AGENDA ITEM NO: 004/18

Performance Report NHS Warrington CCG Governing Body Meeting 10

th January 2018

GOVERNING BODY MEETING:

Governing Body Meeting

DATE OF MEETING:

10

th January 2018

REPORT AUTHOR AND JOB TITLE:

Pam Broadhead Chief Performance Officer

REPORT TITLE:

Performance Report regarding the Improvement and Assessment Framework

STRATEGIC OBJECTIVES:

Please tick which strategic objectives the paper relates to

Improve quality of services

Sustained financial balance

Build an effective and motivated whole system workforce

Sound governance arrangements

Ensure integration and joint working arrangements

OUTCOME REQUIRED (tick)

Approval

Assurance

Discussion

Information

EXECUTIVE SUMMARY

The CCG Improvement and Assessment Framework (IAF) has now been updated for the financial year 2017/18. The updated framework builds on the IAF introduced in April 2016 which was designed to assist improvement, alongside the statutory duty of NHS England to complete an annual assessment of all CCGs. This report to the January 2018 governing body meeting

1. Outlines the areas in exception for the Improvement and Assessment Framework for CCGs (the framework that aligns key objectives and priorities and forms the basis of the NHS England assessment of CCGs) and

2. Provides an update against other performance indicators identified as key lines of enquiry at the NHS England performance meeting in October 2017.

3. Details the performance for NHS Warrington CCG and other CCGs in Cheshire for the current month against NHS Constitution indicators.

RECOMMENDATIONS

Report for information and assurance only

AGENDA ITEM NO: 004/18

Performance Report NHS Warrington CCG Governing Body Meeting 10

th January 2018

Outline any engagement – staff, clinical, stakeholder and patient / public

Not applicable

Are there any conflicts of interest which may be associated with this paper?

None known

Does this paper address any existing risks which are included on the Assurance Framework or Risk Register?

A1 - Failure to performance manage to ensure continuous improvement A2- Failure to agree and measure outcomes

Have the following areas been considered whilst producing this report?

Yes

N/A

Equality Impact Assessment (if yes, attach to paper)

Quality Impact Assessment (if yes, attach to paper)

Regulation, legal, governance and assurance implications (reference in the report if applicable)

Procurement process (reference in the report if applicable)

Document development

Has this document been presented to any other Committee or Forum? If yes, please list which meeting, date and outcome of presentation

Not applicable

AGENDA ITEM NO: 004/18

Performance Report NHS Warrington CCG Governing Body Meeting 10

th January 2018

Strategic Objectives and Risks 2017/18

A1 Failure to performance manage to ensure continuous improvement

A2 Failure to agree and measure outcomes

A3 Failure to ensure clear arrangements are in place for quality management of non-commissioned providers in the independent sector

B1 Failure to implement the financial strategy

B2 Failure to ensure sound business practices are at the heart of running the CCG

B3 Failure to secure best value

B4 Failure to adequately provide for external factors, which impact on financial sustainability

C1 Failure to continuously develop the organisational culture that meets the needs of the changing needs of the workforce

C2 Failure of delivery by outsourced critical business functions

C3 Failure to establish primary care capacity

D1 Failure to ensure that we are compliant with our statutory duties

D2 Failure to demonstrate patient and public engagement

E1 Failure to provide appropriate reporting, for joint working arrangements

E2 Failure to describe benefit of integration and joint working arrangements to local people

AGENDA ITEM NO: 004/18

Performance Report NHS Warrington CCG Governing Body Meeting 10

th January 2018

Improvement and Assessment Framework (IAF)

1. The CCG Improvement and Assessment Framework (IAF) has now

been updated for 2017/18. The updated framework builds on the IAF

introduced in April 2016 which was designed to assist improvement,

alongside the statutory duty of NHS England to complete an annual

assessment of all CCGs.

2. The framework is intended as a focal point for joint work and support

between NHS England and CCGs. It draws together the NHS

Constitution, performance and finance metrics and transformational

challenges and plays an important part in the delivery of the Five Year

Forward View.

3. Appendix A shows the IAF overview dashboard from NHS England.

The report that follows provides a summary of the areas of the IAF that

are showing good or improved performance, those where performance

is challenged and the actions in place to improve and also a summary

of the new indicators included on the framework for the first time.

IAF Indicators with Good/Improved Performance

4. 105b - Number of personal health budgets in place per 100,000 CCG

population – A personal health budget is an amount of money to

support a person's identified health and wellbeing needs, planned and

agreed between the person and their local NHS team. The 2016-17 to

2020-21 Planning Guidance specifically committed to increasing the

number of personal health budgets and NHS Warrington CCG is

currently the 20th out of 209 CCGs in England for the number Personal

Health Budgets in place.

5. To date in 2017/18 162 people in Warrington have a Personal Health

Budget (PHB) in place which exceeds the plan for the whole year. Of

those with a PHB for the end of life care none of the patients designed

their care similar to the traditional offer; 100% of fast track end of life

PHBs were cost neutral or at reduced cost compared to traditional offer

and 83% of end of life patients died in their preferred place on a PHB

compared to around 62% with a traditionally commissioned package.

6. NHS Warrington CCG is one of 16 PHB Champion sites picked by NHS

England due to the excellent outcomes and was awarded the

‘Compassionate Patient Care’ award at the Health Service Journal

Awards for work in improving patient choice and control through PHBs.

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Performance Report NHS Warrington CCG Governing Body Meeting 10

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7. In future the Warrington team is looking to expand into section 117

aftercare (for people who have been in hospital under section 3, 37,

45A, 47 or 48 of the Mental Health Act 1983) ahead of NHS England’s

plan to widen mandate for PHBs.

8. 107a and 107b - Antimicrobial Resistance - Within the IAF there are

two indicators related to encouraging the appropriate prescribing of

antibiotics in primary care to delay the development of antimicrobial

resistance and the associated patient harm from infections that are

more difficult to treat. For both indicators NHS Warrington CCG has

seen consistent reduction in the rate of prescribing as the framework

guidance requires. For appropriate prescribing NHS Warrington CCG

is 4th lowest prescriber in Cheshire and Merseyside.

9. 122c - One-year Cancer Survival – this indicator shows the proportion

of adults diagnosed with any type of cancer in a year who are still alive

one year after diagnosis. NHS Warrington CCG has one of the most

improved cancer survival rates nationally on latest data (comparing

2013 to 2014) and the 4th highest survival rate in Cheshire and

Merseyside. The improvement was recognised at the All-Party

Parliamentary Group on Cancer in July 2017.

10. It should also be noted that there has been improvement in the

proportion of cancers diagnosed at an early stage. In 2014 NHS

Warrington CCG was 11th out of 12 CCGs in Cheshire and Merseyside.

In 2015 NHS Warrington CCG improved to 7th in the region with an

increase of over five percentage points.

11. 128b - Patient Experience of GP Services – This performance indicator

shows the percentage of people who report through the GP Patient

Survey that their overall experience of GP services was ‘fairly good’ or

‘very good’. On the 2016 survey NHS Warrington CCG was in lowest

quartile nationally however the rate of satisfaction increased by over

four percentage points on the 2017 results and now 7th out of 12 in

Cheshire and Merseyside.

12. 129a - Referral to Treatment - In August 2017 NHS Warrington CCG

had the 2nd highest proportion of people on an incomplete pathway

being within 18 weeks within Cheshire and Merseyside. Performance

has been consistently over the 92% requirement.

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Performance Report NHS Warrington CCG Governing Body Meeting 10

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IAF Indicators with Poor/Deteriorating Performance

13. 103a - Diabetes education attendance – NHS Warrington CCG is the

lowest of 12 CCGs in Cheshire and Merseyside for the proportion of

newly diagnosed diabetics attending a structured education course (for

diabetics diagnosed in 2014). This indicator is reported low due to lack

of confirmation of attendance at education programmes in the reporting

period. From April 2016 the provider of the education service was

requested to confirm attendance with the patient’s GP and has reported

that this information was sent to practices.

14. In 2017 the education programme in Warrington has been relaunched

with the number of courses being more than doubled and more

conveniently located. The service has informed the CCG that they are

currently working through a waiting list of diabetics to invite to the

education service and the uptake from this cohort has been quite low.

The uptake from those who have been recently diagnosed is however

reportedly much better.

15. 104a - Injuries from falls in people aged 65+ - NHS Warrington CCG is

in the lowest quartile nationally for emergency admissions to hospital

due to falls in people aged 65+ on the latest data (Q4 16/17). For the

12 months to July 2017 the activity for falls admissions has been fairly

static and is not showing a consistent reduction.

16. There has been a redesign and update of the existing Falls Strategy,

led by Warrington Borough Council. The Falls Strategy Group has

been re-launched and actions to improve the incidence of falls

identified and assigned to appropriate leads. Care homes with “no lift”

policies are currently being identified and reviewed as these can lead to

increased calls to North West Ambulance Service (NWAS) and

potentially onward conveyance to hospital. Lifting equipment is being

trialled in a Warrington care home for potential roll out if found to be

beneficial. NWAS is also using an algorithm in six care homes in

Warrington to try to avoid calling 999 for falls when possible. A project

is progressing with clinical pharmacists and general practice to identify

patients most at risk of falling to have a medication review and agree a

care plan to help prevent falls, injury and admission.

17. 122b - Cancer waiting times – 62 day from referral to treatment – NHS

Warrington CCG is rated as being in the lowest quartile for 62 day

waiting times from referral to first definitive treatment for people with

diagnosed cancer on the NHS England dashboard based on the data

from quarter four 2016/17. The Governing Body should note that in the

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Performance Report NHS Warrington CCG Governing Body Meeting 10

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latest cancer waiting times data (October 2017) the required target of

85% was achieved by both Warrington & Halton Hospitals NHS

Foundation Trust and NHS Warrington CCG. Warrington & Halton

Hospitals NHS Foundation Trust has improved cancer waiting times

performance as a whole in the last few months due to improvements in

tracking and escalation processes. There remain issues in some

tumour sites and internal meetings with Cancer Nurse Specialists,

Consultants and RTT Business Manager in the challenged areas to

review and improve processes. Warrington & Halton Hospitals NHS

Foundation Trust has recruited a new Lead Cancer Nurse (start date

probably March 2018) and will soon begin the process to recruit a new

Cancer Data Manager.

18. 122d - Cancer patient experience – This indicator is presented as a

score from 1-10. In the 2015 survey the CCG score was the same as

the national average (8.7) but this has decreased to 8.6 and is now in

the lowest quartile nationally. NHS Warrington CCG supported

Warrington & Halton Hospitals NHS Foundation Trust in instigating a

series of workshops for Cancer Nurse Specialists. At the September

workshop, Warrington & Halton Hospitals NHS Foundation Trust

reviewed the results and addressed the areas where improvements

can be made. An action plan has been developed and the CCG has

requested an update on the progress against this plan.

19. 125a and 125b - Choice in maternity services and experience of

maternity services – From the 2015 survey NHS Warrington CCG was

11th out of 12 CCGs in Cheshire and Merseyside for both indicators.

The 2016 survey has been completed and is expected to be published

in January 2018. NHS Warrington CCG has created a patient

information leaflet regarding choice in maternity services, which is now

routinely available.

20. 127b and 106a - Emergency admissions for urgent care sensitive

conditions / inequality of unplanned hospitalisation for ACS/UCS

(ambulatory care sensitive/urgent care sensitive) conditions - NHS

Warrington CCG is 10th out of 12 for the inequality measure and 8th

out of 12 for UCS admissions within Cheshire and Merseyside. A

significant proportion of the activity within this category is also within

the definition of Ambulatory Emergency Care (AEC) and therefore an

increase in admissions from April 16 not unexpected following the

implementation of the AEC pathway at Warrington & Halton Hospitals

NHS Foundation Trust. The AEC pathway includes a short admission

to hospital (less than 24 hours) as part of the appropriate management

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Performance Report NHS Warrington CCG Governing Body Meeting 10

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of certain conditions. This has been evidenced by the increased

proportion in zero length of stay activity within this patient cohort.

21. Internally NHS Warrington CCG has recently implemented a small

working group to identify any themes or trends in the admissions for the

conditions within these cohorts to identify actions which may impact on

the rate of emergency admission.

22. 127f - Population use of hospital beds following emergency admissions

– There has been a focus on the same day treatment model for urgent

care at Warrington & Halton Hospitals NHS Foundation Trust, aiming to

reduce the rate of emergency admissions. “Discharge to assess” and

“red and green” bed days methodologies have also been employed to

reduce emergency bed days. Between April and September 2017 the

total length of stay associated with emergency admissions at

Warrington & Halton Hospitals NHS Foundation Trust for NHS

Warrington CCG patients was lower than in the corresponding period in

the previous year by approximately 2% (local data extraction from

Secondary Uses Services (SUS)). This corresponds with an increased

proportion of zero length of stay admissions, in line with the same day

treatment model that has been adopted.

23. 164a - Effectiveness of working relationships in the local system - This

indicator is taken from the stakeholder 360 survey. An average score

from 0-100 is calculated for each CCG from all respondents. In

2015/16 the score was 64. In 2016/17 this reduced by 1.8 points to

62.5. The average change in score across all Cheshire and

Merseyside CCGs was a reduction of 2.2 points. There are actions in

place with primary care colleagues to support working relationships,

such as supporting Federation Leads and facilitating more effective

dialogue across the four federations regarding commissioning business

and Primary Care Service Development Managers are in post to

support the development of the Primary Care Clusters and the Local

Enhanced Service delivering the Warrington Brand.

New IAF Indicators

24. The indicators below are included in the framework for the first time. The requirements for each of the new measures will be confirmed to appropriate leads internally.

25. 123b – IAPT access - This indicator is included within the framework

for the first time but has always been included on internal monitoring

reports. The CCG performance in quarter two was below requirement.

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Performance Report NHS Warrington CCG Governing Body Meeting 10

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A workshop was held on 29th November with stakeholders to identify

ways in which access could be increased. The NHS England

dashboard contains performance from July 2017 but it should be noted

that the activity in November has increased.

26. 124c – Completeness of the GP learning disability register - This

indicator is intended to improve the coverage of GP learning disability

registers. This indicator will be measured annually from QOF but more

frequent local reporting should be possible to indicate the direction of

travel.

27. 131a – Percentage of NHS CHC full assessments taking place in an

acute hospital setting - For the Quality Premium there is a requirement

that more than 80% of all full NHS Continuing Healthcare assessments

are completed within 28 days and less than 15% of full NHS Continuing

Healthcare assessments take place in an acute hospital setting. The

latter of these indicators is now also included within the IAF. NHS

Warrington CCG has seen a notable reduction to 5% of assessments

taking place in an acute hospital setting in quarter two from 10% in

quarter one. It should be noted that the NHS England dashboard

(Appendix A) suggests that NHS Warrington CCG performance against

this indicator is in the lowest quartile. However this assertion has been

queried by NHS Warrington CCG as it appears that the rating of this

indicator has been done the wrong way around (low performance =

good performance but the dashboard seems to have inverted this).

28. 132a – Evidence that sepsis awareness raising amongst healthcare

professionals has been prioritised by the CCG - Evidence for this

indicator will be provided via an annual self-certification (towards the

end of the financial year) to be signed by the Accountable Officer and

Audit Chair. The requirements for this indicator include confirmation

that sepsis awareness raising and education on the use of National

Early Warning Score (NEWS) is included in the commissioning

priorities of the CCG and is included (or there is evidence of a planned

commitment to include) in service specifications and in any local

incentive schemes funded by the CCG, confirmation that Health

Education England resources around sepsis are referenced and used

and confirmation of the number of GP practices that have a sepsis lead

/ link. The requirements have been internally circulated within the CCG

to enable a baseline assessment to be conducted.

29. 166a – Compliance with statutory guidance on patient and public

participation in commissioning health and social care - This indicator

aims to evidence the implementation of the revised statutory guidance

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Performance Report NHS Warrington CCG Governing Body Meeting 10

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on patient and public participation in commissioning and fulfilling

statutory guidance. CCGs will be assessed based on the Annual

Report (16/17), and publically available information (Governing Body

papers, involvement webpages, engagement plan etc.). NHS England

undertook a desktop review in June 2017 of CCG’s work to engage

with the people and communities.

30. The NHS Warrington CCG assessment against the five domains within

the patient and community engagement indicator from the desk top

review is below:

31. The CCG is in the process of submitting evidence for further review

and assessment as it is felt that the assessment is not a true reflection

of patient and community engagement. The CCG’s Engagement,

Experience and Communications Strategy 2015-2018 and Duty to

Involve Engagement Report 2016-17 highlights a diverse range of

engagement activities within geographical areas, ‘hard to reach’

communities and communities protected under the Equality Act 2010.

The CCG had also implemented Equality Delivery Systems 2, with best

practice highlighting engagement with carers and people with learning

disabilities. It is believed that this supports the current assessment (as

outlined above).

32. The CCG has recognised the need to increase evidence of good

practice in patient and community engagement and is in the process of

reviewing the website in this respect. This review will also include

taking steps to ensure the various engagement methods and

approaches are clearly reported.

Pam Broadhead Chief Performance Officer 21st December 2017

Domain Rating and Grade

A. Governance 3 Outstanding

B. Annual Reporting 2 Good

C. Practice 2 Good

D. Feedback and evaluation 1 Requires improvement

E. Equality and health inequalities 1 Requires improvement

CCG Summary Dashboard

NHS Warrington CCG

Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend

R 102a % 10-11 classified overweight /obese2013/14 to

2015/1631.5% 4/11 75/207 R 121a High quality care - acute 17-18 Q1 63 4/11 43/207

103a Diabetes patients who achieved NICE targets2015-16 40.6% 6/11 69/207 R 121b High quality care - primary care 17-18 Q1 65 7/11 120/207

103b Attendance of structured education course2014 0.0% 11/11 205/207 R 121c High quality care - adult social care17-18 Q1 64 4/11 28/207

R 104a Injuries from falls in people 65yrs +16-17 Q4 3,051 11/11 206/207 122a Cancers diagnosed at early stage2015 51.0% 6/11 131/207

R 105b Personal health budgets 17-18 Q1 69 2/11 20/207 122b Cancer 62 days of referral to treatment16-17 Q4 76.4% 9/11 161/207

R 106a Inequality Chronic - ACS & UCSCs16-17 Q4 3,826 11/11 202/207 122c One-year survival from all cancers2014 71.3% 2/11 46/207

R 107a AMR: appropriate prescribing 2017 06 1.072 2/11 106/207 R 122d Cancer patient experience 2016 8.6 10/11 177/207

R 107b AMR: Broad spectrum prescribing2017 06 8.3% 7/11 82/207 R 123a IAPT recovery rate 2017 06 51.7% 6/11 99/207

108a Quality of life of carers (not available) R 123b IAPT Access 2017 07 2.8% 8/11 106/207

Sustainability Period CCG Peers England Trend R 123c EIP 2 week referral 2017 08 84.9% 5/11 54/207

R 141b In-year financial performance 17-18 Q1 Green #N/A #N/A 123d MH - CYP mental health (not available)

R 144a Utilisation of the NHS e-referral service2017 06 63.1% 8/11 75/207 123f MH - OAP (not available)

Leadership Period CCG Peers England Trend 123e MH - Crisis care and liaison (not available)

R 162a Probity and corporate governance17-18 Q1 Fully Compliant #N/A #N/A R 124a LD - reliance on specialist IP care17-18 Q1 66 5/11 141/207

163a Staff engagement index 2016 3.74 7/11 154/207 124b LD - annual health check 2015-16 36.4% 9/11 113/207

163b Progress against WRES 2016 0.07 3/11 19/207 124c Completeness of the GP learning disability register (not available)

164a Working relationship effectiveness16-17 62.50 8/11 165/207 R 125d Maternal smoking at delivery 17-18 Q1 7.4% 1/11 60/207

166a CCG compliance with standards of public and patient participation (not available) 125a Neonatal mortality and stillbirths2015 3.8 6/11 57/207

R 165a Quality of CCG leadership 17-18 Q1 Green #N/A #N/A 125b Experience of maternity services2015 75.2 11/11 186/207

Key 125c Choices in maternity services 2015 61.1 10/11 182/207

Worst quartile in England R 126a Dementia diagnosis rate 2017 08 71.9% 7/11 71/207

Best quartile in England 126b Dementia post diagnostic support2015-16 78.0% 9/11 131/207

Interquartile range R 127b Emergency admissions for UCS conditions16-17 Q4 3,444 11/11 195/207

R 127c A&E admission, transfer, discharge within 4 hours2017 09 91.2% 5/11 59/207

R 127e Delayed transfers of care per 100,000 population2017 08 12.9 6/11 120/207

R 127f Hospital bed use following emerg admission16-17 Q4 621.9 10/11 203/207

105c % of deaths with 3+ emergency admissions in last three months of life (not available)

R 128b Patient experience of GP services2017 86.3% 5/11 77/207

128c Primary care access (not available)

R 128d Primary care workforce 2017 03 0.93 6/11 144/207

R 129a 18 week RTT 2017 08 93.6% 4/11 17/207

130a 7 DS - achievement of standards (not available)

Requires Improvement

Note: There is no data for NHS Manchester CCG (14L) for the following indictors: 121a, 121b, 121c, 122c, 122d, 124a, 125b, 125c, 126b,

130a, 141b, 163a, 163b, 164a & 165a

2016/17 Year End Rating:

Agenda Item 004/18 Performance Report - Appendix 1

R 131a % NHS CHC assesments taking place in acute hospital setting16-17 Q4 10.8% 9/11 158/207

132a Sepsis awareness (not available)Agenda Item 004/18 Performance Report - Appendix 1