NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING … · 2020-07-08 · Page 1 of 4. NHS WIRRAL...

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING – A Formal Meeting

Tuesday 14th July 2020

Virtual Meeting

2.30pm – 5pm

AGENDA

Ref No.

No Time Item Action Papers

GB20-21/0006

1. 2.30pm PRELIMINARY BUSINESS/ADMINISTRATIVE ITEMS (Chair) 1.1 Welcome & Apologies for

Absence Dr Paula Cowan

1.2 Public Questions

1.3 Chair’s Announcements To Inform

1.4 Declarations of Interest

1.5 Minutes and Action Points of Last Formal Meeting

• 5th May 2020• 16th June 2020

(Accounts Sign Off)

• Action Points

To Approve

1.5 a WCCG Governing Body PUBL

1.5 b WCCG GB mins - accounts sign off 160

1.5 c GB Public Action Log - July.pdf

1.6 Matters Arising To Inform

GB20-21/0007

2. 2.45pm BUSINESS ITEMS

2.1 2.1.1 Strategic System Leader Overview on Covid-19 (Simon Banks)

2.1.2 Finance Report (including new Financial Regime) (Mark Chidgey)

To Inform/ Assure

To Approve

2.1.1 Strategic System Leader Overvi

2.1.2 Governing Body July 2020 Finance Pa

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Ref No.


2.1.3 Quality and

Safeguarding during Covid-19

(Lorna Quigley)

2.1.4 Covid-19 Primary Care/Corporate Overview

(Paul Edwards)

2.1.5 Governing Body Assurance Framework (Paul Edwards)

2.1.6 Covid-19 Clinical System Oversight (Dr Paula Cowan / Dr Simon Delaney)

2.1.7 Covid-19 Health & Care Cell Report (Graham Hodkinson /Nesta Hawker)

2.1.8 Second Phase Planning (Nesta Hawker)

2.1.9 Director of Commissioning – Performance Report during Covid-19

(Nesta Hawker)

To Inform/ Assure

To Inform/ Assure

To Discuss/ Approve

To Inform/ Assure

To Inform/ Assure

To Inform/ Assure

To Inform/ Assure

2.1.3 a Governing Body Cover Sheet QS

2.1.3 b Governing Body Quality Report J

2.1.4 a Gverning Body Cover Sheet Prim

2.1.4 b Governing Body Report Primary C

2.1.4 c Cover sheet - Corporate Affairs Rep

2.1.4 d Corporate Affairs Report - July 2

2.1.5 a AF Cover Sheet July 2020.docx

2.1.5 b AF July 2020 Governing Body narra

2.1.5 c Wirral CCG Assurance Framework

2.1.6 a Governing Body Cover Sheet MD

2.1.6 b GBMD7.20.docx

2.1.7 a Governing Body Cover Sheet - He

2.1.7 GB Report Health and Social Care

2.1.8 a Governing Body Cover Sheet 2nd

2.1.8 b Second phase GB July 2020.docx

2.1.9 a Director of Comm Governing Bod

2.1.9 b Governing Body Performance Re

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Ref No.


GB20-21/0008

3. 4.30pm RISK MANAGEMENT

3.1 Risk Register (Paul Edwards)

To Discuss / Approve 3.1 Risk Register GB

14.07.20.pdfGB20-21/0009

4. 4.45pm COMMITTEE MINUTES & LAY CHAIRS REPORTS 4.1

4.2

4.1.1. Finance Committee Chair’s Report (Lesley Doherty)

4.1.2. Primary Care Commissioning Committee Chair’s Report (Sylvia Cheater)

4.1.3. Quality and Performance Committee Chair’s Report (Ian Huntley)

Committee Meeting Minutes

• Finance CommitteeMinutes from April andMay 2020.

• Audit Committee Minutesfrom April 2020.

• Quality and PerformanceMinutes April and May2020.

To Inform/

Assure

To Inform/

Assure

To Inform/

Assure

To Note

To Note

To Note

4.1.1 Governing Body Finance Chair's Repor

4.1.2 PCCC Chairs Report 26th May for 1

4.1.3 QP Chairman's Report as at 26 Jun 20

4.2 a ratified finance com minutes 28.4.20.d

4.2 b ratified finance com minutes 26.5.20.d

4.2 b ratified Audit Committee minutes 2

4.2 d Ratified Quality Performance minutes

GB20-21/0010

5. 4.55pm ANY OTHER BUSINESS

Communications from this meeting

Date and Time of Next Meeting:

Tuesday 8th September 2020 (Formal), Virtually via MS Teams Please send any apologies to [email protected]

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4.2 d Ratified Quality Performance minutes

mailto:[email protected]

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Governing Body Meeting Attendees’ Guidance

Under the direction and guidance of the Chair, all members are responsible for ensuring that the meeting achieves its duties and runs effectively and smoothly. Before the meeting • Prepare for the meeting in good time by reviewing all reports (the amount of time allocated for each agenda item can be used to guide your preparation); • Submit any reports scheduled for consideration at least 10 working days before the meeting to the Governing Body Chair (using the standard report template); • Ensure your apologies are sent if you are unable to attend to the Governing Body Chair and meeting support. *some members may send a nominated representative who is sufficiently senior in order to talk through agenda papers in their absence, however, it is understood that deputies do not have voting or decision making authority. At the meeting • Arrive on time; • Mobile phones to be on silent as it is recognised that individuals may be on call; • Focus on the meeting at hand and not the next activity or on your emails; • Actively and constructively participate in the discussions; • Think about what you want to say before you speak; explain your ideas clearly and concisely and summarise if necessary; • Make sure your contributions are relevant and help move the meeting forward; • Respect the contributions of other members of the group and do not speak across others; • Ensure you understand the decisions, actions, ideas and issues agreed and to whom responsibility for them is allocated; • Accept corporate ownership of decisions made; • Do not use the meeting to highlight issues that are not on the agenda; • Re-group promptly after any breaks; • Take account of the Chair’s health, safety and fire announcements (fire exits, fire alarm testing, etc). Attendance • Members are expected to attend all meetings held each year. After the meeting • Follow up on actions; • Inform colleagues appropriately of the issues discussed. Standards • All documentation will be prepared using the standard Governing Body templates. A named person will oversee the administrative arrangements for each meeting; • Agenda and reports will be issued 7 days before the meeting; • An action schedule will be prepared and circulated to all members after the meeting; • The minutes will be available at the next meeting. Also under the guidance of the Chair, members are also responsible for the meeting’s compliance with relevant legislation and policies, up-to-date versions of which are available on the CCG website, or via the communications team.

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NHS WIRRAL CLINICAL COMMISSIONING GROUP

Governing Body Meeting Minutes of Meeting – Public Session

Tuesday 5th May 2020

Virtual Meeting 2.30pm-5pm

Present: Dr Paula Cowan (PC) (CHAIR) Chair Simon Banks (SB) Chief Officer Mark Chidgey (MC) Chief Financial Officer Nesta Hawker (NH) Director of Commissioning & Transformation Paul Edwards (PE) Director of Primary Care and Corporate Affairs Lorna Quigley (LQ) Director of Quality & Safety Alan Whittle (AW) Lay Member (Audit & Governance) Sylvia Cheater (SC) Lay Member (Patient Champion) Ian Huntley (IH) Lay Member (Quality & Outcomes) Dr Sian Stokes (SS) GP Lead – Long Term Conditions Dr Saket Jalan (SJ) GP Lead – Unplanned Care & Medicines Management Dr Lax Ariaraj (LA) GP Lead – Planned Care Dr Simon Delaney (SD) Medical Director Dr Bennett Quinn (BQ) Members Council Representative Julie Webster (JW) Director for Health and Wellbeing (DPH) In Attendance: Karen Duckworth (KD) Acting Senior Corporate Officer

Ref No. Minute Action

GB20-21/0001

Preliminary Business 1.1 Apologies for absence: Apologies were noted from Graham Hodkinson, Karen Prior and Lesley Doherty. 1.2 Comments/questions from members of the public None

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1.3 Chairs Announcements/Opening Remarks The Chair welcomed all attendees to the virtual meeting held via MS Teams and shared her sincere thanks to all staff across the organisation for adopting to the new ways of working and the strong response to Covid-19 pandemic. 1.4 Declarations of Interest The Chair reminded the Governing Body members of their obligations to declare any interest they may have on any items arising at that might conflict with the business of NHS Wirral Clinical Commissioning Group (CCG). There were no declarations of interest raised by the members present. The Conflicts of Interest Register is available either via the secretary to the Governing Body or the CCG website at the following link: https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff-listing-august-2017.pdf 1.5 Minutes & Action Points from previous meeting held on the 10th March 2020. Minutes The minutes of the previous meeting held on 10th March 2020 were reviewed by the members and were agreed to be a true and accurate record of the meeting, with one minor amendment to section 4.1 to include 95% to the A&E Performance target not being achieved. Action Points Actions are currently on hold due to COVID-19, however, it was agreed that action 63 could be closed. 1.6 Matters Arising None

GB20-21/0002

2.1 Business Items 2.1.1 Strategic System Leader Overview on Covid-19 SB updated members with an provided outlining the strategic Wirral health and care system response to COVID-19 and the high level the actions taken

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https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff-listing-august-2017.pdf


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by Wirral Health and Care Commissioning (WHCC)/ NHS Wirral Clinical Commissioning Group (CCG) to maintain business continuity and support the health and care system response. SB went on to advise that the enactment of Emergency Preparedness Resilience and Response (EPRR) protocols and the declaration of a Level 4 incident by the NHS provided the certainty of a command and control environment developed in line with Joint Emergency Services Interoperability Principles (JESIP). He went on to outline the establishment of various Incident Response arrangements with the CCG and ‘cells’ across the wider Wirral partnership to support the management of Covid-19, which are covered in detail in the paper. SB went on to advise of the need to now start thinking about recovery and the restoration of normal service provision from an organisational and Wirral health and care system perspective, including the return to commissioning activity whilst reviewing the lessons learned and benefits from new ways of working. 2.1.2 Emergency Budget for Covid-19 and New Financial Approval /

Governance Arrangements MC updated members on the proposed Emergency Budget for 2020/21, and it was noted that this replaces the “Operational and Financial Plan 2020/21” which would ordinarily be proposed to the Governing Body for approval before the start of a new financial year. The reason a full Operational and Financial Plan cannot be presented this year is that the CCG is following national guidance, as of 17th March 2020, to immediately suspend tactical contracting activities for core contracts, and to implement block contract payments (prescribed by NHSE) for NHS Trusts. MC advised that this proposed approach would enable the CCG to maintain financial probity, governance and value for money. The budget proposed to the CCG for 2020/21 is therefore an extraordinary and interim budget reflecting the CCG Governing Body responsibilities for: • Maintaining access to prioritised services. • Providing extra resources needed by the NHS and associated public

services to tackle the virus. • Ensuring that financial probity, governance and value for money in

delivering the above are maintained.

MC advised that the Finance elements of the Business Continuity Plan ensure that providers of care have the cash balances to rapidly redeploy and mobilise services as part of the COVID-19 plans and are able to resume normal

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service delivery following the COVID-19 pandemic, whilst all contract negotiations with Providers have been paused. MC went on to confirm that the proposed budget comprises four elements: • The core “Business as Usual” (BAU) allocation which, within standard

business rules, the CCG is required to operate and plan within. • An additional element of financial risks, in excess of confirmed allocations,

that the standard CCG operational plan would have planned to address through a combination of planning, negotiation, efficiency (QIPP) processes and serious consideration would have been given as to whether the CCG needed to operate with a deficit and associated recovery plan.

• Recognition that measures taken to deliver the 19/20 control total may result in additional non-recurrent expenditure in 2020/21.

• An additional element of extraordinary and exceptional costs which are anticipated to be recovered through funding from the national COVID-19 response plan.

MC drew members’ attention to Section 4 of the report highlighting that nationally it is anticipated that an additional £1.3bn will be spent by CCGs, and from this an estimate of £7.2m has been assumed for Wirral CCG and included within the budget. MC also highlighted that with regards to market management, the CCG will be reviewing those contracts that are due to expire in the next 12 months and will set out a recommendation and process for each contract so as to support stabilisation. This will include support to providers of health and care with a cash based approach. MC asked members to note the recommendations within the report to: • Understand the expenditure budget proposed, that the CCG is not enabled

to include a recovery or mitigation plan for the £30.2m and therefore the CCG will operate with a significant deficit whilst the current situation endures.

• Support for the approvals process for COVID-19 related expenditure and that this is likely to continue to require use of procurement waivers for significant values. These will be reported to the Audit Committee.

• Approve the proposed extraordinary budget 2020/21 • Confirm that the need to continue to operate under this extraordinary

budget will be reviewed by the Governing Body as a minimum at the end of each quarter.

LQ queried if the proposed budget had been discussed with the regulators. MC confirmed that the regulators have received a copy of the proposal and are fully aware.

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LQ queried the block payments made and if this will have an impact going forward in terms of commissioning activity. MC confirmed that the block payments have been made only during the COVID-19 period, but it is not clear has yet how long these arrangements will be in place. AW stated that this paper was reviewed and endorsed at the Finance Committee, with the recommendation for the Governing Body to support the proposal. SC commented that the paper presented to the Governing Body was clear and concise and, as a Lay Member, found it easy to understand. The Governing Body approved the proposed Extraordinary Budget and noted the key aspects of the report. 2.1.3 Covid-19 Primary Care Overview

PE updated members on the current measures that have been taken to ensure General Practices across Wirral remain resilient and in order continue to provide care to their patients. General Practices has moved swiftly to a total triage system (whether by phone or online), so as to minimise contact in line with government guidance on Covid-19. Some patients, however, will still require face-to-face consultations or home visits, and for this reason, 5 GP Hubs had been established to manage these patients. PE highlighted that the GP Hubs were set up quickly in order to assist General Practice resilience, but it is now time to assess these in the context of planning for the restoration of services as mentioned in SB’s report to ensure the right model is in place in the longer term.

In support of managing the Covid-19 pandemic, PE advised that the CCG has a daily meeting (‘Primary Care Cell’) with representatives of the two GP Federations, the Local Medical Committee (LMC), CCG Clinical Leaders and Medicines Management, in order to identify and resolve issues that are occurring in General Practice. PE went onto share that discussions have also been held with LMC around the re-thinking of how care is delivered on Wirral, learning the lessons from new ways of working and establishing a blue print for the future models of Primary Care provision. Members support this approach. LA also flagged that there are patients in deprived areas that would not have access to technology in order to have remote consultations with GPs. PE suggested that there is the need to work with the Third Sector and Council colleagues to help with supporting patients accessing technology. ACTION: NH / GH to review and ascertain what is currently available that could assist patients with technologies.

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2.1.4 Covid-19 Clinical System Oversight

PC updated members on the role and progress of the system Clinical Group since establishment on 17th March 2020, which was formed to facilitate senior clinical overview and input into Covid-19 management, which links with both Scientific and Technical Advisory Cell (STAC) and the Health & Care cell via Public Health and Local Authority. PC asked members to note the key messages in the report, highlighting the work to support Covid-19 from Wirral University Teaching Hospital NHS Foundation Trust, Wirral Community Health and Care Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, Hospices, Primary Care and Medicines Management. PC went on to flag the main on-going cross organisational issues which still remain availability Personal Protective Equipment (PPE). Access to staff testing has improved now that a local service at Bidston is in place. 2.1.5 Covid-19 Health & Care Cell Report NH updated members with the aims of the Health and Social Care System Tactical Cell, which meets daily, with representation from key stakeholders across the health and care system: • To Preserve Life • To Protect and Safeguard Vulnerable People • To Collaborate across the system to ensure Hospital flow and apply

COVID- 19 discharge requirements • To ensure that the care market, community services, primary care and the

voluntary sector are supported to respond to the challenge in meeting the above priorities.

NH advised that the key areas of focus are bed capacity, shielded/vulnerable patients, staffing, Personal Protective Equipment (PPE), testing, mental health and technology. NH highlighted a number of positive developments I these areas, including Wirral’s reduced Long Lengths of Stay that are now amongst the best in the North West, and subsequently Wirral has been asked to report on how this has been enabled in order to share with other areas.

2.1.6 Director of Commissioning – Performance Report during Covid-19 NH updated members that During COVID-19 the only performance measures that CCGs have been asked to continue monitoring and reporting are:

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• Accident & Emergency (A&E) • Ambulance • Cancer • Referral to Treatment (RTT)

A&E performance for January and February has deteriorated and continued to be below target trajectory of 90.5% primarily due to wider system flow pressures such as acute bed capacity and discharge pressures. Ambulance performance in both January and February, North West Ambulance Service, also deteriorated, failing to achieve most of the performance standards except the Category 1 and 4 90th Percentile targets. RTT 18 week wait for incomplete pathways standard was not met in January 2020 (80%) and February 2020 (79.9%). During this time a Wirral patient breached 52 week RTT standard at Countess of Chester Hospital NHS Foundation Trust, this breach has been raised with their lead commissioners, NHS Cheshire CCG, which is investigating, but has confirmed that this patient was seen in February 2020. Indicative data for March 2020 shows overall RTT performance is in decline due to reduced elective activity. Wirral University Teaching Hospital NHS Foundation Trust RTT team confirmed that they continue to be actively tracking and risk stratifying urgent and cancer patients while prioritising their action plan for responding to COVID-19 outbreak. Cancer Performance Indicators dropped in January 2020 and February 2020, in both months NHS Wirral CCG failed the 2 Week Wait Referral to First Assessment target due to a mixture of Patient Choice and Elective Capacity. There are currently actions in place and also support is being received from the Cancer Alliance. Improving (Increasing) Access to Psychological Therapies (IAPT) The January and February 2020 data shows that NHS Wirral CCG has consistently achieved 2 of the national standards for access to first treatment within 6 weeks and 18 weeks. The February 2020 access rate reduced again from January 2020 despite efforts to raise awareness. Although referrals have been seen to have reduced, it was noted that following COVID-19, there will be an expected increase to the service.

LQ went on to update members in relation to Mixed Sex Accommodation (MSA) breaches, which has a strong correlation with patient flow and the ability to timely access an appropriate bed. There is some evidence of more recent improvement; this may be due to the changes in reporting definitions that were implemented from January 2020. However, it was noted that the ability to maintain single sex accommodation during the national pandemic is increasingly challenged and NHS England and Improvement have identified MSA breaches as

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one of the measures that will suspended during this time. LQ also provided an updated regarding Healthcare Acquired Infections (HCAI): Methicillin-Resistant Staphylococcus Aureus (MRSA) There has been an increase in cases during December 2019 and February 2020. The first 2 cases have had full post infection review completed and identified some learning points but no lapses in care that led to the infections. The further post infection reviews have been halted during the pandemic response but will need to be explored thoroughly during recovery. C-Difficile infections are within tolerance. During Quarter 3 and early Quarter 4 the HCAI review meetings between the systems presented robust challenge and indicated key areas of focus for on-going improvement. These system discussions have been deferred during the COVID-19 pandemic due to Infection Prevention and Control (IPC) staff resource but will be reinstated during the recovery stage. E-Coli rates of infection have demonstrated a slight reduction over the year. One significant factor in relation to this rate of infection is appropriate antimicrobial prescribing and this continues to be tackled through the AntiMicrobial Resistance (AMR) group. BQ highlighted that although the IAPT service has seen a drop in referrals, the GPs are seeing an increase in mental health cases. NH will raise this with the IAPT provider. 2.1.7 Quality and Safeguarding during Covid-19 LQ updated members with regards to the quality measures which have been suspended in line with NHS England/Improvement’s guidance, Reducing the Burden Releasing Capacity, a number of quality metrics have been suspended, these include: • Staff Friends and Family Test • Learning from Patient Safety • Learning from Deaths • Mixed Sex Accommodation • Quality accounts and Quality reporting

LQ confirmed that all quality schedules have been reviewed and shared with providers, highlighting only the key assurance items that are identified as essential and proportionate whilst undergoing the pandemic response. LQ update that Safeguarding is still maintaining its statutory requirements and there have been no significant changes to services.

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LQ confirmed that Medicines Management priorities have been reviewed with system partners and they will change/reshape as necessary, with the next review round concentrating on Care Homes. LQ went on to advise that there is also an ‘out of meeting’ approvals process in place for policies that are ratified at the Quality and Performance Committee, especially with the medicines management policies, to ensure rapid deployment during the current pandemic. LQ advised members with regards to the changes in Continuing Health Care (CHC)/Complex Care Hospital Discharge Service Requirements as advised by NHS England. LQ Updated regarding the CHC service delivery model and transfer process, as Wirral Health and Care Commissioning (WHCC) are in continued discussions with Cheshire and Wirral Partnership NHS Foundation Trust (CWP) as the proposed new host employer and provider of the service. It is anticipated that WHCC will employ the CHC and Complex Care team until a successful transfer to CWP is achieved which is currently planned for May/June 2020. LQ advised that the Care Quality Commission (CQC) Report have now published their report following the inspection of Wirral University Teaching Hospital NHS Foundation Trust in November 2019. The trust received an overall rating of Requires Improvement, which is the same rating as May 2018. LQ updated on Independent Investigation into One to One Maternity Services. AW queried the timescales for this and LQ advised that it was initially thought this would start on 1st April 2020, however, due to COVID-19, a hybrid approach is being undertaken, so that documents previously received are currently being reviewed and post COVID-19, service interviews will take place.

GB20-21/0003

3.1 Risk Register PE updated members with regards to the current risks and advised members that all risks have been reviewed and controls have been updated following the Quality and Performance Meeting. However, 3 of the risks need further updates following the Governing Body meeting: 19/20/F – Business Continuity Plan remains resilient 19/20/G – Emergency Budget now approved 19/20/H – Updated to include 2nd phase of Covid-19 with a focus on restoration of services, in a phased and measured way Members approved the updated risk register and supported the amendments

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set out.

GB20-21/0004

4.1.1 Audit Committee’s Chair Report during Covid-19 AW updated members of the report by PE around the arrangements the CCG had put in place to support the COVID-19 response, and that the Committee was highly assured as to the robustness of these arrangements and the overall response. AW advised that MC had presented an update to assure the Committee of compliance with an assessment framework issued by the Healthcare Finance Management Association (HFMA). AW also advised that the Head of Internal Audit Opinion which informs the Annual Governance Statement which is included within the Annual Report. The committee approved the HOIAO report, noting and accepting the assessment of Moderate Assurance. It was also noted that there had been clear evidence of improvement and only just missed the Substantial Assurance assessment rating. AW confirmed that all the standards had been met within the Counter Fraud Specialist Report. AW also highlighted that the Data Security and Protection Toolkit was completed by the end of March deadline, however, the CCG has opted to re-submit an updated version of the toolkit by the end of September. Members noted the Chair’s reports and no comments were made. 4.1.2 Quality and Performance Committee Chair’s Report IH gave a verbal update to members highlighting the activities of the February and March committees. IH went on to advise Covid-19 Operating Principles to be adopted for the committee which had been agreed at the March meeting:

• Ensure that we do not add to the pressure felt by those dealing with the Covid-19 Pandemic.

• Identify whether there are any novel ways in which we, as a committee, can assist those dealing with the Covid-19 Pandemic or its consequences.

• Continue with the routine scrutiny of those areas that are largely unaffected by the Covid-19 Pandemic.

• Assist with gathering any ‘lessons learned’ to enable the CCG and wider NHS to identify ways in which to cope better with any

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subsequent pandemic. • Passively monitor, where possible, those services affected by Covid-19

with a view to gradually resuming routine, active scrutiny as the pandemic subsides.

IH outlined various other updates from the meeting, which will be circulated to members in written report following today’s Governing Body Members noted the Chair’s report and endorsed the Operating Principles set out. 4.2 Committee Meeting Minutes Members noted the following ratified minutes:

• Quality and Performance Minutes February 2020.

• Finance Committee Minutes from February 2020.

• Audit Committee Minutes from January 2020.

GB20-21/0005

Any Other Business None

Date and Time of Next Formal Meeting (Public) Date and time of next public meeting: Tuesday 14th July 2019, 2.30pm – 5pm, The Council Chamber, Birkenhead Town Hall. Please forward any apologies to [email protected]

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NHS WIRRAL CLINICAL COMMISSIONING GROUP Governing Body Board Meeting

Accounts Sign Off Minutes of Meeting

Tuesday 16th June 2020 @ 2pm Virtual Meeting via MS Teams

Present: Dr Paula Cowan (PC) (CHAIR) Chair Simon Banks (SB) Chief Officer Mark Chidgey (MC) Chief Financial Officer Nesta Hawker (NH) Director of Commissioning & Transformation Paul Edwards (PE) Director of Primary Care and Corporate Affairs Lorna Quigley (LQ) Director of Quality & Safety Alan Whittle (AW) Lay Member (Audit & Governance) Sylvia Cheater (SC) Lay Member (Patient Champion) Ian Huntley (IH) Lay Member (Quality & Outcomes) Dr Sian Stokes (SS) GP Lead – Long Term Conditions Dr Saket Jalan (SJ) GP Lead – Unplanned Care & Medicines Management Dr Lax Ariaraj (LA) GP Lead – Planned Care Dr Simon Delaney (SD) Medical Director Dr Bennett Quinn (BQ) Members Council Representative Lesley Doherty (LD) Registered Nurse Julie Webster (JW) Director of Public Health In Attendance: Karen Duckworth (KD) Acting Senior Corporate Officer Claire Shelley (CS) Head of Financial Services Ken Jones (KJ) Deputy Chief Financial Officer Jon Roberts (JR) Grant Thornton Helen Stevenson (HS) Grant Thornton Laura Leadsom (LL) Corporate Affairs Manager


GBAASO20-21/01 1. Preliminary Business

1.1 Apologies for absence: Apologies were noted from Karen Prior and Graham Hodkinson. PC welcomed everyone to the Governing Body Meeting convened to approve the Annual Report, Annual Governance Statement and Annual Accounts.

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GBAASO20-21/02 2. Business Items

2.1 Draft Annual Report / Annual Governance Statement and Draft Financial Statements PE introduced the Annual Report and Annual Governance Statement to the Governing Body. PE thanked all CCG staff who had helped produce the documents and the Audit Committee and Governing Body Members who had commented during the development of the papers. He particularly commended staff who had taken on additional duties amidst the current pandemic conditions, but still managed to deliver the papers today on time and to a very high standard. Whilst noting the many positive areas the CCG has reported on, PE drew members’ particular attention to the Key Strategic Developments section of the Annual Report. This section highlights the many service changes that had directly improved patient care and demonstrates the real value in the CCG’s work. PE then handed over to SB, who talked members through the Annual Governance Statement, highlighting the strong internal control systems the CCG has in place and how they remained resilient throughout the Covid-19 pandemic. MC then introduced the Financial Statements to the Governing Body. MC advised that the allocation for Wirral was £565.9m and as at year-end the CCG was reporting a deficit position of £13.9m. There had been an underspend on running costs, which had been reinvested into commissioning clinical services. MC went on to advise that the CCG achieved a Better Payments standard of 99.93% against a 95% target. MC thanked the Grant Thornton team for completing the audit in challenging circumstances. CS went on to update in more detail the Financial Statements to the Governing Body and explained the key primary statements. MC thanked CS for leading on the accounts process. AW reported that the Annual Report, Annual Governance Statement and the Financial Statements had been reviewed by the Audit Committee that morning and commended them for approval by Governing Body. AW commented that the Audit Findings Report was balance and fair. Governing Body approved the Annual Report, the Annual Governance Statement and Financial Statements on this basis.

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2.2 Draft External Audit Findings Report JR presented the draft Audit Findings Report, which had also been discussed in detail at the Audit Committee earlier that day. JR reflected on the technical and logistical impact of working through the pandemic, but stressed that constructive engagement had taken place between Grant Thornton and the CCG throughout using remote working technology and the process had ultimately worked well. The Audit Findings Report included an unqualified opinion on the accuracy of the financial statements and accounts. It was noted, however, that a qualified ‘except for’ Value for Money opinion has been given, to reflect the CCG’s risks associated with delivering a sustainable financial position. The deficit position will result in a Section 30 letter being issued to the Secretary of State by Grant Thornton, as is required of them. JR stated final checks are taking place over the next week, but no significant changes are expected and it was anticipated that everything would be ready for final submission on 23rd June 2020. HS went on to draw members’ attention to the Audit Adjustments section of the report, highlighting the prescribing accrual adjustments. HS also advised that some control weaknesses within third party providers has also been reported to the CCG as part of the governance process. AW confirmed that the Audit Committee have picked up an action for this and will be reviewing and the control systems with the third-party providers concerned. Governing Body members received and accepted the External Audit Findings Report. 2.3 Draft Letter of Representation SB confirmed that the Letter of Representation confirmed that Governing Body were assured that the financial statements had been present a true and fair view in accordance with Financial Reporting Standards. Governing Body members noted and supported the letter of representation, after which it was signed by SB and PC.

GBAASO20-21/03 3.1 Any Other Business

PC gave her personal thanks to all staff in the production of the reports, with specific mention to the Finance and Corporate Teams and also took the opportunity to thank KJ for his support and efforts as Deputy Chief Finance Officer and wished him well in his new role at Aintree Hospital.

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Item NoDate

Opened

Agenda

Item NoRef no Item of discussion

Action Points Responsib

ilityDate Due Status

Status and progress (including updates) Closure

dateOutcome of action

Requires

review?

Date of

review

62 10.03.20 4.1 GB19-20/0049

Director of

Commissioning

Report

NH to explore if there are any impacts to

patients waiting for robotic operations due to

capacity issues

NH 14.04.20 On Hold On hold due to Covid-19

63 10.03.20 4.1 GB19-20/0049

Director of

Commissioning

Report

NH to obtain a system report to show impacts of

the ECIST system for stranded patients NH 14.04.20 closed 05.05.20: Closure agreed 05.05.20

65 05.05.20 2.1.3 GB20-21/0002

Covid-19 Primary

Care Overview

NH / GH to review and ascertain what is

currently available that could assist patients with

technologies (in order to have remote

consultations with GPs)

NH / GH 14.07.20 Open

GOVERNING BODY BOARD - MEETINGS ACTION LOG

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD REPORT

Risk Please indicate High Medium Yes Low

STRATEGIC SYSTEM LEADER OVERVIEW ON COVID-19

Agenda Item: 2.1.1 Reference GB20-21/0007 Public / Private Public Meeting Date 14th July 2020 Lead Officer/Author of paper

Simon Banks, Chief Officer and Accountable Emergency Officer, NHS Wirral Clinical Commissioning Group (CCG) and Wirral Health and Care Commissioning (WHCC) and Strategic Commander COVID-19 Response, Wirral Health and Care System.

Contributors To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This paper provides an update on the strategic Wirral health and care

system response to COVID-19. It describes at a high level the actions taken by Wirral Health and Care Commissioning (WHCC)/ NHS Wirral Clinical Commissioning Group (CCG) to maintain business continuity and support the health and care system response. It seeks to provide assurance that all appropriate measures have been taken to maintain the effective functioning of the health and care system and of WHCC/NHS Wirral CCG as part of that system. The paper links to other reports on the agenda that give more detail on our response. The paper should be read in conjunction with the reports shared at the last public Governing Body on 5th May 2020.

Recommendations The Governing Body is asked to: • Note the report.

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Detail of Risk Description

COVID-19 remains a significant risk to the health and safety of the whole population of Wirral. The enactment of Emergency Preparedness Resilience and Response (EPRR) protocols and the declaration of a Level 4 incident by the NHS provide the certainty of a command and control environment. The business continuity plans of WHCC/NHS Wirral CCG have also been mobilised and have to date demonstrated significant resilience. The challenge for the health and care system is threefold (a) continuing to provide services in response to a pandemic, (b) restoring services in an operating environment where COVID-19 is present and (c) preparing for surges in activity due to winter pressures and/or further outbreaks of COVID-19.

Clinical engagement taken place Y Patient and public involvement taken place N Equality Analysis/Impact Assessment completed N Quality Impact Assessment N

Strategic Themes Working as One, Acting as One – we will work together with all partners for the benefit of the people of Wirral.

Y

Listening to the views of local people – we are committed to working with local people to shape the health and care in Wirral.

Y

Improving the health of local communities and people – Wirral has many diverse communities and needs. We recognise this diversity and will help people live healthier lives, wherever they live.

Y

Caring for local people in the longer term – we will focus on having high quality and safe services, with the best staff to support the future as well as the present.

Y

Getting the most out of what we have to spend – we will always seek to get the best value out of the money we receive.

Y

Governance route prior to Governing Body

Meeting Date Objective/Outcome

CCG Governing Body 5th May 2020 Governing Body noted the report. Quality and Performance Committee

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Finance Committee Audit Committee Remuneration Committee Health and Wellbeing Board Business Management Group

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Strategic System Leader Overview on COVID-19 1. Background 1.1 On 31st December 2019, the World Health Organisation (WHO) was informed of a

cluster of cases of pneumonia of unknown cause detected in Wuhan, Hubei Province, China. On 12th January 2020 it was announced by WHO that a novel coronavirus had been identified in samples obtained from cases and that initial analysis of virus genetic sequences suggested that this was the cause of the outbreak. On 11th February 2020 this virus was named by WHO as SARS-CoV-2 and the associated disease as COVID-19. On 11th March 2020 WHO labelled the outbreak as pandemic. A pandemic occurs when a new virus emerges and spreads around the world, and most people do not have immunity.

1.2 Coronaviruses are a large family of viruses which may cause illness in animals or

humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). The most recently discovered coronavirus causes coronavirus disease COVID-19.

1.3 The most common symptoms of COVID-19 are fever, dry cough, and tiredness. Other

symptoms that are less common and may affect some patients include aches and pains, nasal congestion, headache, conjunctivitis, sore throat, diarrhoea, loss of taste or smell or a rash on skin or discoloration of fingers or toes. These symptoms are usually mild and begin gradually. Some people become infected but only have very mild symptoms or are asymptomatic. Most people (about 80%) recover from the disease without needing hospital treatment. Around 1 out of every 5 people who gets COVID-19 becomes seriously ill and develops difficulty breathing. Older people, and those with underlying medical problems like high blood pressure, heart and lung problems, diabetes, or cancer, are at higher risk of developing serious illness. However, anyone can catch COVID-19 and become seriously ill. People of all ages who experience fever and/or cough associated with difficulty breathing/shortness of breath, chest pain/pressure, or loss of speech or movement should seek medical attention immediately. If possible, it is recommended to call the health care provider or facility first, so the patient can be directed to the right clinic.

1.4 People can catch COVID-19 from others who have the virus. The disease spreads

primarily from person to person through small droplets from the nose or mouth, which are expelled when a person with COVID-19 coughs, sneezes, or speaks. These droplets are relatively heavy, do not travel far and quickly sink to the ground. People can catch COVID-19 if they breathe in these droplets from a person infected with the virus. This is why it is important to maintain a distance from others. These droplets can land on objects and surfaces around the person such as tables,

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doorknobs and handrails. People can become infected by touching these objects or surfaces, then touching their eyes, nose or mouth. This is why it is important to wash your hands regularly with soap and water or clean with alcohol-based hand rub.

1.5 More information on COVID-19 can be found at https://www.gov.uk/coronavirus and

https://www.nhs.uk/conditions/coronavirus-covid-19/ 1.6 This paper provides an update on the strategic Wirral health and care system response

to COVID-19. It describes at a high level the actions taken by Wirral Health and Care Commissioning (WHCC)/ NHS Wirral Clinical Commissioning Group (CCG) to maintain business continuity and support the health and care system response. It seeks to provide assurance that all appropriate measures have been taken to maintain the effective functioning of the health and care system and of WHCC/NHS Wirral CCG as part of that system. The paper links to other reports on the agenda that give more detail on our response. The paper should be read in conjunction with the reports shared at the last public Governing Body on 5th May 2020.

2. System Strategic Response to COVID-19 2.1 On 2nd March 2020 at 1815 hours, in response to spread of COVID-19 across the

world, the NHS declared a Level 4 incident. NHS England and NHS Improvement established an Incident Management Team (National) (IMT- N) with an operational Incident Coordination Centre established 7 days a week, working closely with the Department of Health and Social Care (DHSC), Public Health England (PHE) and other government departments. All NHS Regions also established an operational COVID-19 Incident Coordination Centre to the same hours working with the national team and their NHS local organisations, Clinical Commissioning Groups (CCGs), other health care providers and Local Resilience Forums.

2.2 The declaration of a Level 4 incident placed the NHS in a “command and control”

environment through which all activity is directed from the IMT-N through regional structures to individual organisations. All organisations within the NHS have been required to establish their own incident management approaches and teams and put into place business continuity arrangements. They have also been required to respond to directions, not guidance but “must do” actions, through the “command and control” mechanisms in regard to all aspects of their business including governance, service delivery, supply chain management and clinical standards. All the guidance to the NHS can be found at https://www.england.nhs.uk/coronavirus/.

2.3 The paper presented to Governing Body on 5th May 2020 set out how the Wirral

system has organised itself to respond to COVID-19. The arrangements set out in that paper remain in place and will do so for the duration of this incident. There are three areas of focus within these arrangements:

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https://www.gov.uk/coronavirus

https://www.nhs.uk/conditions/coronavirus-covid-19/

https://www.england.nhs.uk/coronavirus/


a. continuing to provide services in response to a pandemic, b. restoring services in an operating environment where COVID-19 is present, and c. preparing for surges in activity due to winter pressures and/or further outbreaks

of COVID-19. 2.4 On 29th April 2020 the NHS Chief Executive, Simon Stevens, and the NHS Chief

Operating Officer, Amanda Pritchard, set out the second phase of the NHS response to COVID-19. This letter set out expectations of health and care services in regard to the three areas of focus set out in 2.3 above. This letter can be found at https://www.england.nhs.uk/coronavirus/publication/second-phase-of-nhs-response-to-covid-19-letter-from-simon-stevens-and-amanda-pritchard/. The key points from the letter were that:

• The NHS will continue to need capacity to looking after COVID-19 positive patients,

although h hopefully in decreasing numbers. • The pressure on many of our staff will remain unprecedented, and they will need

enhanced and active support from their NHS employers to ensure their wellbeing and safety.

• We are going to see increased demand for Covid19 aftercare and support in community health services, primary care, and mental health.

• The NHS will continue to partner with local authorities and Local Resilience Forums (LRFs) in providing mutual aid with our colleagues in social care, including care homes.

• Preparations need to be made for a rebound in emergency demand, so the NHS must retain the demonstrated ability to quickly repurpose and ‘surge’ capacity locally and regionally, should it be needed again.

• All NHS local systems and organisations working with regional colleagues have to fully step up non-Covid19 urgent services. This needs to be a safe restart with full attention to infection prevention and control as the guiding principle.

• All systems should plan for further capacity for at least some routine non-urgent elective care.

• We should also take this opportunity to ‘lock in’ beneficial changes that have been brought about in recent weeks. This includes backing local initiative and flexibility; enhanced local system working; strong clinical leadership; flexible and remote working where appropriate; and rapid scaling of new technology-enabled service delivery options such as digital consultations.

2.5 This letter has been followed by a range of guidance to support the implementation of

the second phase of the NHS response. The Health and Social Care Cell is working with all partners to ensure that the Wirral system responds to these expectations and requirements and aligns these to Wirral Council, Merseyside LRF and NHS command and control approaches to ensure continuity with Cheshire and Merseyside, regional and national requirements.

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https://www.england.nhs.uk/coronavirus/publication/second-phase-of-nhs-response-to-covid-19-letter-from-simon-stevens-and-amanda-pritchard/

https://www.england.nhs.uk/coronavirus/publication/second-phase-of-nhs-response-to-covid-19-letter-from-simon-stevens-and-amanda-pritchard/


2.6 At the time of writing preparations are being made for the third phase of the response

to COVID-19. This will continue to be shaped by national directions that will be delivered through regional and Cheshire and Merseyside command and control structures. Within these arrangements Wirral is viewed as a “place” and a distinct planning footprint, so our local response mechanisms will remain in place. In engaging with the third phase we will continue to ensure that the needs of the Wirral population are take into account and we are clear on the legacy issues that will need to be addressed when we emerge from the COVID-19 major incident.

3. Organisational Response 3.1 The daily COVID-19 Executive Management Team (EMT continues to meet and will do

so through the duration of the Level 4 incident. This meeting ensures that there is daily control over the business of the organisation and enables rapid but considered decision making in a fast changing operating environment. This mechanism also ensures that the governance arrangements of the CCG are adhered to. Due to these arrangements, at the time of writing, the CCG has not had to invoke any emergency powers or make changes to decision making and governance processes and procedures.

3.2 NHS Wirral CCG has put in place processes to review on a case by case basis whether competitive tendering processes need to be waived. This is in accordance with procurement law and as set out in the Cabinet Office’s Procurement Policy Notice – Responding to COVID-19 (Information Note PPN 01/20 March 2020). In accordance with the CCGs constitution, the register of waivers is reported to the Audit Committee.

3.3 The business continuity arrangements of the organisation were enacted on 3rd March 2020. All staff are able to work remotely and we have put in place mechanisms to support them in doing so. We will continue to take account of the advice from Her Majesty’s Government in regard to workforce wellbeing, safety, working patterns and environment. We are working with other tenants and the University of Chester as our landlord to explore when and how Marriss House can be reopened.

4. Conclusions and Recommendations 4.1 COVID-19 remains a significant risk to the health and safety of the whole population of

Wirral. The enactment of Emergency Preparedness Resilience and Response (EPRR) protocols and the declaration of a Level 4 incident by the NHS provide the certainty of a command and control environment. The business continuity plans of WHCC/NHS Wirral CCG have also been mobilised and have to date demonstrated significant resilience. The challenge for the health and care system is threefold (a) continuing to provide services in response to a pandemic, (b) restoring services in an operating environment where COVID-19 is present and (c) preparing for surges in activity due to winter pressures and/or further outbreaks of COVID-19.

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4.2 This paper has updated the Governing Body on the strategic Wirral health and care

system response to COVID-19. It has described at a high level the actions taken by WHCC/ NHS Wirral CCG to maintain business continuity and support the health and care system response. It has provided assurance that all appropriate measures continue to be in place to maintain the effective functioning of the health and care system and of WHCC/NHS Wirral CCG as part of that system.

4.3 It is recommended that the Governing Body notes this report.

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FINANCE REPORT TO THE CCG GOVERNING BODY – MAY 2020 (MONTH 2)


Mark Chidgey, Chief Finance Officer

Contributors Louise Morris – Deputy Chief Finance Office Emma Edwards – Senior Planning & Reporting Accountant

To Approve Yes To Inform Yes To Assure Yes To Endorse Executive Summary As part of the Covid-19 response plan NHSE/I has reissued CCG allocations

and amended the finance regime that CCGs and NHS Trusts work within. This report confirms:-

• The CCG risks to delivery of the national financial performance standards.

• Changes that have been made to the NHS CCG Finance regime and seeks Governing Body approval for adoption of a revised, mandated budget.

• The key variances as at Month 2 against the nationally mandated budget.

Recommendations The Governing Body is asked to: 1. Approve the adoption of the nationally mandated budget for the

period April 2020 to July 2020 and to note that allocations and budgets for the period August 2020 to March 2021 are yet to be confirmed.

2. Note that the Strategic Budget approved by the CCG Governing Body in May remains part of the overall system of control and will continue to inform management decisions.

3. Note that for M2 (actual) and M4 (forecast) the CCG is reporting adverse variances to plan of £3.222m and £6.022m respectively.

4. Note that the CCG is anticipating retrospective allocations in relation to these adverse variances but should these not be approved then the CCG would move back into deficit.

5. Approve sign up by Wirral CCG to the nationally led scheme thereby enabling business continuity for Wirral General Practice and the CCG to MSOffice products.

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Risk Please indicate Detail of Risk Description

High Yes Medium Low Yes

• That the CCG operates within it’s notified cash allocations (Low).

• That the CCG is able to achieve the break even duty expected within the new finance regime, including the delegated budget for Primary Care (High).

Clinical engagement taken place N Patient and public involvement taken place N Equality Analysis/Impact Assessment completed N Quality Impact Assessment N


Y


Y


Y


Y


Y



CCG Governing Body Quality and Performance Committee Finance Committee 30th June 2020 Recommendations Approved Audit Committee Remuneration Committee Health and Wellbeing Board Business Management Group

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD REPORT CFO Report to the Governing Body including Financial Position as at May 2020. 1. Introduction 1.1 The CCG focus remains on the Wirral system CV-19 response plan and this includes

enabling access for the Wirral population to urgent and priority services unrelated to CV-19. From a financial perspective there have been revisions to the level of resources we receive and of our prioritisation for the deployment of these resources. It has also meant working within a changed finance regime which has a continued focus on achieving break-even duty and with the ability for costs of “reasonable” adverse variances to be retrospectively recovered.

1.2 Throughout this period our fiduciary duties and maintenance of high standards of governance and financial control remain. The CCG is therefore continuing to monitor ourselves against the key national financial deliverables that are risk assessed below. Where relevant exception reports are included within the relevant sections of the report below. Table 1: Statutory Duty and Performance Targets

1.3 Note that whereas the QIPP target has been confirmed as suspended, the guidance on

the Mental Health Financial Performance Target is still awaited. Therefore, where the CCG is committed to a specific investment in Mental Health, the investment is continuing; where a decision is yet to be made, national guidance is awaited before proceeding with business case investment decisions.

2 Budgetary Changes

2.1 Following recommendation by the CFO to the CCG Finance Committee, the CCG

Governing Body approved the Strategic Budget at the May 2020 meeting. This Strategic budget was adopted in exceptional circumstances, whereby planning, financial and contracting processes had been suspended nationally. Subsequent to this suspension NHSE/I replaced the contracting process with a series of mandated block contract payments from CCGs to NHS Trusts.

Area Statutory Duty / Performance Target PerformanceForecast

M4

Revenue Not to exceed revenue resource allocation.

Net Risk (links to revenue above) All risk to be fully mitigated

Running Costs Not to exceed running cost allocation.

Capital Not to exceed capital resource allocation (No Capital Received).

Cash Operate within the maximum drawdown limit.

Business Conduct Comply with Better Payment Practices Code.

QIPP QIPP Targets suspended.

Mental Health Financial Performance Target National guidance awaited.

Breakeven Duty

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2.2 During May NHSEI published new CCG allocations and

an associated mandated budget for each CCG. The Finance Committee has considered and recommends that the CCG now formally transitions to the nationally mandated allocation and budgets.

2.3 The mandated budget will be used within the finance ledger and for all operational reporting. It is proposed that the Strategic Budget is maintained as a key element of addressing the recurrent challenges of the CCG and Wirral system and for informing associated management decisions.

2.4 The table and notes attached as Appendix 1 show the key differences between the Strategic and Mandated budgets. Because CCG allocations are yet to be issued for the period August 2020 to March 2021, comparison is only possible for the April 2020 to July 2020.

2.5 In summary the CCG has received additional (prospective) allocation that recognises in part a level of recurrent deficit and also reflects increased payments to NHS Trusts through the mandated block payments.

2.6 The mandated budget includes the prospective allocation which is assumed to be sufficient to deliver a breakeven position. Where this is not the case, for example because of increased costs of CV-19 then CCGs can assert that the variance is “reasonable” and seek a retrospective increase in allocation. The CCG analysis of reasonable variances is included within section 3 of this report below.

3 Achievement of Breakeven duty and associated variances to budget at Month 2

3.1 The focus on achieving a breakeven position both within the reporting period and

recurrently remains. Under the revised financial regime and as stated above, where the CCG has an adverse variance that is deemed “reasonable”, then NHSE/I has committed to providing a retrospective allocation.

3.2 For the two month period ending May 2020, the CCG has reported an adverse variance to plan of £3.222m and is forecasting that this will increase to £6.022m by the end of July 2020. An analysis of these variances both by budget category and more importantly by the financial driver of the variance is detailed within Appendix 2.

3.3 From Appendix 2 there are a small number of programmes and issues that can be shown to be driving the CCGs adverse variance to plan. These are:- CV19 Response Plan A full analysis of CCG expenditure is attached as appendix 3. Within this and in accordance with national policy, the CCG has invested additional resources to suspend CHC assessment and enable the new nationally defined discharge pathways from the acute sector. Similarly General Practice is operating under a new model of care and the CCG has invested in establishing GP hubs within each of the Primary Care Network locations.

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By the end of July the CCG is forecasting to have spent an additional £4.422m on the CV19 response of which £0.400m is funded from within Extended Access and therefore the associated underspend will be used as a funding source. It is asserted that this meets the criteria of “reasonable” variance. FNC Nationally Agreed uplifts NHSE/I announced two uplifts to Funded Nursing Care payments. The first is a retrospective increase to the 2019/20 rate and the second is then added as an increase for 2020/21. The CCG has paid both increases to providers in full but is yet to receive confirmation of the allocation relating to the retrospective increase. The cost to the CCG of this increase is c£0.6m and it is asserted that this is a “reasonable” variance. Prescribing 2019/20 The CCG included an estimate for 2 months (February and March) prescribing expenditure within the finalised 2019/20 accounts. The subsequent final figures were £0.4m above the accrued level. It is thought that is a consequence of individuals’ CV-19 preparations as we went into lockdown, for example increased repeat prescriptions for asthma inhalers. At this stage the CCG has not received any information on prescribing levels for the period April and May, therefore we have used the nationally assumed expenditure levels upon which the budget set. Should this prove to be an under-estimate then the prescribing variance will increase in future months. It is asserted that the 2019/20 adverse variance is linked to CV-19 and therefore “reasonable”. Healthy Wirral Commitments Within the CCGs original plan was a 0.5% commitment to fund 1 Cheshire and Mersey Partnership running costs 0.1%. 2 Cheshire and Mersey Transformation schemes 0.2%. 3 Healthy Wirral Partnership programme infrastructure and schemes 0.2%. The basis of the revised allocations means that the majority of the funding for the above has been removed from the CCG baseline and it is unclear where responsibility for funding elements (1) and (2) lies. The CCG is prudently continuing to report all of the forecast expenditure within our position until we receive clarification as to the national approach. This will lead to an adverse variance of £1.0m by month 4 and it is asserted that this should be considered a reasonable variance.

4 CASH AND BUSINESS CONDUCT 4.1 The CFO raised a risk on cash due to the level of deficit under the strategic budget,

which would not initially be cash backed. Because the planned position for the mandated

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budget is breakeven and because the CCG has received a cash (but not revenue) allocation in relation to the CV19 response, this risk is significantly mitigated.

4.2 The CCG’s cash book balance at the end of May was £0.300m. This is higher than the amount which would be expected as the CCG received an unanticipated receipt of £0.200m.

4.3 The Better Payment Practice Code (BPPC) monitors public sector organisations on the timeliness of their financial payments both in terms of volume and value. Guidance recommends that 95% of payments are made within 30 days, the CCG performance was 99.6% for May. The following table shows the number of invoices paid against target. All expenditure incurred above £0.025m is collected monthly and published on the CCG’s website in line with the requirement set out by NHS England.

4.4 Whilst the national standard remains 28 days, CCGs have been encouraged to move to a 7 day payment standard to support providers and suppliers in their CV-19 response. Information on performance against this standard will also be provided in future reports.

4.5 A particular focus will be placed on providers of care for those with Continuing Care

need. This is the area of commissioning for the CCG that has the greatest challenge in achieving a standard price level, with providers seeking to set their prices on an individual client/patient basis. EMT has considered and approved a paper that takes steps towards aligning prices with the Local Authority but this remains a long way from the highly structured pricing framework that we need to implement.

5 GP IT BUSINESS CONTINUITY

5.1 The existing national agreement on MS Office licences is due to expire with a nationally led process having secured N365 licences on a subscription basis effective from September 2020.

5.2 CCGs are able to access national capital funding as a contribution towards the 30 month

licence cost, with the remaining element to be funded by Wirral CCG. This net contribution is set at £0.106m and represents value for money when compared to the alternative of procuring separately as a single CCG.

5.3 To access the national scheme and funding CCGs are required to give a definitive

response before the 17th July 2020.

Month Period Number Paid Year Total Number of Invoices Paid

Total Paid Within Target No.

%age Total Value of Invoices Paid £

Value paid w ithin Target £

%age

APRIL 01 20 1183 1178 99.58% 92,783,926.04 92,713,231.11 99.92%MAY 02 20 1493 1487 99.60% 45,186,114.13 45,134,224.46 99.89%

2676 2665 99.59% 137,970,040.17 137,847,455.57 99.91%

Performance Against Better Payment Practice Code (BPPC) ALL

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6 SUMMARY AND RECOMMENDATIONS 6.1 The CCG’s main financial challenge is that of achieving the breakeven duty both in-year

and recurrently. Should NHSE/I agree that the CCGs adverse variances match their “reasonable” criteria then the CCG would achieve break even at Month 4. This would not impact the recurrent position of a deficit of £24.9m and therefore progression of efficiency and improvement programmes remains critical.

6.2 In adopting the mandated budget the Governing Body should note that this extends only until 31st July and that we are therefore likely to be operating within a further revised finance regime from the 1st August 2020. At this stage guidance on this is yet to be issued.

6.3 The Governing Body is asked to:

1. Approve the adoption of the nationally mandated budget for the period April 2020 to July 2020 and to note that allocations and budgets for the period August 2020 to March 2021 are yet to be confirmed.

2. Note that the Strategic Budget approved by the CCG Governing Body in May remains part of the overall system of control and will continue to inform management decisions.

3. Note that for M2 (actual) and M4 (forecast) the CCG is reporting adverse variances to

plan of £3.222m and £6.022m respectively.

4. Note that the CCG is anticipating retrospective allocations in relation to these adverse

variances but should these not be approved then the CCG would move back into deficit. 5. Approve sign up by Wirral CCG to the nationally led scheme, thereby enabling business

continuity for Wirral General Practice and the CCG to MSOffice products. Mark Chidgey Chief Finance Officer 26th June 2020

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD REPORT APPENDIX 1 COMPARISON OF STRATEGIC AND MANDATED BUDGETS The following table and narrative provide further details in order to help Governing Body members understand the key changes and significant variances between the strategic budget and the new mandated budget.

A. Core Allocation (Allocation) - Under the mandated regime the allocation for “Core” programme spend is £6.4m higher, this is because it is based upon 2019/20 expenditure levels and therefore includes an element of the deficit.

B. Running Costs (Allocation & Expenditure) - The mandated budget assumes that the CCG’s underspend against running costs in 2019/20 will be repeated and that the CCG will further reduce expenditure in 2020/21. This represents a double count of QIPPs which is reflected in both the allocation and expenditure budgets.

C. Covid 19 (Allocation & Expenditure) - The strategic budget assumed that support for the CCG’s planning response to the COVID-19 pandemic would be provided up-front by way

Strategic Budget

Approved by GB

Strategic Budget

Months 1 - 4

Proposed Mandated

Budget Months 1 - 4

Variance between

Strategic and Mandated

Budget Months 1 - 4

Key to significant variances

31/03/2021 31/07/2020 31/07/2020 31/07/2020

Year Ending Period EndingPeriod Ending

Period Ending

Allocation £m £m £m £mRecurrent Programme £562.019m £187.340m £193.747m £6.407m (A)Primary Care Co-Commissioning

£50.488m £16.829m £16.829m £0.000m

Running Cost Allocation Recurrent

£6.205m £2.068m £1.613m -£0.455m (B)

Covid-19 Support £7.204m £2.401m £0.000m -£2.401m (C)Total In-Year allocation £625.916m £208.639m £212.189m £3.550m

ExpenditureNHS Contracts £398.573m £132.858m £134.761m £1.903m (D)Non Acute Contracts £17.279m £5.760m £5.131m -£0.629m (E)Prescribing £66.605m £22.202m £21.248m -£0.954m (F)Commissioned out of Hospital

£59.947m £19.982m £18.762m -£1.220m (G)

CCG Core Primary Care £6.715m £2.238m £4.094m £1.855m (H)Delegated Primary Care £50.488m £16.829m £16.829m £0.000mBetter Care Fund £28.657m £9.552m £9.420m -£0.132mOther £11.496m £3.832m £0.332m -£3.500m (I)Covid-19 Recovery Plan £7.204m £2.401m £0.000m -£2.401m (C)

Total Programme Costs £646.965m £215.655m £210.576m -£5.078mRunning Costs £6.094m £2.031m £1.613m -£0.418m (B)Contingency £3.094m £1.031m £0.000m -£1.031m (L)

Total Costs £656.153m £218.718m £212.189m -£6.528m

Budgeted Deficit £30.237m £10.079m £0.000m -£10.078m

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of a specific allocation. However, the mandated budget requires CCGs to request reimbursement of expenditure from NHSE/I through the retrospective “reasonable” allocation process.

D. NHS contracts (Expenditure) - These have been matched to the national block contract values and explicitly include higher levels of payment than the CCG had assumed, for example +1.1% to fund the impact of Trust’s reduced cost improvement programmes. They also include some transactions that have not been funded through the revised allocations, for example 2019/20 non-recurrent allocations that have been maintained as payments.

E. Non Acute Contracts (Expenditure) - NHSEI has taken on commissioning responsibility for many of the IS providers and therefore the associated budget has been withdrawn.

F. Prescribing (Expenditure) - The mandated budget assumes a significantly lower level of growth and inflation for prescribing (0.7%) than the strategic budget assumed (4.0%). The data required to test this assumption has not yet been published for 2020/21.

G. Out of Hospital (Expenditure) – As with prescribing the national budget assumes a much lower impact of demand and price increases (2.0%) than the Strategic Budget assumed (9.0%).

H. Core Primary Care (Expenditure) – The national budget assumes expenditure for schemes such as Extended Access which were yet to be varied into the CCG budget.

I. Other (Expenditure) – The mandated budget assumes that all 2019/20 expenditure was recurrent and therefore some expenditure is assumed to be maintained in 2020/21 when it was in fact non-recurrent.

J. Contingency (Expenditure) – The CCG is no longer required to budget for contingency with an assumption that this risk will be managed through “reasonable” variances.

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD REPORT APPENDIX 2 VARIANCE ANALYSIS AND DRIVERS OF ADVERSE VARIANCE

Expenditure Area M2 Annual

Budget to 31.07.20

£'000

M2 YTD

Budget £'000

M2 YTD actual

£'000

M2 YTD

variance £'000

Month 2 Forecast

Outturn to 31.07.20

£'000

Month 2 FOT

Variance to 31.07.20

£'000

NHS 134,761 67,380 67,445 65 134,761 0Non NHS 5,131 2,566 1,720 (846) 5,131 0Prescribing 21,248 10,623 10,997 374 21,648 400Commissioned out of Hospital 18,762 9,381 9,879 498 19,362 600

Primary Care 20,923 10,462 10,518 56 20,528 (394)Better Care Fund 9,420 4,710 4,710 0 9,415 (6)Other (Incl Contingency/ reserves) 332 166 3,180 3,014 5,754 5,422Running costs 1,613 807 868 61 1,613 0In Year Operational performance 212,189 106,095 109,317 3,222 218,211 6,022

Wirral CCG Financial Position as at 31st May 2020 (Month 2)

Variance by theme M2 YTD variance

£'000

Month 4 FOT

Variance (31.07.20)

£'000COVID-19 Pandemic Response 2,120 4,422Redirection on Extended Access Funding into COVID-19 (200) (400)FNC nationally agreed uplifts (19/20 & 20/21) 500 600Prescribing incl additional pressures from 19/20 373 400Healthy Wirral programme commitments 254 1,000Reduced Activity with IS Providers (846)Honouring 19/20 year-end mitigation agreements 636Underfunded Delegated Primary Care 250Other (Incl Running Costs) 135In Year Operational performance 3,222 6,022

0

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY BOARD REPORT APPENDIX 3 - FORECAST EXPENDITURE ON CV-19 RESPONSE PLAN BY APPROVED SCHEME NHS Wirral CCG – Expenditure incurred on CV19 response plan as at May 2020

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High Medium Yes Low

There a number of risks associated due the suspension of reporting mechanisms in relation Continuing Health Care and Complex Care. These have been identified both nationally and locally and are contained within the corporate Risk Register with mitigations.

QUALITY AND SAFETY REPORT


Lorna Quigley Director of Quality and Safety

Contributors Richard Crockford, Deputy Director of Quality and Safety Richard Miller Holiday, Assistant Director Continuing Health Care/Complex Care Services Helen Heeley, Designated Nurse Safeguarding Children and Children Looked After Paul Carr Head of Safeguarding Adults Tracy Wood Health Protection Programme Manager

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This paper provides Governing Body with a report on the statutory functions

and duties that the Director of Quality and Patient Safety is responsible for, and the processes and the reporting mechanisms that have been suspended, or changed in response to COVID-19.

Recommendations The Governing Body is asked to:

• To note the suspensions of the quality measures contained within the Directors responsibility during this period.

• To note the priorities for the teams in response to COVID-19.

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Clinical engagement taken place (If Y – further information to be provided as an Appendix) N

Patient and public involvement taken place (If Y – further information to be provided as an Appendix)

N

Date Equality Analysis/Impact Assessment completed (If Y – Include date of completion)

N

Quality Impact Assessment (If Y – Include date of completion) N


Y


Y


Y


Y


Y



CCG Governing Body Quality and Performance Committee 30th June 2020 Risk register/ safeguarding/ medicines

management agenda items Finance Committee Audit Committee Remuneration Committee Health and Wellbeing Board Business Management Group

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Report Title Quality and Safety Report

Lead Officer Lorna Quigley Director of Quality and Safety

Recommendations Governing Body is asked to:-

1. To note the suspensions of the quality measures contained within the Directors responsibility during this period.

2. To note the priorities for the teams in response to COVID -19.

1. INTRODUCTION

This report outlines the main duties and responsibilities of the Director of Quality and Safety in response to COVID-19. It gives the Governing Body an oversight of Quality and Safety and provides areas for assurance and identifies gaps in assurance.

2. KEY ISSUES / MESSAGES

Quality Reporting Contained within the NHS England/Improvement’s guidance, Reducing the Burden Releasing Capacity, a number of quality metrics have been suspended, these include: • Staff Friends and Family Test - this has been suspended for Quarter 4 with no publication

of data until further notice.

• Learning from patient safety incidents - Reporting and uploading patient safety incidents to the NRLS should continue as is practical and appropriate. Particular categories of incidents such as Never Events and Serious Incidents should be reported as usual wherever possible. Where Serious Incidents have occurred, immediate action must be taken to ensure patient safety, the mandatory requirement to undertake investigations is likely to be removed. However, if an investigation (or appropriate response for deriving learning) can be achieved this should be undertaken. Additionally, Providers should keep in place a core response so that any immediate action to protect patient safety that is feasible in the current circumstances is taken. The requirement to meet a hard 60-day deadline for the investigation of identified serious incidents will be suspended.

• Learning from deaths - The national requirement for Learning from Deaths processes for

Acute Hospitals, Mental Health Services and Ambulance Trusts is likely to be suspended until further notice.

• Mixed Sex accommodation- This quality and dignity measure has been suspended as the

priority during this period is to ensure that there is critical care and bed capacity within the hospital setting.

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• Quality accounts and Quality reporting- this work is to be stopped to allow organisations to

focus on their response to COVID 19.

Wirral Health and Care Commissioning have acknowledged the direction from NHS England/Improvement and have progressed amendments to existing quality assurance processes. All quality schedules have been reviewed and shared with providers highlighting only the key assurance items that are identified as essential and proportionate whilst undergoing the pandemic response.

Health Care Acquired Infections (HCAIs) 2019/20

The total number of HCAIs in Wirral for 2019/20 was 485; this is a 6.5% decrease on 2018/19 (n=519). The majority of HCAIs were E. coli (280 or 57.7%). Followed by C. Diff (124 or 25.6%) and MSSA (77 or 15.9%). There were 4 MRSA cases (0.8%).

Figure 1: Healthcare Acquired Infections (HCAIs) in Wirral, 2019/20

Hospital Onset vs Community Onset MRSA Of the 4 cases in 2019/20, 2 were hospital onset and 2 were community onset. C Difficle Of the 124 C Diff cases, 60 were Hospital Onset (48.4%) and 64 were Community Onset (51.6%). The following table shows the breakdown of C Diff by new assignment (HOHA, COHA, COIA and COCA) and month:

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MSSA Of the 77 MSSA cases in 2019/20, 27 were hospital onset (35.1%) and 50 were community onset (64.9%). E Coli Of the 280 E Coli cases in 2019/20, 204 were community onset (72.9%) and 76 were hospital onset (27.1%). Following a case MRSA and C- difficle a system wide Post Infection Review is undertaken to review the case, which includes the patient’s pre-existing condition, prescribing data and treatment plan. Following discussion the cases are assigned. Due to the lag in the national reporting system and the suspension of full Route Cause Analysis process due to COVID 19 there a number of cases awaiting assignment. Once these have been undertaken, Governing Body will be informed of the assigned cases.

Safeguarding Children and Adults

Safeguarding Adults The Coronavirus Act 2020 has provided Supplemental Guidance for staff regarding Care Act (2014) easements. It is critical and expected that statuary organisations fulfil existing duties under the Care Act 2014. However, in the event that this is not possible the Local Authority, through governance structures laid out in the document will have the power to streamline present assessment arrangement and, if needed, prioritise care so ‘the most urgent and acute needs are met’. To date Wirral has not had to enact the Care Act Easements and guidance was sent to all health and social care providers and staff to support the mitigation of the coronavirus and reinforce the need for appropriate and robust safeguarding referrals during the pandemic. We continue to engage at a regional level to support safeguarding practice and have been liaising with CQC and the health providers regarding Domestic Abuse / Violence. Currently Wirral has moved to a daily Multi Agency Risk Assessment Conference (MARAC) and the Multi Agency Safeguarding Hub (MASH) and Integrated Front Door redesigns continue. The Merseyside adult Safeguarding board has continued to meet virtually during this period. The focus of these meetings has been updates from Partner agencies sharing updates and intelligence regarding any emerging trends or themes, across the area. Moving into the reset phase, the board has reviewed its work plan and will be implementing the recommendations of the recent peer review process that was undertaken Safeguarding Children Face to face Children Looked After Initial Health Assessments have now recommenced following Risk Assessment process and in accordance with Public Health Guidance. On behalf of NHS Wirral CCG, the Designated Nurse continues to engage with local, regional

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and national Safeguarding children colleagues during COVID 19, This engagement has ensured that NHS Wirral CCG remain sighted on safeguarding children activity and provide assurance to the CCG that safeguarding children systems and processes are sustained during the pandemic and remain robust. Established local safeguarding children partnerships across the health economy and with multi-agency partners have continued. The independent scrutineer has maintained contact with the statuary partners and has produced an assurance report which has been presented at the Quality and Performance committee. Statutory Safeguarding Children/Children Looked After (CLA) nursing posts have been maintained across the health economy and safeguarding children/CLA roles and responsibilities have been sustained. There have been some necessary adaptions of how some services are delivered and monitoring arrangements reflect this. In May 2020, NHS England and NHS Improvement (North) Safeguarding Team advised of their intention to fund the roll out of the ICON programme across Cheshire and Merseyside through CCGs The core of the campaign both locally and nationally is based around coping with a crying baby with the aim of reducing the incidence of Abusive Head Trauma (AHT). Research suggests that some adults lose control when a baby’s crying becomes too much and could go on to shake a baby with devastating consequences. The Designated Nurses Safeguarding Children across Cheshire and Merseyside are working collaboratively to ensure a structured approach to ICON implementation. Gaps in Assurance Named GP Safeguarding Children Post – This post remains vacant despite previous adverts and 2 subsequent expressions of interest being later withdrawn. It is recognised that this vacancy is an ongoing risk for the CCG and that moving forward, not having a Named Safeguarding Children Lead for Primary Care inhibits aspects of CCG and safeguarding children activity. A solution focused action plan is being developed for consideration to mitigate this risk, which is being discussed in Quality and Performance Committee. Medicines Management

A review of the priorities for the Medicines Optimisation team has been undertaken by commissioners, and teams have been reorganised in order to comply with the new priorities due to the current pandemic. The teams have delivered a number of initiatives including:

o Electronic Repeat Dispensing (eRD): to reduce the footfall of people entering GP

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practices. o Outpatient Antibiotic therapy (OPAT): to enable patients to have IV antibiotics

administered at home. o Palliative Care: review of the formulary to ensure appropriate stock drugs o Reconciliation of drugs in care homes: to maintain patient safety following rapid

discharges form Hospital.

The teams are now looking at “phase 2” or recovery and are in the process of setting priorities from July until March 2021.

Correspondence has been received from the Pan Mersey Area Prescribing Committee (APC), that phased activity will resume from July 2020, working up to full activity by December 2020. System pressure will be kept under constant review. It is acknowledged that at any time there may be a need to maintain the current level of priority without progressing to the next stage, or to move back to focus on a higher level of priority, if system pressures arise. This plan will be progressed in a proactive manner with the intention of preserving APC function for high priority work for as long as possible and within system capacity.

Continuing Health Care/Complex Care (CHC/CC)

Following the measures that were introduced in relation to the CHC/CC process (mainly the suspension of the assessment process), some of the CHC/CC staff have been redeployed to the integrated discharge team. To support this change, there has been a suspension to the monitoring of quality/performance metrics. Independent Review panels have continued at a reduced volume, and response times to complaints have continued as normal.

Due to the change in processes and redeployment of staff, it is anticipated It is anticipated that a deterioration in position will be seen in Q1 including a number of cases waiting for assessment and review. These patients continue to be tracked in order to prioritise their cases post COVID-19. A paper is planned to be presented at Quality and Performance Committee addressing the issues.

Service Delivery Model and Transfer

As previously reported the Cheshire and Wirral Continuing Healthcare Service was hosted by NHS South Cheshire CCG since February 2015. In February 2019, a report presented to the Wirral Health and Care Commissioning Joint Strategic Commissioning Board and Cheshire CCGs Joint Executive Team described a need to revise the current service delivery model in line with the changes in the commissioning landscape to enable Wirral Health and Care Commissioning (WHCC) and Cheshire CCGs to achieve their strategic objectives.

Throughout this period, discussions have continued with Cheshire and Wirral Partnership NHS Trust and a Memorandum of Understanding and Service Specification has now been finalised. Staff have been through a consultation period for their employment to transfer to CWP. It is

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now anticipated that the Wirral CHC and Complex Care service will transfer to CWP on Wednesday 1st July 2020.

Care Quality Commission (CQC) As previously reported, The published CQC report is available for Wirral University Teaching Hospital. www.cqc.org.uk/provider/RBL The Trust have produced their ‘must do’ action plan, and the ‘should do’ action plan will be produced and submitted on 30th June 2020. The Clinical Quality Performance Group (CQPG) will monitor progress against the plan with the trust. The CQC published their report on 22nd June 2020 following the inspection of Cheshire Wirral Partnership Trust during January 2020. The trust received an overall rating of GOOD and OUTSTANDING in caring which is the same rating as December 2018, however, there have been a number of improvements across the including the child adolescence mental Health Unit. Work has already been undertaken with the Trust in regard to the waiting times for the ADHD service, which has been highlighted as an area of concern within the report.

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http://www.cqc.org.uk/provider/RBL


A full copy of the report can be reviewed : www.cqc.org.uk/sites/default/files/new_reports/AAAJ9402.pdf Independent Investigation into One to One Maternity Services. An independent investigation is being undertaken in line with the Serious Incident Framework Policy (Appendix 3) Investigations carried out under this Framework are conducted for the purposes of learning to prevent recurrence. They are not inquiries into how a person died (where applicable) as this is a matter for Coroners. Neither are they conducted to hold any individual or organisation to account. An independent investigation is an investigation into an incident which is both commissioned and undertaken independently of those directly responsible for and directly involved in the delivery of the elements that the investigation is considering. Niche Social Care has been formally appointed to undertake this review by NHSE/I using the national independent framework. The terms of reference have been agreed, and in view of the current situation a desk top review is currently being undertaken of the evidence that has been provided by NHS Wirral CCG and NHS England. When this is complete the next phase of the review will be considered which includes patient engagement and interviews with Professionals. COVID Testing In response to the COVID 19 pandemic, testing has been a key requirement to observe and control the spread of infection. The national plan has been designed around 5 pillars, the first three of which have seen the most local movement. Pillar 1 testing has include Public Health England testing related to outbreaks in residential settings but more recently extended to other vulnerable settings such as schools. In addition to PHE testing this has also included testing within NHS laboratories including inpatient testing, some key worker testing and testing prior to admissions to adult social care residential settings. The provision of testing in this area has been delivered through acute hospital care and a small commissioned community service. Pillar 2 testing is largely a national offer including regional testing centres and delivery of home self-testing kits. This pillar has also been known as mass testing. The national offer has also included a rolling programme for care homes to have all residents and staff tested. In addition to the national offer the Wirral has secured some pillar 2 testing capacity to establish a local Satellite Testing Centre at Bidston Station which has significantly increased the ease of access for many Wirral residents. Pillar 3 testing includes antibody blood tests and this has significantly increased during June 2020 to see all NHS staff offered a blood test to monitor for antibodies and plans are underway to support all social care staff to access antibody testing along with a roll out to the public when

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http://www.cqc.org.uk/sites/default/files/new_reports/AAAJ9402.pdf


accessing venepuncture for other blood tests. Antibody testing is currently being used for epidemiology in order to improve the knowledge about the spread of infection but as more is understood about the implications of having antibodies this could become increasingly valuable. During review of the local offers with regards to testing, it has been identified that these have been effective in complementing the national offers, however there are a group of vulnerable individuals who may have greater difficulty accessing testing offers. NHS Wirral CCG is working with providers to develop a greater offer targeting some of these vulnerable groups including; people suffering homelessness, people with a Learning Disability, people from deprived communities and some groups who have a greater risk of morbidity and mortality including Black, Asian and Minority Ethnic Groups. Support to Care Homes The Wirral Health and Care system has been providing additional intensive support team to care homes during the pandemic in a variety of ways this has included:

• The integrated quality team maintaining weekly telephone contact to care homes to ensure PPE availability.

• Increased medicines management support to support the rapid discharge process form hospital into Care homes.

• Specialist Community Infection Prevention and Control (IPC) advice for outbreak management, and other IPC advice,

• By 30th May, All care homes had been offered national IPC, PPE and swabbing training, this has been delivered locally by members of the integrated quality team.

• GP support though various media to reduce the risk of infection and access to MDT support

• Tele-triage service to support best care of care home residents. • National end of life care training for care home staff to include the death verification

process. • A memorandum of understanding has been developed with care homes and Wirral

Health and Care Community Trust, to provide additional nursing support to care homes should they require it.

3. IMPLICATIONS Due to the current position relating to COVID-19, there a number of quality measures and business processes that have currently suspended, other reporting mechanisms will continue using a proportionate response. Those suspended measures have been captured centrally in order for these to be re-established as part of the recovery phase. This will minimise the risk of quality and safety issues not being addressed. With regard to the suspension of eligibility assessments CHC/CC patients, these patients continue to be tracked through the system to ensure that appropriate levels of care is being delivered.

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4. CONCLUSION

Governing Body is asked to:-

• To note the suspensions of the quality measures contained within the Directors responsibility during this period.

• To note the priorities for the teams in response to COVID -19.

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High Medium Yes Low

At present, practices and the GP Hub models are proving resilient. In future, however, the potential for reduced staffing or increased demand due to Covid-19 presents a risk, as does the reliance on national supply chains. These have been included in on the CCG’s Risk Register.

PRIMARY CARE REPORT


Paul Edwards, Director of Primary Care and Corporate Affairs

Contributors To Approve To Inform Yes To Assure Yes To Endorse Executive Summary The enclosed paper outlines recent activities in Primary Care, with a

particular focus on the response of Wirral GP Practices and NHS Wirral Clinical Commissioning Group (CCG) to Covid-19. It seeks to provide assurance that all appropriate measures are being taken to ensure General Practices across Wirral remain resilient and are able to continue to provide care to their patients. It also seeks to assure that NHS Wirral CCG and General Practices have responded to the requirements set out at a national level by NHS England and Improvement.

Recommendations The Governing Body is asked to: • Note the report

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N


N



Y


Y


Y


Y


Y

This section gives details not only of where the actual paper has previously been submitted and what the outcome was but also of its development path i.e. other papers that are directly related to the current paper under discussion.



CCG Governing Body Quality and Performance Committee Finance Committee Audit Committee Remuneration Committee Health and Wellbeing Board

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Business Management Group

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Report Title Primary Care Update

Lead Officer Paul Edwards, Director of Primary Care and Corporate Affairs

Recommendations To note the report

1. INTRODUCTION

Primary Care on Wirral has responded extremely well over the past 3 months to the global pandemic and its impact on Wirral people as illustrated below. Discussions between the Local Medical Committee (LMC), Primary Care Networks (PCNs) and both Wirral GP Federations have now started work on the ‘recovery’ stage to establish what Primary Care need to look like in an ongoing/post-COVID environment.

‘Business as usual’ is likely to be redefined for Primary Care and NHS services generally, as management of patients into services include symptomatic and asymptomatic presentations and the associated risks.


Digital developments

The CCG secured a total of 458 laptops between 12th March 2020 and 17th April 2020 to support remote working for Primary Care, and a deployment schedule arranged by Midlands and Lancashire Commissioning Support Unit (MLCSU) commenced the delivery to all practices (and GP Care Hubs) starting at the end April/early May 2020.

In addition, 300 licences for web-based software that supports remote working for GPs/Nurses was secured as an interim measure whilst laptop delivery was awaited.

Practices’ rapid adoption of all available digital solutions aided the crisis response. Along with use of e-Consult for online consultations, a system called AccuRx was enabled at all practices to offer video consulting medium and has recently been extended to support Care Home patients. The national availability of MS Teams to NHS Mail users has also helped maintain and improve communication between PCNs, the LMC, Federations and the CCG during this period.

Estates

As a delegated commissioner, the CCG is now responsible for the associated areas relating to Primary Care estates, including rent reviews/reimbursement, lease agreements and improvement grants in accordance with Premises Costs Directions.

A new Primary Care Estates Steering Group has been created (reporting to the Primary Care

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Commissioning Committee), chaired by the Chief Finance Officer. Its objectives are to:

• Prepare a Wirral Primary Care Estate Strategy to ensure the delivery of effective and

appropriate Primary Care medical services in Wirral as a minimum, and also the implementation of a place based care approach;

• Ensure Primary Care premises are developed in Wirral to support the implementation of CCG commissioning plans and in particular the Primary Care Strategy;

• Ensure Primary Care premises are developed to provide the capacity and quality of premises required to meet needs associated with population growth and new housing;

• Ensure that any developments deliver value for money for the public purse and is affordable; • Oversee operational risk to the Primary Care Estate.

A longstanding premises development for West Kirby is progressing with Wirral Community Health and Care NHS Foundation Trust leading the project to create a new health and wellbeing centre which will house Marine Lake Medical Practice. The Trust has approved the outline business case and is working with the CCG to confirm future commitment to rental reimbursement for the GP space. Initial project estimates for completion of the new build is November 2021.

Personal Protective Equipment (PPE) for General Practice

As the COVID pandemic began to occur, the availability of PPE for general practices quickly diminished with business as usual supply chains depleted of stocks and struggling to replenish from their own supply routes.

A combined approach between the CCG and both Federations led to funding being made available to the Federations to directly purchase PPE supplies on a larger scale. Alongside this there has been CCG representation on a Local Resilience Forum PPE cell (consisting of Liverpool City Region local authority procurement leads and CCG representatives) to help co-ordinate and offer mutual aid between organisations when successful PPE orders were secured.

For General Practices, a proportion of these supplies were made available as emergency stock and the CCG organised collection and distribution via the Federations. Acknowledgement is given to Miriam Primary Care Group which, at short notice, arranged the logistics for collection of these weekly supplies and storage at Birkenhead Medical Building (and continues to do so).

Service provision

At the outset of the pandemic situation, the CCG agreed with practices that provision of services to patients had to take account of the virus transmission risk to healthcare staff and patients. To this end some locally commissioned services provision were managed by the practices, informed by their individual risk assessments, in a way that continued to meet clinical need where appropriate, but gave flexibility to the practices to consider alternative means of delivery, such as the use of digital technologies (video consulting) and practical

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steps such as phlebotomy delivered in practice car parks/patient entrance and exit flows into practices to ensure reduced person contact.

As practices now start to plan for their ‘recovery’ stage, they will be focusing upon any restoring routine care to patients for these locally commissioned services.

To inform the wider system intelligence about flows of demand and capacity, all practices have enabled a software system called APEX Insight and project work is underway with the system supplier to develop validated anonymised data extracts on primary care appointments to help support practices through the likely ebb and flow of COVID impact in the future.

Care Homes Enhanced GP Support and Multi-disciplinary Team (MDT) Working

Since May 2017, Wirral has commissioned an enhanced GP service for Care Homes. This service involves a GP practice being aligned to a care home and as part of this undertaking a weekly ward round of the home. This entails a weekly proactive care review of residents within the Care Home, considering current medical needs as well as proactive care planning. Up until recently, this service has only been provided to older people’s Care Homes. In May 2020, NHS England and NHS Improvement asked for a similar approach to be adopted nationally covering all CQC registered care homes including, those for people with learning disabilities and mental health conditions. This offer will include:

• Weekly check in/ward round – these are virtual at present due to COVID-19 and requirement to reduce risk of infections spreading further within care homes

• Personalised care and support plans in place for all residents • Delivery of pharmacy and medications support including structured medication reviews,

supporting care homes to supply medications, offering advice and reviewing new patients and patients following discharge from hospital

• Patients may then be referred for a wider MDT discussion if the GP practice feels additional support would be beneficial.

The aim of the service is to provide a more co-ordinated approach to supporting patients with complex needs and tis scheme focuses on routine/proactive care. Any patient who is unwell and requires medical attention will continue to receive this and during COVID-19, this will be via telephone/video consultation initially and followed up by a visit if deemed necessary.

This service expansion is temporary in nature until the Care Home Direct Enhanced Service (DES) commences from October 2020. A business case will consider how the service continues into the new DES phase.

Wirral GP Care Hubs (Covid-19) – second phase from 15th June 2020

The GP Care Hubs service has moved into a second phase as levels of infection have reduced across Wirral. The service is still provided at the 5 GP Care Hub sites across Wirral by Wirral’s two GP Federations. Care is provided either in a hub setting or in some instances via home visiting for patients with suspected or confirmed Covid-19. In addition, a limited amount of home visiting is provided for ‘shielded’ patients.

3. IMPLICATIONS

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Overall, Primary Care on Wirral has responded extremely well and instigated a series of initiatives to meet the recent challenges, maintain as much business as usual as possible and identified new ways of working that should become embedded for future care delivery.

4. CONCLUSION

Governing Body is asked to:

• To note the report

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High Medium Low Yes

The Risk Register is presented as a separate item on this agenda, but no key risks are identified within the report itself.



N


N


CORPORATE AFFAIRS’ REPORT


Paul Edwards, Director of Primary Care and Corporate Affairs

Contributors Michael Chantler, Assistant Director Communications and Engagement Laura Leadsom, Corporate Affairs Manager

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary This paper provides the Governing Body with a report on the statutory

functions and duties that the Director of Corporate Affairs is responsible for Recommendations The Governing Body is asked to:

• Note the report

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Strategic Themes

Working as One, Acting as One – we will work together with all partners for the benefit of the people of Wirral.

Y


Y


Y


Y


Y




CCG Governing Body Quality and Performance Committee Finance Committee Audit Committee Remuneration Committee Health and Wellbeing Board Business Management Group

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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT

Report Title

Director of Primary Care and Corporate Affairs’ Report

Lead Officer Paul Edwards, Director of Primary Care and Corporate Affairs

Recommendations Note key messages in report

1. INTRODUCTION

This paper provides Governing Body with a report on the statutory functions and duties that the Director of Primary Care and Corporate Affairs is responsible for.


3. Emergency Preparedness, Resilience and Response

Since the advent of the Covid-19 Pandemic, the CCG is part of a national Command and Control structure following the declaration of the Pandemic as a Level 4 incident. Feedback from groups Local Resilience Forum (LRF): • NHS England represents the NHS at the main LRF group. • No issues were raised for the CCG at the last meeting.

Local Health Resilience Partnership (LHRP) Meeting: • No issues were raised for the CCG at the last meeting.

Business Continuity The CCG have been working in line with the Business Continuing Plan to support remote working for staff members, in line with the Covid-19 Pandemic. COVID-19 Risk Assessments for staff

COVID-19 has had and still has a disproportionate impact on people according to individual and population demographics including age, gender and ethnicity. In response to this the CCG has shared guidance with all staff that has been developed by NHS Employers to enable staff and line managers consider whether a risk assessment is appropriate according to individual circumstances. The use of this tool is particularly useful for staff if they feel they are in one of the at-risk groups. The tool provides the basis for a process by which staff members and line managers can assess and discuss any risks and also plan any mitigating actions.

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https://www.nhsemployers.org/covid19/health-safety-and-wellbeing/risk-assessments-for-staff


NHS England has commenced an assurance process to ensure that staff in at-risk groups are assessed for any risk. Of particular note is the impact on Black and Minority Ethnic (BAME) people and those staff who have previously identified as BAME have been contacted directly to encourage them to complete a risk assessment with their line manager and to identify and mitigate any actions that may be appropriate. This will be extended to any staff in at-risk groups with numbers of risk assessments completed being reported to the Governing Body.

4. Commissioning Support Unit

The CCG contracts for the following elements from Midlands and Lancashire Commissioning Support Unit (MLCSU): End to End services (including areas such as Human Resources and Communications and Information and Communications Technology (ICT) together with Medicines Management, Individual Exceptional Funding Requests, Retrospective Continuing Healthcare (CHC), Health and Safety and Local Security Management. All service lines are performing well and MLCSU are actively working with the CCG to deliver efficiencies in support of the Quality, Innovation, Productivity and Prevention (QIPP) targets.

5. Communications and Engagement

Following the declaration of the Level 4 incident in response to Coronavirus pandemic, an approach for communications was developed across all current CCG channels. The CCG has senior representation on the Wirral Council Communications Cell which ensures that NHS considerations are integral to the actions developed by the cell. In addition, the CCG has developed a NHS Communications Cell for local providers and this is ensuring that the NHS response is coordinated across the local system.

Public Communications In response to the pandemic the CCG developed dedicated on line content which is visual and impactive on the CCG website and social media channels. This includes generic content from Public Health England, information about local changes to services and the development of Frequently Asked Questions (FAQ’s). The development of the FAQ’s was done in partnership with Healthwatch Wirral and included themes derived from their feedback from members of the public. This continues to be developed over the course of the pandemic response. The CCG has also been integral to the wider development of communications by the Wirral Council Communications Cell. This has included NHS content into a Digital Resource Pack and media publications.

Stakeholder communications have included a briefing letter to MP’s, Local Councillors and stakeholder organisations. This summarised the governance arrangements locally and changes to local services. The CCG is being responsive to enquires from MP’s and Councillors in line with usual processes.

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Pro active communications have taken place in relation to shielded patients, use of face coverings and changes to local NHS services.

Planning is underway to undertake a multi-agency public question time in partnership with Healthwatch Wirral. This would be held virtually and similar in nature to the WHCC sessions held previously.

Primary Care Communications The response to the pandemic has required rapid changes to Primary Care services. It was recognised that the CCG needed to ensure that Primary care colleagues are kept informed about not only local changes but the significant amount of national guidance received from NHS England and Improvement. A daily Coronavirus Bulletin was developed from the commencement of the Level 4 incident being announced and this has been sent out daily to all staff in Primary Care. This has been supplemented with standalone communications were it is deemed appropriate for urgent and important actions. A repository of information and guidance has also been developed on the members website.

Enquiries and questions from primary care colleagues are channeled through the Communications Team to ensure that an appropriate and timely response during the incident management.

Staff communications All CCG staff have been required to work remotely and this has presented ways in which the organisation adapts to staff communication. It was recognised that the importance of maintaining a collective staff team was paramount and with this is mind a dedicated closed Facebook group has been developed to provide a means of briefing staff and providing information. This has been used for staff briefings via Facebook live from the Chief Officer and the sharing of staff wellbeing resources. The rollout of MS teams has facilitated team working virtually and all teams are holding ‘keeping in touch’ sessions. Resources to help staff during remote working have been shared on the staff intranet.

Recognising that staff will be working remotely for an extended period, an engagement strategy has been developed which includes a weekly wellbeing survey, a ‘ways of working’ survey as well as wider staff satisfaction survey which will include key areas from the national NHS staff survey. The aim of this engagement is to check how staff are feeling now, discussing current and future working arrangements as well as developing a baseline for future action planning.

6. Policies

The following updated policy was approved by Quality and Performance Committee members in February 2020: • Self-Care Policy

The following updated policy was approved by Quality and Performance Committee members in March 2020:

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• Prescribing Commissioning Policy

The following updated policies were approved by Quality and Performance Committee members in April 2020: • Homely Remedy Policy • Information Governance and Data Security and Protection Policy

The following updated policies were approved by Quality and Performance Committee members in May 2020: • Whistleblowing Policy • Conflict of Interests Policy

The following updated policies were approved by Quality and Performance Committee members in June 2020: • Health and Safety Policy • Fire Safety Policy • Office Safety Policy • Security Management Strategy

7. Complaints

Within the period of 1st February 2020 to 31st May 2020, 26 new complaints were received, all of which were acknowledged within 3 working days of receipt in line with national guidance.

Complaints continued to be received with regards to Continuing Healthcare (CHC) funding assessments and requests for retrospective reviews. All complaints that were investigated and reviewed by the CHC Team provided assurance that the original decisions made were sound and robust. There has also been a continuation in complaints and concerns regarding the processes involved in assessments, and these require a response based on individual cases. Complaints, concerns and patient enquiries also saw an increase Covid-19 based issues being raised during this period. A number of complaints received before the pandemic, are on hold until the end of June 2020 due to providers suspending their investigations as staff have been redeployed to assist with the Covid-19 Pandemic response.

Since 1st April 2020, there have been a number of complaints received in relation to GP practices, which can now be directed to the CCG given the Level 3 full delegated commissioning status.

5 complaints are currently are being investigated by the Parliamentary and Health Service Ombudsman (PHSO). The CCG is awaiting the final outcomes and reports with recommendations in relation to the remaining cases and further updates will be provided at a future meeting. However, investigations are currently on hold, until the end of June 2020, in line with the current Covid-19 Pandemic.

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There were 26 complaints closed within this reporting period (some of which were received in the previous reporting period). Full details of each investigation, outcome and lessons learned, where applicable, were provided in all complaint responses, in line with the national standards for managing complaints and National Health Service Complaints (England) Regulations 2009.

8. Patient Advice and Liaison Service (PALS) The PALS is commissioned by NHS Wirral CCG and provided by Wired to provide ‘on the spot’ help whenever possible, with the power to negotiate immediate or speedy resolution (within 48 hours) of problems. Where appropriate, the PALS will refer patients to independent advice and advocacy support from local and national sources including Healthwatch. There were 61 PALS enquiries received within the period of 1st February 2020 to 31st May 2020. The two dominant areas of these related to Wirral University Teaching Hospital NHS Foundation Trust (WUTH) and GP Practices. Of the 61 calls received, 9 were formally raised as complaints with the relevant organisation and the remaining 52 were resolved satisfactorily.

(Source: Monthly PALS report provided from Wired.)

9. MP Enquiries Within the reporting period of 1st February to 31st May 2020, 46 new MP enquiries were received, all of which were acknowledged within 3 working days. There was a large increase in MP enquiries received within this period mainly regarding Personal Protective Equipment (PPE), testing and care home issues relating to the Covid-19 pandemic. Timely responses were provided by the Management Team to these enquiries received. All MP enquiries responded to and closed w within the CCG’s Key Performance Indicator of 20 working days and therefore the CCG was fully compliant in managing and responding to MP enquiries within this period.

10. Freedom of Information (FOI) requests Within the reporting period of 1st February 2020 to 31st May 2020, 46 new FOI requests were received. The subjects of the FOI requests received are detailed below:

Subject Number Received Primary Care 6 Continuing Healthcare (CHC) 2 Mental Health 5

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ICT 5 Financial Expenditure 6 CCG Commissioning 11 Contracts and Procurement 3 HR 2 Other 6 Total 46

All FOI requests received during this period were responded to within 20 working days, with the exception of 1 whereby a holding letter was sent to the applicant to advise that further time was required, due to the content of the data requested.

11. Subject Access Requests (SARs) There were 0 new SAR’s received within this reporting period.

12. IMPLICATIONS The CCG will actively seek to ensure Statutory and Mandatory training targets are continued to be completed.

13. CONCLUSION Governing Body is asked to note the contents of the report.

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GOVERNING BODY ASSURANCE FRAMEWORK


Paul Edwards, Director of Corporate Affairs

Contributors Governing Body Members, Mersey Internal Audit Agency To Approve To discuss and agree impact of Covid-19 on the Assurance Framework To Inform To Assure To Endorse Executive Summary The Assurance Framework was developed by the Governing Body in

conjunction with Mersey Internal Audit Agency and identifies key risks to NHS Wirral CCG’s Strategic Objectives. The changes agreed at January 2020 Governing Body are incorporated here, but the main focus of the papers enclosed is the potential impact of Covid-19 on the CCG’s Strategic Aims.


• Assess the impact of Covid-19 on the CCG’s Strategic Aims in the medium to longer term in the context of the Assurance Framework.

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High Yes Medium Low

The Assurance Framework allows the Governing Body to consider the risks that may hamper the Clinical Commissioning Group from delivering its statutory duties and functions – these are the strategically significant risks facing the Clinical Commissioning Group. The Framework also outlines how the Governing Body is provided with assurance that these risks are being effectively managed and, as such, acts as a documented risk assessment



N


N



Y


Y


Y


Y


Y

Working as One, Acting as One – we will work together with all partners for the benefit of the people of Wirral.

Y

This section gives details not only of where the actual paper has previously been submitted and

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what the outcome was but also of its development path i.e. other papers that are directly related to the current paper under discussion.



Governing Body 14th January 2020 Agreed alignment to refreshed Strategic Aims

Informal Governing Body 8th October 2019 Agreed to adopt Wirral Health and Care Commissioning Strategic Aims and to align risks for presentation at formal Governing Body

Governing Body 10th September 2019

Reviewed scores and agreed amendments

Governing Body 7th May 2019 Reviewed scores and agreed amendments. Accepted MIAA recommendations.

Governing Body 11th December 2018


Governing Body 11th September 2018


Governing Body 8th May 2018 Reviewed scores and agreed amendments

Governing Body 6th February 2018 Reviewed scores and agreed amendments

Governing Body 2nd May 2017 Reviewed scores and agreed amendments

Governing Body 10th January 2017 Reviewed scores and agreed amendments

Governing Body

4th October 2016 Reviewed scores and added risks

Governing Body 5th July 2016 Reviewed scores and add ‘risk appetite’ section

Governing Body 1st March 2016 Updated to align to new refreshed Strategic Aims, facilitated by Mersey Internal Audit Agency

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Report Title Assurance Framework Lead Officer Paul Edwards, Director of Corporate Affairs

Recommendations The Governing Body is asked to assess and agree the impact of

Covid-19 on the CCG’s Strategic Aims in the medium to longer term in the context of the Assurance Framework.

Introduction

When presented at Governing Body in June 2013, key controls and assurances were identified against each risk, with any gaps identified as requiring an action plan to address them. The Assurance Framework has been reviewed a number of times since then, with the whole structure of the Assurance Framework structure itself being reviewed at the Informal Governing Body session held on 1st March 2016 where risks were re-aligned to refreshed CCG Strategic Aims. This session also suggested the inclusion of ‘risk appetite’ and this is now incorporated within the Assurance Framework.

Mersey Internal Audit Agency produced a report on the CCG’s Assurance Framework in 2019, with the key recommendations noted and adopted at May 2019 CCG Governing Body.

Summary of Assurance Framework changes agreed at January 2020 Governing Body

Since May 2018, NHS Wirral CCG has been working in an integrated manner with the commissioning functions of Wirral Council under the auspices of a strategic partnership called ‘Wirral Health and Care Commissioning’ (WHCC). On the 10th September 2019, at the Joint Strategic Commissioning Board, the vehicle by which the CCG and the Council make joint decisions, a set of Strategic Aims were agreed that reflected that aspirations of the WHCC integrated commissioning arrangements. At October’s informal CCG Governing Body, a discussion took place around aligning the CCG’s historic Strategic Aims. On the whole, there was deemed to be a good fit and it was also agreed that the risks associated aligned well to the WHCC Strategic Aims. At January 2020 Governing Body, a paper was presented that aligned existing CCG risks to the Strategic Aims of WHCC and this was approved by Governing Body. In terms of the Assurance Framework itself, no other changes were agreed, other than:

• An extension to the deadline for Constitution changes on risk D5. This is because the approval process is still in progress between the CCG and NHS England.

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Changes proposed to the Assurance Framework for consideration at July 2020 Governing Body

The CCG has adopted its Corporate Risk Register to incorporate risks specifically related to Covid-19. The purpose here is outline for discussion the potential impact of Covid-19 on the CCG’s Strategic Aims on the assumption that Covid-19 may persist for some time into the future. The proposed areas for discussion by Governing Body are highlighted in red on the Assurance Framework. Conclusion

The Governing Body is asked to assess and agree the impact of Covid-19 on the CCG’s Strategic Aims in the medium to longer term in the context of the Assurance Framework.

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Wirral CCG

Controls Assurances Gaps Responsible CommitteeRisk No Risk Owner/ Lead Risk Description Impact

Rating Key Controls Assurance on Controls Likelihood Rating

Risk Score

Risk Rating Status Gaps in Control and Assurance Action plan Target Impact Target Likelihood Target Score Target

Deadline Narrative

1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

A1

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Failure to engage general public in change, difficultly in engaging with hard to reach groups.

3

Governing Body Reporting Format incorporating Engagement reports. Engagement and Experience

Strategy in place. Assistant Director of Communications and Engagement in place.

Public/Patient Reference Group now established. Action Plan for Healthy Wirral Communications

and Engagement Framework agreed with Partners, with deliverables set out.

Quality and Performance Committee minutes and reports, Governing Body minutes and reports, including Engagement Report. Several extensive engagement exercises evidenced through Governing Body papers

4 12 ↑

Some statutory CCG consultation requirments around service changes are currently suspended.

Face to face engagement activities suspended

Interim process for stakeholder engagement and NHSE

approval in place.

Consideration given to virtual engagement approaches

OngoingLead: Director of Primary Care

and Corporate Affairs

Governing Body 3 2 6 Mar-21

A2

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

CCG fails to understand people's health experiences due to lack of engagement.

3

PALS, Complaints management, website feedback mechanisms. Quality and Performance Committee monitoring. Patient Engagement Reports to CCG Governing Body. CQC relationship, Quality Surveillance Group, Complaints Monitoring. Healthwatch links and representation on Governing Body. Governing Body Reporting Format incorporating Engagement reports. Engagement and Experience Strategy in place. Public/Patient Reference Group now established. Action Plan for Healthy Wirral Communications and Engagement Framework agreed with Partners, with deliverables set out.

Quality and Performance Committee Minutes and reports, Governing Body minutes and papers including Engagement Report. Quality Surveillance Group minutes. Healthwatch member on Governing Body. Quality & Safety Group. Several extensive engagement exercises evidence through Governing Body papers

4 12 ↑




approval in place.





B1

Dire

ctor

of C

omm

issi

onin

g

Failure to promote and commission safe services, therefore, outcomes for patients don’t improve or deteriorate.

4

CCG Strategy and Plans, Health & Wellbeing Strategy, Contractual Quality and Performance requirements, patient engagement feedback, public health support and reports, Quality and Performance Committee monitoring and reporting. Assurance process from NHS England. New Governing Body Reporting Format addresses outcomes/performance/quality and safety on regular basis.. Serious Incident Review process in place.

JSNA and public health data and reports. Quality and Performance Committee minutes. Governing Body minutes. Shared measures via the Better Care Fund. External CCG Assurance Framework. Minutes of Serious Incident Review received at Quality and Performance Committe. Operational Plan delivery monitored through Governing Body

4 16 ↑New CCG Financial Regime and suspension of elements of commmissioning/contracting processes may inhibit effective commissioning

Chief Finance Officer to advise Governing Body on new

Financial Regime.September 2020

Lead : Chief Financial Officer

An approach to Phase 2 Commissioning to be agreed

September 2020.Lead: Director of Commissioning


Risk Appetite

Listening to the views of local people

Improving the health of local communities and people

What actions are in place to close the gaps in the controls and

assurance

What controls / systems does the CCG have in place to manage the risk

Strategic Aim B

Strategic Aim A

What are the principal risks that could prevent the CCG from achieving this

aim/ objective e.g types of risk - clinical, financial, reputational, statutory,

Priority

Detail of gaps where the controls / systems / assurances have either not yet been put in place or are yet to be fully

effective. What needs to be done

Evidence that the controls are operating and the CCG is reasonably managing its risks with aims/ objectives

being delivered

Page 1

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Wirral CCG



Risk Score


Deadline Narrative

Risk AppetitePriority

B2

Dire

ctor

of C

omm

issi

onin

g

Fail to deliver agreed health priorities and objectives. 4

CCG Strategic Plan, NHS England performance monitoring, Patient Feedback, Quality and Performance Contract meetings, Quality and Performance Committee Monitoring. Financial Recovery Plan. QIPP Reports. Finance Committee now established and revised to incorporate Turnaround Group functions. Executive Management Team (EMT) replaced Operational Management Group and now has revised focus on delivery.

Performance reports to Governing Body, Quality and Performance Committee Committee minutes. External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Finance Committee and EMT focus on delivery evidenced through minutes and papers.

4 16 ↑New CCG Financial Regime and suspension of elements of commmissioning/contracting processes may inhibit effective commissioning






Quality and Performance Committee 3 3 9 Mar-21

Acute care does not have sufficient focus on parity of esteem, therefore leading to failure to deliver high quality services for mental health patients. Contractual values could also impact on the quality of services being provided.

3

Friends and Family test, Quality Impact meetings. Monitoring of CQUINS. Implementation of Datix risk management system. Hospital visits & walk arounds. Quarterly aggregated reports to Quality and Performance Committee. Lay Member for Quality as part of Governing Body. Assistant Director of Contacting and Delivery in post. Director of Commissioning in post. New Governing Body Reporting Format.

3 9 ↔Quality and Performance

Committee 3 3 9 Mar-21

B4

Chi

ef F

inan

cial

Offi

cer

Inabiliy to manage rising demand and reducing capacity in a constrained financial environment.

4

CCG Strategic Plan, QIPP Plan with measurable outcome targets, Quality and Performance Committee monitoring. Indicators of success/ failure in demand management and action plans as needed. Quality Surveillance Group. CQUINS monitoring. Clinically led workstreams. New Governing Body Reporting Format. Financial Recovery plan developed. Primary Care Quality Scheme introduced, PMO established and Finance Committee established, incorporating functions of Turnaround Group. Through 'Healthy Wirral System'' sessions, agreement by system leaders to adopt principled of a capped expenditure/system control total approach. Executive Management Team (EMT) replaced Operational Management Group and now has revised focus on business cases and QIPP

Quality and Performance/Finance Committee monitoring of QIPP. Systeme Resilience Group now in place to address economy wide pressures. Governing Body minutes. External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Finance Committee and new EMT focus. Monitoring impact of Primary Care Quality Scheme through Quality and Performance Committee. "Healthy Wirral System'' sessions actions logs and minutes of Partners' Board

4 16 ↔New CCG Financial Regime and suspension of elements of commmissioning/contracting processes may inhibit effective commissioning






Finance Committee 4 3 12 Mar-21

B5

Dire

ctor

of Q

ualit

y an

d Sa

fety

Organisations fail to put the patient at the heart of everything they do.

3

Continuing work with community partners in voluntary, community and faith sectors plus representatives of individuals with protected characteristics to ensure their full representation in our commissioning plans . Friends and Family Test. Public Health intelligence. Analysis of provider organisations complaints. Public/Patient Reference Group now established. Action Plan for Healthy Wirral Communications and Engagement Framework agreed with Partners, with deliverables set out.

Quality and Performance Committee Committee reports on shifting local demographies and take up of services by diverse populations. Friends and Family Test results. Quarterly aggregated complaints reports to Quality and Performance Committee. Incidents reported and reviewed. Engagement activities reported through Governing Body

4 12 ↑




approval in place.





Quality and Performance Committee receives regular reports from providers which include an agreed set of HR metrics indicating adequate levels and competencies of staffing. Friends and Family test result. Monitoring of patient complaints. Safe staffing levels now reported. External CCG Assurance Framework

B3

Dire

ctor

of Q

ualit

y an

d Sa

fety

Page 2

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Wirral CCG



Risk Score


Deadline Narrative


B6

Dire

ctor

of C

omm

issi

onin

g

Failure to adequately benchmark with peers.

3

Involvement in Clinical Senates; use of benchmarking analyses when undertakng needs assessments. Joint work on reshaping the health provider economy with neighbouring CCGs. CLRN meetings. AQUA and other membership/subscription

Quality dashboard, Right Care data, minutes of Cheshire and Merseyside Chairs and Chief Officers.

2 6 ↔Quality and Performance

Committee 3 2 6 Risk level achieved

C1

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Socio demographic changes (e.g. ageing population, migrant population) prevent inclusion.

3

CCG Strategic Plan, use of JSNA in plans, Lay member for Patient Engagement, Public Health inclusion on CCG Governing Body.Engagement events and activities. Patient Engagement Reports to CCG Governing Body. Healthwatch member at Governing Body. Healthy Wirral work re self care & prevention. New Public/Patient Reference Group now established. Action Plan for 2019/20 Healthy Wirral Communications and Engagement Framework agreed with Partners, with deliverables set out.

Public Health Reports. Plans based on JSNA presented at Governing Body. Engagement activities reported through Governing Body

4 12 ↑




approval in place.





C2

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Failure to engage widely means that decisions may be skewed by particular interest groups.

3

Website development, Use of social media, Engagement events and activities, Public CCG Governing Body meetings. Engagement Reports to CCG Governing Body. Links to Healthwatch via Governing Body attendance and ongoing relationship. Engagement and Experience Strategy in place. Assistant Director of Communications and Engagement recruited. Public/Patient Reference Group now established. Action Plan for 2019/20 Healthy Wirral Communications and Engagement Framework agreed with Partners, with deliverables set out.

Patient and public feedback, feedback/ interaction with public at engagement events. Governing Body minutes. Engagement activities reported through Governing Body

4 12 ↑




approval in place.





C3

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Cultural and attitudinal issues skew expectations against self care.

3

CCG Strategic Plan. Integration team work re patient care. Healthy Wirral workstream re self care and prevention.Engagement and Experience Strategy in place. Assistant Director of Communications and Engagement recruited. New Public/Patient Reference Group now established. Action Plan for 2019/20 Healthy Communications and Engagement Framework agreed with Executive Partners, with deliverables set out.

Engagement activities reported through Governing Body 4 12 ↑




approval in place.





Caring for local people in the longer termStategic Aim C

Page 3

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Wirral CCG



Risk Score


Deadline Narrative


C4

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

CCG fails to get information across in a way that engages the public and is understandable to them (allowing for differing levels of understanding).

3

Website development, Choose Well/ Public Health campaigns, use of social media. Patient Engagement Reports to CCG Governing Body. Engagement and Experience Strategy in place. Assistant Director of Communications and Engagement recruited. New Public/Patient Reference Group now established. Action Plan for 2019/20 Healthy Wirral Communications and Engagement Framework agreed with Partners, with deliverables set out.

Patient and public feedback, feedback/ interaction with public at engagement events, PALS/ Complaints reporting through Quality and Performance Committee. Engagement activities reported through Governing Body

4 12 ↑

Some statutory CCG consultation requirments around service changes are currenlty suspended.



approval in place.





C5

Med

ical

Dire

ctor

Ineffective engagement from clinicians 4

Clinical involvement through the Clinical Senate, Provider Forum and Membership Council as well as clinical membership of other committees and Governing Body New Governing Body Reporting Format. Advice and Guidance established, cycle of Practice Visits established, CCG introduced locality approach. Review of Clinical Senate, Membership Council and Provider Forum taken place. New approach to Members' Group adopted based on Members' survey. New Clinical Advisory Group established as part of Covid-19 response.

Clinical Senate minutes. Key themes from practice visits. Membership Council Minutes. 360 results. Minutes of Clinical Advisory Groups

3 12 ↔ Some face to face activities suspended

Explore virtual approaches to Member Engagment.

September 2020Lead: Medical

Director/Chair/Members' Councl Chair


C6

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Adverse public reaction to decommissioning or reduction in access

3

Public consultations. Use of different comms mechansims e.g local press, social media. Engagement Reports to CCG Governing Body. Engagement and Experience Strategy in place. Assistant Director of Communications and Engagement recruited. Commissioning Decision Making process agreed. New Public/Patient Reference Group now established. Action Plan for 2019/20 Healthy Wirral Communications and Engagement Framework agreed with Partners, with deliverables set out.

Patient group feedback, web site and social media feedback. Engagement activities reported through Governing Body. Several extensive engagement exercises evidence through Governing Body papers

4 12 ↑




approval in place.





D1

Chi

ef F

inan

cial

Offi

cer

Reducing financial resource available across health and social care and failure to agree financial arrangements.

4

QIPP Strategy and plans, DASS membership on CCG Governing Body, Health & Wellbeing Board, Quality and Performance Committee. Joint Strategic Commissioning Board being established. Section 75 agreement in place with plans to expand further. Development and monitoring of Financial Recovery Plan. QIPP Plan. Finance Committee now established and revised to incorporate Turnaround Group functions. Through 'Healthy Wirral System'' sessions, agreement by system leaders to adopt principled of a capped expenditure/system control total approach. Executive Management Team (EMT) replaced Operational Management Group and now has revised focus on delivery/

Health and Wellbeing Board, Quality and Performance Committee minutes. Reports to Health and Well Being Board. Pooling arrangements for Better Care Fund. External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Finance Committtee, and new EMT focus evidenced through minutes and papers. "Healthy Wirral System'' sessions actions logs

5 20 ↔

New CCG Financial Regime and suspension of elements of commmissioning/contracting processes may inhibit effective commissioning and achievement of Financial Recovery






Finance Committee/Governing Body 4 4 16 Mar-21

Strategic Aim D Getting the most out of what we have to spend

Page 4

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Wirral CCG



Risk Score


Deadline Narrative


D2

Dire

ctor

of C

omm

issi

onin

g

Failure to deliver QIPP targets 4

Quality and Performance Committee Committee monitoring. Development and monitoring of Financial Recovery Plan. QIPP Plan. Financial Recovery Group established. Finance Committee established and PMO established. Business Management Group established to bring rigour to Programme Management approach

Quality and Performance Committee minutes. Finance Committee minutes External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Financial Recovery Group

4 16 ↔

New CCG Financial Regime and suspension of elements of commmissioning/contracting processes may inhibit effective commissioning and delivery of QIPP






Finance Committtee 4 3 12 Mar-21

E1

Acco

unta

ble

Offi

cer /

Cha

ir

Providers/ Health and Social Care fail to work together in partnership 4

JSNA and HWB Strategy and Board, development of service specifications and a Commissioning Prospectus which require collaborative approach, Joint CQUIN development, Social Care/Public Health represenentation on CCG Governing Body. Integrated planning processes. Joint Strategic Commissioning Board in place. Integration Project Board established and key work now complete. Intregrated Target Operating Model implemented. Expanded Section 75 agreement in place for 2019/20

Social Care/Public Health updates to CCG Governing Body. Reports to Health and Well Being Board. Better Care Fund Plan sign off by HWB and pooled budget arrangements. Minutes of Integration Project Board. Development of Commissioning Prosectus and Target Operating Model.

2 8 ↔

More work needed to strengthen/accelerate provider integration. Support offer developed by Director of Health and Care and Director of Corporate Affairs and presented to Healthy Wirral for consideration

Support accelerated development of provider

integrationMarch 2021

Leads: Director of Health and Care and Director of Primary Care and Corporate Affairs


E2

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Failure to be proactive with opinion makers and the population of Wirral.

3

Regular communications with local politicians, open, transparent communication with local media. Staff and community newsletters from CCG , Patient Engagement Reports to CCG Governing Body. Public/Patient Reference Group now established. Action Plan for Healthy Communications and Engagement Framework agreed with Partners, with deliverables set out.

Engagement activities reported through Governing Body

3 9 ↑




approval in place.





E3

Acco

unta

ble

Offi

cer

Failure to secure buy into Healthy Wirral and the CCG's role as systems leader.

3

Healthy Wirral Memorandum of Understanding in place.

Series of 'Healthy Wirral System' events held with system leaders where agreed to system control total approach and supported proposal for single regulatory approach.

New Healthy Wirral arrangement supported by partners


Action Log from 'Healthy Wirral System' events and Partners' Board minutes

3 9 ↔ Governing Body 3 3 9 Risk level achieved

E4

Acco

unta

ble

Offi

cer/

Dire

ctor

of P

rimar

y C

are

and

Cor

pora

te A

ffairs

Failure to agree and operate appropriate and efficient governance processes and framework.

4

Healthy Wirral Memorandum of Understanding in place

Formation of Ingtegrated Commissioning Project Board and strengthened partnershp arrangements between commissioners

Formation of Joint Strategic Commissioning Board

Series of 'Healthy Wirral System' events held with system leaders where agreed to system control total approach and supported proposal for single regulatory approach

Healthy Wirral Independent Chair appointed

New Healthy Wirral arrangement supported by partners


Minutes of Joint Commissioning Project Board

Minutes of Joint Strategic Commissioning Board

Action Log from 'Healthy Wirral System' events and Partners' Board minutes

3 12 ↔

More work needed to strengthen/accelerate provider integration. Support offer developed by Director of Health and Care and Director of Corporate Affairs and presented to Healthy Wirral for consideration

Support accelerated development of provider

integrationMarch 2021

Leads: Director of Health and Care and Director of Primary Care and Corporate Affairs


Working as one, Acting as OneStrategic Aim E

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High Medium Low Yes

Clinical engagement taken place Y Patient and public involvement taken place Y

Equality Analysis/Impact Assessment completed N

Quality Impact Assessment N

MEDICAL DIRECTOR REPORT


Dr Simon Delaney

Contributors Dr Stokes, Dr Ariaraj, Dr Jalan To Approve To Inform Yes To Assure Yes To Endorse Executive Summary Update detailing the work of the Medical Director and clinical leads


• note the contents of this report and the activities of the clinical leads.

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Y


Y


Y


Y


Y





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Report Title Medical Director Report Lead Officer Dr Simon Delaney

14th July 2020 Recommendations Governing Body is asked to note the progress of the activities of the

Medical Director and Clinical team

1. INTRODUCTION This report provides Governing Body with an update on the activities and delegated duties of the Medical Director and CCG clinical leads


System Clinical Response to COVID Pandemic The system Clinical COVID group was established in March 2020 to support a system senior clinical approach to managing the COVID pandemic, linking into the Health and Care Cell and Scientific and Technical Advisory Cell (STAC). It was agreed in May to review the function and governance of the group, resetting the Terms of Reference, purpose and objectives. This has been now accomplished with agreed set of objectives and aims for the group going forward. The Chair will remain a clinical lead from NHS Wirral CCG and the group will continue to have both senior medical and nursing representation from across with system, along with input from Public Health. It was been also agreed that henceforth the group will be a ‘Clinical Advisory Group (CAG) to the Healthy Wirral Partners board, overseeing and signing off pathway and clinical change. This CAG will meet fortnightly and will give updates to both the Healthy Wirral Partners Board and as part of the Medical Director report for NHS Wirral CCG Governing Body. Black, Asian and Minority Ethnic (BAME) NHSE North West have set up a BAME advisory group. Dr Ariaraj has accepted nomination to attend this group. Engagement with Local Medical Committee (LMC) and Federations There have not been formal meetings with the LMC Officers or with the Federations since the onset of the COVID pandemic. However, there have been regular meetings at the Primary Care Incident Management Group and through the system clinical group. Monthly LMC meetings have continued to be attended remotely by either the Chair or Medical Director. Relationships with LMC and Federations remain strong and collaborative.

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Clinical Senate Senate for March was well attended. Dr Longford (MD from Wirral Hospice St John’s) presented a proposal for Palliative Care redesign. This was debated within the committee and the clinical model was agreed. The agenda for a joint meeting with Wirral University Teaching Hospital NHS Foundation Trust was discussed and agreed (but the meeting was stood down due to COVID pandemic). A presentation was received on the current position of Wirral Care Record. Unfortunately, subsequent Clinical Senates have been stood down due to the COVID pandemic. A restart date has yet to be agreed. GP Protected Learning Time These have been stood down since March. We are currently looking at ways these may be reinstated using technology. Planned Care Committee The Planned Care Board from March onwards has been suspended due to the COVID pandemic and is awaiting a relaunch from Healthy Wirral.

Urgent Care Update: Dr S Jalan, Clinical Lead for Urgent Care and Medicine Management A new referral process for the emergency surgical admissions introduced which has shown promising results. We are currently reviewing it based on the feedback received. The urgent care team has started working on winter care planning. The Medicines Management Team have been working with the system lead and other providers of pharmacy services to support the medication deliveries for shielding patients and supporting primary care hubs. There is ongoing work on supporting care homes with medication reviews, reuse of medications and bulk prescribing. There has been a lot of work done in supporting end of life care for Wirral population in care homes and also in their own homes. The medicines team is also supporting the switch to EPS4 and eRD (electronic repeat dispensing). Ongoing review of the current Outpatient Parenteral Antibiotic Therapy (OPAT) service.

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Primary Care Update Homeless Locally Commissioned Servicer is suspended currently. Dermatology – The scheme has restarted until approximately the end of July. The Healthy Wirral Programme is now going to lead an 8 week redesign of Dermatology across the system. The outcomes of the Primary Care pilot will be submitted into this process for consideration. Long Term Conditions update: Dr Sian Stokes, Clinical Lead Long Term Conditions Work is ongoing in the areas of Diabetes, Respiratory, Elderly Care, Neighbourhoods and End of Life Care. Telehealth: Wirral Health and Care Commissioning have received some funding to set up a Telehealth Service for patients with Chronic Obstructive Pulmonary Disease (COPD) and/or Heart Failure. This project will supply some equipment to allow patients to monitor their own condition at home, such as oxygen saturation monitors, BP machines etc. In addition to this, the patient’s data will be monitored remotely and patients will receive regular support from the community matrons/heart failure service to manage their condition. A similar service in Liverpool has seen excellent patient outcomes with reduced unplanned hospital admissions and high levels of patient satisfaction reported. Gastroenterogy: Much of the work in Gastroenterology has been put on hold during the COVID-19 pandemic, with all routine gastroscopies suspended initially due to this being a high risk procedure. Work is underway to get services up and running again. Elderly Care: The COVID-19 outbreak led to the introduction of a national Care Home service to increase the provision of proactive care to vulnerable patients in care homes, both elderly and for those with learning disabilities. The Wirral have responded swiftly to the requirements of this scheme, with Primary Care Networks (PCNs) aligning themselves to the care homes and arranging a weekly proactive ‘ward round’ for patients within these homes. This builds on the previous model that Wirral have had in place for a number of elderly care homes for some time. During the early stages of the pandemic the community geriatricians set up a ‘hospital at home’ service in conjunction with the rapid response service, to enable frail elderly patients who might otherwise have required hospital admission to be managed at home. This included the provision of daily patient review with consultant input, intravenous antibiotics and subcutaneous fluids where required and many other interventions. Early data showed this service drastically reduced unplanned admissions to hospital in this age group, whilst providing patients with high levels of care in the community. Unfortunately the model was not sustainable; however a business case is being compiled looking at setting up a similar, more

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sustainable service going forward. Planned Care update: Dr Lax Ariaraj, Clincial Lead Planned Care Musculoskeletal Service current areas of focus: • Review of Delivery Options by Primary Care (Workshop July 2020, implementation October

2020) • Review of podiatry access criteria • Progress use of virtual technology for appointments and extend on-line resources • Review of rheumatology and pain management services • Recruitment of additional Rheumatology resources (on-going) • Recruitment of GPwSI • Development of patient portal to support self-management • Chronic Pain: Refresh all Directories of Service

Ophthalmology • Transformation work on hold to enable services to focus on emergency and urgent

patients. • Effective system working demonstrated during the last 3 months • Services are now starting to re-open initially with cataract surgery (SpaMedica),

intermediary services (Wirral Vision and Minor Eye Clinics (Community Optoms) • Services at Wirral University Teaching Hospital NHS Foundation Trust (WUTH) are

planning restart and are subject to suitable clinic space being identified away from Arrowe Park Hospital. Spire Murrayfield services are not available due to commissioning those hospital services for urgent and essential surgery.

• Transformation work is expected to be progressed in Autumn, assuming providers are back on track and are able to release staff for transformation work.

Outpatients redesign WUTH have completed some significant pieces of work in order to support the management of COVID: • Gained agreement for and published Outpatient Standards for the organisation • Established telephone clinic guidance to help admin and clinical teams – to ensure teams

are clear on processes and that common issues raised are addressed, • Completed a clinicians survey in relation to telephone clinics – and have responded to the

key queries and issues raised through communication of a report to all consultants, • Completed a patient survey in relation to telephone clinics – and will work through

responses through the project group.

Looking forward, WUTH are planning to keep up the momentum in the next few weeks, embedding the huge change we have seen across the organisation and focussing on: • developing and rolling out the video solution • confirming processes for referrals and referral triage • collating where we need to develop electronic solutions to support paperless outpatient

clinics • collating list of exceptions where face to face attendance is required, so that this can be

signed off by Clinical Advisory Group

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• embedding reporting and mechanisms

Cancer • Overall there remains a reduction in 2 Week Wait referrals. The drop represents about 1/3

on pre-COVID levels. This is similar to the national picture. • The CCG achieved all other performance measures. Wirral is currently ranked 2nd across

Cheshire & Merseyside for the 62 day wait standard. • Currently there are 1500 patients on cancer pathways at WUTH. As diagnostics reopen,

the backlog secondary to COVID is being worked upon. Endoscopy still has a significant reduction in capacity due to infection control and the potential for some activity to take place at Murrayfield is being explored

• New proposals have been shared from NHS England and Improvement regarding Cancer Waits Guidance. The proposals have been received positively by WUTH and the Lead GP for Cancer and feedback has been provided to the Cancer Alliance.

• Plans for the introduction of Faecal Immunochemical Test (FIT) for 2WW Colorectal patients are still actively in development and it is anticipated that this will be in place within the next month.

• Clatterbridge Cancer Centre – Liverpool is due to open Saturday 27th June.

3. IMPLICATIONS:

• Ongoing Clinical system co-ordination in response to COVID-19. • Delegated Commissioning commenced from 1st April 2020. • Ongoing work on engagement with LMC, Primary Care and Secondary Care. • Note the work of the Clinical Leads.

4. CONCLUSION


• To note update on the ongoing work of the Medical Director and Clinical Team of the CCG recovery schemes in progressing the objectives of NHS Wirral CCG.

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High Medium Yes Low COVID-19 is a significant risk to the health and safety of the whole population of Wirral. The enactment of Emergency Planning Resilience and Response (EPRR) protocols and the declaration of a Level 4 incident by the NHS provide the certainty of a command and control environment. The business continuity plans of WHCC/NHS Wirral CCG have also been mobilised and have to date demonstrated significant resilience. There have been significant challenges for our system in regard to testing of people, including staff, for COVID-19 and the availability of Personal Protective Equipment (PPE). These have been included on the Risk Register.

HEALTH AND SOCIAL CARE SYSTEM TACTICAL CELL COVID-19 RESPONSE


Graham Hodkinson, Director of Health and Care, Wirral Council and Deputy Chief Officer, Wirral Health and Care Commissioning (WHCC) Nesta Hawker, Director of Commissioning and Transformation, NHS Wirral Clinical Commissioning Group (CCG) and WHCC

Contributors Barry Graham, Programme Management, Wirral Council and WHCC To Approve To Inform Yes To Assure Yes To Endorse Executive Summary In response to the COVID-19 pandemic the Wirral system has set up a

command and control governance system of which the Health and Social Care System Cell sits as the system wide command meeting. The report highlights the strategic objectives and aims of the Health and Social Care System Cell and shares an update of the key themes reviewed by it. It also covers a reflection upon the transformational changes that have occurred for service delivery with the Health and Care system.

Recommendations The Governing Body is asked to: • To note the aims and purpose of the Health and Social Care

System Tactical Cell • To note the functions and decisions undertaken in response to the

COVID-19 pandemic

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Clinical engagement taken place (If Y – further information to be provided as an Appendix) Y


N


N



Y


Y


Y


Y


Y





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Report Title Health and Social Care System Tactical Cell COVID-19 response

Lead Officer Graham Hodkinson, Director of Health and Care Wirral Borough Council Nesta Hawker, Director of Commissioning and Transformation NHS Wirral CCG

Recommendations Governing Body is asked: -

1. To note the aims and purpose of the Health and Care System Tactical Cell

2. To note the functions and decisions undertaken in response to the COVID-19 pandemic

1. INTRODUCTION

1.1 In response to the COVID-19 pandemic the Wirral system has set up a command and control

governance system of which the Health and Care System Tactical Cell sits as the system wide command meeting. The diagram below shares the key relationships of the Cell within the Wirral command and control approach to managing the impact of the pandemic.

1.2

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1.3 As of the 24th June the Health and Social Care System Cell meets Monday, Wednesday and

Friday and has representation from key stakeholders across the health and care system. The System Planning Implementation Group sub group meets on Tuesday and Thursday. The ability to flex the meeting frequency exists based upon changes in circumstances.

1.4 The aims and objectives of the cell were revised on the 8th June to reflect the function of the

cell post the initial emergency response to Covid-19.

Strategic Aims

• Work as an integrated Health and Social Care system to co-ordinate and support local communities and providers.

• To return to business as usual and/or adapt operating models to restore a ‘new normal’ • Meet the Health and Social Care needs of our communities. • Build on critical lessons learnt during our initial Covid-19 response phase.

Objectives of the Cell

• To identify and lead on recovery issues and report through the Chief Executive’s Group and through organisational command structures as appropriate. To share risks and issues identified by the members of the Cell to the system.

• To communicate effectively across Wirral’s Health and Social Care system • Ensure and maintain system flow • Oversee support to the care market • To seek to understand and co-ordinate the return to ‘the new normal’ operational levels

for Health and Social Care. • To protect the most vulnerable, aim to reduce any potential harm due to reduction

of Health and Social Care provision, and that shielded or vulnerable groups who may have continued restrictions continue to receive the necessary Health and Social Care required.

• To explore and share good practice and embed this in the implementation of the ‘new normal’. Ensure that lessons learnt are embedded as business as usual.

• To understand the interdependencies between safe and strong communities and the wider determinants of Health and Social Care demand.

• To feed into and influence local and regional plans to ensure all organisations are adequately prepared for any future waves.

• To seek to ensure that the wider system has capacity to improve health outcomes for all.

• To build on the collaborative working between agencies to ensure we have a resilient, agile Health and Social Care system going forward.

• To promote system-focus on infection prevention and control in order to minimise risk of outbreak and further transmission of Covid-19 across Wirral.

• Utilise intelligence to have an agreed system single version of the truth, inform interventions and evaluate outcomes

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2. KEY MESSAGES

The following outlines the continuation of the key functions of the Cell and highlights some key actions that have been completed since its inception.

2.1 Bed capacity and patient flow 2.1.1 The Health and Social Care System Cell receives detailed daily updates from system partners in order to oversee the system flow of patients to and from the hospital to community care providers. This information includes the bed capacity at Wirral Hospital University Teaching NHS Foundation Trust, including number of COVID-19 beds, number of patients ready for discharge and the required discharge pathway numbers plus community care capacity.

2.1.2 Partners form the Health and Social Care cell have fed into the ‘Cheshire and Merseyside Additional Community Capacity Step Down/Rehab (Seacole) Beds Business Case’. The rationale for these beds is to deliver safe care to patients requiring rapid step down from hospital from early October to the end of March 2021

2.1.3 Following the introduction of a system owned ‘8 Point Improvement Plan’ the Cell has evidenced improved integrated discharge processes amongst partners and increased the ability to support each other and feedback constructively when required.

2.1.4 Wirral partners were chosen to present to NHS England and NHS Improvement on how Wirral’s Health and Care system responded to COVID-19. The presentation detailed the improvement in long length of stay and bed occupancy rates aided by effective partnership and collaborative working. Wirral was one of three positive case studies chosen.

2.1.5 The Cell also receive updates from the Hospital Trust and care homes when outbreaks

occur which limit bed capacity and admissions, which facilitates a rapid response to limit delays in the system,

2.2 Shielded Patients and Vulnerable patient list 2.2.1 The Health and Social Care System Cell oversees approaches to those Wirral residents

who were classified as at very high risk of severe illness from Covid-19, because of an underlying health condition. Reviewing and assessing potential impacts that service resumption may have upon those individuals on this list such as safe access.

2.3 Staffing 2.3.1 The Cell undertakes a review of staffing resources across sectors with awareness and the

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risks associated with high levels of staff self-isolating. A daily dashboard includes updated sickness rates for partners to view. 2.3.2 Organisational partners fed back to their Human Resource teams to share best practice to

support approaches to managing their staff during these times and to limit potential levels of absence impacting upon service delivery.

2.3.3 Due to the frequency of the group and prompt feedback, escalation of issues has been

raised and quickly resolved. An example being the Test and Trace system directing health and care staff contacts to self-isolate even if they were using PPE, which was then clarified in guidance to limit higher levels of absenteeism.

2.4 Personal Protective Equipment (PPE)

2.4.1 The system continues to support each other if issues of PPE arise as occurred last week when a request for masks for the weekend was issued, for which partners were able to rapidly support.

2.5 Testing/Swabbing

2.5.1 Organisational partners feed information back into the cell regarding developments such as the block care home resident testing, numbers of staff tested, frequency of testing, process for testing future elective hospital patients and delays in discharge potential attributable to receiving test results within the Hospital Trust.

2.6 Mortality Review Updates

2.6.1 The intelligence team provide weekly updates on Wirral’s cumulative and weekly confirmed

Covid-19 Cases, Covid-19 deaths in hospitals and care homes and excess deaths relative to national, regional, and local authority areas. This analysis provides valued weekly trend analysis for the Health and care system which informs decisions on the environment that surrounds any service reset.

2.7 Reset Plans 2.7.1 The Health and Social Care cell has been the focal point in which organisational reset plans

have been reviewed. With the group’s membership covering Health and Social Care partners implications for reset decisions can be highlighted and discussed, including the impact it will have on connective services and the need to deliver effective communication of any changes to the public.

2.8 Mental Health

2.8.1 The group receives immediate feedback from Healthwatch, Age UK and Wirral Citizen’s Advice

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Bureau of the level and nature of the queries that they are receiving. A large proportion of these over the previous months have focused on concerns regarding mental health and increased levels of anxiety and uncertainty. Several of these have been attributable to lockdown, shielding measures and reacting to changing national guidance. Having the regular input and resident feedback has been essential to help the cell gain insight and early warning indicators into how services will need to be configured to meet these needs in the system reset.

2.9 Funding investment reviews

2.9.1 Since the onset of the pandemic Wirral has received one off national funding allocations to

meet specific needs. The partners within the Health and Social Care Cell have reviewed plans for how the use of these funds can be used to gain the best return for the system.

Allocations received to date have included:

£4,743,521.00 -Adult Social Care Infection Control Fund. The primary purpose of this fund is to support adult social care providers, including those with whom the local authority does not have a contract, to reduce the rate of COVID-19 transmission in and between care homes and support wider workforce resilience.

75% of the fund (£3,557,640.75) has been allocated on a “per bed” basis for each CQC Registered Care Home, and should be invested by the Care Home into workforce resilience, by topping up sick pay, ensuring staff only work in one care home, recruiting additional staff, taking steps to limit staff using public transport and steps taken to support the segregation of COVID-19 positive residents.

25% of the grant (£1,185,880.25) may be used on other COVID-19 infection control measures including domiciliary care and wider system workforce measures. Proposed allocations to meet these aims and working up by system partners are:

£2,733,018-Test and Trace funding. As part of this work, local authorities will need to ensure testing capacity is deployed effectively to high-risk locations. Local authorities will work closely with the test and trace service, local

No. Areas of Investment Budget £1,185,880.25

1 Council Spend on PPE from June to September £500,000

2 Care Homes Direct Investment £300,000

3 Community Infection Prevention Control Service

Staff Investment to Sept and B) Online Assurance framework

Additional IPC support to care sector

Dedicated training, advice and guidance

Development of the champions network

£300,000

£182,500 and £117,500

4 Domiciliary Care (PPE) £85,000

Total £1,185,000

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NHS and other partners to achieve this. Deadline for how this funding will be allocated as well as the collation of the local outbreak plans is the end of the month.

3 REFLECTION ON THE CHANGES IN PRACTICE AND SERVICE DELIVERY

3.1 Wirral Health and Care partners contributed and submitted a return on the 23rd June detailing

the positive transformational changes that they believe they would wish to retain from this crisis. Along with consideration of what they believe has enabled these positive changes to help shape the next phase of the Covid-19 response.

3.2 The submission covered seven themes and some of the outputs from the shared exercise

included:

System Leadership, Culture & Partnership Working: What’s changed:

• “Organisational relationships are more open, supportive and effective, sharing information and enabling quicker solutions to issues raised. Including daily identification of the ‘What, How and Why,’ of what needs to be done to enhance better care.”

• “Greater promotion of Voluntary, Community and Faith services as key partners.” • “Implementation of a daily hospital discharge cell group to ensure low long length of

stay numbers and further embed “home first” model. Organisations doing today’s work today. Shared accountability”

• “Commitment to creation of a 24- hour, 7-day resident support helpline. Wider awareness of mental health issues and the assets/offer available to support these on the Wirral.”

Enabled by:

• Common purpose, all working together towards the same set of priorities. Command and control structure. Governance structure. Enhanced 7-day arrangements. Long length of stay reviews.

Market Shaping and Provider Sustainability What’s changed:

• Mutual Aid (across boundaries and across agencies). • Enhanced care home model. • Additional financial resource was made available to local systems to support provider

resilience and sustainability, including intermediate capacity commissioned to enable flow and manage risk.

• On line virtual provider forums and remote training sessions, which have been well attended and well received.

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Enabled by: Realigning resources to prioritise support. Need to reconsider ‘old approaches’ and utilise technology. Additional funding to support the market. Review of level of information and contractual data required, proportionate to provider responsibility for delivery. Workforce What’s changed:

• 7-day whole system response-commissioners and providers. • Greater use of technology / virtual meetings to support flexible working arrangements. • Role of frontline care staff in all Health and Care settings has national recognition. • ‘Flexing’ of staff in order to deal with emergency issues and meeting specific demands,

across health, care and Independent sector. Enabled by:

• Re-prioritisation of resources. Need to work differently and ability to focus and deliver at pace. System agreement of the benefits of this approach.

Digital, AT & ICT What’s changed:

• Greater use of technology / virtual meetings to support flexible working arrangements e.g. Microsoft teams. Agile working capability.

• Virtual provision removes barriers to being able to access for some learning disability/autism/mental health clients.

• Monitoring via tele heath and telemedicine working with the Community Trust/Primary care to support the creation of a virtual ward and remote clinical assessments

Enabled by:

• Awareness that culture has had to be different. Need to maintain safe patient contact in the COVID environment. Greater access to digital options then previously available.

Finance and Procurement What’s changed

• Funding - Uplift of the fees in the market to support workforce and provider costs. • System reviews of how to achieve the most effective use of national one-off funding-

’Care Home-Infection Control’ funding. • Council role to procure for the care sector. Utilisation of buying power. (PPE).

Enabled by

• Need to manage risk and support sector costs. National funding and recognition of need to fund sector. Support to the market to meet additional costs attributable to higher staffing absences, PPE and care costs.

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Intelligence What’s changed

• System reporting-single version of truth and transparency. • Performance dashboards have been put in place for daily reporting. • Increased sharing of intelligence / market management with other Local Authorities and

Health Partners. Enabled by

• Need for expediency to identify increase for COVID attributable care in community settings. Reliance on accurate health and care system information to enable prompt response for issues when they arise. Partners working closer together.

Premises and Estate What’s changed

• More virtual meetings, highlights potential to minimise numbers of premises required for organisations. Positive environmental impact.

• Reduction in people transported regularly to care facilities where they have been supported as determined by individual needs as well as in their own homes.

Enabled by • Evidence of effectiveness of online meetings Identification of services that can be delivered

form bases, alternative uses to buildings. More flexible use of existing workforce and technology.

4. CONCLUSION

Governing Body is asked: -

• To note the aims and purpose of the Health and Care System Cell • To note the updates of the functions and decisions undertaken in response to the COVID-

19 pandemic. • To note the feedback and reflection on the changes in practice and service delivery.

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High Yes Medium Low

COVID-19 is a significant risk to the health and safety of the whole population of Wirral. The enactment of Emergency Planning Resilience and Response (EPRR) protocols and the declaration of a Level 4 incident by the NHS provide the certainty of a command and control environment. The CCG remains accountable for the quality and delivery of constitutional standards are statutory requirements of the CCG. The recovery of the elective care provision for Wirral patients is important to meet the health care needs of our population and ensure that waiting times are kept to the minimum possible whilst we remain in a COVID environment. The current corporate risk register includes risks to our system as a result of the pandemic.

COVID-19 WIRRAL RESPONSE TO SECOND PHASE - ELECTIVE AND PLANNED CARE


Nesta Hawker Director of Commissioning and Transformation NHS Wirral CCG

Contributors To Approve To Inform Yes To Assure Yes To Endorse Executive Summary The report highlights the role of NHS Wirral CCG, working with our system,

as we are moving through the phases of the pandemic. Our role in particular has been of assurance and on the co-ordination and oversight of the actions and plans of our providers across Wirral to restart urgent elective care and non urgent elective services safely, whilst maintaining provision for COVID-19.

Recommendations The Governing Body is asked to: • To note the actions taken by NHS Wirral CCG working in partnership

with our system for the safe and effective restart of elective and planned care services.

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Clinical engagement taken place (If Y – further information to be provided as an Appendix) Y


N


N



Y


Y


Y


Y


Y





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Report Title COVID-19 Wirral Response to Second Phase - elective and planned care

Lead Officer Nesta Hawker Director of Commissioning and Transformation NHS Wirral CCG

Recommendations Governing Body is asked

1. To note the actions taken by the CCG working in partnership with our system for the safe and effective restart of elective and planned care services.

1. INTRODUCTION 1.1 Since the declaration of a Level 4 incident on the 12th March, the NHS has been placed

in a “command and control” environment through which all activity is directed through regional structures to individual organisations. Once a level 4 incident is declared, in health NHS England take responsibility for “running the emergency”. This means that new governance arrangements have been established for decision making within the scope of the emergency. As a Governing Body we retain all of our responsibilities apart from those brought into the emergency governance arrangements. Our retained responsibilities include assurance on quality, safeguarding, staff welfare, equalities, and financial probity.

1.2 In response to the COVID-19 pandemic, the Wirral system has received a number of

national and regional guidance, including clinical best practice and guidance, and standard operating frameworks on the reset of different aspects of health services. On the 29th April 2020 NHS England issued guidance on moving to the second phase of the pandemic response. This requested providers to step up non-Covid19 urgent elective services as soon as possible, with a safe restart with full attention to infection prevention and control as the guiding principle. There was further advice for providers to make judgements on whether there was further capacity for at least some routine non-urgent elective care. National guidance on moving to phase 3 is still expected.

1.3 As within other systems on Wirral the immediate health and care response to the ongoing

challenges raised by COVID-19 has been exceptional. For a system placed under unprecedented, sudden and intense pressures, we have seen a rapid transformation in clinical practice, new and innovative approaches to service leadership and provision that spans organisations, and a greater understanding of the skill, value and flexibility of our people and workforce. Whilst Wirral moves into the restart phase of the pandemic it is important to reset health services in a way that captures the lessons learnt and transformation that has taken place. Further guidance issued was to take this opportunity to ‘lock in’ beneficial changes that have been collectively brought about in recent weeks.

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1.4 The challenge now facing the NHS as it begins the second phase of its response to the outbreak is to maintain the capacity to provide high quality services for patients with COVID-19, whilst increasing other urgent clinical services and important routine diagnostics and planned surgery.

1.5 As we are moving through the phases of the pandemic, the focus of our assurance is

also required to change and this paper is to give an oversight of the actions and plans across Wirral and our providers to restart elective care services safely and maintain provision for COVID-19. Our role has involved seeking assurance and ensuring co-ordination across providers and pathways in restart plans. In support of our system the Healthy Wirral Programme Delivery team have reviewed the restart plans of our three largest NHS providers and their compliance against the national ask made on the 29th April. As our provider plans are being updated with more detail this assurance undertaken by the Healthy Wirral team is ongoing.

2. KEY MESSAGES

2.1 Within the Wirral system the Health and Care Cell has been asked to oversee the system response to restarting of services and ensure visibility across the system to ensure impacts on other parts of pathways are understood and mitigated. The terms of reference of the Cell have been changed to reflect this more proactive and planning aspect of the Cell. The Health and Care Cell have also collated the lessons learnt during the initial phase of the pandemic. As previously stated the Healthy Wirral Programme Delivery team are undertaking an assurance exercise on the restart plans of our three main NHS providers against the national ask.

2.2 Whilst the Health and Care Cell has had oversight of the restart plans, NHS Wirral CCG have had much closer oversight of activity plans and as a team we have co-ordinated and given permission for providers outside of the main NHS providers to restart services. Whilst the NHS providers have been directed by the national and regional command structure we have also sought clarity and assurance on plans, again to ensure a co-ordinated restart across pathways.

2.3 From NHS Wirral CCG perspective our priority has also been to review the impact of the

restricted elective care offer to the Wirral population and to seek assurance from our providers of their approach to restarting services. As previously stated our statutory duty and responsibility remains to ensure quality of care and our aim has been to ensure that our providers are continuing to deliver care to the priority cohorts of patients in the first stages of the second phase and adherence to national clinical guidance.

2.4 On the 11th May NHS Wirral CCG requested assurance from our providers on their

response to the second phase of the pandemic in particular to their management of restarting elective care, including approach to management of risk. Responses were received from all our providers other than two specialist hospitals (responses continue to be requested) and shared with the Health and Care Cell. (All responses received have been

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collated and available on request). All providers have confirmed they are complying with national guidance in terms of restart of elective care and have maintained treatment of those patients clinically deemed urgent. As providers are now progressing to a phased restart of non-urgent elective care, further information on these plans has now been requested on the 19 June 2020 to ensure we continue to have oversight and assurance of restart plans for elective care.

2.5 As a result of the COVID-19 pandemic access to elective care has been severely restricted.

From review of the elective care performance the total number of Wirral patients waiting more than 18 weeks has significantly increased and since March the number of people waiting over 52 weeks has been increasing. Restarting elective care beyond urgent categories is needed to address the waiting times and review of any harm as a result of prolonged waits.

3. IMPLICATIONS

3.1 The Health and Care Cell has captured the lessons learnt from the changes undertaken by

health and care providers in response to the pandemic and we will continue to review these to ensure they are embedded going forward. The transformation in primary care in particular of virtual triage and virtual appointments being available, and of the transformation to virtual out patient appointments being the default are of particular benefit to patient’s experience of care and will enable elective care to restart safely.

3.2 For our three main NHS providers in Wirral assurance has been given of compliance with national guidance and the management of new referrals and existing patients. All providers are offering virtual appointments and all have continued to receive urgent referrals. The Wirral Community Care and Health NHS Foundation Trust (WCHC) are complying with specific guidance issued for community services. WCHC has maintained all of its commissioned services, either in a partially stopped or continued capacity and adopting virtual appointments for a range of community services. All stepped down services continue to receive urgent referrals. WCHC have undertaken assessments of all active caseloads, prioritising patient’s based upon established clinical triage of need and risk. Caseloads continue to be reviewed within all WCHC services along with new referrals. Further guidance on restarting community services has yet to be issued.

3.3 Our main mental health provider Cheshire and Wirral Partnership NHS Foundation Trust (CWP) is also compliant with national guidance and have also adopted virtual out patient appointments. In terms of clinical assessment and prioritisation CWP have confirmed that the process is happening as it normally would in all services for new referrals. All community caseloads have been prioritised utilising a clinical prioritisation framework, which are monitored on a weekly basis. In addition, learning disability teams are using a dynamic risk stratification tool. In line with national guidance, CWP are now providing a 24 hour, 7 day a week crises help line for all ages. Some waiting times for services have improved as a result of adoption of virtual appointments and for those services that waiting times have increased, such as the Memory Assessment Service, mitigating actions have been undertaken. Our provider for Improving Access to Psychological Therapies (IAPT) have continued to provide ‘talking therapies’ virtually and have adopted innovative ways to widen

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this offer to group therapies.

3.4 The majority of Wirral patients access their elective care from Wirral University Hospital Teaching NHS Foundation Trust (WUTH). The initial plans of WUTH have complied with the ask within the second phase guidance and the Trust has set up a Planned Care Recovery Programme led by the Chief Operating Officer. Each specialty within the hospital has outlined demand and capacity required to meet the non COVID urgent categories and all patients in these groups have now been booked for an appointment by the national deadline.

3.5 WUTH, Liverpool University Hospital and Countess of Chester Hospital, where Wirral

patients are regularly referred to have now confirmed that they have produced a divisional mobilisation plan to outline the proposed timescales for reintroducing routine elective activity in line with national guidance. WUTH especially have developed and agreed a recovery plan with their divisions to support the activities required to undertake electives safely and appropriately. In August WUTH is planning 80% of out patient activity (in comparison to August 2019) and theatres will be delivering 50% of what was done in the respective months of July and August 2019 with the exception of trauma and orthopaedics who from mid July will be operating on 1 list per day with 1 revision patient.

3.6 We will continue to monitor the impact of the pandemic on elective care and the waiting

times across the different specialties. It is envisaged that elective care will be restricted for the foreseeable future due to the infection prevention and control measures. GP Referrals for May 2020 are 33% of May 2019 and Non GP are 51% of May 2019. The drop in referrals to WUTH is shown below is of concern and communication to the public to encourage access to health care will continue.

The referrals for all suspected cancer tumour groups received by the hospital has also

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reduced to 27% compared to pre COVID-19. We will continue to work with the Cancer Alliance to ensure consistent communications to the public and review of capacity to meet future cancer treatment requirements.

3.7 NHS Wirral CCG have maintained quality and performance meetings with our three main providers and will continue to seek assurance on the management of any risks to patients as a result of prolonged waits with all our providers and any cancer waiting times breaches and 52 week breaches for elective care. As Spire Murrayfield continue to be commissioned nationally to support provision of urgent elective care, they are presently unable to restart provision of care to those on their waiting lists that are not classed as urgent. We are reviewing these waits and will ensure choice is offered for those patients who could receive treatment elsewhere.

3.8 In order to co-ordinate the restart of pathways we have had numerous meetings with

providers and assurance given prior to our approval to restart services in our non NHS providers, such as ophthalmology and audiology pathways which have now been given permission to restart their elective non urgent provision. Our co-ordination and oversight role across the system has also included weekly review of capacity and updates of restart plans with our patient transport service provider, bi weekly meetings with all of our mental health providers where plans to prepare for the impact on mental health of the pandemic have been agreed.

3.9 The Wirral system has now commenced planning for winter to ensure that the health and

care services can continue to deliver care safely during the winter period. As a result of the restricted elective care provision already experienced the requirement to ensure that elective care provision continues during the winter months is critical. We will ensure that the demand and capacity planning model will include this requirement and that there are robust plans across our providers for providing elective care during a winter period with COVID-19.

4. CONCLUSION


• To note the actions taken by the CCG working in partnership with our system for the safe and effective restart of elective and planned care services.

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APPENDIX 1: Key financial decisions made under emergency procurement powers

Funded initiatives Duration Bed numbers

Wirral Bourough Council funding

NHS Wirral CCG

funding

Total funding

Step Down (T2A) Nursing Care beds at Marine Point

9 months 50 £2,900,000 £2,900,000

21 EMI (Dementia Support) beds at Marine Point

9 months 21 £800,000 £800,000

Commission of 19 residential beds. 6 additional nursing beds and primary care support to be funded by Wirral CCG.

6 months

25 £368,888 £182,997 £551,885 Elderly Medical Infirm beds as part of the emergency discharge pathway. Wirral CCG to meet additional nursing and primary care costs .

25 weeks

6 £97,200 £32,520 £129,720 Consultant led beds to be commissioned from Wirral Hospice St Johns for Covid-19 patients who are deemed end of life.

12 weeks

6 £85,176 £85,176 20 residential short term beds at Homecrest

6 months 20 £278,325 £278,325

Support to Age UK to support increased capacity and vulnerable people in the community

6 months

- £600,000 £600,000 Support for care home providers’ present cost pressures staffing, infection control and PPE/food.

6 months - £256,000 £256,000

Support additional care home admissions via a £200 one-off additional payment for each new care home admission at standard contract rate.

3 months

- £100,000 £100,000 Support care sector via increase of fee rates across the care sector. Increase attributable to significant pressures related to staffing costs and staff availability in sector.

6 months

- £2,900,000 £2,900,000 Total 128 £8,022,088 £579,018 £8,601,106

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High Yes Medium Low

Financial recovery and delivery of constitutional standards are statutory requirements of the CCG. The CCG remains in formal directions of CCG and delivery of the financial recovery plans and improvement in performance of the constitutional standards are a priority for the CCG. The current corporate risk register includes the performance against the A&E target, the ambulance performance and also the ambulance handover times.

Director of Commissioning and Transformation

Performance Report

Agenda Item: 2.1.9 Reference GB20-21/0007 Public / Private Public Meeting Date 14 July 2020 Lead Officer/Author of paper

Nesta Hawker Director of Commissioning and Transformation

Contributors Steve Cocks, Assistant Director Performance & Delivery Richard Crockford, Deputy Director of Quality and Safety Siju George, Assurance & Procurement Lead Sue Borrington, Senior Commissioning Manager Heather Harrington, Senior Commissioning Manager

To Approve To Inform Yes To Assure Yes To Endorse Executive Summary Summary of April 2020 NHS England/Improvement (NHSE/I) nationally

published performance data along with more recent local intelligence. Recommendations The Governing Body is asked to:

• Note the performance of constitutional standards and actions taken

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Clinical engagement taken place Y Patient and public involvement taken place Y

Equality Analysis/Impact Assessment completed Y

Quality Impact Assessment Y


Y


Y


Y


Y


Y





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NHS WIRRAL CLINICAL COMMISSIONING GROUP GOVERING BODY

Report Title Performance of constitutional standards up to April 2020

Lead Officer Nesta Hawker Director of Commissioning and Transformation


• Note recent performance of the four constitutional standards and actions taken

1. INTRODUCTION

This paper provides Governing Body with a report on the key performance issues in the four NHS Constitutional standards that remain during the current COVID-19 pandemic related to the delegated duties of the Director of Commissioning.

2. PERFORMANCE AGAINST THE NHS CONSTITUTIONAL STANDARDS (April 2020)

The four constitutional performance standards are discussed and overseen at the Quality and Performance Committee. A full NHS Wirral Clinical Commissioning Group (WCCG) Performance Pack is prepared on a monthly basis and reviewed at each Committee along with deep dives into specific performance areas. A copy of the full WCCG performance pack is available on request. The Activity Management Group of the WCCG also reviews performance and any over or under performance triggers a deep dive in order to identify if there is opportunity for mitigating actions.

LATEST PUBLISHED DATA ANALYSIS & TRENDS

The following dashboard demonstrates the performance against the national standards in April 2020 for the above four standards and includes a trend analysis (May 2019 to April 2020).

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3. ACCIDENT & EMERGENCY

4 Hour Accident & Emergency (A&E) Standard

Performance against the 4 hour Accident & Emergency (A&E) standard improved in April 2020 achieving 88.4%. This compares to 72.7% in March 2020. The England average for April was 90.4% and the Cheshire and Merseyside Health and Care Partnership (C&M HCP) average performance was 92.7%. A&E attendance at Arrowe Park Hospital (APH) dropped significantly during April to an average of 160 attendances per day, this compares to 254 attendances per day in March. This is likely to be a result of the COVID-19 lockdown with potentially less accidents occurring and a reluctance of patients to attend the hospital site.

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The locally available data for May 2020 demonstrates a further improvement reaching 93.62% against the 95% standard. Data for June 2020 (1st – 16th) is demonstrating a slight decline from May’s position with performance of 89%. Attendances have begun to increase to an average of 223 per day during May, and 246.5 per day during June (1st to 16th).

Despite improved performance in April and May, the national standard of 95% failed to be achieved. The reasons for this are multifaceted and include:

• Division of A&E into suspected COVID-19 and Non COVID-19 units to avoid further spread

• Reduced workforce across hospital staff due to COVID-19 related sickness • Clinical breaches due to severity of patients attending • Additional time to ensure adequate Personal Protection Equipment (PPE) and Infection

Prevention Control (IPC) requirements followed

NHS England / Improvement (NHS E / I) and Emergency Care Intensive Support Team (ECIST) have been working with the system to address underperformance across the unplanned care system. The team have developed an 8 point plan to address the issues identified. The plan starts with A&E moving to supporting simple and complex discharges, capacity and demand modelling and intermediate care.

Actions have commenced within A&E to implement the recommendations. This includes;

• Implementation of electronic A&E record to replace Clinical Assessment Service (CAS) cards – this enables improved oversight of the department by the shift leader

• 2 hourly huddles consistently held within A&E and documented electronically • Real time escalation encouraged through the huddles • Redesign of A&E department underway to facilitate a Clinical Decisions Unit (CDU)

Streaming

Streaming activity dropped significantly during April 2020 to an average of just 10 patients streamed out of A&E per day. This compared to an average of 19 per day in March. This is reflective of the reduced footfall into the department. Activity has subsequently increased during May (average 19 patients streamed / day) and June (average 26 patients streamed / day 1st - 16th June). This performance is demonstrated on the Statistical Process Control (SPC) below which illustrates the last 60 days:

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18/04/2020-16/06/2020

The graph above demonstrates that despite an overall improvement trend, the data is variable on a day to day basis. System streaming meetings have now re-commenced following a pause during the initial phase of the COVID-19 pandemic. The group are working to optimise streaming in line with agreed targets (20% A&E attendances streamed). This includes review of GP utilisation and introduction of minor injuries pathways suitable for streaming.

Long Length of Stay

Long Length of Stay (LLOS) performance saw a significant improvement during April ending the month with just 36 patients with a Length of Stay (LOS) of 21 days or more. This is against a national target of 107 patients and a March average of 173 patients. This improvement is illustrated below:

This improvement has been facilitated by a number of factors:

• Increased workforce to support discharge with staff redeployed from non-essential services

• Pausing of some processes such as Continuing Healthcare (CHC) assessments

050

100150200250

Stranded Patients vs Target

Target Patients 14 Day Patients

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• Focussed support from NHS E / I and ECIST working with the Integrated Discharge Team to improve processes

• Application of the COVID-19 National Discharge guidelines which include removal of choice regarding discharge destination

• Additional community bed capacity commissioned across general nursing, Elderly Mentally Infirm (EMI - specialist homes for patients with dementia and other mental health conditions) nursing, EMI residential and general residential care homes

• Increased support from family/ friends to support relatives discharge due to potential risks of contracting COVID-19 whilst within the hospital

Despite this significant improvement during April, more recent data is demonstrating a slight increase to LLOS fluctuating between 50 and 60 patients currently. The ward with the largest number of these patients is a respiratory ward which will include patients with post COVID-19 complications.

As part of the implementation of the 8 point plan recommendation, the following actions have been taken to support timely discharge:

• Improved consistency with Integrated Discharge Team (IDT) support to ward rounds • Divisional directorate ownership of discharges – good progress across nursing/matrons

with additional work ongoing to enhance medical support and oversight • LLOS reviews / point prevalence reviews have recommenced with thematic analysis

underway and shared with system leads • Improved flow within intermediate care (Transfer to Assess (T2A)) bed base – including

introduction of commander of the day to mirror IDT approach to discharges and breach analysis taking place of all T2A LLOS patients with thematic analysis undertaken and shared

4. AMBULANCE

Due to COVID-19 and the need to prioritise COVID-19 related work, it has been agreed that the North West Ambulance Service (NWAS) will not report the local ambulance data. This position is likely to change as we move to phase 2 / 3 of the COVID-19 pandemic.

NWAS are able to share performance overall for the region. Cheshire & Merseyside performance has been reported as follows:

Standard Response time (secs)

w/c 24.04.2020 Response time (secs)

w/c 30.05.2020 Response time (secs)

Pre COVID-19 Response time (secs)

Cat 1 mean 00:07:00 00:07:03 00:07:12 00:07:14 Cat 1 90th centile 00:15:00 00:11:49 00:11:01 00:12:17 Cat 2 mean 00:18:00 00:19:31 00:17:31 00:20:07 Cat 2 90th centile 00:40:00 00:38:15 00:34:08 00:41:02 Cat 3 90th centile 02:00:00 02:01:31 01:43:58 02:13:37 Cat 4 90th centile 03:00:00 02:40:04 02:25:54 02:28:18

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The data above demonstrates that NWAS performance across Cheshire & Merseyside has improved during the COVID-19 period.

In April the system achieved the turnaround standard of 30 minutes. This has been supported by the implementation of an ‘Ambulance Deep Cleaning & Infection Control deep cleaning service for all ambulances as they arrive at the APH site. Whilst in April the system achieved the turnaround standard of 30 minutes, the arrival to handover standard was missed by 3 minutes as demonstrated below. This will likely be due to the same factors as the failure to achieve 4 hour standard as referenced above.

Standard (National Target) Plan Apr-20 Avg Arrival to Handover (Arrowe Park) The above two measures have been combined into this one

<15m 18 mins

Avg Handover to Clear Time (Arrowe Park) <15m 11 mins Avg Overall Arrival to Clear Time all Attends (Arrowe Park) <30m 30 mins

5. NHS 111 PERFORMANCE

The demand on the NHS 111 service during April & May has fallen compared with March with communications messages advising patients to access NHS 111 online as an alternative to calling NHS 111.

The data below demonstrates improved performance against all indicators measures compared with March 2020. However all continue to breach national standards.

111 Standard (National Target) Plan Mar-20 April 20 Calls answered within 60 seconds >=95% 47.1% 52.30% Abandoned calls <5% 41.2% 23% Calls warm transferred >=75% 12.83% 15.20% Calls backs within 10m >=75% 13.87% 18.40% Clinical calls >=50% Not available yet Not available yet

Activity levels are starting to return to business as usual however there are some changes in call patterns that need to be reflected in the working rotas, such as previous peak after school whereas that is less applicable. A number of actions have been taken to improve performance which include deployment of 100 student paramedics to support pathways on the COVID-19 line and continued promotion of NHS 111 online to reduce demand on call handlers.

6. REFERRAL TO TREATMENT

At the end of April 2020, nationally 71.3% of patients waiting to start treatment were waiting up to 18 weeks, thus not meeting the 92% standard, some 3.9 million patients nationally. Of those, 11,042 patients were waiting more than 52 weeks.

Nationally, the number of Referral to Treatment (RTT) patients decreased by 8.2% compared to the end of April 2019, at the end of April 2020 and the national trend shows a reduction in waiting list size since the start of COVID-19.

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Incomplete Pathways Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

National % waiting <18w 86.5% 86.9% 86.3% 85.8% 85.0% 84.8% 84.7% 84.4% 83.7% 83.5% 83.2% 79.7% 71.3%

At local level, in April WCCG’s total RTT waiting list size remained within target, however the number of patients over 18 weeks who were unable to be treated reached 15,149 (out of a total of 22,819 patients). This mainly reflects the actions taken by providers as a result of COVID-19 mandate to stand down routine activity, which had a significant impact on WCCG’s RTT performance, at 66.39% in April.

At provider level, WCCG’s main provider WUTH has stepped down majority of their routine activity in April due to the Trust’s response to COVID-19 in line with national guidance. This has severely affected the achievement of the RTT standard and performance will continue to be affected until routine activity increases significantly. The significant reduction in referrals has also affected the RTT performance by reducing the overall denominator of the waiting list.

RTT incomplete performance

RTT Incomplete Pathways Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Wirral CCG % waiting <18w 81.00% 82.70% 82.20% 82.00% 81.70% 81.60% 80.80% 80.00% 79.80% 80.00% 79.90% 76.40% 66.40%

WUTH only % waiting <18w 79.00% 80.70% 80.20% 80.10% 79.90% 79.60% 79.00% 78.20% 78.80% 78.30% 78.50% 75.00% 64.80%

National Trajectory 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00% 92.00%

Local Trajectory 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% N/A

WUTH Total Pathways 26,223 27,317 25,733 24,733 24,846 24,721 24,368 23,597 23,233 22,988 23,207 22,350 21,344

The total number of patients waiting more than 18 weeks at WUTH has significantly increased from 7,476 patients at March end to 13,837 patients at the end of April 2020 (an increase of 6,361, 85.09%).

52 Week Breaches

The Trust 52 week breach position deteriorated in April with 45 WCCG patients waiting longer than 52 weeks for treatment at WUTH and 1 Wirral patient breached at Lancashire Teaching Hospital. This is a direct result of stopping routine elective surgery and the performance is expected to deteriorate as a result of COVID-19 lockdown though patients are being seen where possible. May position is again based on indicative data only. All 52 week breaches will have a harm review undertaken by the Trust.

SPECIALITY Jan-20 Feb-20 Mar-20 Apr-20 May-20 52 week breaches at WUTH 0 0 15 45 200

Diagnostics Performance

The Diagnostic performance deteriorated significantly in April, at 43.29%. This is a direct result of the national mandate to cease non urgent elective activity, where patients are referred for

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tests and added to the waiting list but the Trust was unable to offer an appointment at this time. Diagnostic services for ‘two week waits’ and urgent patients continued and primary care have been urged to continue referring patients through these pathways.

Recovery Plans

Three major providers in the region, WUTH, Liverpool University Hospital and Countess of Chester Hospital where Wirral patients are regularly referred to have now confirmed that they have produced a divisional mobilisation plan to outline the proposed timescales for reintroducing routine elective activity in line with national guidance. WUTH especially have developed and agreed a recovery plan with their divisions to support the activities required to undertake electives safely and appropriately.

It is envisaged that RTT performance will be negatively impacted for the foreseeable future due to the inability to provide pre-COVID-19 levels of routine activity and also the risk stratification of individual patient pathways. Performance improvement will vary per speciality depending on the interdependencies on diagnostics and the need for Aerosol Generating Procedures (AGP). These are all being considered as part of the divisional mobilisation plans.

As part of WUTH recovery plan, the Trust is now moving to reinstate elective activity beyond those assessed as urgent. Their plan includes agreed increased activity levels for June, July and August 2020 focusing on resuming Outpatient and Theatre activities from 1st July. The Trust has already commenced activities in line with guidance for phase 2 and the following patient categories all have an appointment booked by 3rd July 2020.

1. Overdue follow up by 12 months 2. RTT 40+ weeks 3. Urgent diagnostics 4. Diagnosed CA P2 and P3 (suspicion for malignancy are graded - P2: benign, P3:

uncertain / likely benign) 5. 2 Week Wait (2WW) referrals CA

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Outpatient July 2020 activity has been planned with a 10% rise in activity over June 2020 and is planned to achieve 70% of the activity carried out in July 2019. Similarly August 2020 has been calculated with a further rise of 10% over July 2020 to achieve 80% of the activity carried out in August 2019. The default for outpatient activity will be either telephone or video appointments. Theatres will resume from 1st July at 50% capacity, i.e. from July 50% of July 2019 activity with the exception of Trauma and Orthopaedics (T&O). T&O initially is planning to deliver one list per day, during weekdays at APH commencing from 13th July. Diagnostic provision is also increasing and all patients on the radiology waiting list have been identified and prioritised as to urgency of request.

Endoscopy plan is to carry out 820 elective scopes over the next 12 week period as below.

Location w/c 15-Jun

w/c 22-Jun

w/c 29-Jun

w/c 22-Jun

w/c 06-Jul

w/c 13-Jul

w/c 20-Jul

w/c 27-Jul

w/c 03-Aug

w/c 10-Aug

w/c 17-Aug

w/c 24-Aug

WUTH 50 50 50 50 50 50 50 50 50 50 50 50 Spire 0 10 21 21 21 21 21 21 21 21 21 21 Total 50 60 71 71 71 71 71 71 71 71 71 71

WCCG are now attending weekly meetings with WUTH to review their actual performance and plans for delivering activity going forward.

NHS E is currently working on a Cheshire and Mersey level approach to RTT and Diagnostics and these plans are due to be shared with CCGs in July.

7. CANCER

Summary Performance for April 2020:

Cancer Performance in the month of April shows a significant deterioration in 2 week wait (2WW) performance, this was across all tumour groups due to cancellation of clinics in response to COVID-19 and also a high proportion of patient cancellations. This trend is expected to continue into May and potentially June performance.

Overall there remains a reduction in 2WW referrals as demonstrated in the chart below:

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Source CACM

Currently, at 22nd June, overall WUTH 2WW referrals are reduced by 28% of pre-COVID levels, this compares to 27% overall reduction for Cheshire & Merseyside.

WCCG achieved all other performance measures. However, the 62 day wait standard shows amber with 1 patient breach. The diagram below shows Wirral as ranked 2nd across Cheshire & Merseyside for the 62 day wait standard.

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There are currently 1500 patients on cancer pathways at WUTH, of these 370 remain suspended sue to COVID-19. This is a significant reduction from May figures, which is due to re-opening of diagnostics and therefore patients being able to progress on their pathway. All diagnostics for cancer patients are now available, however endoscopy has a significant reduction in capacity due to infection control, the potential for some endoscopy activity to take place at Spire Murrayfield is being explored. Of the 370 suspended patients, 200 are urology and 100 are colorectal.

Robotics theatres were due for re-start mid-June but WUTH have not yet advised of a firm re-start date. Previously WUTH advised WCCG, in mid-May, that a re-start was expected in 4/5 weeks. Clarification is therefore being sought as there is a significant amount of Stage 3 procedures outstanding, many of which are pre-COVID-19.

WUTH are closely monitoring and actively reducing the suspended patients list are these pose the biggest risk, along with the backlog and any potential surge in referrals. All patients are being treated according to clinical priority.

Two key documents have been issued in the last month. Cancer Waits Guidance in draft form and also a Phase 2 Letter for Cancer Restoration.

The WCCG Cancer Commissioner and Lead GP for Cancer continue to have bi-weekly meetings with the WUTH in order to discuss performance and any delivery issues. Plans for the introduction of Faecal Immunochemical Test (FIT) are still actively in development and it is anticipated that this will be in place within the next month.

8. ASSURANCE & RECOVERY

Reviewing the measures above indicates there has been improvement in several areas due to the focused work taken to prepare for and manage the COVID-19 pandemic. There are also some areas that have significantly deteriorated.

The assurance through recovery will be two fold; both to see improvements in the areas of deterioration and to see sustainability within the areas of recent improvement. The paper highlights some of the assurance that has been provided through focused meetings such as the Cancer meeting, elective surgery and outpatient restart plans, and progress monitoring of the 8 point urgent care plan. Whilst this provides some assurance that operational progress is being made, the regular Clinical Quality and Performance Group (CQPG) meeting is designed to support assurance in relation to organisational oversight of quality. This is a key meeting for WCCG to gain assurance with regards to the quality of care provided for Wirral patients.

During May 2020 WUTH was unable to attend the CQPG meeting, this was held internally with WCCG submitting a letter to WUTH for response.

With regards to the above measures the correspondence related mostly to the concerns about RTT performance and has now confirmed that WUTH are completing the required reviews for 52 weeks breaches to the RTT standards; however this has not provided assurance with regards to proactive harm reviews to mitigate risks to long waiting patients. There is

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confirmation that waiting lists have seen patients clinically prioritised but not that this has an agreed review frequency should priority change during waiting times.

CQPG meetings will continue to seek assurance around the safety of patients waiting prolonged periods against the RTT standards.

The correspondence referenced also sought assurance with regards to other aspects not detailed earlier in this report but vital for quality assurance and to support the recovery phase; response to WUTHs CQC report, Healthcare Associated Infections (HCAI) reporting and staffing. Assurance has been received that these items are being reviewed within WUTH, however similarly to assurances highlighted earlier there is further detail required at the next CQPG meeting.

9. CONCLUSION

The Governing Body is asked to:-

• Note the content of this performance report and actions being taken.

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Master

Risk ID Date added Source Committee

Risk Description Organisational Objectives (reference to detail)

Consequence

Likelihood

Matrix Score

Key Control Established Key Gaps in Control (reference to evidence)

Assurance on Controls (reference to evidence)

Gaps in Assurance (reference to evidence)

Consequence

Likelihood

Previous Risk

Rating

Owner Date of next review

Date of last review Last review

19/20/F Mar-20 CCG GB Covid-19 - Impact on CCG affecting ability to continue business as usual (Such as HQ building closed by landlord, staff shortages through self isolation, sickness etc).

All 4 3 12.00 Business Continuity Plan.

Staff skills audit to allow redeployment to key roles

Daily Incident Management Team meeting.

Remote working (including diversion of calls)in place for all staff

Communications team have developed channels to promote Staff .

None. Action plan from daily Incident Management Team meeting.

Business Continuity Plan measures.

Cross cover and matrix working, if required.

Bulletins regularly issued, KIT meetings established and Facebook

group established, including resources for wellbeing and mental

health.

None 4 5 20.00 PE July 20 QP May 20 QP New risk agreed to e added at GB held in March 2020.

Likelihood score reduced to 3 at June 20 QP as Business Continuity Plan has been successfully implemented with no major disruptions to key work. Score to be kept under review as new developments could impact on business

19/20/G Mar-20 CCG GB Covid-19 - Financial impact of commissioning new services and additional primary care requirements.

Financial / Commissioning

4 5 20.00 New Business Case Approval Structure in place

Clarity on reimbursement process for CCGs

CFO has prepared Covid-19 Emergency Budget and presented to Finance Committee and included in May Governing Body for approval.

No guarantee that reimbrisement will match

expenditure

Business Cases process designed by CFO and managed via the CCG's

PMO functon

Scheme of Reservation and Delegation

Governance arrangements may hamper rapid

decisions.

Process for "reasonable" variances and

retrospective allocations not tested.

Operating Guidance and

Allocations for M5-M12 to be published in July.

4 5 20.00 MC/ NH July 20 QP May 20 QP New risk agreed to be added at GB held in March 2020.

QP members agreed at June 20 QP to keep scores the same

19/20/H Mar-20 CCG GB Covid-19 - Impact on commissioning activity, redesign and plans e.g. elective procedures cancelled and subsequent impact on the wellbeing of the Wirral population.

Commissioning / Quality and Safety

4 5 20.00 National Guidance on NHS service delivery

Health and Care Cell established

Clinical System Oversight Group established

Letter from Simon Stevens dated 29.04.20 outlines NHS second phase of

response to Covid-19.

Changing landscape alters rapidly and could cause

lag in adoption

Daily updates/cascades from Regional/National Level

Action Log for both groups

Action plan being developed in response to letter from Simon

Stevens dated 29.04.20

Changing landscape alters rapidly and could cause lag

in adoption

4 5 20.00 NH July 20 QP June 20 QP New risk agreed to be added at GB held in March 2020.


19/20/I Mar-20 CCG GB CHC:

- People being lost in the system due to the new arrangements of "care without predujice" .- People having care packages that don’t meet all their needs

due to relaxation of 3/12 month reviews.- Quality of services reduces due to assurance standards not being required.- Post Covid 19 backlog of LR and assessments .


4 5 20.00 National Guidance on NHS service delivery

System to be established in order to track people .

Telephone calls with clients/families to ensure package meets needs.

Monitor standards even if they are not reported formally.

Tracking system to be implemented

Resources, time and staffing will be required to

address backlog

Daily updates/cascades from Regional/National Level

Tracking system to be implemented

Resources, time and staffing will be required to

address backlog

4 5 20.00 LQ July 20 QP June 20 QP New risk added at QP in March 2020.


19/20J Mar-20 CCG Audit Potential of an increase in fraudulent activity across the NHS as outlined by the Counter Fraud Specialist.

All 4 5 20.00 Counter Fraud Specialist to advise on fraud prevention.

Audit committee to review approproiate counter fraud measures.

None. Briefings provided by Counter Fraud Specialist

Minutes of Audit Committee.

None. 4 5 20.00 MC July 20 QP June 20 QP New risk added at QP in March 2020.

QP members requested that the Anti Fraud Specialist consider whether the mitigations have reduced the likelihood score.

19/20K Mar-20 CCG GB Covid-19 – Impact on mental wellbeing and IAPT service

provider to cope with additional demand as people may require additional support..


4 5 20.00 Request for IAPT provider to increase capacity.

Unprecedented pandemic so demand and impact

unclear.

Weekly video conference with the provider to review plans to increase capacity. Weekly review staff levels,

performance, waiting list and referrals.

Potential for poor patient experience.

Lack of capacity to meet increase demand and lack of additional trained staff.

4 5 20.00 NH July 20 QP June 20 QP New risk added at QP in March 2020.


19/20L Apr-20 CCG PCCC Covid-19 – Impact on resilience and service delivery of core

General Practice activityCommissioning / Quality and Safety

4 5 20.00 Daily Primary Care Incident Management Team established

GP Hub model deployed

PPE to support resilience o General Practice reliant on national supply chain

Action Log from PCIMT

Hub Delivery supported and monitored by Project Team

PPE to support resilience o General Practice reliant on national supply chain

4 5 20.00 PE July 20 QP June 20 QP New risk added at QP in April 2020.


19/20M May-20 CCG Finance Covid 19 - Cash management. Financial 4 4 16.00 Treasury Management Process.

Cash allocation for CV19 Expenditure confirmed.

Monthly review and reporting to NHSEI.

Budget approved by GB, including risks.

Specific documentation of risk with NHSEI and clarification of NHS

Framework for response.

Internal audit review of financial processes.

Non ISFE monthly reports.

GB approval of Budget 20/21.

CFO to write to NHSEI. 4 4 16.00 MC July 20 QP June 20 QP New risk added by MC on 15/05/2020.


19/20N May-20 CCG Finance Covid-19 - Financial Pressures on Primary Care Delegated Budget

Financial 3 4 12.00 Review and raise with NHS E / I.

PCCC governance in place and committee operational.

CCG agreement with NHSE/I for

tapered non-recurrent allocation of £1m.

Funding gap on transfer of budgets greater than

anticipated (£2m v £1m). Significant proportion of

Delegated budget expenditure determined

nationally, therefore gives limited opportunity to

address deficit recurrently

Internal audit review and action plan for PCCC in 2019/20. Follow up

audit planned Q3 2020/21. Letter from NHSE/I confirming

agreemen

CFO to complete additional due diligence review for transfer and

raise resultant issues with NHSE/I.

3 4 12.00 MC July 20 QP June 20 QP New risk added following QP held in May 20.


14-15G Apr-19 CCG QP Risk to patient safety due to corridor waits Quality / Patient Safety 5 4 20.00 A&E Delivery Board established and meeting regularly with representation

from the CCG.

Clinical Quality and Performance Group

Service Development Improvement Plans (SDIPs) agreed that will give additional leverage in contractual

management.

Regular Board to Boards held with WUTH where this risk is discussed.

Quality Surveillance Group Process

None Minutes from the A&E Delivery Board

Minutes from Contract Meetings.

Written SDIPs in place.

Minutes from Board to Boards.

Review of the delivery of the Improvement Action Plan.

Potential patient safety issues.

Poor patient experience.

Long length of stay impact on patients long term care

needs.

4 5 20.00 NH/LQ July 20 QP June 20 QP April 2019 : Quality review visits undertaken, ECIST visits are taking place on the 30th April 2019. Implementation of the RCP Report and Peer Review undertaken.

June 2019 update: Improvement seen in turnaround time. CQC targeted inspection has taken place March 2019. Actions implemented as per review.Quality review visit undertaken for assurance in relation to actions. 10th June. Deep dive into urgent care to take place in July’s Q&P. Risk rating to reconsidered in Julys Q&P.

July 2019 update: Following the deep dive into urgent care by QP Committee, there is a request for the risk rating to be reconsidered.

July QP Meeting update: Following the A&E Deep Dive, members were impressed by the range of measures and actions in place that collectively aim to address Urgent Care performance. In spite of this, members felt that these had yet to result in sustained improvement. As a result, members agreed to retain current risk scores but to assess risk again in Quarter 3 to establish if the actions have had the desired effect.

05/12/19 Improved streaming in place, including Paediatrics now being streamed. Interim UTC to start on 16/12/19. Long length stays remain an issue and this has been escalated by the A&E Board with actions on top of the winter plan, to aim to tackle this.

December QP Meeting Update: Members discussed in depth this risk in light of recent deteriorating performance within the Emergency Department at WUTH. Members concluded that whilst there was some evidence of potential harm, this was deem to be not clinically significant. Therefore it was agreed to raise the consequence level to 5 (recognising the potential for more significant harm) but to reduce the likelihood of this occurring to level 4, because robust mitigation are in place to safeguard against major patient safety issues.

January 2020: There is now a national focus on this area. Performance to be continue to be monitored.

January 2020 QP Meeting Update: Discussed at QP and members agreed as there was no change to the risk of patient harm, for the scores to remain the same.

February 2020:The position remains the same and will continue to be monitored.

28/02/2020: A number of actions are being taken as outlined above in previous updates. The Emergency Care Intensive Support Team (ECIST) have been supporting the system to implement robust weekly Long Length of Stay (LLOS) reviews with the aim of unblocking some of the issues creating delayed discharge. Whilst this has provided further oversight into what these patients are waiting for, it has yet to make a material difference to the number of LLOS patients within the acute. It is acknowledged that improvements to ward based care as a whole will result in improvements for LLOS patient cohorts as well as facilitating more efficient and timely non-complex discharges. Availability of beds will eradicate the need for corridor waits.

17/04/2020: Performance continues to be monitored, no surge predicted at present.

16/06/2020: As above, performance continues to be monitored.

16-17C Reviewed April 2019

CCG QP Increase in potential patient safety issues leading to moderate or severe harm at acute provider organisation.

Quality / Patient Safety 4 2 8.00 Monthly Serious Incident Review Group, of which minutes are also reviewed at

QP Committee.

System Improvement Board.

CQPG Meetings.

None. Minutes of Serious Incident Review Group.

Minutes of the System Improvement Board.

Minutes of CQPG Meetings.


4 3 12.00 LQ TBC - On hold (During Covid-19 Pandemic)

March 2020 QP September 2019 update: A Quality Review was conducted on August which provided some assurance on the actions completed by the Trust. Following a review of the documentation from the review, this is going to be shared with the Provider for comments.

24/09/19 QP noted actions and agreed not to change scores.

10/10/19 Documentation following the review of the department has been shared with the Provider for comments. CQC are with the Provider organisation at present and we are therefore awaiting feedback from this inspection.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed to reduce the likelihood to 2 as some of the most important issues have been progressed following the review of the department.

26/11/19 Suggested amendment to scores (as above) agreed at November QP.

January 2020: Awaiting feedback from CQC inspection.

February 2020: CQC report is awaited and no recorded episodes of harm.

February 2020 QP: LQ updated that the report is now with the provider organisation and the CCG are awaiting a copy of this report.

March 2020 QP - Agreed as risk on hold (during Covid-19 pandemic).

COVID-19

OTHER RISKS

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16-17D Reviewed April 2019

CCG QP Risk of potential patients harm due to non achievement of RTT (Referral to Treatment).

Quality / Patient Safety / Commissioning

3 2 6.00 RTT Strategic Board.

Data Trackers in place.

Oversight and Activity Management Group.

Contract Meetings.

System Improvement Board.

Data Trackers not rolled out all specialties.

Minutes from the RTT Strategic Group.

Performance Data.

Minutes from Contract Meetings.

Minutes from System Improvement Board.


Processes not universal.

3 3 9.00 LQ TBC - On hold (During Covid-19 Pandemic)

March 2020 QP August 2019 QP meeting update: The QP Committee reviewed the RTT harm review paper and agreed that this risk could be reduced. The likelihood of the risk was reduced to a 2 as the risk is being managed and the consequence as a 3 to ensure that the risk remains highlighted for discussion.

September 2019 update: MK advised that there were no further updates to be added to the risk this month.

24/09/19 QP noted actions and agreed not to change scores.

15/10/19 The position remains the same and will continue to be monitored.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed for the scores to remain the same as the risk is being managed appropriately. To remain on the risk register as a 'watching brief'.

January 2020: The position remains the same and will continue to be monitored.


February 2020: The position remains the same and will continue to be monitored.

28/02/20: Gap in assurance identified with other provider organisations who the CCG has an associate contract with. Work is being undertaken within the Contracts Team to ensure measures in place to prevent this from occurring in the future.


17/18F Reviewed April 2019

CCG QP Managing effectiveness of staff and development. All 3 3 9.00 PDR process. Awaiting development of new PDR process.

Action plan in place as per the key controls established.

PDR compliance rate.

Compliance reports provided.

Implementation of new PDR process to allow accurate compliance

reporting.

3 3 9.00 PE TBC - On hold (During Covid-19 Pandemic)

March 2020 QP September 2019 update: The workforce team have apologised for the delay in producing the PDR template suitable for the ESR system and advised that time will be dedicated to producing the template within the next two weeks.

10/10/19 Draft template of new PDR template has been shared and a meeting has been arranged with the Workforce Team and Corporate Affairs Manager on 24th October 2019, to test the system prior to roll out to all staff.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed no changes to be made at present until PDR system has been agreed with the CSU.

05/12/19 Discussions have been taking place around integrating PDR processes with the Electronic Staff Record (ESR). It has emerged that this is now proving technically difficult, so the CSU are developing an alternative proposal.

January 2020: New proposal for system has been received from the CSU. To be trialled by CCG staff to assess the effectiveness of the new approach. Further update to be provided in February 2020.

February 2020: In light of the national changes to Agenda for Change Terms and Conditions, Midlands and Lancashire Commissioning Support Unit (MLCSU) have been looking to develop a new system of recording appraisals within ESR. This is in preparation for appraisal dates linking directly to pay progression. MLCSU have now suggested an alternative appraisal approach is put into place, which MLCSU staff themselves are now using. Therefore, the CCG will be trialling the new approach with a small number of staff throughout February, in the first instance, to assess the effectiveness of the new approach and iron out any problems.

February 2020 QP: LL updated that the deadline for feedback to be provided with regards to the new approach is due to be received by 28/02/2020.


17/18H Reviewed April 2019

CCG QP Failure to meet Category 1 and Category 2 ambulance response times leading to potential patient safety issues.

Commissioning/Quality 4 4 16.00 Strategic Board in place that oversees ambulance performance on behalf of

several CCGs including Wirral.

Incidents Meeting.

None. Minutes of Strategic Board.

Minutes of Incident Meeting.

Delivery again the Improvement Trajectory.



4 5 20.00 NH July 20 QP June 20 QP September update 2019: latest data available is July 2019 which shows targets for category 1 and 2 have not been met. Performance July is slightly better than June. Improvement plans in place. It is likely that performance will deteriorate August/September as handover times and turnaround times have increased which will likely have a knock on effect on cat 1 and 2 calls. This will be closely monitored.

24/09/19 QP noted actions and agreed not to change scores. Given the ongoing performance concerns the members asked that a deep dive at QP be expedited.

10/10/19 Deep dive to be undertaken. This is scheduled on the workplan for QP for November 2019.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed to reduce the likelihood to 4 as there is no evidence of harm.


05/12/19 Due to winter pressures ambulance handover times and targets for category 1 and 2 have deteriorated.

December QP Meeting Update: Members discussed in depth this risk in light of continued poor performance of the ambulance service. Members concluded that scores should remain the same as the risk of potential harm remains present, but at this stage there has been no significant risk to patient safety.

January 2020: No further update to position - Next update therefore due in February 2020.


February 2020 QP - Committee members noted that further assurance relating to risks is being requested, negotiations are ongoing with regards to a regular report relating to Emergency Department safety.

28/02/2020: A Contract Performance Notice has been issued on the category 2 performance by the Blackpool Commissioners. An improvement trajectory has been agreed, which outlines achievement of all categories in Quarter 4 2019/20, with the exception of Category 1 mean, which will be achieved in Q2 2020/21. Full roster changes will be implemented in order to achieve the standards. The performance improvement plan is monitored by Northwest Strategic Partnership Board (Blackpool CCG, lead commissioners, NHSE and NHSI). Additional paramedics have been recruited to support across West Cheshire and Wirral. There is a correlation between ambulance performance and ED performance as when ED is under increased pressure, crews are at increased risk of delayed handover and turnaround times which consequently impact their ability to respond to calls in a timely manner.

17/04/2020 - Ambulance service are only responding to category 1 now, in light of Covid-19 Pandemic.

16/06/2020 - Update as above.

18/19C Reviewed April 2019

CCG QP Failure to meet Ambulance Turnaround target of 30 minutes.

30 minute target includes time from when the ambulance arrives on the hospital grounds to the time the patient is handed over to A&E and the ambulance is made ready to respond to the next call.

Arrowe Park hospital are amongst the six worst performing hospitals in the North West on turnaround.

Commissioning 4 4 16.00 WUTH and NWAS are jointly implementing all aspects of NHS

Improvement's handover guidance. A monthly meeting is held between WUTH,

NWAS an CCG to monitor progress. This feeds into A&E Delivery Board.

WUTH are one of six trusts in the North West that have been selected to

participate in a rapid improvement programme with NWAS.

None. Ambulance Handover Action Plan

Minutes of A&E Delivery Board.

Minutes of Urgent Care Operational Group.



4 5 20.00 NH July 20 QP June 20 QP September 2019 update – Performance has started to deteriorate with Wirral becoming one of the worst performing Trust’s in the region again. Reverse cohorting is in place and nurses are supporting the corridor to minimise delays to handover and turnaround times however it remains a significant issue. ECIST are

supporting with long stay patients and streaming. The number of long stay patients has increased significantly over recent weeks correlating to deterioration in handover times and an increase in corridor waits. As a result a daily multi organisation response is in place to review patients with extended length of stay and a senior lead is given responsibility for progressing their discharge. It is anticipated that as discharges increase, occupancy will drop and the pressures in ED will be significantly reduced. Streaming also includes internal options to assessment and specialty level support this will also reduce ED pressures. 24/09/19 QP noted actions and agreed not to change scores. Given the ongoing performance concerns the members asked that a deep dive at QP be expedited.

10/10/19 Deep dive to be undertaken. This is scheduled on the workplan for QP for November 2019.

01/11/19 Following an action agreed at October 19 QP, PE and LQ reviewed this risk and agreed to reduce the likelihood to 4 as there is no evidence of harm.


05/12/19 Performance has deteriorated due to hospital pressures. Escalation protocols are being adhered to.

December QP Meeting Update: Members discussed in depth this risk in light of continued poor performance of the ambulance service. Members concluded that scores should remain the same as the risk of potential harm remains present, but at this stage there has been no significant risk to patient safety.

January 2020: No further update to position - Next update therefore due in February 2020.


February 2020 QP - Committee members noted that further assurance relating to risks is being requested, negotiations are ongoing with regards to a regular report relating to Emergency Department safety.

28/02/2020: Performance has deteriorated due to winter pressures. Ambulance handover performance is reviewed on a regular basis both in Wirral System meetings and with NHS E / NHS I.

17/04/2020: Performance continues to be monitored and any pressures highlighted in light of Covid-19 Pandemic. but it will be due to pressure of COVID if there are issues.

16/06/20: Update as above.

19/20A Jul-19 CCG Finance CCG has been set a balanced position control total, but this would require a £24m QIPP which is clearly not deliverable. In addition, the Wirral system has the opportunity of receiving £20m of external funding, but only if Provider control totals are met.

Consequently the CCG with partners, has adopted a collaborative place based approach to help WUTH deliver it's control total in order to receive the external funding, which includes a explicit subsidy of £4.5m, and 'ring fences' WUTH income from being targeted by the CCG QIPP.

The impact of this is that the CCG is facing a deficit of £14.8m, resulting in a system deficit of £13.6m (as opposed to a system deficit of £33.6m). Discussions with NHS England/Improvement have clarified that the system control total remains as £1.2m surplus. which presents a significant risk in terms of the CCG achieving a break even position

Financial 4 2 8.00 Turnaround Director and Healthy Wirral Finance Lead appointed for some time.

Regular Financial reporting to Finance Committee and Governing Body which will now also incorporate the system

wide financial reporting as each Board and Health Wirral Partners Board.

Production of a Wirral system Financial Recovery Plan

Negotiations have taken place with NHS E / I to seek a revision to the control

total.

Additional savings/mitigations yet to

be fully identified with significant risk on the ability to implement.

Minutes from Finance Committee and Governing Body

Minutes from the Healthy Wirral Partners Board

The regulator has revised the control total deficit to £13.975 million in line

with the CCG's financial plan.

Poor patient experience. 4 5 20.00 MC TBC - On hold (During Covid-19 Pandemic)

March 2020 Finance August 2019 update: A meeting has taken place with the regulators on the 6th August 2019 who have reiterated the requirement of the system to meet the sum of the individual organisational control totals (£1.2m surplus). A further submission is to be made 13th September 2019 which will need to demonstrate the recovery and mitigation actions to be implemented, in order to eradicate the net risks of £14m. Work is currently ongoing in this area.

September 2019 update: work is ongoing to finalise the update for the 13th September 2019 and preparation for the 25th September meeting. conversations are being had with the regulations in advance of the submission and meeting to ensure the regulators are briefed and aware of our current position.

October 2019: Meeting took place on 25th September 2019 in respect of overall system performance including finance. Generally well received by the regulators but recognised that further scrutiny and meetings will be taking place on finance.

16th October - Letter was received from Graham Urwin in respect of financial position and reiteration that the system needs to do all it can to achieve its control total, including the CCG's control total of nil. Regulators anticipate revised FRP on 1st November 2019 detailing how this will be achieved.

04/12/19 Revised FRP submitted to regulators, who still wish to see the Wirral System to achieve a breakeven position. The current overall potential system deficit is £24.1 million, due to over performance in a number of areas. The CCG continues to explore all opportunities to manage its year end position.

January 2020: The 2019/20 financial year end position for the Wirral System has now been fixed at circa £20million net of WUTHs £4.4 million Provider Sustainability Funding which will now not be received. The CCG element within this overall system position is a deficit of £13.975 million, which will need to be delivered.


February 2020: The position remains the same at present. Previously the £13.975 million was the CCG's risk adjusted deficit. This has now been formally approved by NHSE/I and will now be reported as a formal forecast outturn.

February 2020: Negotiations have taken place with NHS E / I to seek a revision to the control total and the regulator has revised the control total deficit to £13.975 million in line with the CCG's financial plan. In line with this likelihood score reduced to 2 from 5. Interim CFO meeting with Finance Committee representatives on 10/03/2020 to discuss mitigation.


19/20/C Aug-19 CCG Finance Implications of an independent review being commissioned by the CCG of a provider that became unsustainable and went into administration.

Financial / Quality 3 4 12.00 Regular discussion with NHS Resolution and have been seeking advice from Hill Dickinson's to minimise the impact of

litigation against the CCG.

Independent Review commissioned by NHS E / I.

Review team have been identified and Terms of Reference established.

None identified at present (awaiting report).

Report from the Independent Review commissioned by NHS E / I.

3 4 12.00 MC/LQ TBC - On hold (During Covid-19 Pandemic)

March 2020 QP 10/10/19 Independent investigation to be commissioned by NHS England and NHS Improvement. The Terms of Reference are currently being drafted for this investigation.

December QP Update: No change to last update.

January 2020: The final version of the Terms of Reference are currently being drafted for this investigation.


February 2020: The Terms of Reference for the investigation are going for consultation and data is being collected to support the investigation.

28/02/2020: CCG has inputted into TOR and review to commence in April 2020. Suggestion to revise scores at QP to be held in March 2020.


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19/20/D Nov-19 CCG QP The Special Educational Needs and Disability (SEND) reforms came into effect in 2014 and were detailed within a Code of Practice which was published in 2015. A recent review of the CCG Compliance and Local system compliance with the reforms has indicated several areas for improvement. Whilst there is ongoing work across the system, a inspection is expected within the next few months and likely to be critical.

Quality/Patient Safety 2 4 8.00 SEND Operational and Strategic Group chaired by the Local Authority and

leading on majority of improvement work required.

There is an Inspection Planning Group also chaired by the Local Authority.

The Quality and Performance Committee will be receiving regular

updates in relation to the specific areas for improvement in the CCG.

The Health and Wellbeing Board will be receiving regular updates in relation to the system position in relation to the

reforms.

Time restrictions Minutes of SEND Operational and Strategic Group.

Minutes of Inspection Planning Group.

Minutes of Quality and Performance Committee.

Minutes of Health and Wellbeing Board.

Time restrictions. 2 4 8.00 LQ TBC - On hold (During Covid-19 Pandemic)

March 2020 QP 04/12/19 New risk added following QP held in November 2019. Suggested scoring as consequence 2 and likelihood 4, to be reviewed and agreed at QP to be held in December 2019.

December QP Update: Members agreed to proposed wording and risk scores.

January 2020: The position remains the same at present.


February 2020: The position remains the same at present - Next update due for March 20 QP.

28/02/20: Inspection awaited at present.


19/20/E Feb-20 CCG QP MSK failure to meet key performance indicators of the service. Commissioning 3 5 15.00 A contract Performance notice has been issued.

Remedial action plan agreed and a number of actions with deadlines

agreed.

The Quality and Performance Committee will be receiving regular updates in relation to performance.

Awaiting redesign of the MSK pathway.

Minutes of the Contract meeting.

Performance dashboard.

Remedial action plan.

Reputational damage.


Prolonged waits for patients.

Cost to the system.

3 5 15.00 NH TBC - On hold (During Covid-19 Pandemic)

March 2020 QP 28/02/20: New risk agreed to be added following QP Meeting held on 25/02/2020. Suggested scores with consequence of 3 and likelihood of 5.Progress has been made against the Contract Performance Notice and performance is now being achieved for Physiotherapy. Ongoing action required against pain management and rheumatology and the pathway redesign work will capture this.

17/04/20: MSK work is limited to urgent and critical work only, in light of Covid-19 Pandemic.

April 2020 QP - Agreed as risk on hold (during Covid-19 pandemic).

Impact ValuesNegligible 1 Minor 2Moderate 3Major 4Catastrophic 5

Probability Values

Rare 1Unlikely 2Possible 3Likely 4Almost Certain 5

Green/Yellow/Red Threshold ValuesGreen - maximum score 4Yellow - minimum score 5Yellow - maximum score 12Red - minimum score 15

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Report Title Finance Committee Chair’s Report

Committee Chair Lesley Doherty, Lay Member

Recommendations The Governing Body is requested to note the 28th April

Chair Report

1. PURPOSE

To scrutinise NHS Wirral Clinical Commissioning Group (CCG) financial and provider contractual performance and the financial recovery programme on available levels of assurance and/or escalate risks and issues requiring action.

2. KEY ISSUES Month 12 Financial Position

• At the end of 2019/20, the CCG is reporting a year to date deficit position of £13.947m which compares to a revised forecast agree with NHSEI of £13.975m.

• Deficit position driven by an unidentified Quality Innovation Productivity and Prevention (QIPP) of £17.9m, less the CCG’s £2.7m contingency.

• Also includes the expenditure pressures within commissioned out of hospital healthcare and prescribing.

] Any mitigation in 2019/20 which has a financial risk in 2020/21 has been included within the 2020/21 budget setting process. Although the deficit position at the end of 2019/20 is not where we wanted to be, the team have worked really hard for us to hit the revised target which was achieved and NHS England/Improvement have noted this.

2019/20 QIPP plan delivery The CCG hit its internal target for QIPP. The total QIPP achieved in 19/20 was £6.377m, meaning a slight over achievement against planned savings. Extraordinary Budget 2020/21 The Committee received the proposed budget for 20/21. The budget considers the previous operational plan and looks at what part of the operational plan could still be delivered and the financial risks given the local and national response to pandemic COVID-19. To note:

• The CCG has not budgeted for financial benefits of QIPP as normal for this financial year because of the very high risks to delivery whilst in Level 4 Major Incident. Whilst the CCG is not planning for a financial return on QIPP there will be significant

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improvement work that is undertaken in prioritised areas; outpatient (OP) reform, Continuing Healthcare (CHC) and medicines optimisation.

• The CCG must re-create the full contingency as it was fully utilised in 2019/20. • The budget includes an estimate of the additional national funding that will be provided

to resource the locality COVID-19 response plan. • For 20/21 the CCG is forecasting a £25m recurrent deficit and a £5m non-recurrent, this

is a significant pressure.

The Committee reviewed 2 key risks, which have also been discussed at the Audit Committee:

• Addressing the Q4 shortfall in cash that without mitigations will result from a £30m deficit.

• Recovery of COVID-19 costs will be contingent upon the CCG having controls and processes in place to assure that resources funded have been appropriately and fully deployed.

The Committee was also apprised of the current Cheshire and Merseyside Capacity Management plan. From July 2020 onwards there will be an overarching plan on how the NHS will work from April 21. The Finance Committee recommended the paper to Governing Body for sign off.

CHC Position & Contracts 20/21 A detailed paper on CHC and Complex Care for 2020/21 was discussed in detail. The 3 highlights are:

• The planned transfer of care • The changes to the CHC process • Approval of the uplift to provider and process.

Current demand has exceeded the budget allocation with an overspend for 2019/20 of £3.9m, (7.96%). A ‘deep dive’ exercise to identify cost improvements and development of a financial recovery plan is planned. Initial draft planning has allocated a target of £1.986m QIPP/efficiency savings against this budget for 20/21. However it is to be noted that due to COVID-19, only realistic savings for 20/21 will be monitored. The risks discussed:

• Transfer of CHC & Complex care team to Cheshire and Wirral Partnership NHS Foundation Trust (CWP), delayed in some part due to COVID-19.

• Potential for CHC and complex care patients being ‘lost’ in the system due to new arrangements of ‘care without prejudice’, actions are in place to mitigate against this.

• The suspension of 3- & 6-month care package reviews could mean that packages may not fully meet needs.

• Post COVID-19 backlog of assessments and the potential financial implications.

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Turnaround Director Handover report The report reviewed the work of the 2-year turnaround programme the CFO identified the priority areas for action:

• CHC and out of hospital care • Medicines Optimisation • Better Care Fund (BCF) and integrated work with the Local Authority • Healthy Wirral programmes

The Committee members noted the paper and the Executive Management Team (EMT) would develop a recovery plan for the CCG and Wirral System.

3. IMPLICATIONS Risks & Mitigations Finance Committee Risk Register The risk register has been split into two with the new COVID-19 risks identified separately as high-level issues. There are currently 2 financial risks under COVID-19 to be updated post meeting to include updated mitigation and assurance actions such as the emergency budget to be approved at Governing Body and also reflect that the Audit Committee has had oversight and is assured. On the Chief Finance Officer (CFO) recommendation the CCGs cash position in light of COVID-19 is to be added as a risk.

4. CONCLUSION The Governing Body is asked to:-

• Note the year end 2019/20 £13.947m deficit position. • Note the key risks for the CCG in regards to the COVID-19 response and actions taken

to support the system. • Approve the extraordinary budge that has been identified. • Note the ongoing work for the management of expenditure in CHC and out of hospital

care • Note the revised financial risks to be included in the CCG risk register.

Lesley Doherty 01/05/20

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Report Title Primary Care Commissioning Committee 6th May 2020

Committee Chair Sylvia Cheater MBE, Lay Member (Patient Champion)

Recommendations The Governing Body is requested to note the Primary Care Commissioning Committee Chair Report

1. INTRODUCTION / PURPOSE NHS Wirral Clinical Commissioning Group’s (CCG) Primary Care Committee’s (PCCC) key purpose is ensuring upon quality, efficient and cost effective commissioning of primary medical services for the people of Wirral. The Committee will function as the corporate decision making body for such, including the management of the delegated functions and exercise of delegated powers and responsibilities. Responsibilities relating to individual GP performance management are reserved for NHS England.


• This was the first PCCC meeting following full delegation; • The Committee met virtually for the first time without problem; no requests from the

public to attend; • The Committee was asked to note that a proposal for practices to claim back their non-

GP staff costs (in relation to COVID-19) had been approved outside of Committee, at an earlier date

• The Committee received and approved a paper outlining commissioning actions taken to support General Practice in light of the ongoing challenge of COVID-19. These included changes to existing commissioned services and new commissioned services. Primary Care Quality Scheme 2020/21 performance measures have been suspended for the first quarter whilst a COVID-19 focus for the remainder of the year is considered;

• The Committee was pleased to note that the CCG had secured, from multiple sources, 458 laptops to support remote-enabled primary care. The procurement built on plans implemented before COVID-19 and accelerated to ensure all practices were equipped.

3. IMPLICATIONS

The Committee has transitioned to full delegation of Primary Care Commissioning and is continuing to hold effective robust meetings virtually, during the COVID-19 pandemic.

4. CONCLUSION Governing Body is asked to note the key issues managed by the Primary Care Commissioning Committee. Chair Name: Sylvia Cheater MBE Date: 26th May 2020

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Report Title Quality and Performance Committee Chair’s Report – 26 June 2020

Committee Chair Ian Huntley, Lay Member (Quality and Outcomes)

Recommendations The Governing Body is asked to: Note the Quality and Performance Chair’s Report of 26 June 2020.

1. INTRODUCTION / PURPOSE During this reporting period the Q&P Committee met on 28 April and 26 May via Microsoft Teams.


Key Services. The committee has continued monitoring services and activities that may be impacted by the Covid-19 pandemic, such as A&E, ambulance performance and Referral To Treatment. In addition, we have continued to monitor the performance of cancer treatment. a. A&E. Although overall levels of attendance were below those of 2018 and 2019, the A&E performance for January and February did not hit the target. The Covid-19 pandemic led to a further, significant reduction in attendances at A&E. As a result, performance against the 4 hour A&E standard improved in March and April and continued into May but still failed to hit the target. Covid-19 has also had an impact on patient streaming and the Q&P committee is looking into this. b. Ambulance. In both January and February, North West Ambulance Service (NWAS) failed to achieve most of the performance standards. The performance data for March indicates a failure to meet all targets except for Category 1 (90th percentile) and Category 4. On 3 April it was decided to respond primarily to life threatening cases, establishing alternative pathways for the remaining patients contacting 999. c. Referral to Treatment (RTT). WCCG has not met the 92% standard for a <18 week wait for incomplete pathways, since December 2015. The number of patients exceeding 52 week waits in March 2020 was 15 against a trajectory target of 0; all these breaches were in surgical specialties at WUTH. Prior to this, no 52 week breaches at WUTH had been reported since February 2019, although a Wirral patient did breach the 52 week RTT standard at Countess of Chester Hospital. RTT further deteriorated at the end of March and in April, due to the reduction in elective activity. This will remain the case until elective capacity is restored. On the resumption of more normal referral patterns and clinical activity, a backlog of patients will inevitably enter the RTT waiting list. d. Cancer. In January and February, WCCG failed to hit the 2 Week Wait Referral to First Assessment target. During the pandemic, Cancer Services have continued to accept referrals and, after an initial dip, activity is steadily increasing with WUTH experiencing around 70% of expected referrals. WUTH are aware that there is likely to be a surge in referrals which, along with the current backlog, will impact performance. To support recovery, the WCCG Cancer Commissioner and Lead GP are meeting fortnightly with representatives from WUTH. In

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2

addition, WUTH have proposed a recovery trajectory to manage and assess progress to pre-Covid-19 performance levels.

Other Issues for Assurance. The other items discussed for assurance were:

f. Covid-19: Safeguarding Children/Children Looked After. The committee reviewed reports on the arrangements put in place across the Wirral for Safeguarding and Children Looked After, in light of the pandemic. The committee was fully supportive of these arrangements and approved the guidance. g. Area Prescribing Committee (APC) Report: March 2020. The committee was briefed that this would potentially be the last APC report it would receive. There was nothing contentious in the report and it was noted. h. Commissioning Plan – Second Phase of Covid-19 Pandemic. The committee noted the proposed response from commissioners to the second phase of the Covid-19 pandemic. i. Complaints. The following were noted by the committee:

(1) In the period 18 March to 12 May 2020, 12 new complaints were received, and 10 complaints were closed. Overall, complaints, concerns and patient enquiries saw an increase due, in large part, to Covid-19 related issues.

(2) During this reporting period, there have been 32 new MP enquiries, the key themes of which related to Personal Protective Equipment (PPE), testing and care home issues, again, because of the pandemic. Timely responses were provided by the Management Team to these enquiries.

(3) Wirral has had 12 new serious incidents reported between 1 March 2020 – 30 May 2020.

(4) WUTH has also had a second ‘Never’ event in 2 months.

e. HR Report. The committee were briefed on the HR Performance report, which highlighted:

(1) BME Representation. At the end of March 2020, 5.95% of the CCG workforce were

from a BME group, against a target for the CCG of 3.01%. (2) Staff Turnover. In the 12 months to March 2020, the CCG had an annual staff turnover

rate of 16.36%. This ranks the CCG as the 10th highest in comparison with other CCG organisations, where the average turnover rate was 17.11%.

(3) Sickness. At the end of March, the monthly sickness absence rate was 0.85%,

showing an encouraging decrease from 5.51% at the end of December 2019, against a target of 2.00%.

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f. Whistleblowing Policy. The committee endorsed the Whistleblowing policy, which had been examined in line with the planned review date of May 2020.

g. Special Educational Needs and Disability (SEND) Quarterly Report. The committee received a verbal update on SEND. There are 10 key areas that require action. However, the pandemic has slowed progress and strategy meetings had initially been cancelled. These have now been reinstated via MS Teams.

h. Joint Agency Response – Sudden Unexpected Death in a Child Interim Guidance. The committee reviewed the guidance on changes to be adopted in a Joint Agency Response to child deaths during the pandemic.

Items Approved. 1. Palliative Care drugs/Specification. The committee approved the paper and agreed to an

extension of the Community Pharmacy Palliative Care Scheme for 24 months.

2. Mesalazine Guidance Pan Mersey Adoption. The committee agreed to approve the policy.

3. Expiring Wirral CCG Medicines Management Guidelines during Covid-19. The committee approved an extension for one year or until the Pan Mersey APC resumes business as usual, whichever is the earlier.

Approved Out of Committee. A quorum approved the following policies out of committee: 1 HR Policy: Complaints Policy and Procedure. This policy was updated to reflect the

CCG’s change of role in undertaking fully delegated commissioning for Primary Care Medical Services, from 1 April 2020.

2 HR Policy: Conflicts of Interest Policy. 3 Covid-19 Guidelines for Rapid Approval:

• Early Use of Antibiotics in High-Risk Patients. • Disease-Modifying Anti-Rheumatic Drugs

4 Regional Medicines Optimisation Committee: Homely Remedy Template Policy. Lessons Identified: The importance of mangers completing their mandatory training was highlighted by a safeguarding incident that was related to the committee.

3. IMPLICATIONS

The Covid-19 pandemic has had a profound impact on the delivery of healthcare across Wirral. Services that were already struggling to meet mandated targets have been heavily disrupted. A reduction in elective care and other consequences of the pandemic, such as patients presenting with cancer at later stages than normal, means that a significant backlog is developing. It will

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therefore be necessary for the CCG to chart a realistic route back towards the required standards, in concert with our delivery partners.

4. CONCLUSION

The Governing Body is asked to note the Quality and Performance Committee Chair’s Report of 26 June 2020.

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WIRRAL CLINICAL COMMISSIONING GROUP

Finance Committee

Tuesday 28th April 2020 10:15am

Via MS Teams

Present: Lesley Doherty (LD) Registered Nurse (Chair) Alan Whittle (AW) Lay Member Mark Chidgey (MC) Chief Finance Officer Anna Coyle (AC) PMO Manager Lorna Quigley (LQ) Director of Quality and Patient Safety Paul Edwards (PE) Director of Primary Care and Corporate Affairs Ken Jones (KJ) Deputy CFO Simon Banks (SB) Accountable Officer Dr Simon Delaney (SD) Medical Director Steve Cocks (SC) AD for Contracts and Delivery Emma Edwards (EE) Senior Reporting Accountant Paula Cowan (PC) Chair Nesta Hawker (NH) Director of Commissioning and Transformation In Attendance: Chelsea Worthington (CW) Acting Senior Corporate Officer Richard Miller-Holliday (RMH) AD for Continuing Healthcare Zoe Delaney (ZD) Commissioning Manager

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Preliminary Business 1.1 Apologies for absence There were no apologies received.

1.2 Declarations of Interest Declarations made by members are listed in the CCG’s Register of Interests. The Register is available via the CCG website at the following link:

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https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/ There were no declarations of interest made. 1.3 Minutes & Action Points from previous meeting held on 24th March 2020 Minutes The minutes of the previous meeting held on 24th March were agreed as a true and accurate record. LQ advised that on page 3 under section 2.3 that the CHC team has been temporarily deployed with the Integrated Discharge Team. Action Points Members noted the 1 action from the last meeting which has been closed. PE advised that this has not been completed but GP Practices have been told if they need to change premises there will be no financial disadvantage. 1.4 Matters Arising LQ noted that there was another action within the minutes not included within the action log for John Doyle to write to the CCG Lay Members outlining the governance processes in place for COVID expenditure decisions. LD advised that this has been actioned.

2.1 Month 12 Financial Position At the end of 2019/20, the CCG is reporting a year-end deficit position of £13.947m.

The deficit position is largely driven by unidentified QIPP of £17.9m, less the CCG’s £2.7m contingency. This also includes the significant pressures within commissioned out of hospital healthcare and primary care prescribing. Where utilisation of a mitigation action in 2019/20 has a financial consequence in 2020/21 then this has been included within the 2020/21 budget setting process. For example, utilisation of the contingency budget to support (mitigate) the 2019/20 financial position means that the CCG will incur an additional budgetary pressure in 2020/21.

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The total QIPP achieved in 2019/20 was £6.377m, meaning a slight over achievement against planned savings. A summary of programme areas has been provided within a table for members to note. NH commented on the significant positive increase for the Gastro figures and asked if we had any further information on how this increase happened. EE advised that the activity data in M11 impacted on M12 figures which had seen the spike, AC also advised that there was initial slippage in commencement and we anticipated an increase in the figures. NH asked if this favourable outturn was likely to be recurrent. Action- EE to look further into the data and give NH an update re Gastro. MC advised that although the deficit position at the end of 2019/20 is not where we wanted to be, the team has worked really hard for us to hit the revised target which was achieved and NHS England/Improvement has noted this. He asked that the committee also note that the CCG hit its internal target for QIPP.

2.2 Extraordinary Budget 2020/21 MC presented the interim budget for 2020/21, which will be presented to May’s Governing Body for approval. MC explained the process of developing the budget. This picked up where preparation of the previous operational plan has paused, the CCG is looking at what part of the operational plan can still be delivered and the associated financial risks given the current situation. The CCG position is adversely affected as it is not realistic to budget to deliver a QIPP programme as normal for this financial year. Reinstatement of contingency is an additional pressure but all expenditure on COVID-19 and producing a response/recovery plan is assumed to be matched by income and hence revenue neutral. For 2020/21 the CCG is forecasting a £25m recurrent deficit and a £5m non-recurrent, approval of the budget is therefore a significant decision in relation to compliance and statutory duties. NHS England/Improvement has an understanding that this is a realistic approach given circumstances and that the CCG will revert to normal plan as soon as we can. Members noted that

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as yet there has been no formal response from NHS England/Improvement on this. MC highlighted 2 key risks, which have also been discussed at the Audit Committee:

• Cash flow, in particular in the final quarter of the year. • Full recovery of COVID-19 costs

SB shared with members via PowerPoint the current Capacity Management plan and a 4-6-week plan for Cheshire and Merseyside for Capacity and Management. From July 2020 onwards there will be an overarching plan on how the NHS will work from April 21. LD asked for clarification about the recent announcement on NHS historic debt which was made by the SoS for Health. MC explained that it is the conversion of NHS Trusts’ debt into PDC (Public Dividend Capital). However, this will not have any effect on the in-year position for the Wirral System or Wirral University Teaching Hospital. LD asked if a short briefing could be produced on this which MC could share with Governing Body members. Action- MC to produce a briefing note paper for the Governing Body. Finance Committee supported and recommended the interim budget 2020/21 to the Governing Body for sign off.

2.3 CHC Position & Contracts 2020/21 LQ advised members that this paper details all the changes which have been made for CHC and Complex Care: The 3 highlights are:

• Finance Committee to be informed of the transfer of the CHC team as previously supported

• The changes to the CHC process • Approval of the uplift to charges by providers and the review process.

The paper outlines the current steps being taken to progress the planned transfer of the CHC & Complex care team to Wirral Health and Care Commissioning (WHCC) through the necessary governance and HR structures within the organisation, as an interim measure whilst work is undertaken through continued discussions with Cheshire & Wirral Partnership NHS Foundation Trust (CWP) as the proposed new host employer and provider of the service, with the aim of securing contracts and agreements for service commencement. This was originally planned for April

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1st 2020 however, due to the current COVID19 pandemic situation CWP raised concerns regarding the ability to achieve the 1st April 2020 deadline so a Memorandum of Understanding was drawn up to cover an interim arrangement. Consultation with staff is currently underway when it is anticipated that WHCC will employ the CHC & Complex Care team until a successful transfer to CWP is achieved, currently planned for May/June 2020. It also outlines a continued growth in demand for more patients to receive long term care out of hospital which requires funding by the NHS. Current demand has exceeded the budget allocation with an overspend for 2019/20 of £3.9m, (7.96%). The current interim period gives WHCC an opportunity to complete a ‘deep dive’ exercise to identify cost improvements and development of a financial recovery plan. Initial draft planning has allocated a target of £1.986m QIPP/efficiency savings against this budget for 2020/21. It should however be noted that due to COVID-19, only realistic savings for 2020/21 will be monitored. RMH went on to discuss the risks:

• Transfer of CHC & Complex care team is significantly delayed due to

protracted negotiations with CWP and the impact of COVID 19 • CHC & Complex care patients being ‘lost’ in the system due to new

arrangements of ‘care without prejudice’ • Patients receiving care packages that don’t meet their needs and may

therefore cost more due to the current relaxation of the 3- & 12-month reviews

• Post Covid 19 backlog of assessments and the potential financial implications

RMH advised that the first 2 risks can be mitigated and these will no longer be main risks. Members noted the budget value within the recommendations section of the cover sheet and RHM advised that members should note that the £53.54m is for all Commissioned out of Hospital Care. The CCG is coming to the end of the consultation stage and on May 1st staff will TUPE over to WHCC, continual discussions will take place with CWP for transfer of the service and staff from late May to early June.

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NHS England has provided clear guidance in the document; NHSE (19th

March 2020) ‘COVID-19 Hospital Discharge Service Requirements’ that set out the requirements for all NHS trusts, Community Interest Companies and private care providers of acute, community beds and community health services and social care staff in England, and this policy was effective from Thursday 19th March 2020. There were 2 sections within the policy which were most relevant to CHC which were section 1.5 and 1.7, RHM has included these within the report for members to note. Section 4 shows the financial implications and RHM has included a number of graphs for members to note. It can be seen from graph 1 that there was a reduced overspend in for 2019/20. ZD discussed the annual provider uplift requests. Historically the process for uplift requests has been largely fragmented with providers requesting a variation of uplift amounts ranging from the standard 1.1% to 7% upwards (for specific cases). As has already been highlighted there is a significantly higher cost for packages of care than some of our comparators, which has restricted WHCC from controlling the market. Previously the Wirral population has been benchmarked against other Cheshire comparators; however, it must recognised that in order to obtain accurate benchmarking data; the population of Wirral must be measured against comparators with the same or similar demographic footprint and factors e.g. age, socioeconomic factors, housing etc. In future modelling it is intended to utilise the ‘Rightcare’ comparator data for benchmarking purposes. All current providers are delivering services through a standard NHS contract and therefore are subject to the standard uplift fees of 1.1% for 2020/21 (2.5% minus 1.4% efficiencies, giving an increase of 1.1%). WHCC is still in the process of understanding the operating procedures that were in place previously through discussion with Cheshire CCG contract and finance colleagues regarding the uplift requests going into 2020/21 financial year however; to date it appears that requests were dealt with on a case by case basis, as opposed to applying a blanket uplift fee of 1.1% across all providers (in line with NHS standard contracts) and communicating this to all providers. Individual cases for higher amounts would then be dealt with via a full clinical assessment/needs based analysis. The recent change in management to

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WHCC gives an opportunity to review these processes and apply a systematic approach as outlined below, providing consistency and allowing control over the market value: 1. Apply standard 1.1% uplifts across all providers (in line with standard NHS contracts) 2. Assess individual cases for additional funding on a case by case basis, with clinical input 3. Ensure this is communicated to all providers, demonstrating transparency and openness 4. In parallel to this, benchmark against Rightcare comparators with a similar demographic footprint and factors. The team is also working with Finance and Contracts teams plus an efficiencies group set up to review the individual cases. Members also noted that the Local Authority has increased its uplift to the national average which is closer to the 7%. EMT will need to review this further as the work continues to be done internally. MC advised that this paper also links in with the Turnaround Director’s recommendations paper next on the agenda. AW commended the report providing the CCG with significant assurance. AW also asked with regards to the TUPE of staff, if the team had factored in any TUPE risk with staff being transferred twice from provider to provider and had any HR advice been taken? PE advised that he has had discussions with HR, and while this was not an ideal situation for staff to be TUPED twice, staff had been kept informed throughout the whole process and any risk was minimal. There is a small risk that CWP do not take the staff on, in which case WHCC will continue to host. LD raised her concerns regarding a QIPP expectation from the CHC allocation and felt that making sure we keep within the allocated budget at this point would be a more prudent approach. LD also raised that we should not underestimate the impact of COVID-19 causing a significant backlog of reviews that will need to be done and the time that will take, particularly those patients that may go to required Funding Nursing Care. AW also supported these 2 points of view, noting that there may be a need to increase the actual CHC team to build capacity and enable the proposed system improvements to be delivered. This had been recognised as an issue by the committee before. MC advised that he has not set a budgeted QIPP but is expecting improvement (finance, performance, quality) to be achieved. Moving forward he will work with LQ in ensuring a capacity and process review.

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Members noted the paper, and approved the recommendations.

2.4 Turnaround Director Handover SB advised members before he had to leave the meeting for another call that the EMT will lead on the review of this paper and turn into an action plan. MC presented the paper and informed members of the key areas which have been picked up:

• CHC • Meds Optimisation • BCF and integrated work with the Local Authority • Healthy Wirral

Regarding the BCF AW raised concern that lack of control / oversight could affect the assessment of our governance arrangements. He asked members to note that that the Head of Internal Audit Opinion was given moderate assurance for the 2nd year and BCF was one of those areas where more assurance was identified as required.

MC will develop a financial strategy paper to establish where we are, how do we spend our allocation, are resources invested in the most appropriate services to meet population needs?.

Committee members noted the paper and the EMT would develop a recovery plan for the CCG and Wirral System.

LD expressed concern as to the continued clarity of objective with limited progress on delivery and asked if possible, there is discussion by the EMT and clarification given as to whether it is the Governing Body or Finance committee who will have the oversight for gaining assurance on the Healthy Wirral financial recovery.

2.5 Communication requirements from this meeting To inform staff members of the emergency budget at the next staff brief.

3.1 Finance Committee Risk Register PE discussed the risk register, the risk register has been split into 2 with the new COVID-19 risks being highlighted in red, noting the focus on the high-level risks at present and keep at the front of all discussions.

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The 2 risks under COVID-19 will be updated after this meeting to include that the emergency budget is to be approved at Governing Body and to also reflect that Audit Committee has had oversight and is assured. MC advised that he felt it worth considering the CCG’s cash position in light of COVID-19 to be added as a risk, PE & MC will action.

3.2 PFEG Finance report Given the current situation there has been no Pooled Fund Executive Group meeting.

Any Other Business There were no further items discussed.

Date and Time of Next Meeting

Tuesday 26th May 2020, 10.15-11.45am, vis MS Teams

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WIRRAL CLINICAL COMMISSIONING GROUP

Finance Committee

Tuesday 28th April 2020 10:15am

Via MS Teams

Present: Alan Whittle (AW) Lay Member (Vice Chair) Lesley Doherty (LD) Registered Nurse (joined at the end of the meeting) Mark Chidgey (MC) Chief Finance Officer Anna Coyle (AC) PMO Manager Lorna Quigley (LQ) Director of Quality and Patient Safety Paul Edwards (PE) Director of Primary Care and Corporate Affairs Ken Jones (KJ) Deputy CFO Simon Banks (SB) Accountable Officer Dr Simon Delaney (SD) Medical Director Steve Cocks (SC) AD for Contracts and Delivery Emma Edwards (EE) Senior Reporting Accountant Paula Cowan (PC) CCG Chair Nesta Hawker (NH) Director of Commissioning and Transformation In Attendance: Chelsea Worthington (CW) Acting Senior Corporate Officer

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Preliminary Business 1.1 Apologies for absence There were no apologies received.

1.2 Declarations of Interest Declarations made by members are listed in the CCG’s Register of Interests. The Register is available via the CCG website at the following link: https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/

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There were no declarations of interest made. 1.3 Minutes & Action Points from previous meeting held on 28th April 2020 Minutes The minutes of the previous meeting held on 28th April were agreed as a true and accurate record. Action Points AP 31- NH updated and advised that the Gastro data has been sent and noted the way the data was profiled. The action was therefore completed and closed. AP32- this action has been completed and closed. 1.4 Matters Arising There were no matters arising.

2.1 Month 1 Financial Position MC talked to the M1 financial position for the CCG, the report has been prepared in line with the budget approved by Governing Body, but 10 days ago a new finance regime and allocations were notified by NHS England to CCGs. Allocations are non-recurrent and limited to months April to July, with the associated budgets now national mandated and set. The policy intention is seen to be positive to make sure CCGs’ financial positions are covered during Covid, as described in the first bullet point within the report, there is also more information expected. Action- MC will produce a briefing paper to include the revised interim financial governance arrangements and financial position. Normally allocation is given and the CCG set the budgets but this year, the allocations and budgets have been set for each service area. In response to a question regarding are there certain areas which are more at risk, there is a financial risk for CHC due to temporary cessation of assessments and reviews, and when returning to normal there will be a higher risk. Technical issues for allocations in certain areas, for example top-slice to the C&M HCP, and cash are at higher risk for over the next few months.

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Any over or underspending should effectively be neutralised for the first 4 months but there remains some risk and uncertainty over this. It was noted that there have been no changes to reporting in April. EE took members to section 3 of the report relating to payments and principles. Due to the Covid-19 pandemic, NHSEI has taken the unprecedented decision to mandate to CCGs payments that are to be made to NHS providers in order to ensure that cash flow is maintained.

For non-NHS providers it has been largely for the CCG to determine the basis of payment through a combination of national payments guidance and national direction as to the services that can continue or must cease.

The headline approach we have taken to arrive at the April deficit is based on the following principles:

NHS Providers:

Block payments are being made to all NHS providers for whom NHS Wirral CCG holds a contract. These payment values have been provided by NHSEI and are based on expenditure in 2019/20 uplifted for a range of factors such as activity changes and inflation. The 2020/21 contracts inadvertently include non-recurrent funding that providers were receiving in 2019/20, for example cancer initiatives or mental health crisis funding, which are not included in the CCG’s approved recurrent budget. The resultant variances are reflected below and this is one of the reasons why NHSEI has opted to implement a nationally mandated non-recurrent budget. Non NHS Providers/ Independent Sector Contracts:

Due to the national contract for IS capacity and furloughing of staff by smaller providers, there is limited activity that has continued to be commissioned by the CCG from this group of providers. This has led to a significant underspend against plan. The CCG has initiated communications with providers to plan for how and when these services should recommence.

Delegated Budget for Primary Care

This is the first month for which the CCG has delegated financial responsibility for Primary Care Commissioning. The CCG was made aware of a deficit position within the budget of £1m as part of the agreed transfer from NHSEI. As a result of further assessment, it is believed that a further £1m of risk is included within the budget. The CFO has requested that an additional due diligence exercise is

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undertaken on the budget and the outcome of this will be progressed with NHSEI. At This stage the full risk has been, consistent with agreements reached with NHSEI, offset by assumed additional national funding.

Hospices:

Hospices have adapted their service offerings so that they can continue to receive the benefits of voluntary donations and fundraising. The CCG has sought to support hospices by providing six months of cash flow in advance and a national scheme has now been developed to address the, hopefully temporary, loss of income from other sources. Prescribing:

Prescribing data is normally received two months in arrears so a breakeven position is assumed at present. When prescribing information is received it is anticipated that there may be significant volatility with high expenditure in March in the period leading up to lockdown.

Out of Hospital Healthcare:

Based on guidance received 19th March from NHSE/I, all CHC healthcare assessments were halted and any patients requiring supported discharge must have an appropriate package in place funded nationally via CV-19. The CCG has received an additional cash allocation for this with expenditure recovered through national recharge processes.

Because CHC assessments have been suspended it is likely that over time, costs will temporarily reduce against CHC budgets and increase on the national discharge scheme. The national expectation is that localities will pool their full resources for discharge across Health and Care so that any such under-spends offset the national recharge. At this stage the Local Authority position is that this outcome can be achieved without further pooling. SB advised that the CCG is at a greater risk for CHC creating the necessity for greater scrutiny of payments to providers. EE then went on to discuss the CV-19 recovery plan expenditure. NHSEI require CCGs to report monthly on the level of expenditure being incurred in relation to CV-19. Based on the Governance tracker maintained by the CCG of scheme approvals, the latest return submitted on 15th May contained spend for April of £1.3m. As already confirmed, there is no negative impact of these costs assumed within the CCG financial position. Details were summarised in a table which members noted.

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Although the QIPP programme is paused, the CCG should still be developing plans for implementation when the pause is lifted. Members noted that the cash management has been included in the risk register. It would normally materialise at year end which is March but it has been brought forward to July. MC has written to Jonathan Stephens highlighting the risk and hopefully this is acknowledged. SB asked where the additional £1m risk for the delegated Primary Care Commissioning budget had come from? This is something the CCG and NHSEI have had conversations about re risk share. PC suggested that this should be included on the risk register. Action- MC to review and update the risk register accordingly. Although the CV-19 figures are currently only reported on a monthly basis, the CCG has completed an estimate of total forecast expenditure, this has also been approved by EMT. The second risk which was highlighted at the last meeting was the fully recovered Covid cost and recharge from providers. Members noted that MIAA has been commissioned to review this to provide independent assurance. KJ provided members with an update on External Audit progress with the review of Annual Accounts for 2019/20. The Finance team is meeting on a regular basis with the Auditors who have not yet raised any significant issues or challenges. They will continue to do their spot checks and the CCG will continue to provide them with information they require for the year end accounts sign off. The CCG is on track for the dates in June, it may just be an issue of the timing of papers for the Audit Committee and Governing Body. Members were happy with the recommendations and points to note within the paper.

2.2 Communication requirements from this meeting To continue working on the CCG’s underlying deficit and to update Governing Body members on the new interim financial regime notified by NHSI/E

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3.1 Finance Committee Risk Register Members noted the current Finance Committee risk register and were happy with the updates which have been included. PE advised that MC will be updating risk 19/20/G and adding a separate new risk for delegated commissioning as per earlier discussion. There will also be a verbal update at QP this afternoon.

Any Other Business

As today is KJ’s last Finance Committee meeting, PC thanked KJ on behalf of the CCG for his help and support over the years and best of luck in the future. AW also thanked KJ for this contribution to the Remuneration and Audit Committee. KJ thanked everyone for the opportunity and development in his time at the CCG.

Date and Time of Next Meeting

Tuesday 30th June 2020, 10.15-11.45am, vis MS Teams

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Audit Committee Meeting

Thursday 23rd April 2020 10am - 12pm

Virtual Meeting via MS Teams

Present: Alan Whittle (AW) Lay Member (Audit & Governance) Chair David Murray (DM) Audit Lay Member Dilys Quinlan (DQ) Audit Lay Member Bernard Halley (BH) Audit Lay Member In Attendance: Karen Duckworth (KD) Acting Senior Corporate Officer (minute taker) Paul Edwards (PE) Director of Corporate Affairs and Primary Care Mark Chidgey (MC) Chief Finance Officer Clare Shelley (CJ) Head of Financial Services Ann Ellis (AE) MIAA Jon Roberts (JR) Grant Thornton Helen Stevenson (HS) Grant Thornton Ken Jones (KJ) Deputy Chief Finance Officer Alun Gordan (AG) Counter Fraud MIAA

Item No. Agenda Items

Action

AC20-21/1

PRELIMINARY BUSINESS

1.1

Apologies: Pippa Joyce and Robin Baker. AW introduced and welcomed MC to his first meeting of the Audit Committee, as Chief Finance Officer. Members and attendees made brief introductions to MC.

1.2

Declarations of Interest: AW reminded members of their requirements to declare any interest they may have on any issues arising at committee meetings which

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might conflict with the business of NHS Wirral Clinical Commissioning Group. This will be addressed at each meeting and a declaration must be made by anyone who has an ‘individual’ conflict of interest with an agenda item in the meeting. The chair will then make a ruling as to the action to take considering the significance of that conflict.

Declarations by members are listed in the CCG’s Register of Interests. The Register is available via the CCG website at the following link: https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/ There were no declarations of interest made.

1.3

Minutes /Action points of previous meeting held on Thursday 30th January 2020 The minutes from the previous meeting held on Thursday 30th January 2020 were agreed as a true and accurate record, with one small amendment to page 4 to confirm PCCC as Primary Care Co-Commissioning Committee. Actions The actions agreed at the meeting held on 30th January 2020 were discussed: AP49: Action Closed AP50: Action not due till September (to include governance from Healthy Wirral as part of presentation). AP51: Action Closed AP52: Agreed for action to be closed. AP53: Action Closed AP54: Now that MC is in post this will now be progressed through EMT. LL will continue to cover the role of Anti-Fraud Champion until decision is reached to ensure that there are no gaps. AP55: Action Closed

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1.4 Matters Arising None

AC20-21/1

ITEMS FOR DISCUSSION

2.1 General update RE: COVID-19 PE updated the committee with regards to the measures that have been put in place to reduce the burden and release capacity. Also a realigned Annual Report timetable has been shared with both Audit Committee and Governing Body Members. ACTION: PE to share with committee members the first draft of the Annual Report and Accounts in order for members to have early sight of the document. Comments are to be sent to Laura Leadsom. PE went on to advise the items which this year have been excluded from the Annual Report, in light of the current COVID-19, in line with national guidance and also the processes which have been put in place in order to stream line committees in order for focus to be towards COVID-19 related issues. In addition, PE advised that a COVID Risk Register has been developed and sits alongside the CCG’s Risk Register. PE went onto advise that in his role as Emergency Preparedness, Resilience and Response (EPRR) Lead, the Emergency Response and Business Continuity Plans are robust, with staff now working from home. The Business Continuity Plan will further be enacted should staff sickness levels increase due to COVID-19. PE went onto explain the daily routine of response meetings which include: • Incident Management Team • Primary Care Incident Team Meeting • Health and Social Care Cell Meeting • Clinical Oversight Cell Meeting • Executive Management Team Meeting PE explained that staff from the commissioning teams have been redeployed in order to support the primary care team and to ensure that services are being made available, to be as responsive as possible. It was noted that there are now in place 5 GP Hubs that specifically support COVID-19 patients to ensure primary care resilience.

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PE also flagged that as planned operations and routine appointments have been cancelled, there will be a future impact by way of seeing an increase in low level conditions and the impact to people’s mental health, and measures are being pit in place to support this. AW fed back that he was impressed by staff responsiveness to working from home and although there have been some technical issues, the current running is very much business as usual. Committee members wished to share their praise and appreciation of the excellent staff response to the new working arrangements brought about by the pandemic. DQ queried what advice was available for patients who have had procedures/appointments cancelled. PE advised that GPs are all open and able to offer advice and guidance for all their patients. It was noted that all urgent procedures will still continue and once the peak passes, planning will start on how to manage patients back into services. DQ also queried what measures are in place around those patients who need help but who are not seeking it. MC advised that this is under review and work around this has started to see what the impacts are. DM flagged due to the redeployment of commissioning staff has this flagged any weaknesses. PE advised that those who have been redeployed are those who would be working generally on pathway redesign, so there are no adverse impacts on services. PE also highlighted that the CCG’s response has been in line with several letters and guidance received from the center in order to have assurance that processes are in place and he congratulated staff on the way they have responded. 2.2 Response to HFMA paper on financial governance The Committee noted the report and MC drew the committee’s attention to the HFMA paper which provides a good checklist to ensure that that the CCG is doing the right things and keeping on track. Home working is now in place as all members of staff have laptops and mobile phones with remote working capability. All of the finance systems, applications, network files and working papers are accessible remotely. MC advised that the Finance Team has prioritised in line with the

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Business Continuity Plan: - • Financial advice and support to development of the Wirral COVID-

19 system response. • Following the national process to enable cash payments to

providers from 1st April 2020 and supplementing this process where required.

• Maintaining a register of all COVID-19 investments and following the process for recovery of this expenditure from NHS England/Improvement.

• Completion of the Annual Accounts and Annual Report. • Maintaining high levels of financial probity across all areas of

expenditure including anti-fraud policies and procedures. MC went on to advise that the Finance Workforce is monitored and a tracker is in place so that on a daily basis each member of the team is required to register their status from a specified set of options, for example WFH (Working from Home) or SI (Self Isolating but still available for work), a daily dashboard is provided to the CFO. In addition, MC advised that whilst operational planning requirements have been paused nationally around contracts, an Extraordinary Budget has been prepared and will be considered through CCG governance including EMT, Finance Committee and the Governing Body. NHSE/I is also fully sighted on the budget proposals and feedback from regulators and partners will inform the Governing Body’s consideration of the recommendations. MC highlighted that delivering financial balance still needs to be addressed, however, QIPP plans to reduce expenditure have been temporarily paused. MC updated that the CCG remains on track for completion of the annual accounts process and is in close contact with and fully supported by both MIAA and Grant Thornton. Also, MC advised that in accordance with national guidance, a block contract process has been put in place with the main providers (WUTH, CWP and WCHC) until July 2020 and monthly payments are calculated based on the Month 9 position from last year plus inflation adjustment. This will dictate the payments to be made throughout May – July, with the first payment already made on 1st April. KJ confirmed that the CCG has implemented a process for approving and tracking additional expenditure relating to COVID-19 and a submission with all necessary information (capital and revenue) to recover expenditure incurred prior to 31st March 2020 has been made to NSHE/I, with the next monthly submission due on 30th April to recover expenditure.

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KJ went on to advise that £1.3bn has been made available to CCGs to support hospital discharges to care facilities and Wirral has received £9.4m for this purpose. DM queried control measures to safeguard fixed assets. KJ advised that the only purchase made so far is for laptops to support primary care, therefore there is minimal risk to the CCG at present. DQ asked with regards to the letter which had been sent to Clinical Directors within PCNs and the documenting of resource deployment, could a statement be signed to strengthen the request for resources? MC advised that variations to contracts are being considered to capture this. BH fed back on the impressive response to the current situation made by staff but queried how staff welfare is being monitored. PE advised that MLCSU have shared a suite of information which is available to all staff and managers are having regular check in with their teams, although its difficult to assess remotely staff well-being there are resources available for staff should they need them. AW also feedback that he felt assured that there are regular communications made to staff and a Facebook page has been created which also provides links to external resources. 2.3 Deferral of Annual Report & Accounts submission dates, revised Audit Committee dates to review/endorse The Committee noted and approved the changes to submission dates. 2.4 NHSE/I guidance on relaxation of routine information returns, impact for Audit Committees The Committee noted the report which had been shared. 2.5 Wirral CCG IG Policy The committee noted and approved the IG Policy. 2.6 Internal Audit Plan (MIAA) Internal Audit follow up AE updated the committee with the Internal Audit followed up reviews, where all recommendations were past their original completion date or

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revised completion date, to determine the level of implementation. This meant that a total of 3 reviews (12 recommendations) were followed up. Reviews from 2018/19 as at end of March, 9 recommendations have been fully implemented, with any outstanding items rolling forward to 2020/21. The committee noted the report and agreed the extension dates. Internal Audit Progress Report

AE advised that the 2019/20 Internal Audit Plan is complete. Since the previous meeting of the Audit Committee MIAA has finalised the following reviews:

• Data Security and Protection Toolkit (DSPT) – Assurance N/A. • Managing Conflicts of Interest review – Assurance N/A. • Assurance Framework Review – Assurance N/A.

Due to the current events affecting all NHS organisations, NHSX has taken the decision to extend the DSPT submission deadline as it would be difficult for many organisations to fully complete the toolkit without impacting on their COVID-19 response. Although organisations can still submit their DSPT on the original date, the CCG has opted to take advantage of this extension. MC advised that he has also met with PJ and a first submission of the toolkit was been made on 31st March in line with the deadline. This will be reviewed and a revised submission is planned for quarter 3 which will inform the 2020/21 improvement plan. AE advised that the CCG satisfies the NHSE Managing Conflicts of Interest standards although MIAA has made recommendations for areas to improve. DQ queried the amber rating in relation to declaring interests, gifts and hospitality within the report. PE fedback that this also factors in GP Practices and is not just the CCG. AW also flagged that the Remuneration Committee will add Declarations of Interest as a standing agenda item for future meetings. ACTION: AW/PE to review future requirements for Remuneration Committee meeting agendas for declaration of interests to be included. The Assurance Framework is to support the overall assessment of governance, risk management and internal control. MIAA’s review included assessment of the following sub objectives:

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1. The structure of the Assurance Framework meets the requirements 2. There is Governing Body engagement in the review and use of the Assurance Framework 3. The quality of the content of the Assurance Framework demonstrates clear connectivity with the Governing Body agenda and external environment 4. Appropriate controls and assurances are in place DM queried what further engagement was required for the Assurance Framework. AE advised that the Finance Committee and Quality and Performance Committee minutes, had been reviewed. Although the Assurance Framework may have been discussed the detail was not reflected in the minutes. PE went onto update that traditionally the full Assurance Framework is not taken to sub committees as this is fully discussed at the Governing Body meeting. AW suggested that it would be useful if MIAA could attend the Governing Body meeting when the Assurance Framework is discussed in order to gain assurance of the level of discussion which takes place. BH queried the risk factor target dates and if they are monitored, up darted and noted chronologically to show changes. PE confirmed that target dates are usual set for the year end however there is the need to do this better and have more realistic dates. ACTION: Assurance Framework review by the Audit committee to be enhanced, in order to challenge the completion dates and impact of risk mitigating actions. Update to be brought to the September Committee. AE advised that the overall Head of Internal Audit Opinion rating given was moderate assurance but to note that although this is the same as last year, things are showing to be going in the right direction. PE also fed back that the review of Personal Health Budgets and the Pooled Fund Executive Group effectiveness will also make improvements to this future score. The committee noted and approved the report. Internal Audit Plan AE advised that the Internal Audit Plan was presented and approved at the January committee, however, the fee section has now been updated and requires further approval. The committee noted the changes to the fees and approved the changes to the report.

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2.7 Anti-Fraud Annual Report The anti-fraud annual report was noted by the committee and AG highlighted that the CCG year end assessment was a green rating for compliance with Standards for Commissioners due to the CCG’s commitment and solid progress. Good progress made over the last year in relation to standard 2.2 and standard 2.4 covering the anti-fraud policy and the conflicts of interest policy and both resulted in positive evaluation exercises being undertaken which showed that staff were aware of both policies. AG updated that during International Fraud Awareness Week AFS walkabout, supported by use of the fraud display stand, was held at Marriss House and 70 staff received anti-fraud handouts, with 30 staff completing the quiz. AG also advised that MIAA Fraud alerts 1 to 6 and two Sentinel newsletters were issued on the intranet. MIAA alert number 3 covering ESR bank account diversion fraud was supported by a Pay-slip message alert to all staff. In March 2020 both alert 6 and the spring Sentinel covered the latest COVID19 virus scam/ phishing emails emerging from criminal activity in order to inform management and staff of the emerging fraud threats. AG confirmed that Appendix A of the report has already been signed off with the Chief Finance Officer (CFO). BH queried standard 4.6 being amber rated, as there had been no opportunity to evidence this. AG confirmed that this was a process issue which will be addressed through the 2020/21 Anti-Fraud Work Plan. DM queried if standard 1.4 risk monitoring to be incorporated into the Finance Committee sub risk register had happened. AG confirmed that now the new CFO is in place that this will be addressed. Also once the Fraud Champion is in place this will help. The committee noted and approved the report. Anti-Fraud Annual Work Plan - 2020/2021 AG presented the proposed Anti-Fraud risk-based work-plan for the 2020/21 financial year. The risk-based fraud plan has considered both CCG local and national NHS fraud risks and has been designed to

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continue the work to safeguard systems and prevent financial loss of resources from those who would attempt to defraud the NHS. The identified fraud risks were ranked as low being scored at six or below and covered the following: - 1. Staff payroll fraud, (including bank diversion fraud) 2. Recruitment Fraud, 3. Invoice payments & procurement systems fraud (mandate fraud), 4. Conflicts of interest fraud, 5. NHS Asset Misappropriation fraud, 6. Patient ID fraud and phishing AG confirmed that the Anti-Fraud Plan includes core work which takes account of the NHS Counter Fraud Authority’s Organisational Strategy, risks identified through considering national and local anti-fraud risks and any specific management requests. MIAA Anti-Fraud insights, including benchmarking, briefings and anti-fraud related events will be integral to the plan. The fee for 2020/21 will be £6,408. ACTION: Self Review Tool (SRT) link to be shared with AW and MC for sign off completion. The committee noted and approved the report. 2.8 External Audit Progress Report - Grant Thornton HS introduced Jon Roberts who will be taking over for Robin Baker for the foreseeable future. HS updated the committee with the progress report which sets out the details of planned audit work on the 2019/20 financial statements including the value for money conclusion. HS confirmed that the Audit Plan covers 5 main areas: Significant risks Those risks requiring special audit consideration and procedures to address the likelihood of a material financial statement error having been identified as: • presumed risk that management over-ride of controls is present in all entities. The CCG faces external pressures to meet agreed targets, and this could potentially place management under undue pressure in terms of how they report performance. • risk of inaccurate recording of contract variations for healthcare due to the significance of the overall expenditure • risk of inadequate disclosures relating to material uncertainties that may cast doubt on the CCG’s ability to continue as a going concern

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• risk of Covid-19 impact on the production and audit of the financial statements. AW queried if today’s debate around the CCG’s COVID-19 response had given assurance to Grant Thornton. HS confirmed that she was impressed by the debate and that the meeting had been informative and provided assurance. Materiality HS advised that Grant Thornton has determined planning materiality to be £7.46m (2018/19: £10.34m), which equates to 1.4% (2018/19: 2%) of the CCG’s forecast total operating expenditure for the year. Grant Thornton is obliged to report uncorrected omissions or misstatements other than those which are ‘clearly trivial’ to those charged with governance. The ‘Clearly trivial’ threshold has been set at £0.3m (2018/19: £0.3m). Value for Money arrangements Grant Thornton’s risk assessment regarding the CCG’s arrangements to secure value for money has identified Financial Sustainability as a significant risk. The CCG continues to face a difficult financial position and has a financial recovery plan (FRP) in place. The CCG originally set a breakeven plan for 2019/20, which included £24.245 million of cost savings of which £17.941 million remains unidentified. NHS England has now agreed to revise NHS Wirral CCG’s 2019/20 control total to a £13.975m deficit which is consistent with the reported forecast at month 10 and the latest financial recovery plan. Audit logistics Grant Thornton’s interim visit took place in February 2020 and a final visit will start at the end of April through to June 2020. Grant Thornton’s key deliverables are the Audit Plan and Audit Findings Report. Grant Thornton’s fee for the audit will be £51,000 (2018/19: £49,500) for the CCG, subject to the CCG meeting Grant Thornton’s requirements in relation to financial statements and working papers as detailed in the Audit Plan. Independence Grant Thornton has complied with the Financial Reporting Council's Ethical Standard and Grant Thornton as a firm, and each covered person, confirm that Grant Thornton is independent and is able to express an objective opinion on the financial statements. AW queried if the going concern issue was attracting more attention, in light of a Section 30 letter being issued to the Secretary of State, and if there was any further evidence that could be given in support. HS advised that there were disclosure within the accounts and Grant Thornton understands the full position.

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AW aired concerns about the impact on the CCG’s financial position which the provision of significant support to the Trust had reflected. This was approved by the Governing Body in order to support the system, and enabled the Trust to obtain a further substantial allocation from the Provider Sustainability Fund. HS drew members’ attention to Grant Thornton’s fee increase which is for approval. The committee noted and approved the report and Grant Thornton fee. 2.9 Information Governance Information Governance Annual Service Report Unfortunately, a representative from the CSU IG team could not dial in for the meeting, however prior to the meeting an FAQ sheet was distributed to inform and help with any questions or queries. Further queries will be fed back to PJ following the meeting. The committee noted the report but felt that things had considerably moved on, since the report was written in early March. MC highlighted that IG Training reviews will be discussed at Executive Management Team (EMT) meeting. Also, the Data Security and Protection Toolkit (DSPT) will be reviewed and MC will meet with PJ and Ian Hart to discuss items for improvement. ACTION: PJ to provide another IG update for the next committee meeting.

AC20-21/1 ITEMS FOR INFORMATION

3.1 Audit Committee – Workplan Members noted the workplan. 3.2 Losses & Special payments & Tender waivers KJ updated the committee regarding the current position of Losses & Special Payments and Tender Waivers. KJ advised that there have been no losses written off or special payments made for period 31st January 2020 to the 23rd April 2020.

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KJ went onto share the organisation’s approach to Tender Waivers, given that the CCG has acted at pace in reaction to the COVID-19 crisis. The CCG has created a more streamlined process for approving business cases and proposals required to put in place facilities to alleviate capacity pressures. This revised approach has various stages of consideration and review that a proposal passes through before it is ultimately approved by the CCG’s Executive Management Team (EMT). KJ advised that to date 8 business cases have been approved since the end of March, all of which have required the need to “waive” the formalised procurement tendering process. All the approved business cases are related to supporting the Wirral system’s approach to the COVID-19 pandemic, for which the usual procurement processes have been “waived” and are covered by a single tender waiver. This approach has been approved by the Chief Officer and Chief Finance Officer and is also in line with the government process. The committee noted the tender waivers.

AC20-21/1 ANY OTHER BUSINESS

4.1

Discussions took place as to whether it was felt there should be a Governing Body Lay Member representative to have oversight of Business Case approvals. It was advised that with a 24 hour turn around between IMT and EMT daily meetings, which are reviewing and scrutinising Business Cases, the Audit Committee was assured that any oversight will be picked up through the Audit Committee normal review process.

AC20-21/1 DATE AND TIME OF NEXT MEETING

The next meeting will be held on: Thursday 15th June 2020, 10.00am in room 539 Please forward apologies / agenda papers to [email protected]

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Minutes of the WCCG Quality & Performance – Tuesday 28th April 2020 Page 1 of 9

MINUTES OF A MEETING OF THE NHS WIRRAL CLINICAL COMMISSIONING GROUP QUALITY AND PERFORMANCE COMMITTEE HELD ON 28 APRIL 2020


QP19/20/0088

Preliminary Business 1.1 Apologies for Absence

No Apologies were received.

1.2 Declarations of Interest Declarations of Interest submitted by members of the QP committee are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link:

https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff- listing-august-2017.pdf

There were no further declarations of interest.

Ian Huntley (Chair) Lay Member Quality and Outcomes NHS Wirral CCG Simon Banks (SB) Chief Officer, NHS Wirral CCG and WHCC Alan Whittle (AW) Lay Member, NHS Wirral CCG Lorna Quigley (LQ) Director of Quality & Safety, NHS Wirral CCG and WHCC Paul Edwards (PE) Director of Primary Care & Corporate Affairs, NHS Wirral

CCG and WHCC Mark Chidgey (MC) Chief Finance Officer, NHS Wirral CCG and WHCC Richard Crockford (RC) Deputy Director of Quality & Safety, NHS Wirral CCG and

WHCC Dr Simon Delaney (SD) Medical Director, NHS Wirral CCG and WHCC Dr Paula Cowan (PC) Chair, NHS Wirral CCG Nesta Hawker (NH) Director of Commissioning, NHS Wirral CCG and WHCC Iain Stewart (IS) Assistant Director for Primary Care, NHS Wirral CCG and

WHCC Stephen Cocks (SC) Assistant Director for Performance and Delivery, NHS

Wirral CCG and WHCC

In attendance:

Jennifer Galle (JG) Corporate Affairs Officer, NHS Wirral CCG and WHCC

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1.3 Chair’s Announcements IH welcomed members of the Committee and outlined the protocols for videoconferencing via Microsoft Teams. IH referred to the Out of Committee Approval document (copy attached). IH proposed that silence procedure be adopted for routine matters and outlined the governance around this. IH informed the Committee that Emma Jaegar, Medicines Optimisation Pharmacist, had proposed that pharmacy policies/guidelines that require out of committee approval should be collated and forwarded on a Monday, with the aim that they should be approved by Thursday and put into practice on Friday. These approved policies will then be formally noted at the next Q&P meeting. The Committee agreed to adopt this approval schedule.

1.4 Minutes & Action Points from previous meeting held on 31 March 2020

Minutes

With the addition of the amendments noted below, the minutes of the previous meeting held on 31 March 2020 were discussed, agreed as a true and accurate reflection of the meeting, and therefore ratified. The following amendments were made:

• AW requested that on page 9/10 Item 4.0 Work Plan 20/21, ‘Work Plan noted’ is added to minutes.

• SB requested that on page 5/10 ‘WITH is corrected to WUTH’

Action Points

Reports were provided on the outstanding actions and the log was updated.

QP19/20/0089

2.0 Items for Assurance 2.1 Risk Register PE indicated that the CCG’s business continuity plan had worked well, and that routine business had been able to continue. He then proposed that a new risk be added to the register: 19/20/L - Covid-19 – Impact on resilience and service delivery of core

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General Practice activity

• RAG: 20 (consequence 4; likelihood 5) • Owner: PE

All agreed to the above risk being added to the risk register. SB outlined how, over the next 12 months, or so, the response to Covid-19 will consist of three phases: Restoration, Recovery and Reset. Phase 1 will cover the next 4-6 weeks and will see the reestablishment of normal (non Covid) services (e.g. cancer treatment). Phase 2 is more uncertain and will be driven by the capacity within the system. Phase 3 will cover the period April 2021 – March 2023 and will aim to entrench the good practices developed during the Covid pandemic, in order to have an improved health service. Once further guidance and details are received these will be reflected in the Risk Register. Action: PE to update Risk Register to reflect the 3 Rs when details become available. NH proposed that the MSK risk should be placed on hold. In response, PE stressed the importance of not taking the focus off any pre-Covid risks. The Committee agreed that the MSK risk would remain the same. SB noted that MSK provision may not continue as a discrete service in future and indicated that it may be re-designed.

PE

2.2 Performance Update Covid-19 SC informed the Committee that the first of two papers presented was a report on the Key Performance Issues relating to the delegated duties of the Director of Commissioning and Transformation and the Director of Quality and Patient Safety. NH explained that this paper will also be presented to the Governing Body on 5th May 2020. The Committee was asked to note the content of the report and to note the NHSE/I reporting requirements during the pandemic. In line with this, NH stated that during the Covid pandemic the CCG will continue to monitor and report on the following:

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A&E The A&E performance for January and February continued to be below target trajectory, primarily due to wider system flow pressures such as acute bed capacity and discharge pressures. The Urgent Treatment Centre co-located with A&E was fully operational during the period. The service on average saw approximately 25 patients a day streamed from A&E. Overall levels of A&E attendance continue to be below the levels of 2018/2019. The current A&E performance indicated a 90% performance rate.

Ambulance In both January and February, North West Ambulance Service (NWAS) failed to achieve most of the performance standards except the Category 1 and 4 90th Percentile targets. The current prioritisation of Cat 1 calls has means that NWAS is currently meeting its Cat 1 target. Cancer Achievement of the Cancer Performance Indicators dropped in January and February. In both months NHS Wirral CCG failed the 2 Week Wait Referral to First Assessment target due to a mixture of Patient Choice and Elective Capacity. In February, elective capacity also impacted on the achievement of the 31 day target with 8 breaches. Whilst there were 21 breaches in respect of the 62 day referral to treatment target, this was due to a variety of reasons across a number of different providers and tumour groups. The long term impact of people not presenting for cancer screening is not yet clear.

Referral to Treatment NHS Wirral CCG’s RTT 18 week wait for incomplete pathways standard was not met in January (80%) or February (79.9%). WCCG has not met the 92% standard since December 2015. Wirral University Teaching Hospital NHS Foundation Trust (WUTH) also failed the national standard in both months, performing at 78.3% and 78.5% respectively. During this time a Wirral patient breached 52 week RTT standard at Countess of Chester Hospital but there were no 52 week breaches reported at WUTH since February 2019. WCCG has raised the 52 week breach at Countess of Chester Hospital with their commissioning organisation, which is aware of the incident and investigating it; this patient was seen in February 2020. NH explained that the Covid pandemic is already having a drastic impact on RTT, with only 66% of patients meeting the referral time last week (against a target of 92%)

A spreadsheet showing performance trends for the period April 2019 to February 2020 was discussed. As full data collection is not currently taking place, except for the four areas indicated above, for the coming

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months the document displayed predicted trends. This spreadsheet will be maintained monthly and will hopefully be a useful tool as the system starts to recover from Covid. In terms of Mental Health performance, NH explained that good progress had been made with IAPT although the number of referrals has decreased. LQ stated that there had been a reduction in mixed sex accommodation breaches, due to improvements in the recording of data. However, LQ expressed concern over the levels of Health Care Acquired Infections. She indicated that the current situation makes tracking these a challenge. AW commented on the value of having the MRSA reporting that had been provided. IH asked members of the Committee whether they felt they had a good level of granularity of information concerning the performance of providers, given that the Covid pandemic had now been ongoing for over a month. In response NH explained that the dashboard reporting is awaited in order to see the impact on pathways and to understand what pathways need to be targeted. However, the A&E performance dashboard is reviewed daily.

2.3 COVID 19 Safeguarding Children/Children Looked After

LQ informed the Committee that both reports had been compiled by Helen Heeley, Designated Nurse for Children’s Safeguarding and Children Looked After. The purpose of these reports was to make the committee aware of COVID-19 Safeguarding/ Children Looked After arrangements across the Wirral. They also sought to provide assurance that these arrangements continue to ensure NHS Wirral CCG fulfils its Statutory Safeguarding/Children Looked After responsibilities. The first report highlighted the effects of isolation on parents/carers and children. It noted that the risk of children being at harm is increased as society becomes distracted and children are no longer attending school. LQ provided an overview of the WHCC care arrangements that have been put in place for this period, stressing the importance of these measures, as safe places for children such as schools, are no longer available. LQ made the Committee aware that even though many named nurses for safeguarding have been redeployed across the frontline, the service has retained a team of 40 practitioners who are delivering the service virtually, in line with National guidance. She assured the Committee that the

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relevant pathways are in place for managing Safeguarding children cases. IH stated that the policy is sensible and that the Committee noted it and were assured by the Covid-19 Safeguarding Children arrangements. LQ informed the committee that the second report addressed the management of Initial Health Assessments (IHAs) and Review Health Assessments (RHAs) for Children Looked After (CLA) during the Covid-19 pandemic. All IHA and RHAs will continue virtually, ensuring that the child is both seen and heard. The local authority should continue to submit referrals for these assessments. This is in line with government guidelines. Although all KPIs have been suspended, providers have been asked to perform audits to record the work completed. LQ explained that the CCG still has statutory responsibility for Children / Children Looked After and there are still measures in place to check that children are safe. She also explained that she was involved in twice-monthly meetings with the Police and other stakeholders. LQ requested that the Committee approve the IHA/RHA guidance and be assured of COVID 19 Safeguarding Children/Children Looked After arrangements. PC expressed her full support for the paper and stated that it was a brilliant piece of work. IH confirmed that the Committee was fully supportive and approved the guidance.

2.4 Area Prescribing Committee – APC Report March 2020 LQ explained that this would potentially be the last APC report to the Committee. There was nothing contentious in the report and the report was for noting. The Committee noted the report.

QP19/20/0090

3.0 Items for Approval 3.1 Palliative Care drugs/Specification LQ explained that the paper has been collated by Steve Cocks, Claire Huntley: Commissioning Manager, and Victoria Vincent: Medicines Optimisation Pharmacist. The Committee were asked to approve the paper and agree an extension of the Community Pharmacy Palliative Care Scheme for 24 months.

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It was explained that the contract was currently in place with 12 pharmacies across Wirral. It enabled them to keep a stock of palliative care drugs in case patients are not able to get them from their own pharmacy. SC queried the length of time that was being requested for the extension to the contract. LQ confirmed it would be an extension of 24 months. PC stated that she whole heartedly supported this paper, especially considering the amount of people being discharged from hospital who require these essential drugs. IH confirmed that the Committee approved this requested extension of 24 months to March 2021.

3.2 Approved out of Committee The Committee noted the following policies that had been approved out of Committee:

• HR Policy

o Complaints Policy and Procedure (updated to reflect the CCG’s change of role in undertaking full delegated commissioning for Primary Care Medical Services, from 1st April 2020).

• Covid-19 Guidelines for Rapid Approval

o Early Use of Antibiotics in High-Risk Patients (RDTC)

Regional Drug and Therapeutics Centre. o DMARD (Disease-modifying anti-rheumatic drugs) Guidance

MLCSU (Midlands and Lancashire Commissioning Support Group)

• Regional Medicines Optimisation Committee (RMOC): Homely Remedy

Template Policy IH asked LQ to respond to Dr Lax Ariaraj’s questions regarding the approval of the Homely Remedy policy. Action: LQ to respond to Lax Ariaraj's email, regarding his queries on the RMOC Homely Remedy template policy.

LQ

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QP19/20/0091

4.0 Items for Information 4.1 2020 Work Plan Update LQ advised the Committee that all items highlighted in purple had been put on hold to focus on Covid-19 matters and will be reviewed on recovery.

QP19/20/0092

5.0 Risk Register Review

There was nothing further to add

QP19/20/0093

6.0 Lessons Identified There were no further lessons identified other than those which had already been discussed.

QP19/20/0094

7.0 Any Other Business

There was no further business discussed.

QP19/20/0095

8.0 Review of Actions

The Sec provided a review of actions

QP19/20/0096

9.0 Date and Time of Next Meeting Tuesday 26th May 2020, 14:00pm – 16:00pm Microsoft Teams

Papers Submission

Deadline

Papers to be distributed to

committee

Date of the meeting

Venue

17th January 20 21st January 20 28th January 20 539 14th February 18th February 20 25th February 20 539 20th March 20 24th March 20 31st March 20 539 17th April 20 21st April 20 28th April 20 539 15th May 20 19th May 20 26th May 20 539 19th June 20 23rd June 20 30th June 20 539 17th July 20 21st July 20 28th July 20 539

14th August 20 18th August 20 25th August 20 539 18th September

20 22nd September

20 29th September

20 539

16th October 20 20th October 20 27th October 20 539 13th November

20 17th November

20 24th November

20 539

11th December 15th December 22nd December 539

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20 20 20

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Minutes of the WCCG Quality & Performance Committee – Tuesday 26th May 2020 Page 1 of 12

MINUTES OF A MEETING OF THE NHS WIRRAL CLINICAL COMMISSIONING GROUP QUALITY AND PERFORMANCE COMMITTEE HELD ON 26 MAY 2020


QP19/20/0108

Preliminary Business 1.1 Apologies for Absence

No Apologies were received.

1.2 Declarations of Interest Declarations of Interest submitted by members of the QP committee are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link:

https://www.wirralccg.nhs.uk/media/3842/copy-of-conflicts-of-interest-staff- listing-august-2017.pdf

There were no further declarations of interest.

Ian Huntley (Chair) Lay Member Quality and Outcomes NHS Wirral CCG Simon Banks (SB) Chief Officer, NHS Wirral CCG and WHCC Alan Whittle (AW) Lay Member, NHS Wirral CCG Lorna Quigley (LQ) Director of Quality & Safety, NHS Wirral CCG and WHCC Paul Edwards (PE) Director of Primary Care & Corporate Affairs, NHS Wirral

CCG and WHCC Mark Chidgey (MC) Chief Finance Officer, NHS Wirral CCG and WHCC Richard Crockford (RC) Deputy Director of Quality & Safety, NHS Wirral CCG and

WHCC Dr Simon Delaney (SD) Medical Director, NHS Wirral CCG and WHCC Dr Paula Cowan (PC) Chair, NHS Wirral CCG Nesta Hawker (NH) Director of Commissioning, NHS Wirral CCG and WHCC Stephen Cocks (SC) Assistant Director for Performance and Delivery, NHS

Wirral CCG and WHCC

In attendance:

Gareth James (GJ) Senior HR Business Partner, MLCSU

Jennifer Galle (JG) Corporate Affairs Officer, NHS Wirral CCG and WHCC

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1.3 Chair’s Announcements IH welcomed members of the Committee and outlined the protocols for videoconferencing via Microsoft Teams.

1.4 Minutes & Action Points from previous meeting held on 28 April 2020

Minutes

With the addition of the amendments noted below, the minutes of the previous meeting held on 28 April 2020 were discussed, agreed as a true and accurate reflection of the meeting, and therefore ratified. The following amendments were made: AW requested that on page 5/9 Item 2.3, Covid 19 Safeguarding Children/Children Looked After: ‘children are hidden away’ is changed to more appropriate wording. LQ suggested ‘children are no longer attending school.’ Action Points Reports were provided on the outstanding actions and the log was updated.

QP19/20/0109

2.0 Items for Assurance 2.1 Risk Register PE informed the committee that MC would provide an update regarding the Covid Finance risk in light of the newly announced Financial Regime. A new risk around pressures on Primary Care Delegated budget is to be added to the risk register. There were no further updates to the risk register discussed.

2.2 Performance Report- March 2020 NH presented the report on the key performance issues within the four NHS Constitutional standards that remain during the current Covid-19 pandemic.

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A&E Performance against the 4 hour A&E standard improved in March 2020. This correlates with a decrease in A&E/APH walk in centre attendances. This pattern continued into April 2020 where attendances dropped to just 4,809 and performance increased to 85.38%. Performance to date for May 2020 (1st-13th) is 91.71%. Despite the significant drop in attendances, the 4 hour standard failed to be achieved in March 2020.

Streaming figures deteriorated slightly in March, with an average of 19 patients streamed per day. This further reduced during April but is starting to increase again. The likely cause of this decrease is a change in patient behaviour as a result of Covid-19. As noted above, there has been a significant reduction in attendances at A&E; this is especially the case for patients who would previously have been streamed elsewhere due to their condition being deemed less severe. This cohort of patients will have self-managed, contacted their own GP, or utilised one of the walk-in centres/urgent treatment centres. Non elective admissions have reduced by 3.5% against the planned position and there was a significant drop of 500+ patients in March 2020 compared with February 2020. This is reflected nationally and is likely to be due to a reduction in attendances as well as the fact that the hospital site has diagnosed cases of Covid-19. Additional help has been given to support admission avoidance and step up to community-based beds, where appropriate. Long length of stay has seen a significant reduction and the CCG is in the top 5 in the country for its performance in reducing long length of stay. At the end of February 2020, there were 201 patients with a length of stay of 21 days or more, this dropped to 112 at the end of March and to 36 by the end of April 2020. Ambulance The performance data for March 2020 indicates a failure to meet all targets except for Category 1 (90th centile) and Category 4. Performance in the remaining categories has deteriorated. On 3 April it was decided to respond primarily to life threatening cases, establishing alternative pathways for the remaining patients contacting 999. The ambulance service has seen an increase in demand of 6% for 999 activity across the region, with some areas seeing a rise of over 10%, with

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5,000 999 calls received per day. In addition to this, the service is managing increased sickness due to Covid-19/related symptoms.

Referral To Treatment Referral to Treatment (RTT) at the end of March 2020 deteriorated due to the reduction in elective activity. This continued into April 2020 and will remain the case until elective capacity is restored. Despite there being fewer new referrals, there has been a drop of up to 75% in elective activity over historical levels nationally. Consequently, the waiting time for routine patients will increase. At WUTH specifically, the reduction was: 38% (GP) and 22% (Other). The forecast is for a continued deterioration of the RTT figures as a higher proportion of patients wait over 18 and 52 weeks. The Covid-19 pandemic has resulted in a reduction of GP referrals and the cessation of the vast majority of elective work. The short term effect on RTT will be a reduction in waiting list size and a deterioration in the % of incomplete pathways waiting less than 18 weeks. The total RTT wait list size in March 2020 at WUTH was 22,350; a reduction of 857 patients compared to previous month. Although the overall number on waiting lists is not increasing, it is likely that on the resumption of more normal referral patterns and clinic activity, a backlog of patients will start to enter the RTT waiting list. The restoration of capacity to see routine patients in all settings, including outpatients, diagnostics, and treatments, will be critical in offsetting the challenges once the Covid-19 escalations are eased off. RTT 52 week breaches – The number of patients exceeding 52 week waits in March 2020 was 15 against a trajectory of 0; all of these breaches were in Surgical Specialties at WUTH. Elective activity cancellations as a result of the Covid-19 response have been a significant factor in the deterioration in the 52 week wait position and the 18 week RTT performance. Cancer Since March 2020, Cancer Services have continued to accept referrals and despite the changes in resources and available treatments, performance has been maintained. Activity is steadily increasing, with WUTH experiencing around 70% of expected referrals. WUTH are aware that there is likely to be a surge in referrals which, along with the current backlog, will impact performance. In addition, patients will be presenting with later staging than usually expected; indeed, MDTs are already reporting an increase in late staging.

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In order to support recovery, the WCCG Cancer Commissioner and Lead GP are meeting fortnightly with representatives from WUTH. They are also holding ad hoc project meetings. In addition, WUTH have proposed a recovery trajectory to manage and assess progress to pre-Covid-19 performance levels.

IH questioned why the data is not up to date. NH explained that the data is required to be validated and this can cause a delay. SC explained that attempts are being made to use more local intelligence. However, there is a requirement to relate back to nationally reported data. PC raised the issue of streaming and asked what was being done, in terms of working with the walk in centre, to try and increase the streaming figures. NH responded by explaining that unfortunately streaming is not included in the 8 point plan. However, this has been flagged and will remain a focus. NH informed the committee that a plan for this is currently being worked on and that she will provide an update at the next Q&P meeting. Action: NH to report on a streaming plan at the next Q&P meeting 30/06/2020.

NH commented that the poor RTT performance was primarily due to the Covid pandemic. SB stated that, looking at Cheshire and Merseyside data, whilst contractual performance is suspended it is unlikely that recovery will be quick. LQ informed the committee that the methodology of harm reviews will be brought to the next meeting and this will give the opportunity to review local figures against national harm levels. Action: LQ to introduce 'harm review' process to the next Q&P meeting 30/6/2020.

NH assured the committee that those cancer patients requiring treatment are being prioritised.

NH

LQ

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IH questioned the timescale on the use of Robotic theatres recommencing. SC confirmed that the use of Robotic theatres is expected to recommence in mid-June.

2.3 Commissioning Plan – Second Phase of COVID-10 Pandemic This report is for the committee to note the proposed response from commissioners to the second phase of the COVID-19 pandemic. NH explained that there are three aspects covered:

• Provider meetings Regular meetings with providers will continue and discussions will take place regarding plans to increase the services delivered. System triggers will be reviewed and there will be an opportunity to gain an understanding of new risks and issues. The meetings will form part of the intelligence gathering for the system wide approach to be adopted for quality improvement and assurance. NH agreed that, as discussed earlier, more up to date data is required.

• Second phase commissioner response

NH explained that the second phase commissioner’s response has been placed into care categories with proposed actions against them.

• Performance monitoring NH discussed the importance of performance monitoring in order to understand the changing demands on services, to ensure that services are commissioned to meet the changing needs and ensure the NHS and care sector remain resilient. Reviewing the system dashboard will highlight trends and help to inform future commissioning decisions. AW raised the issue of the national requirement to return to pre Covid performance levels. The committee discussed whether this was deemed appropriate and the acceptability of seeing people face to face.

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2.4 Compliance Report PE provided an update to assure the committee that complaints and MP enquiries are managed in line with the agreed policies and procedures.

In the period 18 March to 12 May 2020, 12 new complaints were received and 10 complaints were closed. Overall, complaints, concerns and patient enquiries saw an increase due, in large part, to Covid-19 related issues. During this reporting period, there have been 32 new MP enquiries. PE explained that the key themes of these enquiries related to Personal Protective Equipment (PPE), testing and care home issues as a result of the Covid-19 pandemic. Timely responses were provided by the Management Team to these enquiries. PE made the committee aware that due to Marriss House being closed, the team had made arrangements for the post to be delivered elsewhere. However, Royal Mail has struggled to divert the post and, as a result, two sacks of undelivered mail have been discovered. LQ questioned whether there is any risk around this that needs to be documented. In response, PE explained that his team will be working through the backlog of mail as quickly as possible. They will send out letters of apology where appropriate, explaining why some correspondence has not received an earlier response. PE also explained that a message to the public was put on the website encouraging communication via email. RC informed the committee that Wirral has had 12 new serious incidents reported between 1 March 2020 – 30 May 2020. WUTH have also had a second ‘Never’ event in 2 months. These are preventable events which, if all the appropriate procedures are followed, will not occur. RC stated that the incidents will be investigated to ensure there are no recurring themes. AW commented on the above and questioned whether WUTH are still using the WHO checklist. RC explained that WUTH do use the WHO checklist and that when this latest incident is investigated, this should be commented on in

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the review.

2.5 HR Report GJ provided an overview of the HR Performance Report, explaining that it outlines relevant information for NHS Wirral CCG. The paper highlights key areas for the most recent quarter January 2020 – March 2020. GJ commented that the percentage of the CCG workforce from a BME group was 5.95% at the end of March 2020. The target for the CCG is 3.01%. It is recommended that the CCG continues to proceed with any actions that it is taking regarding BME representation. MC questioned whether the target BME representation figure is based on an up to date analysis of the local population. GJ agreed to look into this and ensure the target figure is reflective of the local area, rather than being a national target. Action: GJ to provide assurance that the target percentage of CCG workforce from a BME group is up to date and based on local population data. GJ informed the committee that in the 12 months to March 2020, the CCG had an annual staff turnover rate of 16.36%. The monthly turnover rate was 2.30% as at the end of March 2020. This ranks the CCG as the 10th highest in a direct comparison with other CCG organisations. The average turnover rate for the peer group was 17.11%. IH questioned whether managers perform exit interviews with employees. GJ explained that this was up to individuals if they wanted to pursue this. GJ explained that there was positive news around sickness absence. The monthly sickness absence rate was 0.85% as at the end of March 2020 which was a decrease on the figure of 5.51% as at the end of December 2019. The 0.85% rate as at the end of March 2020 is below the CCG target of 2.00%. AW queried whether the CCGs figures were skewed due to long term absence and GJ replied that previously the figures had been affected by staff on long term sickness but that several had now returned to work. GJ stated that the Statutory and Mandatory training compliance rate was

GJ

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87.09% which has increased since December 2019. However, it is still below the 90.00% target. This is, however, higher than other CCGs in the peer group. GJ informed the committee that a new appraisal system has been developed and that the CCG had been trialling the system during February. However, due to the current pandemic, it has been decided to suspend the completion of formal appraisals. The appraisal compliance rate is therefore not being monitored at present.

2.6 Whistleblowing Policy The policy has been examined in line with the planned review date of May 2020 and there are no changes to note. IH discussed protected disclosure and questioned the implications of this. PE explained that it is impossible to proceed unless a certain level of information is disclosed. The committee agreed to endorse the policy.

2.7 SEND (Quarterly) Report RC provided a verbal update on SEND, informing the committee that a report has been submitted covering 10 key areas that require action. However, he explained that the pandemic had slowed progress and that initially, strategy meetings had been cancelled. These meetings are now starting to be re-instated, using MS Teams. It has been agreed to focus on gathering accurate data whilst improving the dashboard. Ofsted/CQC inspections have been paused and will not be restarting before January 2021. RC discussed the delay in people receiving useful advice in response to enquiries concerning Speech and Language Therapy and stated that this has been raised with the relevant organisation. AW commented that SEND is on the risk register and it was agreed to update the risk with RC’s commentary.

2.8 Joint Agency Response – Sudden Unexpected Death in a Child Interim Guidance

LQ informed the committee that this guidance describes how, during the pandemic, certain changes will need to be adopted in the management of

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child deaths and that this would require a Joint Agency Response. The likelihood of children contracting Covid-19 is low and it is not expected to cause a significant numbers of child deaths. Social isolation may, however, lead to an increase in child abuse and self- harm and children living in socially challenging circumstances may be at higher risk. LQ discussed the circumstances in which a Joint Agency Response is required. However, she explained that during the COVID-19 pandemic, certain changes will need to be adopted in the management of child deaths requiring a Joint Agency Response, primarily with regarding social distancing.

IH asked who coordinates the Joint Agency Response meetings, and in reply, LQ explained it was the Local Authority followed by the CCG, Police, and various other health agencies.

QP19/20/0110

3.0 Items for Approval 3.1 Mesalazine Guidance Pan Mersey Adoption LQ informed the committee that this is not a Covid-19 related policy, it is a new policy and the committee were asked to approve the contents of the report. Assurance is provided by the policy being submitted via the Medicines Management Committee, which recommended that the policy is adopted. The committee agreed to approve the policy.

3.2 Expiring Wirral CCG Medicines Management Guidelines during COVID-19 LQ explained that the Wirral CCG guidelines in the report have or are due to expire. The committee were asked to approve an extension for 1 year or until the Pan Mersey APC resumes business as usual, whichever is the earlier. This approach has been recommended by the Wirral CCG Medicines Management committee. The committee agreed to approve the contents of the report.

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3.3 Approved out of Committee The Committee noted that a quorum had approved the following policy out of committee:

• HR Policy

o Conflicts of Interest Policy

QP19/20/0111

4.0 Items for Information 4.1 Other Committee Minutes • Serious Incidents Review Group

The Committee noted minutes from the meeting. 4.2 2020 Work Plan PE made the committee aware that there could be a potential delay with HR policies presented to the committee due to staff redeployment during the pandemic.

QP19/20/0112

5.0 Lessons Identified

LQ made the committee aware of a safeguarding incident that involved an on-call manager not completing their online safeguarding training. The lesson identified is that if the manager had completed their safeguarding mandatory training then they would have been more confident in decision making.

QP19/20/0113

6.0 Risk Register Review 6.1 Revision of Risk Register There was no further risk identified.

QP19/20/0114

7.0 Any Other Business

There was no further business discussed.

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QP19/20/0115

8.0 Review of Actions

The Sec provided a review of actions.

QP19/20/0116

9.0 Review of Meeting

The committee reviewed the meeting and there were no further issues to address.

QP19/20/01

10.0 Date and Time of Next Meeting Tuesday 30th June 2020, 14:00pm – 16:00pm Microsoft Teams

Papers Submission

Deadline

Papers to be distributed to

committee

Date of the meeting

Venue

17th January 20 21st January 20 28th January 20 539 14th February 18th February 20 25th February 20 539 20th March 20 24th March 20 31st March 20 539 17th April 20 21st April 20 28th April 20 539 15th May 20 19th May 20 26th May 20 539 19th June 20 23rd June 20 30th June 20 539 17th July 20 21st July 20 28th July 20 539

14th August 20 18th August 20 25th August 20 539 18th September

20 22nd September

20 29th September

20 539

16th October 20 20th October 20 27th October 20 539 13th November

20 17th November

20 24th November

20 539

11th December 20

15th December 20

22nd December 20

539

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