Scheme (D1,3,4,5) • Review current service and provide

recommendations on changes to service specification for contracting.

• Develop revised service specification. • Implement revised service specification

• Care Homes less likely to call 999 and admit patients to hospital.

• Patients feel they receive better co-ordinated care • Reduce risk of Hospital Acquired Infection • Sustain current low levels of emergency attendances and

admissions to hospital

Service review is currently underway and to be concluded by April 2014. A decision on the future of this scheme will be made by April 2014 based on the review.

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Children & Young People with Disabilities (SEND) To meet the requirements of the Children and Families Bill 2013 (SEND)

Improvements in Education, Health and Social outcomes, Compliance with Children and Families Bill 2012-13 (Clause 26) - legal requirement on CCGs Clear joint commissioning strategy is in place for CCGs and LAs to commission services that support children and young people with special educational needs and disability (up to age 25) Implementation of the single ‘Education, Health & Care Plan’ that replaces “statement” needs treating the child/ young person’s needs holistically. Transitional Care Pathways between Children’s and Adult services are seamless removing transition risks to the young person./ Personal Health Budgets give patients and children more autonomy to buy their healthcare.

Start review of commissioning implications for CCG – Quarter 1 & 2, 2014-15. Whole project infrastructure established with both local authorities (CWaC, CEC) and partners, to set action plan. Delivery according legislative timetable.

Pain Management Service Review This is a project to find improvement to the current community pain management patient pathway.

An aligned NHS contract will be in place for 2014/15. A reviewed pain management patient pathway service will be complete for 2015/16 Measurable outcome indicators will be developed during the review period.

Align existing contract with current best practice – Complete by April 2014 Review of patient pathway to commence – April 2014 Tender for new contract – During 2014/15 New contract awarded to commence – April 2015 (for 2015/16)

Third Sector Grants (D4) To work in partnership to review current spend and develop a strategic approach to working with and commissioning from the 3rd Sector. This programme of work will be reviewed in light of the Better Care Fund. It includes:

- Pathway Support (e.g. Stroke service support)

- Partnership Carer support - End of life review - Partnership work with CWAC (dementia) - Other grants (e.g YMCA homeless

worker in Crewe, Drop in centre in

There are a wide range of outcomes based on individual grants. They support people with LD, Older People, lower socio-economic status and disabilities. E.g. Stroke survivors, Neuromuscular patients. We aim to have one standard contract jointly commissioned by health and social care for the financial year 2015/16.

April 2014 - Collating current levels of spend to identify duplication, identify gaps in locality provision, and to identify future joint commissioning opportunities. June 2014 - Production of a commissioning plan identifying services to be jointly commissioned August 2014 - Agree an approach to developing the Third Sector’s opportunity and ability to deliver local services, this will include info sessions, workshops and networks

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Winsford for people with mental health difficulties)

Dec 2014 - Work with Locality commissioners to develop protocols to ensure that the needs identified in locality action plans are reflected in any newly commissioned.

Community Equipment Services To provide equipment to support independent living. Community equipment is to aid independent living, usually for the elderly or disabled. This is provided locally by way of an innovative nationally recognized model of best practice via a local retailer (or a supplier for larger items that are then reused). The current service is a collaboration of 6 partners – the 4 CCGs and 2 local authorities.

• People are supported to live independently • Support effective discharge from hospital • Value for money based on partnership approach • Prevention hospital admissions • Supports Reablement • People have the ability to test equipment locally to suit their

needs • Equipment is available quickly to people at a local level

Memorandum of Understanding (MoU) between the 6 partners is due for renewal form April 2014. Pilot scheme on extended hours provision in West Cheshire is due to conclude by June 2014. Review of current project plan will take place in light of the pilot in this area during July 2014.

Community Services Review During 2014-2015 South Cheshire CCG will be developing proposals for the future configuration of community provision that will deliver improvements in patient care.

To provide care in a way that better meets the needs of the whole person. A range of different approaches to the organisation and delivery of care will be explored. These include: • Integration of services across health and social care

providers • Better coordination of care between professional groups, for

example, case management, disease management programmes, virtual wards, care pathways and hospital at home

• A range of financial incentives to encourage higher-quality and integrated care

• Commissioning of services on an outcome basis • Tools to help patents better understand and self-manage

their health problems • Technology devices aimed to deliver health care at a

distance • Efforts to increase personalisation, such as personal health

budgets

This review and subsequent actions/ commissioning will conclude by March 2016.

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Enablers There are a number of areas of work that need to take place in order to ‘enable’ the delivery of the above projects and the overall delivery of the domain: Enabler Projects

Primary Care Innovation in Primary care to support Patient self-management

Innovation in Primary Care to support improved outcomes for circulatory disease, diabetes, cancer, COPD and dementia. At least 3% fewer hospital admissions for COPD, acute adult asthma, acute child asthma – as average for all practices; and per practice that attains clinical targets; compared to March 2013. Practice average prevalence rate at least 70% of expected for COPD, diabetes, CHD, asthma, CKD, hypertension (compared with most recent public health observatory figures and NHS England benchmarks). Practice identification of carers at least 60% of expected carers register as identified by The Carers Association. Improved outcomes for patients with one or more long term conditions through tailored single care planning and wider access to patient self-management resources and education, with a focus on diabetes and hypertension. Target quality improvements and interventions towards our changing demographics and increasing frail, elderly population with multiple morbidities. Supporting the adoption and implementation of the Dementia strategy

Quality Quality report on stroke pathways will monitor improvement to services as community responses improve. Quality and Performance Dashboard assurance reports Nurse leadership process to engage harder to reach groups

Information Technology Electronic Prescribing Service (EPS) Release 2 - to send prescriptions electronically to a dispenser (pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. Development of integration Disease registers - hospital disease registers will enable audit and research and provide better joined up care across boundaries as well as supporting detailed information needs and analysis on the causes of hospital admissions and allow us to target commissioning more effectively Cheshire Health Record – access to a (consenting) patient’s summary of their GP patient record. To provide partner health professionals up to date and accurate information that will enable more coordinated decision making about the treatment provided for the patient, which is also vital to the provision of coordinated and seamless services. Risk Profiling and stratification – will identify patients earlier at risk of crisis to reduce likelihood

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EMIS Developments – move towards integration systems across primary, secondary services to improve communications about individual patients needs. Telehealth/ Telecare Improved Data Sharing and Transparency - Working with colleagues and current / new partners to identify and plan for the delivery of integrations across acute care, Primary Care, community and Social care settings by connecting data and information across pathways, seamlessly integrating across organisations and systems


Integrated Neighbourhood Teams • Understand current patient experience of NHS and social care services

following individual patient story to identify improvements at practice level.. • Understand current patient flows GP Care Homes Scheme • To engage with the GP’s and homes to learn, strength and weaknesses

and develop the new service specification. • To understand the patient experience and what are the benefits of the

scheme. Choose Well • To check brand awareness of Choose Well amongst groups and revise if

necessary • Engagement of ‘expert patients’ who can devise appropriate Choose Well

messages for people with LTC. Third Sector Grants • To ensure that the sector are engaged in the suggested new process of

commissioning, ensuring that funds are allocated in the best way to meet the needs of the population. It is intended that this will be done jointly with Cheshire East Council 2014-16.

Medicines Management Maintain and develop the Local Health Economy Formulary including a work

plan taking into account NICE Technology Appraisals programme, new product introductions and patent expiries Develop the capability of prescribing support software (Eclipse Live and Scriptswitch) to support improvements in patient safety Work with the local Acute Trusts to improve financial and clinical governance for patients receiving medicines from Homecare services

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Domain 3 There has been an ever-increasing demand on our hospitals over the past 10 years – a 35% increase in people being admitted to hospital as an emergency and a 65% increase in the episodes of care in hospitals for over 75s. Patients in our hospitals are older and frailer, and around 25% have a diagnosis of dementia. Care that is not joined up, particularly between health and social care services is causing increased admission and readmission amongst those with long term conditions and the elderly. The outcomes of care vary significantly across the country (Source: NHS England). We are committed to ensure that if people do experience an episode of ill health or suffer an injury, our NHS provider services should treat them effectively and support them to recover and restore their maximum independence as quickly as possible. This domain focuses on helping people to recover from episodes of ill health or following injury. In particular it targets:

• Improvement of outcomes from planned treatments • Preventing lower respiratory tract infections in children from becoming serious • Improving recovery from injuries and trauma (no CCG measure at present) • Improving recovery from stroke • Improving recovery from fragility fractures • Helping older people to recover their independence after illness or injury (no CCG

measure at present) • Improving recovery from mental illness

Our JSNA findings state: The Stroke Improvement National Audit Programme (SINAP) assesses the quality of stroke care in hospitals in England by describing the pathway followed by patients with acute stroke in the first three days and assessing the quality of care provided to them during this time. This information is helping us to steer improvements in care for acute stroke patients. Stroke Improvement National Audit Programme (SINAP) – selected results for Oct to Dec 2012 Leighton Nth Staffs England Stroke patients brain scanned within 1 hour of arrival at hospital

23% 43% 40%

On a stroke bed within 4 hours of hospital arrival (out of hours)

42% 86% 65%

Seen by stroke consultant or associate specialist within 24 hours

78% 100% 85%

known time of onset for stroke symptoms 57% 53% 66% Eligible stroke patients who received thrombolysis 67% 100% 70% Nutrition screening and swallow assessment within 72 hours 83% 87% 68% Average score of 12 key stroke indicators (high is good) 71.7 86.3 74.7 Quartile ranking on 12 key stroke indicators (high is good) 3rd 1st Results are available for each quarter from April 2011 to December 2012, during which time Leighton improved from the fourth to third quartile of hospitals in the country, and North Staffs from the second to first quartile. A new Sentinel Stroke National Audit Programme (SSNAP) is now measuring acute

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

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care, rehabilitation, 6-month follow-up, and outcome measures. These longer-term outcomes have not yet been published for local areas. 2014-16 Areas of Action (Commissioning Intentions): Under this domain a number of key areas have been identified. These are actions/ Projects which will need to be taken forward (in some cases in partnership with our partners – public health, third sector, providers and other Clinical Commissioning Groups) in order to make an impact on improving outcomes • Keeping people out of hospital when appropriate • Effective interfaces between primary, secondary and community care • High quality, efficient care for people in hospital • Co-ordinated care and support for people following discharge from hospital

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Intermediate Care Services Review (D1,4) To understand the Capacity and Demand requirements for Intermediate Care Services Beds (Home Based Capacity and Bed Based Capacity) and the Quality and Performance Issues within the current contracted services. This work will run alongside the review of transitional care/ community intervention beds to develop “alternative beds to an acute setting” bed.

The CCG will gain an understanding of the capacity and demand requirements for Intermediate Care Services Beds (Home Based Capacity and Bed Based Capacity) for the:

- short term (next 12 months) - medium term (next 5 years) - long term (next 10 years).

The CCG will gain an understanding of the Quality and Performance Issues within the current contracted services.

- The report will then be used to; - Inform the Community Services Review - Inform the Connecting Care Board

Inform the Better Care Fund transfer of funding arrangement to Cheshire East Council

Review commenced - December 2013 Engagement with GP’s, Patients, primary care, secondary care and social care providers – Complete by March 2014 Review complete – May 2014 (this will inform and contribute to other related projects within 2014-16)

Transitional Care/Community Intervention Beds Winter 2013-14 (D1,4) To provide additional step-up and step-down capacity. Evaluate pilot from 2013-14 and develop a business case to inform the Community Services Review contracting. Work to timescales for Better Care Fund. Extend contracts with pilots to ensure continuity of service between end of pilot and permanent service commencing.

90% of patients are to be discharged home from the community intervention beds

100% of patients transferred to the service within 16 hours of the decision of the transfer being made

The maximum LOS is not to exceed 21 days

A 20% reduction in delayed discharges from MCHFT compared to 2012/13 baseline

Reduction in emergency admissions outcome measure (CCG measure to be in place following evaluation of the pilot)

Improvement in patient experience

Improvement of staff experience

Evaluation to be completed by June 2014. Tendering for permanent service to form part of the Community Services Review process and subsequent timescales.

24/7 Urgent Care (1,2,4,5) To develop and implement an integrated urgent care system across health and social care that is both responsive to patient need and delivers quality

Reduction in A&E attendances - 7% reduction from April 2015

Reduction in non-elective Admissions - 30% reduction from

Project Implementation Plan to be developed and approved by March 2014. • Q1 – The development of protocols,

processes and governance with providers

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care in the most suitable setting. Delivering a high quality, cost effective, seamless, responsive services both in and out of hours.

April 2015

Improvement in A&E 4hr target - 97% from April 2015

Patients feel better supported for their ambulatory care sensitive condition (in the community) - 55% feel supported from April 2015

Reduction in unplanned hospital admissions for chronic ambulatory sensitive conditions per 100,000 population - VR 850 SC 800 Per 100,000 from April 2015To improve people’s experiences of A&E services via the Friends and Family test to the national upper quartile.

for the integration of ED, Urgent care Centre and Out of Hours

• Q2 – Implementation of an integrated ED, UCC and OOH.

• Q3 – Identification of other services for integration to the urgent care system.

• Q4 – The development of protocols, processes and governance with providers for integration of additional services into the urgent care system.

1st April 2015 – New integrated Urgent care systems fully operational.

Diagnosis and Treatment Pathways Compliant with NICE Guidance (1,2,4) • Choose and Book progressed for suspected

cancers from GP • One stop or direct access diagnostic clinics for

lung, colorectal and breast cancer to speed diagnosis

• Pathway redesign of Urology, Gynaecology and Skin Cancers to ensure NICE Improving Outcome Guidance compliant pathways in partnership with Greater Manchester

• Lung pathway review across primary and secondary care

• Macmillan Practice Nurse Course to train a Practice Nurse from 15 practices as Cancer champions in recognising earlier signs and symptoms of cancer and support the cancer care reviews in Primary Care

• Reduction in premature mortality from cancer (under 75) • High quality Patient Experience measures • Cancer Waiting Time Standards achieved • Stretch of 2ww Cancer Waiting Time standard to Day 9

by 2014 • Cancer Peer Review assures of NICE Improving

Compliant pathways • Enhanced recovery for lung cancers with reduced LOS • Patients in GP practice receive faster support at an

earlier stage of cancer from the practice nurse.

• Pathway redesign of the following cancers – urology, gynae and skin (2014-16)

• Lung pathway review across primary and secondary care (March 2015)

• Cancer peer review (Sept 2014, 2015, 2016)

MERIT Response (1,4) There is a National requirement for CCG to commission ambulance service providers to deliver Medical Emergency Response Incident Teams (MERIT). The CCG will work with North West Ambulance Service to deliver an appropriate level of clinical care at the scene of major incidents across the health footprint during 2014/16.

• Lives saved and clinical outcomes improved • Medical implications reduced for casualties by using

advanced specialist clinical interventions at the point of delivery in the pre-hospital environment.

• To bring senior clinical decision making and critical care interventions closer to the point of injury.

• Greater public confidence in anticipated clinical assistance in the event of becoming a casualty

Service specification prepared by NWAS by April 2014. Service will commence from Q2-3 2014. Annual service review to be carried out by the Lead Commissioner (Blackpool CCG).

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‘Think Pharmacy’ - Minor Ailments Service To provide patients with access to advice and treatment for a range of Minor Ailments from every community pharmacy in the CCG area to:

• Reduce presentations in A&E • Reduce attendance at urgent care and out

of hours primary care services • Release opportunity costs through freeing

up GP consultations.

Rapid access to treatment for a range of minor conditions provided by a health care professional for no more than the price of prescription charge (and free if patients are eligible for free prescriptions). Manage the costs of medicines for minor ailments by enforcement of a limited formulary. Empower patients to care for themselves in a community setting.

• Service to be launched by 1 April 2014. • Reduced attendance at general practice and urgent

care facilities for the named conditions to be demonstrated by 1 April 2015

Community Pharmacy will provide consultations at a lower unit cost than other urgent care providers

• Define range of conditions and protocols for treatments by 31 March 2014

• Determine method of self -accreditation for provision of service by 31 March 2014

• Register providers from 1 Apr 2014 • Increase number of consultations

throughout 2014 and 2015

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Enablers There are a number of areas of work and assurance mechanisms that will/do take place in order to ‘enable’ the delivery of the above projects and the overall delivery of the domain: Enabler Projects

Primary Care Innovation in Primary Care to reducing emergency admissions for respiratory

conditions High quality general practice with sufficient capability and capacity to support reductions in avoidable referrals and admissions to secondary care

Quality Quality and Performance Dashboard assurance reports monitor the progress of services delivered to patients.

Information Technology Electronic Prescribing Service (EPS) Release 2 - to send prescriptions electronically to a dispenser (pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. Development of integration Disease registers - hospital disease registers will enable audit and research and provide better joined up care across boundaries as well as supporting detailed information needs and analysis on the causes of hospital admissions and allow us to target commissioning more effectively Cheshire Health Record – access to a (consenting) patient’s summary of their GP patient record. To provide partner health professionals up to date and accurate information that will enable more coordinated decision making about the treatment provided for the patient, which is also vital to the provision of coordinated and seamless services. Improved Data Sharing and Transparency - Working with colleagues and current / new partners to identify and plan for the delivery of integrations across Primary Care, community and Social care settings by connecting data and information across pathways, seamlessly integrating across organisations and systems Risk Stratification – identifying patients at an earlier stage, before a crisis, then care/support can be arranged to reduce the risks.


Think Pharmacy • Engagement of local community to test existing knowledge of minor

ailments scheme • Development of engagement and communication strategy to promote the

‘Think Pharmacy’ brand to target audiences. Integrated Neighbourhood Teams • Understand current patient experience of health and social care services • Understand patient concerns about lack of joined up services • Understand what drives patient choices • Understand what services are used and when – and how this can be

improved Transitional Care/ Community Intervention beds (Winter 2013-14) • Understand patient experience in order to change, develop etc. • Identify gaps in current service provision • Understanding patient experience of returning home from hospital GP Care Homes Scheme • To engage with the GP’s and homes to learn, strengths and weaknesses

and develop the new service specification.

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Medicines Management Maintain and develop the Local Health Economy Formulary including a work

plan taking into account NICE Technology Appraisals programme, new product introductions and patent expiries Implement the extended Think Pharmacy; Minor Ailments service to support the Urgent Care Working Groups to reduce demand in general practice and Accident and Emergency departments

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Domain 4 Positive patient experience is common in NHS. However, care is inconsistent, as seen in recent examples of the unacceptable care documented in the Francis and Winterbourne View reports. The poorest care is often received by those least likely to make complaints, exercise choice or have family to speak up for them, and there is evidence of unequal access to care. Patient experience is everybody’s business, yet evidence suggests the NHS does not consistently deliver patient-centred care, and that there are particular challenges in coordinating services around the needs of the patient (rather than passing the patient between services). Good patient experience is associated with improved clinical outcomes and contributes to patients having control over their own health. We also know that good staff experience is also fundamental for ensuring good patient experience (Source: NHS England). We are committed to achieving and supporting our providers to achieve consistently: compassion and respect for patient’s preferences and expressed needs; equal access to services; good communication and information; physical comfort; emotional support; welcoming the involvement of family and friends. We are also introducing to our providers the requirements to adopt “quality improvement” and “systems thinking”, meaning all providers have to continually critically question “how” and “what” they provide and seek to improve it to meet the needs of their patients. This is done across the whole system that the patient uses, not just the part that any one provider provides. As a CCG we will continue to improve the mechanisms by which we seek out, listen to and act on patient feedback, ensuring the patient and carer voice is heard and directly influences improvements across our health and social care landscape. This domain focuses on the introduction of the Friends and Family Test (FFT) – aiming to achieve ‘real-time’ feedback. In particular it targets:

• Improving people’s experience of outpatient care • Improving hospitals’ responsiveness to personal needs • Improving peoples experience of A&E services • Improving women and their families ‘ experience of maternity services • Improving the experience of care for people at the end of their lives • Improving the experiences of healthcare for people with mental illness • Improving children and young people’s experiences of healthcare (no CCG measure at

present) • Improving people’s experience of integrated care (no CCG measure at present) • Improving the experience for people with learning disabilities experience –

implementing reasonable adjustments Our JSNA findings state: The adult social care survey in 2012-135 provides an invaluable insight into user experience of adult social care and within the context of personalisation and transformation of social and health care provide is critical analysis for understanding the impact and outcomes achieved, enabling choice and informing service development.

5 Cheshire East Council, Adult Social Care Survey, 2012-13, Internal Report, July 2013

Ensuring that people have a positive experience of care

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The introduction of Adult Social Care Survey (ASCS) in 2010-11 was the first time all service users had been surveyed on a national basis using the same methodology and questionnaires. The 2012-13 survey aims to build on this to provide another set of survey data which can be benchmarked across councils and within councils with the 2010-11 and 2011-12 results. A summary of the results is given below: Overall 92% of respondents said they were extremely/very/quite satisfied with the care and support service they received. Quality of life:

• 90% felt that care and support services help them to have a better quality of life and the majority of respondents, nearly half felt they had adequate control over their daily life.

• 80% of respondents said they had as much social contact as they want or adequate social contact and

• 70% felt they were able to spend time as they wanted doing enough of the things they value or enjoy.

• 59% felt that the way they helped and treated made them feel better about themselves. Only 1% felt that they way they were helped or treated completely undermined the way they felt about themselves.

Your health:

• Nearly half of respondents felt the health was fair. 17% felt their health was bad or very bad. • 13% of respondents said they had extreme pain or discomfort. • 8% of respondents said they were extremely anxious or depressed. • Over half (59%) of respondents said they couldn’t manage finances and paperwork by

themselves. • 41% of respondents said they couldn’t manage to wash all over, using a bath or shower, by

themselves.

About your surroundings: • 91% of respondents said their home met all or most of their needs. • Just over a quarter said they could get to all the places in their local area that they want. Over

half said they found it difficult at times or they were unable to get to all the places in their local area that they wanted to. Just under a quarter do not leave their home.

The NHS Patient Survey has been in place for several years and presents a picture of the public’s satisfaction with the way in which the NHS runs and with important parts of its services such as general practice, inpatients and outpatients as well as satisfaction with social care provided by local authorities.with patients reporting. The latest survey was carried out over the summer of 2012 and Satisfaction with the way the NHS runs now stands at 61%, the third highest level since the survey began in 1983. This follows a record fall in satisfaction, from 70% in 2010 to 58% in 2011. The survey also measured satisfaction with individual services. Satisfaction with A&E services increased by 5 percentage points from 54% to 59% while satisfaction with outpatient services (64%) and inpatient services (52%) showed no real change from 2011. Satisfaction with GP services (74%) and dentists (56%) are also unchanged. In contrast to the high levels of satisfaction with the NHS, satisfaction with social care services was much lower, at only 30 per cent. 2014-16 Areas of Action (Commissioning Intentions):

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Under this domain a number of key areas have been identified. These are actions/ Projects which will need to be taken forward (in some cases in partnership with our partners – public health, third sector, providers and other Clinical Commissioning Groups) in order to make an impact on improving outcomes.

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Citizens Advice Bureau To improve patient’s health and wellbeing, by addressing the underlying issues affecting health outcomes that often relate to non-medical issues such as welfare benefits, debt, employment, housing and relationships.

• More people kept in work – retaining jobs • Reduction in child poverty • Increase in disabled people’s income • Supporting people with mental health • Helping people remain in their own homes • The overall health and wellbeing in our deprived

population is improving as identified by the Marmot Report.

• Service review currently taking place, to complete by April 2014.

• New contracts to be in place subject to

service review – from April 2014.

Chemotherapy Reform AND Acute Oncology (1,2,3) To provide care closer to home by transferring the delivery of chemotherapy from Christie’s and North Staffs to Leighton Hospital. To Purchase and set up of electronic prescribing of chemotherapy with each tumour group regimes uploaded Acute Oncology team accessed from A&E and extended into primary care

• 80% solid tumour chemotherapy delivered locally by 2015 • Patients travel no more than 45 minutes for specialist

chemotherapy and 20 minutes for local chemotherapy by 2015

• E-prescribing of chemotherapy • Reduction of mortality within 30 days of chemotherapy • Emergency admissions for cancer related reasons

reduced by the primary care and acute oncology teams • Average length of stay for cancer related admissions

reduced from 9 days to 6 days by end 2014.

• To identify next tumour group where chemotherapy can be moved from the Christie to Leighton Hospital and implement change by 31st March 2015.

• E-prescribing to be in place by 31st December 2014

• Establish pathway to develop primary care implementation to the acute oncology service by 31st March 2015

Dementia/EoL • 2 year Pilot of a specialist Dementia EOL team

across the 3 CCGs (to commence July 2014) • Education and training programmes for staff on

dementia EOL • Consultancy / case management where the

specialist team will co-work clinical complex cases with “mainstream” clinical teams

• Practice development to facilitate best practice pathways within care settings

• Brief educational work with families / carers re: disease trajectory, difficult conversations, and planning for future care

• Increase in the knowledge, skills and confidence of the workforce

• 70% of people with dementia, their carers and families, report a positive experience of End of Life care

• 10% reduction in unplanned hospital admissions at EOL for people with dementia

• 10% reduction in hospital length of stay for people with dementia at EOL

• 10% increase in the number of people being treated in and dying in their preferred place of care

• Increase in patient and carer satisfaction and experience • 80% of NHS patient facing staff will have accessed

communication skills by 2015 • EOL Care will be a core component on education and

induction programme for staff who care for people in their last years of life.

• 20% reduction in A&E attendance over 2 years for people with dementia

• 60% of people with dementia who have a recorded

• Recruitment to dementia/EOL team – July 2014

• Engagement and Communication on the new service – July – December 2014

• Formal evaluation to the service to commence April 2014

• Education and training programmes for staff on dementia EOL – July 2014

• Formal evaluation against agreed outcomes (31st March 2016)

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preferred place of care achieve this. • 10% increase in patients with dementia on the GP GSF

(Gold Standards Framework)register End of Life (D1,2,3) • Normalising death, dying and loss within

communities • Enabling future life planning and making

informed choices • Increased knowledge, skills and confidence of

workforces in EoL care • Enabling public/patient/carer experience to

shape future behaviour and practice in EoL care

• Development of robust evidence base in EOL • Facilitating excellent and compassionate EoL

care • Leading, influencing and developing behaviour

and practice in EoL Care

• 1% of practice population are on the GSF register by December 2015

• 25% of ALL deaths had an advanced care plan by December 2015

• 80% with a preferred place of death achieve their choice by December 2015

• Increase in usual place of residence to 48% by March 2016

• 15% reduction in A&E attendances for people in their last year of life by December2015

• Reduce average length of hospital stay for people at end of life by 2 days by March 2016

• Support 8 Care Homes through quality programmes in EoL care by March 2016

• Have 2 research based published articles on EoL Care by December 2015

• Obtain research funding from a national research body December of 2015

• 80% of staff can evidence change practice due to modules of learning in EoL

• Development of EoL Partnership to support delivery of project outcomes

EPACCS (D1) • To implement an end of life electronic shared

care record that is accessed from all care settings including NWAS, OOHs, hospices, primary and acute care.

• Improve communication between services and enable access to real time palliative care real time information for clinicians 24/7

• 80% with a preferred place of death achieve their choice by December 2015

• Increase in usual place of residence to 48% by March 2016

• 15% reduction in A&E attendances for people in their last year of life by December2015

• Reduce average length of hospital stay for people at end of life by 2 days by March 2016

• information standard by December 2014 • Procure AMIG to allow data sharing

across organisations by December 2014 • Ensure data sharing agreements in place

across practices by September 2014 • Support hospices with N3 connectivity

and consider development of EMIS Web as preferred clinical system by September 2014

• Roll out of EPACCS by March 2016 • Engagement and Communication with

primary care, throughout development and implementation

NHS 111 (1,2,3,5) Commissioning of national NHS 111 service across the Cheshire and Merseyside footprint.

• 13%* decrease in A&E • and UCC attendances by April 2015 • 15%* reduction in 999 calls by April 2015 • ** reduction in number of

1st April 2014 – 31st March 2015: Limited service provided by NWAS as stability partner. Development of service specification and financial plan.

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• RRVs/ambulances activated prior to grading • of call by April 2015 • 4%* reduction in ambulance conveyance by April 2015 • ** reduction in Ambulance response times by April 2015 • 5%* reduction in out of hours contacts by April 2015 • Achieve national target (consider stretch target locally). • Achieve national target (consider stretch target locally).

31st March 2015: • Full service commences • Decision on re-procurement • 1st September 2015 – New contract in

place.

CAMHS Specification Review All CAMHS specifications to be reviewed Delivered under Living Well programme project review of specifications (interdependency Neuro-developmental Pathways – See Domain 2)

• Better understanding of un-met need/ required pathway improvements

• Better understanding of CAMHS offer/cost/activity

• CWP provide current specifications with details of spend and resources – timescale to be agreed

• Agree a mandate in order to progress further redesign as required - timescales to be agreed

• Report identifying next steps to ensuring specifications are fit for purpose and reflect the required provision and needs of children and young people (including benchmarking analysis and review of best practice)

Complex & High Risk Adolescents (D5) Ensure robust system and care pathway across agencies that can identify and support vulnerable young people Improving commissioning process across partners (governance improved and assurance)

• Ensure robust transitional arrangements between services

• All young people with complex and chronic mental health needs have planned and robust transition arrangements in place.

Strategic oversight group established (CCG and LA) – timescales to be agreed

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Primary Care Innovation in Primary Care to support reducing the incidence of teenage

pregnancy Improved access to a wider range of Primary Care based services, through 7 day working

Quality Quality and Performance Reports to monitor progress of improvements to patient services . Quality Surveillance Group and Action Plans to challenge current providers improvements Nurse leadership to plan quality visits to provider organisations to identify any improvements needed 6 C’s Plan to drive quality through commissioning activity

Information Technology Electronic Prescribing Service (EPS) Release 2 - to send prescriptions electronically to a dispenser (pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. National Summary Care Record (SCR) - will improve patient safety, increase efficiency and effectiveness and increase quality of patient care. GPs will know that their patients are being treated in out of hours or in urgent care settings across England using accurate, up to date information. Patient access to their digital clinical information


Paediatric Pathways 0-5 • Focus groups with parents of under-fives to identify strengths and areas for

improvement CAMHS specification review • Understand patient experience • Identify gaps in current service • Gather information on accessibility of service • Identify potential improvements within current services • Find out what is working well and what needs to be improved Integrated Neighbourhood Teams • Understand what drives patient choices • Understand patient experience • Identify gaps in current service of health and social care services

Intermediate Care Services Review • Understand patient experience and identify gaps in current service • To gather information on whether patients feel supported in returning to

their own home and whether the support they were given helped reduce admissions to care homes (following discharge from hospital) and helped reduce readmissions to hospital.

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Transitional Care/ community intervention beds (Winter 2013-14) Understand patient experience in order to develop and reshape services. Identify gaps in current service Understanding patient experience of returning home from hospital GP Care Homes Scheme • To understand the patient experience and what are the benefits of the

scheme. Choose Well – understand patient and public expectations of NHS through use of alternatives to a hospital Third Sector Grants • To ensure that the sector are engaged in the suggested new process of

commissioning and ensuring that funds are allocated in the best way to meet the needs of the population. This work will be done in partnership with Cheshire East Council.

Medicines Management Continue phased introduction of the Blueteq system to capture the information

on usage and provide clinical assurance of compliance with NICE guidance and local protocols

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Domain 5 Although research suggests around 90% of patients admitted to hospital will not experience an adverse incident, around 10% of patients will experience an adverse event, half of which are considered avoidable. Older patients are disproportionately affected by patient safety incidents causing severe harm or death. Over a million patient safety incidents are reported to the National Reporting and Learning System each year, over 90% of which involved low or no harm. However, we know this is an underestimate of the true burden of harm (Source: NHS England). We are committed to protecting people from avoidable harm and ensuring care is provided in a safe environment. This Domain focuses on measuring the broader outcomes resulting from development of a patient safety culture across the NHS, in particular it targets:

• Reducing the incidence of avoidable harm Our JSNA findings state: We are committed to support our providers to ensure there is a zero tolerance approach for MRSA (as required by national targets). We support our providers to ensure that infection prevention and control (IPC) practices are robust, meet best practice standards and are adopted at all levels within each organisation. We are also committed to support our providers to meet national targets for C Difficile. 2014-16 Areas of Action (Commissioning Intentions): This Domain focuses on measuring the broader outcomes resulting from development of a patient safety culture across the NHS, in particular it targets:

• Reducing the incidence of avoidable harm • Caring for patients in a safe environment

In the table on the following page we have identified a number of management methods to enable us to seek and gain assurance regarding quality and patient safety (This is not an exhaustive list but highlights some of the key areas of work):

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

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Quality and Performance Committee The aims of the committee are to develop, implement and audit our Quality strategy that commissions appropriate actions from providers to ensure quality outcomes measures are realised. This group also has a sub-group looking in detail at all complaints, SUIs and professional concerns raised by clinicians about providers.

Information from a number of sources is triangulated to identify areas or risk and to mitigate risk and identify actions.

Meets on a monthly basis, action plans monitored to meet individual milestones.

Quality dashboard This dashboard has been developed by the CCG to provide information on all providers to identify trends in quality issues, performance and patient safety. This also includes complaints and SUI’s.

By identifying areas of concern this allows the CCG to efficiently and timely act upon and mitigate risk.

All provider information/ data will be available via the quality dashboard by July 2014. The dashboard will be reviewed on a monthly basis at the Quality and Performance Committee.

Provider Quality Review Meetings The aims of the meetings are to discuss performance relating to quality and patient safety. This also includes patient story.

• Providing support and developing relationships with our providers to foster a culture of openness and transparency in reporting.

• Enabling all organisations to act quickly in response to areas of concern regarding quality and patient safety.

• To review serious untoward incidents and lessons learned.

All providers Quality Review Meetings to include a patient story by September 2014. These review meetings are held monthly with all providers.

Safeguarding Contract Review Meetings A scorecard is in place for our 3 main providers (MCHFT, ECT and CWP), which is monitored by the CCGs and gaps/ improvements identified to be addressed.

• Regular performance monitoring of safeguarding activity addresses weaknesses at an early stage to protect vulnerable adults/ children locally.

• The LSCB/LSAB are assured that health commissioners/ providers are addressing safeguarding issues systematically and pro-actively.

• Action plans have individual milestones relevant to the issue.

• Quarterly meetings are held.

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Primary Care Quality Safeguarding Dashboards

Local Commissioner Regulator Action Plans

Information Technology National Summary Care Record (SCR) - will improve patient safety, increase efficiency and effectiveness and increase quality of patient care. GPs will know that their patients are being treated in out of hours or in urgent care settings across England using accurate, up to date information.


Paediatric Pathways 0-5 • Patient feedback and patient stories from MCHFT Children with LTC • Identify gaps in current service • Gather information on accessibility of service • Identify potential improvements within current services Find out what is working well and what needs to be improved.

Medicines Management Develop the capability of prescribing support software (Eclipse Live and Scriptswitch) to support improvements in patient safety Work with the Quality team and local Acute Trusts and Primary Care to implement the Medicines Safety Thermometer and medicines-related CQUIN schemes and Quality Schedule requirements. Develop a local strategy to reduce the pressure on antibiotic resistance and support providers to meet targets for incidence of Healthcare Acquired Infections including MRSA and Clostridium difficile

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6.2. Strategic Objectives: Improving Health & Reducing Health Inequalities

The Marmot Review “Fair Society, Healthy Lives” found that health inequalities result from social inequalities, and that action on health inequalities requires action across all the social determinants of health. Reducing health inequalities will involve concerted action by ourselves and our partners across six objectives:

• giving every child the best start in life; • enabling all children, young people and adults to maximise their capabilities and have control

over their lives; • creating fair employment and good work for all; • ensuring a healthy standard of living for all; creating and develop healthy and sustainable

places and communities; and • strengthening the role and impact of the prevention of ill health.

Marmot also found that focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the gradient in health, actions must be universal but with a scale and intensity that is proportionate to the level of disadvantage. This is called proportionate universalism and it has particular significance in South Cheshire because of the local variations that include widespread social deprivation (in Crewe), small communities experiencing deprivation (parts of Alsager, Middlewich, Nantwich, Scholar Green and Sandbach), and areas of rural deprivation (to the west of Nantwich and Crewe, and around Sandbach). All three CCG Locality Groups are developing health inequality strategies for their areas. We are committed to systematic action to meet this concern and to commission services effectively to meet this challenge.

Institute of Public Health

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Public Health Resources The principles of ‘proportionate universalism’ apply also to the allocation of Public Health resources; and focussing public health interventions on reducing the health impacts of social gradients will mean that there is a differential preventive investment in the more deprived communities such as Crewe. Public Health will lead on the following actions:

• Promoting the NHS Health Check for people aged 40-74 years; identifying those with major or multiple risk factors which could lead to premature death and reducing these risks

• Ensuring maximum uptake of current national cancer screening programmes and promotion and support of early detection

• Reducing harmful drinking • Reducing smoking amongst highly addicted smokers and reduce the number of young people

starting to smoke • Increasing physical activity; helping people to build it into their day and promoting low cost

physical activities which are accessible to all • Working with local businesses and food banks and others to promote healthy eating;

encourage and support people to eat healthier, locally grown, cheaper unprocessed foods • Using readily available data to identify people at greatest risk of premature mortality and target

action appropriately Aligning our Health Inequality Plan in South Cheshire CCG

The diagram demonstrates the various partnerships and work streams that we are involved with to improve health and social care for all our populations. However, each of these elements has a distinct contribution to make to also reducing health inequalities as an overarching factor, i.e. all children have universal health checks but we have to target additional resource in our more deprived areas of Crewe to make sure local children have additional chances of improved health through additional nursing or

Developing a prioritisation approach for vulnerable groups with differing health

needs

Working in Partnership with the Health and Well Being Boards to identify

and act upon shared priorities for health Work with Public Health

Departments to understand local health

inequalities

Annual Equality Impact

Assessments to influence commissioning decisions

Commissioning Intentions and Quality Assurance Programmes with due

heed to the promotion of health equality

Joint Commissioning

Activities with our partners

Promoting Health Equality across South Cheshire

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GP sessions through schools or children’s centres. Our priorities are aligned to the main health inequalities in South Cheshire: Health Inequality CCG Commissioning Plan 2014-16 Priority

Male life expectancy Targeted work needed in Crewe, particularly ‘north’ Crewe.

Female life expectancy

Targeted work needed in Crewe, particularly ‘north’ Crewe.

Higher than (national) average incidence for long term condition (respiratory disease, cancers, strokes, heart disease) and higher than (national) average ageing population.

Commissioning intentions to improve community and primary care provision for people with long term conditions including stroke, respiratory conditions and cancers. Once again targeted work needed in Crewe, especially in women, but also for men in Nantwich, Sandbach, Alsager and Crewe. Commissioning intentions to improve end of life services, dementia care and hospital admissions avoidance schemes.

High levels of deprivation in some towns and medium super output areas (MSOA)

Commissioning intentions to improve outcomes for children experiencing domestic abuse/safeguarding /admission to hospital. Commissioning intention to improve access to mental health services, particularly relates to parity of esteem with higher mortality rates in Crewe. Alignment with Cheshire East Health and Wellbeing priorities from JSNA and Joint Health & Wellbeing Strategy to include:

• Alcohol • Smoking • Obesity

Tackling Health Inequalities in South Cheshire CCG 2014-16 Working alongside Cheshire East Council we will: For Children and Young People:

• Target effective outreach services on identified ‘troubled families’ (shared between health and council services) to increase early prevention work increasing understanding of primary care services and access.

• Target schools in deprived parts of Crewe to have additional health input to increase understanding of /and access to healthcare – GPs to visit schools to educate young people in primary care services and how best to access services.

• Support women to put their health first before and during pregnancy, to stop smoking and drinking alcohol, and to obtain good quality healthcare throughout their pregnancy. The Family Nurse Partnership nurses are particularly focussed on very young mothers in Crewe, currently to improve outcomes for their children.

For Adults:

• Assist Public Health programmes to be targeted to specific geographic areas where health

outcomes are poorest. • Assist public health to investigate access to diagnostics and access to early treatment in

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deprived populations. • Actively publicise when to seek medical help for cancer/liver disease/heart

disease/respiratory disease, specifically in deprived areas. • Target help for patients with multiple lifestyle issues in deprived areas alongside Public

Health i.e. weight loss and motivational support. • Improve preventative support in secondary care services (hospital) to target advice/help

patients on lifestyle support (weight/smoking/exercise) For Older People:

• Assertive outreach through Extended Practice Teams to frail older people to avoid hospital admission/breakdown of carer support.

• Work with Cheshire East Council and East Cheshire CCG to shape the local nursing/care home market to improve quality and create the right capacity and services to meet identified need.

In developing our plan, we have discussed and aligned our priorities with Cheshire East Health and Wellbeing Board. This ensures our plan:

• Aligns with and supports delivery of the Joint Health & Wellbeing Strategy • Gives a focus for the future work of our established joint commissioning arrangements with

Cheshire East Council and East Cheshire CCG. • Reflects the Joint Strategic Needs Assessment. • Contributes to the wider vision for our communities shared with partner commissioners in

Cheshire East (other CCGs, council) • Shapes other local commissioning plans to enable integration of services/pathways. • Integrates local planning with Cheshire East Council to use local resources to better effect

in the most deprived areas. • Develops a shared vision (and consensus) with Cheshire East Council and local

communities about the priorities for local services (including integrated services.) Equality and Diversity As Commissioners we know and understand that there is clear evidence that people’s health, their access to health services and experiences of services are affected by:

• Age • Sex • Race • Disability • Religion and belief • Marriage and civil partnership • Pregnancy and maternity • Sexual orientation • Gender reassignment

These are known as the nine protected characteristics. We also understand the benefits of commissioning services that meet the needs of our communities and we will strive to improve access and outcomes for patients, by:

• Meeting our Public Sector equality Duty and our requirements under the equality Act 2010 • Our commitment to reduce health inequalities.

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The mechanisms we will use to improve access and outcomes are by:

• Delivery against our Strategic Equality Objectives • Strong Leadership and Governance via our Health Inequalities sub-group • Ensuring we make fair and transparent commissioning decisions using Equality Analyses so

we consider our Public Sector Equality Duty and improving the equality performance of our providers through the quality contract schedule

• Undertaking a Equality Delivery System 2 (EDS2) self-assessment • Working closely with HealthWatch Cheshire East and other expert patients and stakeholders

to engage meaningfully in the process • Partnership working with the local authority and community, voluntary, and faith sector.

Through undertaking an equality analysis on priority commissioning intentions we will take into consideration the nine protected groups; and by acting on the findings aim to minimise health inequalities and improve access to services. As a statutory organisation, we have a duty to have due regard for the need to eliminate unlawful discrimination, harassment and victimisation; advance equality of opportunity and foster good relations between different groups. As part of our Health Inequalities Plan, we have also identified certain groups within the nine protected characteristics that need specific targeting of commissioning resource in order to reduce their potential health inequality, they are: • the Polish community in Crewe unable to access health services easily due to language barriers; • children in deprived wards in Crewe with poor health outcomes; • higher level of cancer in women in parts of Crewe; • earlier deaths at a younger age in parts of Crewe; • higher admission to care/nursing homes for older people; • higher paediatric admissions due to respiratory issues.

6.3. Strategic Objectives: Parity of Esteem (Physical and Mental Wellbeing)

‘Parity of esteem’ means that, when compared with physical healthcare, mental healthcare is characterised by:

• equal access to the most effective and safest care and treatment • equal efforts to improve the quality of care, the allocation of time, effort and resources on a

basis commensurate with need • equal status within healthcare education and practice • equally high aspirations for service users; and • equal status in the measurement of health outcomes.

We value mental health equally with physical health and aim to commission high quality care for all. However there has been, historically inequity in services for people with mental health problems who also have physical problems. There is significant evidence that links poor mental health with poor physical health, and poor physical health can lead to poor mental health. For example; over 75% of those with heart disease are in treatment, for people with diabetes or

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hypertension more than 90% are in treatment. Conversely only 25% of people with depression or anxiety receive treatment. If you have mental illness it can reduce your life expectancy by 10 years because of your poor physical health. Mental health illness influences premature mortality in the following ways:

• People with schizophrenia and bipolar disorder die on average 20 years earlier than the general population, largely owing to physical health problems.

• People with mental disorder(s) smoke almost half of all tobacco consumed and account for almost half of all smoking-related deaths. Rates of smoking on in-patient mental health units are 70% compared to 21% in the general population. 6

• Depression doubles the risk of developing coronary heart disease • People with depression have a significantly worse survival rate from cancer and heart disease • People with two or more long-term physical illnesses have a seven-fold greater risk of

depression • Excessive consumption of alcohol is associated with higher levels of depressive and affective

problems, schizophrenia and personality disorders as well as with suicide and self-harm7 This highlights that many of the problems are circular. For example if you drink large amounts of alcohol you increase your risk of poor mental health. By increasing the focus on mental health some of these issues can be addressed which will have knock on benefits for poor physical health and premature mortality rates. We are committed to ensure that we commission services to provide services to support people with both physical and mental health conditions and also those who have learning disabilities. To this end, a number of key commissioning priorities and areas of action have been identified to address the identified health inequalities identified above:

6 ‘Living Well for Longer in Cheshire East’, The Annual Report of the Director of Public Health 2012-13 7 Royal College of Psychiatrists, 2010. No health without public mental health: the case for action

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Challenging Behaviour (including Winterbourne View Concordat) ‘Transforming Care’ and the ‘Winterbourne Concordat’ set out a number of recommendations for the development of community based services to support people with challenging behaviours. In line with this concordat the CCG working with local partners will agree a joint strategic plan to commission high quality health, housing and support services for people of all ages with challenging behaviours.

• Review of current provision and develop proposals for

future models of care • People with challenging behaviour will be able to continue

to live locally near their families and social networks with high quality services to support them.

Local partners are committed and have agreed to develop the joint strategic plan. We have a national target to meet by June 2014 to review the individual cases of those currently placed out of area with a view to bringing people closer to home.

Physical Health Needs – Mental Health This commissioning intention builds on the work done during 2013/14 to address physical health needs, working with providers to systematically improve health screening, and to commission a programme of brief interventions targeted at this vulnerable group of people. Much of the learning has come from the AQUA programme ‘Don’t just screen, intervene’. This new programme of work will take things to the next step and provide a service to ‘intervene’ to support this population group.

• The monitoring of physical health needs of this client group will be carried out in a systematic way.

• A brief intervention programme will be available to deliver targeted interventions. This will focus on weight management, stop smoking, alcohol awareness, healthy eating and physical activity.

• A brief intervention programme will be available specifically focused on the physical health of children and young people who experience their first episode of psychosis.

• The physical health of people with mental health issues will be dealt with quickly and as a part of their overall health and wellbeing.

• CQUIN will be agreed in April 2014 • Adult brief intervention programme will be

available by June 2014. • A children and young people’s brief

intervention programme will be available by October 2014.

• Programmes will be reviewed on a

monthly basis throughout.

Review of Liaison Psychiatry Service To review the existing liaison psychiatry service, with a view to understanding the demand and scope of such a service. To create a service re-design project extending the scope and capacity of the existing service. This will form part of an accountable care system linking into Extended Practice

• Prevention of unnecessary admissions for patients with physical and mental ill health

• Reduced length of stay for patients with physical and mental ill health

• Reduces rates of re-admission for patients with physical and mental ill health

• Reduction in rates of frequent attenders for patients with physical and mental ill health

• Full business case presented Feb 2014 • Engagement with partners by April 2014 • Project implementation from April 2014

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Teams. • Improved clinical outcome for patients with physical and mental ill health

• Improving experience of healthcare for patients with physical and mental ill health

• (The baseline assessment for this project will form part of the scope of the project. A balanced scorecard approach to assessing performance will be developed as part of the re-design of the service).

Perinatal Mental Health (links with Liaison Psychiatry Service) Review provision of perinatal mental health support in CCG commissioned services, primarily midwifery With Local Authority and NHS England partners ensure a joined up commissioning approach to peri-natal health Develop a robust, integrated and evidenced based pathway of care and ensure commissioned services can effectively support this. Implement findings of review into year 2.

Early identification of mental health problems and prevention of further ill health (mental and physical) for mother and baby (‘Parity of Esteem’) to reduce risks of poor mental health.

• Review findings of Liaison Psychiatry Service review – Qtr1

• Commence the review of commissioned

per-natal mental health services – Qtr 2 2014-15

• An understanding of the quality of

existing provision, gaps in services, total resources, met and un-met need for maternity services - Qtr 2

• Identify any joint commissioning

opportunities that exist – Qtr 3-4.

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Carers - key to integration and delivering transformation Carers – quality of life The statutory ‘Carers survey’ (Caring for others), commissioned by the Department of Health, is the first of its kind. The Cheshire carers survey completed in June 2013 presented its key findings:

• Over two thirds of carers do some of the things they value or enjoy with their time, but not enough

• Over a quarter of carers have as much control over their daily life as they want • Almost two thirds are able to look after themselves (this is in relation to getting enough sleep

and eating well) • The majority of people have no worries about their personal safety • Almost half of the respondents have as much social contact as they want with people • Almost half feel they have encouragement and support in their caring role.

Supporting carers can help us meet priority areas for improvement in the NHS and ensure that they are meeting the post-Francis agenda. We believe that commissioning services for carers can improve the interface between health and social care by improving information sharing between services and through joined up aftercare. Integration between health and social care can also be improved if statutory services also promote the involvement of carers. Commissioning for carers can help meet a number of our strategic objectives. This can be achieved through: Reducing the amount of time spent in hospital by people with long-term conditions Admission or readmission to hospital by a person with a long-term condition can be an indication that the carer is no longer able to care, often due to the strain of caring causing physical or mental ill health, or that discharge planning is poor and the carers is not involved as an expert partner in care. Tackling health inequalities Carers are more likely to have poor health compared to those without caring responsibilities. Health problems such as stress, anxiety and depression and poor physical health can occur due to their caring role. Their health can also suffer as they consider their own health needs unimportant compared to the needs of the person they look after and their caring role means they can find it difficult to attend clinical appointments. Support for young carers can also tackle health inequalities. Young carers’ health and wellbeing can be impacted by feelings of stress, anxiety, depression, panic and problems such as poor sleep, risk of self-harm, and neglect of their own health, and failure to do well at school. Improving the care of people with dementia Improving the diagnosis, treatment and care of people with dementia in England and support for their carers is a key part of the NHS Mandate and one of the Secretary of State’s key priorities. Carers support people with dementia to stay independent for as long as possible which delays and prevents the cost of residential care. However, many carers feel unsupported and uninformed about the condition of the person they care for, and the demands of caring for someone with dementia are challenging. Carers of people with dementia experience particular difficulties, they are older people themselves and many have their own long-term health conditions or disabilities. Often carers who support someone with mental health issues know best about how the condition affects the person but least about the diagnosis and prognosis due to issues around confidentiality.

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Improving the quality of life of people with long-term conditions and help people recover from illness Carers often provide the majority of care that would otherwise be the responsibility of health or social care professionals. They therefore need support the appropriate knowledge and skills to care safely and in a way that promotes wellbeing for the care recipient. When carers are well supported they provide better care to the person they care for and are able to enjoy the caring experience whilst having some time for themselves as well. Ensuring people have a positive experience of care and are protected from harm The Francis Report called for CCGs to work with NHS England to develop enhanced quality standards to drive improvements in the Health Service. The NHS Mandate states that NHS England’s objective is to ensure the NHS is better at involving patients and carers and that by 2015 carers have access to information and advice about support available. For carers, as well as patients, information relating to conditions and services and how these are to be paid for can be complicated and confusing. Many carers struggle alone not knowing what help is available to them through local carers support services. It is important that carers are able to access information and advice on balancing their employment and education with their caring role,. They need advice about welfare, respite breaks and training in areas such as first aid, moving and handling and stress management. If carers build up a relationship with a trusted local provider of advice, such as a local carers organisation, they are more likely to seek support in advance of a future crisis. One of the key recommendations from the Francis Report is to create a system that is more responsive to feedback from friends and family. Involving carers in a patient’s care can then ensure that any potential problems or concerns are picked up quickly and dealt with to reduce harm and distress. Areas of Action: We have worked with our partners, NHS East Cheshire CCG and Cheshire East Council to jointly develop an action plan for a joint Carers strategy. Key areas of action over the next two years are highlighted below: Key Areas of Action

By When

Deliver the carer break application and commission activities 2013 /14

Finalise reviewed strategy and ensure delivery of the 5 objectives: • To help and advice carers so that they are not forced to into financial hardship • To ensure carers will be respected as expert care partners and will have access

to integrated and personalised services they need to support them in their caring role

• To ensure children and young people are protected from inappropriate caring roles and have the support they need to learn, develop and train and to enjoy positive childhoods

• To support carers to stay mentally and physically well and ensure they are treated with dignity

• To support carers to have a life of their own alongside their caring role

April 2014 – March 2015

Commence delivery against reviewed strategy

April 2015 - March 2016

The commissioning of carers support services will be done jointly by South Cheshire CCG, Cheshire East Council and ECCCG from 2014.

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7. Our ‘Enablers’ to Transformation NHS England have identified that any high quality, sustainable health and care system in England will need to have the following six characteristics (models of care) in five years:

1. A completely new approach to ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care;

2. Wider primary care, provided at scale; 3. A modern model of integration; 4. Access to the highest quality urgent and emergency care 5. A step-change in the productivity of elective care; and 6. Specialised services concentrated in centres of excellence.

As a commissioner, the enduring challenge is for us to transform the way care is delivered, improve the quality and outcomes that matter most to patients (and carers), their friends and family and the public. We have the ability to use our resources for investment in what matters most to patients and the public in different ways. The following sections outline how we have started to deliver some of the transformation required and what our plans are to take this further.

7.1. Making a Difference – Engagement, Involvement and Communication

To achieve improvements in quality and to enable change to meet our challenges we see great value in ensuring that citizens are fully included in all aspects of service design and change and that patients are fully empowered in their own care. We hold patient and public involvement in high regard and believe that true success occurs when we share, involve and engage with our local population. Much emphasis has been placed on ensuring this has occurred over the last year, and every effort is being made to ensure our engagement activity increases and becomes a sustainable and vital role within the development and transformation of the health and social care system. Therefore our engagement, involvement and communications plans to enable this transformational change do not start from scratch but builds on that early work and it’s subsequent developments. Our transformation agenda, embedding the Connecting Care vision is “to ensure quality, personal, seamless support in a timely, efficient way to improve health and wellbeing” is a central driver in all of our forthcoming engagement, involvement and communications work, to ensure the most insightful results can no longer take place in isolation. To this end, an Engagement Network of all those working within engagement and communications from our partner organisations has been initiated, so that we can maximise our partnership working, ensuring consistency of message and approach and reduce duplication of effort.

During the next year, our emphasis will be on the integration of care systems and joint working across health and social care and different care organisations, developing Care Improvement Panels. These panels will feature strong patient representation, professionals, local councillors, clinicians, CCGs and social care and will add a further dimension to the way that patients have a local voice in shaping locally delivered healthcare.

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Working, communicating and engaging with our stakeholders to make a difference.

We have a wide range of stakeholders that we need to engage, involve and communicate with in order to deliver our vision and objectives. In order to ensure that all communication and engagement activities are tailored to individual stakeholder needs, it is very important to analyse the various audiences and plot their level of interest and influence. It is important that specific stakeholder analysis is carried out regularly and routinely to underpin all specific programmes of work. By carrying out a formal stakeholder analysis this will further support the deliverables within Transforming Participation in Health and Care (NHS England, 2013) as it will allow us to, 1) Identify key messages for each identified audience (or participation level) and, 2) identify communication opportunities and challenges Below is an overview of our key stakeholders:

Public Public Carers Patients Cheshire East HealthWatch Patient Participation Groups South Cheshire Federation of Patient Participation Groups Community organisations which represent local people/service

users (CVS) Local, regional and national press

Providers Practice staff MCHFT staff North West Ambulance Trust Other specialist Trusts (Cheshire and Wirral partnership

Trust) Voluntary sector providers Cheshire and Merseyside Commissioning Support Unit Pharmacists Dentists Ophthalmologists

Commissioners South Cheshire GPs SCCCG staff Cheshire East Council Vale Royal CCG Eastern Cheshire CCG Public Health (within Cheshire East Council)

Public Partners Cheshire East Council Parish Councils Voluntary sector representatives Regulatory bodies Health and Wellbeing Board

Professional Bodies NHS England Royal Colleges Unions (GMC etc.) Public Health England

Political Partners Department of Health Members of Parliament Health Overview and Scrutiny Committee Council leaders Councillors from parish to County level MPs and MEPs

Embedding engagement in the whole health and social care system working with our partners is the key to achieving excellent, safe and quality services. We consider our local population to be the ‘experts’; knowing what services and support they may need to support their health and wellbeing. We will aim harness their local knowledge to commission the most appropriate services that provide value for money. For us, ‘engagement’, ‘involvement’ and ‘communications’ means the full spectrum of patient and public relations work that leads to the public conversations that will influence health and wellbeing outcomes. This is at all levels, individual, organisational and population levels.

In developing our plans we have taken into account the duties for NHS commissioners as set out within the Health and Social Care Act (2012) with respect to public and patient participation:

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NHS commissioners should: At NHS South Cheshire CCG:

Make arrangements for and promote individual participation in care and treatment through commissioning activity.

We actively encourage individual participation through patient stories and experiences. These have been used in order to investigate issues of quality and service improvement.

Listen and act upon patient and carer feedback at all stages of the commissioning cycle – from needs assessment to contract management.

Embedding patient and carer feedback is a crucial part of the commissioning cycle. At present patient and carer feedback is included during the initial stages of commissioning cycle. However during 2014-16 we want to build patient and carer insight into the expectations of our local providers to deliver accountable care systems around patient’s needs.

Engage with patients, carers and the public when redesigning or reconfiguring healthcare services, demonstrating how this has informed decisions.

We base our public engagement and communication planning around the Engagement Cycle of Participation; this ensures that patients, carers and public are involved. You Said, We Did is the mechanism that the CCG uses to demonstrate how feedback informs our decisions.

Make arrangements for the public to be engaged in governance arrangements by ensuring that the CCG governing body includes at least two lay people.

We have a lay member of Participation and Public Engagement, who sits on the Quality and Performance Committee and who also proactively supports the South Cheshire Federation Of Patient Participation Groups. We also have 2 lay audit members that support the Governance and Audit Committee of the CCG. Our meetings of the Governing Body are held in public bi-monthly.

Publish evidence of what ‘public and patient voice’ activity has been conducted, its impact and the difference it has made.

We will be collating information during 2014-2016 (and onwards) gathered from public and patient voice activity into a monthly insight report, which will be issued to all Service Delivery and Clinical Project Managers and lead GP commissioning clinicans.

CCGs will publish the feedback they receive from local HealthWatch about health and care services in their locality.

We will publish feedback from HealthWatch Cheshire East about our locality as and when it becomes available. This will be published via all methods we have available to us to suit audience requirements.

Patients and carers to participate in planning, managing and making decisions about their care and treatment, through the services they commission

We will ensure that engaging with patients and carers is at the forefront of all elements of the commissioning process via a transformational shift to person-centred commissioning We will invite patient/ public to be involved in specific service areas i.e. cancer/ stroke/ urgent care/ mental health or the transformational changes i.e. Extended Practice Teams, Connecting Care.

The effective participation of the public in the commissioning process itself, so that services provided reflect the needs of local people

We will report back via You Said, We Did to ensure that engagement, involvement and communications activity has been effective and reflects the needs of local people.

The overarching aims within our approach to public engagement, involvement and communications are:

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• To continue to build meaningful engagement with the public, patients, carers, stakeholders and

our own staff to influence the shaping of health services and improve the health of people in South Cheshire.

• Deliver effective communications that encourage patients, stakeholders and our own staff to better understand and take advantage of CCG led developments.

• To further develop the culture within the CCG that promotes open engagement, involvement and communication within and outside our clinical commissioning group to demonstrate how engaging people helps to make a difference.

• Develop effective communication channels that encourage leadership, involvement and engagement across the 18 member GP practices within South Cheshire.

• Increased involvement at commissioning level via person-centred commissioning. • To increase confidence in the CCG as a responsive commissioning organisation. • Increase awareness of the CCG vision, strategic objectives, principles and ways of working.

Our public engagement, involvement and communications work does and will include the following activity:

• Using a range of activities and approaches to ensure that the public voice visibly influences

and is directly involved in the decisions we make , underpinned by our ‘Making a Difference - Good Engagement Charter’. We plan to launch the Charter at the same time as our new Membership Scheme in June 2014.

• A wide range of communication channels will be used to reach and receive feedback from a wide range of audiences including those groups and individuals whose voices are not always heard. We have recently reviewed the Paediatric Pathway with parents and grandparents within the Polish and Bengali community. Other planned work includes engaging with frail elderly to gain their perspective of the GP Care Home Pilot. A proactive assessment of all protected characteristics underpins all engagement activity.

• Continuing to develop our external reputation as a leading commissioning organisation. As leaders of the local health economy, our reputation is critical to successful relationships. Effective management of our identity and house style is an important element in protecting the organisations reputation and it is important that our identity is not used inappropriately.

• Proactive and planned internal and external communications assist us to operate effectively and gain the support of staff and stakeholders needed to implement wider scale changes. For example – regular team brief, CCG Intranet (which is also accessible to all 18 member practices), quarterly GP Member Newsletter, Stakeholder Newsletters, CCG website, Twitter feed, LinkedIn members group.

Engaging with our location population to make a difference In line with Transforming Participation in Health and Care (September 2013) Individual Participation Why? People’s lives can be transformed when they have knowledge, skills and confidence to manage their own health, when they are able to shape their care and treatment to fit with what is important to them. When health outcomes and goals are agreed, needs are better met and people are supported to manage their own care. There is now a growing body of literature to show that patient participation: • Improves outcomes (linked to achieving our strategic objectives - Domains 1-5) • Improves quality of life (linked to achieving our strategic objectives - Domains 2 and 3)

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• Provides value for money (linked to achieving our organisational objectives - Domains 2 and 3) Ways of communicating and measuring success – Individual Participation • Patient stories and voices It is often said that individuals are the best experts to manage their own health and care. Patient stories are an incredibly rich, powerful but underused source of information. They bring to life issues that really matter to people, in their own words. Engaging at an ‘individual’ level, means that we will be able to work closely with ‘experts’ (the individual) in order to create a real difference by taking this experience and making the insight real and meaningful for those who deliver services, so they can change their service to reflect the needs of the individual. Insight gathered from individual participation links directly to Domains 1, 2, 4 and 5.

Public Participation to make a difference Why? Evidence suggests that engaging and involving communities in the planning, design and delivery of health and care services can lead to more, co-ordinated and efficient services that are responsive to local community needs. Public participation can also build partnerships with communities, learn more about their aspirations for their health and care and identify areas for service improvement. Ways of communicating and measuring success – Public Participation • Patient Participation Groups • The South Cheshire Federation of Patient Participation Group • The South Cheshire CCG Readers Panel • Membership Scheme (to commence June 2014) • Making a Difference Good Engagement Charter (to commence June 2014) • Use of electronic survey with registered patients Not everyone will want to participate in the same way or at the same times and therefore it is essential that a range of options is provided. This will include: • Online survey tools • Dedicated events to enable discussion about proposals • Seeking views from the community at local events or venues e.g. attending local festivals,

markets, schools, leisure centres, libraries etc. • Understanding the assets within our local community and collaborating to identify and solve

problems together (Asset Based Community Development) • Pro-active work through local voluntary and community sector organisations, including small

grass roots organisations in order to collaborate and solve problems together, particularly with communities of interest e.g. mental health charities, homeless organisations.

Insight and Feedback to make a difference

Why? The NHS Constitution is clear that every individual deserves to have as good an experience of the NHS as we can possibly provide. To ensure this happens, we need to listen to people in order to understand what they need and what works for them, this is what we mean by insight and feedback. Using insight and feedback at South Cheshire CCG Insights occur when people recognize relationships or make associations between objects and

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actions that can help them solve new problems. Therefore, South Cheshire CCG will start to create insight reports which draw together the various strands of feedback which we receive. In order to become more insightful with this information we need to be asking more thoughtful questions, looking beyond the obvious and not being afraid to reframe what is it is that we need to find out. Equality and Diversity work (and the nine protected characteristics), is embedded into our regularly public engagement and communications work as standard in order to gain insight from as wide a range of our public as possible. Engagement and Communication within our work programmes In development of our Plan, each of the three work programmes have been identifying their public engagement and communications priorities for the coming year, examples of the priorities are presented across each of the Domains (see section 6). Insight from Partners The following are sources of information and insight from external sources to us. Together, these sources of information allow us to develop a broader context to any engagement, involvement or communications activity which takes place:- • Working with our local authority and partner CCGs In order to maximise the insight which we gain from our engagement and involvement activity, we work with our partners - Cheshire East Council and Eastern Cheshire CCG to regularly share updates on what our local citizens are telling us. This allows us to share best practice and to avoid duplication. Our shared management team arrangements means that we also work very closely with NHS Vale Royal CCG on much of our commissioning work. • Healthwatch Cheshire East Healthwatch is the independent consumer champion that gathers and represents the public's views on health and social care services in England. It operates both on a national and local level ensuring that the views of the public and people who use the services are taken into account. Healthwatch Cheshire East is our local partner. We have formed close working arrangements with Healthwatch through sharing public engagement work (minor ailments/pharmacy and Prior Approval Policy Review), introducing Healthwatch to our Patient Participation Groups and supporting Healthwatch with their Youth Engagement project. • NHS Patient Survey The NHS patient survey programme systematically gathers the views of patients about the care they have recently received. Patients are asked specific factual questions about what happened to them during their recent healthcare experience. These 'reporting' style questions highlight where the problems are and what needs to be done to improve care. • Patient Choices We make choices all the time, whether it is about our lifestyle or healthcare, most people would agree that it's important to be involved in the decision process. By carrying out desktop research into what the general public are telling us about their experiences of services commissioned by us, we can capture an array of almost ‘real-time’ information. • Patient Opinion Patient Opinion is an independent feedback service that aims to promote honest and meaningful conversations between patients and health services. It believes that telling your story can help make health services better. Whilst the reports generated via Patient Opinion may not always be directly linked to our local context, they can provide us with further insight. However, there is good use made of this site by patients using Mid Cheshire Hospitals Foundation Trust.

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7.2. Wider Primary Care, Provided at Scale We are committed to delivering the transformational change and integration agenda across the whole health economy. In doing so, we recognises the need to develop resilience within primary care in order for it to meet the increasing needs and expectations of the residents of South Cheshire and as a body of NHS providers, be able to compete and achieve an level of expectation for service delivery that this programme of change will expect. To enable us to do this we have been developing a primary care strategy that will be published in June 2014. This will encapsulate and further develop the areas highlighted below. NHS England has emphasised that ‘primary care professionals’ are best placed to make effective preventative interventions and to impact positively on the quality and efficiency of the whole health service to deliver a consistent offer to patients of high quality, patient centred services and build on the very best practice to deliver continuous improvements in health and care outcomes. We will be able to drive greater integration between primary care and other services. Services that are provided in individual practices form part of a broader network of integrated, community based care for patients (Extended Practice Teams) with shared clinical leadership, clinical pathways/protocols and clinical information systems. This approach is our CCG’s 5 year Strategic Plan (Connecting Care), and is supported by the Membership. Over the next 12 – 18 months, we will be working to develop the systems that deliver improvements, such as enhanced access to Primary care services through 7 day working, developing patient centric care through extended practice teams, developing a model of co-ordinated care that at its core, marries patient need and wellbeing to a named GP or Nurse co coordinator, that prioritises effective care management through single care plans including social care, mental health, end of life and therapy teams support. Over the next 6 – 9 months, we will be looking at the workforce requirements across general practice in South Cheshire in order develop a greater understanding of what level of nursing and clinical workforce will be required to deliver our ambitious plans, this is also being considered as part of Connecting Care Board priorities for transformation. We are looking to develop training programmes on quality improvement and system change for all health and social care staff locally to deliver changes “on the ground” to patient facing services. Commissioning for Quality in Primary Care We have a shared responsibility with NHS England, for the continual improvement of quality in primary care. We believe the CCG is ideally placed to support practices to improve the quality of GP services; that not only meet the changing needs of the local health economy but also put the needs of the patient at the centre of primary care development, achieving excellence together. We firmly believe that Primary Care quality, in all of its forms - engagement, development and education should be embedded throughout the culture of our organisation. We recognise the pivotal role Primary Care plays in supporting a reduction in health inequalities and the valuable contribution general practice makes towards achieving our strategic objectives and the aims of the 5 domains of the NHS Outcomes Framework. Our member practices support our belief that Primary Care acts as an enabler for the successful delivery of many of our commissioning intentions and in doing so, strengthens our resolve to ensure that we get in right. See the ‘enablers’ sections across each of our Strategic Objectives in Section 6.

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We recognise the scope of this challenge and over the course 2014/16 we will fully developing and implementing our Primary Care Strategy in consultation with our stakeholders, including lay members, public, clinical representatives as well as NHS England and Social Care. Key elements of our strategy will be: Engagement – As a membership organisation robust and regular engagement with our member practices is a fundamental activity. We do this through numerous methods, which include monthly Membership Council, regular newsletters, Locality Lead GP (who are also Governing Body members) and also through strengthening the role of our Practice Engagement Managers. Our Practice Engagement Managers are a visible presence in Primary Care, acting as a “critical friend” enabling all members of the CCG to share experiences and to voice the views of Primary Care. We are also intending to support practices to improve the quality of primary care delivery through the introduction of quality improvement processes. Resources are being identified to support this quality initiative. We also recognise the increasing value in public, patient, third sector contributions towards shaping Primary Care and are working closely with the CCG Practice Engagement Managers to develop this important relationship further over the next two years. Practice Nurse Membership Council As a clinically led organisation we are keen to empower a strong nursing voice, particularly from practices nurses who have well developed relationships with patients and take a big role in supporting patients to manage their own health needs and have valuable knowledge and skills relating to impact for and approaches with patients. Practice Nurses across South Cheshire want to ensure consistently high quality care for all patients, delivering on all of the 6C's of the nursing strategy. Therefore a Practice Nurse Membership Council has been established. The Council provides the opportunity for a consistent approach to achieve quality and share best practice within practice nursing and also to influence nursing developments and approaches within the South Cheshire area. The Practice Nurse Membership Council is a mechanism to:

• facilitate implementation of the national nursing strategy- 'Compassion in Practice', • provide consistency in policy, procedure and protocols • Development of quality framework detailing practice nurse quality standards • Facilitate and share best practice across South Cheshire • Consistent approach to quality within practice nursing, benchmarking, peer review • Workforce development • Raise awareness of key nursing issues and implications in practice locally for patients to

the Governing Body • Mechanism for communication with CCG membership council, CCG shared management

team, wider primary care, community and acute care Transformational Change We have established a Primary Care Quality, Engagement, Development and Education Group (the Primary Care Group) to oversee the delivery of Primary Care quality initiatives supporting the delivery of the integration and transformational change agenda within primary care. The group benefits from strong clinical leadership, through which the Membership allows the development of ideas and initiatives to grow, specifically those that involve the voluntary sector to target vulnerable or isolated communities. Over the next 12 months we will be gathering intelligence and ideas to plan and prioritise our innovation opportunities, channelling these

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through Programme Boards to understand the health needs or gap analysis within existing work streams. Data Quality/ Dashboard Development We are working towards developing a comprehensive and meaningful set of Practice level information (‘Primary Care Quality Dashboard’), encompassing clinical benchmarks as well as supporting the delivery of improved quality measures to support the practice and inform the population. This information will provide relevant, timely and benchmarked information based on practice demographics and performance. Information from the CCG Quality team will also help to develop the ‘dashboard’ to capture, triangulate and audit professional concerns and significant events. We also recognise the role of NHS England has in reporting significant events and professional concerns, and we aim to work collaboratively to ensure that any such concerns are dealt with quickly and sensitively. The information will be able to support practices in understanding the requirements from both NHS England as well as CQC as their regulatory body. Through supportive engagement it is our ambition to raise the bar of quality across the CCG and for practices to be held up as exemplars of best practice. We are working in conjunction with the Cheshire and Merseyside Commissioning Support Unit (CSU) to tailor and develop our Primary Care data sets, it is envisaged that this information will be available in practice by the end of June 2014. We will then start to work with practices around action planning for the next 12 months. Enhanced Quality Frameworks (CQUIN) The Locally enhanced Quality Framework (LeQOF) - Primary Care CQUIN affords us with an opportunity to examine local health need and develop a system of targeted improvement initiatives for roll-out in General Practice. The scheme aims to improve the quality of services for patients as well as reward innovation in GP commissioning. We will continue to align several of the LEQOF initiatives for primary care with those in place with our main secondary care providers as a means of promoting integrated quality improvement schemes – linked to delivering our intention of quality improvement embedded with all our providers across systems. These initiatives will continue to benefit the quality, range and access of primary care services in South Cheshire as well as the proactive management of long term conditions. It is our intention to align the initiatives for 2014-15 closely with the health needs of the population. Through the Primary Care Quality Group, we are taking informed decisions to the areas that are to be identified for quality improvement. We know we have specific health issues in certain geographies i.e. Crewe, Alsager and Nantwich, so will be targeting specifically to improve health outcomes. We have outlined some ambitious targets within the Primary Care CQUIN that not only draws from Public Health intelligence, Right Care data models and directly from the Membership. We recognise the value in the improvement scheme - over the next two years we will be developing the programme to encapsulate Innovation in Primary Care. At a locality level, we will draw support from Public Health to identify service improvement opportunities that are tailored to meet the needs of specific communities, e.g. dementia awareness, improving outcomes for lung cancer, reducing teenage pregnancy, reducing emergency admissions for respiratory disease, targeting isolated or vulnerable groups. These pieces of work are currently CCG commissioning intentions now supported through primary care interventions as well as work with other commissioned health, social care providers.

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We will continue to maximise our use of IT systems to ensure data accuracy. We will encourage practices to undertake audit and validation to support quality, education and shared learning. We will be promoting peer review across the CCG to develop transparency and openness.

Education We firmly believe in the importance of education and mentorship for all of its members which provides a platform across General Practice that promotes pastoral and developmental learning. Diabetes, chronic heart failure, paediatrics, asthma, COPD, mental health, atrial fibrillation, cancer, self-care, medicines management, substance misuse and patient experience continue to be clinical areas prioritised for learning and development support in 2014-16 - a selection of local workshops will take place to promote the best practice guidelines. A programme of review for elective referrals to support the delivery of efficient use of health resources and promote best practice across all of our primary care providers is also on-going locally. We will try to anticipate knowledge, skills and professional behaviour required to deliver clinical pathways that support a secondary to primary care shift. We will actively interface with CCG localities / membership and their provision of learning & development to ensure that we minimise duplication and optimise a range of learning and development opportunities to match local practitioners’ needs. We will continue to enhance exemplary clinical care in relation to patients with long term conditions (LTCs). We will continue to commission accredited courses and other learning activities to promote effective working for practice managers, practice nurses, GPs and others. Innovation Local priorities for innovation will be derived from the Joint Strategic Needs Assessment and other associated public health needs. Our challenges and innovations will be mapped to the CCG commissioning priorities – in particular the prevailing health issues including long term conditions: circulatory disease, diabetes, cancer, COPD and dementia. The CCG profile generated by NHS England highlights our high levels of respiratory disease, cancer mortality and the challenges to achieve improved patient outcomes. Patient self-management is highlighted as an area for potential improvement across South Cheshire. High quality general practice with sufficient capability and capacity is seen as key to reductions in avoidable referrals and admissions to secondary care – avoiding deterioration of patients’ long term conditions, meeting QIPP targets, and enhancing patients’ health and wellbeing.

We believe a key part of clinical commissioning is the recognition of innovative ideas coming from staff and patients within primary care. We will ensure that GPs have access to a formal system to follow any suggestions or ideas through. The system will actively support the delivery of one or more of the following areas:

• Improving quality of care provision • Ensuring patient safety • Ensuring emergency admissions are appropriate • Preventing of exacerbations • Areas for commissioning or service improvement • Improving access to local Primary General Medical Services • Promoting a positive experience of care

Suggested outcomes by March 2016 through Primary Care initiatives

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The following initiatives are areas of work that primary care will focus on over the next 2 years, to support the delivery of the CCG Strategic Objectives (Domains). There are also other initiatives that will developed to support the wider integration strategy.

Strategic Objective 1: Domain1 • At least 3% fewer strokes admitted to Acute/intermediate care, - as average for all

practices, for each long term condition - hypertension, diabetes, AF; compared to March 2013.

• At least 3% fewer myocardial infarctions admitted to Acute services – as average for all practices; compared to March 2013.

• Enabling flexibility within the Primary Care Quality Improvement scheme to enable targeted health inequalities interventions at community level that provide support and interventions where greatest need has been identified. i.e. improving cancer outcomes in Crewe.

Strategic Objective 2: Domain 2 • At least 3% fewer hospital admissions for COPD, acute adult asthma, acute child asthma

– as average for all practices; and per practice that attains clinical targets; compared to March 2013.

• Practice average prevalence rate at least 70% of expected for COPD, diabetes, CHD, asthma, CKD, hypertension (compared with most recent public health observatory figures and NHS England benchmarks).

• Practice identification of carers at least 60% of expected carers register as identified by The Carers Association.

• Improved outcomes for patients with one or more long term conditions through tailored single care planning and wider access to patient self-management resources and education, with a focus on diabetes and hypertension.

• Target quality improvements and interventions towards our changing demographics and increasing frail, elderly population with multiple morbidities.

• Supporting the adoption and implementation of the Dementia strategy Strategic Objective 2, 3 and 4: Domain 2, 3 and 4 • Implementation of Extended Practice Teams - the CCG will support the practices to

transform the care of patients aged 75 or older and reduce avoidable admissions by providing funding for practice plans to do so. We will be providing additional funding to commission additional services which practices, individually or collectively, have identified to further support the accountable GP in improving quality of care for older people. This funding will be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over. The implementation of Extended Practice Teams as a major transformational point supports this initiative and has been included in the Better Care Fund with Cheshire East Council.

Strategic Objective 4: Domain 4 • Improved access to a wider range of Primary Care based services, through 7 day

working • Delivery of the Primary Care strategy in conjunction with NHS England Area Team Strategic Objective 5: Domain 5 • To embed a culture of quality improvement and clinical safety in each practice, delivered

through a named practice clinical champion for quality and safety.

7.3. Quality Premium

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The ‘quality premium’ is intended to reward CCGs for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing health inequalities.

For 2014-15 the ‘quality premium’ is based on six measures that cover a combination of national and local priorities these are: Domains National Measures Local Measure

Domain 1 Prevent people from dying prematurely

• Reducing potential years of life lost from amenable mortality (15%)

Addressing locally agreed priorities for reducing premature mortality. (Please see projects outlined on page 31)

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

• Improving access to psychological therapies (15%)

Domain 2 Enhancing quality of life for people with long term conditions & Domain 3 Helping people to recover from episodes of ill health or following injury

• Reducing avoidable emergency admissions (25%)

Domain 4 Ensuring people have a positive experience of care

• Addressing issues identified in the 2013-14 FFT, supporting roll-out of FFT in 2014-15 (15%)

Showing improvement in a locally selected patient experience indicator (Please see projects outlined on pages 53-55)

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

• Improving the reporting of medication-related safety incident based on a locally selected measure (15%)

To develop a clinical audit in primary care focussed on deaths within 30 days discharge, to support the work being undertaken by MCHFT and AQUA. This work will also focus on deaths occurring in Nursing homes patients admitted and subsequently discharge back to the home i.e. appropriateness of original admission.

The Quality Premium payment for achieving 2013-14 will be invested locally during 2014-15. A summary of the position for 2013-14 is shown below:

NHS South Cheshire CCG Quality Premium 2013-14

6 Month Summary Progress

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Measure on Target – End of Quarter 2

RAG

Four National Measures Reducing potential years of life lost from amenable mortality (12.5%)

Yes

Reducing avoidable emergency admissions (25%) Yes (one of composite measures is

currently failing)

Improving patient experience of hospital services (12.5%)

Yes

Preventing healthcare associated infections (12.5%)

No (MRSA breaches June & Sept)

Three Local Measures People feeling supported to manage their condition (12.5%)

Yes

Reduce emergency readmissions within 30 days of discharge hospital (12.5%)

Yes

Reduce unplanned hospitalisation for asthma, diabetes epilepsy u19s (12.5%)

In development

The maximum quality premium payment for a CCG will be expressed as a £5 per head of population, calculated using the same methodology as for CCG running costs. (This is in addition to the CCGs main financial allocation for 2014-15 and in addition to its running cost allowances). Regulation 2 sets out that the quality payment should be used in ways that improve quality of care or health outcomes and/ or reduce health inequalities. We have not had formal notification of the quality premium payment for 2013-14 and so have not yet confirmed how it will spend its quality premium, this is currently under review.

7.4. A Modern Model of Integrated Care

In Section 4 (from page 18) of this operational plan we illustrate our plans for a modern model of integration. However for our patients with multiple, complex, mental or physical long-term conditions, often compounded by being elderly and perhaps frail, NHS England says a modern model of integrated care with a senior clinician taking responsibility, through a personal relationship, for active co-ordination of the full range of support from lifestyle help to acute care is needed. Through the implementation of Extended Practice Teams, we will support GP practices to transform the care of patients aged 75 or older, and reduce avoidable admissions. We will be resourcing appropriate support for the accountable GP in improving quality of care for older people. This funding will be at around £5 per head of population for each practice, which broadly equates to £50 for patients aged 75 and over. The implementation of Extended Practice Teams as a major transformational focus supports this initiative and has been included in the Better Care Fund.

7.5. Access to the Highest Quality Urgent & Emergency Care In 2013 we undertook a cross-organisational, clinically led, review of current urgent care services. The review included local engagement events: a set of workshops designed to develop understanding of the current services and issues faced locally; a provider day that was advertised on Connecting for Health, and a review of national guidance and independent reports.

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The following key objectives were identified for this project: • Develop and implement an Integrated Urgent Care System across health and social care that is

both responsive to patient need and delivers quality care in the most suitable setting.

• The New Model of Care must deliver a high quality, cost effective, seamless, responsive services both in and out of hours.

Successful implementation of a new model of care will require a co-ordinated commissioning approach across health and social care, involving primary, community, ambulance, acute, mental health and social care services. There will be no scope for additional funding; all developments will have to be undertaken within the current financial envelope of current health and social care services. The urgent care work during 2014/15 will focus on establishing the most effective and robust contracting models for our urgent care services, while delivering these policy objectives. System redesign: A new model of care Emerging principles for urgent and emergency care locally and nationally outline a system that:

• Is simple and guides good choices by patients and clinicians; • Provides consistently high quality and safe care, across all seven days of the week; • Provides the right care in the right place, by those with the right skills, the first time; • Is efficient in the delivery of care and services.

The system redesign opportunities identified through work undertaken in 2013 and the national documentation and guidance, will be evaluated within the full business case prior to implementation in 2014/15. CQUINs will be used as a lever to incentivise services within the urgent care system to work together to develop an Integrated Urgent Care Team (IUCT). Commissioners and providers will work together to agree pathways, protocols and governance that meet the vision of the IUCT across urgent care services.

7.6. A Step Change in Productivity of Elective Care Commissioning Intentions and service developments As a CCG we will continue to support the development and delivery of Out-Patient, Elective In-Patient and Diagnostic services within the local health economy. This programme of work will review planned care service provision, patient outcomes, health needs and health Inequalities to establish priorities for pathway improvements and developments. We will establish priority areas of action to initiate service developments and pathway changes across Primary Care, Community Services and Secondary Care. We will complete a number of service/pathway reviews during 2014-16 that will improve outcomes, quality and productivity within the local healthcare system, we will triangulate current patient outcomes, health needs, health inequalities and the NHS England benchmarking data to establish which of these priorities will be agreed. CQUIN – incentivising Partnership working

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We will incentivise the provider trust to work with us to:

• Review planned care service provision, patient outcomes and health Inequalities to establish priorities for pathway improvements and developments by July 2014.

• Establish the benchmarking data for the areas of development against indicators to measure contribution towards the delivery of Health Needs, Health Inequities and the NHS Outcome Domains by July 2014.

• Incentivise trusts to work together on the integration of services locally i.e. urgent care and extended practice teams.

We will incentivise the trust to work with us to undertake pathway/service review and implementation of priority 1 by September 2014. We will incentivise the trust to work with us to undertake pathway/service review and implementation of priority 2 by December 2014. We will incentivise the trust to work with us to undertake pathway/service review and implementation of priority 3 by January 2015. We will incentivise the trust to work with partner providers to deliver extended practice teams by March 2015.

7.7. Specialised services concentrated in centres of excellence.

From 1st April 2013, under the terms of the Health and Social Care Act 2012, NHS England became the sole direct commissioner of specialised services. With a consolidated budget of approximately £11.8billion, NHS England is in a strong position to set a course for the future of specialised services. A five-year strategy for specialised services has been developed over the past few months, and will be published in April 2014. This has been a vital opportunity to engage with patients, the public, NHS organisations and others, to articulate a clear vision for the future for specialised services and we look forward to the publication of the Strategy. This will address the service specific objectives for the next five years, overarching strategic objectives for the provision of a system of specialised healthcare as a whole and the impact of co-dependency between service areas. The Specialised services commissioning approach has six strands:

1. Ensuring consistent access to effective treatments for patients in line with evidence based clinical policies, underpinned by clinical practice and audit.

2. A Clinical Sustainability Programme with all providers, focused on quality and value. 3. An associated Financial Sustainability programme with all providers, focussed on better value. 4. A systematic market review for all services to ensure the right capacity is available,

consolidating services where appropriate to address clinical or financial sustainability issues. 5. Adopting new approaches to commissioning care where it promotes integrated care and

clinical oversight for patients in particular services and care pathways. 6. A systematic rules-based approach to in-year management of contractual service delivery.

We will continue to work with NHS England Area Team to ensure our local providers, where required, are able to offer specialised centres of excellence. However we also recognise that geographically our patients already travel greater distances to access the full range of specialist services (University Hospital of North Staffordshire and The Christie in South Manchester) and we will need to co-

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commission local integration of care and clinical oversight of patients.

8. A FOCUS ON ESSENTIALS 8.1. Access Convenient access for everyone:

We are committed to ensure good access for everyone to a full range of services, including general practice, community services, and mental health services in a way which is timely, convenient and also consider the needs of disadvantaged and minority groups. To deliver meaningful outcomes, the CCG will engage and consult with patients, carers and the public to develop and improve our constitutional commitments. It is important that patients don’t have to wait for treatment. We acknowledge that waiting can be very distressing. Evidence also suggests that waiting can make health outcomes worse and can even make services unsafe. We also know that to improve outcomes for patient services need to be available and easily accessible to them, that they receive those services quickly, when they need them and in a way which is convenient for them and fits with their daily lives.

Disadvantaged and minority groups (e.g. people who live with mental health conditions) need tailored services which suit their circumstances or they will simply not be accessible to them. There are many minority groups who will struggle to get the care they need if they are expected simply to fit in with what works for the majority. During 2014/15 we will explore opportunities to develop pilots designed to extend access to general practice services and stimulate innovative ways of providing primary care services, supported by the Prime Minister’s £50 million Challenge Fund.

Meeting the NHS Constitutional Standards

The NHS Constitution identifies a range of standards to which patients are entitled and which NHS England has committed to deliver. Our Operational Plan seeks to make services accessible and deliver the standards in the constitution. We are committed to ensuring delivery of the full range of NHS Constitution measures and support measures:

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NHS Constitution Measures Referral to Treatment waiting times for non-urgent consultant-led treatment

Admitted patients to start treatment within a maximum of 18 weeks from referral – 90% Non-admitted patients to start treatment within a maximum of 18 weeks from referral – 95%

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral – 92%

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral – 99%

A&E waits Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E

department – 95% Cancer waits – 2 week wait

Maximum two-week wait for first outpatient appointment for patient referred urgently with suspected cancer by GP – 93%

Maximum two-week wait for first outpatient appointment for patient referred urgently with breast symptoms (where cancer was not initially suspected) – 93%

Cancer waits – 31 days Maximum one month (31 day) wait from diagnosis to first definitive treatment for all cancers – 96%

Maximum 31-day wait for subsequent treatment where that treatment is surgery – 94% Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime –

98% Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy –

94% Cancer waits – 62 days

Maximum two month (62 day) wait from urgent GP referral to first definitive treatment for cancer – 85%

Maximum 62-day wait from referral from an NHS screening service for first definitive treatment for all cancers – 90%

Maximum 62-day wait for first definitive treatment following a consultant’s decision to upgrade the priority of the patient (all cancers) – no operational standard set

Category A ambulance calls Category A calls resulting in an emergency response arriving within 8 minutes – 75% (standard to be

met for both Red 1 and Red 2 calls separately) Category A calls resulting in an ambulance arriving at the scene within 19 minutes – 95%

NHS Constitution Support Measures Mixed Sex Accommodation Breaches

Minimise breaches Cancelled Operations

All patients who have operations cancelled, on or after the day of admission (including the day of surgery), for non-clinical reasons to be offered another binding date within 28 days, or the patient’s

treatment to be funded at the time and hospital of the patient’s choice. Mental health

Care Programme Approach (CPA): The proportion of people under adult mental illness specialties on CPA who were followed up within 7 days of discharge from psychiatric in-patient care during the

period – 95% Referral To Treatment waiting times for non-urgent consultant-led treatment

Zero tolerance of over 52 week waiters A&E waits

No waits from decision to admit to admission (trolley waits) over 12 hours Cancelled Operations

No urgent operation to be cancelled for a 2nd time Ambulance Handovers

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8.2. Quality, Safeguarding and Patient Safety Quality is about delivering an excellent service in an effective way whilst ensuring a positive experience. It is central to all aspects of commissioning within NHS South Cheshire CCG. Our main quality drive is centred on patient feedback to ensure they get the right services in the right location delivered by the right health care professionals at the right time (NHS Outcome Framework Domain 4.

We work collaboratively with NHS Vale Royal CCG on the quality agenda as both CCGs have prioritised quality and safeguarding vulnerable adults and children. We have a joint Quality and Performance Committee. We ensure delivery of a cohesive strategy and makes best use of shared resources with monthly reporting on quality and performance with all our main providers. (Domain 4 & 5).

We aim to ensure that all our providers deliver the expected rights and pledges from the NHS Constitution, complies with national quality standards such as the National Institute for Health & Care Excellence (NICE) and that they operate to the high standards expected within the NHS Standard Contract.

The safety of patients is our highest priority; we will expect our providers to comply with national standards set out in the NHS contract for example relating to safeguarding vulnerable adults and children and reducing Hospital Acquired Infections such as MRSA. We also have quarterly safeguarding contract meetings to ensure providers are meeting statutory and contractual duties through a balanced scorecard methodology. (Domain 1,2,3,4,5)

We monitor the quality of healthcare provision in South Cheshire by reviewing quality and performance indicators, serious incidents, patient experience information, complaints, morbidity and mortality data and GP feedback through a variety of means including professional concerns (this is an internal system that GPs/ providers use to raised clinical concerns about patients care as they arise). We use a standard escalation policy to ensure providers rapidly improve sub optimal services. This includes the use of contractual levers where necessary such as contract enquiries and financial penalties. (Domain1,3,4,5)

We undertook a reflective review on the recommendations of the Francis Report into the failings at Mid Staffordshire NHS Trust. We used feedback from patients, staff, clinician, members and partners to pinpoint actions we needed to take: increasing the amount of information on quality we receive and broadening the resources from which we receive it.

During 2013-14, we have been using information from commissioner service review visits; information from provider complaints, serious incidents, workforce indicators and information directly sourced from clinicians and patients. These additional multiple sources of information has built a comprehensive view of quality in provider organisations that is triangulated to ensure we have a comprehensive picture of local providers i.e. mortality rates and safeguarding incidents, stroke services. We will ensure a duty of candour is embedded in all provider organisations through the contract requirements as per recommendation 181 of the Francis report (Domain 1,3,5) from 2014.

We participate in Cheshire Warrington and Wirral Quality Surveillance Group to look more broadly at quality issues across the health economy. Led by NHS England Cheshire Warrington and Wirral Area Team, participants include HealthWatch from all areas, Care Quality Commission, Monitor and the Trust Development Agency, Cheshire West and Chester Council, Cheshire East Council, Health Education England, and representatives from all Clinical Commissioning Groups in Cheshire Warrington and Wirral. The purpose of the group is to share quality/safeguarding concerns and improve services on a thematic basis across a larger footprint. (Domain 4,5,)

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There is also a local monthly meeting with CQC, ourselves, Eastern Cheshire CCG, Cheshire East Council and HealthWatch to triangulate and share poor quality care concerns or safeguarding issues on the Council footprint. The work is action planning, based on local intelligence, working with our main providers (and the nursing home sector) to prompt improved quality of care. The new rating system from CQC will be included in the shared intelligence at these meetings.

We also currently receives reports from our main providers on the Patient Safety Alerting System, this is overseen through the quality reporting process within the CCG. The New Patient Safety Alerting system will be included in the contracts for 2014-15 for our main providers. The NHS Safety Thermometer in included in the 2014-15 contracts and there has been work happening with our local nursing home sector to investigate whether the same system could be applied to this sector. This work is on-going. MRSA and C.Diff targets are challenging for our local health economy and were not achieved in 20313-14. However we continue to require that providers demonstrate they are actively working to achieve their specific targets. There are action plans in place when an incident occurs and these are monitored by us. Our clinicians regularly attend provider reviews to ensure robust and challenging investigation is carried out when an incident has occurred. We hold monthly Clinical Quality and Performance Review meetings with our providers. When issues arise and/or performance is failing, action plans are put in place. An example of this was in Stroke services, where targets were not being met. A multi-agency working group was convened to address the issues. This led to a set of proposed change in the stroke pathway that has been approved by the Commissioning Advisory Board and will commence in 2014/15.

Quality visits to provider organisations form an integral part of how we assure ourself that quality standards are being implemented. These visits can be reactive – in response to concerns, or proactive to review the safety, quality and effectiveness of commissioned services. These visits also help develop and strengthen good working relationship between the commissioner and the provider.

We routinely monitor commissioner and provider Quality, Innovation, Productivity and Prevention plans (QIPP) and Cost Improvement (CIP) plans to ensure that we deliver on quality whilst meeting financial challenges. We use the operational delivery system to ensure quality impact assessments are carried out on proposed service changes and we will use the Star Chamber Methodology to determine the overall impact. We have a statutory duty to safeguard children and adults in partnership with other agencies locally. We are members of both statutory Safeguarding Boards and contribute to various working groups that ensure improvement in safeguarding activity continues. There are regular quarterly contract meetings with our main providers as well as multi-agency meetings with CQC regulators and CEC to ensure intelligence from providers is shared at an early stage of concerns locally. Friends and Family Test In April 2013 the Friends and Family Test was introduced across the NHS in England. The Friends and Family Test (FFT) is a survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. It also provides the opportunity for general feedback. The FFT for acute in-patients and patients discharged from A&E became mandatory on 1 April 2013. From 1 October 2013, all providers of NHS funded maternity services in England will ask women the same question.

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The results of the FFT are published online on the NHS Choices website. The FFT enhances patients’ choice with patients’ able to use the information to make decisions about their care and make comparisons between different providers. We use the information from the FFT to:

• Work with providers to identify areas of good practice, acknowledge what is going well and identify areas of weak performance to improve services for patients and families

• Look at trends in the FFT results to provide triangulation with other quality measures to provide a more in-depth understanding of issues and areas for improvement.

Complaints, Management of Serious Incidents and FOIs We are responsible for discharging its duty in respect of a number of statutory and regulatory requirements, together with NHS directives; which focus on patient safety for the population which we serve. The key components which we are committed to ensuring on-going compliance with and continual improvement of service are summarised in the table below:

Management of Complaints and PALS (Patient Advice and Liaison Service)

How we will deliver this

The Local Authority, Social Services and NHS Complaints (England) Regulations 2009 and The NHS Constitution places specific duties on the CCG. Duty to ensure complaints are:

• Dealt with efficiently. • Properly investigated.

and complainants are:

• Fully informed of the outcome of the complaint investigation.

• Advised of their rights to take Independent advice from The Independent Complaints Advocacy Service and the Parliamentary & Health Service Ombudsman.

Systems and processes are in place to provide a comprehensive complaints management service which includes: • A single point of contact for members of the

public/complainants. • Recording and documenting system for the

management and investigation of concerns and complaints.

• Act as a co-ordinating hub for the process of investigation of multiple commissioned provider complaints.

• Respond promptly to complainants on the outcome of complaint investigations, providing clear and concise explanations.

• Trend analysis of complaints to identify repeated occurrences and monitor effectiveness of implemented actions to improve commissioned service provision.

Management of Serious Incidents, Never Events and Incident Management


Patient safety directives set by the NHS Commissioning Board require the CCG to ensure key actions are undertaken as follows: • When a serious incident or never event does

occur, that there are systematic measures in place for safeguarding people, property and the services it commissions; and for understanding why the event occurred.

• Steps are taken to learn from incidents and to reduce the chance of a similar incident happening again in order to:

o Improve the safety of patients, staff and visitors

o Improve the work and care environment

Systems and processes are in place to provide a comprehensive Serious Incident, Never Event and Incident Management service which includes: • Single point of contact to receive notifications of

serious incidents, never events and incidents. • Monitoring progress of provider investigation

reports to ensure mandatory 45 day deadline is adhered to.

• Facilitation and co-ordination of sharing lessons learned across the CCG health economy.

• Trend analysis monitoring to identify repeat

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o Improve patient experience

occurrences and monitor effectiveness of implemented actions to improve commissioned service provision.

Freedom of Information Act 2000 (FOIA)


The aim of the FOIA is to promote greater openness in public authorities, about operational decisions and how public money is used.

The CCG is obliged to publish certain information regarding its function and commissioning activities.

In addition, the CCG is required to respond to information requests made by members of the public, except where an exemption applies.

Systems and processes are in place to provide a comprehensive Freedom of Information service which includes:

• Single point of contact for receipt, logging and management of requests for information.

• Establishment and maintenance of the CCG

Publication Scheme.

• Statistical analysis of information requests.

SMART Objectives 2014-2016: • Continue to monitor the provision of systems and processes which allow the CCG to

discharge its statutory duties in respect of patient safety. This process is managed through the Performance & Quality monthly meetings.

• Continue to monitor for changes in legislation and/or statutory regulations which impact on current CCG systems and processes which relate to patient safety.

• Continue to develop the Serious Concerns system to improve quality of commissioned services, this will include primary care (GP) services from April 2014.

Compassion in Practice

The National Nursing and Care Strategy states that leadership is necessary at every level of health and social care, ‘every person involved in the delivery of care needs to contribute to creating the right environment and providing clear leadership to patients, carers, staff and colleagues’.

The values and action areas of Compassion in Practice align with our vision in particular the 4 facets of quality identified and agreed with patients/service users and staff across South Cheshire referred to as CASE:

Care- the patient experience must be positive. Patients are treated as individuals and afforded dignity and respect

Accessibility- Patients must be able to readily access services. Services are designed to meet the different needs of communities and individuals

Safe- it is vital that we protect our patients and staff, and manage all risks effectively

Effectiveness- it is important that our interventions result in positive outcomes and that our work is cost-effective. Services must co-ordinate with other health and social care services to ensure patients receive seamless care

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We have responsibility for assuring quality in all commissioned services and driving up quality in primary care. The 6C’s present an opportunity to embed core values and provide a framework to develop quality putting the person at the centre, focusing on quality and challenging poor practice.

Actions/objectives taken and planned:

• Proposal for Governing Body to use the 6C’s as a checkpoint for all commissioning decisions • A Practice Nurse Membership Council established to: facilitate implementation of the

Compassion in Practice within primary care, ensure a consistent approach to quality within practice nursing and primary care, to have a clear nursing voice into the governing body

• Executive Nurse is working with a number of colleagues to develop a Leadership programme for Practice nurses the focus of which will be Compassion in Practice

• Through quality visits, patient feedback and contract monitoring actively seek evidence of how provider organisations are embedding the 6 C’s

• Quality and safeguarding strategy incorporates the values of Compassion in Practice • Work together with provider trust to develop and pilot a quality visit framework based on the 6

C’s identified in the Nursing and Care Strategy Our approach to quality is based on the well-established measures of patient experience, safety and clinical effectiveness as set out in the NHS Outcomes Framework. The aims of South Cheshire CGG are to:

• Put the patient at the centre to ensure that we listen, hear and learn from their experience • Support learning and development of all our staff to embed quality and safeguarding as the

foundation for all that we do • Continually improve our systems and processes for ensuring and assuring quality in all

commissioned services and primary care so that standards of patient safety and quality are understood, met and effectively demonstrated

• Work in partnership with key stakeholders to increase choice maximising the health and wellbeing of all patients and service users.

2014-16 will see the implementation of our South Cheshire Quality and Safeguarding Strategy; to ensure quality is incorporated into all aspects of our commissioning activities and our key aims achieved. The key components of the South Cheshire Quality and Safeguarding Strategy and the activities we have planned for the next two years are summarised in the table below: Priority Action

By when

Bringing Clarity to Quality

Use information collated from focus group events around Francis to confirm with patients, partners and staff what we mean by quality and implementing different approaches to monitor and improve Continue to develop mechanisms and ways of working together with providers, Local Authority partners, Health Watch and 3rd Sector to gather patient, carer and staff experience, data and evidence of impact on outcomes Work together with provider trust to develop and pilot a quality visit framework based on the 6 C’s identified in the Nursing and Care Strategy Work together with NHS England to further develop systems for quality improvement and monitoring

May 2014 December 2014 April 2014 December 2014

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Measure Quality

Implement the Quality of Health Principles as part of quality monitoring approach Work with local patient /service user groups and Health Watch to develop patient experts as part of quality visits Plan and carry out announced and un-announced quality visits to our providers, with Governing Body GP and lay members Develop quality assurance in care homes, implementing a quality dashboard Revise framework for Quality monitoring visits within Care Homes

March 2015 March 2015 Plan April 2014 June 2014

Publish Quality

Publish and share this quality and safeguarding plan with patients, public and providers including an easy read version and accessible presentation Quality reports to Governing Body in public will be published with the meeting paper s on the CCG website Ensure that take trends/themes to Quality Surveillance Groups in order to work collaboratively with other CCGs, NHS regulators, Local Authorities, Health Watch and NHS England in order to have whole system intelligence that informs quality improvement Statutory safeguarding inspection reports, improvement plans and annual safeguarding report

May 2014 May 2014 On-going

Reward Quality

Commissioning for Quality and Innovation (CQUIN) schemes will be developed to incentivise local priorities for improvement with providers Primary Care CQUIN/QoF will be reviewed annually and re focused to maximise health outcomes where the CCG has any influence over indicators

From April 2014 From April 2014

Leadership for Quality

Use the organisation development plan to build a culture throughout the organisation that supports the CCGs vision and values, embracing the 6C’s, valuing quality at the heart of everything we do Develop and deliver a leadership programme for Practice Nurses focused on implementation of the 6C’s Delivery plan to Ensure GPs and other clinicians are fully engaged in the quality assurance system and processes via on-going workshops, GP and Practice Nurse Membership council/assembly. Agree and implement a mechanism to always engage clinical and service user expertise in commissioning of services to ensure consideration of ‘reasonable adjustments’ for patients with disability(physical, mental health and learning disability) Continue to build relationships with our health and social care providers, patients and public in providing information about the quality of health services to inform service redesign Establish a Practice Nursing Membership Council/Assembly to implement the 6C’s and empower PN voice Develop a local implementation plan for 6C’s in Practice Nursing Establish a primary care quality development group

April 2014 Plan in place by May 2014 Plan in place by September 2014 On-going Achieved April 2014 Achieved March 2015 June 2014 October 2014

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Develop a primary care quality framework Establish a clear process to engage with all patient and carer groups in particular increasing the voice of ‘harder to reach’ groups i.e. children and young people, people with disability (physical, mental health, learning disability) Develop a system of quality continual improvement that is provider led

Innovate for Quality

Work with key partners to agree and develop innovative ways to use clinical audit approaches, evidence and research to support quality improvement Work in partnership with all key partners to ensure that vulnerable groups have fair and equal access to services and experience best care ensure that there is a structure in place to follow any suggestions or ideas through, provide feedback and understand how innovation can align to clinical priorities Patient stories to be presented at Governing Body to provide further opportunity for learning and challenge

December 2014 On-going March 2015 September 2014

Safeguarding Quality

Contracts with our providers to include safeguarding, all elements of quality and patient safety Seek evidence through contract monitoring and quality visits Have safeguarding dashboards for both children and adults in the main contracts that are monitored quarterly Completion of the annual safeguarding assurance framework, organise confirm and challenge focus group Support providers to have robust systems to monitor and respond to trends and themes Share lessons learnt from serious incidents, complaints and any patient safety issues and build systems to ensure necessary changes are implemented Work with Membership assembly/council to identify a lead for safeguarding in each GP practice Develop a robust partnership with Regulators (CQC) and Local Authority safeguarding teams to have early warning systems in place across all providers locally

Achieved September 2014 June 2014 On-going May 2014 On-going May 2014 April 2014 On-going On-going

Staff Satisfaction and Workforce Development We have developed both an Organisational Development Plan (OD Plan) for the next two years 2014-16 and an HR Strategy to cover the same period. The OD Plan identifies needs fed from the Personal Development (PDP) processes, as well as Membership and Governing Body analysis. The OD Plan supports the transformational agenda ensuring that knowledge and skills in leading change, applying new techniques such as quality systems improvement (for example Lean and Vanguard), developing a robust Governing Body with the required skills, project management skills, senior leadership and management skills, clinical leadership skills etc. The OD plan:

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• Has been developed with staff • Draws from the Francis Report, bringing together key Francis report recommendations and

priorities for example staff training, the promotion of good governance and leadership • Identifies employed staff, lead clinicians, Governing Body and Membership needs.

The OD plan and agreed objectives cover the following areas of development:

• Leadership, Workforce and Team Development • Member Practice Engagement • Values, Style and Change Management • Complaints and SUI’s • Strategy and Performance Management • Communications, Engagement and Collaboration

The HR strategy supports us to ensure good HR policies and procedures are in place and are understood by employees of the CCG. This ensures that we meet our statutory requirements as an employer and is also able to include GPs, and practices as Member constituents, in a fair and equitable manner. We have carried out a staff survey internally to help shape and improve the organisation and demonstrate staff involvement and engagement at an early stage. We intend to repeat staff surveys on a regular basis for staff to continue to feel involved in the development of the organisation. This approach has also included Membership Council and practices to identify additional actions we need to take, to ensure continued engagement of its Members. i.e. the introduction of a regular newsletter to practices about the work of the CCG and Quality Improvement Facilitators to improve quality of primary care and delivery of CCG objectives. Seven Day Working We are identifying in Local contracts for 2014/15 t h a t t h e y should include an action plan to deliver the clinical standards identified within the Service Development and Improvement Plan section of the 7-day Forum’s report; A local Commissioning for Quality and Innovation scheme should be considered based on time from arrival to initial consultant assessment

8.3. Innovation & Research We are not a teaching CCG and the PCT had research support from Keele University. This was largely primary care research with Keele; studies that were separately or centrally funded. The practices and patients provided the population base for the primary care musculoskeletal focus of the university. This work continues unchanged at the moment.

Other areas of interest require contact and travels to other centres. It is possible to undertake postgraduate study at many Universities but there is contact with Manchester and Liverpool. There is no funding from the CCG to support these clinicians and no list of those engaged.

We have contacted and are working with Lancaster University School of Design to understand and help to design Mental health services.

Funding for research into the CCG is based in Liverpool. Liverpool University holds the CLAHRC funding in this area. Their bid was created with Liverpool Teaching CCG. Participation requires matched funding from the CCG. The CCG would like to be involved with projects on health

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inequalities and the use of Generalism to redesign services. This will require specific research questions and funds and as yet no money has been committed.

We are keen to be involved in research and is actively working with NIHR research project into leadership style involving Open University and University College London. CCG leaders are actively co-producing this research. This project is externally funded.

8.4. Information and Technology At South Cheshire CCG we recognise that to deliver system change and integration across our health and social care landscape we need to make improvements and changes across Information Technology and the way in which we share information. We aim to deliver a better standard and experience of joined up care focusing on the support, integration and interoperability across existing clinical systems. Our ambition is to bring together health and social care to commission and deliver seamless patient flows and care packages: linking these with the aims of the Pioneer proposal and Connecting Care Boards requirements. We have an IT Strategy agreed, which sets out a framework for the transformation of services across the health and social care system.. Throughout 2014-16 we will be working with our partners including, HSCIC, Cheshire and Merseyside Commissioning Support Unit (CSU) and the NHS Area Teams to mobilise our IT programme and portfolio of projects to ensure that a robust governance structure is in place to monitor delivery and provide an appropriate decision making. In addition to the Capital Bid Programme, we will continue to support national, regional and local initiatives to improve service delivery. A summary of some of our key projects are detailed below. We have achieved over 90% adoption of the NHS number across local health and social care providers in 2013 through extensive use of EMIS and local authority agreement. Electronic Prescribing Service (EPS) Release 2: This has been nationally mandated for implementation across all GP Practices. EPS enables prescribers - such as GPs and practice nurses - to send prescriptions electronically to a dispenser (pharmacy) of the patient's choice. This makes the prescribing and dispensing process more efficient and convenient for patients and staff. The rollout will run from Q1 2014 until end of Q4 2015. We will work with their CSU partners, GP Practices, Medicines Management and EMIS to ensure planning and delivery is scheduled in a joined up process across Cheshire ensuring the identification of key pilot sites and that minimum impact to practices is maintained. It is anticipated that the lifecycle for each practice will be twelve weeks from engagement to implementation. Benefits:

• Patients can collect repeat prescriptions and will not have to visit the GP practice to pick up your paper prescription. GPs will send the prescription electronically to the place you choose, saving time. The prescription is an electronic message so there is no paper prescription to lose.

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• Increased Patient choice about where to get medicines from because they can be collected from a pharmacy near to where patients live, work or shop.

• If the prescription needs to be cancelled the GP can electronically cancel and issue a new

prescription without patient return to the practice.

• Patients may not have to wait as long at the pharmacy as the repeat prescriptions can be made ready before they arrive.

National Summary Care Record (SCR):

The Summary Care Record (SCR) is an electronic summary of key health information from a patients GP practice record which is securely held on the National Spine. A core SCR contains a patient’s medications, allergies and adverse reactions. Changes made to these core data items in the GP record will be updated in the SCR automatically. The SCR is optional; the patient is in control and can choose to opt out of having an SCR or change their mind at any time. Authorised healthcare staff can access the record to help with the care they provide to patients in urgent and emergency situations, where access to this information can be difficult to obtain in a timely manner. Summary Care Record is the only national record sharing solution, SCR has many high level benefits including improving patient safety, increasing efficiency and effectiveness and increasing quality of patient care. The rollout is due to be completed by end of Q4 2014 in South Cheshire. Benefits to GP Practices include:

• GPs will be able to view an SCR for treating temporary residents / unregistered patients • GPs will know that their patients are being treated in out of hours or in urgent care settings

across England using accurate, up to date information. • Hospitals and pharmacies often have to telephone GP practices and ask for clinical information

when admitting a patient. This is a significant inefficiency for both the acute staff and GP staff. The SCR has been shown to reduce the need for many of these types of calls.

SCR is in the GP Contract for 2014, all of the population of England have been informed that their GP practice is going to be creating SCRs. Currently there are over 32 million patients in England that have an SCR created (circa 53% of the national population), and this figure is expected to rise significantly over the coming months (increasing at a rate of circa 200,000 records a week). Windows XP to Windows 7 and Office 2012 Upgrade: There is a requirement to upgrade the operating system on all Desktop / Laptop devices in the GP Practices following Microsoft’s formal statement released to the public and private sectors, with a clear date for end of their current product support for Windows XP of April 8th 2014. This will include the replacement of GP Practice PCs that are five years or older. The rollout will run from Q1 2014 until end of Q2 2014. Benefits to GP Practices include:

• Enhanced technology and upgraded operating system enabling future requirements • Remove potential security risk due to Microsoft support finishing • Upgrade of Microsoft Office suite to ensure compatibility to with other organisations

Wireless into GP Practises: We are developing proposals for submission to NHS England for the provision of Public Wi-Fi across

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all South Cheshire GP Practices by March 2015. It is proposed this development will also incorporate the installation of patient access and information screens as required in the GP Practice and public access to services and potential for information capture and patient feedback. Benefits to GP Practices include:

• Installation of patient access and information screens as required in the GP Practice • Public access to services and potential for information capture and patient feedback

Development of integration Disease registers: We are working with MCHfT in the development of hospital disease registers. Currently Hospital IT is targeted at single aspects of care, but disease registers will enable audit and research and provide better joined up care across boundaries. Disease Registers will support detailed information needs and analysis that is currently only available from paper records, and to a very limited extent. Disease registers will enable audit of the whole hospital population with a disease and a move to criteria and standards to demonstrate the hospital performance on finding managing and controlling disease. Integration planning with primary care provided scheduled Q.2 2014. CCG input will be required in the planning and implementation of this work. Benefits:

• Disease register at MCHfT will provide better information of the causes of hospital admissions and allow the CCG to target commissioning more effectively.

• Disease registers will enable a step change in quality and information on performance for

dissemination to the public.

• Population disease registers will enable information on whether specialist care treats or helps the whole population with a disease and audit of which diseases benefit form specialist management.

Cheshire Health Record: The Cheshire Health Record utilises the EMIS Web application to enable doctors, nurses and other local healthcare professionals working in Cheshire accessing a consenting patient’s summary of their GP patient record. This may occur in hospital or unplanned care settings such as A&E or Out of Hours centres. Access will also be available to some community providers. The system is designed to provide essential, timely medical information that will allow other health professional staff to make decisions about the treatment they provide for the patient, based on up to date and accurate information. Work commenced in Q4 2013 with colleagues at MCHfT, CSU, GPs and Cheshire NHS colleagues to re-establish requirements and data sharing activations for key clinical conditions across Cheshire. Further work with EMIS is required to evaluate activate data sharing agreements where required and resolve outstanding issues with notifications in the Primary system, this is causing a potential risk of delay until resolved. All required activations and sharing agreements planned to be in place before end of Q4 2014. Benefits:

• Sharing information between partner organisations is vital to the provision of coordinated and

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seamless services. In addition, the sharing of information can help to meet the requirements of statutory and local initiatives.

Risk Profiling and Stratification: There are currently multiple options available within the CCG for use by GP practices, to date these options have yet to deliver the required outcomes and data expected with development still progressing. A new option for has been discussed with EMIS potentially removing some issues experienced with processing the data extracted. Once a viable solution is agreed this can be used as an enabler but not limited to Neighbourhood teams. Eclipse Third Party: Primarily focuses on medicines and assesses the risk to the patient based on the individual patient’s current medicines. There is a view in the CCG that risk profiling should be more patient focused and include a wider range of risk factors than medicines. If risk assessment involves installing safety fittings in patients home, e.g. to reduce risk of falling, then cost will increase. To date Eclipse have been unable to prove any tangible solutions for their product, therefore a short term solution is being explored using a CSU offering being used across Vale Royal practices. EMIS: We have recently engaged with EMIS to be a part of their Early Adopter Programme (EAP) in the North of England. This EAP will involve the development with a GP practice of the functionality and outputs for this module. EAP will be a free development programme with the supplier and will look to start Q2 2014 after CCG Board approval. EMIS developments: We are currently working with the EMIS accounts team on future developments of the Primary Care system, the below examples will be the enablers to fulfil the required integration for commissioning intentions, Extended Practice teams, Mandated requirements, and providing patients with fuller and easier access to their GP record.

• New Risk Stratification Early Adopter Programme • Care Planning modules • Integration of EMIS Community and EMIS Web datasets • Patient access to GP records • TeleHealth Integration via Black Pear Partnership • EPaCCS - (Electronic Palliative Care Data set and Integration) • Integration with new MCHfT EPR • Integration with existing Primary Care system and “out of hours” and 111 • MIG integration for associated providers

A full schedule of deliverable timescales and associated pilots will follow during 2014 and will be part of the on-going development programme with our EMIS Partner, CSU, Cheshire NHS organisations and required integration with Social Care and MCHfT. Telehealth/ Telecare: We will use latest risk profiling technology and Telecare / Telehealth technology to identify people at risk and to treat more patients within their own homes, Patients will be able to use technology in their own home to participate in the management of their condition. We are currently working with MCHfT and a third party provider, Tunstall, on a pilot in South Cheshire. This will include the identification of the correct type of conditions and associated patients. The Pilot, upon GP partner approval, will begin in Q2 2014 for 6 months, and for an expected 10 patients. There will be a benefits review after the pilot and decision on future Telehealth and Telecare

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requirements. Other providers are also being considered for similar type of pilots. Improved Data Sharing and Transparency: Working with colleagues and current / new partners to identify and plan for the delivery of integrations across Primary Care, community and Social care settings by connecting data and information across pathways, seamlessly integrating across organisations and systems including:

• health & social care • separate specialities within health services • services provided in the community and services provided in the hospital

To pursue this strategy we will improve and extend the sharing of clinical information within primary care, and between primary care and secondary care. We are planning for care.data to join up clinical data sets through HSCIC improving access for commissioners to high quality delivery data and for individual patients to access their own health record to improve transparency of information. By summer 2014 at least 5% of GP practices should be linked to hospital data and our strategic plan 100% coverage will need to be refreshed with partners during 2014. Benefits to clinicians:

• Analysis of the patterns of care received by patients with long-term conditions would lead to significant improvements in care.

• Improved monitoring of outcomes through linkage between primary and secondary care. • Improved monitoring of performance through linkage between primary and secondary care • Earlier diagnosis of illness • Improving contribution of primary care to wider CCG outcomes • Improved data quality • Monitoring and understanding trends • Predictive modelling • Evaluation of prevention services and interventions • Exploring patient pathways • Detecting unwarranted variation

GP Access to Radiology Reports: 2014/15 will see South Cheshire CCG delivering a pilot to promote GP access to radiology reports in primary care. Medical Information Gateway (MIG): This will be a joint venture with other Cheshire NHS organisations to establish technical interoperability and potential use for our Pioneer objectives. Benefits:

• Shared view of interoperability future • Improve patient care • Improve clinical efficiency • Recognition GP systems contain rich clinical records • Open to ALL Healthcare system suppliers • Secure Gateway for exchanging bi-directional Real time data between Primary Care and other

health and Social Care Settings plus a best price option • MIG Infrastructure

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• Intelligent brokering, routing and mediating • Single technical entry point • Accredited by NICA Technology Office- Department of Health

• Use Case Services • Data flows- based on Message sets • Accredited to NHS ITK Toolkit Standards • Payload Message independent

8.5. Medicines Management

The Medicines Management Team supports the Starting Well, Living Well and Aging Well Programmes with commissioning services that make best use of medicines. In addition, pharmacists and technicians work closely with general practices and Acute Trust clinicians to:

• Maintain control of primary care prescribing costs to manage growth and remain within the allocated budget.

• Develop systems for managing use of High Cost Drugs (excluded from Payment by Results [PbRe]) to allow monitoring of activity and budgetary impacts and provide assurance of compliance with guidance (e.g. NICE Technology Appraisals).

• Implement projects/ actions to optimise the use of medicines to improve outcomes, enhance patient safety and improve capacity within the local health economy.

Compared with peers, South Cheshire CCG has had lower costs per population (population weighted for age and sex) in 6 of the last 8 quarters with costs being slightly higher in the Oct-Dec quarter in the past 2 years. The Medicines Management Team working with the GP Prescribing Lead and local prescribing and medicines management committees will support the CCG to continue to maintain prescribing growth at or below the national average. Higher level actions to achieve the priority objectives are set out in the table below:

Priority Objective

Planned Actions Deliverables

Maintain control of primary care prescribing costs

Maintain and develop the Local Health Economy Formulary including a work plan taking into account NICE Technology Appraisals programme, new product introductions and patent expiries (D1,D2,D3)

Forward schedule completed by 1 April 2014 Formulary updated monthly thereafter Action plan developed by 1 April 2014

Trajectory:

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Understand and address savings opportunities identified in the Right Care data packs8 (prescribing savings have been identified in the data pack for South Cheshire CCG in the following areas: Gastrointestinal Respiratory System Problems Neurological System Problems Endocrine, Nutritional and Metabolic Problems Genitourinary)

Savings of £522,000 delivered by 31 March 2016 (based on capturing 50% of the potential savings if the CCG performed at the average of 10 similar CCGs)

Work with practices to minimise variation between them and so improve overall performance on the nationally identified medicines QIPP topics9 .

South Cheshire CCG has improved the status of at least 3 QIPP indicators by at least 1 quartile by 31 March 2016

Continue to develop locally identified prescribing savings opportunities for implementation at practice level including selection of more cost effective prescribing choices (e.g. blood glucose testing strips) and systems (e.g. alternative means of managing the supply of appliances).

Savings on Blood glucose testing strips to be delivered by 1 June 2014

Develop systems for managing use of High Cost Drugs (excluded from Payment by Results [PbRe])

Continue phased introduction of the Blueteq system to capture the information on usage and provide clinical assurance of compliance with NICE guidance and local protocols (D4)

Blueteq system in use by dermatology, gastroenterology and rheumatology in MCHFT by 1 September 2014

Develop budget management processes for High Cost Drugs (PbRe).

Develop budget management process by 1 April 2015

Implement projects/ actions to optimise the use of medicines to improve outcomes, enhance patient safety and improve capacity within the local health economy.

Develop the capability of prescribing support software (Eclipse Live and Scriptswitch) to support improvements in patient safety (D1, D2, D5)

Eclipse Live available to all practices by 1 April 2014

Work with the Quality team and local Acute Trusts and Primary Care to implement the Medicines Safety Thermometer and medicines-related CQUIN schemes and Quality Schedule requirements. (D5)

By 1 June 2014

Develop a local strategy to reduce the pressure on antibiotic resistance and support providers to meet targets for incidence of Healthcare Acquired Infections including MRSA and Clostridium difficile (D5)

By 1 June 2014

Implement the extended Think Pharmacy; Minor Ailments service to support the Urgent Care Working Groups to reduce demand in general

Service launched by 1 April 2014

8 http://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/ 9 Quality Innovation Production and Prevention topics see http://www.nice.org.uk/mpc/keytherapeutictopics/KeyTherapeuticTopics.jsp

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practice and Accident and Emergency departments.10 (D3) Work with the local Acute Trusts to improve financial and clinical governance for patients receiving medicines from Homecare services.11 (D2)

Hackett report implemented by 1 April 2015

8.6. Procurement of Healthcare

We have developed and implemented a local policy on the Procurement of Healthcare services. This policy follows the implementation of the NHS (Procurement, Patient Choice and Competition) (No2) Regulations which were implemented under section 75 of the Health and Social Care Act 2013 on 01 April 2013. The Policy also takes into consideration the substantive guidance published by the Regulator – Monitor in May and December of 2013. The aims of our approach are specifically to promote: • Choice: ensuring a range of providers for our population to choose from • Competition: encourage a degree of competition within the health system, with the aim of

continuously improving quality of service and innovation • Consistency: ensuring clinical safety, equity of access and quality of outcomes for our patients Implementing our approach will ensure that through the utilisation of best practice procurement processes we are able to: (i) Demonstrate value for money for all expenditure of public money, (ii) Adhere to relevant legislation governing the award of contracts by public bodies, (iii) Comply with our own Standing Financial Instructions/Standing Financial Orders (SFI’s/SFO’s) We have adopted a proactive stance towards securing services that meet the needs of the local patient population and competitive procurement will be a key part of this in the coming years; as will the option for greater integration within the existing health economy. To support consistency in the decision making process regarding the use of competitive procurement, a key part of our approach will be to adopt a decision making matrix which will support a clear and unbiased decision. We will adopt a fair, open and transparent approach, publishing procurement opportunities and decisions related to the contracting of services. To facilitate the procurement process, the CCG will utilise the professional procurement team at the Cheshire and Merseyside Commissioning Support unit to provide an overarching procurement support service. Utilising one of the nationally accredited CSU’s will ensure that the CCG remains compliant with the procurement regulations and obtains maximum benefit from the procurement process. We are reviewing contracting and commissioning activity as contracts expire, areas currently subject to a competitive procurement process include Community Stroke services as a competitive tender and additional Elective Services via an Any Qualified Provider exercise. An annual work-plan of activity will be developed each year so there is full oversight of the competitive procurement activity at CCG level. In addition to the proactive approach to the procurement of healthcare services, we will encourage the adoption of the ‘Better Procurement, Better Value, Better Care’ guidance which was published in

10 http://www.monitor.gov.uk/closingthegap 11 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213112/111201-Homecare-Medicines-Towards-a-Vision-for-the-Future2.pdf

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2013. As well as adopting the principles in the procurement of all internal goods and services, we aim to include a mandate around the adoption of the same principles into all standard contracts held with local NHS Providers, ensuring that the overarching health economy takes responsibility for improving procurement efficiency for the benefit of patient care.

8.7. Delivering Value – Financial Summary The financial plan is intended to cover a 5 year period with the first two years providing the detail required to monitor the CCG financial performance at an operational level. The financial plans are prepared based on assumptions and rules set out by NHS England. Additional information on local trends and the impact of local commissioning intentions are also included in the plan to giving a view of the financial health of the CCG. The financial plan is aimed at producing a sustainable, high performing organisation commissioning care for its population. Revenue Resource Limit CCGs are funded based on the size of their population and its demographic make-up. The details of the South Cheshire population are included in section 5 and so are not discussed here. A new allocation formula was developed and tested during 2013/14 and is being introduced in 2014/15. The new formula takes into account three main factors in healthcare needs: population growth, deprivation and the impact of an ageing population. Ten percent (10%) of the total available funding is based on a deprivation indicator to reflect unmet need, enabling CCGs to tackle the impact of health inequalities. In 2013/14 we have been funded at (£1.085 per head) a lower than average allocation per head of population (£1.115 per head). If NHS England had moved the CCG to the national target allocation per head we would have received an additional £12million, however only a small element of this has been reflected in the new allocations, as nationally it is recognised that a pace of change is required. We have received notification of a two year allocation, a summary is shown in the table below:-

It can be seen that the revenue funding per head has increased by £29 per head of population for 2014/15. The allocation for 2015/16 increases again by £25 per head and the CCG moves closer to target by 1.02%.

Programme Allocation 2013/14 2014/15 2015/16£'000's £'000's £'000's

Allocation 187,094 191,446 197,482 Growth 4,352 6,036 5,634 Sub total 191,446 197,482 203,116 Population ( registered) 176,449 177,339 178,251 % Growth 3.15% 2.85%Revenue Allocation Per Head of Population 1.085 1.114 1.139Target Revenue Allocation per Head of Population 1.187 1.202Distance from target -0.073 -0.063% distance from target -6.19% -5.17%

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The movement towards target is positive for the CCG however South Cheshire still remains below the average for the North of England in 2015/16 by £120 per head of registered population and below its target allocation by £63. The graph below shows the relative funding for South Cheshire CCG in comparison to other CCGs in the North of England:-

Planning Assumptions The plan developed by the CCG is governed by a number of planning assumptions issued by NHS England. The table below indicates the planning assumptions relating to provider services. The providers are required to make year on year efficiencies of 4% for the next 5 years with recognition of an inflation increase of between 2.2% to 3.4%

Nationally the CCGs are provided with the following commissioning assumptions. A number of areas are identified for local determination based on local knowledge. These are supported by a number of business rules from NHS England in relation to allocating monies either to protect the CCG from risk (contingency 0.5%) or to indicate where non recurrent spend should be identified to be targeted at transformational change.

Table of Assumptions 2014/15 2015/16 2016/17 2017/18 2018/19Secondary Care Health Cost Inflation 2.30% 2.20% 3.00% 3.40% 3.40%Provider Sector Efficiency -4.00% -4.00% -4.00% -4.00% -4.00%Tariff Deflator -1.70% -1.80% -1.00% -0.60% -0.60%

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These assumptions are derived or adopted to allow the CCG to produce financial plans which reflect the on-going commissioning of services in South Cheshire to ensure that finances are in place to support additional demand or to support service redesign. Better Care Fund One of the main strategic drivers nationally is for social and health care commissioners to work more closely together. In order to facilitate closer working the Government has identified the Better Care Fund which will be a pooled resource to facilitate joint planning, information sharing and services. The Department for Communities and Local Government and the Department of Health has identified £3.8 billion of funds for investment in this integration. £3.4 billion is expected to come from CCG budgets; in order that the creation of the fund does not result in a financial pressure the associated investments will need to identify significant transformational change to reduce demand for social and health care. If these changes do not lead to more effective use of services this could result in a financial pressure across the health and social care system. Draft plans will be jointly agreed between South Cheshire CCG and Cheshire East Council by the 14th February. The overarching local Pioneer Project Connecting Care will provide a structure for the development of these plans. The total better care fund to be identified by the CCG is £10.481 million. The table below shows the National and local picture.

Demographic growth

Demographic growth Tariff Changes

Price Inflation-Prescribing

Price Inflation - Continuing Health CareLocal Determination - expected to be in a range of 2% to 5% per

annum increase2014/15- Minimum 0.5% Contingency- 1% cummulative Surplus- 2.5% non recurrent spend ( including 1% for transformation)

2015/16- Minimum 0.5% Contingency- 1% cummulative Surplus Carry Forward- 1% non-recurrent spend- Better Care Fund as notified £10.481(additional) ( including 1% for transformation)

CCG Commissioning Assumptions

Business Rules

Local Determination using age profiled population projections

Local Determination based on historic analysis and evidenceSee Below

Local Determination - expected to be in a range of 4% to 7% per annum increase

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The funding will formally sit with the local authority and will be overseen by the Health and Well Being Boards and be subject to assurance from NHS England. Financial Plan 2014/15 -2015/16 An early draft financial plan was produced and early presented to the Governing Body in January 2014, a summary is shown below:-

The initial budget has identified a planning gap which will be removed over the period to March producing a balanced budget. The financial plan for the CCG will be finalised and presented to the CCG Governing Body in March 2014. The national planning assumptions previously identified have been adopted in producing the financial plan. The key challenges have been to identify the contingencies and non-recurrent funding to allow for risk and non-recurrent support to transformational change and the creation of the Better Care Fund. Key Budget Background

National £3.8bn 2014/15 2015/16£ billion £'000's £'000's

£0.9 billion already transferrd to fund social care in 2013/14 ( via NHS England) 0.9 2.4An additional £0.2 billion in social care from CCG resources in 2014/15( via NHS England in 14/15) 0.2 0.8

£0.4 billion of Capital Grants carruently Administered by the Department of Health and other Government Departments 0.4£0.3 billion Reablement 0.3 1.1 1.1£0.1 billion Carers Breaks 0.1 0.2 0.2An additional investment from CCG budgets of £1.9 billion 1.9 5.9Total 3.8 1.3 10.4

Better Care Fund

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Provider Services (Acute, Ambulance, Community and Mental Health Services) Planning assumptions have indicated a reduction on the overall provider funding of 1.7% in 2014/15 (1.8% in 15/16) this is constructed from an increase for inflation of 2.3% in 2014/15 (2.2% in 2015/16) and a cost improvement target of 4%. The quality and innovation payment (CQUIN) remains a non-recurrent allocation of 2.5% as in 2013/14. There has been on-going pressure on the CCG provider services budgets during 2013/14, previously pressure has mainly resulted from additional urgent care demand, however in 2013/14 the additional pressure on resources has resulted from increasing referrals and the resultant elective care. In 2013/14 there was a significant risk related to Specialist Commissioning and the changes identified, it is anticipated that this area has now mainly resolved. The main challenges in 2014/15 are;-

• the on-going drive to improve the effectiveness of the Urgent Care Services leading to a reduction in demand and;

• maintaining the 18 week target and other constitutional requirements whilst keeping financial control on the elective services costs.

• The impact of counting changes proposed by our main acute provider The CCG is in 2014/15 – 2015/16 trying to develop a new collaborative contracting approach between our main acute, community and mental health providers using either alliance or lead contractor models. DN insert list of contracts over £250k for 2013/14 and subsequent years Prescribing Primary care providers within South Cheshire CCG have always maintained a focus on efficient and effective prescribing, the details of the medicines management actions to control expenditure can be seen in the dedicated section 9.5. Continuing Health Care and Funded Nursing Care There is pressure on these budgets locally due to the demographic changes and the increasingly aged population. Primary Care The planning guidance has indicated the need to increase expenditure in services identified by primary care which will support the transformation of care of patients aged 75 and older. It is expected that this will be in the region of £5 per head (£885,000) Running Cost Allowance The CCG has planned to reduce its expenditure in this area by 10% in 2015/16 in line with national guidance. DN for the final plan a full analysis of expenditure with graphical representation will be inserted at this point. Quality Innovation Productivity and Prevention (QIPP) 14/15-2018/19

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In 2009/10, it was recognised nationally that the NHS would be required to save £20 billion by 2014/15 in order to fund increased costs and demand pressure. It has been further recognised that the NHS savings required in the four years from 2015/16 to 2018/19 will be an additional £30 billion i.e. a total NHS savings requirement of £50 billion over a period of 8 year. The potential challenge to the CCG’s local economy can be seen in the table below:-

Locally the initial CCG requirement in respect of the £20 billion has been achieved. The additional financial challenge has been identified above. The response to this challenge is limited in the next two years as the transformation change is embedded particularly in respect of the Better Care Fund. The most significant projects delivering change and productivity are:-

• Transitional Care Beds impact Urgent Care • Extended Practice Teams impact Urgent Care • Redesign Urgent Care 24/7 impact Urgent Care • Stroke Rehabilitation impact Urgent Care • Better Care Fund impact Urgent Care • CCG Commissioning for Value impact Elective Care • Improved Procurement driving Value for Money • Information Sharing and additional ICT developments in Primary Care

Quality, Innovation and Prevention is included within the appropriate sections of the plan. DN Insert the analysis of projects and associated productivity savings. Key Financial Priorities for 2014/15 to 2018/19 The CCG has a number of statutory financial and national requirements the key items are identified:-

• To maintain a balanced position and deliver the 1% surplus as required by the NHS England; • To deliver our QIPP targets whilst ensuring that we are delivering improved care to patients; • To invest the commissioning budget to maximise value for money; • To ensure the financial resources are applied to support the CCG commissioning Strategy; • To utilise the Better Care Fund in 2015/16 locally on health and care to drive closer integration

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and improve outcomes for patients and service users and carers; • To remain within the CCG running cost allowance of £25 per head of population; • To set aside 2.5% of recurrent resource for non-recurrent expenditure in 2014/15; 1% of this

spend to be applied to transformation of local services, focusing on preparation for the introduction of the Better Care Fund.

Key Financial Risks:

• increased pressures in elective and non-elective care, continuing health care, funded nursing care and learning disabilities services;

• changes to the learning disabilities pooling arrangements • ensuring the drive to closer integration can be achieved within existing allocations and change

recognised through provider contracts; • ensuring the 2.5% in 2014/15 and 1% in 2015/16- 2018/19 is identified for non-recurrent

expenditure to enable change, given the scale of the challenge and the requirement to maintain financial balance, this is a key risk;

• ensuring the financial risks associated with the introduction of Personal Health Budgets is managed, particularly in respect of safeguarding;

• the productivity requirements are achieved to deliver the CCG element of the £30 billion national productivity challenge

• identification of an additional £5 per head to invest in primary care identified additional support services for the over 75s.

Capital Plan

The CCG has applied for the capital resource identified above. Cash The planning assumption is that cash matches the CCG planned resource, adjusted for working balances. Statement of Financial Position (Balance Sheet) The CCG planned Statement of Financial Position is shown in the table below:-

Capital Programme 2014/15 2015/16£000 £000

Capital Grants -Commissioning Intentions 96Rolling IT Equipment 26 26Bevan House refurbishment 128Total 250 26

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The above statement shows anticipated assets, liabilities and taxpayers’ equity for the next two years. Risk Management: We maintain an Assurance Framework in accordance with the governance regulations applied to the NHS, which allows the Governing Body to consider the risks that may prevent them from delivering the strategic objectives and eventually its statutory duties. The Assurance Framework is a self-assessment process which allows the Shared Management Team and the Governing Body to identify where it may need to prioritise the use of resources to improve services – disinvest or slow development to achieve strategic objectives/ financial balance. Risks are scored using the system based on likelihood of the risk occurring and the impact if the incident were to occur (a modified Australian scoring system). The high level risks on the Assurance Framework give details of the controls and actions in place to address the risks. These are reviewed by the Governing Body on a monthly basis. The Governance & Audit Performance Work Group regularly reviews and discusses the High Level Risks (above 12) and the Programme Boards update and review the Assurance Framework monthly.

2014/15 2015/16PPE 250 276

Accumulated Depreciation (25) (50)

Net PPE 225 226

Non-Current Assets 225 226Cash 6 6

Accounts Receivable 700 700

Inventory 0

Investments 0

Other Current Assets 0

Current Assets 706 706TOTAL ASSETS 931 932Trade & Payables (11,000) (11,000)

Provisions (400) (400)

Short Term Borrow ing 0

Current Liabilities (11,400) (11,400)Non-Current Payables 0

Provisions 0

0

Long Term Liabilities 0 0total Assets Employed (10,469) (10,468)General Fund (12,489) (12,538)

Retained Earnings In Year 2,020 2,070

Total Taxpayers Equity (10,469) (10,468)

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9. Key Trajectories The following section of this plan provides the key trajectories needed to support the assurance of, and measure performance against the strategic plan. The plan will deliver improvement against the measures to support the seven outcome ambitions are as follows: Clostridium Difficile The national target for South Cheshire has been set as 33. We will aim to reduce this by a small proportion (1). Dementia diagnosis The CCG seeks to improve the ability of people living with dementia to cope with symptoms, and access, treatment, care and support. The table below illustrates the CCG projected diagnosis rate for people with dementia, expressed as a percentage of the estimated prevalence.

IAPT coverage and recovery The table below illustrates that over the next year we will support our provider to achieve a 50% recovery rate.

Other Activity Measures: E.C.7-8: A&E Attendances This activity measure considers the number of attendances at accident and emergency departments. (Data Source: A&E Attendance figures are sourced from weekly SitRep data provided to a central Unify2 collection by Trusts – this is a weekly total taken from a reporting period of 00.01 Monday to 24.00 Sunday).

E.A.S.1number of people

diagnosedPrevalence of dementia

% diagnosis rate

2014/15 1460 2194 66.55%2015/16 1497 2234 67.01%

The number of people who have completed treatment having attended at least 2

treatment contacts and are moving to recovery (those who at initial assessment achieved "caseness" and final assessment did not)

(The number of people who have completed treatment

within the reporting quarter, having attended at

least two treatment contacts) minus (The

number of people who have completed treatment not at clinical caseness at

initial assessment)

% recovery rate2014/15 562 1124 50.00%2015/16 579 1135 51.00%

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Threshold The CCG seeks to ensure that patients requiring urgent and emergency care get the right care by the right person at the right place and time. There are instances where people presenting to accident and emergency departments because they either do not know how, or are unable, to access the care they feel they need when they want it. NHS 111 will assist patients in finding the most appropriate and convenient service for their needs so they receive the best care first time. A reduction in the growth of the number of A&E attendances may indicate a more appropriate use of expensive emergency care, and improve use of other services where appropriate. The table below illustrates attendances calculated according to prov/Com allocations 2012/13.

Seven Outcome Ambition Measures Outcome Ambition One (Please note that this is draft at the point of submission) Our ambition for securing additional years of life from conditions considered amenable to healthcare.

A table to show the percentage years of life lost per 100,000 population

A&E Attendances -All Types

2013_14 OT 446132014_15 44672Forecast Growth 0.13%2015_16 44782Forecast Growth 0.25%2016_17 44892Forecast Growth 0.25%2017_18 45002Forecast Growth 0.24%2018_19 45111

E.A.1PYLL Rate per 100,000 population

Baseline 2028.92014/15 1964.02015/16 1901.12016/17 1840.32017/18 1781.42018/19 1724.42019/20 1669.2

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Outcome Ambition Two (Please note that this will be revised for final submission) Our ambition for improving health-related quality of life for people with long term conditions. A table to show the average EQ-5D score for people reporting having one or more long-term conditions

Outcome Ambition Three (Please note that this will be revised for final submission) Our ambition is to reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital

A table to show the avoidable emergency admissions indicator

Outcome Ambition Four - (Please note that this will be revised for final submission) The CCG are currently identifying a quantifiable level of ambition for this outcome ambition. The CCG level of ambition will form part of the Better Care Fund, set for 2 years at Health & Wellbeing Board level. This will be included within our final submission in April 2014. Outcome Ambition Five (Please note that this will be revised for final submission) The following table shows the CCG ambition for increasing the proportion of people having a positive experience of hospital care.

E.A.2

Average EQ-5D score for people reporting having one or more long-term conditions

Baseline 74.12014/15 74.22015/16 74.32016/17 74.52017/18 74.62018/19 74.7

E.A.4Emergency admissions composite indicator

Baseline 2159.22014/15 2137.62015/16 2116.22016/17 2095.12017/18 2074.12018/19 2053.4

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Outcome Ambition Six (Please note that this will be revised for final submission) The table below shows the CCG ambition for increasing the proportion of people having a positive experience of care outside hospital, in general practice and the community.

Outcome Ambition Seven. (Please note that this will be revised for final submission) The CCG seeks to make significant progress towards eliminating avoidable deaths in our hospitals caused by problems in care. DN: The CCG are continuing to work to define and calculate appropriate outcome measures for this ambition. The Quality Premium measure will be to improve the reporting of medication errors. Quality Premium Measures Domain One: Preventing people from dying prematurely Potential years of life lost (PYLL) from causes considered amenable to healthcare: adults, children and young people To earn this portion of the quality premium, the CCG will need to: a) agree with Health and Wellbeing Board partners and with the NHS England area team the percentage reduction in the potential years of life lost (adjusted for sex and age) from amenable

The proportion of people reporting poor patient experience of inpatient care

162.7157.7

152.7149.0146.7142.0

This rate is at Provider Level for MCHFT

2012 Baseline: 162.7

Lower Limit : 151 Upper Limit 175

England Average :142

E.A.6

The proportion of people reporting poor experience of General Practice and Out-of-Hours services

Baseline 6.1 England Average :6.12014/15 6.02015/16 5.9 Reduction of 0.1 per year 2016/17 5.82017/18 5.7 SC CCG Currently on England Average

2018/19 5.6

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mortality for the CCG population to be achieved between the 2013 and 2014 calendar years*. b) Demonstrate that, in developing the reduction to be achieved and its plans to deliver it, the CCG and its partners have taken into account: i) The local causes of premature mortality for those living in areas of deprivation; ii) Other relevant needs set out in the local joint health and wellbeing strategy; c) Achieve the planned reduction. * This should be based on the 10-year average annual reduction in potential years of life lost from amenable mortality. (Data Sources: Primary Care Mortality Database, ONS population estimates, Ambitions Atlas) Value: 15% of quality premium. DN: Please note that Quality Premiums are still to be agreed by the Health and Wellbeing Board CCG Projection is to achieve a 3.2% decrease against baseline (12/13) as illustrated below.

Domain 2: Enhancing quality of life for people with long term conditions. Domain 3: Helping people to recover from episodes of ill health or following injury. Avoidable Emergency Admissions Composite measure of:

- unplanned hospitalisation for chronic ambulatory care sensitive conditions (adults) - unplanned hospitalisation for asthma, diabetes and epilepsy in children - emergency admissions for acute conditions that should not usually require hospital

admission (adults) - emergency admissions for children with lower respiratory tract infection.

Threshold To earn this portion of the quality premium, there will need to be a reduction or a zero per cent change in emergency admissions for these conditions for a CCG population between 2012/13 and 2013/14, or the Indirectly Standardised Rate of admissions in 2013/14 is less than 1,000 per 100,000 population. Value: 25% of quality premium. The table below shows the avoidable emergency admission composite indicator

E.A.1 PYLL Rate per 100,000 population2014/15 1964.0

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Improving access to psychological therapies (IAPT) Threshold To earn this portion of the quality premium, the CCG will need to: a) Achieve IAPT access levels of at least 15% by 31 March 2015; and b) if the CCG IAPT access level was 13% or greater by 31 March 2014, to further increase access levels by 31 March 2015 to an additional amount agreed by the CCG with the relevant Health and Wellbeing Board and with the NHS England area team which should be no less than an additional 3%. For a) and b), CCG plans to increase access levels during 2014/15 should include plans to increase the proportion of individuals accessing IAPT services from communities where use of IAPT is known to be disproportionately low. (Data source: CWP, HSCIC) Value: 15% of quality premium. The table below illustrates for IAPT, the proportion of people that enter treatment against the level of need in the general population planned for 2014/15 and 2015/16. The CCG projection is to achieve 15% by March 2015 against 12/13 baseline (Nationally Mandated).

Domain of NHS OF Domain 4: ensuring that people have a positive experience of care Addressing issues identified in the 2013/14 Friends and Family Test (FFT), supporting roll out of FFT in their local health economy in 2014/15 and showing improvement in a selected indicator from Domain 4 of the CCG Outcomes Indicator Set. To earn this portion of the Quality Premium: 1. The CCG will need to: a) Agree a plan with their local providers with specified actions and milestones for addressing the

E.A.4Emergency admission composite indicator

Q1 2014/15 385Q2 2014/15 599Q3 2014/15 727Q4 2014/15 4282015/16 2116

E.A.3The number of people who receive psychological therapies

The numbers of people who have depression disorders (local estimate based on National Adult Psychiatric Morbidity survey 2000) Proportion

Q1 2014/15 431.0 10345 4.17%Q2 2014/15 441.0 10345 4.26%Q3 2014/15 331.6 10345 3.21%Q4 2014/15 348.1 10345 3.37%2015/16 1655.2 10345 16.00%

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issues that are identified from 2013/14 FFT results, particularly where they highlight issues which relate to poor care, and for: i) These actions to be achieved in line with the milestones; ii) The number of negative responses received via FFT from patients in respect of local providers to reduce between Q1 and Q4 of 2014/15; b) Obtain appropriate assurance and evidence that providers have taken action in response to FFT feedback; c) Support local providers to co-ordinate the roll out of FFT by the end of 2014/15 and to address roll-out issues as required. Appropriate evidence of advice and support being provided where this has been sought should be recorded by the CCG, and: 2. There is an improved average score achieved between 2013/14 and 2014/15 for one of the patient improvement indicators set out in the CCG Outcomes Indicator Set with the specific indicator agreed by the CCG with the Health and Wellbeing Board, the NHS England area team and the relevant local providers. Value: 15% of quality premium. The CCG plans to meet the national set objective for the Friends and Family Test in 2014/15 and 2015/16. The CCG plans to meet the nationally set objective from 2014/15 till 2018/19 for improving the reporting of medication errors. Activity trajectories (Please note that the following trajectories will be revised for final submission) Referrals and Outpatient Attendances

The CCG has experienced an increase in GP referrals over the last year and it is anticipated that this may grow due to the change in demography and the increasing pressure in primary care. The local trust operates at peer level for first to follow up ratios.

0

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OP following GP Refs - SC

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Elective Care

The CCG and local main provider are increasing the ratio of day-case to elective procedures to improve efficiency. The provider has recently implemented a new theatre suite and has a dedicated day-case unit. The CCG and trust are reviewing locally the commissioning for Value pack to improve effectiveness. The impact of this has not been taken into account above but it is anticipated that this will have a significant effect in a number of specialties e.g. gastroenterology. A&E attendances

A&E attendances have remained stable over 2013/14 and have been predicted to continue at the current level. A number of initiatives have been carried out at the local provider to achieve this level of stability additional schemes will be put in place over the planning period to ensure that the level remains stable. Non Elective Admissions

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The connecting care strategy focusses on decreasing non elective activity. The main drivers of a reduction in NEL admissions are Extended Practice Teams and additional beds in community to prevent admission and ensure earlier discharge. Better Care Fund Permanent admissions of older people (aged 65 and over) to residential and nursing care homes per 100,000 population: The English average is currently 690.3 admissions per 100,000 population, whilst across the Cheshire East area we currently reporting achievement at 561.1. We know that current performance reported is distorted by the treatment and categorisation of our respite care, which we believe is incorrect, resulting in an increased baseline. We will review our baseline during the early part of 2014/15 and following this review we will determine our collective ambition around the level of improvement we wish to achieve. Proportion of older people (aged 65 and over) who were still at home 91 days after discharge from hospital into re-ablement / rehabilitation services: The English average is currently 82.6% of older people remaining in their own homes after 91 days from discharge from hospital, whilst across Cheshire East 79.3% were still at home. It is important to note that across the Cheshire East area whilst our % performance is lower than the national average our delivery is to a larger % of the population, which will have a greater impact as we improve the proportion of older people still at home after 91 days. Our aim is to improve performance by continuing to expand the number of older people who have received reablement services whilst also seeking to increase those staying at home more than 91 days by 1% each year, until we reach our ambition of being upper quartile. Delayed transfers of care from hospital per 100,000 population: The English average is currently not known so it is not possible to compare the local performance against the national delivery. Locally across the Cheshire East area we are currently achieving 302.75 and will aim to reduce this by 5% from our baseline by 31 March 2015, continuing to improve on that performance year on year until we are recording high quartile performance. Detailed below is a graph showing the average monthly delays from April 2011, which is one of the indicators being

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monitored locally:

Avoidable emergency admissions: We have detailed our performance below for our two CCGs along with our collective ambition to improve performance, reflecting the differing age profiles of the two CCGs. Await the information provided by NHS England.

CCG English Avg Baseline March ‘15 South - 2,093.3 Tbc East - 2,211.0 Tbc

The projected trajectory below is Eastern Cheshire CCG’s plan, included in the “ year 2014/16 Operational Plan.

Baseline 2014/15 2015/16 2016/17 2017/18 2018/19

2026.6 2026.6 2016.467 2006.334 1965.802 1823.94 At Mid Cheshire Hospital Foundation Trust (MCHFT), South Cheshire CCG and Vale Royal CCG we have invested in additional services within the hospital setting (A&E) in particular to increase levels of staffing to treat patients quickly. There has been detailed analysis of the flow of patients both in A&E, but also across the wider hospital services to target those areas needing improvement to ensure the “ front door” is not in crisis. The CCGs have also invested in alternatives to acute care beds – these are multi agency services outside of the hospital setting ensuring patients can be discharged quickly, either from A&E or from hospital wards. The combination of investment and new services in place have meant that MCHFT has managed to deliver the four hour A&E target, and non elective admissions have remained on or slightly under plan for 2013/14. The experience of patients and service users: Proportion of people who feel supported to manage their long-term condition:

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The English average is currently tbc, whilst across the Cheshire East area we are currently achieving % of 74.1 in the South Cheshire CCG area and 77.5 in the Eastern Cheshire CCG area, with an aim to increase this to upper quartile levels by 31 March 2015. It is notable to state that within the south there are 18 GP practices and 23 GP practices in the east. The table below is the Eastern Cheshire CCG submission in the operating plan to cover “what is your ambition for improving the health related quality of life for people with long term conditions”

Average EQ-5D score for people reporting having one or more long-term condition

Baseline 77.50 2014/15 78.60 2015/16 79.70 2016/17 80.80 2017/18 81.90 2018/19 83.00

Locally important indicators: Whilst these national indicators will provide an important measure of success in creating a more integrated model of care and support services, it is also important that partners monitor local outcomes that are tailored to the pressures that we know exist within local services. Therefore, alongside these national outcomes, we have focussed on the area where we know we need to make significant improvements Direct admissions from hospital to long-term care settings: Information needed, this is a common theme across the CE HWB area for both Councils as we both have challenges with direct admissions from hospital to long term care settings. Our local performance is x against our regional comparator performance of y. We will seek to improve this performance to upper quartile levels within a three year period.

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APPENDICIES Glossary of Terms A Call to Action This is an NHS England document and programme of action focused on the challenge to staff, the public and politicians to help the NHS meet future demands and tackle the funding gap through honest and realistic debate. Better Care Fund (BCF) A single pooled budget for health and social care services to work more closely together in local areas, based on a plan agreed between the NHS and local authorities. Care.data An information system which will make increased use of information from medical records with the intention of improving health services. The system is being delivered by the Health and Social Care Information Centre (HSCIC) and NHS England on behalf of the NHS. Commissioning for Quality and Innovation (CQUIN) The system introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. Everyone Counts: Planning for Patients 2013/14 outlines the priorities, incentives and levers that were used to improve services from April 2013, the first year of the new NHS, where improvement was driven by clinical commissioners. Friends and Family Test The Friends and Family Test (FFT) aims to provide a simple headline metric which, when combined with follow-up questions, can drive a culture change of continuous recognition of good practice and potential improvements in the quality of the care received by NHS patients and service users. CCG Outcomes Indicator Set (CCG OIS) The CCG Outcomes Indicator Set is part of the NHS England’s systematic approach to promoting quality improvement. Its aim is to support clinical commissioning groups and health and wellbeing partners in improving health outcomes by providing comparative information on the quality of health services commissioned by CCGs and the associated health outcomes – and to support transparency and accountability by making this information available to patients and the public. Compassion in Practice Compassion in Practice is the three year vision and strategy for nursing, midwifery and care staff drawn up by NHS England and the Department of Health. NHS Outcomes Framework The NHS Outcomes Framework sets out the outcomes and corresponding indicators used to hold NHS England to account for improvements in health outcomes. Quality Premium The Quality Premium rewards CCGs for improvements in the quality of the services that they commission and for associated improvements in health outcomes and reducing inequalities. Unit of Planning A number of CCGs who have joined together with relevant Area Teams, providers, Local Authorities and Health and Wellbeing Boards to create a footprint of a size large enough to enable effective strategic planning.

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Prepared By : Jo Vitta, Business Manager NHS South Cheshire CCG Governing Body

REPORT



Annual Report and Accounts 2013-14 27 March 2014

1415-1700 7.6.3

PURPOSE OF REPORT This paper provides the Governing Body with a summary on the progress being made to prepare the CCG Annual Report 2013-14, following the NHS England guidance published in draft form in January 2014.

AUTHOR

Jo Vitta Business Manager Executive Lead Simon Whitehouse Chief Officer

GOALS 2013-14




VISION


RECOMMENDATIONS


i) Note the progress being made with the development of the CCG Annual Report 2013-14.






Yes Yes

No

No

No

No

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Prepared By : Jo Vita NHS South Cheshire CCG Governing Body

2

REPORT TITLE

NHS South Cheshire CCG Annual Report and Accounts 2013-14

1.0 Introduction

The CCG team are currently working on the Annual Report and Annual Accounts for 2013-14. It will be an honest and open account of our first authorised year, and will include our key achievements and progress made.

As per the CCG Constitution, the Annual Report and Annual Accounts are to be signed off by our Membership Council. There is no delegated authority for this. However it is anticipated that the Governing Body will receive the accounts and then present them to the Membership Council.

The CCG will submit a first draft report and accounts by 12 noon on 23rd April.

Our final Annual Report and Accounts will be submitted on 6th June by Grant Thornton (External Auditors) on our behalf.

2.0 Timetable

Please see appendix one of this report for the proposed timetable to complete the CCG Annual Report and Accounts in readiness for draft submission on the 23rd April 2014 and final submission on 6th June 2014.

3.0 Draft Annual Report Template

Please see below for suggested content based on national guidance (Draft CCG Annual Reporting Guidance: 2013-14, NHS England).

Report Contents: 3 main sections:

1) Annual Report. This will include the following sections;

Governing Body Report Operating and Financial Review Sustainability Report

GP and Senior Management profiles Remuneration Report

2) Statements by Accountable Officer. This will include the following sections;

Statements of Accountable Officer’s responsibilities Governance statement

3) Annual Accounts. This will include the following sections;

Report by auditors to the Governing Body Financial Statement

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Prepared By : Jo Vitta, Business Manager NHS South Cheshire CCG Governing Body

REPORT

Annual Report Process Map Internal Committee Papers deadline

Papers out

Meeting Date Action Required

1 Governance and Audit Committee (VR)

17.03.14 18.03.14 25.03.14 1) Approve draft Governance Statement content; 2) Approve and agree Committee statement; 3) Approve Chief Finance Officer Statement; and 4) Note Annual Report Process Map.

2 Governance and Audit Committee (SC)

19.03.14 20.03.14 27.03.14 1) Approve draft Governance Statement content; 2) Approve and agree Committee statement; 3) Approve Chief Finance Officer Statement; and 4) Note Annual Report Process Map.

3 Governing Body (VR) 19.03.14 26.03.14 02.04.14 1) Outline of process as per Constitution, including timescales

4 Governing Body (SC) 17.03.14 20.3.14 27.03.14 1) Outline of process as per Constitution, including timescales

5 Membership Assembly (7 GP’s plus SW & LR)

26.03.14 02.04.14 09.04.14 1) Outline MA responsibility as per Constitution; and 2) Note Annual Report Process Map.

6 Membership Council (15 GP’s plus SW & LR)

04.04.14 10.04.14 17.04.14 1) Outline MA responsibility as per Constitution; and 2) Note Annual Report Process Map.

7 Joint (special) Governance & Audit Committee

08.05.14 15.05.14 22.05.14 1) Sign off Annual Governance Statement and draft final accounts

8 Internal CCG meeting 12.05.14 1) To evaluate status of action plan and any matters arising

9 Internal CCG meeting 19.05.14 1) To evaluate status of action plan and any matters arising

10 Governing Body (VR) 21.05.14 28.05.14 04.06.14 1) Grant Thornton present Annual Report and Accounts; and 2)GB formulate a recommendation to Membership Assembly

11 Membership Assembly (7 GP’s plus SW & LR)

21.05.14 28.05.14 04.06.14 1)Receive a recommendation from the GB; and 2)Sign off Annual Report and Accounts for NHS Vale Royal CCG

12 Governing Body (SC) 22.05.14 29.05.14 05.06.14 1) Grant Thornton present Annual Report and Accounts; and 2)GB formulate a recommendation to Membership Council

13 Membership Council (15 GP’s plus SW & LR)

22.05.14 29.05.14 05.06.14 1)Receive a recommendation from the GB; and 2)Sign off Annual Report and Accounts for NHS South Cheshire CCG

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4

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Prepared By : Julia Burgess, Service Delivery Manager NHS South Cheshire CCG Governing Body – Learning Disabilities

REPORT



Learning Disabilities, including: • Winterbourne View Concordat Progress report • 2013 Joint Health & Social Care Self-Assessment

Framework for Learning Disabilities

27 March 2014 1415-1715 7.6.4

PURPOSE OF REPORT This report provides the NHS South Cheshire CCG Governing Body with a summary update on local progress in Learning Disabilities Commissioning. In particular the report will focus on two areas of significance for the CCG, the Winterbourne View Concordat and the annual Learning Disabilities Joint Health and Social Care Self-Assessment. The Winterbourne View Concordat programme (2012) set out to transform services for vulnerable people who have behaviours viewed as challenging, ensuring that these people no longer live inappropriately in hospitals but receive the care and support they need closer to home and in line with best practice. The 2013 Joint Health and Social Care Self-Assessment Framework for Learning Disabilities replaces previous versions of the framework which have had a singular health focus. The aim of this joint framework is to provide a way of identifying the challenges in caring for the needs of people with learning disabilities, and documenting the extent to which the shared goals of providing care are met. The report will outline the governance arrangements locally, provide assurance on local delivery and highlight any risks associated with meeting key milestones.

Report Prepared By: Julia Burgess Service Delivery Manager Catherine Mills Clinical Project Manager Governing Body Lead: Fiona Field Director of Governance & Partnership

GOALS 2013-14




VISION To maximise health and wellbeing and minimise health and inequalities, informed by local voices and delivered in partnership.

RECOMMENDATIONS The SCCCG Governing Body are asked to: i) Note the progress with regard to implementation of “Winterbourne

View – Transforming Care” and meeting the requirements of the Winterbourne View Concordat.

ii) Be assured that the actions required from the Health & Social Care Self-assessment are being addressed through local action planning.

ACTION REQUIRED DECISION: Approval Assurance EQUALITY: Impact Assessed COMMUNICATION: Disclose on Website RISKS: Issues outlined RESOURCES: Issues outlined

No

Yes

No

No

No

No

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REPORT TITLE

Learning Disabilities, including: • Winterbourne View Concordat Progress report • 2013 Joint Health & Social Care Self-Assessment Framework for Learning Disabilities 1. Introduction – Winterbourne View Concordat Following the shocking abuse of patients at Winterbourne View independent hospital, the Department of Health published “Transforming Care”. This final report on the situation at Winterbourne View called for fundamental change to take place so that people with learning disabilities or autism and mental health who display behaviours that challenge will receive safe, appropriate high quality care. The accompanying Winterbourne View Concordat: Programme of Action, which was the Government’s collective response to the events of Winterbourne View set out specific actions to be undertaken by health and social care commissioners, who have a critical role to play in driving forward real change. The Concordat set out a number of actions, summarised as;

• Maintain a register of people currently placed in specialist in-patient services for people with learning disability or autism.

• Discharge people with learning disability or autism who are inappropriately placed in in-patient services to more appropriate care and support in the community by June 2014.

• By April 2014, produce a Joint Plan with the local authority that sets out the range of community services that will be commissioned to reduce the number of people with learning disability or autism being admitted to specialist hospitals i.e. ensure that a new generation of people do not replace those currently in in-patient settings.

Local progress against these actions is as shown in the table below. Actions Progress to date RAG status

By end of March 2013, CCGs to put in place a register of people with LD or autism funded by the NHS for their care needs.

Completed. The register is well established and regularly updated.

G

By June 1st 2013, review the care of all those included on the register and agree a care plan for each individual based on their and their families’ needs.

Completed -100% G

By June 1st 2013, all current placements will be reviewed and everyone in hospital inappropriately will move to community based support as quickly as possible, and no later than June 2014.

Partially completed A

By April 2014 CCGs and their local authorities will have a locally agreed joint plan to ensure high quality care and support services for all people with learning disabilities or autism and mental health conditions or behaviour described as challenging.

There are strong links between this plan and the outcome from the LD Lifecourse Review.

A

As a consequence of these actions, there is expected to be a dramatic reduction in hospital placements for this group of people at a national level. 2. Governance Arrangements to support delivery

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2.1 Local Delivery Local delivery of the Winterbourne Programme of Action is supported through the Cheshire East Council LD Life Course Project. This is a multi-agency project to secure new integrated health and social care pathways for people with LD. The overall aim of the project is to review, redesign and commission services for children and adults with learning disabilities to ensure that value for money, person centred care, planning and support will meet the needs of this population now and in the future. The approach taken is very much in keeping with that required nationally. The life course review includes anticipating levels of future demand in order to plan services with an emphasis on community settings. The Life Course Review has a programme and project management approach, reporting in to the Joint Commissioning Leadership Team and subsequently the Cheshire East Council Health and Wellbeing Board.

2.2 Winterbourne View Joint Improvement Programme In response to the abuse which took place at Winterbourne View, a national Joint Improvement Programme (JIP) was established to help local areas fundamentally transform health and care services for people with learning disabilities or autism and behaviour that challenges. The programme is led by the Local Government Association (LGA) and NHS England, and funded by the Department of Health. The JIP identified certain actions required by local authorities, CCGs and NHS England Area Teams to ensure:

• Rapid expansion and improvement in community provision, encompassing a range of supported living options and housing with accompanying care and support, to enable the transfer of people from in-patient facilities.

• Commissioners plan not only for current clients but also people who are and will be referred into services. Any use of in-patient services must be based on proper assessment of an individual’s needs.

• That the development of community based support is not held back by funding issues. Community based care is likely to need on-going contributions from both health and social care.

• CCGs and local authorities should pool resources currently deployed on the care of this group to help fund new models of care.

• People who do require in-patient care due to the severity of their condition should have the highest quality of care and an agreed plan to return to their community.

In July 2013 a national stock-take of progress in addressing these recommendations was undertaken as part of the JIP. A questionnaire was circulated to all local authorities asking them to assess their progress against the commitments outlined in the Winterbourne View Concordat. The CCG was actively involved in this process along with other partners including social and health care service providers and carers of people with learning disabilities.

Following submission, each area received a summary report and more recently, a status report in November 2013. This status report seeks feedback on current numbers of people in inpatient settings, funding and commissioning arrangements. The aim of this exercise is to identify progress and highlight any barriers to achievement, and the results are shown below.

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Cheshire East JIP Local Status Report

Strengths Areas for Development Current Status

Funding Pooled budget arrangements well established but do not currently include CHC or specialist commissioning

Agreed and in place

Commissioning Joint processes and registers reported as in place and role of specialist commissioning being clarified. Realistic about what can be achieved by June 2014. Significant barriers in relation to MHA.

Fully integrated

Meeting the June 2014 deadline

Concern expressed that not all clients would meet the deadline due to a range of factors including legal barriers and compliance with client wishes.

Partially meet with evidence or plans

To assure the public and the Department of Health that the NHS commitments in the Winterbourne View Concordat are delivered, a quarterly data collection for all NHS commissioners was introduced with effect from 9 January 2014.The information was on the number of patients currently in inpatient care and whether they have been transferred or there is a planned date to transfer and who had been admitted in the last quarter. The data from the first data collection has recently been published, and shows that across the country, the reason why a large percentage of people do not have a planned transfer date is a clinical decision. Many of these people have very complex needs. Some may be too ill or possibly a danger to themselves or the public. Some patients might have treatment orders or be detained due to Ministry of Justice order. As can be seen in the table in Appendix One, these national findings are consistent with the situation in South Cheshire CCG. NHS England recognises that more progress needs to be made to help more of these people move out of in-patient care into the community. To this end, it is using the latest data to establish, for those people without a transfer date, (i) those who should appropriately be helped to move to community-based settings; and (ii) those for whom the complexity of their needs is such that on-going in-patient care is required. Ultimately, these are decisions for clinicians to make with the full engagement of patients, their families, carers and advocates. NHS England will be working through local commissioners to drive change to ensure all patients are safe and agree the number of people who, with the right assessment, can be moved into the community. It will be providing additional support to CCGs from the Improving Lives Team established by NHS England, to review the care of former patients of Winterbourne View and other complex cases. It will also develop clinical guidelines to support local areas to provide good quality joint planning and assessment.

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3. Assurance a. Register

Live registers of all CCG and NHSE commissioned placements have been compiled for the CCG, as required by the Winterbourne View Concordat. The criteria for those included on the register are those people of any age in in-patient beds for mental and/or behavioural healthcare who have either learning disabilities and/or autistic spectrum disorder (including Asperger’s syndrome). The register covers all levels of security (general / low / medium / high) and any status under the Mental Health Act (informal or detained). These placements include local and out of area NHS and private sector hospitals including secure hospitals. The CCG has a robust process to ensure the register is updated on a monthly basis, to take account of new people meeting the criteria and any moves to other settings. Since the register was first established, in May 2013, it has included 10 people from South Cheshire CCG who remain in independent hospitals. Anonymised details of the South Cheshire register are included as Appendix One. These 10 people, due to the complexity of their needs, are considered clinically appropriate to remain in their present placement. The Governing Body can be assured that those clients who remain in their current placements do so following robust clinical assessment and decision making and that there is a continuous process of review. The Governing Body are asked to note that the original guidance contained within the Winterbourne View Concordat, specified that: By June 1st 2013, all current placements will be reviewed and everyone in hospital inappropriately will move to community based support as quickly as possible, and no later than June 2014. This clearly sets a deadline of June 2014 to move people from inpatient settings and from the description above, those individuals remaining in hospital by the due date of June 2014 can be regarded as appropriately placed. However there is some ambiguity in the wording of which the Governing Body should be aware. Recent documents have interpreted the target as needing all clients to have moved from in-patient settings. It may transpire, therefore, that having people in hospital settings, despite this being appropriate for them, will be regarded as non- compliance. This lack of clarity has been recognised in a recent Joint Improvement Programme report.

The table in Appendix One reflects the ability of the CCG to meet the target, however worded, and is based on the principle that clients should always be placed in the least restrictive setting that is clinically appropriate.

b. Placement reviews All CCG placements were routinely reviewed by June 2013 as required. These reviews were carried out under the Care Programme Approach (CPA) and were attended by each patients’ Care Co-ordinator and/or Care Manager from their local area.

c. Joint Learning Disability Programme of Action (April 2014)

Progress towards the goal of reducing the numbers of people with challenging behaviour in hospitals or in large scale residential care will be dependent on developing a range of responsive local services which can prevent admission. The Concordat is clear that new models of community based support should be identified and put in place. This will involve mapping current provision with a view to commissioning more community based services able to support people with challenging behaviour.

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A wide range of stakeholders are needed to undertake this task, including health and social care, children’s services and specialist housing. This Joint Strategy is an outcome of the Cheshire East Learning Disability Life Course Review, creating considerable overlap with this programme of work. Due to this specific local context, the information included within the work of the Life Course Review will feed the strategic plan required by the JIP. The Life Course Review is regarded by the JIP as an example of good practice, worthy of sharing with other areas. A member of the JIP team is due to visit Cheshire East Council in April to discuss the project in more detail. This programme of work which supports delivery of the joint commissioning plan aims to bring together in one document not only the nationally mandated requirements from the Winterbourne View Concordat but also the action plan arising from the LD Self-Assessment, and other national drivers such as the confidential inquiry into deaths of people with learning disability (2013) A copy of this work programme is attached as Appendix 2. 4. Pooled Budgets

Currently there is a section 75 pooled budget arrangement between the local authority and South Cheshire CCG. Recent discussions have highlighted that the basis of this pooled arrangement needs review. A proposal to disaggregate the existing pool and introduce a new arrangement has been a recommendation to the Joint Commissioning Leadership Team. Any future funding arrangements need to be considered alongside the wider context of the Pioneer bid and Connecting Care Programme.

5. Health and Social Care Learning Disability Self-Assessment

The LD Self- Assessment Framework (SAF) was originally created to provide a robust and consistent framework to document a shared perspective of the LD services available This year the SAF has been a joint self- assessment between health and social care, rather than a singular health focus. The SAF is designed to help Learning Disability Partnership Boards, Health and Wellbeing Boards, Clinical Commissioning Groups and Local Authorities identify the priorities, levers and opportunities to improve care and tackle health and social care inequalities in their areas. It also provides a good evidence base against which to monitor progress. This year, 2013/14, is the fourth year such an assessment has been undertaken.

The Cheshire East LD SAF framework, together with supporting evidence, was submitted in November 2013. Although the validation process has not yet concluded, the process of self-assessment and evidence gathering has enabled the working group to identify areas of good practice as well as areas for development.

The actions arising from the LD SAF have been incorporated into the Cheshire East Joint Work Programme for Learning Disabilities. This work Programme is included at Appendix 2.

The LD SAF includes three sections: • Keeping Healthy • Staying Safe • Living Well

The Governing Body are particularly asked to note the implications of the LD SAF for primary care.. The uptake rate of health checks amongst participating practices is 70%, which compares well against national benchmarks, however, only 14 of the 18 practices in South Cheshire CCG participate in the Directed Enhanced Service providing annual health checks, creating some inequality. The

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CCG, together with the NHS Area Team, need to work with practices to ensure 100% coverage. Variability in the quality and content of LD health checks across practices also needs to be addressed.

Good use of information to support improvement is vital to continued monitoring of health inequalities and for the first year our submission has included comparative data from practices. The local data is consistent with national evidence that people with learning disabilities experience poorer health outcomes and are less likely to access screening programmes than their non-disabled peers. Plans to tackle this are included within the joint programme of action and will include colleagues from Public Health England as well as local public health teams.

A regional event was held in February which enabled commissioners of learning disabilities services to come together and agree what were the common challenges across the North West. An outcome of this event was to identify areas of work which would benefit from a regional approach. This is now being progressed through a number of task and finish groups, sharing approaches and solutions across a wider footprint..

Services provided by Cheshire and Wirral Partnership Trust include LD health facilitation, a service which provides named LD Health Facilitators whose role is to support primary care through training, validation of LD Registers and advice. They will also support individuals to access health services if this is requested. Good partnership working between the GP practices and the health facilitators will support good outcomes for people in South Cheshire with learning disabilities, and is to be encouraged.

6.0 Contracting

The transformational change that will result from this combined programme of work will rely on underpinning contractual changes. This section of the report refers to the adoption of core service specifications, local commissioning intentions and Commissioning for Quality and Innovation Schemes (CQUINs)

6.1 Core Service Specifications

As part of the national Joint Improvement Programme a core service specification toolkit has been developed which provides a clear evidence based commissioning tool for Local Authorities and CCGs. The recommendation is that existing local service specifications are removed and amended to include the relevant sections of the core service specification toolkit with a view that greater consistency will contribute to improved quality, safety and positive experiences for individuals and families requiring support to have fulfilling and rewarding lives in their local community.

The toolkit is made up of three distinct elements:

Core Elements This includes standard descriptions of service specifications written in such a way that they can be inserted into the NHS standard contract. Local Service Descriptors It is accepted that a “one size fits all” approach would not be appropriate and that specifications should reflect the local commissioning environment. This section therefore prompts the inclusion of local needs. Outcomes Different outcome measures have been included and heavily influenced by the Quality of Health principles. It is recommended that these outcomes measures are used within all relevant service specifications as a minimum set of indicators and should be expanded to reflect additional outcome measures that relate to specific services, levels of support or the local area.

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The use of the toolkit has influenced the learning disabilities services specifications for the 2014-15 CWP Contract.

6.2 Local Commissioning Intentions and CQUINs

NHS South Cheshire CCG has set out a commissioning intention to “improve the Mortality Rates of people with learning disabilities”. This project encompasses four areas of work;

• Introduction of the Health Equalities Framework, a tool to measure and monitor improvements in individual health outcomes

• Promotion of health screening including national cancer screening programmes • Implementation of integrated annual health checks and health action plans • Completion of a cross organisational audit of deaths among the LD population

We have also commissioned our providers to deliver a number of schemes that are designed to improve service quality;

• A proposal has been put forward, through the primary care incentive scheme, to improve the services for vulnerable groups, including people with learning disabilities It is hoped that this will include an audit of health checks.

• Mid Cheshire Hospitals NHS Foundation Trust will carry out a data analysis to understand the reasons for un-planned admissions among the population with learning disabilities and how these can be prevented

• All providers (hospitals, mental health and community services) will be required to carry out Learning Disability awareness training and provide evidence of how they have met their legal requirements in relation to making reasonable adjustments.

7. Transition

A key work stream for the Life Course Review centres on the requirement to implement the Children and Families Bill. This work stream will address the significant changes arising from the Bill to the existing SEN code of practice to be introduced in September 2014. The aims of the work will be to consider the full life course of a person with learning disabilities to ensure that conflicts and tensions represented by transition from children’s to adult services are resolved.

The ability to join up funding as well as practice across Health, Education and Social Care in a single plan from birth – 25 years will promote effective investment decisions from the earliest age possible. Plans are in place for single plans from 1 September 2014.

8. Conclusion

This report covers wide ranging policy improvements for people with learning disabilities. The approach taken has been influenced by principles of joint working, engagement with service users and carers through Learning Disability Partnership Board arrangements and “My Life My Say” engagement events which provided a rich source of information and opportunities for consultation.

The approach is reliant on close relationship working led by the Learning Disabilities Life Course Review Board whose role is to oversee the interagency planning and commissioning of integrated and inclusive services that will provide a genuine choice of service options for people in their local community.

Members of the Governing Body are asked to note the approach taken in the commissioning for people with learning disabilities and to be assured that plans in place will cover areas of risk and areas of development.

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The table below gives an overview of the 10 patients from South Cheshire who are currently included on the CCG Winterbourne View register. The registers include people of any age in in-patient beds for mental and/or behavioural healthcare who have either learning disabilities and/or autistic spectrum disorder (including Asperger’s syndrome). The register covers all levels of security (general / low / medium / high) and any status under the Mental Health Act (informal or detained). The Register does not include people in accommodation not registered with the CQC as hospital beds, people in beds for physical health care or people who do not have either learning disabilities or autism.

Placement April 2013

Current Placement January 2014

Date of last review

Date of next planned review

Who is carrying out review

Reasons for clinical decision

Long term plan

Outcomes to achieve before move to community

Details of advocacy/family arrangements

Will meet target*

S1 Independent Hospital

Independent Hospital

September 2013

March 2014 Brian Patterson (CWP)

Community setting is not appropriate at present due to risk and enduring Mental Health problems Section 3 MHA.

CWP Behavioural Nurse was asked to carry out an independent review in December to ensure that placement is still appropriate. Recommendations have since been acted upon. Reduction in risk behaviour required before move to community could be considered. May require additional level of security to manage risk.

Independent Person and IMHA

No

S2 Independent Hospital

Independent Hospital

February 2014

May 2014 Claire

Community setting currently unsuitable due to risk factors

Plan to step down to rehabilitation ward in April 2014.

No family contact at client

No

APPENDIX 1

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Date of last review




Long term plan



Will meet target*

(October 2011)

Howarth (CWP)

Section 47/49. request Independent Person

S3

Low Secure Unit (January 2009)

Low Secure Unit

September 2013

March 2014 Brian Patterson (CWP)

Community setting currently unsuitable due to risk factors Section 37/41. Forensic client.

Transfer to non-secure periphery housing at same site, subject to Ministry of Justice approval and funding from CCG

Independent Person

No

S4

Medium Secure Unit (November 2010)

Medium Secure Unit

October 2013

April 2014 Claire Howarth (CWP)

Section 37 MHA. Transitioned from children’s services. Admission primarily for PD and self harm issues.

Long term plan to step down to Low Secure and from there to non-secure setting however placement remains appropriate at present due to ongoing intensive psychological therapies.

Limited family contact due to victim issues. IMHA Independent person

No

S5 Low Secure Unit

Low Secure Unit

30 January 2014

May 2014 Claire Howarth (CWP)

In line with client wishes. Section 47/49. Forensic client.

Client moved placement in February 2014 in order to be closer to his family. Once placement well established, client will be assessed for a step down pathway. CWP will continue to monitor and review at least six monthly.

Family Independent Person

No

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Date of last review




Long term plan



Will meet target*

S6

Low Secure Unit

Low Secure Unit

8 January 2014


Section 37/41. Forensic client. Plans in place for client to transfer to Mental Health Rehab Pathway via Complex Assessment and Recovery Service. This is subject to funding for agreed care package and availability of bed. Ministry of Justice approval granted. Client continues to be supported to continue studies locally.

Family Independent Person IMHA

No

S7

Low Secure Unit (June 2012)

Low Secure Unit

December 203

24 March 2014 Claire Howarth (CWP)

Section 37/41. Forensic Client Client has begun to access leave. Plans in place for client to transfer to unlocked step-down provision subject to Ministry of Justice approval.

Independent Person IMHA

No

S8

(May 2013) Low Secure Unit

22 January 2014

March 2014 Claire Howarth (CWP)

Undertaking Treatment Order Section 37 MHA. Forensic client.

Will return to family subject to completion of treatment order.

Family IMHA

No

S9

(August 2013)

Assesssment & Treatment Unit

5 March 2014

19 March 2014 Claire Howarth (CWP)

Due to move to residential setting imminently.

CWP will continue to monitor and

Family IMHA

Yes

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Date of last review




Long term plan



Will meet target*

review as appropriate.

S10

(May 2013) Residential setting

February 2014


N/A has now moved Discharged from section, placed on aftercare in community setting. CWP will continue to monitor and review as appropriate

Family IMHA

Yes

*RAG status reflects whether the client is expected to be in a community setting by 1 June 2014 as per Winterbourne Concordat.

• Red indicates this is not expected and the client is likely to remain in a restricted setting beyond 1 June • Amber indicates that a move to community provision is planned but is subject to external factors so cannot be guaranteed that the deadline will be met • Green indicates that a move is expected within the timescales with no issues foreseen

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APPENDIX 2

Learning Disabilities Programme of Action 2014 -15

• This is a Joint Programme of Action between Cheshire East Council, local Clinical Commissioning Groups, providers of health, social and mental health care

• The Programme reflects the requirements and priorities set out in a number of key documents including:

o Transforming Care: A national response to Winterbourne View o Confidential Inquiry into premature deaths among people with learning disabilities o The 2013 Cheshire East Joint Health and Social Care Self-Assessment Framework for

Learning Disabilities (LDSF)

• This programme also needs to be seen in the context of the broader work being done under the banner of the Cheshire East Council Learning Disabilities Life Course Review. A number of the activities described in the plan will contribute to the work streams of the Life Course review.

• Aspects of this Programme to be delivered through the Learning Disabilities Implementation Group are highlighted in the colour shaded boxes.

• The Learning Disabilities Implementation Group membership includes commissioners and providers of services for people with Learning Disabilities. It meets bi-monthly and is jointly chaired by a Clinical Commissioning Group and Cheshire and Wirral Partnership NHS Foundation Trust.

• Many of the actions within this Programme have been identified as priorities as they scored red

in the LD SAF. The self-assessment process is still underway as our scores have yet to be validated by an external team. This will happen in mid-March 2014 and in the event that other areas are scored red, further actions will need to be added to the Programme described below.

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Prepared By : Lisa Carr, Performance & Risk Manager NHS Vale Royal CCG Governing Body – 03-04-13 – Risk Assurance Update – Corporate Risk Register February 2013

14

Joint Learning Disabilities Programme of Action 2014 -15

No Sourcei Action (High Level) Local Response/Action LEAD Mapping Due for completion

Commentary

1 WV CCGs and local authorities will set out a joint strategic plan to commission the range of local health, housing and care support services to meet the needs of people with challenging behaviour in their area.

Need to map where this sits in terms of the wider Lifecourse review.

CEC

CWP

ECCCG

SCCCG

Life Course Review Commissioning work stream

April 2014 Plan to be shared with the Health and Wellbeing Board and Learning Disabilities Partnership Board

2 WV Develop and maintain a register of all people with learning disabilities or autism who have mental health conditions or challenging behaviour in NHS funded placements. ( as defined by the Winterbourne Concordat)

Submit data on a quarterly basis to NHS England as required.

A complete register has been created. Need to ensure that it remains robust and up to date with any changes.

CSU

CWP

ECCCG

SCCCG


Completed

Ongoing

Data to be submitted on:

14/4/14

14/7/14

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15


Commentary

3 WV

LD SAF B1

CI4

Review of all out of area hospital placements to provide assurance in relation to safety and quality.

• Ensure that clients are in the least restrictive setting

• Ensure that all placements meet the requirements set out in the Winterbourne Concordat and Confidential Inquiry

All partners to jointly review all relevant placements, namely:

People in in-patient beds for mental and/or behavioural healthcare who have either learning disabilities and/or autistic spectrum disorder (including Asperger’s syndrome) • Any age • Any level of security (general / low /

medium/high) • Any status under the Mental Health

Act (informal or detained)

CEC

CWP

ECCCG

SCCCG


June 2014 Target for June 2014 is that everyone inappropriately placed in hospital to move to community based support as quickly as possible, and no later than 1 June 2014.

4 WV

WV

LCR

Develop local, community based services that offer an alternative to out of area placements and that can meet the needs of clients with challenging behaviours.

Develop proposals for new provision based on/including:

• Potential caseload (see Action 1) • Anticipated needs • Potential service models /pathways

CEC

CWP

ECCCG

SCCCG


April 2014 CWP are planning to run a workshop to look at positive support models for adults with complex challenging needs

4a CI6

LDSAF A2

Address the Health Inequalities experienced by people with Learning

Review and improve the quality of health checks within primary care

CWP LDIG March 2015 Action incorporated into the work plan for Health Facilitation team

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16


Commentary

& A3

LCR

Disabilities living locally

ECCCG

SCCCG

across CCG

Primary Care CQUIN on health check audit Cheshire East

4b LDSAF A5

LCR

Increase the uptake of national cancer screening programmes among people with Learning Disabilities

• .Training for primary care • Awareness raising programme

CWP (Health Facilitator)

NHSAT

LDIG March 2015 Action incorporated into the work plan for Health Facilitation team across Cheshire East.

Work also being co-ordinated at LAT level with input from Public Health

4c LDSAF

Confid inquiry

Conduct an audit of deaths among our population with Learning Disabilities and identify lessons to be learned

CEC

CWP

MCHFT

ECCCG

SCCCG

LDIG September 2014

This is a Commissioning Intention within SCCCG for 2014/15.

4d CI2

CI7

LDSAF

Use commissioning “levers” to ensure that providers meet their obligations in relation to reasonable adjustments

Audit of reasonable adjustments ECCCG

SCCCG

?LDIG June 2014 CCGs are proposing to use a commissioning incentive scheme to ensure that all providers meet the requirements in this respect

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17


Commentary

A8, B5

5a CI5

CI6

LDSAF A4 & A6

LCR

Improve communication about a person’s Learning Disability Status and their needs. This includes flagging systems in primary care as well as secondary care.

Improve the quality and uptake of communication tools that support people to access health services (Health Action Plans, Patient Passports)

CWP

SCCCG

ECCCG

MCHFT

ECT

LDIG March 2015 CWP identified as Lead at LD Implementation Group in relation to communication tools

5b CI1

LDSAF A6 & A7 & A8

Clear identification of people with learning disabilities on the NHS central registration system and in all healthcare record systems

Use commissioning “levers” to ensure clear and consistent recording and identification of people with learning disabilities across all healthcare record systems

ECCCG

SCCCG

Area Team Quality Surveillance Group

June 2014 CCGs are proposing to use a commissioning incentive scheme to deliver an audit of hospital attendances/admissions among the LD population

6 LDSAF B1

WV

Review existing contracts to ensure they include an appropriate specification , clear individual outcomes and sufficient resources to meet the needs of the individual.

Increase the proportion of people within both health and social care commissioned placements who have received an annual review

CEC

ECCCG

SCCCG


March 2015 Scored red in SAF as did not meet 80% target

7 LDSAF B7 Ensure that the needs of people with Learning Disabilities are taken into

Review and improve the level of evidence of commission Strategies and

CEC Life Course Review

March 2015 Limited evidence of Equality Impact Assessments. It is the responsibility of

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18


Commentary

account when planning and delivering all mainstream public services

Equality Impact Assessments for people who use the services based on demand

ECCCG

SCCCG

Commissioning work stream

all partners to review.

6 CI10

CI12

LDSAF B9

Ensure that the Mental Capacity Act is implemented by all providers

Commission to ensure that training is in place for all staff and that advice and support are available at all times

CEC

ECCCG

SCCCG

Area Team Quality Surveillance Group

June 2014 Contractual function for all health and social care commissioners.

9 LDSAF C9

Implementation of the joint Carers Strategy for Cheshire East

Ensure that the needs of people caring for those with learning disabilities are reflected in the strategy and implementation plans

CEC

ECCCG

SCCCG

Carers Strategy Group

March 2015 Scored red in SAF however considerable work has been undertaken since submission.

10 WV Strong presumption that the LD programme of work will be supported by pooled budget arrangements.

Discussions are ongoing to establish pooled budget arrangements which will be fit for purpose.

CEC

SCCG

ECCCG

LD recovery group

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i WV: Winterbourne View Concordat CI: Confidential Inquiry LD SAF: Joint Health and Social Care Self-Assessment Framework for Learning Disabilities LCR: Cheshire East Learning Disabilities Life Course Review

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Prepared By : Guy Kilminster, Corporate Manager Health Improvement CEC

NHS South Cheshire CCG Governing Body – Better Care Submission

REPORT


NHS South Cheshire Governing Body REPORT TITLE DATE/TIME AGENDA

ITEM

The Cheshire East Health and Wellbeing Board Better Care Fund Plan

27 March 2014 1415-1715 7.6.5

PURPOSE OF REPORT

To brief the Governing Body on the Better Care Fund Plan final Submission document and seek their endorsement of the Plan.

Report Prepared By: Guy Kilminster Governing Body Lead: Dr Andrew Wilson

GOALS 2013-14




VISION


RECOMMENDATIONS


i) Endorse the Cheshire East Health and Wellbeing Board Better Care Fund Plan.






Yes N

N

Y

Y

Y

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Prepared By : Guy Kilminster, , Corporate Manager Health Improvement CEC NHS South Cheshire CCG Governing Body – Better Care Submission

2

REPORT TITLE

The Cheshire East Health and Wellbeing Board Better Care Fund Plan

1. Report Summary 1.1 The Better Care Fund was announced by Government in June 2013. It provides an opportunity to transform local services so that people are provided with better integrated care and support. It encompasses a substantial level of funding to help local areas manage pressures and improve long term sustainability of their health and care economies. The Fund will be an important enabler to take the integration agenda forward at scale and pace, acting as a significant catalyst for change.

1.2 The Cheshire East Better Care Plan unites a shared vision of Cheshire East Council, NHS Eastern Cheshire Clinical Commissioning Group and South Cheshire Clinical Commissioning Group, for improving outcomes for residents through improving how and social care services work together. The Better Care Fund provides the level to drive a transformed model of integrated care, which will ensure that residents experience care and support of quality that is appropriate to their needs and supports them to live as independent and fulfilling lives as possible. Critically it will ensure that when needs require it, specialist care and support is provided by services best equipped to cater for those needs.

1.3 There is a requirement to submit our Better Care Fund Plan to NHS England by the 4th April. A first draft was submitted in February. The final draft is attached as Appendix One with the Metrics and Finance Technical Appendix as Appendix Two. This has been compiled following extensive work by a team of officers from across the Council and the two CCGs and consultation with provider organisations. 2. Policy Implications including - Health 2.1 Following Local Government reorganisation in 2009 and the NHS reforms of 2013, Social Care and Health Services in Cheshire East have strengthened opportunities to secure improved outcomes for residents. This is evidenced through stronger engagement at strategic and operational levels of the organisations and focussing upon identifying opportunities to secure integrated working. 2.2 Across Cheshire all organisations recognise the need to better connect the business of health and social care, in order to ensure that our residents receive the most effective and responsive care and support appropriate to their needs. We also acknowledge that we all need to take greater responsibility for preventing our own ill-health, enabling us to live longer and more fulfilling lives. 2.3 The Health and Wellbeing Board’s Joint Health and Wellbeing Strategy identifies the priorities for commissioners to address over the next two years. The principle of integrating services where appropriate underpins the Strategy

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3. Financial Implications 3.1 The Better Care Fund is a national pooling of £3.8b from a variety of existing sources within the health and social care system, with £23.9m being pooled locally within the Cheshire East Health and Wellbeing Board area. The local pooling is made up of LA funding from the Disabled Facilities Grant and Capital Allocation for Adult Social Care of £1.8m, South and Vale Royal CCG funding of £10.5m and Eastern Cheshire CCG of £11.6m. The local health and social care economy is expected to work together to deliver better care arrangements for its population, seeking to keep individuals within the community, avoiding hospital/residential nursing care.

3.2 During 2014/15 Council, CCGs and its providers are expected to plan to deliver services in a way that impacts on the system to improve the outcomes for its population, through improving Community Services (including Primary Health Care [GPs]). A small development team has been created that is establishing schemes that will deliver the required funding and the governance changes from 2015.16 (i.e. achieving the £23.9m changes).

3.3 It will be important that during 2014/15 financial and governance arrangements between the various partners are agreed, to include the risk sharing arrangements, funding to invest in the system initially and the arrangements for dealing with the potential double running costs and any savings arising. 4. Legal Implications 4.1 Under the National Health Services Act 2006 local authorities and NHS bodies can enter into partnership arrangements to provide a more streamlined service and to pool resources, if such arrangements are likely to lead to an improvement in the way their functions are exercised.

4.2 The powers under that Act allow for pooled budgets, lead commissioning and integrated provision and therefore enable the kind of working suggested in the Better Care Plan.

4.3 Advice needs to be taken as the project develops to ensure that specific issues such as sharing of information are dealt with in a legally sound way. 5. Risk Management 5.1 An initial risk assessment is included within the Better Care Fund submission. 6. Integrating Health and Care in Cheshire East 6.1 The opportunity afforded by the Better Care Fund is to translate the ideas that are already well established within the Cheshire East health and care economy into action, to drive change and transformation at pace.

6.2 This commitment is acknowledged by the ambitions of the Cheshire Pioneer Programme which aims to ensure that individuals in Cheshire stop falling through the cracks that exist between the NHS, Social Care and support provided in the Community, and we will avoid:-

• duplication and repetition of individuals experience, with people having to re-

tell their story every time they come into contact with a new services;

• people not getting the support they need because different parts of the system don’t talk to each other or share appropriate information and notes;

• the “revolving door syndrome” of older people being discharged from hospital to homes not personalised to their needs, only to deteriorate or fall and end up back in A & E;

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• home visits from health or care workers are not co-ordinated, with no effort to

fit in with people’s requirements;

• delayed discharges from hospital due to inadequate co-ordination between hospital and social care staff.

6.3 The clear commitment is that we will move away from commissioning costly, reactive services and commission those that will develop self-reliance, focus on prevention, improve quality of care, reduce demand and take cost out of the system for re-investment into new forms of care. Across Cheshire we are aligning our commissioning approaches and where relevant jointly commissioning services to deliver consistency and integration in the wider service landscape. 6. 4 By 2015, the communities of Cheshire will begin to experience world class models of care and support that are seamless, high quality, cost effective and locally sensitive. Better outcomes will result from working together with:-

• Better experiences of local services that make sense to local people rather

than reflecting a complex and confusing system of care;

• More individuals and families with complex needs are able to live independently and with dignity in communities rather than depending on costly and fragmented crisis services;

• Enhanced life chances rather than widening health inequalities.

6. 5 Every community in Cheshire is different and that is true in Cheshire East. Local solutions will reflect local challenges, but our shared action will be united around four shared commitments:

i. Integrated communities: Individuals will be enabled to live healthier and happier lives in

their communities with minimal support. This will result from a mindset that focuses on people’s capabilities rather than deficits; a joint approach to community capacity building that takes social isolation; the extension of personalisation and assistive technology; and a public health approach that addresses the root causes of disadvantage.

ii. Integrated case management: Individuals with complex needs – including older people with

longer term conditions, complex families and those with mental illness will benefit from their needs being managed and co-ordinated through a multi-agency team of professionals working to a single assessment, a single care plan and a single key worker.

iii. Integrated commissioning: People with complex needs will have access to services that

have a proven track record of reducing the need for longer term care. This will be enabled by investing as a partnership at real scale in interventions such as intermediate care, re-ablement, mental health services, drug and alcohol support and Housing with support options.

iv. Integrated enablers: We will ensure that our plans are enabled by a joint approach to

information sharing, a new funding and contracting model that shifts resources from acute and residential care to community based support, a joint performance framework, and a joint approach to workforce development.

6.6 We recognise that the current position of rising demand and reducing resources make the status quo untenable. Integration is at the heart of our response to ensure people and communities have access to the care and support they need.

6.7 Locally within Cheshire East, two integration programmes are at the heart of this work, connecting workstreams across the Cheshire footprint as appropriate, while also affording opportunities for learning and remodelling care according to the needs of local populations.

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6.8.Caring Together (including NHS Eastern Cheshire Clinical Commissioning Group and Cheshire East Council) - This area covers a population of approximately 201,000 residents, and includes the urban areas of Macclesfield, Congleton and Knutsford. Whilst life expectancy is above the national average, there are significant disparities between areas. The main causes of premature death are circulatory and respiratory disease, cancers, and diseases of the digestive system, with particular links back to lifestyle issues of obesity and alcohol consumption. This area includes 23 GP practices, and works closely with the Local Authority of Cheshire East.

6.9 A partnership of health and social care organisations have developed a shared vision across Eastern Cheshire that is called ‘Caring Together’ – joined up local care for all our wellbeing. This is aimed at bringing about a radical shift in care from reactive hospital based approach to a proactive community based care model. Our approach is patient-centred and will use a new and enhanced primary care approach as the foundation. The notion of the empowered person is at the starting point of great care. The model builds out from this using a locality team approach and specialist in-reach to support primary and community care more effectively.

6.10 The vision in this area was developed in partnership between professionals and the public, and is clinically driven, incorporating the National Voice Principles. In Eastern Cheshire we believe that integration cannot be delivered by one organisation working alone in isolation, but must be delivered through genuine collaboration.

6.11 Connecting Care (including NHS South Cheshire Clinical Commissioning Group and Vale Royal Clinical Commissioning Group, Cheshire East Council and Cheshire West and Cheshire Council) - This locality has a population of approximately 278,500 and includes 30 GP practices (18 in South Cheshire CCG, 12 in Vale Royal CCG). This area covers a proportion of Cheshire East and Cheshire West and Chester Council. The two Clinical Commissioning Groups share a management team to provide efficiencies. Patient flows to the DGH have illustrated that 92% are from people living within the boundaries of the two Clinical Commissioning Groups. There are significant financial pressures that exist within the health and social care geographies in this locality and this is due in part to a relative lack of deprivation against national benchmarking making it difficult for local organisations to individually draw resources to create the headroom for innovation.

6.12 The local Partnership Board recognises the work that is already taking place with regards to developing integrated services to meet the needs of the local communities. Our approach so far has been to deliver integrated services locally, led by empowered staff groups and with a clear focus on improving outcomes and reducing health inequalities. This has engaged front line health and social care staff, clinicians, patient groups, the voluntary sector and commissioners. The Partnership Board has now acknowledged the need for further work to produce an integrated plan that will ensure this ‘bottom up’ approach is co-ordinated and meets the needs of the local Health and Wellbeing strategies to achieve real scale and pace.

6.13 Commissioning of Integrated Services Effective commissioning of services to secure improved outcomes for residents is at the heart of the Better Care Fund, and the partnership within Cheshire East acknowledges this.

6.14 Consideration has been given to whether additional joint activity and commissioning resources should be included in the Better Care Fund pooled budget from April 2015. The partners, through our Joint Commissioning Board, have discussed this extensively and determined that we would wish to take a cautious and measured approach to growing the pool as we extend our collective reach in identifying appropriate activity to be included. Common areas for commissioning reviews have been identified for 14/15 and 15/16 across the partnership. Currently commissioning reviews are underway in the areas of alcohol and substance misuse, and learning disabilities. At the point of each review decisions will be considered to joining the activity and commission to the pool. Part of the reason for doing this is to ensure we do not lose a focus, via BCF on addressing the shared outcomes and

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measures that we are aiming to secure. For this reason we do not wish to get ahead of ourselves or overstate our ambition early and then under-deliver.

6.15 The ambition of the partnership is clearly to connect commissioning activity to improve the health and care outcomes for residents. The Better Care Fund, commencing in 2015 is seen as a staging post on the journey which will result over time in significant combining of resources to more effectively drive innovation and improvement.

7. Access to Information The background papers relating to this report can be inspected by contacting the report writer: Name: Guy Kilminster

Designation: Corporate Manager Health Improvement Phone: 01270 686560 Email [email protected]

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Yellow highlight deletion of text proposed GK Version Two 12/03/2014 Green highlight NHS England emphasis on instructions as to what to include Blue highlight my comment or emphasis

1

Cheshire East Health and Wellbeing Board Better Care Fund planning template 1) PLAN DETAILS a) Summary of Plan

Local Authority Cheshire East Council Clinical Commissioning Groups NHS South Cheshire Clinical Commissioning Group NHS Eastern Cheshire Clinical Commissioning Group

Boundary Differences

Cheshire East Health and Wellbeing Board (HWB) has a population of approximately 370,000 residents. This area is coterminous with the geographic boundaries of the Local Authority, and the area contains two Clinical Commissioning Groups; NHS Eastern Cheshire CCG and NHS South Cheshire CCG. Our two CCGs whilst established from the same Primary Care Trust come with some quite different population needs and requirements, high numbers of the frail elderly in parts of the area and differences in the levels of affluence, both of which affect the care needs and the drivers for change. The health needs of Eastern Cheshire patients are provided mainly by a small District General Hospital in Macclesfield, however the patient flow for additional acute and the majority of specialist services is into the Greater Manchester configuration. South Cheshire CCG was formed in close collaboration with Vale Royal CCG (within Cheshire West and Chester) – the close working relationship and shared management arrangements are due to the patient flows of patients around Leighton, a small District general hospital (Mid Cheshire Hospital Foundation Trust).Over 90% of patients from both CCGS use MCHFT as their acute provider of services. We are working closely with our neighbouring Cheshire West and Chester Health and Wellbeing Board to help improve the patient flows across the broader Cheshire geography as well as into neighbouring areas beyond the Cheshire boundary, in line with our joint and collective involvement in the Cheshire area Pioneer Programme.

Date agreed at Health and Well- Draft version approved: 14.02.2014

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2

Being Board: Final version approved: 25.03.2014

Date submitted: Draft version approved: 14.02.2014 Final version submitted: 05.04.2014

Minimum required value of

BCF pooled budget: 2014/15 £1.209m

2015/16 £23.891m

Total agreed value of pooled budget: 2014/15 £9.221m

2015/16

£23.891m The above £23.891m includes the S256 funding from the Council and two CCGs for Reablement and Carers Breaks.

b) Authorisation and signoff

Signed on behalf of the Clinical Commissioning Group NHS South Cheshire CCG By Simon Whitehouse Position Chief Operating Officer

Date Informally approved 14/2/14 Formal approval for April.

Signed on behalf of the Clinical Commissioning Group NHS Eastern Cheshire CCG By Jerry Hawker Position Chief Operating Officer


Signed on behalf of the Council Cheshire East Council By Lorraine Butcher

Position Executive Director of Strategic Commissioning


Signed on behalf of the Health and Wellbeing Board Cheshire East Health and Wellbeing Board By Chair of Health and Wellbeing Board Councillor Janet Clowes


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3

c) Service provider engagement Please describe how health and social care providers have been involved in the development of this plan, and the extent to which they are party to it. The Cheshire East Health and Wellbeing Board’s Better Care Plan builds upon the work already underway as part of our successful Integrated Care Pioneer submission. The Cheshire Integrated Care Pioneer involves providers from across the health and social care economies within the geographies of the two authorities (Cheshire East and Cheshire West and Chester). The vision and ambition of the Pioneer submission has been endorsed by both commissioners and providers who worked together to secure Pioneer status. The Better Care Plan supports and integrates the change programmes from Cheshire East Council (CEC) and our two CCGs; ‘Caring Together’ in Eastern Cheshire and ‘Connecting Care’ in South Cheshire. In the development of the Plan a number of engagement events have been undertaken, seeking the views and engagement of our various providers. This engagement builds upon the local engagement activity underway within the CCG integration programmes. Both are proactively involving providers in their planning. For example the four work-streams developing the caring Together future care model all include provider representatives, from the hospital and mental health trusts, GPs and the community and voluntary sector. Additionally there are a number of ongoing multi-agency programmes of work involving a range of partners – namely Cheshire East Council, East Cheshire Trust (as the main provider of community health services), housing and voluntary, community and faith sector providers. These are all contributory activities towards the broader integration agenda. Further work will be required to continue the dialogue with Providers, particularly in relation to the outcomes of the Plan and the risks and impacts of the changes that will be taking place. A meeting of Hospital and Mental Health Trust Chief Executives with the Health and Wellbeing Board took place recently and further telephone conference calls are booked in with the BCF steering group. This is in addition to the ongoing provider engagement in the two CCG localities in relation to the detailed work already underway. d) Patient, service user and public engagement Please describe how patients, service users and the public have been involved in the development of this plan, and the extent to which they are party to it Health Watch Cheshire East are engaged with the Better Care Fund planning through their representation on the Health and Wellbeing Board and the integration programmes of the two CCGs. They are also assisting with aspects of the Adult Social Services improvement initiative which links into the integration agenda (for example in relation to developing the Carer Strategy). Within the Eastern Cheshire part of the HWB area the Caring Together Programme has undertaken detailed engagement with the community with the support of ‘Participate’ who, working in partnership with the CCG and partner’s communications teams, have

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4

captured insight from patient/carer groups through previous work undertaken and new engagement events and street surveys. This has been analysed and coded for common themes. Participate have undertaken a series of interviews with individuals from three different stakeholder groups to capture their insight on the barriers to achieving integrated care and how they can be overcome within Eastern Cheshire. The three stakeholder groups were GPs, representatives from NHS and social services workforce and leadership (Other Professionals), and representatives of voluntary, community, and faith sector organisations (VCFS). In addition the four work-streams that are developing the new care model all include patient representatives. A full breakdown of all events is included in the embedded document below:

engagement log.docx

The outcomes and relevance of the engagement to the whole community is currently being assessed, aiming to identify where additional engagement might be beneficial, taking into account the different aspects of the community in the south of our area. The early assessment suggests that the engagement will be sufficiently representative at this stage, ahead of more detailed engagement around the Better Care Fund. Connecting Care for Vale Royal and South Cheshire CCG footprints is to undertake engagement with patients and public alongside key stakeholders to ensure, at an early stage of planning, that the valuable engagement with our population is embedded. Initial engagement has taken place through a workshop based on the SCCCG operational plan which highlighted the strategic direction of travel for Connecting Care. e) Related documentation Please include information/links to any related documents such as the full project plan for the scheme, and documents related to each national condition. Document or information title Outline

Pioneer Programme Expression of Interest

http://caringtogether.info/videos/8?project_id=1&client_id=1

This Pioneer programme outlines the commitment and plans of the Cheshire West and Chester and Cheshire East Health and Wellbeing Boards to integrate care and support services across the County area of Cheshire. The Pioneer programme sets out the common framework for integration; Communities, Case Management, Commissioning and Enablers as reflected in our BCF submission.

Caring Together (Eastern Cheshire CCG)

This programme outlines NHS Eastern Cheshire CCGs and partners proposals to redesign services

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The Case for Change document will be supplied once signed off by all parties. Need to Insert

across the Eastern Cheshire area, including the integration of activity across health and social care functions. This is the pre consultation document which describes the rationale behind the Caring Together Programme. Key headlines are the imperative to change to enable the population of Eastern Cheshire to be empowered to manage their own health, and the delivery of a sustainable health and social care system both in terms of cost and capacity

Connecting Care (South CCG)

Connecting Care vision statement 9Dec

This programme outlines NHS South Cheshire CCGs and partners proposals to redesign services across the South Cheshire area, including the integration of activity across health and social care functions.

Joint Strategic Needs Assessment http://www.cheshireeast.gov.uk/social_care_and_health/jsna.aspx

This is a joint CCG and local authority assessment of the needs of residents across Cheshire East Council. This provides a common evidence base for the design and delivery of services.

Additional documentation/links to documentation

Health and Wellbeing Strategy 2014 - 16 v

The Provision of Early Help in Cheshire

Briefing Paper The Strategic Direction of Need to Insert Need to Insert

Cheshire East Health and Wellbeing Draft Strategy 2014 - 2016 Early Help Strategy – Cheshire East Council Promoting Open Choice – Strategic Direction of Travel for CE Adults Social Care – Cheshire East Council Adult Social Care – Informal Support to Address Prevention and Early Intervention – Cheshire East Council Draft 2 Year Operational Plans - EC CCG and SC CCG Draft Vulnerable People Housing Strategy – Cheshire East Council

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http://www.cheshireeast.gov.uk/social_care_and_health/jsna.aspx




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Draft_VPHS[1].pdf

National Conditions Any documentation specific to these to insert?? Plans to be jointly agreed Protection for social care services (not spending)

7 day services in health and social care…

Better data sharing between health and social care, based on the NHS number

Ensure a joint approach to assessments and care planning and ensure that where funding is used for integrated packages of care, there will be an accountable professional.

Agreement on the consequential impact of changes in the acute sector

VISION AND SCHEMES a) Vision for health and care services Please describe the vision for health and social care services for this community for 2018/19.

• What changes will have been delivered in the pattern and configuration of services over the next five years?

• What difference will this make to patient and service user outcomes? Our submission under the Better Care Fund is designed to deliver our collective vision that within three-years the individual’s residing within Cheshire East will enjoy improving standards of health and well-being through the implementation of our joint and collective plans. This will be delivered through our framework of integration, which incorporates that of the Pioneer Programme that is built around:

• Integrated Communities: residents will be supported within their communities by employing a mind-set that builds on the principle of community capabilities rather than deficits.

• Integrated Case Management: residents will receive a more coordinated experience of care and support services through the use of a single point of access and our support of seven-day working.

• Integrated Commissioning: services commissioned for local residents will be based upon strong evidence and proven effectiveness and commissioned as part of a whole system approach to commissioning.

• Integrated Enablers: on a pan-Cheshire geography we will use this work-stream to support the issues that will enable long-term integration, addressing issues such as; data-sharing, funding and contracting, and workforce development.

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Over the next five years, and starting with those individuals with complex needs, our models of care will focus on:

• empowering people to live full and healthy lives, self-manage and where required supporting people and their families with improved information and technology

• strengthening primary care and its role in proactive long term condition management

• increasing the investment and portfolio of services in the community to support care closer to home where safe and effective to do so

• providing access to specialised services to optimise the safe care and clinical outcomes for patients

• people knowing where to get the right help at the right time • people feeling safe in their communities • people being active members of their communities and reducing social isolation • carers supported to continue caring in partnership with other support services

Partners are committed to the following statements, to ensure that our future model of care and support services deliver the practical outcomes to local stakeholders/ People will agree that the following statements reflect their experience of local care and support:

• I am in control and treated with dignity and respect • I feel part of a tight-knit team that works with me and tackles any obstacles to

getting the help I need • I only have to tell my story once • I don’t have to wait for a crisis to get the help I need • I know that I, my family and carers have the support and information to help me • I only need to go to hospital when I need to and have access to quality support in

my local community • I am in control of what happens to me

With improved outcomes that seek:

• Improved (better compared to current baseline) experiences of care • Improved (exceed national best practice benchmarks) clinical and care outcomes • Reduced health inequalities (better access to hard to reach groups) • Increased range of low level support services

And building on the work from each of our areas we want our public to be able to simply say, ‘I am supported to live well and stay well because I can access joined up care and support when I need it’ Commissioners will agree that the following objectives have been achieved:

• We don’t let organisational boundaries get in our way of what is right for our communities

• We jointly invest in the things that our residents need and the things that work • We work as a team and rarely plan or commission as separate organisations • We work to a shared plan that will help us secure good outcomes even as demand

for services rise and budgets reduce.

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Providers will tell us that the new system displays the following features: • We work in an environment that helps us put people first • We are given the permission to imagine, experiment and learn • We work like a single organisation with joint systems, staff and ways of working.

With improved outcomes that seek:

• Improved utilisation of services (including reduced use of acute and residential care and increased use of primary and community services)

• Better use of financial resources through improved productivity because of the reduction of duplication, waste and variation and opportunity to draw on resources from other sources

• Achievement of the national outcome for integration to support sustained health and social care organisations and services

• Collaborative working across organisations Our plans highlight the activity and approach to the implementation of projects contained within our BCF submission, which will result in continued improvement in the health and well being out comes for the individual’s with our area. b) Aims and objectives Please describe your overall aims and objectives for integrated care and provide information on how the fund will secure improved outcomes in health and care in your area. Suggested points to cover:

• What are the aims and objectives of your integrated system? • How will you measure these aims and objectives? • What measures of health gain will you apply to your population?

The primary aim of our proposals is to provide quality care more efficiently and effectively to local residents. As outlined above we are committed to delivering improvements outlined against the payment by result elements agreed within our BCF against the five national outcomes attached to the BCF. Caring Together Within the Eastern Cheshire CCG area of the HWB geography the Caring Together programme, a whole health and care economy initiative, aims to transform the way all care is delivered. A case for change has been developed which is based on intelligence and analysis from all partners and is cognisant of challenges to be met, organisational accountabilities and joint outcomes to be achieved across health and social care and the wider communities sector. Caring Together (CT) brings together professionals, patients, stakeholders, providers, community groups and the public to help shape the future of health and social care services in Eastern Cheshire. The aim is to deliver a new person centred model of care, with a seamless approach to be co-designed and tested in Eastern Cheshire, shaping integrated community focused models of care in conjunction with the other areas within the Cheshire Pioneer area.

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There are specific work streams that include providers from the NHS, Social Care and the Community and Voluntary Sector. They are informing the Case for Change, the Quality Standards and the design of the new Care Model. Given the flow of patients within Eastern Cheshire, the Caring Together Programme links into the Greater Manchester acute service reconfiguration programme to ensure that specialist services can be accessed within agreed pathways. Connecting Care Within the South Cheshire area of the HWB area the Connecting Care in communities programme, a whole health and care economy initiative has been established to ensure quality, personal, seamless support in a timely, efficient way to improve health and wellbeing’. The overall aim of the programme links closely with the Caring Together programme, where the commitment is that the Cheshire partners will transform the health and social care system by: • Working much more closely together and in smarter ways to provide reliably

and without error, the care that will help people and ONLY the care that will help o Putting the individual at the centre of all care – ‘no decision about me,

without me’, improving their experience of care o Assure quality by employing high quality, well trained staff with strong

leadership and development skills o Focusing on the multiple determinants of both physical and mental ill-health

and creating innovative solutions across partners o Creating more opportunities for and embedding cross organisational working

that reduces duplication and achieves the best use of available resources o Adding value to the lives of individuals and their families/carers and

decommissioning care that does not add value o Exploiting the use of new technologies to support independence, self-care and

information sharing across partner organisations

• Building and strengthening community based services and support o More care will be organised and delivered outside of traditional hospital

settings, in local communities with the development of integrated teams and closer collaboration across teams

o People will access services differently: with GP practices/neighbourhood focused teams and community

services delivering care and support ‘closer to home’ with a smaller, more flexible community facing hospital delivering

emergency and specialist care and regional specialist hospitals continuing to deliver specialist care, some

of which will be in the community setting o Traditional 5 day per week community services will be extended to offer

support when needed, 7 days per week o Care and support will be personalised, timely, responsive and seamless

• Developing our workforce and community assets to deliver new ways of working

o Empowering individuals at a local level to lead change and problem solve with

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full support from their colleagues o Supporting people, their families/carers to take responsibility for their own

wellbeing and make choices about their care based on their personal goals o Offering education, training and development programmes to support the

implementation of new ways of working, self-care, local leadership, change management and improvement approaches.

The HWB will through the BCF, align and integrate the two distinct programmes, so that the specific flavours and requirements unique to the two CCGs areas can be supported and delivered, within the overall co-ordination and oversight of the HWB and the wider Pioneer submission. Remove below in yellow and add into Metrics Technical Template??

Below we set out our current benchmarks against these outcomes, and highlight the improvements we hope to deliver through the BCF. It is important to note that in examining the local performance against the nationally recorded data there are a number of concerns about the quality of the data. There is continued work in progress on our performance, which will receive further scrutiny and refinement through 2014/15, with the current analysis of our performance being detailed below: Permanent admissions of older people (aged 65 and over) to residential and nursing care homes per 100,000 population: The English average is currently 690.3 admissions per 100,000 population, whilst across the Cheshire East area we are currently reporting achievement at 561.1. We know that current performance reported is distorted by the treatment and categorisation of our respite care, which we believe is incorrect, resulting in an increased baseline. We will review our baseline during the early part of 2014/15 and following this review we will determine our collective ambition around the level of improvement we wish to achieve. Proportion of older people (aged 65 and over) who were still at home 91 days after discharge from hospital into re-ablement / rehabilitation services: The English average is currently 82.6% of older people remaining in their own homes after 91 days from discharge from hospital, whilst across Cheshire East 79.3% were still at home. It is important to note that across the Cheshire East area whilst our % performance is lower than the national average our delivery is to a larger % of the population, which will have a greater impact as we improve the proportion of older people still at home after 91 days. Our aim is to improve performance by continuing to expand the number of older people who have received reablement services whilst also seeking to increase those staying at home more than 91 days by 1% each year, until we reach our ambition of being upper quartile. Delayed transfers of care from hospital per 100,000 population: The English average is currently not known so it is not possible to compare the local performance against the national delivery. Locally across the Cheshire East area we are currently achieving 302.75 and will aim to reduce this by 5% from our baseline by 31 March 2015, continuing to improve on that performance year on year until we are recording high quartile performance. Detailed below is a graph showing the average

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monthly delays from April 2011, which is one of the indicators being monitored locally: Avoidable emergency admissions: We have detailed our performance below for our two CCGs. We will add our collective ambition within the final submission, which will seek to improve performance and reflect the differing age profiles of the two CCGs. Await the information provided by NHS England. CCG English Avg Baseline

(2012/13) March ‘15

South - 2,093.3 Tbc East - 2,211.0 Tbc

At Mid Cheshire Hospital Foundation Trust (MCHFT), South Cheshire CCG and Vale Royal CCG we have invested in additional services within the hospital setting (A&E) in particular to increase levels of staffing to treat patients quickly. There has been detailed analysis of the flow of patients both in A&E, but also across the wider hospital services to target those areas needing improvement to ensure the “front door” is not in crisis. Eastern Cheshire has invested in a ‘primary urgent care’ service linked to the NWAS pathfinder scheme providing an acute GP visiting services to optimise care outside of hospital and prevent avoidable admissions. The CCGs have also invested in alternatives to acute care beds – these are multi agency services outside of the hospital setting ensuring patients can be discharged quickly, either from A&E or from hospital wards. The combination of investment and new services in place have meant that both MDGH and MCHFT has managed to deliver the four hour A&E target, and non elective admissions have remained on or slightly under plan for 2013/14. The experience of patients and service users: Proportion of people who feel supported to manage their long-term condition: Across the Cheshire East area we are currently achieving % of 74.1 in the South Cheshire CCG area and 77.5 in the Eastern Cheshire CCG area, with an aim to increase this to upper quartile levels by 31 March 2015. The table below is the Eastern Cheshire CCG submission in the operating plan to cover “what is your ambition for improving the health related quality of life for people with long term conditions”:

Average EQ-5D score for people

reporting having one or more long-term

condition

Baseline 77.50 2014/15 78.60

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2015/16 79.70 2016/17 80.80 2017/18 81.90 2018/19 83.00

Equivalent information is currently being sought for the south area. Locally important indicators: Whilst these national indicators will provide an important measure of success in creating a more integrated model of care and support services, it is also important that partners monitor local outcomes that are tailored to the pressures that we know exist within local services. Therefore, alongside these national outcomes, we have focussed on the area where we know we need to make significant improvements Direct admissions from hospital to long-term care settings: We know that across the HWB we have challenges with direct admissions from hospital to long term care settings. We have regularly reviewed the information provided by the North West AQUA survey and will seek to develop strong robust indicators that will stand ongoing measurement. Our local performance is x against our regional comparator performance of y. We will seek to improve this performance to upper quartile levels within a three year period. We are currently considering the impact of additional local indicators such as falls and dementia. It is also important to note that like all HWB areas there will be a need to take into account the recent Zero Based Review of the coding and classification by CIPFA and the Department of Health of Adult Social Care. This will require a full rebaslining of activity and the selection of appropriate indicators during 2014/15. It is suggested that a quick assessment of the situation be undertaken by CIPFA and DH.

c) Description of planned changes Please provide an overview of the schemes and changes covered by your joint work programme, including:

• The key success factors including an outline of processes, end points and time frames for delivery

• How you will ensure other related activity will align, including the JSNA, JHWS, CCG commissioning plan/s and Local Authority plan/s for social care

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Three key schemes underpin our BCF proposals in the immediacy with recognition that further work programmes will be added as joint commissioning activity progresses and indentified synergies emerge. As these schemes progress, other funding sources for those activities will be added to the BCF as appropriate. Transition planning during 2014 – 2015 will be facilitated by early changes to current working practices, and learning from changes already introduced (for example the extension of GP urgent care in the Eastern Cheshire CCG area using winter pressures monies which has demonstrated significant impacts upon A and E admissions). We will move towards full implementation in 2015-2016. Section 256 monies will be used to help achieve these quick wins.

PLANNED SERVICE AREA 1

SELF CARE AND SELF MANAGEMENT INITIATIVES

SERVICE DESCRIPTION

Within the Connecting Care and Caring Together whole system major change programmes it is recognised that to achieve transformational change which provides lasting benefits to local residents we need to ensure that the individual is empowered to take responsibility for their own care and health. The aim is therefore to continue to develop our voluntary, community and faith sectors to provide vital services to support individuals, families and local communities to support themselves and thereby reducing reliance on statutory services. As individuals, we want to be given the right advice, information and support to be independent. Families want to be enabled to continue to care and share care. Communities want to be self-reliant (with support) to provide for themselves. Statutory commissioners can enable this to happen locally by stimulating and where necessary contracting with the sector to ensure low level advice, information and support services are available at all levels (individual, family, community). The BCF will be utilised to ensure an enhanced range of advice, information, care navigation and community development services are available in a range of settings and where possible to have these work as part of integrated teams and services. The Fund will be further used as investment in the community infrastructure to develop a range of services and initiatives with the aim of these becoming self sustaining over time. The focus on changing the dependency on statutory services to a culture of self help and self management will

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require a range of interventions from public health promotional initiatives through to community development interventions.

Intended Target Group

All Residents of East Cheshire

Impact Assessment on Patient Groups

All patient groups will be positively impacted by the range of information, advice and community support to be made available. The intention will be to have a generic level of support available and fully accessible within local neighbourhoods and communities. Additional targeted support and information for specific high risk groups will be prioritised e.g. mental health, frail elderly.

Impact on Acute Care Sector

The impact on the Acute Care Sector will be to divert people from resorting to attending A&E directly or via NWAS by providing the public with the necessary support and information to ensure that people know how to access appropriate community based support. The initiatives will target prevention measures and early intervention by providing access to early support to prevent a situation escalating. By diverting from A&E attendance and requests for ambulance call outs there will be a reduced likelihood of inpatient admissions. Demand on A&E will also be reduced.

Support for Seven Day Services

Service and support initiatives will ensure consideration of seven day support and selected advice and information sources being available 24/7.

Use of NHS Number as basis for Information Sharing

There will be limited use of NHS number with the lower level support initiatives and advice / information sources. Where this is possible this will be linked into public sector provision.

Protection of Social Care Services

The shift of focus to prevention and early intervention initiatives is critical for the needs of individuals to be appropriately met at an early stage. Utilisation of the BCF pooled budget to deliver low level response services will prevent deterioration and facilitate early access to the appropriate care pathways and will be an essential element of the prioritisation of spend. Services being considered for further investment include care navigators and care brokers for people who are not eligible for social care services or those who choose not to access services via a formal route. The offer of support and care navigation is an essential part of the advice and

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information services which takes account of the need to provide this in a way that is supportive and responsive to an individual who may struggle to make sense of what is available on their own. The development of the personalisation agenda required the support of the whole system to support the principle of the empowered person having access to the range of information and advice and support to ensure they accessed the right help at the right time. The focus of support to enable self help and self management inevitably supports the social care agenda and the wider whole system support for independence and self reliance.

Joint Assessment and Accountable Lead Professional

The initiatives within this planned area of enhanced service development is dependent on linkage with statutory services to ensure those who need a more formal assessment of their health and social care needs are able to access this quickly and appropriately. Once the access is determined the joint assessment and lead professional principles within statutory provision will become effective. There is however the development of the care navigator role which is intrinsic to more specialist types of voluntary sector and community provision which mirrors the principles of a lead professional maintaining oversight of the person and their family to ensure they get to the right help when they need it.


INTEGRATED COMMUNITY SERVICES

SERVICE DESCRIPTION

Integrated health & social care services will be needed for those people likely to be identified through risk profiling with increasing frailty and multiple health and social care needs (largely but not exclusively people over 70 years old). The core teams will be focused around groups of GP practices and will have the team as the single point of access. An appropriate professional will take on the co-ordination of care for each individual within the team – this could be the GP or another professional depending on the needs of the person. We are considering new models for contracting where a lead provider could co-ordinate services from one or more provider and is held accountable for the overall service model of delivery. The Better Care Fund is the opportunity to expand the capacity within social care beyond the

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current levels determined by critical and substantial needs (current Cheshire East Council Fair Access to Care criteria) in order to support those people whose care needs are complex and without such support would be at risk of hospital admission. The integrated teams will be the basis of transformation of services and will extend to wider integrated teams including community based geriatricians, mental health services, alternative beds to the acute hospital and new services to focus the long term care of these patients outside hospital or long term care settings in a co-ordinated, responsive manner. This will include provision currently referred to as Intermediate Care. The voluntary, community, faith and private care sectors will play a key role in supporting the integrated team model by providing additional wrap around services to keep people at home and help co-ordinate services. The range of community care support services will be expanded to increase the range of services which provide short term interventions with a recovery focus which will target specific patient groups e.g. stroke care. Lower level support services which provide a monitoring and oversight role will be included in the service model. This service response aims to provide short term and flexible care and support which may prevent the need for more costly service provision. We believe short periods of monitoring and assessment over time will ensure that the person gets the right care and treatment following a robust and thorough assessment. The plan will be to use the integrated community service model to assess, treat and provide the required interventions to people within the community to prevent the need for people to need to access hospital based services apart from those with the most urgent and/or critical conditions. Further exploration of assistive technology solutions for care and telehealth options will be part of this service development in addition to seeking new and innovative care and support solutions not currently available. The early work completed in designing the new community model of service has included the development of new job roles, which have a multi functional purpose. The aim being to be proactive in engaging people deemed to be in the high risk groups to develop coping strategies linked to their condition/situation and make available to them information and advice regarding a range of issues eg financial support, forward planning, contingency risk planning, local community support etc.

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The early work within the major change programme has seen the emergence of multi disciplinary teams of staff working together around specific GP practices/clusters of practices. The model described above will take this early step change to the next level of incorporating a more structural change to the multi disciplinary working and move to a robust model of care coordination for those within the agreed target group. Single assessments, care plans, care record systems will be key deliverables in addition to single contact number to access the new integrated community service. People having to tell their story once and being central to shaping the care they receive and how it is delivered will be key design criteria of the service model. This model of service is heavily dependent on having a range of skilled and highly trained assessing professionals with the skills to provide treatments and interventions in the community. To support this it is essential that there is a broad and accessible range of wrap around care and support services which will largely be commissioned within the voluntary and private care sector. The intention would be to develop a menu of services which will be flexible and responsive 24/7. This will include domiciliary care support, intermediate care services, bed based community assessment options, home based nursing, allied health professionals.


The priority target group will be those individuals who are deemed to be experiencing complex and multiple long term conditions. This will include a significant proportion of the over 70 population. This will for some areas of high deprivation include more people under the age of 70


There will need to be a full equality impact assessment as the service model is further developed. It is however intended that people with dementia and other mental illness diagnoses will be included as part of the target group. The research and evidence available identifies the significance of the co morbidity of dementia and mental illness alongside other long terms conditions. The integrated community service model has a clear interface with specialist mental health services for adults and older adults. The plan is to have link professionals to ensure this interface is a dynamic and effective one to benefit the individuals using the service and the focus will

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be to maintain the concept of care coordinator across the generic and specialist care sector.


It is intended that the impact will be to reduce the need for A&E attendance and inpatient admission. This impact will be effected by a more proactive and coordinated approach to patient care and the use of risk profiling which will ensure the coordination of care will be aligned with the timely and appropriate response to an exacerbation of condition(s). It is also intended to facilitate early and safe discharge from inpatient stays by developing the seven day service for all relevant service areas. It is intended that the risk profiling will be utilised to identify potential candidates who may become high risk in the future and thereby offer preventative measures linked to self help and self management techniques which will reduce the risk of condition exacerbation becoming critical. Ultimate impact will be to reduce attendance at A&E, admissions to hospital and to facilitate early discharge and reduce lengths of stay. Intention will be to ultimately reduce beds within inpatient units and increase alternatives outside of the hospital setting. Linkage between the integrated community teams and hospital discharge services will ensure a coordinated approach to ensuring the patient profile and wide support network is known at the point of admission which will reduce the need for duplication of assessment whilst an inpatient. The model of service will be dependent on strong team linkages between the secondary care specialists and diagnostics i.e. community physician and mobile diagnostics.


Integrated Community services will provide a seven day service according to the needs of the local population. There will be the need to utilise the BCF to review the contract arrangements for all wrap around services which will need to be available and accessible seven days a week. This will include access to packages of care support from a range of services which will need to have staff available and on standby in the same way they are within Monday to Friday service provision. This will include statutory and private and voluntary care support services.

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This will be required to be in place as part of the new service model.


The protection of social care services will include further expansion of reablement and recovery based services for older people and people with dementia; extension of services to provide respite for carers within the community setting as a real alternative to residential care options (both short and long term); development of social care focussed assistive technology solutions within an overall health and social care range of assistive technology solutions. The BCF is an opportunity to ensure that the social care sector is fit for purpose in terms of scale and range of social care support and care services. It is necessary to reflect that the focus on the development of integrated community assessment and intervention services will be dependent on a wide range of wrap around care and support services to support the initiatives needed to deliver viable alternatives to residential care provision. These services will be required to be skilled in a range of interventions in a crisis and be able to work as part of a multi professional approach. They will also need to be accessible 24/7 and be sufficiently resourced to work alongside NWAS and OOH medical services.

Joint Assessment and Accountable Lead Professional

The service model will incorporate a single assessment process involving the most appropriate members of the multidisciplinary team. Following assessment the person will be provided with a coordinated plan of care which will be overseen by a named lead professional who will take on the role of Care Coordinator.


INTEGRATED URGENT CARE/ RAPID RESPONSE SERVICE

SERVICE DESCRIPTION

We intend to commission and provide integrated urgent care and rapid response services spanning primary, community and secondary care (, Urgent Care Centre)The range of provision will include elements currently provided by A&E, out of hours social care services, NWAS, GPs, social care, mental health, learning disability and community health services. This will mean patients’ urgent care needs will be met in a rapid and responsive way, avoiding duplication of work and unnecessary visits to A&E or hospital admission. Urgent care services will be able to respond to patients in their own home, in a residential care setting or at A&E, OOH, Urgent Care Centres in a co-ordinated system, rather than fragmentation of service

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providers. The model being developed involves the coordination of key services including GPs, NWAS, assessment specialists from health and social care professionals, all of whom will work together to ensure the prompt assessment of people who need a more urgent care and/or treatment response but one which need not be hospital based. The service will develop further the shared contingency crisis plan established by the NWAS pathfinder project and to develop this to a full health and social care plan for an agreed target group identified by an agreed risk profiling tool. The model will be implemented as an early step change in a phased transformation of the whole system within the two major change programmes. The intention is for the urgent care/rapid response service to have access to a range of wrap around services which will facilitate home assessments of both health and social care needs including where appropriate diagnostic services. In addition the range of wrap around provision will include ongoing assessment and treatment over a period of time to stabilise the condition and this will include domiciliary care to provide both personal care, low level health interventions and where appropriate carer support. The use of assistive technology solutions for both health and social care support will be a key element of this service. The intention would be to develop a menu of services which will be flexible and responsive 24/7. This will include domiciliary care support, intermediate care services, bed based community assessment options, home based nursing, allied health professionals. The service will ensure that urgent care where possible is delivered in a community setting. The service will be further developed to provide an effective service response to facilitate early discharge from hospital where a level of health and social care oversight is required for a short period following discharge. This will reduce the length of stay in hospital and avoid residential placements straight from an inpatient stay with the inherent risk of this becoming a longer stay or permanent residential placement. We are considering new methods of contracting for services which will support providers to “own” or be held accountable for the patient journey from urgent need/rapid response to a more stable situation within the home setting. The scheme will include the NWAS pathway pilot, nursing care home discharge initiative, 24/7 working to include increased medical and nursing cover, additional pharmacy

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access, increased social worker and access to social care services. This will also involve a redesign of urgent care, OOH services and A&E together in order to support patients with an urgent need requiring rapid responses to avoid an unnecessary admission to hospital or residential care. The intention is that access to the rapid response/urgent care service can be made from any of the patient contact points.


The priority target group will be those individuals who are deemed to be experiencing complex and multiple long term conditions.


All patient groups within the target group will benefit from the ability to access an urgent care and raid response service. The need to access hospital based services for assessment, diagnostics, monitoring and treatment will be reduced. For patients with dementia related illnesses or for those with caring responsibilities there will be a service response appropriate to meet their needs within their own homes wherever this is practicable.


The impact on the Acute Care Sector will be to divert people from resorting to attending A&E directly or via NWAS by providing the public with a contact point for urgent access to a community based assessment in cases where there is a need for an urgent medical, health and /or social care assessment. By providing a viable and robust urgent care response within the community, there will be a reduction in demand for assessments within A&E departments resulting in a subsequent reduction in admissions. There will be a need to consider how the current arrangement for accessing A&E departments for certain diagnostic tests can be relocated to alternate community settings to ensure that the access to an community based urgent care response can be safe and effective.


This service model will deliver 24/7. There will be the need to utilise the BCF to review the contract arrangements for all wrap around services which will need to be available and accessible seven days a week. This will include access to packages of care support from a range of services which will need to have staff available and on standby in the same way they are within Monday to Friday service provision. This will include statutory and private and voluntary care support services. Commissioning of these services will need to reflect the

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flexible and responsive nature of the service model and will require a focus on service responses having the flexibility of multi tasking. The workforce development plans will reflect the need for new types of professional and support staff roles.


This will be required to be in place as part of the new service model.


The BCF is an opportunity to ensure that the social care sector is fit for purpose in terms of scale and range of social care support and care services at times of crisis. It is necessary to reflect that the focus on the development of integrated community assessment and intervention services will be dependent on a wide range of wrap around care and support services to support the initiatives needed to deliver viable alternatives to residential care provision. These services will be required to be skilled in a range of interventions in a crisis and be able to work as part of a multi professional approach. They will also need to be accessible 24/7 and be sufficiently resourced to work alongside NWAS and OOH medical services. The commissioning of care services will require a variety of care and support responses which will be required in an emergency. The risk of providing alternatives to hospital is that there is a default to residential based services. The urgent care/rapid response model of service will ensure an enhanced range of social care provision is available to provide a real alternative to a buildings based service response whenever that can be safely achieved.

Joint Assessment and Accountable Lead Professional (Care Coordinator)

The joint and coordinated assessment of people in a crisis situation will be a critical element of this service. It will draw on the crisis and contingency planning which will be in place for those people deemed to be at risk of crisis or relapse of their condition(s). The accountable lead professional will be nominated according to the individual situation and will ensure that the crisis plan of care is effective and is attending to the medical, social care and health needs of the person. The accountable professionals will be highly trained skilled professionals who are suitably qualified in the assessments of people within crisis situations and who are able to mobilise and coordinate the range of professionals and support staff needed in any given situation.

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Other Initiatives/Tasks We are developing a range of tasks and activity to ensure the outcomes are delivered, for example developing the governance surrounding the pooled budget, regular risk management, contingency planning etc.

Draft Better Care Fund Initiatives 21 Ja All of the planned changes detailed above are part of the two transformational change programmes – Connecting Care and Caring Together. The broader context of the Pan Cheshire Pioneer programme is a critical element to our programme of change and planning. The pioneer programme takes account of the strategic ambition of the partner agencies involved and the opportunity to look at the whole system change on a far greater footprint. Inevitably this means that the planning at this stage for the Better Care Fund process is not totally aligned with the final proposal and planning stages of these three key programme areas. The plan therefore reflects a combination of the current position in terms of agreed plans and stated intentions of the whole system redesign. Alignment of Activity Across Cheshire East and Cheshire West and Chester a ‘Pioneer Panel’ has been established to lead and co-ordinate the integration work across the two areas. This will be particularly focussed upon the areas of activity that are better undertaken on a pan-Cheshire footprint, including for example workforce development, ICT infrastructure integration and data sharing. The alignment of all the health and care economy strategic planning and priority activity is overseen through the Cheshire East Health and Wellbeing Board. The Board meets every other month. Over the last 12 months the Board has received reports on the ongoing refresh of the JSNA, the work to update the Health and Wellbeing Strategy, the CCG commissioning plans and integration programmes and ongoing improvement activity within Adults Social Care. A sub-group of the Board is the Joint Commissioning Board with senior representatives from all commissioners (including NHS England, the Police and Crime Commissioner, the CCGs, Public Health and the local authority). This group is prioritising and co-ordinating the re-commissioning activity across the health and care economy and ensuring joint commissioning where appropriate. d) Implications for the acute sector Set out the implications of the plan on the delivery of NHS services including clearly identifying where any NHS savings will be realised and the risk of the savings not being realised. You must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. The details of this response must be developed with the relevant NHS providers. It is recognised that the Better Care funding is money that is already committed to health and social care services. Savings will be required across our health economies.

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The impact of the transformation of services across South Cheshire and Vale Royal CCG collectively, will significantly impact on MCHFT as the local acute provider. The shared plan – ‘Connecting Care’, is building the case for fewer beds and services within the hospital setting. Financial resources released from reduction in number of wards will move to community investment. Locally we have already demonstrated the closure of a winter ward through increased resourcing in community beds/services as alternative provision. Currently 193 beds are available outside the hospital setting, reducing pressure on both A and E and flow through the hospital over winter. We intend to widen the extended practice teams to include community geriatricians (based on the work in Torbay where the inclusion of community geriatricians demonstrated the reduction in acute beds when alternatives are available). The reshaping of current service providers (community health, social care , mental health and the Third sector)and additional investment from South Cheshire and Vale Royal CCGs into extended practice teams, should ensure community based services are able to support older people for longer at home, react quickly to a deterioration in the person’s health or well being and avoid unnecessary admissions to hospital or residential settings. MCHFT is an outlier in relation to the high number of reported delays to discharges. We also need to identify the potential cohort of patients who could avoid a hospital admission through risk profiling. A full business case is being developed that will clearly identify the potential cost reductions/movements and reductions in hospital activity necessary to achieve this transformation. is being driven by the Connecting Care Board where our main providers are full members. The risks associated with not delivering the transformation is that the MCHFT will no longer be financially sustainable as a small DGH, and will not be able to deliver the current requirements of the NHS Constitution targets, for example the four hour A and E waiting times; be unable to deliver the required quality improvements and the seven day working requirements across services. Similarly the Eastern Cheshire health economy is currently mapping services to be delivered across four pillars of care ranging from empowering people to self care and by transforming traditional primary, community acute and specialist care settings. Pillar four of the Caring Together Programme looks specifically at acute and specialist reconfiguration working with commissioning and provider partners in Greater Manchester and the North West of England ‘south sector’. The aim of the change programme is to ensure services deliver quality outcomes against recognised best practice standards. The pre consultation business case is scheduled for completion in Summer 2014, which will include a detailed service and economic model. What is agreed however is that there will be a requirement to close hospital beds and take existing investment out of this part of the care sector to support the health contribution to the BCF. Early estimates are that two 25 bedded wards need to be closed and removed from the system alongside the workforce plans for redeployment etc, to release the level of investment required. Detailed investment and benefit management plans will be designed throughout 2014 –

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2015 in line with CCG and Social Care Commissioning Plans. Need to add additional info about risks of not realising savings. Also must clearly quantify the impact on NHS service delivery targets including in the scenario of the required savings not materialising. e) Governance Please provide details of the arrangements are in place for oversight and governance for progress and outcomes The governance of the BCF will form an integral part of the overall plan of integration across the two CCGs, and inform the wider Pioneer Programme. The diagram below, indicates how the separate programmes of activity across the Councils and CCGs link and combine to form the overall five year Joint Strategy and Plan. Locally across Cheshire East we will place the HWB at the centre of the management of our BCF programme, representing the shared interests of all partners in an open and established forum. This model of governance is illustrated below:

Our HWB will engage with the following bodies to ensure that we create a collaborative, effective and transparent model of governance:

• Pioneer Panel: Made up of representatives from across both Health and Wellbeing Boards to address integration issues on a pan-Cheshire geography.

• Organisational Governance: We will continue to use the existing structures and mechanisms that have been established to make sure that the BCF is aligned to mainstream governance and business as usual.

East and South CGGGs

CEC

CE H&WbB CW H&WbB

VR and West CGGGs

CWAC Caring together

Connecting Care

Cheshire Pioneer Programme

West Cheshire Way

Pioneer Panel

Joint Commissioning

Board

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• Scrutiny and Health-watch: We will use the existing mechanisms to monitor our progress and champion the views of local residents, patients and service users to ensure there is appropriate accountability for this programme.

Governance will be clearly defined through the following roles: (i) Health and Wellbeing Board (ii) The two programmes – Connecting Care and Caring Together (iii) Pan Cheshire Pioneer Panel (iv) HWB Joint Commissioning Board

We will continue to align our varying workstreams to ensure that the overall governance framework remains sufficiently robust as we refine our draft plan, seeking to explore the best governance arrangements in place across the HWB area, including reviewing the items below: Joint commissioning

Joint Commissioning MOU Final Jan 2013jw This is an undated version can anyone advise on date agreement was finalised? Health, social care and a wide range of other community partner organisations across Cheshire have made a commitment to working more closely together in new innovative ways to ensure that within the next five years, the people within our communities will enjoy a better standard of health & wellbeing & will have positive experiences of seamless care and support.

We are committed to delivering the National Voices narrative below:

For the individual: ‘I can plan care with people who work together to understand me and my carer/s, allow me control and bring together services to achieve the outcomes important to me’.

National Voices & Making it Real Our plans are ambitious and we will lead a programme of work to ensure that people within our local communities are empowered and supported to take responsibility for their own health and wellbeing. They will place less demand on more costly public services through the implementation of ground-breaking models of care and support based on:

• integrated communities • integrated case management • integrated commissioning and • integrated enablers to support these new ways of working.

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The two Health and Wellbeing Boards within Cheshire are leading this transformational change through a large-scale change programme with support from the national Pioneer team. The Cheshire wide Pioneer plan encompasses a range of shared integration commitments and is structured as three core components based on local populations:

• Central Cheshire ‘Connecting Care’ programme • East Cheshire ‘Caring Together’ programme • West Cheshire ‘The West Cheshire Way’/’Altogether Better’.

The Connecting Care programme board has been established to provide strategic leadership to the underpinning work-streams, to stimulate transformation of the local health and social care economy, to ensure close working between all partners, to ensure robust monitoring and risk management. The Board comprises representatives from our key partner organisations across health and social care and meets monthly, supporting a cohesive approach to service delivery for the population of South Cheshire/Vale Royal. Membership is currently being expanded to include representation from Healthwatch. Within Eastern Cheshire the Caring Together Transformation programme is well underway having established a robust framework for governance engagement and programme delivery. The case for change as part of the pre consultation phase is being finalised and consultation scheduled for June 2014. Care model development groups are currently developing ambitious standards for new services across the four pillars of care to ensure improved health and social care outcomes are achieved

Caring Together governance structure 2) NATIONAL CONDITIONS a) Protecting social care services Please outline your agreed local definition of protecting adult social care services. Partners recognise the budget challenges that exist across the health and social care economy. We know that social care services have delivered £30m (30%) of efficiencies over the last five years to 31 March 2014, whilst investing £20m in new services over the same period; health services have similarly delivered significant efficiencies. During this time the Council has struggled to maintain the delivery of services, whilst maintaining the consistent Fair Access to Care Service Eligibility Criteria at Critical and Substantial. The protection of social care services does not merely relate to budgetary issues, it more importantly focuses on the outcomes for people who have social care and support needs to maintain and promote independence wherever possible. It also requires the development of an increased range of services to promote the Prevention, Early Intervention and Well Being agenda in line with the Personalisation agenda and the new Care Bill. It is the Health and Wellbeing Board’s intention to maintain services at the critical and substantial level (followed by the national eligibility criteria as determined by

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the Care Bill) with a commitment to developing targeted services for people with moderate needs. The Council is committed to protecting and enhancing services required by the frail and vulnerable individuals of our communities and through combining services provided by both Adult Social Care and Public Health has and continues to enhance services. Protecting services does not necessarily require the protection of funding. The Council, the two CCGs and prior to that the PCT have consistently reduced costs as shown above whilst enhancing service delivery over the first five years of the Council’s existence. This work continues with the delivery of improved outcomes within reduced budget targets over the forthcoming years, which will be enhanced by the BCF. We will not use the BCF to meet the budgetary challenges that are facing social care services over the coming three years. We believe that the BCF represents an exciting opportunity to invest in a wide and varied range of community services and assistive technology with the result of improved outcomes for our population. The changes to the investment pattern will contribute to the development of an integrated and balanced model of care and support that delivers on the ambitions in this plan and complements the range of health care provision. We will use the BCF to promote the principles of integration and prevention to make sure that we have the appropriate funding for social care provision to extend effective services at scale and pace, and deliver wider benefits across the care and support services of Cheshire East. As the structure of health services change, social care services will also be reshaped to compliment and create coherence across the whole system. One of the most notable changes that demonstrate this concept in action across the Council has been the development and change in domiciliary services. The Council has developed the external market for domiciliary services, whilst developing internal specialist services for re-ablement, adding improved outcomes at an overall lower cost to the public purse. Social Care Reform It is recognised that the BCF needs to incorporate statutory responsibilities as part of the Social Care Reform, Care Bill. Whilst there is a national allocation of £135m to cover carer’s assessments and maintaining social care eligibility included within BCF there is no clear allocation to local areas. It is estimated that the funding available to Cheshire East is £1m and work is currently underway to determine the demand for carer’s assessments and the impact of maintaining eligibility. The pathway between people requiring services and the assessment of their carer support network will be reviewed and developed as part of the review of health and social care services. Alongside the Better Care Funding, it has been announced that there is National funding of £335m to support the funding of social care reform in 2015/16. Of this funding, £50m relates to capital which is incorporated within the BCF allocation. The Cheshire East allocation is £0.8m and this is being used to invest in the development of IT systems which incorporate the Social Care Reform policy changes. The allocation to Cheshire East of the £285m revenue allocation to cover increased social care assessments; deferred debt scheme; financial assessments is £1.7m in 2015/16. A recruitment request of 16 social workers is being progressed in February 2014 by the Council to ensure that there are sufficient resources in place to fulfil these additional requirements.

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The Department of Communities and Local Government (DCLG) have not announced 2016/17 funding for further changes to eligibility criteria and the introduction of the care cost cap. The Council are working with ADASS to complete modelling information in relation to the impacts of Social Car Reform changes. Please explain how local social care services will be protected within your plans. Key areas of protection:

• Manage and reduce demand on Residential hospital care

- Maintain and enhance current level of provision for domiciliary care and support at home to provide real alternatives to people to stay at home and especially in a crisis

- Increase reablement resource to increase access and benefits to people especially on discharge from hospital

- Introduce dementia reablement service to focus on this client group at early stage of diagnosis to prevent/slow down deterioration in condition and introduce coping strategies/self management for the individual and carers

- Increase flexibility and response to requests for support from care providers over 24/7. Increased funding required for providers to home services available and accessible 24/7 for both routine and crisis responses

- Lower level short-term Social Care support on discharge to people without need for FACs eligibility assessment.

• Maintain Current Levels of Eligibility

- As LA budgets reduce and demand increases the need to maintain a safe and

effective service response for people eligible for Social Care becomes more pressured and will need protecting.

- Future national eligibility may include greater numbers of people deemed eligible and resources to meet need need to be protected. Care fund criteria includes use of BCF to offset services at risk and the LA response to the Care Bill

• Meeting Responsibilities under Care Bill

Additional Responsibilities include:

- Increased numbers of people requesting assessments to have their contribution for care counted towards their individual care account to be considered for the ‘cap’.

- Increased eligibility for assessments and care and support for carers - Possibly increased eligibility threshold

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- Additional responsibilities for Social Care needs or prisoners in local prisons – ie Styal

- Focus on ‘wellbeing and prevention’ and support services to deliver/support this

• Integrated with health commissioning and provision - Commitment to integration of service provision and commissioning activity will

require a focus on the Social Care agenda and its contribution to the overall health and wellbeing agenda both in commissioning activity and provision

- Focus on wider determinants of health and the need to invest in whole system developments

Therefore, we will use the BCF to invest into areas of integration, prevention and support rather than using these funds to address budget gaps. We are committed to using this fund as the necessary investment to extend evidenced and proven areas of Social Care spending that support the aims of the plan with three main initiatives, which are; developing our Rapid Response/Urgent Care Services, enhancing our Community Services, including neighbourhood teams and introducing more Self-care, self-management and help to live independently at home. Further detail is included within the attached document:

Draft Better Care Fund Initiatives 21 Ja b) 7 day services to support discharge Please provide evidence of strategic commitment to providing seven-day health and social care services across the local health economy at a joint leadership level (Joint Health and Wellbeing Strategy). Please describe your agreed local plans for implementing seven day services in health and social care to support patients being discharged and prevent unnecessary admissions at weekends. The Health and Well-being Strategy contains a commitment to enabling seven-day health and care services. We will use the BCF to support residents seven days a week, as a lever to support proposals contained within the CCG operational plans. Partners are committed to developing timely and effective services that provide timely discharge and prevent unnecessary admissions amongst high-risk cohorts. This will involve a process of risk stratification so that all local organisations have common information when working with common cohorts. The CCGs and partners have utilised the urgent care board planning process to identify the need for seven day service provision within both hospital and community settings. The BCF will be utilised to ensure that all relevant service areas have appropriate staffing levels, contingency planning to provide rapid response services and also commissioning

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arrangements for flexible and accessible seven day wrap around care services. Learning from work already underway (for example using the winter pressures monies in Eastern Cheshire CCG) will inform planning. We will continue to work up the plans utilising the newly formed Provider Board ‘innovation fund’ as a mechanism to develop appropriate 7 day services tpo meet local need. c) Data sharing Please confirm that you are using the NHS Number as the primary identifier for correspondence across all health and care services. We are currently using the NHS number as the primary identifier on a high proportion of our shared cases, capturing the NHS number within the Social Care Case Management system whenever possible. This builds on the earlier work completed across the Cheshire East area with the Common Assessment Framework Demonstrator, where the NHS number was a key element of that project. We continue to improve on the capture of the NHS number and to verify that with the NHS systems. If you are not currently using the NHS Number as primary identifier for correspondence please confirm your commitment that this will be in place and when by We are committed to having the NHS Number as the primary identifier for all local cases by April 2015. Please confirm that you are committed to adopting systems that are based upon Open APIs (Application Programming Interface) and Open Standards (i.e. secure email standards, interoperability standards (ITK)). We are committed to adopting market leading case management systems that utilise open APIs and Open Standards. Please confirm that you are committed to ensuring that the appropriate IG Controls will be in place. These will need to cover NHS Standard Contract requirements, IG Toolkit requirements, professional clinical practise and in particular requirements set out in Caldicott 2. The Council and its partners are committed to being able to satisfy the IG Toolkit level 2 by March 2014 and Level 3 by March 2015.. d) Joint assessment and accountable lead professional Please confirm that local people at high risk of hospital admission have an agreed accountable lead professional and that health and social care use a joint process to

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assess risk, plan care and allocate a lead professional. Please specify what proportion of the adult population are identified as at high risk of hospital admission, what approach to risk stratification you have used to identify them, and what proportion of individuals at risk have a joint care plan and accountable professional. The model of service for rapid/urgent care response and the community service model is built around the principal of a single assessment process by the most appropriate professional(s) with a single care plan incorporating all elements of the persons care and treatment. The person with complex care needs involving multi professional/service input will be allocated a lead professional who could be any professional within the service area. The lead professional will have a coordinating role and be accountable for ensuring the plan of care reflects the range of support and treatment to appropriately meet the assessed care needs and manage any identified risks appropriately. The lead professional will be identified as the most appropriate professional involved in the persons care. This will depend on the frequency of contact, knowledge of the person and the skill and/or expertise needed in any given situation. The individual may wish to influence who the lead professional will be and will have their wishes taken into account wherever possible. The single assessment process will be supported by documentation and a single record system which allows for the professionals involved in the assessment to contribute to the process and record in one place and for a point in time. This assessment will be regularly reviewed and updates in keeping with the needs of the individual. The crisis contingency care plan for the high risk group will be developed to reflect the intended responses across health and social care including NWAS. The crisis contingency plan will be developed in conjunction with the person and their carers. Multi disciplinary groups in Eastern Cheshire currently meet regularly around groups of GP practices. This will be extended as a first step to enhancing the communication and coordination of those patients deemed to be in high risk groups. This is a precursor to the ambition to establish the lead professional role as detailed above. In South Cheshire we are looking to explore a number initiatives, for example in one area, we plan to have three early implementers for extended practice teams by summer 2014 based on town geography clustered around groups of GP practices. There will follow a roll out of four other teams (which are seen as single point of access) through late autumn 2014/early 2015. Coverage of the teams is around 20,000-25,000 patients. The learning will be considered across the HWB area and across the wider Pioneer area to ensure the best practice emerges between the different areas in line with the Pioneer ambition. Patients will be identified through risk stratification within each team and is likely to be 0.5 - 5% of a practice population, expanding over time. We are currently evaluating the use of various risk stratification tools (such as EMIS and ACG) across the HWB area and may pilot a couple of different approaches to assess the benefits and the potential alignment with the LA systems. MDTs are currently indentifying patients known to services already at high risk.

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3) RISKS Please provide details of the most important risks and your plans to mitigate them. This should include risks associated with the impact on NHS service providers Risk Risk

rating Mitigating Actions

Improvement in the quality of preventative services may not achieve outcome improvements by the end of the BCF (2015/15) and would therefore lead to the double-running of costs. This could potentially impact on the funds that are available for preventative services prior to escalation.

High We have modelled our BCF submission on the best available data, and have applied optimism bias to reduce risk. We will monitor these issues throughout 2014/15 and refine assumptions as far as possible.

Operational pressures will restrict the ability of our workforce to deliver the required investment and associated projects to make the vision of care outlined in our BCF submission a reality.

High The BCF will be reported to governance and operational groups on a regular basis to ensure this relationship is monitored, and to stress the importance of this work.

The lack of local data provided and available may result in the targets included in our outcomes and metrics section may not be achieved, and therefore we would be left with a shortfall.

Medium The payment by results targets have been based on the best available local data, including the forecasting for future years. Contingency plans have been developed to highlight potential alternatives should a shortfall occur. Under the Pioneer Programme a wider process of performance benchmarking is being conducted across the County.

The movement of resources may potentially destabilise services and providers, most critically the acute trusts.

Medium We have engaged with the Acute Trusts and other providers throughout the development of these proposals. These plans have been developed over the past three years, and appropriate time has passed for a meaningful dialogue to take place on these issues.

Lack of investment to adequately resource delivery or integration programmes

Medium Seek to review all exiting funding across the S256 programme Additional resources to “pump prime” setting up new alternatives before movement of monies as recurrent funding streams are embedded

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Cultural change will not be delivered over the short and medium term and thus impact on the identified metrics

Medium Programme of workforce development to be established to ensure culture issues addressed Development of Leadership Academy programme based on quality improvement systems.

Public/citizen engagement will be weak and not facilitate robust involvement/transformation redesign of health and social care

Medium Engagement throughout the plan being considered.

Interdependency between programmes and activity, willingness to allow a collective HWB/Pioneer programme to evolve and flourish

Medium Governance arrangements, providers and commissioners to ensure that activity reductions or increases can be tracked against the shared plan.

Interdependency with other areas of whole system change (for example Mental Health)

Medium Governance has main providers, including mental health, ensuring the shared plan delivers whole system ownership and changes across health and social care.

Acute and the ability to lever change, the potential for double running costs.

Medium

There is potential for double running costs as the early implementer sites are embedded before resources can be released from the acute sector.

Caring Together Risks:

Programme Risk and Issue Log 8th Jan 201 Contingency: TO BE ADDED Draft Metrics and Finance Template: TO BE ADDED

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Prepared By : Guy Kilminster, Corporate Manager Health Improvement CEC NHS South Cheshire CCG Governing Body

REPORT


NHS South Cheshire Governing Body REPORT TITLE DATE/TIME AGENDA

ITEM

The Cheshire East Health and Wellbeing Strategy 2014 - 2016 27 March 2014

1415-1715 7.6.6

PURPOSE OF REPORT To brief the Governing Body on the refresh of the Cheshire East Joint Health and Wellbeing Strategy and seek their endorsement of the Strategy.

Report Prepared By: Guy Kilminster Governing Body Lead: Dr Andrew Wilson

GOALS 2013-14




VISION


RECOMMENDATIONS


i) Approve the Cheshire East Joint Health and Wellbeing Strategy 2014 - 2016






Yes N

Y

Y

N

N

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Prepared By : Guy Kilminster NHS South Cheshire CCG Governing Body : Health & Wellbeing Strategy Report

2

REPORT TITLE

The Cheshire East Health and Wellbeing Strategy 2014 - 2016

1. Report Summary 1.1 The Health and Wellbeing Board came into existence on 1 April 2013. The Board has had a

fruitful first year, overseeing the process of submitting to the Department of Health the successful bid to be a Health and Social Care Pioneer authority (in conjunction with the Cheshire West and Chester Health and Wellbeing Board) and supporting the ongoing integration programmes with the Clinical Commissioning Groups. In addition the Board has been monitoring the progress of key initiatives such as the Learning Disability Lifecourse Review, the Dementia Strategy and Implementation Review and the work of the Joint Commissioning Leadership Team.

1.2 The Health and Social Care Act (2012) placed a duty upon the Local Authority and Clinical

Commissioning Groups in Cheshire East, through the Health and Wellbeing Board, to develop a Joint Health and Wellbeing Strategy to meet the needs identified in the Joint Strategic Needs Assessment (JSNA). The interim Strategy was approved in December 2012.

1.3 The interim Strategy was a one year Strategy. A refreshed Strategy has now been drafted for

2014 – 2016 to provide direction for Commissioners over the next two years. This has been based upon the evidence from the refreshed Joint Strategic Needs Assessment and the Annual Report of the Director of Public Health 2013. The revised Strategy is attached as Appendix One.

2.0 Policy Implications including - Health 2.1 To achieve improved health and wellbeing outcomes for local communities, the Health and

Social Care Act 2012 identified the need for increased joint working between the NHS and local authorities, with high quality local leadership and relationships being an essential foundation. The Act described Health and Wellbeing Boards as having the key role of improving joint working by bringing together key commissioners and through their function of encouraging integrated working in relation to commissioning.

2.2 The Joint Health and Wellbeing Strategy will be the mechanism by which the needs identified in the Joint Strategic Needs Assessment are met, setting out the agreed priorities for collective action by the key commissioners, the local authority, the Clinical Commissioning Groups and NHS England.

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3. The Joint Health and Wellbeing Strategy 3.1 The Joint Health and Wellbeing Strategy should demonstrate how the Authority and CCGs, working with other partners will meet the needs identified in the JSNA. This could potentially consider how commissioning of services related to wider health determinants such as housing, education, or lifestyle behaviours can be more closely integrated with commissioning of health and social care services.

3.2 There is a clear expectation within the Act that the JSNA and Joint Health and Wellbeing Strategy will provide the basis for all health and social care commissioning in the local area. This begins with the duty of the Clinical Commissioning Groups, NHS England and the local authority to have due regard to the relevant JSNA and Joint Health and Wellbeing Strategy when carrying out their respective functions, including their commissioning functions. 3.3 Developing the Joint Health and Wellbeing Strategy should incorporate a robust process of prioritisation in order to achieve the greatest impact and the most effective use of collective resources, whilst keeping in mind people in the most vulnerable circumstances. The aim of the Strategy is to jointly agree what the greatest issues are for the local community based on evidence from the JSNA. 3.4 The Department of Health Guidance sets out a number of values that under pin good Strategies:

• Setting shared priorities based on evidence of greatest need; • Setting out a clear rationale for the locally agreed priorities and also what that means for

the other needs identified in the JSNA, and how they will be handled with an outcomes focus;

• Not trying to solve everything, but taking a strategic overview on how to address the key issues identified in JSNAs, including tackling the worst inequalities;

• Concentrate on an achievable amount – prioritisation is difficult but important to maximise resources and focus on issues where the greatest outcomes can be achieved;

• Addressing issues through joint working across the local system and also describing what individual services will do to tackle the priorities;

• Supporting increased choice and control by people who use services with independence, prevention and integration at the heart of such support.

3.5 The Interim Strategy’s priorities have been reviewed and tested against the refreshed JSNA and the recently published Director of Public Health’s Annual Report, to determine their robustness for 2014. Members of the Board have contributed their thoughts to an earlier draft. Changes have been made to the ‘Starting Well’ priority in the light of the refresh of the Children and Young People’s JSNA. Improving the physical health of those with serious mental illness has been highlighted as a new priority and we have introduced a specific reference to reducing social isolation and loneliness in the Ageing Well priority. 4 Access to Information The background papers relating to this report can be inspected by contacting the report writer: Name: Guy Kilminster, Designation: Corporate Manager Health Improvement Phone: 01270 686560 Email [email protected]

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CHESHIRE EAST COUNCIL REPORT TO: Health and Wellbeing Board

Date of Meeting:

25th March 2014

Report of: Corporate Manager Health Improvement

Subject/Title: Review and refresh of the Cheshire East Joint Health and Wellbeing Strategy

Portfolio Holder: Cllr. Janet Clowes - Portfolio Holder for Health and Adult Care

1.0 Report Summary 1.1 The Health and Wellbeing Board came into existence on 1 April 2013. The Board has had a fruitful first year, overseeing the process of submitting to the Department of Health the successful bid to be a Health and Social Care Pioneer authority (in conjunction with the Cheshire West and Chester Health and Wellbeing Board) and supporting the ongoing integration programmes with the Clinical Commissioning Groups. In addition the Board has been monitoring the progress of key initiatives such as the Learning Disability Lifecourse Review, the Dementia Strategy and Implementation Review and the work of the Joint Commissioning Leadership Team. 1.2 The Health and Social Care Act (2012) placed a duty upon the Local Authority and Clinical Commissioning Groups in Cheshire East, through the Health and Wellbeing Board, to develop a Joint Health and Wellbeing Strategy to meet the needs identified in the Joint Strategic Needs Assessment (JSNA). The interim Strategy was approved in December 2012. 1.3 The interim Strategy was a one year Strategy. A refreshed Strategy has now been drafted for 2014 – 2016 to provide direction for Commissioners over the next two years. This has been based upon the evidence from the refreshed Joint Strategic Needs Assessment and the Annual Report of the Director of Public Health 2013. The revised Strategy is attached as Appendix One. 2.0 Recommendation 2.1 That the Health and Wellbeing Board consider and endorse the refreshed Strategy. 3.0 Reasons for Recommendations 3.1 To ensure that the Joint Health and Wellbeing Strategy is fit for purpose.

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2

4.0 Policy Implications including - Health 4.1 To achieve improved health and wellbeing outcomes for local communities, the Health and Social Care Act 2012 identified the need for increased joint working between the NHS and local authorities, with high quality local leadership and relationships being an essential foundation. The Act described Health and Wellbeing Boards as having the key role of improving joint working by bringing together key commissioners and through their function of encouraging integrated working in relation to commissioning. 4.2 The Joint Health and Wellbeing Strategy will be the mechanism by which the needs identified in the Joint Strategic Needs Assessment are met, setting out the agreed priorities for collective action by the key commissioners, the local authority, the Clinical Commissioning Groups and NHS England . 5. The Joint Health and Wellbeing Strategy 5.1 The Joint Health and Wellbeing Strategy should demonstrate how the Authority and CCGs, working with other partners will meet the needs identified in the JSNA. This could potentially consider how commissioning of services related to wider health determinants such as housing, education, or lifestyle behaviours can be more closely integrated with commissioning of health and social care services. 5.2 There is a clear expectation within the Act that the JSNA and Joint Health and Wellbeing Strategy will provide the basis for all health and social care commissioning in the local area. This begins with the duty of the Clinical Commissioning Groups, NHS England and the local authority to have due regard to the relevant JSNA and Joint Health and Wellbeing Strategy when carrying out their respective functions, including their commissioning functions. 5.3 Developing the Joint Health and Wellbeing Strategy should incorporate a robust process of prioritisation in order to achieve the greatest impact and the most effective use of collective resources, whilst keeping in mind people in the most vulnerable circumstances. The aim of the Strategy is to jointly agree what the greatest issues are for the local community based on evidence from the JSNA. 5.4 The Department of Health Guidance sets out a number of values that under pin good Strategies:

• Setting shared priorities based on evidence of greatest need; • Setting out a clear rationale for the locally agreed priorities and also what

that means for the other needs identified in the JSNA, and how they will be handled with an outcomes focus;

• Not trying to solve everything, but taking a strategic overview on how to address the key issues identified in JSNAs, including tackling the worst inequalities;

• Concentrate on an achievable amount – prioritisation is difficult but important to maximise resources and focus on issues where the greatest outcomes can be achieved;

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3

• Addressing issues through joint working across the local system and also describing what individual services will do to tackle the priorities;

• Supporting increased choice and control by people who use services with independence, prevention and integration at the heart of such support.

5.5 The Interim Strategy’s priorities have been reviewed and tested against the refreshed JSNA and the recently published Director of Public Health’s Annual Report, to determine their robustness for 2014. Members of the Board have contributed their thoughts to an earlier draft. Changes have been made to the ‘Starting Well’ priority in the light of the refresh of the Children and Young People’s JSNA. Improving the physical health of those with serious mental illness has been highlighted as a new priority and we have introduced a specific reference to reducing social isolation and loneliness in the Ageing Well priority. 8.0 Access to Information The background papers relating to this report can be inspected by contacting the report writer: Name: Guy Kilminster Designation: Corporate Manager Health Improvement Phone: 01270 686560 Email [email protected]

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Prepared by Amanda Best, Service Delivery Manager NHS South Cheshire CCG Governing Body : Primary Care Strategy

REPORT



Local Enhanced Services Report 15:15 – 17:15 7.6.7

PURPOSE OF REPORT The paper provides the Governing Body with an overview and summary of the CC requirements and status report towards developing and delivering a Primary Care Strategy in conjunction with NHS England Area Team

AUTHOR Amanda Best Service Delivery Manager

STATE HOW THIS PAPER LINKS TO THE NHS VRCCG VISION, AIMS & VALUES & GOALS

This paper directly relates to working with partners to ensure high quality Primary healthcare. Ensuring patients are at the centre of everything we do, by designing services to fit their healthcare needs.

GOVERNING BODY LEAD(s)

Fiona Field Director of Partnerships and Governance

GOALS 2013-14



Use of education and constructive profession challenge to improve quality;

Use patients to inform and introduce challenge at all levels of service provision.

VISION

To maximise health and wellbeing and minimise health and inequalities, informed by local voices and delivered in partnership

RECOMMENDATIONS

The SCCCG Governing Body is asked to:-

• Note the content of the report • Accept the status update and review






No Yes

No

Yes

No

No

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Prepared by Amanda Best, Service Delivery Manager Primary Care Strategy

REPORT TITLE

Local Enhanced Services Report

1.0 Overview Summary

NHS England Area Team have tasked CCGs across the Cheshire Wirral and Warrington footprint with developing the Primary Care 5 year Strategy, that provides and assurance, direction and alignment to the wider transformation and integration agenda by which the CCG is working towards. NHS England Area team have convened a primary Care transformation forum, inviting representation from CCGs within the area to share understanding, commonality of purpose, development and direction. 2.0 Context NHS England area team remains the accountable commissioner for national standards but the CCG’s are responsible for developing the local strategy for primary care transformation. This makes logical sense as Primary care is part of the overall local health system transformation which should be fully integrated and embedded into the plans in each health economy; it is also very much a core element of the integrated care transformation. The CCG have welcomed this opportunity to shape and define the strategic direction and measure of Primary Care development and transformation locally and contextualise this through our strategy within this context and the leadership and drive within each CCG, which will be supported by our central area team. The CCG are participating in learning opportunities with other local CCGs over the coming months whilst the plans are being shaped and delivered, to share progress, guidance and support and to resolve questions as they arise or are arising. 3.0 Forwarding considerations

In response to the CCGs ambition towards proactively developing Primary care, the CCG has identified a defined lead for the primary care strategy work in the CCG who is taking this forward. Underpinned by the Connecting Care agenda and Accountable GP aspirations, the CCG has started to develop a clear CCG vision for primary care within a broader health system The CCG has over the past few month communicate at large with member practices and key provider stakeholders around the case for change, and has clearly articulated these reasons . Through membership agreement all practices are signed up in principle for change. Through the development of the strategy, the outcomes and measures of success for improvement being defined for both populations and pathways Through engagement, strategic debate and emerging models the scope for primary care team development is being more fully considered. The CCG have already defined the populations, outcomes and service specifications that align to locality / community team models. The mechanisms and accountability structure for delivery is being finalised. The CCG are activity engaging in debate and conversation regarding the contracting changes, including incentives that have been identified to enable this vision. 4.0 Milestones

The first high level draft of the overarching NHS England Area Team plan is required by 4 April 2014 with the final detailed local plan to be submitted by 20 June 2014.

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The CCG has been allocated a Programme support manager to develop engage and implement the strategy and who will be aligned to the CCG for one day per week. The CCG has proposed to develop the Primary Care Strategy in alignment with the five year strategic plan, but as a corner stone for mobilisation and leverage, is developing the Primary Care Quality Scheme (formerly known as the Primary Care CQUIN) as a product of delivery around transformational change, Quality Assurance and patient safety, but with a specific focus on the isolated, vulnerable cohort of patients, that also link in with Learning disabilities and dementia. The CCG has worked closely with the membership to agree these priorities and work is underway to define the measures, requirements and outcomes from this scheme. It is envisaged that the Local Quality Scheme for South Cheshire CCG will be in place by April 2104. The Primary Care team and membership have been careful to align any proposals of development to the delivery of extended practice teams and to promote the thinking around community based, integrated initiatives. 5.0 Strategy Content and Measure of Success

In developing the Primary Care strategy, the CCG is building from the national planning guidance and local CCG operation plan and has identified the following elements as key to defining the local strategy. This will include a focus on

• Primary care, at scale and resilience • Integration of health, community and social care • Primary Care quality, assurance and patient safety • Appropriateness in the use of Urgent and emergency care • Appropriateness in the Elective care system • Patient self-help, self-management

The CCG will be looking to support from the Area Team around workforce planning, estates management, data requirements and support as well as contractual requirements. 6.0 Definitions

Over the coming months, the area team have outlined their expectations and requirements from the CCGs in defining their primary care strategy “Vision and Values” - What is the vision and the overarching principles and values of the Primary Care strategy. “Case for change” - Why is change required for example, are there - variation in services offered, outcomes achieved and / or access equity of service, - future changes in population - demographic or need, - needs for financial savings. What is the vision for primary care ‘at scale’ within a modern model of integrated care. “Goals – improving quality and outcomes” - What will change in reality, for the patient, the community and provider and how will success be measured?

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“Sustainability” - What are the challenges with sustainable service provision and how does the strategy meet the goals for deliver sustainable service provision? What is the overall gap between provision and need (demand) and how will primary care transformation impact on this? “Primary Care Service strategy and interventions” – What are the elements which will change in the care model and scope of care? “The Service Offer” – How will the range of services offered be standardised and the quality improved so that each patient receives the same high quality service they require and are entitled to receive. How will this be delivered ‘at scale?’ “Measurement of Success” – How will the outcomes based on, evidence, interventions, patient experience, quality of care and population outcomes be measured? How will access to the right services for that patient and population be identified, including - care co-ordination, - holistic care, - responsive access to care, - prevention of ill health and - more timely diagnosis, - support for self-care and carers, - effective, safe and high quality care - improved patient experience. “Local” – How will the strategy and service model be distilled to a locality or town level describing how the service model and strategy would be tailored to each locality team? What does this look like and how will this change the service offer? “Enablers” – What are the enabling strategies with regards workforce planning, IMT, Estates and contracting models (including incentives). “Prioritised Change Program” – What are the changes over the next 5 years and how have they been prioritised and sequenced and what are the affordability/financial impact? 7.0 Current position

The CCG has been allocated a dedicated resource to support on the defining, delivery and implementation of our primary care strategy over the next 6 – 12 months. This person has been aligned to NHS South Cheshire CCG and NHS Vale Royal CCG for one day per week per CCG. This addition will be an enormous asset to the CCG and brings with them a wealth of expertise and shared learning from across the country. The outline primary care strategy will be presented on the direction of travel and aspiration for change defined within the operational plan, outlining the context, rationale and drivers for change. There are of course the essential drivers through collaborative commissioning and better care fund, which will act as an enabler to contextualise the strategy and set the direction of travel and pace. The Primary Care team are engaging member practices to ensure ownership to the strategy.

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8.0 Recommendations

The Governing Body is asked to:

• Note the content of this report.

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Prepared by Amanda Best, Service Delivery Manager Primary Care Quality and Engagement Report

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Prepared By : S E Cooke, Quality Manager

NHS South Cheshire CCG Governing Body

REPORT




Quality Report 27 March 2014 14:15 - 17:15 7.7.1

PURPOSE OF REPORT

This paper provides the Governing Body with a progress report, in line with statutory requirements, to monitor the performance activity of our providers against clinical quality and patient safety requirements for the period ending February 2014

Report Prepared By: Sue Cooke Clinical Quality Lead Governing Body Lead: Lynda Risk Chief Finance Officer

GOALS 2013-14




VISION


RECOMMENDATIONS

The SCCCG Governing Body are asked to: i) Note the position update relating to clinical quality and patient

safety from our main providers Mid Cheshire Hospitals Foundation Trust; Cheshire and Wirral Partnership Foundation Trust, East Cheshire Trust Community Services and BMI South Cheshire Hospital.






No Yes

No

No

No

No

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REPORT TITLE

Quality Report 1.0 Overview Summary

2.0 As stated in the NHS Standard Acute contract 2013/14 General Conditions 8 providers are required to

supply Service Conditions 37, quality requirements and incentive schemes (Clinical Quality Review) providers are required to supply information to help generate a ‘Clinical Quality’ report detailing its performance against quality requirements.

The key components of a Clinical Quality Performance report are detailed in Service Conditions 37 (Matters for Monthly Review), this report inlcudes:- • Quality Scheme – CQUINs • Provider Service User Complaints • Patient Safety & Serious Untoward Incidents • Regulator Notifications/Inspections (NICE, CQC) • NHS Targets (EMSA, HCAIs)

The following summary presents the performance activity of the quality measures accompanied by exception statements outlining the main issues, risks and proposed corrective management actions to be undertaken to rectify the adverse position. Currently the Quality Dashboard presented is relating to MCHFT only, however, there is work in progress to develop a Quality Dashboards for Cheshire and Wirral Partnership Trust, East Cheshire Community Services and BMI South Cheshire Hospital. These dashboards will be developed by February 2014. This report only present data that is in the public domain and the Governing Body is asked to note this.

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Measures TargetReporting Frequency

Latest reporting

period RAGLatest

Performance YTD Trend Source

Effe

ctiv

ene

ss SHMI 1 Quarterly Jul 2012 to Jun 2013 R 1.15 HSCIC

External Review - Monitor-concerns raised (Governance) Green Quarterly Q3 G Green Monitor

External Review - Monitor-concerns raised (Financial) 5 Quarterly Q3 G 3 Monitor

External Review - CQC warning notices 0 Monthly December G 0 0 CQC

Staff Sickness rate No target set Monthly September 3% HSCIC

Bed Occupancy - Total 86% Quarterly Q3 G 90% NHS England

Bed Occupancy - General & Acute 87% Quarterly Q3 G 91% NHS England

Bed Occupancy - Maternity 58% Quarterly Q3 G 69% NHS England

Never events (published) 0 Quarterly Q2 G 0 1 NHS England

VTE Risk Assessment 95% Monthly December G 96% 97% Unify2

Friends and Family test - Combined (Response Rate) 15% Monthly January G 26% NHS England

Friends and Family test - Combined (Score) No target set Monthly January 67 NHS England

Friends and Family test - Inpatient (Response Rate) 15% Monthly January G 39% NHS England

Friends and Family test - Inpatient (Score) No target set Monthly January 68 NHS England

Friends and Family test - A&E (Response Rate) 15% Monthly January G 21% NHS England

Friends and Family test - A&E (Score) No target set Monthly January 66 NHS England

Friends and Family test - Maternity Antenatal care (Score) No target set Monthly January 42 NHS England

Friends and Family test - Maternity Birth (Response Rate) 15% Monthly January R 12% NHS England

Friends and Family test - Maternity Birth (Score) No target set Monthly January 79 NHS England

Friends and Family test - Maternity Postnatal ward (Score) No target set Monthly January 67 NHS England

Friends and Family test - Maternity Postnatal community (Score)

No target set Monthly January 74 NHS England

Dementia Case finding 90% Monthly December G 92% 66% Unify2

Dementia Cases Diagnosed 90% Monthly December G 100% 53% Unify2

Dementia Cases Referred 90% Monthly December G 100% 90% Unify2

Pressure Ulcers (All) 4.8% Monthly January G 3.5% HSCIC

Falls in hospital (with harm) 0.9% Monthly January R 1.7% HSCIC

UTI Catheter 1.0% Monthly January G 0.2% HSCIC

CQU

IN -S

afet

y Th

erm

omet

erQ

ualit

y an

d Sa

fety

Org

anisa

tiona

l Lev

el Q

ualit

y M

easu

res

CQU

INPa

tient

Exp

erie

nce

Overview

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Prepared By : S E Cooke, Quality Manager, NHS South Cheshire CCG Governing Body

Measures Target Apr May Q1 July August Q2 October November Q3 January February Q4 RAG Q3 YTD Trend

External Review - Monitor-concerns raised (Governance)

Green Green Green Green G Green

External Review - Monitor-concerns raised (Financial)

5 3 3 3 G 3

Bed Occupancy - Total 86% 94% 89% 90% G 90%

Bed Occupancy - General & Acute 87% 95% 91% 91% G 91%

Bed Occupancy - Maternity 58% 77% 66% 69% G 69%

Measures Target Apr May June July August September October November December January February March RAG December YTD Trend

External Review - CQC warning notices 0 0 No data 0 0 0 No data 0 0 0 G 0 0

Measures Target Apr May June July August September October November December January February March RAG September YTD Trend

Staff Sickness No target set 4% 3.3% 3.2% 3.0% 2.7% 3.0% 3.0%

Organisational Level Quality Measures

Measures TargetJuly 2011 to June 2012

Oct 2011 to Sept 2012

Jan 2012 to Dec 2012

Apr 2012 to Mar 2013

Jul 2012 to Jun 2013 RAG

Jul 2012 to Jun 2013 YTD Trend

SHMI 1 1.13 1.13 1.16 1.16 1.15 1.15

Effectiveness

Summary of Hospital Mortality Indicator (SHIMI) SHIMI is still higher than expected.

- Advancing Quality Alliance (AQuA) – review concerning mortality at MCHFT is now complete. Final report will be received in April 2014. - Zero Length of Stay Audit is underway

CARE QUALITY COMMISSION (CQC) – inspection follow-up visit at MCHFT Following the CQC unannounced visit to ward 19 (now 21b) on 5 December 2012, CQC carried out a further unannounced re-inspection in October 2013 in regards to Outcome 9 - Medicines Management. This was to check that MCHFT had taken action to meet this essential standard. CQC reported that:

• significant improvements had been made in the arrangements for managing medicines, however these arrangements were not consistently followed.

• regulation was not being met i.e. people were not protected against the risks associated with medicine because the provider did not have appropriate arrangements in place to manage the medicines.

• Medicines were not always administered and recorded safely. A report was requested by CQC setting out actions for MCHFT to meet the standards. A further visit was undertaken in March 2014. The outcome of this visited is awaited. This will be reviewed at the Clinical Quality and Patient Safety Review Meeting.

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Measures Target Apr May Q1 July August Q2 October November Q3 January February Q4 RAG Q2 YTD Trend

Never events (published) 0 1 0 0 1

Measures Target April May June July August September October November December January February March RAG December YTD Trend

VTE Risk Assessment (Unify) 95% 92.03% 96.59% 97.78% 98.24% 96.36% 96.83% 96.79% 97.55% 95.95% G 95.95% 96.55%

Quality and Safety

Definition of Never Events Never events are a sub-set of Serious Incidents and are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers’ Incidents are considered to be never events if:

• There is evidence that the never event has occurred in the past and is a known source of risk (for example, through reports to the National Reporting and Learning System or Strategic Executive Information System (StEIS)

• There is existing national guidance or safety recommendations, which if followed, would have prevented this type of never event from occurring (for example, for ‘retained foreign object post procedure’ the referenced national guidance is related to the peri-operative counting and checking processes that would be expected to occur at the time of the procedure, including suturing after a vaginal birth).

• Occurrence of the never event can easily be identified, defined and measured on an on-going basis using the never events list published annually by NHS England.

NHS South Cheshire CCG Action following a Never Event • Never events are monitored through the Clinical Quality and Patient Safety Review Meeting • CCG representation at Root Cause Analysis (RCA) review meetings • CCG representation at MCHFT internal governance meetings where incidents are discussed • Never Events are discussed at the Cheshire Warrington and Wirral Quality Surveillance Group MCHFT actions following current Never Events

• Immediate actions were taken to mitigate risk of re-occurrence • Undertaken a Root Cause Analysis investigation • Commissioned an external review into theatre practice across the Trust. It is anticipated that a report will be available in April 2014

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Measures Target April May June July August September October November December January February March RAG January YTD Trend

Friends and Family test - Combined (Response Rate) 15% 17% 21% 21% 20% 18% 15% 22% 21% 19.8% 26.4% G 26%

Friends and Family test - Combined (Score) No target set 63 69 68 61 61 61 67 67 65 67 67

Friends and Family test - Inpatient (Response Rate) 15% 35% 31% 33% 33% 30% 26% 34% 42% 32.7% 39.3% G 39%

Friends and Family test - Inpatient (Score) No target set 69 75 75 76 71 68 77 74 75 68 68

Friends and Family test - A&E (Response Rate) 15% 11% 17% 17% 16% 15% 12% 18% 14% 15.4% 21.4% G 21%

Friends and Family test - A&E (Score) No target set 57 65 64 60 55 56 58 59 58 66 66

Friends and Family test - Maternity Antenatal care (Score) No target set 53 42 42

Friends and Family test - Maternity Birth (Response Rate) 15% 18% 12% R 12%

Friends and Family test - Maternity Birth (Score) No target set 87 79 79

Friends and Family test - Maternity Postnatal ward (Score) No target set 70 67 67

Friends and Family test - Maternity Postnatal community (Score) No target set 63 68 68

Patient experience

NHS Friends and Family Test (FFT) Results The Friends and Family Test asks patients “How likely are you to recommend our ward or A & E to friends and family if they needed similar care or treatment?” The net promoter score is calculated using the proportion of patients who would strongly recommend the ward or department, minus those who would not or who are indifferent. The most common issues highlighted by patients who would not recommend the service related to food (x3); noise at night from other patients (x6) and staffing levels (x3) Maternity The Friends and Family test commenced in Maternity in October at four points across the care pathway; ante natal, labour ward, post natal ward and postnatal community using SMS text messages. Posters are displayed in all areas including GP practices and women are advised they may receive up to 4 text messages, depending on their pathway. It is free for women to respond and they can opt out at any point from the test. The Net Promoter Score is based on the total score across the four points of the pathway. Due to technical difficulties, the response rate for maternity services has not achieved 15%. Insufficient data has been received by the organisation commissioned by MCHFT to send texts to all women seen at all four touch points during their maternity pathway. Work is taking place to address this which includes a weekly teleconference to address on-going issues.

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Measures Target April May June July August September October November December January February March RAG December YTD Trend

Dementia Case finding 90% 22% 46% 51% No data 91% 92% 90% 99% 92% G 92% 66%

Dementia Cases Diagnosed 90% 12% 19% 51% No data 100% 100% 100% 100% 100% G 100% 53%

Dementia Cases Referred 90% 77% 30% 75% No data 100% 100% 100% 100% 100% G 100% 90%

CQUIN

From January 2014, the NHS Friends and Family results for maternity services will be published on the NHS Choices website.

Area Team code

Trust Code Trust name January 2014 Inpatient response

rates

A&E response

rates

Combined response

rates England (including Independent Sector Providers) 31.0% 17.4% 22.2% England (without Independent Sector Providers) 31.0% 17.4% 22.0%

Q44 RJR Countess Of Chester Hospital NHS Foundation Trust 38.9% 12.6% 20.8% Q44 RJN East Cheshire NHS Trust 33.4% 23.0% 26.7% Q44 RBT Mid Cheshire Hospitals NHS Foundation Trust 39.3% 21.4% 26.4% Q44 REN The Clatterbridge Cancer Centre NHS Foundation Trust 49.4% - 49.4% Q44 RWW Warrington And Halton Hospitals NHS Foundation Trust 29.5% 18.7% 22.8% Q44 RBL Wirral University Teaching Hospital NHS Foundation Trust 21.3% 27.0% 24.4%

• MCHFT have improved their combined response rates in January 2014 to 26.4% against the December 2013 target of 21.3%. • MCHFT have produced a poster which has been sent to each ward promoting the FFT.

The posters are reviewed regularly and comments made on the FFT cards are incorporated on the posters in a similar way to ‘you said, we did’ e.g. patients requested soup to put on the menus, this was discussed with the catering team and nutritionists. This has now been added to the menu plans. Patients said ‘sometimes it is difficult to sleep due to noise at night’, MCHFT replied ‘ear plugs are available on request and will aim to reduce the noise at night’.

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Measures Target April May June July August September October November December January February March RAG January YTD Trend

Pressure Ulcers (All) 4.8% 3.6% 5.8% 5.2% 4.8% 3.0% 3.5% 4.8% 4.3% 5.3% 3.5% G 3.5%

Falls in hospital (with harm) 0.9% 2.0% 1.4% 1.6% 2.7% 1.6% 2.5% 1.3% 0.8% 0.9% 1.7% R 1.7%

UTI Catheter 1.0% 0.5% 1.2% 0.6% 0.8% 1.2% 0.8% 2.0% 1.6% 1.3% 0.2% G 0.2%

CQUIN - Safety thermometer

Patient Falls For 2013/14 year to date: • 98.4% (487 falls) have resulted in low harm • 1.6% (8 falls) have resulted in moderate harm • No falls have resulted in serious harm

An increase in low harm incidents has been attributed to changes in NICE guidance as all patients that have an un-witnessed fall now require additional neurological observations until they have been reviewed by medical staff. Due to the level of clinical observations MCHFT categorise these as low risk. • Falls assessment documentation has been reviewed in line with NICE

guidance and was implemented in December 2013 • More emphasis on implementation of continuous falls prevention

interventions • “Fallsafe Project” continues to be rolled out across the organisation • The care bundle includes taking lying down and standing blood pressures

and undertaking medication reviews.

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Activity Report February 2014 (Including: Complaints, MP Letters, PALS, Professional Concerns and Serious Incidents)

Complaints Annual Activity Comparison per Month

Analysis of Complaints Received in Month by Organisation Involved, Specialty, Subject and Sub-Subject

Primary Complaint Number of Complaints

Ref: 616

1

Mid Cheshire Hospitals NHS Foundation Trust

Medicine Accident and Emergency

Clinical Care Treatment

Ref: 654

1

East Cheshire NHS Trust Professional Services and Therapies

Physiotherapy Access to Service

Service Not Commissioned Grand Total 2

January February March April May June July August September October November December2013 2 0 0 0 0 0 0 1 3 0 3 32014 2 2

0

1

2

3

4

Complaints Summary 615 - Triage at 111 south Cheshire, Triage at A&E Leighton 654 - Complaint regarding physiotherapy treatment

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PALS

Annual Activity Comparison per Month

Analysis of PALS enquiries received in Month by Organisation Involved, Type of Enquiry and Stage of Care

Organisation Involved Type of Enquiry

Access, Appointment,

Admission, Transfer, Discharge

Infrastructure or resources (staffing, facilities,

environment) Other Grand Total Audlem Medical Centre 1 1

Information Request 1 1 Continuing Health Care 2 2

Concern 2 2 Patient Transport Service 7 7

Advice 6 6 Information Request 1 1

Victoria Dental Practice 1 1 Advice 1 1

Grand Total 7 1 3 11

January February March April May June July August September October November DecemberSeries1 6 11 3 11 10 10 12 8 7 9 14 9Series2 16 11

02468

1012141618

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Professional Concerns Annual Activity Comparison per Month

Analysis of Professional Concerns Reported in February 2014 by Organisation Involved and Concern raised

Organisation Involved

Concern raised Care Home

East Cheshire

NHS Trust

Grosvenor Medical Centre

Mid Cheshire Hospitals

NHS Foundation

Trust

North West Ambulance Service NHS

Trust Residential

Home

Rope Green Medical Centre

University Hospital Of

North Staffordshire

NHS Trust Grand Total Access, Appointment, Admission, Transfer, Discharge 1 1 1 3

Consent, Confidentiality or Communication 1 1

Implementation of care or on-going monitoring/review 1 1

Medication 1 1 2

Patient Information (records, documents, test results, scans) 2 1 1 4

Grand Total 1 1 1 4 1 1 1 1 11

January February March April May June July August September October November December2012 6 6 5 62013 3 13 3 1 3 3 4 2 8 20 15 22014 20 11

0

5

10

15

20

25

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Open Cases at February 2014 - Number of Serious Untoward Incidents by Organisation Involved

Organisation Involved

Serious Untoward Incidents

Never Events

Grand Total

5 Boroughs Partnership NHS Foundation Trust 1 1

Alder Hey Children’s Foundation Trust 1 1

Cheshire and Wirral Partnership NHS Foundation Trust 23 23

East Cheshire NHS Trust 2 2

Mid Cheshire Hospitals NHS Foundation Trust 20 1 21

Grand Total 47 1* 48 *This incident relates to a patient in the Vale Royal area

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Further information to note

CARE QUALITY COMMISSION (CQC) – Maternity Services Survey Results The Maternity services provided at Mid Cheshire Hospital Foundation Trust (MCHFT) Hospital have been rated highly by the women who use them, according to a national survey conducted in summer 2013. The survey, commissioned by the Care Quality Commission (CQC),asked women who had recently given birth to rate their experience in a number of key areas including antenatal care, the labour and birthing process, and postnatal care, allowing mothers to give their feedback on the entire pregnancy and birth. A total of 137 trusts took part in the survey and MCHFT scored in all other areas about the same as most other trusts that took part in the survey. There is evidence of improvements since the maternity survey was carried out in 2010. Compared to the last survey:

• there has been an increase in the proportion of women who said that they were always spoken to in a way they could understand during antenatal care and labour and birth.

• more women felt that they were always involved during antenatal care and labour and birth • more women felt that they were treated with kindness and understanding and had confidence

and trust in the staff caring for them during labour and birth.

For both antenatal and postnatal care, women who saw the same midwife each time tended to report more positively on some areas of the survey. Women who saw different midwives (and who reported that they didn’t mind seeing different midwives) also tended to have quite positive experiences of care as well. More negative responses on those same aspects of care came from women who had not seen the same midwife but wanted to. Performance in other areas has not improved since 2010 and experiences fell short of expectations. The results show:

• Information and support are being provided inconsistently - and in some cases, basic knowledge

such as medical history was not known. • Information needed to make choices was not consistently provided and the choices themselves

were not universally offered to women. • Fewer women reported that they were not left alone during labour or birth at a time that worried

them. • One in five women felt that their concerns during labour were not taken seriously and some

women felt that hospital wards, toilets and bathrooms are not clean enough, especially toilets and bathrooms.

Results will be monitored at the Clinical Quality and Patient Safety Review meetings. MCHFT CQUIN update Quarter 3

MCHFT Update on CQUIN Quarter 3 October - December 2013 CQUIN GOAL PROGRESS Goal 1- NHS Safety Thermometer Achieved Goal 2 – Dementia Part 1: Assess and Refer Part 2: Training Part 3: Supporting carers

All Achieved

Goal 3- Veno- thromboembolism (VTE) Achieved Goal 4 – Friends and Family Test Achieved

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Goal 5 – AQ Acute Myocardial Infarction (AMI) Achieved Goal 6 – AQ Heart failure

Off Track but recoverable - MCHFT are being measured using the appropriate care score (ACS). In order for MCHFT to meet the target 78% of patients will have to have received all the care elements. Action: • Heart Failure team – to pilot a new heart failure

pathway

Goal 7 – AQ Hip and Knee replacement

Off Track but recoverable – MCHFT are being measured using the appropriate care score (ACS). To meet the target, 82% of patients will have to receive all the care elements. The main area of inconsistency relates to VTE prophylaxis. Due to recent changes in the policy

The guidelines for AQ VTE prophylaxis changed in April 2013. Until that point the Trust had always been a consistent performer in the care bundle delivered to the hip or knee replacement patient. Changes to the criteria (reducing the time frame form 24 to 12 hours and introducing a new drug option) have resulted in a variation in the performance against this measure. Actions: • The standard time for the first administration of the

drug will be 10pm on day of surgery with subsequent doses at 6pm. This new time will make the administration within the 12 hour time frame as required by the AQ measure

• The surgeons are to record clearly on the integrated pathway if they have any reason that a particular patient should not receive the drug at this time, for example, excessive intraoperative bleeding.

Goal 8 – AQ Pneumonia

Off Track but recoverable – MCHFT are being measured using the appropriate care score (ACS). To meet the target, 61% of patients will have to receive all the care elements. Actions: • Highlighting smoking cessation • Improving documentation

Goal 9 –AQ Stroke Off Track but recoverable - The provision of a stroke bed within 4 hours remains the most challenging measure. MCHFT have implemented the following measures to aid recovery. Actions:

• The stroke specialist nurse, discharge coordinator and ward coordinator meet daily to discuss capacity and demand and to identify patients suitable for rehabilitation/ discharge.

• Bed managers provide support when assessing patients suitable to move from the stroke ward

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and are given priority for beds on the rehabilitation ward

Goal 10 – Electronic Patient Records Achieved Goal 11 – Alcohol assessment Achieved Goal 12 Readmissions Achieved Goal 13 – Cancellations Achieved Goal 14 – Patient Carer focus groups (glaucoma, head and neck cancer, stroke)

Achieved

Goal 15 - Staff engagement Part 1: Care rounds Part 2: Staff focus groups (glaucoma,

head and neck cancer, stroke) Part 3: Shared decision making in

outpatient services (cardiac rehab, women on high risk pathway, acne services)

All Achieved

al 16 – Pressure Ulcers Achieved Goal 17 – Prognostication and advanced care planning

Achieved

Goal 18 – Medicines Management Achieved Goal 19 – Improving inhaler techniques Achieved Goal 20 – Advice line for GP’s Achieved Goal 21 – Retinopathy screening – specialised commissioning

Achieved

Goal 22 – Total parenteral nutrition – specialised commissioning

Achieved

Advancing Quality Recovery Plan NHS South Cheshire CCG is in receipt of a recovery plan for the AQ CQUIN, this was discussed at the Clinical Quality and Patient Safety Review Meeting and the Joint Quality and Performance Committee. Actions were agreed – see CQUIN Quarter update. NHS CHOICES MCHFT achieved a 4.5 start rating based on 199 ratings for the hospital, these ratings related to Cleanliness, Staff Cooperation, Dignity and Respect, Involvement in Decision and Same Sex Accommodation. There were 24 postings on NHS Choices during January/February 2014, 16 positive relating to care/treatment received, one parent commented that their baby had received ‘fantastic level of care and attention by all staff’ on the NICU ward, another commented on the kindness shown to her 9 year old son who had been admitted with an eye infection to the Children’s Ward 16/17. Additional positive comments related to services in Orthopaedics and the Treatment Centre. Of the 8 negative comments these related to:

• Ophthalmology waiting times too long and lack of parking • General surgery – various comments relating to waiting times, cancelled appointment and

processes. • General Medicine – lack of care, and waiting for test results in treatment room following

lumber puncture procedure, patient then sent home after being told results clear only to be called back and admitted to hospital for 4 days and ongoing investigations – MCHFT have responded expressing their apologies and stating that at that time there were extreme bed pressures and that was the reason why the procedure was carried out in the treatment room. It was noted by MCHFT that regular checks should have been made to ensure the patient was comfortable and this will be addressed with the nursing/medical staff.

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• After care received – patient’s nephew praising MCHFT; however felt not being listened to in regards to his Aunties after care. MCHFT have replied and asked the nephew to contact the Customer Care team to discuss further

• A/E attendance – stating staff were rude, no facilities and worst A/E experience ever – MCHFT have yet to respond

• Gynaecology – cancelled operation x 2 – MCHFT have yet to respond

One patient raised a comment around General Surgery, the patients’ husband stated that his wife had had a successful operation and that the medical and nursing staff took excellent care of her. However, there were issues around care of the urinary catheter. MCHFT replied that they follow NICE guidance which is evidence based in the best interest of the patient, however they stated that they would pass on the suggestion to the relevant surgeon for careful consideration. Victoria Infirmary - Achieved a 5 star rating based on 31 ratings these ratings related to Cleanliness, Staff Cooperation, Dignity and Respect, Involvement in Decision and Same Sex Accommodation. There were 4 postings on NHS Choices during January 2014 which were all positive regarding excellent care in the Minor Injuries Unit quoting a ‘fantastic service’, hydrotherapy experience stating that the service delivered was ‘second to none’. Another positive experience related to a visit to the x-ray department referred by Gynaecology – the patient praised the unit, stating that ‘what could have been an embarrassing and uncomfortable procedure into a pleasant one’. QUALITY VISIT Elmhurst Intermediate Care Centre /21b(MCHFT) A Quality visit took place at Elmhurst Intermediate Care Centre on 5 December 2013 and Ward 21b at MCHFT on 12 December 2013. Elmhurst Issues raised: • Bath out of order

• Patients raised that there were lack of activities during the day • Length of stay • Wheelchair access

Patient experience - Elmhurst General feedback and comments: • Patients’ experiences of Elmhurst were very positive. Patients were clean and looked well cared for.

The food was fresh, hot and patients felt it was good. • Patients felt they could speak to staff about concerns. Patients had confidence in the staff treating

them. However, 60% of patients questioned did not feel involved in decisions about their care and all not all patients questioned had a clear discharge date.

• One patient felt the days were very long due to a lack of activities. • Patients felt that call bells took a while to be answered but that staff came as soon as they could.

Patient experience at MCHFT Ward 21B General feedback and comments • Patients’ experiences of the ward were very positive. Patients were clean and looked well cared for.

The food was fresh, hot and patients felt it was good. • Patients felt they could speak to staff about concerns and patients had confidence in the staff treating

them. • Patients questioned did not always feel involved in decisions about their care and most patients’

questions did not have a clear discharge date. (One patient was going home the next day). • Patients felt that call bells took a while to be answered but that staff came as soon as they could. Staff interviews at MCHFT Ward 21B The team interviewed a mixture of RGN/HCA/Physio/student nurse

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• Very positive about working on the ward • Had opportunities for development through KSF appraisal • Have ward meetings and folder with information – kept updated by ward manager • Able to undertake mandatory training • The team witnessed staff talking to patients with kindness and compassion • Staff commented that at times when there are more patients with higher dependencies that an extra

Health Care Assistant (HCA) would help. The ward manager told the team that they were looking at skill mix and having an extra HCA when patients are higher dependency.

• Staff felt there was an ‘open culture’ they could express their concerns to senior staff and their concerns were listened to and acted upon

Staff were committed, very happy, felt supported and a number of staff had worked at Victoria Infirmary, Northwich and had moved with the unit. Staff felt they had a good work life balance. The Quality Visit will inform current work being undertaken by the Ageing Well Programme around Intermediate Care Cheshire and Wirral Partnership Foundation Trust (CWP) Patient Survey Report 2013 CWP The 2013 survey of people who use community mental health services involved 58 NHS trusts in England this total included combined mental health and social care trusts, Foundation Trusts and community healthcare social enterprises that provide mental health services. Responses were received from more than 13,000 service users, a response rate of 29%. Service users aged 18 and over were eligible for the survey if they were receiving specialist care or treatment for a mental health condition and had been seen by the trust between 1 July 2012 and 30 September 2012. The survey included service users in contact with local NHS mental health services, including those who receive care under the Care Programme Approach (CPA). Fieldwork took place between February and June 2013. The survey involved asking patients 38 questions of which CWP scored about the same as most other Trusts in the survey for 30 (79%) of the questions asked, 8 (21%) better and 1 worse which related to the following question: Section – Day to Day Living Q38 – has anyone in NHS mental health services ever asked you about your use of non-prescription drugs? The following questions relate to where CWP scored significantly lower than 2012 results, however CWP are still within the ‘about the same’ range as most other trusts who undertook the survey for: Section – Health and Social Care Workers Q7 – ‘Did the person treat you with respect and dignity?’ Section – Care Plan Q22 – ‘Do you understand what is in your NHS care plan?’ Section – Day to Day Living Q37 – ‘Has anyone in NHS mental health services ever asked you about your alcohol intake?’ Q39 – ‘In the last 12 months, did anyone in NHS mental health services ask you about any physical

health needs you might have? Q43 - ‘In the last 12 months, have you received support in getting help with finding and/or keeping your

accommodation?’ The results of the CWP survey will be discussed at the CWP Clinical Quality Review Meeting which is held bi-monthly

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NHS Choices CWP – Achieved a 2 star rating based on 3 ratings for the Trust. It should be noted that patients who comment on the NHS choices website live in all areas served by CWP and not just from South Cheshire area. During January/February 2014 a comment was posted stating that there were no contact details on the web site which gives information about the help for people with dementia and requested a formal contact list who are employed by the Trust in order for the carer to make contact, CWP have yet to respond. A negative comment was posted in relation to lack of response to telephone complaints raised in relation to the care provided by CWP. CWP have yet to respond. CWP have reported 5 Serious Untoward Incidents in January/February 2014, 2 of which relate to patients in the South Cheshire Area and who were in receipt of CWP services. The incidents related to patient safety. CWP have instigated some consequential leaning as follows:

• strengthening of clinical handover • better capture of service user and carer feedback during care and treatment • identification of processes to issue a carer leaflet inviting involvement and feedback to named

team members with contact numbers CWP CQUIN update Quarter 3 CWP Quarter 3 CQUIN GOAL PROGRESS Long Term Conditions Evidence being reviewed

Physical Health Evidence being reviewed

Autism Evidence being reviewed

Dementia baseline screening for people with Down Syndrome

Evidence being reviewed

Patient Experience Evidence being reviewed

Quality Visit – CWP Greenways Greenways is an Assessment and Treatment Unit in Macclesfield for people with Learning Disabilities. The Service Delivery Manager, Living Well Team, visited the unit in July 2013 with CWP representatives as part of their service visits. General Comments: • The buildings infrastructure was modern and well presented. The lounge area had comfortable

seating. The unit had a relaxed feel, and staff were very approachable. Several service users were in evidence, engaged in various activities.

• Staffing levels were discussed and the ratio of qualified to support staff seemed appropriate. Therapy

staff, psychology and psychiatry were all included in the team. • There had been a recent increase in activities co-ordinated for the service users, although some

activities such as ‘pat a pet’ had had to be stopped recently due to a shortage of volunteers. • There is good access to G.P primary care. A staff member takes responsibility for the residents

physical health needs.

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• Training was discussed, a programme of mandatory training is followed, including safeguarding level

3 for which a level of 100% will be achieved by September. • Good feeling of teamwork and mutual support was evidenced by a discussion of the impact on the

staff following the death of a staff member. • There were no immediate risks or issues of concern to be address in the next 3 months. However

there was an area for further consideration identified during the visit where it was felt there should be an emphasis on core documentation following a CQC visit. This should be a sustained improvement.

BMI South Cheshire Hospital NHS Choices BMI – No postings during January/February 2014 Friends and Family Test BMI South Cheshire Hospital response for the Friends and Family Test for January 2014 = 264% BMI CQUIN Update Quarter 3 BMI South Cheshire Hospital - Quarter 3 CQUIN GOAL PROGRESS Goal 1 – VTE Achieved Goal 2 – Friends and Family Test Achieved Goal 3 – Dementia Training Achieved Gaol 4 – Maintenance of normal temperature in theatres Achieved Goal 5 – Safety Thermometer Achieved East Cheshire Trust – Community Services NHS Choices ECT Community – No postings during January/February 2014 ECT Community Services CQUIN Update Quarter 3

East Cheshire Community services - Quarter 3 CQUIN GOAL PROGRESS Goal 1 – Integrated Neighbourhood teams/Extended Practice Teams

Evidence being reviewed

Goal 2 – Falls Prevention Evidence being reviewed

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Prepared By : Steve Evans, Locality Accountant & Relationship Manager NHS South Cheshire CCG Governing Body

REPORT



NHS Performance Outcome Measures 2013-14 27 March 2014

1415-1700 7.7.2

PURPOSE OF REPORT This paper provides the Governing Body with a progress report against the key NHS performance measures for the respective CCGs and the performance activity attributed by our main acute provider Mid Cheshire Hospitals Foundation Trust (MCHfT) for the period ending January 2014.

This report follows the guidance stemming from the ‘Everyone Counts Planning for Patients 2013-14 together with a supplementary supporting planning document published in December 2012. This also includes areas that contribute to the delivery of the CCG Assurance Framework and the CCG Quality Premium.

This report has been produced in collaboration with the Commissioning Support Unit and work is on-going to improve on the reporting format. A RAG rating has been applied to each indicator using the tolerances set nationally. A local rating has been set where national thresholds have not been determined

Report Prepared By: Steve Evans Locality Accountant & relationship Manger Governing Body Lead: Fiona Field Director of Partnerships & Governance

GOALS 2013-14




VISION


RECOMMENDATIONS

The SCCCG Governing Body are asked to: i) note the contents of the report summarising the validated NHS

performance measures for the reporting period ending January 2014, in particular the supporting commentary updates relating to the exceptions where measures are experience adverse






No Yes

No

No

No

No

335 of 371

Date / Time Agenda Item

AUTHOR

Steve EvansLocality Accountant & Relationship Manager

Contributors :

C Fox (BI Analyst)S CookeS MilneS Evans

EXECUTIVE LEAD(s)

Assurance Decision Discussion Information

Committee Venue


REPORT TOPIC

NHS Constitution & Outcomes Framework Measures 2013-14 : January 2014

Joint Quality & Performance Committee

PURPOSE OF REPORT

This paper provides the Joint Quality & Performance Committee with a progress report against the key NHS performance measures for the respective CCGs and the performance activity attributed by our main acute provider Mid Cheshire Hospitals Foundation Trust (MCHfT) for the period ending January 2014.

This report follows the guidance stemming from the ‘Everyone Counts Planning for

Patients 2013-14 together with a supplementary supporting planning document published in December 2012. This also includes areas that contribute to the delivery of the CCG Assurance Framework and the CCG Quality Premium.

This report has been produced in collaboration with the Commissioning Support Unit and work is on-going to improve on the reporting format.

A RAG rating has been applied to each indicator using the tolerances set nationally. A local rating has been set where national thresholds have not been determined.

Fiona FieldGovernance & Partnership Director

Tracy Parker-PriestGovernance & Partnership Director

RECOMMENDATIONS

27th March 20149.00am

Board RoomBevan House

Nantwich0.0

The Quality & Performance Committee is asked to:-

i) note the contents of the report summarising the validated NHS performance measures for the reporting period ending January 2014; and ;

ii) note any exception updates against those measures which are experiencing adverse activity and the mitigating actions to resolve the performance levels.

ACTIONS REQUIRED: Please Indicate Yes/No

STRATEGIC RELEVANCE: Please state link to CCG’s goals

This report sets out the work underway to deliver the national and local NHS targets that underpin the strategic direction of the CCG.

Yes No No Yes

REPORT

Page 1 336 of 371

1.0

1.1

1.2

1.3

2.0

2.1

SCCCG VRCCG

A&E 4hr Targets

Mixed sex accommodation First Outpatient Attendance Elective FFCEs Ambulance Red 1 within 8 Stroke TIA Cases Stroke 90% of Time on Unit A&E 4hr Targets 52 Week Waits

Further guidance describing the CCG Quality Premium and the CCG Assurance Framework helped the CCG to identify the corporate performance targets for the coming year.

NHS England, formerly known as Commissioning Board published in December 2012 the ‘Everyone

Counts Planning for Patients 2013-14 guidance in December 2012, which set out the national priorities and a number of performance Targets. A scorecard presents the trending headline measures together with the full data matrix which summarises all the measures accountable to the respective commissioner levels held in Appendix 1 & 2. Data frequency may differ for certain metrics hence reported on a monthly, quarterly and annual basis.

OVERVIEW

The CCG Assurance Framework will be used by the NHS England Local Area Team to assess how well CCGs are performing against their plans to improve services and deliver better outcomes for patients. This will be conducted at quarterly checkpoints where a review of delivery against the strategic plan, which will include the standards in the NHS Constitution, and improvements against the Outcomes indicators set out in the Everyone Counts. The second scheduled meeting was held in December 2013 and the outcome of the discussions is being presented to the Governance & Audit Committee in January 2014.

Those areas where performance has not met the target for the reporting period December 2013 are as follows:

PERFORMANCE SUMMARY

Mixed sex accommodation First Outpatient Attendance Elective FFCEs Cancer 62 Days Referral Stroke 90% of Time on Unit

Dashboard summaries of key headline measures relating to the respective Clinical Commissioning Group relating to patient experience; access to emergency services and other challenging areas:-

Brief commentary has been provided by relevant lead manager which is included in the appended exception forms.

Page 2 337 of 371

Commissioner : SCCCG

Referral to Treatment (RTT) (Admitted)

Patients seen within in 18 weeks Standards90.0%

Referral to Treatment (RTT) Incomplete

Excess waiters >52 weeks0

Diagnostic Waits

Tests waiting no more than 6 weeks99.0%

Cancer 62 day wait

Patients seen in 2 weeks and treated within 62 days85.0%

Stroke

90% of time on stroke unit & TIAs treated within 24

hours

80.0%

Reducing Health Care Acquired Infections

MRSA0


C DiffYTD

A&E Waiting Times

Patients spending 4 hours or less in A&E95.0%

Ambulance

Calls response to within 8 minutes (Red 1)75.0%

Delayed Transfers of Care 1,530 1,700 1,778 5,645

Proportion of people feeling supported to manage their

condition 2 local measures:

Reduce Emergency readmissions within 30 days of

discharge from hospital: MCHfT as previous provider only14.4% 13.1% 11.5% 13.0%

Emergency Admissions by GP referrals age 0 - 4 years 183 130 219 572

Pat

ien

t Ex

per

ien

ceEVERYONE COUNTS : Planning for Patients 2013-14

COMMITMENTS & TARGETS STATUS @ A GLANCE

Thematic Measure Target Quarter 1 Quarter 2 Quarter 3 Quarter 4 YTD Trend

Acc

ess

to e

mer

gen

cy

Serv

ices

Oth

er C

hal

len

ge A

reas

LOCAL MEASURES

Page 3 338 of 371

Commissioner : VRCCG

Referral to Treatment (RTT) (Admitted)

Patients seen within in 18 weeks Standards90.0%

Referral to Treatment (RTT) Incomplete

Excess waiters >52 weeks0

Diagnostic Waits

Tests waiting no more than 6 weeks99.0%

Cancer 62 day wait

Patients seen in 2 weeks and treated within 62 days85.0%

Stroke

90% of time on stroke unit & TIAs treated within 24 hours80.0%


MRSA0


C Diff19

A&E Waiting Times

Patients spending 4 hours or less in A&E95.0%

Ambulance

Calls response to within 8 minutes (Red 1)75.0%

Delayed Transfers of Care 1,530 1,700 1,778 5,645

Increase the staging outcomes earlier in Cancer intervention for Lung/ Colorectal and Upper GI

Proportion of people feeling supported to manage their condition

Emergency readmissions within 30 days of discharge from

hospital: MCHfT Only13.0% 12.0% 13.4% 12.8%

Pat

ien

t Ex

per

ien

ceEVERYONE COUNTS : Planning for Patients 2013-14

COMMITMENTS & TARGETS STATUS @ A GLANCE

Thematic Measure Target Quarter 1 Quarter 2 Quarter 3 Quarter 4 YTD Trend

Acc

ess

to e

mer

gen

cy

Serv

ices

Oth

er C

hal

len

ge A

reas

LOCAL MEASURES

Page 4 339 of 371

Reporting Period

Q1 Q2 Q3 Jan-14 Feb-14

1 CB_B1 18 Week Referral to Treatment - Admitted Patients 90.0% 0.0 89.7% 92.9% 92.9% 91.4% 91.8%

2 CB_B218 Week Referral to Treatment - Non-Admitted Patients 95.0%

Mth

ly

95.9% 95.9% 96.3% 95.5% 96.0%

3 CB_B318 Week Referral to Treatment - Incomplete Patients 92.0%

Mth

ly

95.7% 95.3% 94.5% 93.7% 95.0%

4 CB_B4 Diagnostic Waits - 6 week waits 99.0%

Mth

ly

99.3% 99.5% 99.4% 99.7% 99.4%

5 CB_B5 A&E Waiting Times - 4hrs Waits 95.0%

Mth

ly

96.7% 96.1% 95.5% 93.5% 91.3% 95.4%

6 CB_B6 Cancer 2 Week Wait - All cancer two week wait 93.0%M

thly

96.0% 94.6% 95.9% 96.5% 95.6%

7 CB_B7Cancer 2 Week Wait - Non-suspected cancer breast symptoms 93.0%

Mth

ly

94.1% 95.1% 95.0% 96.0% 94.8%

8 CB_B8 Cancer 31 day first treatment 96.0%

Mth

ly

99.6% 99.5% 99.0% 99.0% 99.3%

9 CB_B9 Cancer 31 day subsequent treatments - surgery 94.0%

Mth

ly

100.0% 100.0% 97.4% 100.0% 99.3%

10 CB_B10Cancer 31 day subsequent treatments - anti-cancer drugs 98.0%

Mth

ly

100.0% 100.0% 100.0% 100.0% 100.0%

11 CB_B11Cancer 31 day - Subsequent treatments - radiotherapy 94.0%

Mth

ly

100.0% 97.9% 100.0% 100.0% 99.6%

Quarter 1

EVERYONE COUNTS : PLANNING FOR PATIENTS 2013-14 SCORECARD

Commissioner : SCCCG Jan-14

NHS Constitution & Outcomes Framework Measures Programme

NHS Code Measure Target

Freq

uen

cy

Liv

ing

we

ll

Ag

ein

g

We

llQuarter 2 Quarter 3 Quarter 4YTD Trend

Sta

rtin

g

We

ll

APPENDIX 1 – South Cheshire CCG

Page 5340 of 371

Reporting Period


Quarter 1





Freq

uen

cy

Liv

ing

we

ll

Ag

ein

g

We


Sta

rtin

g

We

ll

12 CB_B12 Cancer 62 day referral to first treatment - 85.0%

Mth

ly

93.3% 86.2% 91.5% 85.0% 89.9%

13 CB_B13Cancer 62 day referral to first treatment - NHS screening referral 90.0%

Mth

ly

96.0% 100% 98.3% 90.5% 96.8%

14 CB_B14Cancer 62 day referral to first treatment - consultant referral upgrade 85.0%

Mth

ly

100% 91.7% 87.5% 100.0% 93.5%

15 CB_B15_01Ambulance - Category A (Red 1) - 8 minute response 75.0%

Mth

ly

77.2% 69.8% 66.0% 79.2% 71.9%


Mth

ly

76.5% 74.0% 74.3% 76.5% 75.1%

17 CB_B16 Ambulance - Category A - 19 minute response 95.0%

Mth

ly

96.9% 96.5% 96.3% 96.7% 96.6%

18 CB_B17 Mixed Sex Accommodation Breaches 0M

thly

8 6 5 4 23

19 CB_B18Cancelled Operations - Percentage of patients not offered a binding date within 28 days of a cancelled operation.

Qtr 16.4% 9.2% 15.3% 13.30%

20 CB_B19Mental Health - % of patients on CPA discharged from inpatient care who are followed up within 7 days

95% Qtr 98% 100% 0.955 99%

21 CB_S4 A&E Attendances - number of attendances in A&E

Mth

ly

11,872 12,188 11,541 4,285 3,701 43,587

22 CB_S5_AMental Health - proportion of people who have depression/anxiety who receive psychological therapies

10%

2013/14 Qtr 2.2% 3.3% 3.0% 8.5%

23 CB_S5_BMental Health - proportion who complete treatment who are moving to recovery Q

tr 48.5% 39.2% 36.3% 41.1%

Page 6341 of 371

Reporting Period


Quarter 1





Freq

uen

cy

Liv

ing

we

ll

Ag

ein

g

We


Sta

rtin

g

We

ll

24 CB_S6i Number of 52 Week RTT - Admitted>52weeks 0

Mth

ly

4 0 0 0 4

25 CB_S6ii Number of 52 Week RTT - Non-admitted>52weeks 0

Mth

ly

1 1 0 0 2

26 CB_S6iii Number of 52 Week RTT - Incomplete>52weeks 0

Mth

ly

7 1 1 0 9

27 CB_S7aAmbulance Handover Time - delays of over 30 minutes M

thly

98.7% 99.7% 99.7% 99.2% 99.3%

28 CB_S7b Ambulance Handover Time - delays of over 1 hour

Mth

ly

99.9% 99.9% 100.0% 100.0% 100.0%

29 CB-09Trolley Waits in A&E - 12hr waits from Decision to Admit to Admission 0

Mth

ly

0 0 0 0 0 0

30 CB_S10Cancelled Operations - Number of Urgent Operations Cancelled for a second time 0

Mth

ly0 0 0 0 0

31 CB_A1 Potential Years of Life Lost (PYLL)

An

nu

al

32 CB_A2 Mortality Rate - under 75 - CVD

An

nu

al

33 CB_A3 Mortality Rate - under 75 - Respiratory Disease

An

nu

al

34 CB_A4 Mortality Rate - under 75 - Liver Disease

An

nu

al

35 CB_A5 Mortality Rate - under 75 - Cancer

An

nu

al

Page 7342 of 371

Reporting Period


Quarter 1





Freq

uen

cy

Liv

ing

we

ll

Ag

ein

g

We


Sta

rtin

g

We

ll

36 CB_A6_01Emergency Admissions - Chronic Ambulatory Care Sensitive Conditions (Adults) M

thly

321 254 276 98 949

37 CB_A6_02Emergency Admissions - Asthma, Diabetes & Epilepsy in under 19s M

thly

35 22 37 6 100

38 CB_A6_03Emergency Admissions - Acute Conditions that should not usually require hospital admission (crude rate/100,000 reg pop) M

thly

375 365 419 116 1275

39 CB_A6_04Emergency Admission -Children with Lower Respiratory Tract Infections (LRTI) M

thly

21 6 62 12 101

40 CB_A7Long Term Conditions - proportion of people feeling supported to manage their LTC

41 CB_A8Long Term Conditions - average Health Status Score for individuals (19+) reporting that they have a LTC

42 CB_A9 Dementia - Diagnosis rate

43 CB_A10Emergency Re-admissions - % within 30 days of discharge from hospital M

thly

13.8% 12.9% 11.1% 12.6%

44 CB_A11i PROMS - Hip Replacement n/a Qtr

Figures

suppressed due

to low patient

counts

45 CB_A11ii PROMS - Knee Replacement n/a Qtr

Figures

suppressed due

to low patient

counts

46 CB_A11iii PROMS - Groin Hernia n/a Qtr 0.07

47 CB_A11iv PROMS - Varicose Veins n/a Qtr No data

Page 8343 of 371

Reporting Period


Quarter 1





Freq

uen

cy

Liv

ing

we

ll

Ag

ein

g

We


Sta

rtin

g

We

ll

48 CB_12_APatient Experience of Primary Care - % of patients with positive experience of GP Services A

nn

ual

86.0%

49 CB_12_BPatient Experience of Primary Care - % of patients with positive experience of Out of Hours GP Services A

nn

ual

77.0%

50 CB_A13 Friends & Family Test (A&E)

Mth

ly

66

51 CB_A13 Friends & Family Test (InPatient)

Mth

ly

68

52 CB_A14 Patient Experience of Hospital Care

An

nu

al

53 CB_A15 HCAI - Overall number of cases of MRSAC =

P = Mth

ly

1 1 0 0 0 2

54 CB_A16 HCAI - Overall number of cases of C DifficileC =

P = Mth

ly3 12 11 2 28

55 CB_S1 Non-Elective FFCEs

Mth

ly

4015 3873 3967 1214 13069

56 CB_S2 First Outpatient Attendances

Mth

ly

14,596 15,469 15,435 5,396 50,896

57 CB_S3 Elective FFCEs

Mth

ly

6,039 6,268 6,409 2,223 20,939

Page 9344 of 371

Reporting Period


Quarter 1





Freq

uen

cy

Liv

ing

we

ll

Ag

ein

g

We


Sta

rtin

g

We

ll

58 GM58Stroke - patients who spend at least 90% of their inpatient stay on a stroke unit 80%

Mth

ly

76.8% 75.3% 79.0% 68.4% 76.4%

59 GM59Stroke - proportion of patients arriving in a designed stroke bed within 4 hours of arrival A

nn

ual

60 GM60Stroke - proportion of high risk TIA case investigated and treated within 24 hours 60%

Mth

ly

75.0% 85.7% 57.1% 100.0% 77.8%

61 GM61Proportion of people feeling supported to manage their condition 2 local measures: A

nn

ual

62 GM62Reduce Emergency readmissions within 30 days of discharge from hospital: MCHfT as previous provider only M

thly

14.40% 13.11% 11.48% 13.03%

63 GM63 Emergency Admissions by GP referrals age 0 - 4 years

Mth

ly

183 130 219 40 572

64 GM64 Delayed Transfers of care (MCHfT)M

thly

1,530 1,700 1,778 637 5,645

Key CriteriaNHS ConstitutionNHS Outcomes FrameworkActivity MeasuresLocal Measures

Page 10345 of 371

Reporting Period


1 CB_B1 18 Week Referral to Treatment - Admitted Patients 90.0%

Mth

ly

88.4% 93.0% 93.3% 92.7% 91.8%

2 CB_B218 Week Referral to Treatment - Non-Admitted Patients 95.0%

Mth

ly

96.9% 96.6% 96.8% 96.3% 96.8%

3 CB_B318 Week Referral to Treatment - Incomplete Patients 92.0%

Mth

ly

95.9% 95.6% 94.4% 94.0% 95.1%

4 CB_B4 Diagnostic Waits - 6 week waits 99.0%

Mth

ly

99.2% 99.5% 99.6% 99.6% 99.5%

5 CB_B5 A&E Waiting Times - 4hrs Waits 95.0%

Mth

ly

96.9% 96.2% 95.5% 93.7% 91.6% 95.6%

6 CB_B6 Cancer 2 Week Wait - All cancer two week wait 93.0%M

thly

95.1% 96.0% 96.4% 94.3% 95.7%

7 CB_B7Cancer 2 Week Wait - Non-suspected cancer breast symptons 93.0%

Mth

ly

93.5% 93.5% 97.8% 97.8% 95.3%

8 CB_B8 Cancer 31 day first treatment 96.0%

Mth

ly

98.4% 97.9% 100% 98.0% 98.8%

9 CB_B9 Cancer 31 day subsequent treatments - surgery 94.0%

Mth

ly

100% 100% 100% 100% 100%

10 CB_B10Cancer 31 day subsequent treatments - anti-cancer drugs 98.0%

Mth

ly

100% 100% 100% 100% 100%

11 CB_B11Cancer 31 day - Subsequent treatments - radiotherapy 94.0%

Mth

ly

96.4% 100% 100.0% 88.9% 98.0%

Quarter 1


Commissioner : VRCCG Jan-14



Freq

uenc

y

Liv

ing

we

ll

Ag

ein

g W

ell

Quarter 2 Quarter 3 Quarter 4

YTD Trend

Sta

rtin

g

We

ll

APPENDIX 2 – Vale Royal CCG

Page 11346 of 371

Reporting Period


Quarter 1





Freq

uenc

y

Liv

ing

we

ll

Ag

ein

g W

ell


YTD Trend

Sta

rtin

g

We

ll

12 CB_B12 Cancer 62 day referral to first treatment - 85.0%

Mth

ly

82.0% 87.2% 93.8% 82.1% 87.3%

13 CB_B13Cancer 62 day referral to first treatment - NHS screening referral 90.0%

Mth

ly

100%No

Patients100.0% 60.0% 90.5%

14 CB_B14Cancer 62 day referral to first treatment - consultant referral upgrade 85.0%

Mth

ly

100% 100% 94.1% 100.0% 97.2%


Mth

ly

72.6% 68.5% 69.9% 60.0% 69.3%


Mth

ly

77.6% 75.2% 74.1% 76.5% 75.7%

17 CB_B16 Ambulance - Category A - 19 minute response 95.0%

Mth

ly

96.6% 95.5% 95.0% 97.3% 95.9%

18 CB_B17Mixed Sex Accommodation Breaches (per 1000 admissions) 0

Mth

ly

3 2 4 1 10

19 CB_B18Cancelled Operations - Percentage of patients not offered a binding date within 28 days of a cancelled operation.

Qtr 16.4% 9.21% 15.3% 13.3%

20 CB_B19Mental Health - % of patients on CPA discharged from inpatient care who are followed up within 7 days 95% Q

tr 100% 96% 95.2% 98%

21 CB_S4 A&E Attendances - number of attendances in A&E

Mth

ly

8,960 9,192 8,610 3,194 2,759 32,715

22 CB_S5_AMental Health - proportion of people who have depression/anxiety who receive pschological therapies

10%

2013/14 Qtr 2.1% 2.0% 4.6% 8.7%

23 CB_S5_BMental Health - proportion who complete treatment who are moving to recovery Q

tr 42.8% 31.3% 30.9% 35.1%

Page 12347 of 371

Reporting Period


Quarter 1





Freq

uenc

y

Liv

ing

we

ll

Ag

ein

g W

ell


YTD Trend

Sta

rtin

g

We

ll

24 CB_S6i Number of 52 Week RTT - Admitted>52weeks 0

Mth

ly

1 0 1 1 3

25 CB_S6ii Number of 52 Week RTT - Non-admitted>52weeks 0

Mth

ly

1 0 0 0 1

26 CB_S6iii Number of 52 Week RTT - Incomplete>52weeks 0

Mth

ly

0 0 0 0 0

27 CB_S7aAmbulance Handover Time - delays of over 30 minutes M

thly

98.7% 99.7% 99.7% 99.2% 99.3%

28 CB_S7b Ambulance Handover Time - delays of over 1 hour

Mth

ly

99.9% 99.9% 100.0% 100.0% 100.0%

29 CB-09Trolley Waits in A&E - 12hr waits from Decision to Admit to Admission 0

Mth

ly

0 0 0 0 0 0

30 CB_S10Cancelled Operations - Number of Urgent Operations Cancelled for a second time 0

Mth

ly

0 0 0 0 0

31 CB_A1 Potential Years of Life Lost (PYLL)

An

nu

al

32 CB_A2 Mortality Rate - under 75 - CVD

An

nu

al

33 CB_A3 Mortality Rate - under 75 - Respiratory Disease

An

nu

al

34 CB_A4 Mortality Rate - under 75 - Liver Disease

An

nu

al

35 CB_A5 Mortality Rate - under 75 - Cancer

An

nu

al

Page 13348 of 371

Reporting Period


Quarter 1





Freq

uenc

y

Liv

ing

we

ll

Ag

ein

g W

ell


YTD Trend

Sta

rtin

g

We

ll

36 CB_A6_01Emergency Admissions - Chronic Ambulatory Care Sensitive Conditions (Adults) M

thly

157 170 175 64 566

37 CB_A6_02Emergency Admissions - Asthma, Diabetes & Epilepsy in under 19s M

thly

14 15 23 10 62

38 CB_A6_03Emergency Admissions - Acute Conditions that should not usually require hospital admission (crude rate/100,000 reg pop) M

thly

178 202 222 62 664

39 CB_A6_04Emergency Admission -Children with Lower Respiratory Tract Infections (LRTI) M

thly

10 1 46 13 70

40 CB_A7Long Term Conditions - proportion of people feeling supported to manage their LTC

41 CB_A8Long Term Conditions - average Health Status Score for individuals (19+) reporting that they have a LTC

42 CB_A9 Dementia - Diagnosis rate

43 CB_A10Emergency Re-admissions - % within 30 days of discharge from hospital M

thly

12.0% 11.0% 12.5% 11.8%

44 CB_A11i PROMS - Hip Replacement n/a Qtr

Figures

suppressed due

to low patient

counts

45 CB_A11ii PROMS - Knee Replacement n/a Qtr

Figures

suppressed due

to low patient

counts

46 CB_A11iii PROMS - Groin Hernia n/a Qtr

Figures

suppressed due

to low patient

counts

47 CB_A11iv PROMS - Varicose Veins n/a Qtr No data

Page 14349 of 371

Reporting Period


Quarter 1





Freq

uenc

y

Liv

ing

we

ll

Ag

ein

g W

ell


YTD Trend

Sta

rtin

g

We

ll

48 CB_12_APatient Experience of Primary Care - % of patients with positive experience of GP Services A

nn

ual

82.0%

49 CB_12_BPatient Experience of Primary Care - % of patients with positive experience of Out of Hours GP Services A

nn

ual

72.0%

50 CB_A13 Friends & Family Test (A&E)

Mth

ly

66

51 CB_A13 Friends & Family Test (InPatient)

Mth

ly

68

52 CB_A14 Patient Experience of Hospital Care

An

nu

al

53 CB_A15 HCAI - Overall number of cases of MRSAC =

P = Mth

ly

1 2 1 0 1 5

54 CB_A16 HCAI - Overall number of cases of C DifficileC =

P = Mth

ly

5 6 3 0 14

55 CB_S1 Non-Elective FFCEs

Mth

ly

2,093 2,166 2,222 747 7,228

56 CB_S2 First Outpatient Attendances

Mth

ly

8,032 8,371 8,451 2,920 27,774

57 CB_S3 Elective FFCEs

Mth

ly

3,229 3,446 3,629 1,292 11,596

Page 15350 of 371

Reporting Period


Quarter 1





Freq

uenc

y

Liv

ing

we

ll

Ag

ein

g W

ell


YTD Trend

Sta

rtin

g

We

ll

58 GM58Stroke - patients who spend at least 90% of their inpatient stay on a stroke unit 80%

Mth

ly

71.4% 75.0% 73.0% 44.4% 70.6%

59 GM59Stroke - proporation of patients arriving in a designed stroke bed within 4 hours of arrival A

nn

ual

60 GM60Stroke - proporation of high risk TIA case investigated and treated within 24 hours 60%

Mth

ly

0.0% 60.0% 50.0% 40.0%

61 GM61Increase the staging outcomes earlier in Cancer intervention for Lung/ Colorectal and Upper GI. A

nn

ual

62 GM62Proportion of people feeling supported to manage their condition M

thly

63 GM63Emergency readmissions within 30 days of discharge from hospital: MCHfT Only M

thly

12.98% 12.0% 13.4% 12.8%

64 GM64 Delayed Transfers of care (MCHfT)M

thly

1,530 1,700 1,778 637 5,645

Key CriteriaNHS ConstitutionNHS Outcomes FrameworkActivity MeasuresLocal Measures

Page 16351 of 371

South Cheshire Breach Rate 0.8 0.2

Patient Experience: Breaches of Same Sex Accommodation

Description April May June July August September October November December January February MarchCCG Breaches 5 2 1 2 2 2 4 0 1 4

Description April May June July August September October November December January February MarchActivity 5,208 5,013 4,375 5,660 4,672 5,137 5,305 5,347 4,783 5,396Forecasted 4,486 4,498 4,295 4,952 4,533 4,544 4,990 4,567 4,361 4,809 4,383 4,613


Exceptions - South Cheshire CCG

Mixed Sex Accommodation England Breach Rate

All providers of NHS funded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient, in accordance with the definitions set out in the Professional Letter CNO/2010/3.

CCG commentary : Sue Cooke

Breaches of mixed sex accommodation are in the critical care areas only. The new critical care and theatre build is complete and services will be moving in week commencing 14th April 2014. There should be no further breaches following this.

BI commentary

No Comment

Data Source: Unify 2 and HSCIC

Data Source: Unify

First Outpatient Attendances

All first outpatient attendances (consultant-led) in general and acute specialties.

Elective FFCEs

Number of general & acute (G&A) elective admissions FFCEs

CCG commentary : Sue Milne

15% increase in referrals is leading to increased OP activityThe issue is managed formerly through the monthly Contract meeting and the fortnightly finance and performance meeting, led by the Finance team and on-going liaison with the divisional general managersReferral management Initiatives are being progressed by the Living Well Primary Care Quality team with the GPs in the CCG

BI commentary

Activity for January is showing a 19.8% variance from forecasting with a increase in activity of 17.4% from last month, MCHfT is showing a 18.2% increase.



BI commentary

1st Outpatient appointments remain above the forecasted activity with variance of 12.2% and increase from last month of 12.8%.

Data Source: Unify

0

1

2

3

4

5

6

Mixed Sex Accommodation

0

1,000

2,000

3,000

4,000

5,000

6,000


0

500

1,000

1,500

2,000

2,500

Elective FFCEs

APPENDIX 3 – South Cheshire CCG Exceptions Report

Page 17

352 of 371

353 of 371

Stroke - patients who spend at least 90% of their inpatient stay on a stroke unit


Description April May June July August September October November December January February March% performance 73.9% 78.3% 80.0% 79.2% 72.0% 75.0% 80.0% 82.1% 73.9% 68.4%National Target 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

Stroke - 90% of time on a stroke unit

There contnues to be an issue with late referrals to the TIA service from both GP's and internally in the Trust. GP's have been reminded about the importance of referring patients with suspected TIA immediately to ensure patients can be seen within 24 hours. MCHFT have a service level agreement with University Hospitals of North Staffordshire for out of hours cover

BI commentary

No Comment

Data Source: Providers

CCG Commentary : Sue Cooke

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%


Page 19

354 of 371

Description April May June July August September October November December January February March% performance 94.5% 97.2% 98.4% 97.7% 95.3% 95.5% 95.1% 96.7% 94.7% 93.5% 91.3%National Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

A&E Waiting Times - 4hrs Waits


The Trust are expected to fail the Q4 target. The Trust is expected to achieve the target for the full year. The main issue faced by the trust since early January has been the prevalence of D&V within the hospital closing wards and the inability to discharge patients that have had D&V to care homes for at least 72 hours after symptoms cease. Since the start of the virus there has been an average of 2 wards closed, as well as bays in various other wards, at one point there were a total of 4 wards closed. The trust have been highlighted by NHS England, alongside Harrogate, Countess of Chester, Sheffield teaching and City hospital Sunderland, as being affected by the Norovirus virus, not for serious operating problems.

BI commentary

No Comment

Data Source: NWAS website

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%


Page 20

355 of 371

Vale Royal Breach Rate 0.3 0.2

Patient Experience: Breaches of Same Sex Accommodation

Description April May June July August September October November December January February March

CCG Breaches 1 0 2 0 1 1 1 1 2 1


Exceptions - Vale Royal CCG

Mixed Sex Accommodation England Breach Rate

All providers of NHS funded care are expected to eliminate mixed-sex accommodation, except where it is in the overall best interest of the patient, in accordance with the definitions set out in the Professional Letter CNO/2010/3.

Breaches of mixed sex accommodation are in the critical care areas only. The new critical care and theatre build is complete and services will be moving in week commencing 14th April 2014. There should be no further breaches following this.

BI commentary

Data Source: Unify 2 and HSCIC

CCG Commentary : Sue Milne


All first outpatient attendances (consultant-led) in general and acute specialties.


BI commentary


No Comment

1st outpatient activity remains above the forecasted plans with a variance of 18.2%. Activity has increased by 7.7% from last month.

Data Source: Unify

0

1

2

3

Mixed Sex Accommodation

0

500

1,000

1,500

2,000

2,500

3,000

3,500


APPENDIX 4 – Vale Royal CCG Exceptions Report

Page 21

356 of 371

Description April May June July August September October November December January February MarchActivity 1,061 1,094 1,074 1,229 1,069 1,148 1,300 1,267 1,062 1,292Forecasted 988 991 947 1,093 1,001 1,005 1,104 1,011 966 1,066 972 1,024

Red 1 - Provide a response on site within 8 minutes in 75% of incidents


Stroke - proporation of high risk TIA case investigated and treated within 24 hours

Description April May June July August September October November December January February March% performance 0.0% 0.0% 0.0% 100.0% 100.0% 0.0% 50.0%National Target 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

Number of general & acute (G&A) elective admissions FFCEs



BI commentary

Ambulance - Category A (Red 1) - 8 minute response

Activity remains above forecasted by 21.2% but is showing a increase of 21.7% from last month.

Data Source: Unify

Elective FFCEs


NWAS are measured against all targets at contract level and not CCG LevelCheshire is the only area currently likely to fail full year cumulative performance and that this is against a backdrop of activity consistent with planned contract levels and significant upfront investment. NHS Blackpool CCG have been asked to develop a corrective action plan with NWAS and present to the Cheshire sub-regional governance group as part of new assurance process.Commissioning Intentions for 2014/15 will be for NWAS to continue to report performance at CCG level

BI commentary

No Comment

Data Source: NWAS website

Stroke - TIA cases


There contnues to be an issue with late referrals to the TIA service from both GP's and internally in the Trust. GP's have been reminded about the importance of referring patients with suspected TIA immediately to ensure patients can be seen within 24 hours. MCHFT have a service level agreement with University Hospitals of North Staffordshire for out of hours cover

BI commentary

No Comment


0

200

400

600

800

1,000

1,200

1,400

Elective FFCEs

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Ambulance - Category A (Red 1) - 8 minute response

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Stroke - TIA cases

Page 22

357 of 371



Description April May June July August September October November December January February March% performance 94.8% 97.3% 98.6% 97.8% 95.3% 95.6% 95.2% 96.8% 94.8% 93.7% 91.6%National Target 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

Description April May June July August September October November December January February MarchActivity 1 0 0 0 0 0 0 0 1 1Target 0 0 0 0 0 0 0 0 0 0 0 0

CCG Commentary : Sue Cooke

Capacity issues in the Trust in the last few months have necissitated some patients in the rehabilittaion phase of stroke transferring to other wards, usually care of the elderly wards. This does not count as part of the 90% stay on a stroke unit. There are also issues around patients being discharged from the stroke unit. Currently there is a tender process underway for a specialist community rehabilitation team which will facilitate early discharge

BI commentary

No Comment

No Comment



Number of 52 Week RTT - Admitted>52weeks


The CCG are awaiting an update from MCHFT regarding this patient

BI commentary


CCG Commentary : Sue Milne

The Trust are expected to fail the Q4 target. The Trust is expected to achieve the target for the full year. The main issue faced by the trust since early January has been the prevalence of D&V within the hospital closing wards and the inability to discharge patients that have had D&V to care homes for at least 72 hours after symptoms cease. Since the start of the virus there has been an average of 2 wards closed, as well as bays in various other wards, at one point there were a total of 4 wards closed. The trust have been highlighted by NHS England, alongside Harrogate, Countess of Chester, Sheffield teaching and City hospital Sunderland, as being affected by the Norovirus virus, not for serious operating problems.

BI commentary

No Comment



0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%


0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%


0

1

2

Number of 52 Week RTT - Admitted>52weeks

Page 23

358 of 371

Prepared By : W Jeffries NHS South Cheshire CCG Governing Body

REPORT



Minutes of Statutory Meetings 27 March 2014 14:15 – 17:15 7.8.1

PURPOSE OF REPORT This paper provides the Governing Body with the following Minutes to be noted:

• Quality & Performance Committee 27th February 2014

• Governance & Audit Committee 27th February 2014

Prepared by: W Jeffries Governing Body Lead: Fiona Field Director of Partnerships & Governance

GOALS 2013-14




VISION


RECOMMENDATIONS


i) Noted the Quality and Performance Committee minutes 27th February 2014

ii) Noted the Governance & Audit Committee minutes 27th February 2014






No Yes

No

No

No

No

359 of 371

Prepared By : Irene Fairclough NHS Vale Royal CCG & NHS South Cheshire CCG [] 1

MINUTES

REPORTING GROUP DATE/TIME AGENDA ITEM

QUALITY & PERFORMANCE COMMITTEE 9am 27/02/14 MEETING NO 11

Ref

Discussion & Action Points 1.0 Committee Management 1.1 Apologies for Absence

Lindsay Ratapana, Lynda Risk, Moira McGrath, Sue Cooke, Cathy Fulham, Helen Wormald, Anne Eccles, Dr Robert Pugh, Amanda Best, Judi Thorley, Lisa Carr.

1.2 Declarations of Interest There were no declarations of interest.

MEMBERSHIP

Present Name Organisation Membership Category Committee Quorum √ Diane Noble NHS South Cheshire CCG Lay Member – PPI (CHAIR)

A meeting will be quorate if, one

Executive Member and Lay Member or a GP Clinical Member from the respective CCG are present

√ Terry Savage NHS Vale Royal CCG Lay Member - PPI √ Dr Teresa Strefford NHS Vale Royal CCG Clinical Member (DEPUTY) √ Dr Andrew Hudson NHS South Cheshire CCG Clinical Member x Judi Thorley NHS SCCCG/VRCCG Governing Body Nurse √ Fiona Field NHS South Cheshire CCG Director of Partnership & Governance (SIRO) √ Tracy Parker Priest NHS Vale Royal CCG Director of Partnerships & Governance (SIRO) x Moira McGrath NHS South Cheshire CCG Safeguarding Nurse – Children x Anne Eccles NHS Vale Royal CCG Safeguarding Nurse – Children x Lindsay Ratapana NHS South Cheshire CCG Safeguarding Nurse – Adult x Helen Wormald NHS Vale Royal CCG Safeguarding Nurse – Adult x Sue Cooke NHS SCCCG/VRCCG Clinical Quality Manager ** √ Steve Evans NHS SCCCG.VRCCG Contract Manager x Lisa Carr NHS SCCCG/VRCCG Performance & Risk Manager x Cathy Fulham NHS SCCCG/VRCCG Clinical Project Manager √ Debbie Lowe C&M CSU Locality Manager x Janet Kenyon NHS SCCCG/VRCCG Prescribing Support Manager – ATTENDEE REP

FOR MD x Amanda Best NHS SCCCG/VRCCG Service Delivery Manager x Andrea Lunt NHS SCCCG/VRCCG Prescribing Support Pharmacist ATTENDEE REP

FOR MD √ Mark Dickinson NHS SCCCG/VRCCG Medicines Management Lead √ Mary Barlow CSU Clinical Quality, Safeguarding & Performance Lead x Alison Atkinson C&MCSU Clinical Quality, Safeguarding & Performance x Lynda Risk NHS SCCCG/VRCCG Chief Finance officer – REMOVE – CIRCULATION

ONLY √ Jason Gravestock NHS SCCCG/VRCCG Quality Improvement Manager x Dr Robert Pugh NHS SSCCG/VRCCG Secondary Care Representative

Guest Attendees √ Suzanne Rimmer Clinical Project Manager NHS SCCCG/VRCCG √ Sharon Heeks Clinical Project Manager NHS SCCCG/VRCCG

Minute Taker √ Irene Fairclough NHS SCCCG/NHSVRCCG

360 of 371

Prepared By : Irene Fairclough NHS Vale Royal CCG & NHS South Cheshire CCG []

2

1.3 Minutes of the Meeting & Action log - 30th January 2014. The minutes and action log of the meeting held on 30th January 2014 were agreed. 2.0 Committee Management 2.1 NHS Constitution & Outcomes Framework Measures

There was nothing to report. 2.2 NHS Targets 2012-13

SE presented the December report which was tabled at the meeting. AH referred to the Elective FFCEs graph showing an increase in referrals of 15% which is leading to increased OP activity and asked why this is shown monthly when most other trusts report by days. SE explained that it was the way MCHFT chose to report it. There was a discussion around difficulties experienced in A & E at MCHFT. A & E have been on purple over the last few weeks and discussions are taking place every day around the reasons why. There is an issue around delayed discharge because of the lack of availability of care packages in both local authorities. There is no issue with Continuing Health Care packages. The committee discussed and agreed that the NHS Constitution & Outcomes Framework Measures report should be included as an agenda item retrospectively. The report can then be sent out with the agenda and a verbal update be given on any significant changes since the report was finalised. ACTION: LC to lead on this and amend for future meetings.

2.3 Medicines Management Update MD stated there was nothing to report or highlight from the attached JMMC minutes. AH asked if a more bespoke report could be provided from Medicines Management. A discussion took place around what would be needed in terms of quality and what duties in relation to medicines management would the CCGs have. It was agreed that TPP and MD would meet outside of this meeting to discuss further. ACTION: TPP/MD to arrange to meet.

3.0 Patient Safety & Experience 3.1 Integrated Clinical Governance Report – Quality Dashboard JC presented the report and highlighted the following:

Mortality The ‘Deep Dive’ review will report in April 2014 and a presentation of the initial findings will take place at 9am on 11th March. DrTS has been invited to the presentation. TPP said that the report will be presented to the Governing Body of both CCGs and TPP will send this out. ACTION: TPP to send the Deep Dive report out when available. Never Event MCHFT reported a Never Event in December relating to a retained swab following a surgical procedure in maternity. A Level 2 RCA is currently underway. The committee will be kept updated on this.

361 of 371


3

Advancing Quality It was agreed at the Governing Bodies that the CCGs would subscribe the AQ for 1 year and not 3 years. There is a teleconference arranged for 4th March with Hayley Kitchen from AQ and Sue Cooke and Simon Whitehouse. ACTION: SC to report back to the next meeting if the 1 year contract has been accepted by AQ. It was noted that any further recommendations to the Governing Bodies be agreed at this committee and the decision sent for approval to the Governing Bodies. AH commented that the introduction of the skin bundles in December 2013 and made a significant improvement in the number of pressure ulcers. There is now a Pressure Ulcer Reduction Group who is currently writing Terms of Reference which will further help to make improvements. MCHFT CQUIN Qtr 3 Update Heart Failure is off track but recoverable. The heart failure team will be piloting a new pathway to assist in the reduction of inconsistencies. The pathway will involve reviewing notes of patients whose referral may have been delayed. Hip & Knee Replacement This is off track but recoverable. The main inconsistency relates to VTE prophylaxis. This is due to a change in policy and guidelines. The reduction of the time frame from 24 to 12 hours and the introduction of a new drug option resulted in a variation in the performance against this measure. Friends & Family Test BMI F & F Test response was at 23.14% for December 2013. This is a good response.

3.2 North of England Dashboard JC reported a slight improvement for MCHFT on the North of England dashboard showing

how each trust performs across the quality matrics. MCHFT are now showing in 5th from the bottom moving up from bottom place. MD commented that although they had moved up they were still showing 50% red which was above all other trusts apart from Blackpool. JC explained that a large part of the 50% was due to mortality and that we are aware of this issue. A discussion took place around this and it was agreed that the committee recognises the issues around mortality and that work is being done and that the dashboard should be kept in context as a tool to review in the committee.

3.3 Cheshire, Warrington & Wirral Quality Dashboard The Cheshire, Warrington & Wirral Quality Dashboard was included for information only.

There were no comments made by the committee. 3.4 Safeguarding: Adults/Children There was no report required for this month’s meeting.

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3.5 Nursing Home Update (Nov 13) MB gave an update as an exception on Nursing Homes in South Cheshire and Vale Royal.

The full report will come to the committee in March. South Cheshire CCG Cypress Court Nursing Home This home is being monitored by CQC and is now improving. The provider (Four Seasons) asked for an extension to reach compliance and the proposed date is 28th February. There has now been a new manager appointed and it is hoped that by March the home should be able to have placements on a controlled basis. Rosedale Manor Nursing Home The voluntary suspension remains in place. There is a temporary manager covering the home as it is still not clear when a new manager will be appointed due to recruitment not being successful. Huntercombe Care Home Huntercombe is still on sustainability Church House There was a sudden unexpected death in December 2013. This is currently under police investigation with involvement from CCG Adult Safeguarding Lead and Quality Assurance Teams. A review meeting will take place on completion of the investigation. FF pointed out that these investigations can take a long time but that the SCCCG will be kept updated. Vale Royal CCG Overdean Care Home Following the lifting of the suspension, quality visits from CCG Adult Safeguarding Lead and Continuing Health Care/Complex Care Services continue to ensure sustainability of improvement. The new manager appears to be settling in well. Westwood Court Care Home The ongoing safeguarding incident at Westwood has been passed to the police for investigation. Avandale Lodge MB reported an increase in falls at Avandale which was concerning. A safeguarding investigation was undertaken and a check with regard to the falls protocol and risk assessments will be undertaken. MD raised concern around what happens when there are quality concerns in residential homes which the CCG are not contracted to take any action. FF explained that any concerns would be discussed with the district nursing teams. There was a discussion around training and developing a forum. It was suggested that a trial be run with the local authorities and the 2 CCGs. TPP suggested that a certificate be given. This idea could be trialled along with the work which is presently being done. AH commented on the prescribing issues raised by primary care with respect to care homes. Nursing Homes have a timeline from ordering medicines from the GP and them receiving the patient medicines that may last 3 weeks. When nursing homes request new urgent medications outside of this routine medicine timeline there have been a range of ordering issues.

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MD explained that the MMT were aware that there were issues in the overall medicines ordering process that involve community pharmacy, nursing homes and general practice and it is an area of work that MMT could address as a new area of work if CCGs prioritise it. This is being discussed by MMT and the CCG prescribing leads.

4.0 Operational Management and Regularity Updates The Chair acknowledged the various minutes for information. 5.0 5.1 Any Other Business Dr TS reported on the Post Infection Review meeting which had taken place on the 27th

February concerning a MRSA Bacterium case and highlighted the learning outcomes. The decision of the review meeting was that this MRSA case was attributable to VRCCG.

TPP reported that the Chair of the Vale Royal Audit Governance and Audit Committee will be writing to the Chair of the Quality & Performance Committee for a written summary of the work the committee does.

5.2 Date and time of next meeting: 27th March 2014 at 9am in the Board Room Bevan House

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Prepared By: Lisa Carr / Sharron Spruce NHS South Cheshire CCG Governance & Audit Committee – 2014-02-27 1

MINUTES

Reporting Period 2013-14 REPORTING GROUP DATE/TIME VENUE

Governance & Audit Committee 27th February 2013

13:00- 15.30

Ground Floor Bevan House,

Nantwich

Ref Discussion & Action Points

9.1.1

Apologies For Absence Apologies for absence were received from Paul Basnett and Dr Ged O’Sullivan. The Chair welcomed Suzanne Horrill, VRCCG Governance & Audit Chair to the meeting who had joined for observation purposes. Simon Whitehouse would join the meeting for agenda item 9.5.2.

9.1.2

Declarations of Interest

There were no declarations of interest made.

9.1.3

Minutes of Meeting The minutes of NHS South Cheshire CCG’s Governance and Audit Committee held on 27 February 2014 were circulated with the agenda. Matters arising from the minutes included: • Item 8.1.3 – b/f from item 7.6.3. Fiona Field advised that earlier today a discussion had been

held and a pragmatic decision had been reached between the Clinical Leads regarding the processing of Professional Concerns which were held on the CSU’s database. It was noted that the system would be tested in March 2014.

• Item 8.1.4 Graham Bruce and Suzanne Horrill had held meeting on 27-02-14 to discuss

MEMBERSHIP

Present Name Organisation Membership Category Committee Quorum

Graham Bruce NHS SC CCG Lay Member – Audit A meeting will be quorate if,

one lay member & two Clinical/

Executive representatives

are present.

John Clough NHS SC CCG Lay Member – Audit Lynda Risk NHS SC/VR CCGs Chief Finance Officer Fiona Field NHS SC CCG Director of Partnerships & Governance (SIRO) Mark Stansfield Grant Thornton External Auditor Linda Elliott MIAA Internal Auditor Dr Ged O’Sullivan NHS SC CCG GP Representative Lisa Carr NHS SC/VR CCGs Performance & Risk Manager

Periodic Attendees Matthew Elcock MIAA LCFS Periodic Attendee Suzanne Crutchley CWW CSU Information Governance Officer Periodic Attendee Roger Causer MIAA Counter Fraud (NHS Protect) Periodic Attendee Suzanne Horrill VRCCG Lay Member – Audit Guest Attendee

n/a Dr. Andrew Wilson NHS SCCCG South Cheshire CCG Chair Periodic Attendee Simon Whitehouse NHS SC/VR CCGs Chief Officer Periodic Attendee

Minute Taker Sharron Spruce NHS SC/VR CCGs

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Prepared By: Lisa Carr/Sharron Spruce NHS South Cheshire CCG Governance & Audit Committee – 2014-02-27

2

development sessions for Lay members of Governance & Audit following evident request in the Value for Money Assessment Criteria. Details on scope of workshop, who should attend and cost to be presented at next meeting. J Clough noted that Grant Thorton were holding a number of development sessions for Governance & Audit Lay members throughout March 2014.

• Item 8.2.1 K Highfield had liaised with the ICT support team to resolve issues relating to IT equipment that cannot access the ESR connection.

• Item 8.3.1 findings from survey relating to Governing Body arrangements will be presented in the final audit report findings scheduled in March 2014.

• Item 8.3.1 the Internal Auditor had meet with the Chief Finance Officer a draft Internal Audit Plan 2014-15 has been drafted and circulated to the executives leads. It was requested that a copy be issued to the lay members and a finalised version to be presented to the March 2014 meeting.

• Item 8.3.1 checkpoint assessment findings relating to MIAA’s Briefing Note 3 entitled ‘Investigations in the NHS’ to be presented to the G&A committee in June 2014.

• Item 8.3.2 the Standards of Business and Declaration of Interest Policy has been sense checked by the Task and Finish Group and now needs to be presented in it draft format to the Membership Council in April 2014 for consultation purposes before it can be issued to the Governing Body for ratification.

It was Agreed: Whom When

• that the minutes of 30 January 2014 be approved as a correct record; and

• that the Matters Arising be completed in accordance with the specified timelines.

9.1.4

Committee Calendar & Planner Copies of a paper entitled ‘Committee Calendar and Planner’ prepared by Lisa Carr had been circulated with the agenda. L Carr drew attention to the report noting that in 2014-15 6 meetings have been scheduled to run concurrently for both SCCCG & VRCCG Governance & Audit Committees over a three hour slot from 1.00pm to 4.00pm. An additional meeting scheduled in May would be dedicated to review the draft Annual Accounts and Draft External Audit Management Letter. A request by the VRCCG Governance & Audit members to commence their meeting slot from 1.00pm and join up together with SCCCG from 2.00pm. A review of the draft committee forward planner detailing business topics to be presented over the year was noted. Members were asked to submit any additional items or proposed changes before the next scheduled meeting.

It was Agreed:

• that the proposed Calendar of meetings and Committee Forward Planner be noted; and

• to set up the meeting for May 2014; and • that SCCCG to join the VRCCG members from 2.00pm to 4.00pm;

S Spruce

Feb-14

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and • any additional or alterations to the committee forward planner to be

issued to the Performance & Risk Manager before next meeting.

All

Mar-14

9.2.1

CSU Information Governance Toolkit Update Copies of a paper entitled ‘Main Providers IG Toolkit Status: Monitoring Proposal for 2014-15’ prepared by Suzanne Crutchley had been circulated with the agenda. L Carr stated that the CSU IG Lead had been tasked to incorporate into their periodic reports an overview of the published scores relating to the CCG’s main providers namely Mid Cheshire Hospitals NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust and East Cheshire NHS Trust. In order to provider the assurance that providers are upholding the requirements. The information will relate to overall compliance percentage score, attainment level per IG Toolkit Requirement; by initiative and a baseline and performance update scores. Published scores are available during the month of April.


• that the proposal to present a report on the IG Toolkit scores against the CCG’s three main providers to be approved.

S Crutchley

May-14

9.2.2

Corporate Risk Register – February 2014 Copies of a paper entitled ‘Corporate Risk Register – February 2014’ prepared by Lisa Carr had been circulated with the agenda. L Carr drew attention to the contents of the report which presented a dashboard of all corporate risk entries, together with full summaries from the register detailing the controls and mitigating actions for all risks ranked 12 and above. Also the two new risks added since last reporting period and the Finance Risks. Particular attention was drawn to the two new entries namely CR 2013-35 ‘Never Events at MCHfT’ and CR 2013-36 Learning Disabilities – Winterbourne View Concordat. A detailed explanation was provided noting that MCHfT were arranging a peer assessment to be undertaken into the areas where the ‘Never Events’ had occurred ensure that lessons had been learnt and positive impacts being made on operational practices. With regard Learning Disabilities – Winterbourne View Concordat it was noted that only 6 SCCCG patients were unable to be moved into community based setting following clinical assessments. A comprehensive report was being presented to the Governing Body in March 2014. The Chair drew attention to the five live risk entries scored in the Major category namely CR2013-25 Personal Health Budgets, CR 2013-24 CSU SLA Management; CR 2013-15 Mortality at MCHfT; CR2013-30 Vascular Service Changes and CR2013-31 ICT Security. Also CR 2013-19 on NHS Allocations of Social Care. With regard the Personal Health Budgets it was noted that alternative arrangements were being

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reviewed by VRCCG and the existing provision for SCCG was being improved. It was noted that the CSU SLA Management that a consultant had been appointed to help review the existing SLA and develop meaningful key performance measures. The outputs from the AQUA review relating to Mortality at MCHfT would not be available until April 2014. A request for smarter definitions of the mitigating actions for Vascular Service Changes to be made in the register and to evaluate the risk score thereafter. The NHS Allocations of Social Care will be escalated to the Chief Accountable Officer following discussions held at the VRCCG Governance & Audit Committee. A request for a summary report to be present to the last meeting of 2013-14 regarding the total number of risk entries and those that have been closed and those being carried forward to the 2014-15 register. It was Agreed: Whom When

• to note the contents of the Corporate Risk Register as at the reporting period 19th February 2014; and

• that a progress report relating to CR2013-35 Never Events @ MCHfT to be presented at a future meeting; and

• that risk CR2013-30 Vascular Service Change to have smarter defined mitigating actions and review the score; and

• that risk CR2013-19 NHS Social Care Fund be escalated to the Chief Accountable Officer to write to the Chief Executive at CWAC to seek resolution.

• A summary report reflecting the risk entries for 2013-14 to be presented to the March 2014 meeting.

SC

SM

SW

LC

Jun-14 Mar-14 Apr-14 Mar-14

9.2.3

External Assessments/Publications Not applicable It was Agreed: Whom When

9.3.1

Internal Audit 2013-14 Linda Elliott provided a verbal update advising that fieldwork was being concluded for the last three audit reviews relating to QIPP, Governing Body Reporting and Performance Management. Acknowledging thanks to Governing Body members who had completed the on-line survey which formed part of the Governing Body review. The draft reports are being compiled for circulation to the executive leads for management responses. The final reports will then be presented to this committee in March 2014. Some discussion ensued relating to the audit follow-up work and that the Internal Audit Assurance Opinion would be prepared following the conclusion of all findings and follow-ups. It was further noted that a meeting had been held in February 2014 with the Chief Finance Officer to commence the first cut of the Internal Audit Plan 2014-15 proposals. This has now been drafted and circulated to other executive leads for sense checking. It was proposed that the draft internal audit plan also be reviewed by the Governance & Audit Chair prior to it being presented at the next meeting. It was Agreed: Whom When

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• to note the verbal update from the Internal Auditor relating to the

internal audit plan 2013-14 progress work; and • to note that the management responses will need to be turned around

quickly in order to present the final audit findings to the committee in March 2014; and

• that the draft Internal Audit Plan 2014-15 be circulated to Governance & Audit Lay member for sense checking; and

• that the final Draft Internal Audit Plan 2014-15 be presented to the committee in March 2014.

CCG Executives L Elliott L Elliott

Mar-14 Feb-14 Mar-14

9.3.2

Internal Audit Tracker 2013-14 Copies of a paper entitled ‘Internal Audit Tracker 2013-14’ prepared by Lisa Carr had been circulated under separate cover. L Carr drew attention to the contents of the report which provided a dashboard summary of all internal audit reviews undertaken to date in 2013-14 by MIAA, presenting the auditors assurance level and the number of recommendations which are then risk rated from Critical, High, Medium and Low. In terms of recommendations it was noted that there have been 4 high, 15 medium and 5 low risk areas. Further discussions were held on the contents of the tracker which listed the auditor’s recommendations and the management responses to-date. L Carr stated that there was a process issue in respect of information flow that enabled her to extract the information from the final audit findings and insert into the tracker. Plus the need to establish whether the recommendation has been resolved and could be classified as closed. It was Agreed: Whom When

• to note the contents of the Internal Audit Tracker; and • to modify the tracker to capture whether the actions had been fully

implemented and could be recorded as completed. • copies of the final internal audit findings to be issued to the

Performance & Risk Manager to transpose the information to the tracker.

LC

LE

Mar-14 Mar-14

9.4

External Audit Copies of a paper entitled ‘External Audit Progress Report & emerging issues and developments for VRCCG’ produced by Paul Basnett had been circulated with the agenda. M Stansfield drew attention to the contents of the report and the challenges posed to the CCG. It was noted that these challenges would form part of an external audit tracker to provide a checkpoint assessment that the CCG has process and procedures in place. A request was made to receive a copy of the draft Better Care Fund submission to inform the Value for Money Assessment. A further discussion took place regarding the suggested dates to present the draft annual accounts, External Audit Findings, Annual Governance Statement and the annual report and remuneration report. It was noted that a number of dates had been circulated to hold an extraordinary meeting towards end of May or beginning of June 2014 which needed to be in diaries as soon as possible to ensure the quoracy.

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• to note the contents of the External Audit Progress Report; and • that a copy of the draft Better Care Fund submission for SCCCG to

circulated to the external auditor; and • that the date for the extraordinary meeting of the Governing Body be

scheduled using proposed dates supplied by the external auditors; and

LR LC

Feb-14 Feb-14

9.5.1

Finance Report – Month 10 Copies of a paper entitled ‘Combined Finance Report – Month 10’ had been circulated with the agenda. The Chief Finance Officer took members through the contents of the report stating that the report is based on the current financial information available to the CCG and reports on the required financial targets specified by NHS England and the CCG Constitution. Particular attention was drawn to the CCG forecasted surplus of £3.2 million (current control total of £1.2 million) noting that dialogue being held with the NHS England Area Team to secure the carry forward of this potential underspend into 2014/15. It was also noted that MCHfT reported forecast over performance of £1.5 million and remaining a risk to the forecast surplus. Continuing uncertainty around the impact of legacy transactions relating to Central and Eastern Cheshire PCT. Also to note the current remaining uncommitted resources of £0.3 million previously reported at £0.8 million to manage the remaining risks to the CCG in 2013-14. The QIPP scheme for 2014-15 of £0.744 million to be delivered and monitored via the CCG’s programme and finally the financial plan submitted on 14 February 2014 and the steps taken to address the planning gap of £6 million, this to enable the delivery of the planned surplus in 2014-15 of £1.225 million. After some further discussion the Chief Finance Officer advised that the table in Appendix one would need to be proofed for accuracy prior circulating to the Governing Body meeting. It was Agreed: Whom When

• to note the contents of the Combined Finance Report for Month 10; and • to proof check the table in appendix 1.

9.5.2

Annual Governance Statement Briefing Simon Whitehouse gave a verbal update advising that draft CCG Annual Reporting Guidance 2013-14 had been published on 10 January 2014. It was noted that this was a comprehensive 370 page document which was fairly prescriptive. A task and finish group had been established and a process being rolled out to collate information to assist the development of the CCG’s Annual Governance Statement. It was noted that the statement would describe the CCG’s current position, outline the journey through the year and the problems encountered and how these are being revolved. Particular attention is focussed on the internal controls and risk management to mitigate issues. It was Agreed: Whom When

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• that the verbal update on the Annual Governance Statement to be noted, and

• that a progress update to be presented at the next meeting.

SW

Mar-14

9.6.1

CSU Performance Update Copies of a paper entitled ‘CSU Performance Update’ produced by Phil Meakin, Locality Manager had been circulated under separate cover on day of the meeting. The Chair asked whether any merging issues stemmed from the report. It was acknowledged that given the late circulation not enough time had been given to evaluate the contents. The Chief Finance Officer stated that Cheshire & Merseyside CSU had merged with Greater Manchester CSU. It was Agreed: Whom When

• that the contents of the CSU Performance Report were noted considered in detail due to late circulation.

9.6.2

Committee/ Partnership Minutes The draft copy of the Quality & Performance Committee minutes held on 30 January 2014 had been circulated with the agenda for information purposes. The Chair drew attention to the contents of the minutes with particular interest on the performance measures. He stated that the performance measures did not appear to be reaching the Governing Body meetings. It was noted that a report detailing all the NHS Constitution and Outcomes Framework measures was being produced monthly and circulated to the Quality And Performance Committee for scrutiny. However, noted that the report was note reaching the agenda for the Governing Body meetings.

9.7.1

Any Other Business The next meeting of the Governance & Audit Committee is scheduled on Tuesday 27th March 2014 at 12 noon. Graham Bruce gave his apologies and asked if John Clough could Chair the meeting on his behalf. The Chair advised that he had attended an NHS England CCG Audit Committee Chairs Forum held between 14 & 19 February 2014. Copies of the slides would be circulated for information purposes.

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