Questions from members of the public should be …...2018/12/13 · Hogg GBIC/1819/62 Quality and...

Erewash Clinical Commissioning Group Hardwick Clinical Commissioning Group

North Derbyshire Clinical Commissioning Group Southern Derbyshire Clinical Commissioning Group

NHS DERBYSHIRE CCGS GOVERNING BODY MEETINGS IN COMMON

PUBLIC GOVERNING BODY MEETING

Date & Time: 13th December 2018, 2.45pm – 5.00pm

Venue: Coney Green Business Centre, Clay Cross, S45 9JW

Questions from members of the public should be emailed to [email protected] in which case a response will be provided on the day or will be sent within seven working days.

Confidential items are outlined in a separate confidential agenda; confidential items will be considered in a closed private session.

Item Subject Paper Presenter Time

GBIC/1819/51 Welcome, Apologies & Quoracy Verbal Dr Avi Bhatia

2.45

GBIC/1819/52 Questions from members of the public Verbal Dr Avi Bhatia

GBIC/1819/53 Declarations of Interest Register of Interests•Summary Register for Recording Any•conflicts of interests During MeetingsGlossary•

Paper A Dr Avi Bhatia

CHIEF OFFICERS REPORTS

GBIC/1819/54 Chief Executives Report Paper B Dr Chris Clayton

2.50

DECISION GBIC/1819/55 Voluntary Sector Review Paper C Zara

Jones 3.00

GBIC/1819/56 Gluten Free Consultation Evaluation Report

Paper D Dr Steve Lloyd

GBIC/1819/57 Creating the New CCG • Derbyshire CCGs Merger Update

and consultation plan with CCG memberships for new Constitution

Paper E Helen Dillistone

mailto:[email protected]

GBIC/1819/58 Deprivation of Liberty and Court of Protection position across the Derbyshire CCGs

Paper F Brigid Stacey

GBIC/1819/59 Better Care Closer to Home - Pathway 3 Beds

Paper G Zara Jones

CORPORATE ASSURANCE GBIC/1819/60 Update on Operating Plan for 19/20 Paper H Zara Jones 4.10

GBIC/1819/61 Finance and QIPP Assurance Report for Month 7

Paper I Louise Bainbridge and Sandy Hogg

GBIC/1819/62 Quality and Performance Committee Assurance Report

Paper J Dr Buk Dhadda

GBIC/1819/63 Governance Committee Assurance Report

Paper K Jill Dentith

GBIC/1819/64 Audit Committee Assurance Report Paper L Ian Gibbard

GBIC/1819/65 Risk Register Exception Report November 18

Paper M Helen Dillistone

GBIC/1819/66 Committees in Common Minutes (For Information only) Quality and Performance 4.10.18 •

Audit Committee 19.09.18 •

Governance Committee 12.09.18 •

Paper N Paper O Paper P

Dr Buk Dhadda Ian Gibbard Jill Dentith

GBIC/1819/67 Minutes from other meetings for information: • Derbyshire County Health &

Wellbeing Board Meeting 4.10.18 • Derby City Health & Wellbeing Board

Meeting 13.9.18

Paper Q Paper R

Dr Avi Bhatia Dr Avi Bhatia

FOR INFORMATION GBIC/1819/68 Psychodynamic psychotherapy

consultation

Paper S Zara Jones 4.40

MINUTES AND MATTERS ARISING



Date and time of next meeting: Thursday 24th January, 11.15am – 1.15pm at Coney Green Business Centre

GBIC/1819/69 Minutes of the Derbyshire CCGs GB Meetings in Common 1st November 2018

Paper T Dr Avi Bhatia

4.45

GBIC/1819/70 Matters arising from the minutes not elsewhere on agenda:

• Action Log

Paper U Dr Avi Bhatia

GBIC/1819/71 Any Other Business Verbal ALL 5.00 Close

Table of Contents

Declarations of Interest....................................................................................... 5

Register of Interests................................................................................. 5

Register for recording any conflicts of interests during Meetings............. 19

Glossary................................................................................................... 20

Chief Executives Report...................................................................................... 30

Voluntary Sector Review..................................................................................... 35

Gluten Free Consultation Evaluation Report....................................................... 68

Creating the New CCG....................................................................................... 107

Deprivation of Liberty and Court of Protection position....................................... 110

Better Care Closer to Home - Pathway 3 Beds................................................... 117

Update on Operating Plan for 19/20................................................................... 129

Finance and QIPP Assurance Report for Month 7.............................................. 139

Quality and Performance Committee Assurance Report.................................... 146

Governance Committee Assurance Report........................................................ 187

Audit Committee Assurance Report.................................................................... 191

Risk Register Exception Report November 18.................................................... 194

Committees in Common Minutes........................................................................ 207

Quality and Performance 4.10.18............................................................. 207

Audit Committee 19.09.18........................................................................ 218

Governance Committee 12.09.18............................................................ 231

Minutes from other meetings for information....................................................... 239

Derbyshire County Health & Wellbeing Board Meeting 4.10.18............... 239

Derby City Health & Wellbeing Board Meeting 13.9.18............................ 247

Psychodynamic Psychotherapy Consultation..................................................... 255

Minutes of the Derbyshire CCGs GB Meetings in Common 1.11.18.................. 258

Action Log........................................................................................................... 271

Fina

ncia

l Int

eres

t

Non

Fin

anci

al

Prof

essi

onal

In

tere

st

Non

-Fin

anci

al

Pers

onal

Inte

rest

From To

Amos, Margaret Southern Derbyshire CCGErewash CCG

Lay Member – Audit and Governance Governing Body Audit Chair – Trinity House Department for TransportOwn company - A2 Business Solutions

Indirect Jan-18 Ongoing No action required


Lay Member – Audit and Governance Audit Committees in Common Audit Chair – Trinity House Department for TransportOwn company - A2 Business Solutions



Lay Member – Audit and Governance Remuneration Committee Audit Chair – Trinity House Department for TransportOwn company - A2 Business Solutions



Lay Member – Audit and Governance Primary Care Co Commissioning Committee Audit Chair – Trinity House Department for TransportOwn company - A2 Business Solutions



Lay Member – Audit and Governance Finance Committee Audit Chair – Trinity House Department for TransportOwn company - A2 Business Solutions


Apsley, Gary North Derbyshire CCG Lay Member – Patient and Public Involvement Governing Body Nil No action requiredApsley, Gary North Derbyshire CCG Lay Member – Patient and Public Involvement Audit Committees in Common Nil No action requiredApsley, Gary North Derbyshire CCG Lay Member – Patient and Public Involvement Remuneration Committee Nil No action requiredApsley, Gary North Derbyshire CCG Lay Member – Patient and Public Involvement Primary Care Co Commissioning Committee Nil No action requiredApsley, Gary North Derbyshire CCG Lay Member – Patient and Public Involvement Finance Committee Nil No action required

Austin, Debbie Dr North Derbyshire CCG GP Lead Governing Body

School Governor Taxal and Fernilee Primary School, Whaley Bridge

Spouse is Employee of DCHS, Associate Director of Transformation

Locum GP

Chair of Place Alliance group

Indirect

Indirect

Direct

Direct

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

Withdraw from all discussion and voting if organisation Is potential provider unless otherwise agreed by the meeting chair

NHS DERBYSHIRE CCGS REGISTER OF INTERESTS - DECEMBER 2018

Type of Interest Date of Interest

Name Committee Member Declared Interest (Including direct/ indirect Interest)Direct or Indirect Interest

CCG Job Title Action taken to mitigate risk

5

Austin, Debbie Dr North Derbyshire CCG GP Lead Strategic Commissioner Programme Board



Locum GP


Indirect

Indirect

Direct

Direct

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required


Austin, Debbie Dr North Derbyshire CCG GP Lead Clinical & Lay Commissioning Committee



Locum GP


Indirect

Indirect

Direct

Direct

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required


Bagshaw, Katherine Dr Erewash CCG GP Partner at Littlewick Medical Centre Governing Body

GP Provider

GP Locality Lead and GP Appraiser

Partner Governor on Board of Governors at DCHS

Direct

Direct

Direct

2000

2007

Oct 18

Ongoing

Ongoing

Ongoing

Declare interest at all Committee meetings regarding Co-Commissioning

No action required

Bagshaw, Katherine Dr Erewash CCG GP Partner at Littlewick Medical Centre Finance Committee

GP Provider



Direct

Direct

Direct

2000

2007

Oct 18

Ongoing

Ongoing

Ongoing


No action required

Bagshaw, Katherine Dr Erewash CCG GP Partner at Littlewick Medical Centre Clinical & Lay Commissioning Committee

GP Provider



Direct

Direct

Direct

2000

2007

Oct 18

Ongoing

Ongoing

Ongoing


No action required

Derbyshire CCGs Chief Finance Officer Governing Body Nil No action requiredDerbyshire CCGs Chief Finance Officer Audit Committees in Common Nil No action requiredDerbyshire CCGs Chief Finance Officer Primary Care Co Commissioning Committee Nil No action requiredDerbyshire CCGs Chief Finance Officer Finance Committee Nil No action requiredDerbyshire CCGs Chief Finance Officer Clinical & Lay Commissioning Committee Nil No action required

Belcher, Hannah North Derbyshire CCG Head of Primary Care Primary Care Co Commissioning Committee Nil No action required

Bhatia, Avi Dr Erewash CCG Clinical Chair and GP at Moir Medical Centre Governing Body

Member of Erewash Health (Provider Arm)

GP Contractor at Moir Medical Centre

Spouse works for Nottingham City Hospital

Direct

Direct

Indirect

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

Bainbridge, Louise

6

Bhatia, Avi Dr Erewash CCG Clinical Chair and GP at Moir Medical Centre Strategic Commissioner Programme Board

Member of Erewash Health (Provider Arm)

GP Contractor at Moir Medical Centre

Spouse works for Nottingham City Hospital

Direct

Direct

Indirect

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

Bhatia, Upendra North Derbyshire CCG GP Partner at Newbold Surgery Clinical & Lay Commissioning Committee

GP Partner at Newbold Surgery

GP Practice part of Chesterfield Health Provider Company

Director Veincare Ltd

Consultant Surgeon NUH

Direct

Direct

Indirect

Indirect

2009

2009

Apr-13

2000

Ongoing

Ongoing

Ongoing

Ongoing


No action required

No action required

No action required

Bishop, Nick Dr Southern Derbyshire CCG GP Partner at Whitemoor Medical Centre Governing Body

The practice is a member of the ALEXIN Co-operative

Personal interest of a family member; part time speech and language therapist with DCHS

Direct

Indirect

2013

2013

Ongoing

Ongoing

Declare interests at relevant meetings


Bishop, Nick Dr Southern Derbyshire CCG GP Partner at Whitemoor Medical Centre Clinical & Lay Commissioning CommitteeThe practice is a member of the ALEXIN Co-operative

Personal interest of a family member; part time speech and language therapist with DCHS

Direct

Indirect

2013

2013

Ongoing

Ongoing



Booth, Andrew Erewash CCG Lay Member (Audit) and Conflicts of Interest Guardian Governing BodyDaughter and Son-in-Law both work at Royal Derby Hospitals Foundation Trust

Indirect Ongoing Ongoing No action required

Braithwaite, Bruce North Derbyshire CCG Secondary Care Doctor Governing Body

Director of Clinical Services, Alliance Surgical PLC

Director BD Braithwate

Director Veincare Ltd

Consultant Surgeon Nottingham University Hospitals

Indirect

Indirect

Indirect

2007

2003

Apr-13

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

Butler, Richard North Derbyshire CCG GP Partner at The Valleys Medical Partnership Clinical & Lay Commissioning Committee GP Partner at The Valleys Medical Partnership Direct Ongoing Ongoing


Chawla, Sudeep Dr Hardwick CCG GP Partner at Wingerworth Surgery Governing Body Director of SKC Developments Ltd; Owners of Wingerworth Medical Centre building

House Specsavers Ear Care

Direct

Direct

Feb-17

Nov-17

On going

Ongoing

No action required

No action required

Chawla, Sudeep Dr Hardwick CCG GP Partner at Wingerworth Surgery Quality & Performance CommitteeDirector of SKC Developments Ltd; Owners of Wingerworth Medical Centre building


Direct

Direct

Feb-17

Nov-17

On going

Ongoing

No action required

No action required

Chawla, Sudeep Dr Hardwick CCG GP Partner at Wingerworth Surgery Governance Committee

Director of SKC Developments Ltd; Owners of Wingerworth Medical Centre building


Direct

Direct

Feb-17

Nov-17

On going

Ongoing

No action required

No action requiredClayton, Chris Dr Derbyshire CCGs Chief Executive Officer Governing Body Spouse is a Director at PWC Indirect 2001 On going No action requiredClayton, Chris Dr Derbyshire CCGs Chief Executive Officer Audit Committees in Common Spouse is a Director at PWC Indirect 2001 On going No action requiredClayton, Chris Dr Derbyshire CCGs Chief Executive Officer Primary Care Co Commissioning Committee Spouse is a Director at PWC Indirect 2001 On going No action requiredClayton, Chris Dr Derbyshire CCGs Chief Executive Officer Finance Committee Spouse is a Director at PWC Indirect 2001 On going No action requiredClayton, Chris Dr Derbyshire CCGs Chief Executive Officer Clinical & Lay Commissioning Committee Spouse is a Director at PWC Indirect 2001 On going No action required

Cooper, Ruth Dr Hardwick CCG Chair and GP Partner at Staffa Health Governing Body

GP Partner at Staffa Health

GP Shareholder North East DerbyshireHealth Federation

Direct

Direct

1992

Ongoing

Ongoing

Ongoing

Declare interests in relevantmeetings

Declare interests in relevant meetings

7

Cooper, Ruth Dr Hardwick CCG Chair and GP Partner at Staffa Health Strategic Commissioner Programme Board



Direct

Direct

1992

Ongoing

Ongoing

Ongoing



Cooper, Ruth Dr Hardwick CCG Chair and GP Partner at Staffa Health Clinical & Lay Commissioning Committee



Direct

Direct

1992

Ongoing

Ongoing

Ongoing



Crowson, Richard Dr Southern Derbyshire CCG GP Partner at Mackin Street Surgery Governing Body

GP Partner at Mackin Street Surgery

Spouse consultant in elderly care at UHDB

Practice currently manages Laverstoke Court Initialy asylum seeked accommodation centre

Shareholder in Alexin (not the named individual involved)

Direct

Indirect

Direct

Direct

Nov-16

Nov-16

Jan-18

Nov-16

Ongoing

Ongoing

Ongoing

Ongoing

No action required / Declare interests in relevant meetings




Crowson, Richard Dr Southern Derbyshire CCG GP Partner at Mackin Street Surgery Clinical & Lay Commissioning Committee

GP Partner at Mackin Street Surgery

Spouse consultant in elderly care at UHDB

Practice currently manages Laverstoke Court Initialy asylum seeked accommodation centre

Shareholder in Alexin (not the named individual involved)

Direct

Indirect

Direct

Direct

Nov-16

Nov-16

Jan-18

Nov-16

Ongoing

Ongoing

Ongoing

Ongoing





Dentith, JillHardwick CCGNorth Derbyshire CCG

Lay Member - Audit and Governance Governing Body

Self-employed through own management consultancy business trading as Jill Dentith Consulting

Voting Governing Body Lay Member for NHS Hardwick CCG

Non-voting Governing Body Lay Member for NHS North Derbyshire Clinical Commissioning Group

Providing short-term management consultancy support on corporate governance to Sheffield Teaching Hospitals NHS Foundation Trust

Providing short-term, part-time management consultancy support on corporate governance to Sheffield Children’s Hospital NHS Foundation Trust

Indirect

Direct

Direct

Indirect

Indirect

2012

2012

Dec-17

Feb-18

Aug-18

Ongoing

Mar-19

Mar-19

Aug-18

Nov-18

No action required

No action required

No action required

No action required

No action required

8


Lay Member - Audit and Governance Strategic Commissioner Programme Board






Indirect

Direct

Direct

Indirect

Indirect

2012

2012

Dec-17

Feb-18

Aug-18

Ongoing

Mar-19

Mar-19

Aug-18

Nov-18

No action required

No action required

No action required

No action required

No action required


Lay Member - Audit and Governance Audit Committees in Common






Indirect

Direct

Direct

Indirect

Indirect

2012

2012

Dec-17

Feb-18

Aug-18

Ongoing

Mar-19

Mar-19

Aug-18

Nov-18

No action required

No action required

No action required

No action required

No action required


Lay Member - Audit and Governance Remuneration Committee






Indirect

Direct

Direct

Indirect

Indirect

2012

2012

Dec-17

Feb-18

Aug-18

Ongoing

Mar-19

Mar-19

Aug-18

Nov-18

No action required

No action required

No action required

No action required

No action required

9


Lay Member - Audit and Governance Finance Committee






Indirect

Direct

Direct

Indirect

Indirect

2012

2012

Dec-17

Feb-18

Aug-18

Ongoing

Mar-19

Mar-19

Aug-18

Nov-18

No action required

No action required

No action required

No action required

No action required


Lay Member - Audit and Governance Governance Committee






Indirect

Direct

Direct

Indirect

Indirect

2012

2012

Dec-17

Feb-18

Aug-18

Ongoing

Mar-19

Mar-19

Aug-18

Nov-18

No action required

No action required

No action required

No action required

No action required

Derricott Judy North Derbyshire CCG Head of Primary Care Quality Primary Care Co Commissioning Committee Nil No action required

Dhadda, Buk Dr Southern Derbyshire CCG GP Partner at Swadlincote Surgery Governing Body

GP Partner at Swadlincote Surgery

Practice is a nominal shareholder in Alexin (not the lead partner for this)

Direct

Direct

2013

2013

Ongoing

Ongoing

No action required

No action required

Dhadda, Buk Dr Southern Derbyshire CCG GP Partner at Swadlincote Surgery Quality & Performance Committee

GP Partner at Swadlincote Surgery

Practice is a nominal shareholder in Alexin (not the lead partner for this)

Direct

Direct

2013

2013

Ongoing

Ongoing

No action required

No action required

Dillistone, Helen Derbyshire CCGs Executive Director Corporate Strategy and Delivery Governing Body Nil No action requiredDillistone, Helen Derbyshire CCGs Executive Director Corporate Strategy and Delivery Strategic Commissioner Programme Board Nil No action required

10

Fleming, Isobel North Derbyshire CCG Service Director - Countywide Commissioning Governing Body

Director of Child Outcomes Research Consortium (CORC). CORC is a not for profit organisation. The Director position is not paid.

Co-Author of the THRIVE Elaborated Model

Evidence Based Practice Unit (EBPU) associate. Honorary position

University College London (UCL) - Department of Clinical Educational and Health Psychology. Honorary position

NHSE Health & Justice Children's Assurance Group

Direct

Direct

Direct

Direct

Direct

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Should CORC tender for contracts any interests to be clearly declared and may result in Isobel Fleming withdrawing from involvement in the process.

When relevant - Any interests to be clearly declared




Gibbard, Ian North Derbyshire CCG Lay Member - Audit & Governance Governing Body Nil No action requiredGibbard, Ian North Derbyshire CCG Lay Member - Audit & Governance Strategic Commissioner Programme Board Nil No action requiredGibbard, Ian North Derbyshire CCG Lay Member - Audit & Governance Audit Committees in Common Nil No action requiredGibbard, Ian North Derbyshire CCG Lay Member - Audit & Governance Remuneration Committee Nil No action requiredGibbard, Ian North Derbyshire CCG Lay Member - Audit & Governance Primary Care Co Commissioning Committee Nil No action required

Gooch, Duncan Dr Erewash CCG GP at Golden Brook Practice Governing Body

Chair of Erewash Health Ltd (GP Federation across Erewash

GP Partner and Quality Lead for Erewash Health Partnership. Direct clinical delivery is at the Golden Brook Practice, part of the Erewash Health Partnership

RCGP faculty Board Member

Various roles within the management committee of Long Eaton Rugby Club. Elected President from 2018

Wife is a GP partner within Erewash Health Partnership

Direct

Direct

Direct

Indirect

Indirect

2013

2010

2017

2011

2013

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required


No action required

No action required

No action required

Gooch, Duncan Dr Erewash CCG GP at Golden Brook Practice Quality & Performance Committee

Chair of Erewash Health Ltd (GP Federation across Erewash

GP Partner and Quality Lead for Erewash Health Partnership. Direct clinical delivery is at the Golden Brook Practice, part of the Erewash Health Partnership

RCGP faculty Board Member

Various roles within the management committee of Long Eaton Rugby Club. Elected President from 2018

Wife is a GP partner within Erewash Health Partnership

Direct

Direct

Direct

Indirect

Indirect

2013

2010

2017

2011

2013

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required


No action required

No action required

No action required

11

Harvey, Chris Dr North Derbyshire CCG GP Partner at Stewart Medical Centre Clinical & Lay Commissioning Committee

Locality Lead for High Peak

GP Partner Stewart Medical Centre

OOH Sessional GP

GP Appraiser

Aug-09

2012

Dec-15

Ongoing

Ongoing

Ongoing

Hayes, Anne Erewash CCGHardwick CCG

Public Health Representative Governing Body Nil No action required

Heathcote, David Hardwick CCG Lay Representative Audit Committees in CommonLay Member for Mansfield & Ashfield CCG and Newark & Sherwood CCG

Indirect Apr-15 OngoingDeclare conflict with any potential agenda item on Audit Committee meeting

Henn, Markus Dr Erewash CCG GP at Littlewick Medical Centre Governing Body

GP Provider

Practice provides inpatient services for DCHSFT at Ilkeston Community Hospital

Direct

Direct

Ongoing Ongoing

Ongoing


Henn, Markus Dr Erewash CCG GP at Littlewick Medical Centre Strategic Commissioner Programme Board

GP Provider


Direct

Direct

Ongoing Ongoing

Ongoing


Henn, Markus Dr Erewash CCG GP at Littlewick Medical Centre Governance Committee

GP Provider


Direct

Direct

Ongoing Ongoing

Ongoing


Hogg, Sandy Derbyshire CCGs Turnaround Director Finance Committee NilJones, Zara Derbyshire CCGs Executive Director of Commissioning Operations Governing Body NilJones, Zara Derbyshire CCGs Executive Director of Commissioning Operations Quality & Performance Committee Nil

Jones, Zara Derbyshire CCGs Executive Director of Commissioning Operations Clinical & Lay Commissioning Committee Nil

Jordon, Louise Dr North Derbyshire CCG GP Partner at Baslow Health Centre Clinical & Lay Commissioning Committee

GP Partner at Baslow Health Centre

Chair of the Board of Trustees for Helen's Trust

The Valleys Medical Partnership is a member of the North Derbyshire GP Federation

Direct

Indirect

Direct

Ongoing

2001

Ongoing

Ongoing

Ongoing

Ongoing


To be mindful of the conflict of interest

No action requiredKnight, David North Derbyshire CCG Primary Care Manager - NHS England Primary Care Co Commissioning Committee Nil No action required

Lal, Shokat Southern Derbyshire CCG Lay Member Governing Body

Non-Executive Director at Sahara Project

Employee at Rotherham MBC (There are no contracting arrangements between Rotherham MBC and Southern Derbyshire CCG)

Indirect

Indirect

2013

2017

Ongoing

Ongoing

No action required

No action required

Lal, Shokat Southern Derbyshire CCG Lay Member Audit Committees in Common



Indirect

Indirect

2013

2017

Ongoing

Ongoing

No action required

No action required

Lal, Shokat Southern Derbyshire CCG Lay Member Remuneration Committee



Indirect

Indirect

2013

2017

Ongoing

Ongoing

No action required

No action required

12

Lal, Shokat Southern Derbyshire CCG Lay Member Governance Committee



Indirect

Indirect

2013

2017

Ongoing

Ongoing

No action required

No action required

Lloyd, Steve Dr Derbyshire CCGsHardwick CCG

Medical Director and GP Partner at St Lawrence Road Surgery Governing Body Director of Wildman Medical Services Ltd Indirect Ongoing Ongoing No action required

Lloyd, Steve Dr Derbyshire CCGsHardwick CCG

Medical Director and GP Partner at St Lawrence Road Surgery Strategic Commissioner Programme Board Director of Wildman Medical Services Ltd Indirect Ongoing Ongoing No action required

Lunn, Joe North Derbyshire CCG Head of Primary Care - NHSE North Midlands Primary Care Co Commissioning Committee Nil No action required

Markus, Kath Dr North Derbyshire CCG GP Partner at Calow and Brimington Practice Primary Care Co Commissioning Committee

Chief Executive, DERBY and Derbyshire LMC

GP Partner at Calow and Brimington Practice

Direct

Indirect

Ongoing

Ongoing

Ongoing

Ongoing

No action required


Maronge, Andrew Dr Southern Derbyshire CCG GP Partner at Riversdale Surgery Governing Body

Sessional GP with Derbyshire Healthcare United

Joint Clinical Lead for Belper Place

Riversdale Surgery is a shareholder in Alexin Healthcare

Belper Integrated Community Care Project Board Member

Brother is a salaried doctor at Willington Surgery and a sessional GP with Derbyshire Healthcare United. Willington Surgery is a member of City South Place

Direct

Direct

Direct

Direct

Indirect

Sep-16

Sep-16

Jun-15

Mar-15

Sep-16

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

No action required

No action required

Maronge, Andrew Dr Southern Derbyshire CCG GP Partner at Riversdale Surgery Finance Committee

Sessional GP with Derbyshire Healthcare United

Joint Clinical Lead for Belper Place

Riversdale Surgery is a shareholder in Alexin Healthcare

Belper Integrated Community Care Project Board Member

Brother is a salaried doctor at Willington Surgery and a sessional GP with Derbyshire Healthcare United. Willington Surgery is a member of City South Place

Direct

Direct

Direct

Direct

Indirect

Sep-16

Sep-16

Jun-15

Mar-15

Sep-16

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

No action required

No action required

Merriman, Louise Dr North Derbyshire CCG GP Locality Lead Clinical & Lay Commissioning Committee

GP

Lead GP for Cancer

Member of Pathology liaison group

Direct Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing


Miller, Roger North Derbyshire CCG Local Authority Representative Governing Body Assistant Director Derbyshire Adult Care Direct Mar-16 Ongoing No action required

13

Milton, Ben Dr North Derbyshire CCG Chair and GP Lead Governing Body

Sessional (locum) GP in North Derbyshire CCG Practices

Former Partner at Darley Dale Medical Centre

Darley Dale Surgery is a member of the Primary Care Research Network and is funded to carry out research projects accordingly

Unpaid support to the Medical & Health Coaching Academy

Member of the Advisory Board Medical Health Coaching Academy

Direct

Direct

Direct

Indirect

Oct-16

Oct-03

Apr-13

Apr-13

Ongoing

Sep-16

Ongoing

Ongoing

Withdraw from all discussion and voting if organisation is potential provider unless otherwise agreed by the meeting chair




Milton, Ben Dr North Derbyshire CCG Chair and GP Lead Strategic Commissioner Programme Board






Direct

Direct

Direct

Indirect

Oct-16

Oct-03

Apr-13

Apr-13

Ongoing

Sep-16

Ongoing

Ongoing





14

Milton, Ben Dr North Derbyshire CCG Chair and GP Lead Finance Committee






Direct

Direct

Direct

Indirect

Oct-16

Oct-03

Apr-13

Apr-13

Ongoing

Sep-16

Ongoing

Ongoing





Moore, Laura North Derbyshire CCG Assistant Chief Nurse and Quality Officer Quality & Performance Committee Nil No action required

Mott, Andrew Dr Southern Derbyshire CCG GP Partner at Jessop Medical Practice Governing BodyJessop Medical Practice is a shareholder in Alexin Healthcare Ltd, a primary care provider (not the named individual involved)

Wife is Consultant Paediatrician at the Royal Derby Hospital

Direct

Indirect

2013

2014

Ongoing

Ongoing

No action required

No action required

Mott, Andrew Dr Southern Derbyshire CCG GP Partner at Jessop Medical Practice Strategic Commissioner Programme BoardJessop Medical Practice is a shareholder in Alexin Healthcare Ltd, a primary care provider (not the named individual involved)


Direct

Indirect

2013

2014

Ongoing

Ongoing

No action required

No action required

Mott, Andrew Dr Southern Derbyshire CCG GP Partner at Jessop Medical Practice Clinical & Lay Commissioning CommitteeJessop Medical Practice is a shareholder in Alexin Healthcare Ltd, a primary care provider (not the named individual involved)


Direct

Indirect

2013

2014

Ongoing

Ongoing

No action required

No action required

Mistry, Arvind Dr Erewash CCG Retired GP – Formerly of Gladstone House Surgery Governing Body

Director of The Reading Guide Company

Former GP Provider

Former Practice is member of Erewash Health

Direct

Direct

Direct

2015

1994

2015

Ongoing

2018

Ongoing

Declared at meetings involving discussion relating to Diabetes.

The CCG is aware of the inherent interests which exist for GP Providers regarding Co-Commissioning. Declarations of interests are included as a standing item on the Agendas for all Board and Sub-Committee meetings.Declared at meetings involving discussion relating to MCP procurement

15

Newman, Clive Derbyshire CCGs Director of GP Development Clinical & Lay Commissioning Committee Spouse is CEO of DCHS Indirect Ongoing OngoingNo direct commissioning input to DCHS and be excluded from direct discussions regarding DCHS

Orwin, Gillian Hardwick CCG Lay Member - Patient and Public Involvement Governing Body Patient at Wingerworth Surgery Direct Oct-17 Ongoing Not take part in decisions regarding Wingerworth Surgery

Orwin, Gillian Hardwick CCG Lay Member - Patient and Public Involvement Audit Committees in Common Patient at Wingerworth Surgery Direct Oct-17 Ongoing Not take part in decisions regarding Wingerworth Surgery

Orwin, Gillian Hardwick CCG Lay Member - Patient and Public Involvement Quality & Performance Committee Patient at Wingerworth Surgery Direct Oct-17 Ongoing Not take part in decisions regarding Wingerworth Surgery

Orwin, Gillian Hardwick CCG Lay Member - Patient and Public Involvement Remuneration Committee Patient at Wingerworth Surgery Direct Oct-17 Ongoing Not take part in decisions regarding Wingerworth Surgery

Orwin, Gillian Hardwick CCG Lay Member - Patient and Public Involvement Primary Care Co Commissioning Committee Patient at Wingerworth Surgery Direct Oct-17 Ongoing Not take part in decisions regarding Wingerworth Surgery

Orwin, Gillian Hardwick CCG Lay Member - Patient and Public Involvement Clinical & Lay Commissioning Committee Patient at Wingerworth Surgery Direct Oct-17 Ongoing Not take part in decisions regarding Wingerworth Surgery

Ritchie, Karen North Derbyshire CCG Quality & Performance Committee Chief Executive Healthwatch Derbyshire Direct Ongoing Ongoing


Sadiq, Perveez Governing Body Chair of Place Alliance group Direct OngoingScouse, Marie North Derbyshire CCG Assistant Chief Nurse Officer - Primary Care Primary Care Co Commissioning Committee Nil No action required

Shaw, Ian (Prof) Erewash CCG Lay Member - Governance Governing Body Employed by The University of Nottingham as a Professor or Health Policy

Indirect 1992 Ongoing

Shaw, Ian (Prof) Erewash CCG Lay Member - Governance Strategic Commissioner Programme Board Employed by The University of Nottingham as a Professor or Health Policy


Shaw, Ian (Prof) Erewash CCG Lay Member - Governance Audit Committees in Common Employed by The University of Nottingham as a Professor or Health Policy


Shaw, Ian (Prof) Erewash CCG Lay Member - Governance Remuneration Committee Employed by The University of Nottingham as a Professor or Health Policy


Shaw, Ian (Prof) Erewash CCG Lay Member - Governance Primary Care Co Commissioning Committee Employed by The University of Nottingham as a Professor or Health Policy


Shaw, Ian (Prof) Erewash CCG Lay Member - Governance Clinical & Lay Commissioning Committee Employed by The University of Nottingham as a Professor or Health Policy


Shearer, Carolin North Derbyshire CCG Primary Care Co Commissioning Committee Board member of Healthwatch Derbyshire Direct Ongoing Ongoing


Spooner, Anne-Marie Dr North Derbyshire CCG GP Partner at Inspire Health Governing Body

GP Partner at Inspire Health

Hasland Medical Centre is a member of the Chesterfield GP Federation.


Direct

Direct

Direct

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing


No action required

Spooner, Anne-Marie Dr North Derbyshire CCG GP Partner at Inspire Health Governance Committee

GP Partner at Inspire Health

Hasland Medical Centre is a member of the Chesterfield GP Federation.


Direct

Direct

Direct

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing


No action required

Stacey, Brigid Derbyshire CCGs Chief Nurse Officer Governing Body Nil No action required

16

Stacey, Brigid Derbyshire CCGs Chief Nurse Officer Quality & Performance Committee Nil No action requiredStacey, Brigid Derbyshire CCGs Chief Nurse Officer Finance Committee Nil No action requiredStacey, Brigid Derbyshire CCGs Chief Nurse Officer Clinical & Lay Commissioning Committee Nil No action requiredStone, Isabella North Derbyshire CCG Lay Member - Patient & Public Involvement Governing Body Nil No action requiredStone, Isabella North Derbyshire CCG Lay Member - Patient & Public Involvement Audit Committees in Common Nil No action requiredStone, Isabella North Derbyshire CCG Lay Member - Patient & Public Involvement Quality & Performance Committee Nil No action requiredStone, Isabella North Derbyshire CCG Lay Member - Patient & Public Involvement Remuneration Committee Nil No action requiredStone, Isabella North Derbyshire CCG Lay Member - Patient & Public Involvement Primary Care Co Commissioning Committee Nil No action requiredStone, Isabella North Derbyshire CCG Lay Member - Patient & Public Involvement Governance Committee Nil No action requiredStreet, Jocelyn North Derbyshire CCG Clinical & Lay Commissioning Committee Chapel-en-le-Frith Parish Councillor Indirect Ongoing Ongoing No action required

Stringfellow, Jayne North Derbyshire CCG Interim Chief Nurse Officer (North Derbyshire CCG) Governing Body

Partner Governor Chesterfield Royal Hospital Foundation Trust

Non Executive Director at Chesterfield Royal Hospital from 28.09.18

Spouse is Trustee of Carers Trust East Midlands

Direct

Indirect

Indirect

Apr-13

28-Sep-18

Apr-12

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

Taylor, Samantha Dr North Derbyshire CCG GP Partner at Thornbrook SurgeryQuality & Performance Committee

GP Partner Thornbrook Surgery, Chapel-en-Le-Frith

Shareholder of 3 Valleys Healthcare

GP Partner of Thornbrook Surgery which is a member practice of North Derbyshire GP Federation

Spouse is Consultant Anaesthetist employed by Sheffield Teaching Hospitals NHS Foundation Trust

Sister is Consultant Anaesthetist employed by Addenbrooke's Hospital

Direct

Direct

Direct

Indirect

Indirect

Jul-10

Jul-10

Mar-14

Jun-07

2012

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

Abide by Nolan principles, undergone conflicts of interest training, will withdraw from meeting discussion where appropriate

As above

As above

As above

As above

Taylor, Vikki North Derbyshire CCG Locality Director - NHS England Governing Body Nil No action requiredVoice (Beattie), Valerie Hardwick CCG Lay Representative Audit Committees in Common Nil No action requiredVoice (Beattie), Valerie Hardwick CCG Lay Representative Primary Care Co Commissioning Committee Nil No action required

Watkins, Merryl Dr Southern Derbyshire CCG GP Partner at Vernon Street Medical Governing BodyPractice is a member of Alexin

Husband is a Consultant in chronic pain and anaesthetics

Direct

Indirect

2013

Ongoing

Ongoing

Ongoing

No action required

No action required

Watkins, Merryl Dr Southern Derbyshire CCG GP Partner at Vernon Street Medical Quality & Performance CommitteePractice is a member of Alexin

Husband is a Consultant in chronic pain and anaesthetics

Direct

Indirect

2013

Ongoing

Ongoing

Ongoing

No action required

No action required

Watson, Pamela Erewash CCG Lay Member - Patient & Public Involvement Governing Body Trustee of Migraine Action Indirect 2011 OngoingWithdraw from any discussions relating to the commissioning of headache services

Watson, Pamela Erewash CCG Lay Member - Patient & Public Involvement Audit Committees in Common Trustee of Migraine Action Indirect 2011 OngoingWithdraw from any discussions relating to the commissioning of headache services

Watson, Pamela Erewash CCG Lay Member - Patient & Public Involvement Quality & Performance Committee Trustee of Migraine Action Indirect 2011 OngoingWithdraw from any discussions relating to the commissioning of headache services

Watson, Pamela Erewash CCG Lay Member - Patient & Public Involvement Remuneration Committee Trustee of Migraine Action Indirect 2011 OngoingWithdraw from any discussions relating to the commissioning of headache services

Watson, Pamela Erewash CCG Lay Member - Patient & Public Involvement Primary Care Co Commissioning Committee Trustee of Migraine Action Indirect 2011 OngoingWithdraw from any discussions relating to the commissioning of headache services

Whittle, Martin Southern Derbyshire CCG Lay Member - Patient & Public Involvement Governing Body Nil No action requiredWhittle, Martin Southern Derbyshire CCG Lay Member - Patient & Public Involvement Strategic Commissioner Programme Board Nil No action requiredWhittle, Martin Southern Derbyshire CCG Lay Member - Patient & Public Involvement Audit Committees in Common Nil No action requiredWhittle, Martin Southern Derbyshire CCG Lay Member - Patient & Public Involvement Quality & Performance Committee Nil No action requiredWhittle, Martin Southern Derbyshire CCG Lay Member - Patient & Public Involvement Remuneration Committee Nil No action required

17

Whittle, Martin Southern Derbyshire CCG Lay Member - Patient & Public Involvement Primary Care Co Commissioning Committee Nil No action required

Whitworth, Michael North Derbyshire CCG Interim Director for Contracting and Performance Development Governing Body Owner and Director of Michael Whitworth Consultancy Limited

Jul-16 Ongoing No action required

Williams, Claire North Derbyshire CCG Deputy Chief Finance Officer Finance Committee Nil No action required

Wood, Paul Dr Southern Derbyshire CCG Chair and GP Partner at Dr P A A Wood and Partners Governing Body

GP Partner in general practice, Dr P A A Wood and Partners

The Partnership has a minority interest in First Provider Group which provides some primary care services

The Partnership is a minority shareholder in Alexin Healthcare Ltd (not the named individual involved)

The partnership hosts CRUSE organisation - practice receives a service charge

Spouse is a midwife at DTHFT

Direct

Direct

Direct

Direct

Indirect

Ongoing

2013

2013

2013

1979

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

No action required

No action required

Wood, Paul Dr Southern Derbyshire CCG Chair and GP Partner at Dr P A A Wood and Partners Strategic Commissioner Programme Board

GP Partner in general practice, Dr P A A Wood and Partners

The Partnership has a minority interest in First Provider Group which provides some primary care services

The Partnership is a minority shareholder in Alexin Healthcare Ltd (not the named individual involved)

The partnership hosts CRUSE organisation - practice receives a service charge

Wife is a midwife at DTHFT

Direct

Direct

Direct

Direct

Indirect

Ongoing

2013

2013

2013

1979

Ongoing

Ongoing

Ongoing

Ongoing

Ongoing

No action required

No action required

No action required

No action required

No action required

Woods, Kerrie North Derbyshire CCGPrimary Care Co Commissioning Committee Nil

No action required

18



REGISTER FOR RECORDING ANY INTERESTS DURING MEETINGS

Meeting Date of Meeting Chair (name)

Corporate Secretary/CCG Meeting Lead

Name of person

declaring interest

Agenda item Details of interest declared

Action taken

19

Glossary

A&E Accident and Emergency

AfC Agenda for Change

AHP Allied Health Professional

AQP Any Qualified Provider

Arden & Arden & Greater East Midlands Commissioning Support Unit GEM CSU

ARP Ambulance Response Programme

ASD Autistic Spectrum Disorder

BAF Board Assurance Framework

BCCTH Better Care Closer to Home

BCF Better Care Fund

BME Black Minority Ethnic

bn Billion

BPPC Better Payment Practice Code

BSL British Sign Language

CBT Cognitive Behaviour Therapy

CAMHS Child and Adolescent Mental Health Services

CCE Community Concern Erewash

CCG Clinical Commissioning Group

CDI Clostridium Difficile

C-DIFF Clostridium difficile

CETV Cash Equivalent Transfer Value

20

Cfv Commissioning for Value CHC Continuing Health Care CHP Community Health Partnership CMP Capacity Management Plan CiC Committees in Common CNO Chief Nursing Officer COP Court of Protection

COPD Chronic Obstructive Pulmonary Disorder CPD Continuing Professional Development CPN Contract Performance Notice CQC Care Quality Commission CQN Contract Query Notice CQUIN Commissioning for Quality and Innovation CPN Contract Performance Notice CPRG Clinical & Professional Reference Group

CRG Clinical Reference Group CSE Child Sexual Exploitation CSU Commissioning Support Unit CRHFT Chesterfield Royal Hospital NHS Foundation Trust CTR Care and Treatment Reviews CVD Chronic Vascular Disorder CYP Children and Young People

21

D2AM Derbyshire Dis-charge to address and manage DAAT Drug and Alcohol Action Teams DCC Derbyshire County Council DCCPC Derbyshire Affiliated Clinical Commissioning Policies DCHS Derbyshire Community Health Services DCHSFT Derbyshire Community Healthcare Services NHS Foundation Trust DCO Designated Clinical Officer DHcFT Derbyshire Healthcare NHS Foundation Trust DHU Derbyshire Health United DNA Did not attend DoH Department of Health DoLS Deprivation of Liberty Safeguards DRRT Dementia Rapid Response Service DSN Diabetic Specialist Nurse DTHFT Derby Teaching Hospitals NHS Foundation Trust DTOC Delayed Transfers of Care – the number of days a patient deemed medically fit is still occupying a bed. D2AM Discharge to Assess and Manage ED Emergency Department EDEN Effective Diabetes Education Now EDS2 Equality Delivery System 2 EIHR Equality, Inclusion and Human Rights EIP Early Intervention in Psychosis EMAS East Midlands Ambulance Service

22

EMAS Red 1 The number of Red 1 Incidents (conditions that may be immediately life threatening and the most time critical) which resulted in an emergency response arriving at the scene of the incident within 8 minutes of the call being presented to the control room telephone switch.

EMAS Red 2 The number of Red 2 Incidents (conditions which may be life threatening but

less time critical than Red 1) which resulted in an emergency response arriving at the scene of the incident within 8 minutes from the earliest of; the chief complaint information being obtained; a vehicle being assigned; or 60 seconds after the call is presented to the control room telephone switch.

EMAS A19 The number of Category A incidents (conditions which may be immediately

life threatening) which resulted in a fully equipped ambulance vehicle able to transport the patient in a clinically safe manner, arriving at the scene within 19 minutes of the request being made.

EMLA East Midlands Leadership Academy ENT Ear Nose and Throat EOL End of Life EPRR Emergency Preparedness Resilience and Response FFT Friends and Family Test FGM Female Genital Mutilation FIRST Falls Immediate Response Support Team FRP Financial Recovery Plan GAP Growth Abnormalities Protocol GBAF Governing Body Assurance Framework GP General Practitioner GPSI GP with Specialist Interest HCAI Healthcare Acquired Infections HDU High Dependency Unit HSJ Health Service Journal GBAC Governing Body Assurance Committee GBAF Governing Body Assurance Framework

23

GDPR General Data Protection Regulation GNBSI Gram Negative Bloodstream Infection GPFV General Practice Forward View GPWSI GPs with a special interest GPSOC GP System of Choice HCAI Healthcare Associated Infection HLE Healthy Life Expectancy HSJ Health Service Journal HWB Health & Well-being Board IAF Improvement and Assessment Framework IAPT Improving Access to Psychological Therapies ICM Institute of Credit Management ICO Information Commissioner’s Office ICS Integrated Care Service ICU Intensive Care Unit IGC Information Governance Committee IGT Information Governance Toolkit IP&C Infection Prevention & Control IT Information Technology IWL Improving Working Lives JAPC Joint Area Prescribing Committee JSAF Joint Safeguarding Assurance Framework JSNA Joint Strategic Needs Assessment k Thousand

24

KPI Key Performance Indicator LA Local Authority LAC Looked after Children LCFS Local Counter Fraud Specialist LD Learning Disabilities LGB&T Lesbian, Gay, Bi-sexual and Trans-gender LHRP Local Health Resilience Partnership LMC Local Medical Council LMS Local Maternity Service LOC Local Optical Committee LPC Local Pharmaceutical Council LPF Lead Provider Framework m Million MAPPA Multi Agency Public Protection arrangements MASH Multi Agency Safeguarding Hub MCA Mental Capacity Act MDT Multi-disciplinary Team MH Mental Health MHIS Mental Health Investment Standard MIG Medical Interoperability Gateway MIUs Minor Injury Units MMT Medicines Management Team MoM Map of Medicine MoMO Mind of My Own MRSA Methicillin-resistant Staphylococcus aureus

25

MSK Musculoskeletal MTD Month to Date NDCCG NHS North Derbyshire Clinical Commissioning Group NECS North of England Commissioning Services NEPTS Non-emergency Patient Transport Services NHAIS National Health Application and Infrastructure Services NHSE NHS England NHS e-RS NHS e-Referral Service NICE National Institute for Health and Care Excellence NOAC New oral anticoagulants NUH Nottingham University Hospitals NHS Trust OJEU Official Journal of the European Union OOH Out of Hours ORG Operational Resilience Group PAD Personally Administered Drug PALS Patient Advice and Liaison Service PAS Patient Administration System PCCC Primary Care Co-Commissioning Committee PCD Patient Confidential Information PCDG Primary Care Development Group PEARS Primary Eye care Assessment Referral Service PEC Patient Experience Committee PHB’s Personal Health Budgets PHSO Parliamentary and Health Service Ombudsman

26

PIR Post-Infection Review PLCV Procedures of Limited Clinical Value POA Power of Attorney POD Point of Delivery PPG Patient Participation Groups PPP Prescription Prescribing Division PRIDE Personal Responsibility in Delivering Excellence PSED Public Sector Equality Duty PSO Paper Switch Off PwC Price, Waterhouse, Cooper QA Quality Assurance QAG Quality Assurance Group Q1 Quarter One reporting period: April – June Q2 Quarter Two reporting period: July – September Q3 Quarter Three reporting period: October – December Q4 Quarter Four reporting period: January – March

QIPP Quality, Innovation, Productivity and Prevention

QUEST Quality Uninterrupted Education and Study Time

QOF Quality Outcome Framework

RAP Recovery Action Plan

RCA Root Cause Analysis

REMCOM Remuneration Committee

RTT Referral to Treatment

RTT Admitted The percentage of patients waiting 18 weeks or less for treatment of the patients on admitted pathways

27

RTT Non-admitted The percentage if patients waiting 18 weeks or less for treatment of the patients on non-admitted pathways

RTT Incomplete The percentage of patients waiting 18 weeks or less of the patients on incomplete pathways at the end of the period

SAAF Safeguarding Adults Assurance Framework

SAR Service Auditor Reports

SAT Safeguarding Assurance Tool

SBS Shared Business Services

SDCCG Southern Derbyshire CCG

SDMP Sustainable Development Management Plan

SEND Special Educational Needs and Disabilities

SHFT Stockport NHS Foundation Trust

SFT Stockport Foundation Trust

SNF Strictly no Falling

SOC Strategic Outline Case

SPA Single Point of Access

SQI Supporting Quality Improvement

SRG Systems Resilience Group

SIRO Senior Information Risk Owner

SRT Self-Assessment Review Toolkit

STEIS Strategic Executive Information System

STHFT Sheffield Teaching Hospital Foundation Trust

STOMPLD Stop Over Medicating of Patients with Learning Disabilities

STP Sustainability and Transformation Plan

TCP Transforming Care Partnership

TDA Trust Development Authority

28

T&O Trauma and Orthopaedics

TWG Transition Working Group

UEC Urgent and Emergency Care

YTD Year to Date

111 The out of hours service delivered by Derbyshire Health United: a call centre where patients, their relatives or carers can speak to trained staff, doctors and nurses who will assess their needs and either provide advice over the telephone, or make an appointment to attend one of our local clinics. For patients who are house-bound or so unwell that they are unable to travel, staff will arrange for a doctor or nurse to visit them at home

52WW 52 week wait

29



NHS Derbyshire CCGs Governing Body Meetings in Common

13th December 2018

Report Title Chief Executive Officer Update Author(s) Andy Kemp/ Sean Thornton Sponsor (Director) Dr Chris Clayton, Chief Executive Officer

Paper for: Decision Corporate Assurance

Discussion Information x

Recommendations The Governing Body is requested to receive this report and to note the items as detailed.

BACKGROUND AND PURPOSE This report provides an update on national and local issues of interest to Governing Body (GB) members not covered elsewhere on the agenda, and also provides an indication of where the Chief Executive Officer’s efforts have been directed since the last meeting.

INFORMATION UPDATE 1.0 Overview

In my previous update I described the critical importance of achieving the £44m control total which will release the Commissioner Sustainability Fund and enable us to enter 2019/20 in a positive financial position. I also explained that the majority of the £51m savings plan will be achieved through addressing system inefficiencies with around £6.7m representing the prioritisation of resources and efficiencies. We continue to be on a trajectory to achieve the control total and will continue to focus on ensuring that we achieve this whilst working towards our 2019/20 plan.

In recent days NHS England and NHS Improvement have confirmed that the NHS Long Term Plan will be issued in December 2018 in response to the Government’s commitment to increase the NHS England budget by £20.5bn in real terms by 2023-24. In addition to one year operational plans for CCGs and systems, the Derbyshire STP will be expected to develop and agree their five-year plans during the first half of 2019-20.

The letter, from chief executives Simon Stevens and Ian Dalton, confirmed that this will give STP footprints sufficient time to consider the outputs of the NHS long term plan in late autumn and the spending review 2019 capital settlement (in the spring), and to engage with patients, the public and local stakeholders before finalising strategic plans. Five-year commissioner allocations will be published in December, along with planning guidance. There will be a move away from the current system of control totals in the medium term, not in 2019/20, and CQUIN incentive payment scheme for providers would be significantly reduced. 2019/20 is seen as a transitional year and requires organisations and systems to begin work this autumn on activity, capacity and efficiency planning.

We are making real progress on the next phase of our plans to enhance our engagement with public, patients, our membership and our partners and stakeholders. In November we ran a workshop supported by Healthwatch Derbyshire for a cross-county group of patient representatives. This included a simulated commissioning exercise based on real scenarios which

Item No: 54

30

enabled delegates to work with us on some of the commissioning decisions we make and how we must prioritise and make tough choices. This was a really important exercise in terms of working towards meaningful co-production and feedback was positive from both patient representative colleagues and staff in attendance. As a follow up to this we ran the first of a number of workshops where we involved patient representatives at the very first stage of three potential transformation programmes on a confirm and challenge basis. The feedback we received was extremely positive and we will continue to run these workshops to ensure that patient involvement is at the heart of the roll-out of our commissioning intentions. Last week we ran the first of a series of engagement events for our GP membership so that we can share information, listen to the challenges faced by primary care colleagues and ensure that we continue to understand what matters most to them. Engaging with our wider range of stakeholders is also vitally important and on 9 November we hosted a teleconference for Labour MPs across Derbyshire. This followed a similar exercise for Conservative MPs during the summer. We had some robust but constructive discussions which reflected the issues most important to their constituents and it was reassuring to hear their level of commitment to supporting our local health and care system. Again feedback was positive and we will be doing this on a more regular basis for our local MPs over the coming months. Our merger application is now approved by NHS England subject to a number of conditions. These include the ongoing development and delivery of a robust financial plan and the nomination and appointment of an appropriate Chair, Accountable Officer, and Chief Finance Officer (CFO). These conditions are all in hand and I will update on progress. In the meantime we are at the forefront of CCG mergers at a national level and this was reported in the Health Service Journal last week. 2.0 Chief Executive meetings Members may be interested to note the following meetings and events which the Chief Executive Officer has attended in recent weeks:

31

3.0 Reports, studies, updates and news on health and care services

3.1 Findings from the latest Community Mental Health Survey Findings have been published from the Care Quality Commission’s annual survey on patient experience of community mental health services. More than 12,700 people responded on services across 56 trusts. When asked to rate their overall experience out of 10, 62% gave at least 7 (65% in 2017) and 30% gave 9 or 10 (34% in 2017). Responses suggest scope for improvements in the areas of support and wellbeing, but more respondents knew who to contact out of hours in a crisis. New questions this year revealed that 86% who responded felt their medicines had helped their mental health and another that 83% felt NHS therapies had. 3.2 World COPD Day – improving our approach to Chronic Obstructive Pulmonary Disease 21 November 2018 was World COPD Day, set up to raise awareness of COPD and improve care for people living with it. The NHS RightCare COPD pathway provides a set of resources to support local health economies to concentrate their improvement efforts where there is greatest opportunity to address variation and improve population health. It sets out to health commissioners and providers how to ensure early detection with accurate diagnosis and optimise long term management to reduce hospital admissions and premature mortality. 3.3 Publication of 2018/19 CCG Improvement and Assessment Framework The CCG Improvement and Assessment Framework (IAF) for 2018/19 has been published, covering a total of 58 indicators. Seven new indicators have been included for this financial year. There is a new indicator on demand management and the other new indicators either reflect commissioners’ contribution to the performance of their systems or are to align with the planning guidance for 2018/19. A number of existing indicators have also been updated.

Date Meeting 3.9.18 MP teleconference 6.9.18 Regulator meeting 7.9.18 EMAS meeting

10.9.18 Improvement and Scrutiny Committee meeting 11.9.18 Healthwatch meeting 13.9.18 Health and Wellbeing Board meeting Derby City 18.9.18 Ilkeston Hospital visit and meeting 18.9.18 MP meeting 21.9.18 Joined Up Care Derbyshire meeting 25.9.18 Adult Health Scrutiny Review Board – Derby City 27.9.18 CCG Governing Body in Common meeting 1.10.18 Overview and Scrutiny Committee meeting 4.10.18 Health and Wellbeing Board meeting - county

12.10.18 South Yorkshire Health Services Review meeting 17.10.18 MP meeting 18.10.18 Joined Up Care Derbyshire board meeting 29.10.18 NHS long term plan meeting 1.11.18 CCG Governing Body in common meeting 9.11.18 MPs teleconference meeting

14.11.18 Strategic Health and Wellbeing Group 15.11.18 Joined Up Care Derbyshire board meeting 27.11.18 GP membership forum meeting 28.11.18 Derbyshire and Nottinghamshire QSG 29.11.18 GP membership forum meeting

32

https://ccgbulletin.cmail19.com/t/d-l-ntiuiit-ekkuhyull-x/

https://ccgbulletin.cmail19.com/t/d-l-ntljktt-ekkuhyull-t/

https://ccgbulletin.cmail19.com/t/d-l-njyhrn-ekkuhyull-y/

3.4 Arts and health and wellbeing in the NHS NHS England’s Director for Experience, Participation and Equalities looks at how artists, musicians and museum staff are spreading health and wellbeing in the NHS. Art for health’s sake 3.5 Elective care The Director of NHS England’s Elective Care Transformation Programme explains why a second wave of practical handbooks can help the NHS address a steady rise in referrals for hospital treatment while benefitting patients. Managing demand for elective care 3.6 Mental health support in diabetes care Every day, around 700 people are diagnosed with diabetes. This blog looks at ‘The Future of Diabetes Report’ from Diabetes UK and asks for good examples of mental health support in diabetes care. Diabetes and mental health: call out for examples of best practice 3.8 New ‘GP Access’ campaign launched 3 December A new campaign phase for Help Us Help You, which promotes access to evening and weekend GP appointments, launched on 3 December, by NHS England. This campaign is designed to raise awareness of the availability of appointments with GPs, nurses and other healthcare professionals outside of working hours. www.england.nhs.uk/gp/gpfv/redesign/improving-access/ 3.9 First children to begin revolutionary CAR-T therapy for cancer treatment The first children to receive a game-changing personalised therapy for cancer will start treatment at Great Ormond Street Hospital in London this week. A second centre, Royal Manchester Children’s Hospital, is also ready to start treating children with a rare form of leukaemia while a third, Newcastle upon Tyne Hospitals NHS Foundation Trust, is expected to join the programme next month. Read more on the NHS England website. 4.0 Local news updates for Derbyshire 4.1 Positive media coverage In recent weeks we have seen further positive coverage on BBC East Midlands Today which followed the previous coverage of the On Day Service in Erewash and Brilliant Erewash that described in my last update. The latest piece was on the Time Swap initiative, previously part of the Vanguard in conjunction with Derbyshire County Council where people bring skills which they offer to others in a reciprocal exchange for their skills. The initiative has been shown to generate numerous benefits and in health terms it has been shown to reduce reliance on both primary and urgent and emergency care services. 4.2 Derbyshire Transforming Care Plan (TCP) for learning disabilities and autism We have been working very hard on moving the Derbyshire TCP forward and this has been recognised. The positive letter I received from the Director of Nursing at NHS England, North Midlands region started: "I am pleased to write to you to advise that, in consideration of the strong governance arrangements the TCP has in place to provide oversight to the programme and the strength of your discharge planning, I have decided to put Derbyshire on green escalation status." This is a really clear statement of reassurance from NHS England and an endorsement of our leadership of the Derbyshire TCP.

33

https://www.england.nhs.uk/blog/art-for-healths-sake/

https://www.england.nhs.uk/blog/managing-demand-for-elective-care-services/

https://www.england.nhs.uk/blog/diabetes-and-mental-health-call-out-for-examples-of-best-practice/

http://www.england.nhs.uk/gp/gpfv/redesign/improving-access/

https://www.england.nhs.uk/2018/11/first-children-with-cancer-to-begin-treatment-with-revolutionary-car-t-therapy/

4.3 County-wide Place Alliance Session This was attended by 107 staff from Derbyshire’s 11 partners and providers and in addition to the “buzz” and energy in the room there was also a genuine appetite to work more closely together to provide patient-centred services. Colleagues discussed the future of Place in terms of opportunities, challenges and the structure. The event was also a valuable chance to network and share ideas and information from different parts of the county.

We recently presented a Place update at the North East Derbyshire and Bolsover District Council conference. With around 40 people in attendance there were some lively discussions about the next steps with district and parish council colleagues and they are keen to be involved going forward which is really encouraging.

If you want to find out more about Place visit: https://joinedupcarederbyshire.co.uk/our-places 4.4 Derbyshire campaigns Choosing Self Care for Life was the theme for self-care week 2018, which took place on 12-18 November. Self-care has been an important area of work for us this year and in the summer we launched a campaign to support more people in Derbyshire to manage common minor illnesses by becoming more self-care aware. Since then the Medicines Management Team have continued to progress this work and it is forming a key element of our approach to winter. To find out more go to:

http://nhsstaywellderbyshire.co.uk/services/self-care/ GP extended access is a campaign promoting this service in emergency departments, urgent care centres and minor injuries units across Derbyshire to remind people that they can access their GPs on evenings, weekends and bank holidays. This is another important element in our winter communications plan.

5.0 Recommendation The Governing Body is requested to receive this report and to note the items as detailed. Dr Chris Clayton Chief Executive Officer Derbyshire CCGs

34

https://joinedupcarederbyshire.co.uk/our-places

http://nhsstaywellderbyshire.co.uk/services/self-care/



Derbyshire CCGs Governing Body Meetings in Common

13th December 2018

Report Title Voluntary and Community Sector funding via discretionary grants, infrastructure organisations (CVS) and the voluntary Single Point of Access services.

Author(s) Louise Swain – Interim Deputy Director Joint and Community Commissioning and Kate Brown – Director of Joint Commissioning and Community Development

Sponsor (Director) Zara Jones – Executive Director of Commissioning Operations

Paper for: Decision X Assurance X Discussion X Information Recommendations

The Governing Bodies Committee in Common are asked to:

1.Infrastructure Organisations and vSPA

1A: Infrastructure a. NOTE the progress with reviewing existing arrangements and future needsb. SUPPORT the proposal to develop an infrastructure transitional arrangement

by 1st April 2019 ahead of completion of the joint review and implementationof agreed model. The CCGs remain committed to completing this review assoon as possible in 2019

c. SUPPORT the transition arrangement including a recurrent efficiencyrequirement of £100k in 2019/20.

1B: vSPA a. ACKNOWLEDGE the continued intention to cease current funding

arrangements for vSPA from 31st March 2019 b. CONTINUE to make available 50% of the current vSPA funding for the

infrastructure organisations delivery during the transition period, to include signposting services.

Item No: 55

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2.Discretionary Grants To SUPPORT the panel recommendations for each scheme listed in the summary table in the VCS Report and in Appendix B. For schemes where funding is recommended to continue, GB are asked to support adopting the same contractual mechanism for these schemes in 2019/20 as set out for the three schemes listed below. 3.Contractual Mechanisms

3A: Cruse North and South

• DIRECT AWARDS on NHS small contracts to be made to Cruse North and Cruse South to continue with their current activity from 1st April 2019 for 1 year whilst a wider review of End of Life (EOL) services progresses.

3B: Stroke Association • A DIRECT AWARD on NHS small contracts is made to The Stroke

Association - Communication Support Service to continue with their current activity from 1st April 2019 for 1 year whilst a wider consideration of community stroke provision is undertaken.

Report At the Governing Body Committee in Common meeting on 27th September 2018 it was agreed that a paper would be brought back to the December meeting to present to Governing Body members the following:

• Outputs from reviews and further engagement undertaken on infrastructure and current discretionary schemes

• Proposed contractual mechanisms for 2019/20 for the three services where grant funding has been continued in-year following GB decisions made in August 2018 (Cruse South Derbyshire, Chesterfield & North Derbyshire Cruse Bereavement Care and Stroke Association – Communication Support Service).

The full report can be seen in VCS Report with accompanying information in Appendix A and Appendix B Are there any Resource Implications (including Financial, Staffing etc)? Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? Equality impact assessments have been undertaken for each scheme and findings

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considered for this report. Previously made available for governing body members. Have you involved patients, carers and the public in the preparation of the report? Organisations concerned have been directly engaged with. They have commented on the impact assessments. People who access the services have been directly engaged with by the CCGs. Some organisations have commented and organisations have engaged with them and fed back their findings to the CCGs. Have any Quality and Compliance issues been identified/ actions taken Quality impact assessments have been completed and updated following feedback. Have any Conflicts of Interest been identified/ actions taken? None identified Governing Body Assurance Framework Delivery of QIPP Identification of Key Risks Impact on CCG financial recovery and service sustainability, reputational risks

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Derbyshire CCGs Governing Body Meeting in Common

13th December 2018

Report Title Review of Voluntary and Community Sector funding via discretionary grants, infrastructure organisations (CVS) and the voluntary Single Point of Access services

Author(s) Louise Swain – Interim Deputy Director of Joint and Community Commissioning & Kate Brown – Director of Joint Commissioning and Community Development


Contents

1. Introduction 2. Outline of overall engagement undertaken 3. Summary of GB recommendations 4. Outputs from Infrastructure organisations review and recommendations

(including vSPA) 5. Outputs from discretionary grants review and recommendations (including MH

schemes) 6. Proposed contractual mechanisms for three schemes agreed to continue 7. Transport policy update 8. Summary of ongoing work ahead of 2019/20 and suggested next steps for GB

to consider.

Item No: 55

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Section One: Introduction

At the Governing Body Committee in Common meeting on 27th September 2018 it was agreed that a paper would be brought back to the December meeting to present to Governing Body members the following:

• Outputs from reviews and further engagement undertaken on infrastructure and current discretionary schemes

• Proposed contractual mechanisms for 2019/20 for the three services where grant funding has been continued in-year following GB decisions made in August 2018 (Cruse South Derbyshire, Chesterfield & North Derbyshire Cruse Bereavement Care and Stroke Association – Communication Support Service).

As reported previously, collectively the CCGs spend over £8.5m on the Third Sector (defined as neither public nor private: such as voluntary, charitable or community interest companies). A reminder of the breakdown of spend is shown below and the highlighted sections are the areas covered in this paper (14% of total spend).

Area Types of service Total value (£)

Mental health Advocacy, counselling, support services, crisis care 1,067,245

End of Life Hospice care 4,914,225

Sensory Hearing support, sight support. 179,156 Children

Children’s mental health, eating disorder support 729,000

Infrastructure and vSpa

Voluntary sector support and development 658,348

Discretionary grants

Range of grants 546,706

Advocacy Inpatient; community inc learning disability and CHC 202,408

Other Range including: high service user support, 192,333 TOTAL 8,489,422 * Note does not include spend on carers services – pooled budget of over £2m

The current grants programme commenced in 2016 and was scheduled to cease in March 2018. The Governing Bodies (GBs) have considered the discretionary grant programme, infrastructure spend and vSPA funding on a number of occasions namely April 18, July 18, August 18 and most recently in September 2018.

The GBs agreed in September to continue funding the hospital at home services until the start of the new procured DCC funded services beginning on 1st April 2019 (Peaks and Dales CVS, Amber Valley CVS, South Derbyshire CVS and Erewash

39

Community Concern). It was also confirmed at the September meeting that a number of organisations had already given notice to cease operating schemes that had been funded by the discretionary grant programme (Self-help Nottingham, Well for Life, Erewash Community Concern and Stroke Association). All the aforementioned grants are not included in this paper.

All the engagement work and decision making processes used to determine the proposed recommendations for the future funding arrangements for the discretionary grant programme is detailed within the relevant sections of this paper.

Governing Body members are requested to note the following:

• It was agreed in September by Governing Body members that five mental health discretionary grant schemes would be incorporated into the wider review of current discretionary scheme spend across the 4 Derbyshire CCGs. This has been completed and details are provided later in the report.

• Voluntary Single Point of Access (vSPA) is reported as a separate section for consistency with the September report, but has been reviewed with the infrastructure organisations following GB agreement to do this and to serve notice in September 2018; to align organisations’ notice periods.

• In September, Governing Body members were asked to note that the CCGs intended to create a new policy to be operational from 1st April 2019 to set out the circumstances under which transport services will be CCG funded. An update is provided later in this report to cover how the voluntary sector will be engaged in this process and the work undertaken to date and planned ahead of the policy being received by the CCGs Clinical and Lay Commissioning Committee (CLCC) and ratified by the GBs.

Section Two: Overall Engagement undertaken

Engagement with the sector has been undertaken over a total period of 7 months and has included a range of impact assessments both quality and equality/due regard assessments and engagement with service recipients and staff. This is summarised below:

Engagement prior to September 2018:

• 39 Quality impact assessments completed May 2018 • 39 draft Equality Impact Assessments and Due Regard (EIA/DR)

assessments completed June 2018 • Each VCS organisation was invited to review and add to the draft EIA/DRs.

The engagement period lasted for one month and allowed focused engagement around organisational impact, wider NHS impact, impact of patient pathways and impact on service receivers and patients. This included client feedback forms, case studies, comments, evaluations and outcome measures against KPIs

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• Discussions at steering groups and committees such as the Mental Health Forum, Mental Health Steering Group, Southern Derbyshire Health and Social Care Forum, Erewash community Connectors, Patient Reference Groups (North and South Derbyshire) and stakeholder forums

• Meetings with the County Improvement and Scrutiny Committee and Derby City Overview and Scrutiny Committee

• Series of stakeholder and public events on the CCG financial position including discussions about the VCS sector

• Meetings with Local Authorities (LAs), Derbyshire County Council – social care, corporate and environmental services and Public Health; Derby City Council – social care and Public Health

• August meetings with the VCS sector (discretionary grant programme, infrastructure and vSPA organisations) to discuss joint impact, mitigations and exploration of joint approaches.

Engagement after September 2018

• Series of meetings with the infrastructure organisations have been held to discuss and plan for in-year efficiencies and identify how we can work with LA for a revised offer for next year

• During October and November 2018, the CCGs carried out further engagement with 25 discretionary grant funded organisations with particular focus on proportionate engagement with service recipients. CCGs contacted each group and jointly identified the most appropriate method of engagement The CCGs offered a range of ways to engage with the organisations’ service users which included an on-line survey, postal survey, telephone survey, focus and discussion groups and use of existing client survey findings, case studies and any other information that would describe the services that each organisation provided through their CCG grant funding

• The EIA/DR’s were again reviewed and amended where appropriate as a result of the further engagement work.

• A discretionary grant review panel was set up where each grant organisation was considered and reviewed against agreed criteria. Panel members included: GB GP representative; GB Lay member representative; patient representative; CCG quality representative and CCG commissioning representative. The panel put forward proposed recommendations for the future funding of the discretionary grant programme (further details are given in section 5).

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Section Three: Summary of GB Recommendations

For clarity, the recommendations that the Governing Bodies Committee in Common are asked to support are as follows:

1. Infrastructure Organisations and vSPA

1A: Infrastructure

a. Note the progress with reviewing existing arrangements and future needs b. Support the proposal to develop an infrastructure transitional arrangement by

1st April 2019 ahead of completion of the joint review and implementation of agreed model. The CCGs remain committed to completing this review as soon as possible in 2019

c. Support the transition arrangement including a recurrent efficiency requirement of £100k in 2019/20.

1B: vSPA

a. Acknowledge the continued intention to cease current funding arrangements for vSPA from 31st March 2019

b. Continue to make available 50% of the current vSPA funding for the infrastructure organisations delivery during the transition period, to include signposting services.

2. Discretionary Grants • To support the panel recommendations for each scheme listed in the

summary table in section five of this report. For schemes where funding is recommended to continue, GB are asked to support adopting the same contractual mechanism for these schemes in 2019/20 as set out for the three schemes listed below (and in more detail in section five of this report).

3. Contractual Mechanisms


• Direct awards on NHS small contracts to be made to Cruse North and Cruse South to continue with their current activity from 1st April 2019 for 1 year whilst a wider review of End of Life (EOL) services progresses

3B: Stroke Association

• A direct award on NHS small contracts is made to The Stroke Association - Communication Support Service to continue with their current activity from 1st

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April 2019 for 1 year whilst a wider consideration of community stroke provision is undertaken.

Section Four: Infrastructure Organisations and vSPA

4a). Infrastructure

i. Context

Voluntary and Community Sector (VCS) Infrastructure provides the broad basis of support upon which organisations that form the voluntary sector service offer, is maintained.

VCS infrastructure services in Derby and Derbyshire are active in providing services to more than 5000 voluntary and community organisations across Derby and Derbyshire. The work of these organisations plays a key role in keeping people healthy for longer through their preventative offer which may include, wellbeing advice, help to reduce social isolation, self-help and peer support, personalised interventions that support self-management of health conditions.

The Infrastructure organisations provide the following broad functions to support the sector:

• Building community capacity through local group support. This includes advice on robust governance, financial planning and quality monitoring. They can support new organisations to set up and get established and support organisations through crisis.

• Local presence in the community. A ‘front door’ for and to the VCS.

• Volunteer recruitment, training and support.

• Engagement and communication at both a strategic, individual and local level. This includes providing a clear pathway of communication between statutory bodies and the diverse voluntary sector, ensuring that smaller organisations have voice. They can access groups that statutory bodies may struggle to engage with. As members of national membership bodies like NAVCA, NCVO and Locality they can access a range of nationally available support for, and on behalf of their members.

The Derbyshire CCGs have individually invested in the Voluntary and Community Sector (VCS) through various grants but there has not been an agreed single approach. The move to more joined-up working, the proposed merger of the CCGs and a focus on collaboration with the VCS, provides the opportunity to develop a strategic approach driven by the Joined up Care Derbyshire outcomes.

Whilst not a direct responsibility of the CCGs to fund infrastructure organisations the Governing Body Committees in Common have previously recognised the

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value of maintaining infrastructure provision; and recognise the importance of the infrastructure’s role in maintaining and maximising a thriving VCS.

Derbyshire County Council makes a significant investment into infrastructure provision. Derby City Council does not currently make an equivalent investment but have committed to being part of this review. Having multiple commissioners with differing priorities and separate arrangements with a multiplicity of individual VCS Infrastructure providers has the following challenges:

• No single strategic perspective on the role of infrastructure provision across Derbyshire

• Resources not distributed in accordance to population / need • Inconsistent ‘offer’ for the public, local community groups and

professionals • System inefficiency as providers need to work to multiple funding cycles

and reporting requirements • Potential system inefficiency as providers are assessed individually and

not rewarded for collective effort and co-ordinated delivery.

i. Progress Update

A small working group has been established to undertake the review work and plan for how this will proceed, which has been jointly agreed between the Derbyshire CCGs and Derbyshire County Council, who also fund the sector. Derby City Council are not funders but have supported involvement in the review.

Two sessions have been held with representatives from the infrastructure organisations focussing on gaining a broad understanding of the diverse current provision and identifying the priorities and opportunities for future services and arrangements.

The detailed work is still to be completed but early indications are that the commissioner aims have significant congruity and that these align with the provision the sector wishes to offer.

There is a recognised need to ensure a model which has greater consistency and is clear about which functions are best organised and delivered at which level within the system i.e. at a whole system level, at a Place (which are largely coterminous with district boundaries) or at a more local neighbourhood level.

The review is:

Mapping out current provision, geography, cost;

Identifying what each of the co-funding organisations/departments expects from infrastructure investment and identifying shared organisational outcomes.

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Identifying national expectations and strategic direction especially regarding Civil Society and the role of social prescribing in health.

The outcome of the review will be to develop a framework model that allows the VCS sector to thrive and operate as a partner in the health and social care system to deliver better outcomes for patients/people of Derbyshire.

To date, the review has highlighted that outcomes for the infrastructure model would include VCS members (smaller voluntary sector groups) having:

Better representation, accountability and support from the infrastructure offer to develop viable VCS services in their own right;

Better brokerage and facilitation support from the infrastructure offer to assist VCS members to develop joint approaches between VCS members;

Better support to VCS members to seek alternative funding; Better focus on outcomes and impact on patients and response to core

priorities and For the infrastructure offer to advocate and facilitate collaborative

opportunities on behalf of the VCS members.

From the early review work it is apparent that there are significant overlaps in the aims of the commissioners and real opportunities to be obtained in developing an integrated commissioning approach. It is likely that this will require an integrated response from the sector working to a consistent model. Commissioners will set clear outcomes to be delivered within a defined financial envelope to ensure the VCS sector are clear on what they are being asked to deliver.

At the September 2018 GB meeting, it was agreed that the CCGs would reduce the total infrastructure funding by £100k for the remainder of 2018/19. The sector mobilised quickly and effectively in response to the CCGs request regarding this demonstrating an ability to work collaboratively across the multiple organisations.

From our early review work, engagement with the infrastructure organisations and continued efficiency requirements, we are seeking GB support to recurrently reduce the infrastructure organisations collective funding by £100k in 2019/20. We will work with the infrastructure organisations ahead of the new financial year to update their service specifications.

Recommendation 1A: The Governing Bodies Committee in Common is requested to:

d. Note the progress with reviewing existing arrangements and future needs

e. Support the proposal to develop an infrastructure transitional arrangement by 1st April 2019 ahead of completion of the joint review and implementation of agreed model. The CCGs remain committed to completing this review as soon as possible in 2019

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f. Support the transition arrangement including a recurrent efficiency requirement of £100k in 2019/20.

4b). Voluntary Single Point of Access (vSPA)

i. Background

The CCGs fund two Voluntary Single Points of Access at a total of £155k. There are two distinct areas of activity:

• Signposting to VCS Services • Brief assessment of need and support to access VCS services

The vSPA services are only funded by health, though analysis of referrals shows that there is utilisation by other sectors.

Following agreement by the Governing Bodies Committees in Common in September, notice has been served (6 months) and the contract is due to end on 31st March 2019. This recommendation was made to enable vSPA provision to be considered alongside the infrastructure review.

ii. Progress

Discussion has been undertaken with the existing providers of the vSPA services South Derbyshire CVS and Derbyshire Voluntary Action to understand the existing provision and opportunities for future models of delivery. Whilst currently under separate arrangements there is significant overlap and interdependency with the infrastructure provision.

It is clear from the review work to date that there are a range of information advice, signposting and navigation services across health, care and voluntary sector. Ensuring individuals and professionals have easy access to advice and routes to access support is important in a system that wishes to support self-reliance and early, low level intervention and prevention.

iii. Recommendation

The proposal is that the signposting service currently provided by vSPA is incorporated into the current infrastructure provision. It is proposed that a 50% reduction is made to the current vSPA investment and transferred into the overall infrastructure funding for 2019/20.

Recommendation 1B: the Governing Bodies Committee in Common is asked to:

a. Acknowledge the continued intention to cease current funding arrangements for vSPA from 31st March 2019

b. Continue to make available 50% of the current vSPA funding for the infrastructure organisations delivery during the transition period, to include signposting services.

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Section Five: Discretionary Grants

i. Background

Discretionary grants were awarded in September 2016. The programme officially ended on 31st March 2018. In April 2018 the CCGs agreed to review the discretionary grant programme. Since April 18, focussed engagement has taken place with the sector and their service recipients. This report covers the work carried out since September 2018. This work covered:

ii. Engagement with the Sector

• During October and November 2018, the CCGs carried out further engagement with 25 discretionary grant funded organisations with particular focus on proportionate engagement with service recipients. CCGs contacted each group and jointly identified the most appropriate method of engagement. The CCG offered a range of ways to engage with the organisations which included an on-line survey, postal survey, telephone survey, focus and discussion groups and use of existing client survey findings, case studies and any other information that would describe the services that each organisation provided through the grant funding. In total (engagement during 7 month review), over 750 service recipients sent in their views, with 536 on-line and postal surveys completed and the CCG facilitated 10 discussion groups. (see appendix A)

• The EIA/DR’s were again reviewed and amended where appropriate as a result of the further engagement work

• The feedback gained during the whole of the review was then presented in the form of a stakeholder summary sheet along with the revised EIA and QIA risk levels to the discretionary grant review panel.

iii. VCS discretionary grant review panel Methodology

The purpose of the review panel was to consider each grant funded scheme against a set of criteria (see below) in order to make recommendations on the future funding of these schemes to the December Governing Body meeting. The criteria enabled the CCGs to review each scheme and how it supported key CCG strategic priorities.

The Panel comprised: GB GP representative; GB lay member representative; patient representative; CCG quality representative; CCG commissioning representative. They were all sent a review pack containing the updated EIA/DRs and stakeholder feedback sheet for each of the 27 schemes (incorporating the outputs of engagement activities, quality and equality impact assessments and other information provided by organisations) and the review criteria and methodology prior to the panel meeting and asked to read and prepare for discussion at the panel.

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iv. Discretionary grant review panel criteria

Criteria 1

1a) Does the scheme support key CCG strategic priorities – reduce health inequalities by improving the physical and mental health of the people of Derbyshire and Derby City?

1b) Does the scheme support key CCG strategic priorities – continue to reduce variation in the quality of care across Derbyshire and Derby City?

1c) Does the scheme support key CCG strategic priorities – to make best use of available resources?

Score range Minimum score requirement in order to be considered for future commissioning

1= no evidence, 2=low level; 3=medium level and 4=high level

Must score level 3 or above for 2 measures

Criteria 2

2a) Does the scheme offer any assistance in helping the NHS system to better manage demand so that health needs are met in the right setting, at the right time – through preventative health care supporting people to stay at home/receive care in a community setting?

2b) Does the scheme offer any assistance in helping the NHS system to better manage demand so that health needs are met in the right setting, at the right time – by reducing non-elective activity?

2c) Does the scheme offer any assistance in helping the NHS system to better manage demand so that health needs are met in the right setting, at the right time – by reducing health referrals?



Must score level 4 for 1 measure or level 3 for 2 measures

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Criteria 3

3 If this service was withdrawn would the CCGs need to commission a more costly alternative service to meet its health responsibility?


Yes or No Must score a yes

Once at panel, the representatives discussed the information provided on each scheme and scored against the above criteria. The consensus score was then recorded. The outcome from the panel review is listed in appendix B.

Recommendation 2: GBs are asked to support the panel recommendations for each scheme listed below. For schemes where funding is recommended to continue, GB are asked to support adopting the same contractual mechanism for these schemes in 2019/20 as set out for the three schemes listed in section six below.

Schemes where funding is recommended to cease

Organisation 19/20 FYE saving

DISCRETIONARY GRANTS Brand Recovery £15,333 Citizens Advice and Law Centre Derby £29,266 Vol & Community Services Peak and Dales (night sitting) £32,270 Amber Valley CVS (home from hospital) £14,991 Voluntary and Community Services Peaks & Dales (home from hospital) £18,826 South Derbyshire CVS (home from hospital) £15,246 South Derbyshire CVS (befriending) £15,270 Voluntary and Community Services Peaks and Dales (befriending) £12,000 Amber Valley CVS (befriending) £16,666 Mencap £4,014 Derbyshire Dales Council for Voluntary Service £6,008 The Farming Life Centre £14,520 RHUBARB FARM CIC £15,090 Age Concern Chesterfield Careline £15,538 Age UK Derby and Derbyshire £23,727

SUB TOTAL £248,765

TRANSPORT Bakewell and Eyam Community Transport £12,969 Vol & Community Services Peak and Dales £15,342

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Vol & Community Services Peak and Dales £16,545

Ashbourne community Transport £5,493

SUB TOTAL £50,349

TOTAL (Grants recommended to cease) £299,114

Schemes where funding is recommended to continue

Organisation 19/20 Spend

DISCRETIONARY GRANTS Headway £14,406 Cruse South Derbyshire £17,572 Chesterfield & North Derbyshire Cruse Bereavement Care £15,500 Stroke Association £37,777 Stroke Association Information advice and support £34,867 The Volunteer Centre Chesterfield & NE Derbyshire £15,333 New Mills and District Volunteer Centre £25,000 Mental Health Grants Rural Action Derbyshire £5,633 Relate £6,736 SAIL £15,000 First Steps £34,121 First Steps £21,000 Links BAME Project £19,310

Total (grants recommended to continue) £262,255

Section Six: Contractual Mechanisms

At the September GB meeting it was agreed to continue funding three services based on specific patient pathways that would be impacted should these services cease. These services are Cruse South Derbyshire; Chesterfield & North Derbyshire Cruse Bereavement Care; and Stroke Association – Communication Support Service.

The CCGs have reviewed the options for setting up a contractual arrangement with these three schemes. The most appropriate contractual mechanism would include reviewing the two Cruse services as part of End of Life Care Services (EOL) and

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reviewing the Stroke Association services as part of the Stroke pathway in order to understand the best provision and best commissioning strategy going forward.

Procurement advice has been taken for a direct award of this nature. We are advised that a 12 month direct award / extension to current services with the Cruse services and the Stroke Association to support the re-design and development of the services, with a view to formal tendering of these and other related services in 2019/2020 (as required) is the most appropriate contracting mechanism available to us.

The specific form of NHS contract required would be confirmed with the CCGs contract team once the specification has been agreed.

Recommendation 3:


• Direct awards on NHS small contracts to be made to Cruse North and CruseSouth to continue with their current activity from 1st April 2019 for 1 year whilstthe wider End of Life (EOL) review progresses.

3B: Stroke Association

• A direct award on NHS small contracts is made to The Stroke Association -Communication Support Service to continue with their current activity from 1st

April 2019 for 1 year whilst a wider consideration of Community Strokeprovision is undertaken.

Section Seven: Transport Update

In September, Governing Body members were asked to note that the CCGs intended to create a new policy to be operational from 1st April 2019 to set out the circumstances under which transport services will be CCG funded.

As summarised in section five above, the transport schemes currently in receipt of discretionary funding have been reviewed against set criteria and wider information as set out. The recommendation is that these grants should not be funded from 1st April 2019.

The CCGs are committed to engaging with all partners and the VCS in order to develop a patient transport policy that will clearly set out to the public how they may access patient transport. The policy will clearly set out the circumstances under which transport services would be CCG funded in the future, including how any individual requests for funding would be assessed.

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Further engagement work will take place with VCS representatives, non-emergency patient transport services (NEPTs) and with the Active Transport commissioners (DCC) in order to fully understand the interdependencies. After which the CCGs Clinical and Lay Commissioning Committee (CLCC) will receive a draft policy for consideration in February 2019 and it will be ratified by the GBs in March 2019.

Section Eight: Summary of ongoing work and next steps for GB to consider

It is proposed that the GBs receive an update on the following in February 2019 and March 2019:

Infrastructure (February 2019)

• Confirmed infrastructure transitional arrangements for implementation from1st April 2019 for the CCG funded element of infrastructure services

• Update on wider joint review

Discretionary Grants and Contract mechanisms (February 2019)

• Confirmed contractual arrangements for schemes continuing to receivefunding in 2019/20

Transport Policy (March 2019)

• Receive a draft policy for ratification following approval at CLCC in February2019.

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Voluntary Sector Grants Service User Engagement

536 surveys were completed postal and online

Organisation Methods of Engagement Total Numbers Involved

Age Concern Not complete Not complete Age UK Memory Lane 3 case studies – Nov 2018

70 questionnaires in July 2018 73

Ashbourne transport 10 on line surveys 10 Bakewell and Eyam transport 7 telephone surveys – nov 2018

Approx. 25 surveys in July 2018 32

AVCVS Befriending 21 surveys - postal 21 Befriending Peak and dales CVS 31 surveys - postal 31 Befriending SDCVS 327 surveys completed in July

24% of these were for people receiving befriending (78 people). 16 people in a group discussion also SDCVS declined to carry out any service user engage in November 2018 due to time

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Brand Recovery 12 comments (case studies) 12 CAB 4 cases studies provided 4 Cruse North 14 on line surveys

22 evaluation reports 36

Cruse South 20 on line surveys 20 Dales social Capital 5 surveys on line 5 Farming Life Centre 24 comments recorded in a

group discussion. 13 surveys postal

27

First Steps 28 people at discussion group Referrers 42 on line surveys

70

Headway 7 people at discussion group. Staff from acquired brain injury unit

7

MENCAP 20 postal surveys (completed with support)

New Mills Volunteer centre 79 responses 16 about transport aspects

79

Night Sitting 17 surveys postal and on-line 17 Befriending – Readycall 21 surveys nov 2018

3 case studies Provided own evaluation survey

24 (unknown number in the evaluation)

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with service users from July 2018

Peak and Dales transport 29 surveys postal and on line 29 Relate 8 comments from service users

2 volunteer surveys Provided an evaluation report of their impact on service users

10

Rhubarb Farm 17 postal surveys Group of 10 (but these are part of the same 17 who completed surveys)

17

Rural Life Derbyshire 15 comments – made in July 2018 in reported

15

SAIL Discussion group with 6 people in present 25 surveys postal and on-line

31

SDCVS transport 12 comments on transport made as part of feedback about SDCVS in July 2018 survey where 327 people responded in total

12

Stroke Association North 39 survey s Discussion group

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Volunteer Centre Chesterfield - Elderfriends

2 surveys Nov 2018 Service users surveys provided in July 2018 or approx. 40 people

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Appendix B Funding recommendations for discretionary grants under consideration as part of the Review of Voluntary and Community Sector funding review 2018 . Discretionary grant review panel criteria

Criteria 1

1a) Does the scheme support key CCG strategic priorities – reduce health inequalities by improving the physical and mental health of the people of Derbyshire and Derby City?

1b) Does the scheme support key CCG strategic priorities – continue to reduce variation in the quality of care across Derbyshire and Derby City?

1c) Does the scheme support key CCG strategic priorities – to make best use of available resources?



Must score level 3 or above for 2 measures

Criteria 2

2a) Does the scheme offer any assistance in helping the NHS system to better manage demand so that health needs are met in the right setting, at the right time – through preventative health care supporting people to stay at home/receive care in a community setting?

2b) Does the scheme offer any assistance in helping the NHS system to better manage demand so that health needs are met in the right setting, at the right time – by reducing non-elective activity?

2c) Does the scheme offer any assistance in helping the NHS system to better manage demand so that health needs are met in the right setting, at the right time – by reducing health referrals?



Must score level 4 for 1 measure or level 3 for 2 measures

Criteria 3

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3 If this service was withdrawn would the CCGs need to commission a more costly alternative service to meet its health responsibility?


Yes or No

Must score a yes

Results of the VCS discretionary grant review panel

Services that support independence and self-management

Brand Recovery: The Brand Recovery service provides training, education, meaningful activities, and improved employment prospects to individuals aged 19 or over who are unemployed and have any mental health condition ranging from low level to complex. The service supports individuals to progress into a wider network and range of activities to support their ongoing development and recovery.

Full year Costs

£15,333

Criteria Score (Review Panel)

QIA Risk

Low

Patient

Safety risk

No

1a

3

1b

1

1c

4

2a

2

2b

3

2c

2

3

NO Proposed recommendation: Cease grant funding with 3 months’ notice Comment: Has a positive impact but it was felt that this is outside our core business and shouldn’t be our service to commission ; therefore cease Headway: Headway provides rehabilitative support to adults with brain injuries. Including people who have had meningitis, stroke and traumatic injury. This project delivers a range of accredited training opportunities to service users, leading to an accredited certificate or award (depending on individual’s ability) in Skills for Employment and Further learning. Referral to this service for people who are progressing in their rehabilitation is an option used by the Head Injury Team to help manage their caseloads.

Full year Costs

£14,406


QIA Risk

High

Patient

Safety risk

Yes

1a

2

1b

3

1c

3

2a

3

2b

3

2c

4

3

YES Proposed recommendation: Continue as either grant or commissioned service, level of funding pending review. Comment: Work needs to be done to see how it fits with wider services

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Citizen Advice Derby and South Derbyshire: The GP Outreach Service provides welfare benefits advice and guidance to people with a Derby GP. The service receives referrals or is signposted to from GP practices where Welfare Benefit issues and low income have an impact on health. The service is provided in a number of GP practices weekly or according to need.

Full year Costs

£29,266


QIA Risk

Moderate

Patient Safety

risk

No

1a

1

1b

1

1c

1

2a

3

2b

1

2c

3

3

NO Proposed recommendation: Cease grant funding with 3 months’ notice Comment: This was initially a PCT initiative and is outside CCG core business. Similar services have been commissioned by public health and others elsewhere Stroke Association –Information and Advice Service North Derbyshire

The service provides support to stroke survivors in the North of the County post discharge, including peer groups, information and emotional support. It assists people to self-manage their condition, re-engage with and participate in community activities and improve their emotional recovery by overcoming barriers. Referrals through Early Supported Discharge Team.

Full year Costs

£34,867


QIA Risk

Moderate

Patient Safety

risk

Yes

1a

2

1b

3

1c

3

2a

3

2b

3

2c

4

3

YES

Proposed recommendation: Continue as either grant or commissioned service, level of funding pending review. Comment: Work needs to be done to see how it fits with wider services and a new contracting mechanism put into place by 1 April 2019.

57

Services supporting discharge from hospital or preventing admission

Voluntary and Community Services Peaks and Dales High Peak Emergency and Night Sitting: This is an emergency sitting service supporting people and their carers during periods of concern. The funded service delivers respite care in people's homes to facilitate support during or to prevent periods of crisis to the person or their Carers.

Full year Costs

£32,269


QIA Risk

Moderate

Patient

Safety risk

Yes

1a 1

1b 1

1c 1

2a 4

2b 2

2c 2

3

NO

Proposed recommendation: Cease grant funding with 3 months’ notice Comment: This is a Carers service relating to respite breaks and emergency sitting. It could be considered in the context of the Carers breaks service, funded through the County BCF

Befriending Services

• South Derbyshire CVS Befriending Service. This Service offers befriending support to socially isolated people enabling them to engage with community activities by providing: 1:1 befriending for up to six weeks, Ongoing home visiting and buddying to activities outside the home, befriending groups and connecting service users with each other.

Full year Costs

£25,270


QIA Risk

Moderate

Patient

Safety risk

No

1a 3

1b 1

1c 2

2a 3

2b 2

2c 3

3 3

Proposed recommendation: Cease grant funding with 3 months’ notice Comment: A worthwhile service with a positive impact but it was felt that this shouldn’t be our service to commission as is outside our core business, therefore cease Voluntary and Community Services Peaks and Dales Readycall Befriending South Dales

The Readycall Befriending service Provides a service on a short term basis supporting people to re-engage within their community to help them to gain and improve their independence, plus supporting those who need longer term support.

Full Year Costs

£12,000

1a 3

1b 1

1c 2

2a 3

2b 2

2c 3

3 3

QIA Risk

Moderate

Patient Safety Risk

No

Proposed recommendation: Cease grant funding with 3 months’ notice Comment: A worthwhile service with a positive impact but it was felt that this is not a service that we would commission as is outside our core business, therefore cease

58

Amber Valley CVS Befriending Service. The service provides a short term befriending and buddy service for the benefit of frail and elderly people in Amber Valley who are socially isolated, have poor mobility and are unable to access community services.

Full year Costs

£16,666


QIA Risk

Low

Patient

Safety risk

No

1a 3

1b 1

1c 2

2a 3

2b 2

2c 3

3 3

Proposed recommendation: Cease grant funding with 3 months’ notice Comment: A worthwhile service with a positive impact but it was felt that this shouldn’t be our service to commission as is outside our core business, therefore cease Volunteer Centre Chesterfield Elderfriends Befriending Service. This befriending service aims to reduce loneliness for older, isolated individuals who may have no external contact outside of the service.

The volunteer centre also offers significant volunteer opportunities and volunteer training.

Full year Costs

£15,333


QIA Risk

Moderate

Patient

Safety risk

No

1a 3

1b 1

1c 2

2a 3

2b 2

2c 3

3

NO*

Proposed recommendation: Cease grant funding but pick up funding via the infrastructure review, funding level pending infrastructure review Comment: A worthwhile service with a positive impact but it was felt that this is not a service that we would commission as is outside our core business, therefore cease the befriending element. Some of the volunteer centre (infrastructure element) to be maintained within the infrastructure review. (this will need some resource)

*Some resource required for Infrastructure

59

Mencap Service Swadlincote:

This is a local self-funding volunteer led group in Swadlincote, serving South Derbyshire and supported by Mencap UK. The group supports people with learning disability, providing opportunities to create social networks and peer relationships and offers peer support opportunities to Carers.

Full year Costs

£4,000


QIA Risk

Low

Patient

Safety risk

No

1a 3

1b 1

1c 1

2a 2

2b 1

2c 2

3

NO

Proposed recommendation: Cease grant funding with 3 months’ notice Comment: A service with a positive impact but it was felt that this is not a service that we would commission. Other Similar services are not funded by the CCGs. This is a high priority for VCS Infrastructure Support. Link to the Learning Disability Review

Other Schemes to reduce social isolation

Derbyshire Dales CVS Social Capital grant: The project supports activity that connects socially isolated, vulnerable people to attend community activities, specifically developing and supporting direct action within the community.

Full year Costs

£6008


QIA Risk

Low

Patient

Safety risk

No

1a 1

1b 1

1c 1

2a 2

2b 1

2c 2

3

No

Proposed recommendation: Cease grant funding with 3 months' notice Comment: Link this type of activity to the infrastructure review going forward.

60

New Mills Volunteer Centre

The New Mills and District volunteer centre provides a range of services to an isolated rural population. The centre takes on a number of the activities that CVS organisations offer in other areas although the model is different. They link individuals to available groups and services, recruit volunteers for these groups, support the activity of these groups. They also provide befriending, shopping, gardening and transport services

Full year

Costs

£25,000


QIA Risk

Low

Patient

Safety risk

No

1a 3

1b 1

1c 2

2a 3

2b 2

2c 2

3

NO *

Proposed recommendation: Cease grant funding but pick up funding via the infrastructure review, funding level pending infrastructure review Comment: We would not commission this service package in its entirety as it is outside our core business, therefore cease grant but volunteer centre (infrastructure element) to be maintained within infrastructure review.

• Some monies to support the infrastructure element will be retained

The Farming Life Centre: This grant supports the Farming Life Centre to provide its health and wellbeing service for socially isolated members of the Peak District rural community.

The funding has been used to run and support rural social groups in isolated farming/rural communities which attract many members over the age of 70 weekly or monthly. Without this service the members would not have other opportunities to come together in this way.

Full year Costs

£14,520


QIA Risk

Moderate

Patient

Safety risk

Yes

1a 2

1b 2

1c 2

2a 3

2b 1

2c 1

3

NO

Proposed recommendation: Cease grant funding with 3 months' notice Comment: This is recognised as a valuable service for this group of people but is outside of core business so it is recommended to cease. (It is noted that it is recommended elsewhere in this report that the separate mental health grant for a counselling service serving a similar group of should be maintained)

61

Rhubarb Farm. The Rhubarb Farm Project is aimed at getting socially isolated, vulnerable people with multiple and complex needs onto the farm, to enable them to change their lives for the better by providing purposeful, productive outdoor work, as well as training courses and opportunities to join different social groups combined with high levels of support.

Full year Costs

£15,090


QIA Risk

Low

Patient

Safety risk

No

1 3

1b 1

1c 2

2a 3

2b 2

2c 2

3

NO

Proposed recommendation: Cease grant funding with 3 months’ notice. Comment: This is recognised as a good service. Whilst the value is recognised it is noted that the service necessarily covers a small area only and is relatively high cost due to high level needs being met. As it is not core CCG business it would not be commissioned as a health service Countywide. Use of PHB and PC budgets to be encouraged.

Age Concern. The Age Concern Care Line telephone befriending and support service provides free of charge telephone calls to elderly, lonely or socially isolated people. It is facilitated by a team of specially trained volunteers who make up to 3 calls each week to service users in Chesterfield, NE Derbyshire and Bolsover area.

Full year Costs

£15,538


QIA Risk

Moderate

Patient

Safety risk

No

1a

2

1b

2

1c

3

2a

3

2b

2

2c

3

3

No

Proposed recommendation: Cease grant funding with 3 months' notice Comment It was recognised that this is a worthwhile service with a wide reach and a positive impact but it was felt that this is not a service that we would commission as is outside our core business, therefore cease

62

Age UK Derby and Derbyshire

The Memory Lane service uses reminiscence as a tool to support older people with memory problems arising from dementia or similar conditions. Activities offered encourage high quality interaction and communication and development of memory boxes. The service offers group meetings and appropriate additional activities in the North of the County. Carers are given the option of attending, but can choose not to as a level of informal support is available for group members.

Full year Costs

£23,727


QIA Risk

Low

Patient

Safety risk

No

1a 2

1b 1

1c 2

2a 3

2b 2

2c 2

3

NO

Proposed recommendation: Cease grant funding with 3 months' notice Comment: This is valuable activity but CCG core provision is already in place through commissioned services including alternative Dementia Support Services.

Transport Related Services

Bakewell and Eyam Community transport

This Service provides transport for people attending health related and social appointments. The aim of the service is that users in Bakewell and Eyam and surrounding areas are able to maintain health and wellbeing. The service is provided to rural elderly, infirm and vulnerable people who have mobility issues as well as other complex issues such as dementia, Parkinson’s and cancer. Much of the service activity is provided by volunteers. The CCG funding is primarily intended to support the health related appointments

Full year

Costs

£12,969

QIA Risk

Moderate

Patient

Safety risk

Yes (some)

1a 2

1b 2

1c 1

2a 2

2b 1

2c 1

3

NO

Proposed recommendation: Cease grant funding with 3 months' notice Comment: Whilst recognising the difficulties experienced in rural areas the panel agreed that the obligations for health related transport are met by NEPTS and other arrangements. The existence of the County Council funded service that includes transport to health appointments was noted. Further work is underway and will result in a transport policy by end March 2019.

63

Voluntary and Community Services Peaks and Dales transport and Car services (North Dales and South Dales)

This Service provides transport for older people in rural Derbyshire Dales attending health related and social appointments. A wheelchair accessible vehicle is available to assist with transport in addition to the social cars. The service can support people with sensory and physical disability, mental health conditions and learning disability. The staff are supported by volunteer drivers and other volunteers

Full year Costs

£15,342

and

£16,545


QIA Risk

Moderate

Patient

Safety risk

Yes (some)

1a 2

1b 2

1c 1

2a 2

2b 1

2c 1

3

NO


Ashbourne Community Transport

The grant to Ashbourne community Transport supports a small proportion of the activity undertaken but allows the service to maintain lower costs and to retain its status as a community transport provider rather than a commercial enterprise.

Full year Costs

£5,439.13


QIA Risk

Low

Moderate

Patient

Safety risk

Yes (some)

1a 2

1b 2

1c 1

2a 2

2b 1

2c 1

3

NO


64

Mental Health Services

Derbyshire Rural Community Council Agricultural Chaplaincy service

The service supports farmers who experience difficulties. Farmers are at increased risk of a range of health problems and less likely to access health care in traditional setting. They often have complex, multi-stranded issues to cope with involving issues such as business management, animal welfare, family relationships, finance, physical and mental health issues.

Farmers are at increased risk of suicide and are high risk group in the suicide prevention strategy for Derbyshire in which the role of the agricultural chaplaincy in reducing suicide is recognised.

Full year Costs

£5,633


QIA Risk

High

Patient

Safety risk

YES

1a 3

1b 3

1c 3

2a 3

2b 3

2c 3

3

YES

Proposed recommendation: Continue as either grant or commissioned service Comment: This is a core provision. Counselling available in Sheffield is more costly. Continue funding and develop contract model before March 2019

Relate Psychosexual counselling

Relate Chesterfield provide qualified psychological therapists who offer appointments giving guidance on both physical and psychological problems related to sexual activity that impact on family life and working life

Some clients supported include cancer patients, or patients with other medical conditions such as stroke that can result in problems related to sexual activity Problems with sexual function, such as erectile dysfunction can result in stress and anxiety and impact well-being and family relationships.

The CCG contribution supports the service to train the volunteers and pay expenses. The clients are asked for a donation of £50.

Full year Costs

£6,736.00


QIA Risk

Moderate

Patient

Safety risk

No

1a 3

1b 2

1c 3

2a 1

2b 1

2c 2

3

YES

Proposed recommendation: Continue as either grant or commissioned service Comment: Continue funding and develop contract model before March 2019. To be considered alongside the psychotherapy review.

65

BAME Mental Health First Aiders Project

Support to volunteers from BAME groups. Affected people in these communities are less likely to seek help from mainstream mental health services Volunteers from a select group of BAME organisations are supported to help meet the needs of individuals with mental health conditions. They undertake Mental health first aid training and receive support from DCHS. They support peers in the BAME community with social isolation and signpost to appropriate services. The scheme is administered via Links CVS but they do not receive money from the CCG for undertaking this work.

Full year Costs

£19,310


QIA Risk

Moderate

Patient

Safety risk

No

1a n/a

1b n/a

1c n/a

2a n/a

2b n/a

2c n/a

3

YES

Proposed recommendation: Continue as either grant or commissioned service Comment: Continue funding and make part of infrastructure review

SAIL. Counselling and signposting for survivors of sexual abuse

Clients receive counselling specifically because of childhood sexual abuse. Counsellors help clients to come to terms with what has happened and the devastating effects it has had on their lives in the long term. Clients learn how to heal themselves through strategies and having a trusting therapeutic relationship.

Full year Costs

£15,000


QIA Risk

Moderate

Patient

Safety risk

YES

1a 2

1b 3

1c 3

2a 4

2b 2

2c 3

3

YES

Proposed recommendation: Continue as either grant or commissioned service Comment: This is a health need and a CCG responsibility. Contract model to be reviewed and a commissioned service in place by 1st April 2019.

66

First Steps Eating Disorders service 1 and 2

First Steps provide an eating disorder service to both adults and children. This supports the commissioned service which has stringent inclusion criteria, only accepting people with a very low BMI. This preventative work both helps with individuals with low BMI or other eating related issues but who are just outside of the criteria for the commissioned service from becoming part of the that and also supports maintenance after a patient has achieved a level of improvement.

Full year Costs

£34,121

and

£21,000


QIA Risk

High

Patient

Safety risk

No

1a 3

1b 2

1c 3

2a 3

2b 2

2c 3

3

YES

Proposed recommendation: Continue as either grant or commissioned service Comment: This is a health need and a CCG responsibility. Contract model to be reviewed and a commissioned service in place by 1st April 2019.

67




13th December 2018

Report Title Gluten free prescribing – policy change review Author(s) Jane Roberts Sponsor (Director) Steve Hulme

Paper for: Decision X Corporate Assurance

X Discussion Information

Recommendations It is recommended that the current Derbyshire wide Gluten free prescribing policy continues in its current form.

The Governing Body are requested to APPROVE this recommendation.

Report Summary During 2017 (Feb-Aug 17), a public consultation regarding the future prescribing of gluten free foods was carried out to ascertain the views and needs of local people and stakeholders.

Following this, over the course of November 2017 and December 2017, each Derbyshire Governing Body considered the consultation feedback reports, equality impact assessments and the views of the Joint Area Prescribing Committee (JAPC).

After careful deliberation, each Governing Body independently agreed to:

• Not routinely commission the provision of gluten free food supplements

A Derbyshire wide prescribing policy was published (Appendix 1) and a change made to the local ‘traffic light’ status of gluten free foods. Importantly, the policy recognises that GPs have clinical freedom to act in an individual patient’s best interest where exceptional clinical circumstances exist that warrant deviation from this policy.

The policy was actively implemented during January - March 2018

The CCG Medicines Management Teams (MMT) worked with practices to ensure that every patient who had received a prescription for a gluten free food in the previous six-months received a letter informing them of the change in policy.

The prescribing of Gluten Free Foods has declined significantly and savings of approx. £150K reported during April-June 18.

Item No: 56

68

A very small amount of prescribing has continued. An active decision had been made to continue prescribing in each case. From the data we have there would not appear to be any groups identified for exception from policy. Concerns regarding adherence to a gluten free diet if foods were not made available on prescription were raised during the consultation and during the decision making. The complications of non-adherence to a gluten free diet are generally longer term and can include osteoporosis, malnutrition and increased risk of cancer. It is not possible at present to measure the levels of non-adherence and any increase in longer term complications. During January – April 18, the Derbyshire CCGs had received a total 87 contacts and 4 formal complaints following the decision to withdraw all GF foods from NHS prescription within Derbyshire (approx. 3% of patients affected). Data is very limited but there would appear not to have been an increase in referrals to local Dietetic services. Learning

• The start of a national consultation and subsequent publication of the national guidance shortly after the Derbyshire consultation and guidance would appear to have caused some confusion and distress for patients

• Consideration should be given to the written communications to patients. These should use appropriate language, provide contact details inc address to raise concerns and make clear which groups are affected.

• Lack of notice period for implementation - patients felt it would have been fairer to provide a notice period which would have allowed them to adjust and source alternative products. Many patients were very surprised by this decision and were left feeling vulnerable as a result. The usual process for implementing changes to prescribing policy was followed. This was the first time that a change of this nature has been made in Derbyshire. We will consider giving a notice period for changes in the future.

Note: update to national position since review was carried out – The DHSC guidance has now been enacted through a change to the Drug Tariff, from 1st December. Are there any Resource Implications (including Financial, Staffing etc)? During the 12 months from August 16 to July 17, spend on GF products was approx. £700,000 across Derbyshire. In addition to this a further £88,000 was spent providing products off prescription as part of the GFFS scheme. Since the policy was implemented prescribing has declined significantly and a saving of £155,624 reported for the period April-June 18.

Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? An assessment was carried out as part of the Derbyshire wide consultation and informed the decision making.

69

Have you involved patients, carers and the public in the preparation of the report? Contacts and complaint received by the CCGs since the policy has been implemented have been included and feedback sought from Healthwatch Derby and Healthwatch Derbyshire. Have any Quality and Compliance issues been identified/ actions taken None identified. Have any Conflicts of Interest been identified/ actions taken? There may be potential conflicts of interest where providers or users of the service are part of the decision making process.

Governing Body Assurance Framework Which of the CCG’s objectives does this paper support? Identification of Key Risks Cross reference to risks within GBAF or Risk Registers

70



Gluten free prescribing – policy change review

Background

During 2017 (Feb-Aug 17), a public consultation regarding the future prescribing of gluten free foods was carried out to ascertain the views and needs of local people and stakeholders. Following this, over the course of November 2017 and December 2017, each Derbyshire Governing Body considered the consultation feedback reports, equality impact assessments and the views of the Joint Area Prescribing Committee (JAPC). After careful deliberation, each Governing Body independently agreed to:

• Not routinely commission the provision of gluten free food supplements

A Derbyshire wide prescribing policy was published (Appendix 1) and a change made to the local ‘traffic light’ status of gluten free foods. Importantly, the policy recognises that GPs have clinical freedom to act in an individual patient’s best interest where exceptional clinical circumstances exist that warrant deviation from this policy. The purpose of this report is to describe the actions taken following these decisions and the impact they have had within Derbyshire. National position A national consultation regarding the future of gluten free foods prescribing was also carried out in 2017 (March-June 2017) by the Department of Health and Social Care (DHSC). In their report (published Feb 2018), the health minister stated that their preferred option was to restrict prescribing to gluten free bread and flour. The report also acknowledges:

‘It is for CCGs to decide how they commission local services to best meet the needs of their populations. Some CCGs have made changes that go beyond restricting to a staple range of products, and many have done so following patient engagement and/or consultation. They may wish to undertake a review of their position taking into account patient feedback and the impact of their change. As a consequence they may or may not wish to adapt their position.’

Nationally, it is proposed that the DHSC guidance is implemented via a change to the Drug Tariff. This will require legislation change, which is currently being consulted upon. The DHSC report was considered by the JAPC and the Derbyshire CCGs Governing bodies. It was agreed that there would be no change in the current policy to no longer routinely

71



commission the provision of gluten free food supplements on NHS prescription within the Derbyshire CCGs.

Implementation of the local prescribing policy change The policy was actively implemented during January - March 2018 and the following actions taken: Communication Communications were sent out to stakeholders including GPs, community pharmacies, secondary care and CCG colleagues) at the end of December to make them aware of the pending change in policy. A media release published 11th January 2018 (Appendix 2) and information published on the CCGs website and via social media. The CCG Medicines Management Teams (MMT) worked with practices to ensure that every patient who had received a prescription for a gluten free food in the previous six-months received a letter informing them of the change in policy (Appendix 3). Patient support The above letter also advised patients of information, help and support they might find useful to help them manage a gluten-free diet. Patients were alerted to Coeliac UK and their website, www.coeliac.org.uk which contains a wealth of useful information on how to follow a gluten free diet, including advice about shopping and reading food labels, cooking and baking, eating out, travelling and specific advice for children and for those eating on a budget. Patients were also signposted to the Patient Advice and Liaison Line (PALS) should they feel they need further advice or information. To ensure that the PALS team were able to support patients, information was provided to the team including when a referral to the dietetic service may be appropriate, the local policy, background on the conditions, sources of information and alternative sources for foods or alternatives. The information was provided by the CCG MMT following discussion with a local Dietician. Pre-payment certificate refund During the consultation it was highlighted that a number of patients may have purchased pre-payment certificates from the NHSBSA for the sole purpose of funding the prescription charges when accessing gluten free foods on prescription. These patients would not be eligible for a refund via NHSBSA for any remaining time on their certificate. To support this group, it was agreed that the CCGs would refund remaining months at the request of individual patients.

Gluten Free Food Scheme – off prescription supply scheme via community pharmacies in Amber Valley The Gluten Free Food Scheme (GFFS) had been running in a number of community pharmacies in the Amber Valley locality since 2005. The GFFS was available at all participating community pharmacies to all service users with an appropriate diagnosis of established gluten enteropathy, which includes coeliac disease and dermatitis

72

http://www.coeliac.org.uk/



herpetiformis, who were registered with a participating GP practice within the Amber Valley locality.

In light of the prescribing policy it was proposed to decommission the GFFS in the Amber Valley locality. As gluten free foods were not to be routinely provided in SDCCG, there was no requirement for the scheme. If there were individual exceptional clinical circumstances and continued prescribing, this was to be done via prescription from a GP. The decommissioning of the scheme was agreed by Southern Derbyshire Clinical Commissioning Group in January 2018. Participating community pharmacies were informed, at the end of January 2018, of the intention to decommission the scheme and to give the required contractual 3 months notice for the scheme to end 31st May 2018. Local GP practices were also informed of the end of the scheme. Patients using the scheme were contacted by the MMT as above. Impact of the prescribing policy change Financial During the 12 months from August 16 to July 17, spend on GF products was approx. £700,000 across Derbyshire. In addition to this a further £88,000 was spent providing products off prescription as part of the GFFS scheme. Since the policy was implemented prescribing has declined significantly and a saving of £155,624 reported for the period April-June 18.

0.00

10,000.00

20,000.00

30,000.00

40,000.00

50,000.00

60,000.00

Apr17

May17

Jun17

Jul17

Aug17

Sep17

Oct17

Nov17

Dec17

Jan18

Feb18

Mar18

Apr18

May18

Jun18

Spend (£) on Gluten Free foods across Derbyshire CCGs

73



Costs from the GFFS have also reduced over this period and are zero from June 18.

Prepayment certificate costs A total of 36 pre-payment certificates were refunded, at a total cost to the CCGs of approx. £2K CCG Number of pre-payment

certificates refunded Costs (£)

Erewash 1 43.33 Hardwick 2 115.17 North Derbyshire 13 840.67 Southern Derbyshire 20 1,222.01

Total 36 2,221.18 Review of continuing prescribing and exceptionality Approx 3,000 patients were contacted by letter informing them of the change in policy. The policy recognises that GPs have clinical freedom to act in an individual patient’s best interest where exceptional clinical circumstances exist that warrant deviation from this

0.00

1,000.00

2,000.00

3,000.00

4,000.00

5,000.00

6,000.00

7,000.00

8,000.00

9,000.00

April May June Jul Aug Sept Oct Nov Dec Jan Feb March

Spend £

Gluten Free Food Scheme 17/18 vs 18/19 (Spend)

17/18 18/19

74



policy and states that any such decisions should be recorded clearly in the patient’s clinical record.

A review was carried out by the MMT to identify continued prescribing of gluten free foods to assess adherence to the policy and themes in clinical exceptionality. The May 18 ePACT prescribing data was used to identify if there was any continued prescribing. There was continued prescribing for 4 patients across 4 practices (awaiting confirmation of continued prescribing in further 4 practices).

CCG Number of patients

Number of patients where an active

decision to continue had been

made

Number of patients where exceptional

clinical circumstances had

been recorded Erewash 0 0 0 Southern Derbyshire

2 2 2

North Derbyshire 2 2 2 Hardwick 0 0 0 An active decision had been made to continue prescribing in the 4 patients above. While there are some shared conditions, the circumstances are very individual. From the data received to date there would not appear to be any groups identified for exception from policy. Impact on adherence to gluten free diet Concerns regarding adherence to a gluten free diet if foods were not made available on prescription were raised during the consultation and during the decision making. The complications of non-adherence to a gluten free diet are generally longer term and can include osteoporosis, malnutrition and increased risk of cancer. It is not possible at present to measure the levels of non-adherence and any increase in longer term complications. The evidence in this area was considered as part of the decision making (Appendix 4). In summary, there appear to be a number of factors that may affect adherence to a GF diet. The most frequently reported are membership of an organisation such as Coeliac UK, and regular dietician follow-up. Better education about Coeliac disease and diet appears to be important, as does the ability to understand food labelling. There is limited data regarding the importance of providing GF foods on prescription and much of it is conflicting, but it cannot be ruled out as one of the factors affecting adherence. There appears to be little or no evidence regarding the effect of reducing the number of units available. Most of the evidence would appear to be of low quality.

75



Patient contacts and complaints Between 1st January 2018 and 30th April 2018, the Derbyshire CCGs had received a total 87 contacts and 4 formal complaints following the decision to withdraw all GF foods from NHS prescription within Derbyshire (approx. 3% of patients affected).

Of these contacts Erewash CCG received 9 and 1 formal complaint, Hardwick received 4 and 0 formal complaints, North Derbyshire received 27 and 1 formal complaint and Southern Derbyshire received 47 and 2 formal complaints.

Below are themes from the contacts received:

Letter

• Patients finding out about the withdrawal of GF foods from NHS prescription, beforethey had received the letter informing them of the changes

• Letter not clear- not written in plain English, no address provided to raise concerns,not clear if children were also affected and no date provided as to when the changescame into force

• Some patients found the wording of the letter patronising and were angry at theinsinuation patients could just do without GF staple products if they could not affordto purchase them

Decision

• Patients very confused by the conflicting statement provided by the Dept of Healthand Social Care (DHSC). Patients mistakenly thought that the DHSC decisionsuperseded the CCG decision- this raised expectations and caused confusion

05

101520253035

Num

ber o

f enq

uirie

s

Breakdown by CCG of GF enquires received per month

76



• Upset that the CCG’s have gone against national guidance- patients felt this created a postcode lottery and inequity within the NHS

• Coeliac patients feeling penalised for having a condition which is not of their making when the CCG’s continues to provide help for people with drug and alcohol addictions, which they felt were self-inflicted

• Lack of notice period- patients felt it would have been fairer to provide a notice period which would have allowed them to adjust and source alternative products. Many patients were very surprised by this decision and were left feeling vulnerable as a result

• Many patients supported the withdrawal of a number of the GF products, as they felt they were either luxury items or could be sourced at a reasonable price. However, the general consensus was that the CCG should commission in line with the DHSC guidance and continue to provide the staples of bread and flour via the NHS

• Patients felt that the CCG had failed to consider the impact of this decision on patients who are on a low income and will struggle to pay the inflated prices for GF products, making following a GF diet very difficult. Many felt that the decision to withdraw all products was short sighted and may lead to some patients not following the correct diet, which would have a detrimental effect on their health and may cost the NHS more money in the long term

• Concerns raised regarding the accessibility to GF food for patients who can only shop locally due to the rurality of the area they live in or mobility issues

• A number of patients raised concerns that they were aware that some Amber Valley patients were still able to access GF foods after it had been stopped for other Derby/Derbyshire patients, the feedback was that this was unfair and unequitable. It was felt that the decision should have been delayed so all patients stopped receiving GF products at the same time

• One patient called to advise that he was glad the CCGs had stopped providing GF products as he did not think that they should be provided via the NHS

• Households with more than one person with Coeliac disease felt that they were being particularly penalised and this decision would cause significant financial hardship

• Queries from patients wanting to know if there is any financial assistance available for GF patients on a low income

• Many patients expressed extreme disappointment that they were unable to access Juvela flour- according to feedback received the flour is very good but expensive and difficult to source

• The CCGs have under estimated the importance of a GF diet for coeliac sufferers, a number of patients stated they had been made to feel that this is a lifestyle choice, rather than a serious condition which is only manageable via a strict GF diet- to a coeliac sufferer GF food is their medicine

• Number of enquiries re if GP can over turn decision

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Consultation

• A number of patients felt the consultation which had been conducted by the CCG’s Medicines Management Team, prior to this decision, was a waste of time and that their opinions must not have counted. Patients also expressed that they felt that the questions within the survey were very loaded in favour of withdrawing GF products

Suggestions

• Many callers felt coeliac patients were an easy target. An alternative way to save money would be to stop providing all prescription items for free for patients with specific conditions such as diabetes

• It may have been more cost effective to provide a voucher to patients so they could purchase their own GF products from their local supermarket

• Maybe the CCG could have sourced cheaper GF products rather than withdrawing the products for all

Below a breakdown of the formal complaints received and the outcomes Received Area Detail Outcomes 27.02.18 NDCCG Decision: Concerns are raised that the

decision taken to withdraw GF foods from NHS prescription unfairly discriminates against children and people who live in rural areas. Concerns also raised in relation to lack of notice provided.

Partly upheld: Explanation given for the decision and the consultation, which did take into consideration the age of affected patients. Apology given for the lack of notice. Learning: All feedback on the implementation of this decision will be considered in any future changes of this nature.

05.02.18

SDCCG Decision: Concerns are raised that the decision taken to withdraw GF foods from NHS prescription unfairly discriminates against diagnosed coeliacs and contradicts the DHSC statements which supports the retention of GF bread and flour on NHS prescription.

Not upheld: Explanation given for the CCG decision to withdraw GF foods from prescription.

06.02.18

SDCCG Decision: Concerns are raised that the decision taken to withdraw all GF foods from NHS prescription is going to cause hardship to low income families and/or families with more than one coeliac. Concerns are also raised that the decision contradicts the DHSC statements which supports the retention of GF bread and flour on NHS prescription.

Not upheld: Explanation given for the CCG decision to withdraw GF foods from prescription. Coeliac UK GF diet on a budget leaflet provided

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Received Area Detail Outcomes 12.02.18

EWCCG Decision & Communication: Concerns are raised that the decision taken to withdraw GF foods from NHS prescription unfairly discriminates against diagnosed coeliacs and contradicts the DHSC statements which supports the retention of GF bread and flour on NHS prescription and the lack of notice given before the change came into force.

Explanation given for the decision taken by the CCG and clarification given that CCG can make their own commissioning decisions, despite the DHSC's consultation and new guidance on GF foods. Apology given for lack of notice. Learning: All feedback received will be taken into consideration should the CCG need to make a similar change in the future.

Feedback has been sought from Healthwatch Derby and Healthwatch Derbyshire. Healthwatch Derbyshire have reported that they had received concerns over the planned changes and likely impact and have not received concerns since the changes have been made. MP letters To date the CCGs have received 2 letters direct from MPs responding to concerns from constituents and 2 letters from constituents to MPs where the CCG had been copied into the correspondence. Below is a summary of the themes:

• Difference between local policy and national guidance • Additional cost of gluten free foods and the impact on adherence to a gluten free

diet and therefore long term negative effects of this

Effect on dietetic services – referrals and feedback Referral data for Derby hospital dietetic service is available (limited to ‘non-block’ activity) and shows a slow upward trend in referrals over the past year. The trend started before the policy was implemented so it is not possible to say how much of this increase in activity, if any, could be attributed to the change in policy.

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Referral data is not available for the Chesterfield Hospital Dietetic service. Anecdotally, the Dietetic team report that the number of referrals has not been impacted. Feedback has been sought from the Dietetic services at Chesterfield Royal Hospital and Derby Hospital. Below is a summary of the anecdotal feedback from Dieticians at Chesterfield Royal Hospital:

- Some reported not having had any issues or problems raised with them - Some reports of patients raising their displeasure and disappointment with the

decision - Some reports that a number of patients/families had been buying gluten free foods

for some time prior to the change - One report that a patients food bill had increased by ~£5 a week

Learning

• The start of a national consultation and subsequent publication of the national guidance shortly after the Derbyshire consultation and guidance would appear to have caused some confusion and distress for patients

• Consideration should be given to the written communications to patients. These should use appropriate language, provide contact details inc address to raise concerns and make clear which groups are affected.

• Lack of notice period for implementation - patients felt it would have been fairer to provide a notice period which would have allowed them to adjust and source alternative products. Many patients were very surprised by this decision and were left feeling vulnerable as a result. The usual process for implementing changes to prescribing policy was followed. This was the first time that a change of this nature

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Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

2017 2018

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has been made in Derbyshire. We will consider giving a notice period for changes in the future.

Recommendation

The policy has been successfully implemented across Derbyshire. The small amount of continued prescribing for individuals with clinical exceptionality has not identified any cohorts of patients who should be excepted from the policy. It is therefore recommended that the current Derbyshire wide Gluten free prescribing policy continues in its current form.

Ref - DHSC, p30, Report of Responses Following the Public Consultation on Gluten Free Prescribing Availability of Gluten Free Food on Prescription in Primary Care

- Consultation on the National Health Service (General Medical Services Contracts) (Prescription of Drugs etc.) (Amendment) Regulations 2018- Gluten Free Food on NHS Prescription in England https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/735410/consultation-on-gluten-free-foods-on-nhs-prescription.pdf

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https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/735410/consultation-on-gluten-free-foods-on-nhs-prescription.pdf

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/735410/consultation-on-gluten-free-foods-on-nhs-prescription.pdf

Date produced: December 2017 Review date: November 2019

Page 1 of 3 Adapted from Richmond CCG position statement on the prescribing of gluten free foods

Gluten free foods prescribing policy

This decision was taken by the four Derbyshire CCG Governing Bodies in November/December 2017 and follows a period of public engagement across Derbyshire.

The governing bodies further endorsed this position following the national consultation as CCG’s allowed under NHS constitution to make own decisions to best meet the needs of their

population.

Rationale

Historically, availability of gluten free foods was limited, therefore obtaining these products from community pharmacies via prescriptions improved access to them. With the increased awareness of coeliac disease and gluten sensitivity as well as a general trend towards eating less gluten, these products are now much more widely available. All major supermarkets and many other retailers now commonly stock gluten free foods as well as other special diet alternatives both online and in-store. Furthermore, improved food labelling now means people are able to see whether ordinary food products are free from gluten and can be safely eaten.

The price paid by the NHS for gluten free foods on prescription is much higher than the

supermarket prices available to the public.1,2 We acknowledge that gluten free food products are often more expensive than their gluten

containing equivalents but the price difference is not as wide as it once was. It is also possible to eat a gluten free diet that follows the Eatwell Guide model for balanced eating without the need for any specialist dietary foods, simply by choosing naturally gluten free carbohydrate containing foods (e.g. rice and potatoes) as part of a healthy balanced diet.3

Equality Statement Erewash, Hardwick, North Derbyshire and Southern Derbyshire CCGs aim is to design and implement policy documents that meet the diverse needs of the populations to be served and the NHS workforce has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved as enshrined in the Health and Social Care Act 2012.

The CCGs are committed to ensuring equality of access and non-discrimination, irrespective of age, disability (including learning disability), gender reassignment, and marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation. It takes into account current UK legislative requirements, including the Equality Act 2010 and the Human Rights Act 1998, and promotes equality of opportunity for all. This document has been designed to ensure that no-one receives less favourable treatment owing to their personal circumstances.

DERBYSHIRE JOINT AREA PRESCRIBING COMMITTEE

(JAPC)

The Derbyshire CCGs do not routinely commission the prescribing of gluten free foods

All gluten free foods have been classified as BLACK

North Derbyshire Clinical Commissioning Group Erewash Clinical Commissioning Group Hardwick Clinical Commissioning Group

Southern Derbyshire Clinical Commissioning Group

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Guidance for clinicians on prescribing of gluten free foods Subsequent to the CCGs’ Governing Bodies decisions, the following is recommended:

Newly diagnosed patients should not routinely be prescribed gluten free food products and existing patients receiving gluten free food products on prescription should be informed that prescribing of gluten free foods is no longer routinely available.

Patients newly diagnosed with coeliac disease should have the opportunity to discuss how to follow a gluten free diet with a healthcare professional with specialist knowledge of coeliac disease. Existing patients with on-going symptoms following a gluten free diet should also have access to additional specialist advice.4

In line with the NICE quality standards for coeliac disease5,6 patients should be informed about the

importance of a gluten free diet and given information and support to help them follow it, including:

Information on which types of food contain gluten and suitable alternatives, including gluten-free substitutes

Information on which types of food are naturally gluten-free Explanations of food labelling information Sources about gluten-free diets, recipe ideas and cookbooks How to manage social situations, eating out and travelling away from home, including travel

abroad Avoiding cross contamination in the home and minimising the risk of accidental gluten intake

when eating out The role of national and local coeliac support groups

People with coeliac disease should be offered an annual review which should include:

measuring weight and height review of symptoms considering the need for assessment of diet and adherence to the gluten-free diet considering the need for specialist dietetic and nutritional advice considering the need for referral to a GP or consultant to address any concerns about possible

complications or comorbidities.

In order to support clinicians with the above recommendations, the following supporting documents are available from the Coeliac UK website, www.coeliac.org.uk:

Gluten free checklist Gluten free diet on a budget

In addition signpost patients to the Coeliac UK website www.coeliac.org.uk:

www.coeliac.org.uk contains a wealth of useful information on how to follow a gluten free diet, including a Gluten Free Checklist, advice about shopping and reading food labels, cooking and baking, eating out, travelling and specific advice for children and for those eating on a budget. Their food and drink directory also gives details of where to purchase gluten free foods and gluten free checklist. Please note that access to some areas of the Coeliac UK website requires a subscription.7,8

Advise patients:

Gluten free food products can be purchased from the majority of large and medium sized supermarkets, some smaller local convenience stores and online or from their community pharmacist.

It is possible to eat a healthy balanced gluten free diet without the need for specialist dietary foods. Encourage patients to use as many naturally gluten free foods such as rice and potatoes as possible, rather than specialist products that have been manufactured to be gluten free.

It is important to maintain a healthy, balanced gluten free diet to ensure adequate intake of vitamins and minerals.

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Prescriber: professional and contractual context During discussion with the patient, when considering what treatment and ongoing monitoring is required, prescribers are asked to be mindful of the following:

That GPs have clinical freedom to act in an individual patient’s best interest where exceptional clinical circumstances exist that warrant deviation from this policy. Any such decisions should be recorded clearly in the patient’s clinical record.

That within their Primary Medical Services contract with NHSE, GPs have a contractual obligation relating to patients with chronic disease to make available such treatment (including any prescription deemed to be appropriate after discussion with the patient) as is necessary and appropriate, and to provide advice in connection with the patient’s health, including relevant health promotion advice.

That reference to local prescribing guidelines is good professional practice.

That consideration of GMC professional obligations to use NHS resources wisely is good professional practice.

Guidance for patients on prescribing of gluten free foods The four Derbyshire CCGs have made a decision that routine prescribing of gluten-free food products is not recommended.

Information to support a gluten free diet is available on the Coeliac UK website:

www.coeliac.org.uk/gluten-free-diet-and-lifestyle/food-and-drink-directory/

You will be able to access a comprehensive food and drink directory which gives details on where to purchase gluten free foods. The website also contains a wealth of useful information on how to follow a gluten free diet, including advice about shopping and reading food labels, cooking and baking, eating out, travelling and specific advice for children and for those eating on a budget.7,8 Please note that access to some areas of the Coeliac UK website requires a subscription.

Gluten free food products can be purchased from the majority of large and medium sized supermarkets, some smaller local convenience stores and online. You can also buy gluten free foods through your local community pharmacy.

It is possible to eat a healthy balanced gluten free diet without the need for specialist dietary foods. Use as many naturally gluten free foods such as rice and potatoes as possible, rather than specialist products that have been manufactured to be gluten free.

References 1. Burden et al. Cost and Availability of Gluten Free food in the UK. Postgrad Med J 2015;0:1-5 2. British National Formulary (BNF) [Online]. November 2017. https://bnf.nice.org.uk/ Accessed 08/12/17 3. Public Health England. Eatwell Guide https://www.gov.uk/government/publications/the-eatwell-guide Accessed 08/12/17 4. Diagnosis and management of adult coeliac disease: Guidelines from the British Society of Gastroenterology. June

2014. https://www.bsg.org.uk/resource/bsg-guidelines-on-the-diagnosis-and-management-of-adult-coeliac-disease.html Accessed 08/12/17

5. National Institute of Health and Care Excellence (NICE). NG20. Coeliac disease: recognition, assessment and management. September 2015. www.nice.org.uk Accessed 08/12/17

6. National Institute of Health and Care Excellence (NICE). Coeliac Disease. Quality standard. October 2016. www.nice.org.uk Accessed 08/12/17

7. Coeliac UK. Gluten free diet and lifestyle [Online]. www.coeliac.org.uk Accessed 08/12/17 8. Coeliac UK. Gluten free diet on a budget [Online]. www.coeliac.org.uk Accessed 08/12/17

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http://www.coeliac.org.uk/gluten-free-diet-and-lifestyle/food-and-drink-directory/

https://bnf.nice.org.uk/

https://www.gov.uk/government/publications/the-eatwell-guide

https://www.bsg.org.uk/resource/bsg-guidelines-on-the-diagnosis-and-management-of-adult-coeliac-disease.html

http://www.nice.org.uk/

http://www.nice.org.uk/



MEDIA RELEASE ISSUED: 11 JANUARY 2018

DERBYSHIRE CCGs APPROVE CHANGES TO GLUTEN-FREE PRESCRIBING AND THE INTRODUCTION OF A SELF-CARE POLICY FOR DERBYSHIRE

With an ever increasing demand on NHS services, the NHS at a national and local level is constantly

reviewing the products, services and treatments it provides to ensure that its resources are being

used efficiently to provide the best health outcomes for the population. This enables the NHS to

target its resources at frontline services and people with the most urgent clinical needs.

It is in this context that the four Derbyshire Clinical Commissioning Groups (CCGs) – the

organisations responsible for buying and organising the delivery of NHS services on behalf of the

Derbyshire population - began to review their policies on the provision of gluten-free products and

the provision of medicines and products that can be bought over the counter to treat short term,

self-limiting conditions such as a cough or a cold.

As part of this work, the views of Derbyshire residents and health and social care professionals were

sought and two public consultations were launched - the first was for gluten free food prescribing

which took place between February 2017 and August 2017, and the second was for prescribing

medicines and products to treat short term, self-limiting conditions which took place between June

2017 and September 2017.

Following the conclusion of the public consultations, detailed reports, options and recommendations

were submitted to the four Governing Bodies of the CCGs for discussion and decisions at their board

meetings. These took place in November and December 2017 and their individual decisions all

supported the option to no longer routinely commission the prescribing of gluten free foods and to

stop the prescribing of medicines and products that are available over-the-counter from pharmacies

and shops such as supermarkets to treat short term, minor self-limiting conditions. These policies

will apply to all Derbyshire NHS providers and contractors. The decisions taken by the Governing

Bodies are supported by the Joint Area Prescribing Committee (JAPC), the body responsible for

developing prescribing guidelines.

Dr Avi Bhatia, GP and Chair of Erewash Clinical Commissioning Group, speaking on behalf of the four

CCGs said:

“On behalf of the four Derbyshire Clinical Commissioning Groups (CCGs) and their Governing Bodies I

would like to thank everyone who took part in the two consultations. Listening to the views of our

patients as well as our colleagues across health and social care is vitally important as they really help

to inform our important commissioning decisions. We do not take these important decisions lightly

and we know that the decisions we have taken will involve change for people who are currently

receiving prescriptions for these products.”

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Dr Andrew Mott, Chair of the Derbyshire Joint Area Prescribing Committee (JAPC), the body

responsible for developing prescribing guidelines, said:

“It is essential that the views of our patients and public, and colleagues who prescribe are taken into

account. We have been closely involved with the discussions and the public consultations from the

beginning, and our views have been included throughout.”

Dr Avi Bhatia outlines the next steps for implementation:

“All patients who have received a prescription for a gluten free product in the previous six-months

will receive a letter from us in due course informing them of the change in policy and will advise

them of information, help and support they might find useful to help them manage a gluten-free

diet.

“The adoption of the self-care policy marks the beginning of what will be a sustained campaign

across Derbyshire to raise awareness of the importance of self-care. We will utilise patient notice

boards and information screens in GP practices and pharmacies as well as websites, social media and

other channels to share advice and support as part of our move towards helping people to self-care.

“Our commitment as clinicians is to only use the prescribing budget for medicines and products

which have a clear evidence base of working for most patients. We will support patients to improve

their understanding about medicines and how to look after themselves better and work with other

healthcare staff to help raise awareness of self-care.”

ENDS

Further information

Consultation feedback reports

The consultation feedback reports for gluten-free prescribing and Better Health Starts at Home are available to view at:

http://www.northderbyshireccg.nhs.uk/consultations

http://www.southernderbyshireccg.nhs.uk/have-your-say/consultations/

http://www.erewashccg.nhs.uk/getting-involved/

http://www.hardwickccg.nhs.uk/get-involved/

Better health starts at home – a self-care policy for Derbyshire

The new self-care policy for Derbyshire does not affect the prescribing of items for longer term or more complex conditions. Nor does it affect prescribing for minor illnesses which are a symptom or side effect of something more serious.

Patients who are concerned about a minor ailment will still be able to consult with a health care

professional under the NHS for advice.

The media release announcing the consultation and consultation document is available to view by

clicking here.

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http://www.northderbyshireccg.nhs.uk/consultations

http://www.southernderbyshireccg.nhs.uk/have-your-say/consultations/

http://www.erewashccg.nhs.uk/getting-involved/

http://www.hardwickccg.nhs.uk/get-involved/

http://www.northderbyshireccg.nhs.uk/press_releases/id/6342

Gluten-free foods

The media release announcing the consultation is available to view by clicking here and the

consultation document is available to view by clicking here.

Coeliac UK

www.coeliac.org.uk contains a wealth of useful information on how to follow a gluten free diet,

including a Gluten Free Checklist, advice about shopping and reading food labels, cooking and

baking, eating out, travelling and specific advice for children and for those eating on a budget. Their

food and drink directory also gives details of where to purchase gluten free foods

Eatwell Guide

It is possible to eat a gluten free diet that follows the Eatwell Guide model for balanced eating

without the need for any specialist dietary foods, simply by choosing naturally gluten free

carbohydrate containing foods (e.g. rice and potatoes) as part of a healthy balanced diet.

National policy

The decision to adopt a self-care policy for Derbyshire is in line with NHS England’s Five Year Forward

View and the ambition to support better health through increased prevention and supported self-

care. The Five Year Forward View is available online here.

Derbyshire Clinical Commissioning Groups

NHS North Derbyshire Clinical Commissioning Group

NHS North Derbyshire Clinical Commissioning Group represents 35 GP practices, acting on behalf of

over 290,000 patients covering North Derbyshire.

NHS Hardwick Clinical Commissioning Group

NHS Hardwick CCG represents 16 GP practices, acting on behalf of over 100,000 patients living in

North Eastern Derbyshire including South Normanton, Creswell, Langwith, Pinxton, Clay Cross,

Renishaw, Shirebrook, Tibshelf, Wingerworth, Alfreton, Bolsover, Grassmoor and North Wingfield.

NHS Erewash Clinical Commissioning Group

NHS Erewash Clinical Commissioning Group represents 12 GP practices, acting on behalf of over

97,000 patients covering Erewash.

NHS Southern Derbyshire Clinical Commissioning Group

NHS Southern Derbyshire CCG represents 55 local GP practices to commission health services on

behalf of over 548,000 people in Southern Derbyshire. It is one of four clinical commissioning

groups in Derbyshire.

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http://www.northderbyshireccg.nhs.uk/press_releases/id/5993

http://www.northderbyshireccg.nhs.uk/assets/Formal_Consultations/Gluten_Free_Consultation_Questionnaire.pdf


https://www.nhs.uk/livewell/goodfood/pages/the-eatwell-guide.aspx

https://www.england.nhs.uk/five-year-forward-view/

MEDIA ENQUIRIES

For more information contact:

T: 01926 353810

E: [email protected]

For out of hours enquiries, please call 01522 537887

Ref: DCCGS/DB/02

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[Practice letterhead]

[Patient address]

Dear [patient name]

IMPORTANT INFORMATION REGARDING YOUR GLUTEN-FREE FOOD PRESCRIPTIONS

As part of their routine work to review contracts and financial commitments to ensure NHS resources are being used fairly, last year the four Derbyshire Clinical Commissioning Groups (CCGs) began to review their policies on the provision of gluten-free products.

As part of this work, the views of Derbyshire residents and health and social care professionals were sought through public consultation last year.

Over the course of November 2017 and December 2017 each Governing Body considered the consultation feedback report, equality impact assessment and the views of the Joint Area Prescribing Committee (JAPC), the body responsible for developing prescribing guidelines. After careful deliberation, each Governing Body independently agreed to no longer routinely commission the provision of gluten-free food supplements on NHS prescription.

In making their decision, the four CCGs also considered evidence that gluten is not essential to a healthy diet and can be replaced by other foods. They also recognised that there are a number of widely available, naturally gluten-free carbohydrates that can be used instead of foods like bread and pasta. These include rice, potatoes and flour alternatives such as millet and corn flour.

GLUTEN-FREE FOODS NO LONGER AVAILABLE ON NHS PRESCRIPTION

As someone who has received a prescription for a gluten-free product we are writing to let you know that this change in prescribing policy means you will no longer be able to obtain gluten-free foods on NHS prescription.

This change comes at a time when gluten-free foods are now widely available in shops, supermarkets and online, manufacturers are changing recipes to include corn flour instead of wheat and food labelling has improved to make it easier to see whether ordinary food products are free from gluten and can be safely eaten.

SUPPORT

Coeliac UK, the national charity for people with coeliac disease, provides excellent support and advice on following a gluten-free diet. They offer a wide range of materials and support to help you effectively and affordably manage a gluten-free diet, including a Food and Drink Directory which lists thousands of gluten-free products available in shops. Coeliac UK can be contacted on 0333 332 2033 or via www.coeliac.org.uk.

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National Institute for Health and Care Excellence (NICE) guidelines recommend you have an annual review with your GP to discuss your diet and general health. If you are still under review by the dietitians and gastroenterologists at the hospital, you may also get support there.

PRE-PAYMENT CERTIFICATE

If you have bought a Pre-Payment Certificate to help with the costs of your gluten-free items, you can obtain a refund for any months remaining before it expires. You can do this by completing and returning the Prescription Pre-Payment Certificate Refund Application Form along with your card by 1 May 2018. The form can be found on the Derbyshire Medicines Management website at www.derbyshiremedicinesmanagement.nhs.uk/home. Alternatively you can call the Patient Advice and Liaison Service on the number below to request the form. Please note, if you also receive other prescriptions, you may wish to continue to use your Pre-Payment Certificate.

PATIENT ADVICE AND LIAISON SERVICE (PALS)

We understand that some people who have been managing their coeliac disease in a certain way for any period of time may be worried about how this change will affect them. If after reading this letter you feel you need more support or have any questions, please do not hesitate to contact the Derbyshire CCGs Patient Advice and Liaison Service (PALS) via any of the following channels:

T: 0800 032 32 35 Text mobile facility number: 07919 466 212

Email: [email protected]

More information about the changes to prescribing policy in Derbyshire outlined in this letter is available at any of the following Clinical Commissioning Group websites:

www.northderbyshireccg.nhs.uk www.southernderbyshireccg.nhs.uk

www.erewashccg.nhs.uk www.hardwickccg.nhs.uk

We hope this letter offers clarity and reassurance of the support available to you as these

changes to prescribing policy are implemented.

Yours sincerely

[Medicines Management team member working with the practice on behalf of the four Derbyshire Clinical Commissioning Groups]

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http://www.derbyshiremedicinesmanagement.nhs.uk/home


http://www.northderbyshireccg.nhs.uk/

http://www.southernderbyshireccg.nhs.uk/

http://www.erewashccg.nhs.uk/

http://www.hardwickccg.nhs.uk/

Gluten Free Prescribing in Erewash CCG, Hardwick CCG, North Derbyshire CCG and Southern Derbyshire CCG Summary The evidence on clinical effectiveness, cost effectiveness and safety alone does not support the routine prescribing of Gluten Free Supplements on the NHS provided that equality issues, including access can be mitigated. If equality issues cannot be mitigated then JAPC recommends a reduction in GF supplement units to 4 per month from a formulary of staple foods e.g. bread. 1. Clinical effectiveness Evidence is lacking or of general poor quality with confounders, it is therefore difficult to draw firm conclusions either way. It is accepted that patients with coeliac disease are required to follow a gluten-free diet, and that failure to do so can lead to conditions such as osteoporosis. Lymphoma and small bowel cancer are also rare, but serious, complications and children’s growth and development may be affected. However, there is little, low quality evidence to suggest that GF supplements on prescription enhance adherence to a GF diet. There is also limited evidence that suggests that patients who have access to, and are able to process, information regarding coeliac disease and gluten free foods are more likely to adhere to a gluten free diet. 2. Cost effectiveness Derbyshire NHS spends around £750,000 per year on GF supplements in primary care. GF supplements cost more per unit price to the NHS than if shop bought; indirect costs (NHSE cost not CCG) are GP time to prescribe and dispensing fees. There may be additional on costs (OOP expenses) to the NHS. In purchasing from supermarkets/ shops GF products are generally more expensive than gluten containing equivalents as food, and natural GF foods. Patient purchases may be likely to lead to less waste and stop over ordering. 3. Safety

GF foods are classed as food supplements. These are available from supermarkets and other retail outlets, and are of equal standards. There is a lack of evidence to suggest a gluten free diet without GF supplementation is more or less healthy than a gluten free diet with GF supplementation. 4. Patient factors

A range of equality factors and mitigations were considered and an equality impact assessment was discussed. Access to purchase of GF supplements and increased expense were among the concerns raised. The mitigations listed will help to avoid inequalities but there were some concerns raised that patients on low incomes and patients with low educational attainment may be less likely to be able to afford a naturally gluten free diet or understand the information received. This may mean that it is not possible to mitigate completely for all potential inequalities. This is opinion based considering

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the Derbyshire geography and demographics rather than based on factual evidence. JAPC is divided on the mitigation of equality factors.

JAPC is cognisant of the financial climate and the limited evidence on which a decision can be made. Where mitigations can be put in place to address such patient factors, it may be reasonable to stop gluten free prescribing for all patients. Introduction Coeliac disease is a lifelong autoimmune disease. It is caused by the immune system reacting to gluten - a protein found in wheat, barley and rye. Coeliac disease affects around 1% of the population although a significant proportion of patients are undiagnosed. Consultation figures from North Derbyshire CCG give a diagnosed prevalence of around 0.5% Symptoms range from mild to severe, and can include bloating, diarrhoea, nausea, wind, constipation, tiredness, mouth ulcers, sudden or unexpected weight loss, hair loss and anaemia. Coeliac disease can affect the absorption of vitamins, minerals and other nutrients from the gut and if undiagnosed or untreated may lead to developing osteoporosis. Lymphoma and small bowel cancer are rare but serious complications of coeliac disease. Once diagnosed, the only treatment for coeliac disease is a gluten free diet. Gluten is found in wheat, barley and rye. Some people are also sensitive to oats. Once gluten is removed from the diet, symptoms improve and the risk of developing some long-term complications is reduced. Dermatitis herpetiformis is the skin manifestation of coeliac disease which occurs as a rash that commonly occurs on the elbows, knees, shoulders, buttocks and face, with red, raised patches often with blisters. It affects around one in 3,300 people. For over 40 years the NHS has prescribed gluten-free foods, like bread, flour, cereal and pasta to patients who have been diagnosed with coeliac disease or dermatitis herpetiformis. Initially this was because gluten-free alternatives to common staple foods were expensive and extremely difficult to source. However, most gluten-free foods are now widely available in supermarkets and sold at prices much lower than those paid by the NHS, although there is still a significant cost difference between gluten-free and gluten containing foods.

Coeliac UK has produced prescribing guidelines based on a review of consumption data from the National Diet and Nutrition Survey, and with consideration of the Eatwell Guide for balanced eating. A review of the prescribing guidelines was also carried out following the publication of the Scientific Advisory Committee on Nutrition (SACN) report on Carbohydrates and Health (September 2015). These guidelines have been endorsed by The British Dietetic Association, The British Society of Paediatric Gastroenterology, Hepatology and Nutrition, and The Primary Care Society for Gastroenterology. They provide recommended monthly amounts of gluten free staple foods which will contribute only 15% of daily energy from carbohydrate; in order to reach the current recommendations from Public Health England, that carbohydrates should provide 50% of total calories, patients already need to obtain around two-thirds of their carbohydrates from sources other than prescription.

NHS spend on GF foods across Derbyshire, for the 12 month period from August 2016 to July 2017, was as follows:

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CCG Aug 16 - July 17 spend

Erewash £55,348.54

Hardwick £69,532.41

North Derbyshire £214,945.43

Southern Derbyshire (inc. Amber Valley Scheme)*

£417,570.81

Derbyshire total £757,397.19 * Amber Valley scheme involves community pharmacies supplying GF foods directly to patients without the need to obtain a prescription. Pharmacists are then reimbursed directly by the CCG. As part of the consultation process, patients in NDCCG diagnosed with coeliac disease or dermatitis herpetiformis were identified in order to send them a consultation. The number of patients registered with NDCCG practices was 1,631, meaning an annual spend of around £132 per patient. In light of the reduced costs and improved availability of GF foods in shops and supermarkets, it was agreed that prescribing should be reviewed to ensure that the CCGs’ budgets are spent for the benefit of the whole population as well as ensuring that services meet the needs of individuals. Evidence Summary There is no doubt that patients with coeliac disease need to follow a gluten free (GF) diet in order to relieve symptoms and reduce the risk of long-term complications. However, depending on the setting, methods of collecting data, and the definition of ‘adherence’, various studies have reported adherence to a GF diet to be between 45 and 80%. As this is the only treatment for coeliac disease, efforts have been made to elicit the reasons for non-adherence. A systematic review of adherence to a GF diet from 2009 (N. J . Hall, G. Rubin & A. Charnock. Aliment Pharmacol Ther 30, 315–330) commented that ‘the GF diet is widely reported to be restrictive, complex, costly and difficult to follow. However, there is little evidence that these factors are consistently significantly associated with adherence.’ It found one published clinical audit that concluded that annual review within the context of a dietician–led coeliac clinic can significantly improve adherence and also that membership of a patient support group appears to be associated with adherence. More recently, a 2012 study (N. J . Hall, G. Rubin & A. Charnock. Appetite. 2013 Sep;68:56-62) found that intentional gluten consumption was significantly lower in those who were members of Coeliac UK (n=240 vs n=47, p<0.001), those under regular follow-up (n=185 vs n=97, p<0.01), those receiving GF foods on prescription (n=247 vs n=40, p<0.01) and those diagnosed as adults (n=247 vs n=40, p=<0.05). The study also found that lower scores in intention and self-efficacy and high perceived tolerance to gluten were significant independent predictors of intentional gluten

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consumption. Interestingly, unintentional consumption of gluten was high with 54% of those questioned saying that they had inadvertently consumed gluten over a 6 month period; for these patients there was no significant difference between those who received GF foods on prescription and those who did not.

The authors state that there are limitations to the survey in that they used self-reported measures which may not be reliable and used a previously unvalidated questionnaire to collect the data. They also comment that they can only draw associations from the study, not cause and effect. For example, intentional gluten consumption was lower in patients receiving prescriptions, but that could be because more motivated patients may be more likely to ask for prescriptions than less motivated patients, and more motivated patients may also be less likely to consume gluten – it is impossible to say that receiving GF food on prescription directly leads to less intentional gluten consumption.

A 2017 study (Muhammad H. et al. Nutrients. 2017 Jul; 9(7): 705) also gives some evidence that availability of GF food on prescription is independently associated with adherence to diet. The study used the validated Coeliac Dietary Adherence Test (CDAT) questionnaire to assess patients’ adherence to a GF diet and found that 62% of patients not receiving prescriptions didn’t adhere to a GF diet whereas only 42% of patients receiving GF food didn’t adhere. However, this shows that only 58% of patients were deemed to be adhering to a GF diet even when receiving prescriptions.

There were also a number of other factors found to affect adherence including membership of Coeliac UK and patients’ understanding of food labels.

Interestingly, one of the questions asked in the study was ‘What difficulties do you have in following the GF diet?’ There was no significant difference in CDAT scores between patients who answered ‘My GP does not prescribe sufficient amounts of GF products’ and those who didn’t. The researchers state that there needs to be more research into the effect of reducing quantities on prescription as studies so far haven’t looked at the amount of food received on prescription or the reasons for not getting prescriptions.

Also, the study did not find a significant difference in GF dietary adherence scores between those who considered GF foods expensive and those who did not.

There were some limitations to the study – response rate was only 39% so it is quite possible that this led to some bias. A logistic regression model showed that the factors assessed in the study accounted for only 7-10% of the variance seen in GF dietary adherence. Other factors must be involved and may include psychological traits such as conscientiousness, values, self-efficacy, perceived tolerance to gluten and intention to adhere which weren’t assessed in the study.

An American study from 2015 (Villafuerte-Galvez et al. Aliment Pharmacol Ther, 42: 753–760.) considered;

(i) the cost of a GF diet, (ii) the perceived effectiveness of a GF diet, (iii) the perceived knowledge of the GF diet and (iv) the perceived self-effectiveness at following a GF diet;

as four factors that may affect adherence to a GF diet. All four were found to be statistically significant in their effect on adherence, the two with the strongest correlation being self-effectiveness at following a GF diet and knowledge of the GF diet.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537820/

Interestingly, although the cost of a GF diet was associated with adherence, respondents with an adequate adherence did not have significantly different median annual household income as compared to respondents with inadequate adherence. This finding raises the question of whether perception of cost vs. actual economic limitation is an obstacle to GF dietary adherence.

There are limitations to the applicability of the study to an English population, as availability and cost of GF products may be different in the USA, as may the diagnosis and management of coeliac disease.

Finally, a survey from 2015 (Postgrad Med J. 2015 Nov; 91(1081):622-6) focussed on availability and affordability of GF foods in Sheffield. The study concluded that ‘there is good availability of GF food in regular and quality supermarkets as well as online, but it remains significantly more expensive. Budget supermarkets which tend to be frequented by patients from lower socioeconomic classes stocked no GF foods’.

The study didn’t address the issue of whether these factors affected adherence to a GF diet. It is also true that the study is now two years old and the cost and availability of GF foods is continually improving.

The current NICE guideline (NG20), Coeliac disease: recognition, assessment and management has the following: Moderate quality evidence from 5 studies (Rashid et al., 2005; Olsson et al., 2008; Leffler et al., 2008; Erichiello et al., 2010: Zarkadas et al., 2012) with a total of 6281 participants with CD examined the participant perspective of adhering to a GFD and reported a number of social and emotional factors that influenced adherence, including: embarrassment of eating GF foods in a social environment, feeling a burden to friends and family; the limited availability and palatability of GF foods, difficulty finding appropriate food options at restaurants; and feeling left out of social activities.

It goes on to say that, ‘Making sure that people with coeliac disease and their family and carers were aware of gluten free food prescriptions was also raised by the [guideline development] group as an important consideration,’ although it doesn’t specifically recommend provision of GF food on prescription.

Most clinical guidelines (including NICE) now use GRADE as a way of assessing the quality of evidence. The definitions are as follows:

It seems likely that the quality of most of the evidence would be classified as ‘low quality’.

In summary, there appear to be a number of factors that may affect adherence to a GF diet. The most frequently reported are membership of an organisation such as Coeliac UK, and regular

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https://www.ncbi.nlm.nih.gov/pubmed/26310267

dietician follow-up. Better education about Coeliac disease and diet appears to be important, as does the ability to understand food labelling. There is limited data regarding the importance of providing GF foods on prescription and much of it is conflicting, but it cannot be ruled out as one of the factors affecting adherence. There appears to be little or no evidence regarding the effect of reducing the number of units available. Most of the evidence would appear to be of low quality.

The Derbyshire Consultation

The report for our local consultation is included as appendix 1. Key points include:

1. 70% of respondents were diagnosed with either coeliac disease or dermatitis herpetiformis. 2. 60% of respondents with a diagnosis for either coeliac disease or dermatitis herpetiformis

received GF food on prescription. 3. Of these patients receiving GF food on prescription:

• 59% felt that the NHS should provide foods for their condition • 37% felt that GF foods are too expensive to buy • 11% felt that the choice of GF foods is limited where they live

4. The most commonly prescribed items were bread (57% of patients receive), flour (40%) and pasta (36%)

5. Of the patients receiving prescriptions, 48% received between 0 and 8 units each month; 50% received between 9 and 18 units each month

6. Responses to the three suggested options were as follows:

Options % response (all respondents)

% response (diagnosed patients only)

% response (patients not diagnosed with coeliac disease or dermatitis herpetiformis only)*

Option 1 Stop providing gluten-free foods on prescription altogether

23.82% 10.3% 55.9%

Option 2 Change the gluten-free allowance to eight units per month for everyone eligible for gluten-free food on prescription and have much more limited products available on prescription (e.g. only loaves of bread, pasta and flour allowed on NHS Prescriptions) other products (e.g. breakfast cereals, pizza bases, bread rolls, crackers) would no longer be allowed.

26.50% 29.7% 14.62%

Option 3 Continue to follow the Coeliac Society’s recommendations for number of units (10 to 18 units depending on the age and sex of the patients) but have much more

49.68% 60% 18.27%

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limited products available (e.g. only loaves of bread, pasta and flour allowed on NHS prescriptions) other products (e.g. breakfast cereals, pizza bases, bread rolls, crackers) would no longer be allowed. However, the total gluten-free allowance would remain the same as it is currently.

* 11.18% did not answer the question

Other CCG policies

Data from the Coeliac UK website (https://www.coeliac.org.uk - accessed 24/10/17) shows that out of the 207 CCGs in England: Around 64 CCGs have either completely withdrawn prescriptions or have withdrawn them with some exceptions (e.g. under 18s); around 73 CCGs have restricted products and/or units; 17 CCGs (including Derbyshire CCGs) are currently reviewing their prescribing; and the rest are following the Coeliac UK guidelines. So, approximately one-third of CCGs have withdrawn products and another third have limited prescribing.

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CCGs surrounding Derbyshire have taken different policy decisions regarding GF prescribing. Some of the decisions are listed below along with the effect on GF prescribing rates and costs:

North Staffordshire CCG – In December 2016, North Staffordshire CCG stopped prescribing for adult patients but maintained prescribing of bread, pasta and flour for children and adolescents:

Prescribing costs have fallen from around £12,000 per month to around £2,000 per month

Mansfield and Ashfield CCG – stopped prescribing altogether in March 2017:

West Leicestershire CCG - reduced prescribing to 8 units per month of bread and flour only in December 2016:

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Cost of GF prescribing reduced from around £20,000 per month to around £10,000 per month.

Nottingham West CCG - reduced prescribing to 4 units per month of bread and flour only in April 2016:

Month Items

Net ingredient

cost (£) Actual

Cost (£) 201601 322 5,943.06 5,512.78 201602 351 5,925.88 5,488.19 201603 335 5,610.01 5,199.43 201604 412 7,570.35 7,010.44 201605 192 2,758.91 2,632.20 201606 134 1,632.89 1,606.23 201607 143 1,606.33 1,581.12 201608 124 1,404.22 1,322.59 201609 129 1,485.17 1,459.47 201610 116 1,396.86 1,326.03 201611 106 1,237.92 1,147.13 201612 90 1,116.53 1,035.33

Prescribing costs dropped from around £5,500 per month to around £1,000 per month.

0.00

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For comparison, prescribing across Derbyshire has remained fairly constant:

Prescribing for August 2016 to July 2017 cost £676,871 for Derbyshire County and an estimated cost of £80,000 for the Amber Valley scheme – total cost around £750,000. Information from Open Prescribing (https://openprescribing.net/measure/lpglutenfree/ - accessed 03/10/17) shows that Derbyshire CCGs prescribing of GF foods is among the highest in England:

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https://openprescribing.net/measure/lpglutenfree/

In the graphs above, the red line shows prescribing for the individual CCG and the blue lines show centiles for CCGs across England. The dark blue line shows the 50th percentile nationally. All four Derbyshire CCGs are above the 90th percentile.

Derbyshire prescribing has recently been highlighted in an online article in The Times (https://www.thetimes.co.uk/edition/news/gps-spend-millions-on-treatments-identified-as-a-waste-of-public-cash-m7j0qfl38 - accessed 03/10/17) which stated,

‘Gluten-free foods cost the NHS £19 million, with Derbyshire GPs the heaviest prescribers. People with coeliac disease cannot eat gluten, but Mr Stevens [Simon Stevens] argues that alternatives are widely available in supermarkets.’

Options

1. Stop Prescribing altogether – Potential annual saving £750,000

This would be a simple option to undertake and monitor and would maximise prescribing savings. However, only 24% of consultation respondents favoured this option (only 10% of diagnosed patients) and there is some limited evidence that stopping prescriptions altogether may reduce adherence to a GF diet. A common theme from the consultation was that GF foods are expensive, especially for some elderly patients and families on low incomes and a blanket ban on prescribing may be seen to discriminate against these patients. Harrogate and Rural District CCG stopped prescribing altogether but patient leaflets were sent out advising that patients on benefits for low income could ask their GP to add items back on to their prescription – these would be limited to bread and flour only. Prescribing spend seems to have remained low so this could be an option if the decision was taken to stop prescribing altogether. However, it should be noted that Harrogate is an affluent area and their experience may not be replicated across Derbyshire:

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https://www.thetimes.co.uk/edition/news/gps-spend-millions-on-treatments-identified-as-a-waste-of-public-cash-m7j0qfl38

https://www.thetimes.co.uk/edition/news/gps-spend-millions-on-treatments-identified-as-a-waste-of-public-cash-m7j0qfl38

North Staffordshire CCG stopped prescribing for all adult patients but made no change to prescribing for children and adolescents and this could be another option. Their prescribing costs have fallen to around 1/6th of their previous spend which would mean potential savings of around £600,000 per annum for Derbyshire County.

2. Limit units

Option two on the consultation was to limit the number of units to 8 per month and have a reduced formulary. Considering other local CCGs (e.g. West Leicestershire) prescribing costs would be expected to halve (saving around £375,000 per annum). 27% of consultees favoured this option (30% of diagnosed patients) and there is little evidence to suggest that this will affect adherence to a GF diet. All patients would retain some access to GF foods on prescription and the consultation suggests that 48% of patients receiving a prescription have 8 or fewer units per month already. Again, this option could be restricted to adults only, which would slightly reduce savings. A potential problem with this option is that it is more difficult to monitor and practices would need to check that patients weren’t exceeding the number of units; however West Leicestershire has seen its spend consistently reduced.

An option not on the consultation would be to take the approach of Nottingham West CCG and reduce the number of units to 4 per month, again with a limited formulary. This would have the potential to reduce spend by £560,000 per annum across Derbyshire. This would reduce an individual patient’s prescription to two loaves of bread and 500g of pasta (or equivalent) each month and may be seen as tokenism, although 19% of patients already receive 4 or fewer units each month. Again, there may be difficulty monitoring the policy.

3. Restricted formulary with no change to units

Option 3 on the consultation was most popular with 50% of respondents choosing it as their preferred option (60% of diagnosed patients). No other CCGs seem to have adopted this approach and it is difficult to say whether it would save money or not. Patients would be restricted to bread and flour, or bread, flour and pasta and prescribing of crackers, pizza bases, cereals, etc. would stop. This may lead

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090401 - Gluten Free Foods [Total Actual Cost/Total Cost based Astro PUs]

03E: NHS HARROGATE AND RURAL DISTRICT CCG 000: England

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to many patients reducing the number of units they order, but some patients may substitute ‘banned’ foods with other products (e.g. a box of cereal may be replaced by a loaf of bread) so estimating savings is difficult. For the 12 month period from August 2016 to July 2017, spend on GF products other than bread, flour and pasta was £188,000 so this is the potential annual saving. The most requested items are bread, flour and pasta anyway so savings are limited.

4. Do nothing

The current guidelines could remain in place which would be popular with a lot of coeliac patients but would achieve no savings. A pharmacy supply scheme could be put in place which already exists in Amber Valley; this would remove GF products from prescriptions, saving some GP time, but has not been shown to produce savings. If one of the other options is chosen (e.g. reduced units) a pharmacy supply route could still be considered later.

Analysis of Risks

• In the long-term there is a risk that if patients’ adherence to a GF diet is reduced by Derbyshire CCGs altering their prescribing policy, this could lead to increased risk of dietary-related conditions such as osteoporosis, anaemia, etc. Lymphoma and small bowel cancer are also rare but serious possible complications. However, there is little good evidence to show that reducing prescribing of gluten-free products affects adherence rates. Regular reviews (especially with a dietician) and education have been linked to improved adherence – if GF foods are removed from prescription there is a risk that patients will not receive regular reviews. 12% of patients who responded to the Derbyshire consultation felt that ‘ensuring regular GP check-ups’ was a reason for receiving gluten-free foods on prescription. There is very little evidence from other CCGs as to whether removing GF foods from prescription has had any adverse effect on patients. However, Oxfordshire CCG, which restricted prescribing to bread and flour only in October 2012, ran patient and GP practice surveys over the following year to review the change. It found that 47% of patients reported no change to their diet, 38% reported their diet becoming unhealthier, and 7% reported their diet becoming healthier. In answer to the question, ‘Has your health suffered as a result of the change in policy?’ 59% of patients answered ‘no’ and 25% answered ‘yes’ (the remainder answered ‘don’t know’ or gave no response). In answer to the question ‘Since the more restrictive policy was introduced in October 2012, is your perception that you’ve seen your patients with coeliac disease more frequently?’ 75.6% of GPs answered ‘no change’ and the rest answered ‘don’t know’. In answer to the question, ‘Have you referred more patients with coeliac disease to the dietetics service for advice and support?’ 85% of GPs answered ‘no change’ and the rest answered ‘don’t know’. It should be noted that these responses were after a decision to limit the GF formulary, not reduce units or stop prescribing altogether.

• A national consultation regarding the availability of GF foods on prescription concluded on

22nd June 2017. The feedback is currently being analysed and it is expected that national guidance will be issued towards the end of 2017. It is unclear exactly what form this guidance will take (e.g. Prescriptive or a framework to work within) but there is a risk that Derbyshire CCGs will need to reconsider its policy once the national guidance is published.

• A Quality Impact Assessment (QIA) and an Equality Assessment (EA) have been conducted as

part of the consultation process. The following risks have been identified:

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Elderly patients may rely on more local shops which will tend to stock fewer gluten-free choices and they will tend to cost more. They may also be less likely to utilise internet shopping, reducing their choice of outlets. Also, elderly people may have lower income which may make GF products less affordable. They will also qualify for free prescriptions which will make the cost differential greater. It may also be possible that older people are not as keen to make meals from scratch and rely on more pre-packed and processed foods – again, any policy that reduces the availability of GF alternatives may affect older people disproportionately. The Derbyshire consultation found that 11% of responders think that the choice of GF foods is limited where they live, and 37% feel that the food available to buy is too expensive.

Children rely on parents/carers to make nutrition decisions on their behalf and many

will have little control over their diet. They may also be at greater risk of nutritional deficiencies as they are still developing (e.g. Calcium and vitamin D).

Patients with disabilities may find it more difficult to shop in supermarkets and may rely

on services offered by community pharmacists such as delivery services. They may be more likely to be living on benefits and have a lower income than others. Many may qualify for free prescriptions making the cost differential greater. Patients with learning difficulties may find it harder to follow a GF diet than other patients and could be disproportionately affected.

Pregnant and breast-feeding women are recommended to have a greater allocation of

GF products under the current local guidelines. Any reduction in prescribing may disproportionately affect them.

Socio-economic disadvantage: Some people may not be able to easily afford GF food

substitutes, which are more expensive than gluten containing equivalent products. The cost of GF products was one of the main themes that came out of the Derbyshire consultation (page 18 of the feedback report). Some of the comments received were:

• Maybe over 65 free prescriptions and low income families should be able to get prescriptions as these foods are expensive and people really do need these items as without these items they suffer

• Maybe some kind of means testing e.g. all people on benefits receiving a bigger allowance of gluten-free foods

Rurality: Some people may not have immediate access to GF food substitutes from

smaller shops in rural areas. Internet access may also be poorer in rural areas. The Derbyshire consultation found that 11% of responders think that the choice of GF foods is limited where they live.

The NICE Quality Statement (QS134) on Coeliac Disease suggests the following equality and diversity considerations:

Gluten-free products are more expensive and are usually only available from larger retailers, making access more difficult for people on low incomes or with limited mobility. As coeliac disease can affect more than one member of a family it can also be an additional burden on the family budget. To address this, healthcare professionals

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should highlight if gluten-free food products are available on prescription to help people to maintain a gluten-free diet.

People living in socioeconomically deprived areas are less likely to attend an annual review. Healthcare professionals in these areas should therefore agree a local approach to encourage as many people as possible to attend.

Mitigation: The following factors and actions will mitigate against many of these concerns: GPs will be encouraged to add recalls to patient notes to ensure regular reviews.

Recalls can be added as part of the implementation process. Patients will be sent information including:

About Coeliac UK GF foods checklist GF diet on a budget

to help them adhere to a GF diet without the need for prescriptions. See appendix 2 for examples

Many foods are naturally GF, including fruit, vegetables, potatoes, rice, fresh meat and fish. Coeliac patients have the same access to these foods as other people.

Patients can obtain formulated GF foods at a range of food retail outlets, including supermarkets and online outlets. Patients will be sent information about where and how to source GF foods (appendix 2).

Implementation

Implementation will vary depending on the final decision, but many aspects will be the same. If any change is made to units or formulary individual patients will be sent letters detailing the change and will also be sent the patient information detailed above. Recalls can be added to patient records to make sure they are invited for annual review, whether or not they are receiving GF foods on prescription. Communications officers from each CCG are aware of the consultation and chairs from the CCGs have been briefed to be able to respond to media queries.

If prescribing is stopped altogether any GF items will be removed from the patients repeat prescription list at the same time they are sent the information and the letter will explain this to them.

If prescribing continues but units or formulary are limited, GF items will be removed from repeat and the patient will be issued with a list of formulary products and the number of units each item is worth. Patients will be provided with an order list and can then contact their practice in the usual way to order their monthly supply under the new policy. A draft order form/formulary is included in appendix 3 – the selected products are based on the most commonly prescribed products across Derbyshire (ePACT2 June – August 2017), and excluding products that have attracted ‘out of pocket’ expenses.

Some patients receive products that are either low-protein and/or wheat-free as well as being GF. In many cases this is simply because the selected products are only available as free from both. However, these patients will be reviewed to consider whether or not it is appropriate to remove their foods from prescription.

Any information for patients can be added to the medicines management website so that it is readily available for GPs and practice nurses to share with patients.

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Patient letters will provide contact details in case the patient needs help understanding or ordering products under the new system.

The new policy will be disseminated widely to GPs, specialists and dieticians, and GPs will be given information about NICE guidelines, particularly about the need for annual reviews and what should be considered at those reviews (measure weight and height, review symptoms, consider the need for assessment of diet and adherence to the gluten-free diet, and consider the need for specialist dietetic and nutritional advice). Appropriate messages will be added to OptimiseRx to encourage adherence to the policy.

Summary

There are several options available, none of which would be expected to be popular with the majority of coeliac patients apart from option 4 or, to a lesser extent, option 3. However, with the exception of stopping prescribing completely there is a lack of evidence to suggest that reducing units will decrease patients’ adherence to a GF diet, and most of the available evidence appears to be of low quality. There are several other factors which would appear to be more important than prescribing GF foods: Membership of Coeliac UK; regular reviews and access to dietician advice; and improved knowledge of coeliac disease and the GF diet are all likely to be important. Whatever option is taken with regard to prescribing, improving patients’ knowledge and ensuring annual reviews should be a priority.

It should also be borne in mind that a national consultation has just finished and a recommendation is expected towards the end of 2017. It is not clear what form this will take but it may be difficult for individual CCGs to take actions that are not in line with national guidance.

JAPC are asked to consider the options available and to agree one recommendation for Derbyshire, which will then be considered by each CCG governing body.

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NHS Derbyshire CCGs Public Governing Body Meetings in Common

13th December 2018

Report Title Creating the new CCG – merger update and consultation plan for new constitution

Author(s) Chrissy Tucker - Assistant Director, Corporate Strategy Sponsor (Director) Helen Dillistone, Executive Director, Corporate Strategy and

Delivery

Paper for: Decision x Corporate Assurance

Discussion Information

Recommendations The Governing Body is asked to note the contents of this report and in particular to GIVE APPROVAL to commence consultation with the membership on the new constitution. Report Summary

The Governing Body meeting in common on 01/11/18 received an overview of the organisational developments required to create a single CCG for Derbyshire:

• Naming of the new CCG• Appointment of the CCG Chair; role and process• Options for the composition of the new Governing Body• Appointments process for Governing Body membership• Development of the new CCG Constitution

The Transition Working Group (TWG), met on 23rd November to consider these matters and provide recommendations to the Governing Body.

Naming The views of the membership were sought with regard to the proposed name of the new CCG. No particular views were expressed. NHS England have advised that any change in name to that registered early in the merger process should take place after the formal merger rather than during it, due to technical reasons.

Appointment of the CCG Chair The Governing Bodies approved the proposal to seek a Chair from within the membership. Advertisements have been placed seeking Expressions of Interest for the role, with interviews to be held at the Derbyshire Hotel on the 19th December. The process will be managed by the in house HR team and avoid unnecessary out-sourced HR costs. The applicants’ experience, skillset and competencies will be assessed during the day by panels consisting of current governing body members,

Item No: 57

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stakeholders, senior NHSE representatives and must include clinical representatives from the four memberships. It is anticipated that the post would be appointed to by the end of December. Composition of new Governing Body The Transition Working Group at their meeting on 7th December reviewed options for the composition and membership of the Governing Body. The following membership is proposed:

• Chair, who will be a GP from the membership of the CCG • Vice Chair, who will be a lay representative • Lay Members x 6 (Audit, Governance, Finance, Primary Care Commissioning

and 2 for Patient and Public Involvement). • GPs x 6 (representing North, South, City, Place, General Practice and Quality

and Performance) • Secondary Care Clinician • Public Health Consultants City and County • CCG Officers (Chief Executive Officer, Chief Nursing Officer, Chief Finance

Officer, Medical Director, Turnaround Director, Executive Director of Commissioning and Executive Director of Corporate Strategy & Delivery

Development of the new CCG Constitution Approach to the NHS Derby and Derbyshire CCG Constitution The new constitution for the Derby and Derbyshire CCG has been developed adopting the new NHSE model template. The draft new constitution has been developed over the past few months, with advice and recommendations being provided by the Transitional Working Group on particular areas relating to the membership and composition of the Governing Body. Two drafts have been submitted informally to NHS England for review and feedback. This feedback from NHSE has been reflected in the constitution and appendices. Engagement and Consultation with the CCG Membership As with all previous constitutions, we will consult and engage with our membership and Governing Bodies in the development and approval of the document ahead of it being approved by NHS England for the 1st April 2019. The Governing Bodies meeting in Common are asked to approve the commencement of the engagement with the CCG membership on the new draft NHS Derby and Derbyshire CCG Constitution. The engagement with the CCG membership will take place over a three week period between the 16th December 2018 and the 6th January 2019. Feedback and comments from the membership will be considered and reflected in the final draft constitution, which will then be approved at the Governing Bodies meeting in Common on the 24th January 2019. The Executive Director of Corporate Strategy and Delivery will seek delegated authority from the Governing Bodies to make any further minor amendments to the final draft constitution prior to submitting to NHS England on the 28th January 2019 for approval.

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Approval of the NHS Derbyshire CCG Constitution will be required prior to the 1st April 2019. Are there any Resource Implications (including Financial, Staffing etc)? Due to the reduction from four Governing Bodies to one for the new CCG, some resources will be released and savings made from overall running costs.

Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? Not required for this paper; however, an Equality Impact Assessment has been undertaken as part of the steps to create a single CCG for Derbyshire. The Equality Act 2010 is a statutory responsibility of the CCG and will continue to be an integral statutory duty of the single CCG for Derbyshire. Have you involved patients, carers and the public in the preparation of the report? The public will be involved in any service changes or developments proposed through the delivery of the Commissioning Strategy. Have any Quality and Compliance issues been identified/ actions taken Not required for this paper. Notwithstanding this, where any issues/risks that have been identified from a Quality Impact Assessment and Data Protection Impact Assessment (DPIA) appropriate actions will be taken to managed the associated risks. Have any Conflicts of Interest been identified/ actions taken? The subject matter of this paper represents a conflict of interest for Governing Body members and the Transition Working Group. Conflicts of interest will be managed in a transparent and open way. Governing Body Assurance Framework Any corporate risks relating to this agenda and recorded in the Risk Register are aligned to the Governing Body Assurance Framework. Identification of Key Risks As part of the steps to create a single CCG for Derbyshire, a project risk register is in place to record risks that may impact on the progress of the application. Risks that need to be escalated will inform the corporate risks register.

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NHS Derbyshire CCGs Governing Body Meetings in Common 13th December 2018

Report Title Deprivation of Liberty and Court of Protection position across the Derbyshire CCGs

Author(s) Michelle Grant, Adult Safeguarding Manager Sponsor (Director) Brigid Stacey, Chief Nurse

Paper for: Decision x Assurance Discussion Information Recommendations The Governing Body is asked to:

• ACCEPT the 4 recommendations of the Adult Safeguarding Team in managing thedeprivation of liberty (DoL) authorisation processes within the current legislativeframework.

The recommendations if accepted will as far as is possible minimise the financialcosts of the CCGs legal representation in the Court of Protection.

Report Summary The paper outlines the background to the current deprivation of liberty legislation and the different safeguarding processes for those living in a care home, or those in supported living placements/their own homes.

In summary:

• Where the CCG funds CHC care packages for people in care homes theauthorisation is requested by the care home manager to the local authority.

• Where the CCG funds CHC care packages for people in supported living/own homewe have a legal duty to obtain the authorisation of these care packages via the Courtof Protection.

There are opportunities for the CCG to mitigate the legal costs of obtaining deprivation of liberty safeguard authorisations via the Court of Protection (CoP) whilst the government proposals to the changes to the legislation are being considered.

The Mental Capacity Act (MCA)/ DoL Lead within the Adult Safeguarding Team and the previous Chief Nurse met with two legal representatives from Derbyshire County Council over the summer to work on a proposal where there is no conflict of interest between our two

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positions in supporting the care placement for joint funded cases the legal representation in the court will be the responsibility of the LA solicitor acting for both public bodies. The recommendation to Governing Body is that this 6 month trial is supported for our joint funded cases. Are there any Resource Implications (including Financial, Staffing etc)? Yes, if the Governing Body agree with the Adult Safeguarding Team recommendations and subject to the initial 6 month trial period, then our legal costs will be minimised with further potential opportunities for savings if we were to work with Derby City Council in a similar way assuming they have capacity to assist us in the same way as Derbyshire County Council’s legal team have agreed to. For our CHC packages in supported living/own home which are fully funded by the CCG the legal team at Derbyshire County Council have proposed that they could if the CCG felt the trial on the joint funded cases worked well, extend their legal representation on our behave for the uncomplicated cases suitable for the current Re X process. Our fully funded cases are currently presented to the Court of Protection by Browne Jacobson LLP.

Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? The proposal currently only effects the planned process for Derbyshire residents subject to a deprivation of liberty. We will endeavour to work with the City Council to adopt the same processes. However city residents will still have their deprivation of liberty case heard in court, it will cost the CCG more to do this for these residents if we do not manage to come to the same agreement with the City Council. Have you involved patients, carers and the public in the preparation of the report? Not applicable to this report.

Have any Quality and Compliance issues been identified/ actions taken The quality of the legal service provided to the CCG will be monitored during the six month trial period to identify any quality or compliance issues before any decision to extend the agreement is made. Have any Conflicts of Interest been identified/ actions taken? Conflicts of interest between the LA and the CCG in relation to the care placements has been considered, only those cases where there are no conflicts of interest and those that are straight forward and suitable for the Re X process will be included in the trail period.

Governing Body Assurance Framework The identified corporate risk 005 relating to MCA and DoLs, is aligned to Strategic Objective 1 ‘to reduce health inequalities by improving the physical and mental health for the people of Derbyshire’ and links to strategic risk GBAF 1: The CCG resource allocation impacts on

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effective commissioning decisions which prevents the Derbyshire CCG improving health and reducing health inequalities. Identification of Key Risks This paper links to corporate Risk 005 on the risk register, which describes: ‘Changes to the interpretation of the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLs) safeguards, results in greater likelihood of challenge from third parties, which will have an effect on clinical, financial and reputational risks of the CCGs.’ Not presenting these cases to the Court of Protection poses a risk to the CCG of third party challenge with subsequent reputational damage. The legal costs of this process are under review and the paper outlines the proposals for minimising the financial costs. This risk is assigned to the Quality & Performance Committees in Common.

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Position statement across the Derbyshire CCGs in relation to the current Deprivation of Liberty legislation

There are 3 challenges for Governing Body to be aware of in relation to the deprivation of liberty risk identified on the CCGs risk register; reputational damage and financial risk implications. Background

In 2004 the European Court of Human Rights announced a legal ruling commonly known as ‘the Bournewood Judgement’. The case related to a profoundly autistic man who had a severe learning disability and who lacked the mental capacity to consent to or refuse admission to hospital for treatment. The Court ruled that the man had been ‘deprived of his liberty’ when he was admitted to Bournewood Hospital. To prevent this from happening again the Mental Capacity Act (2005) was amended to include the Deprivation of Liberty Safeguards (DoLS). The Mental Capacity Act (2005) provides a statutory framework for those people who lack the mental capacity to make decisions, or take actions, for themselves. It clearly states that when others have to make decisions on their behalf they should always act in the persons best interests. They should not act in a way that deprives a person of their liberty unless it is in accordance with the law. Deprivation of Liberty Safeguards

For someone to meet the threshold for an adult DoLS to apply they must meet the following criteria:

a) Be over the age of 18 b) To have been assessed as lacking mental capacity c) The person is assessed as not meeting the threshold for care or treatment

under the Mental Health Act. d) Where they are under constant supervision and control and would be

stopped from leaving the care setting (even if they were physically unable to) if they or a carer attempted to remove them. This is known as the ‘Acid Test’.

N.B. Point d) of the criteria is an important point because:- In March 2014 the Supreme Court ruled in another legal case known as ‘Cheshire West’ which stated that a person doesn’t have to physically try to leave the care setting for a DoL to exist.

The legislation permits a deprivation of liberty providing that it is done in accordance with a procedure which is set out in law. The use of DoLS recognises the fact that some people require care that involves a level of control and/or restriction that

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results in their detention, and that it is in their best interests. For a deprivation of liberty in either a hospital or care home setting the place the patient resides in is known as the ‘Managing Authority’ they make the application for the deprivation of liberty to the Local Authority (LA) known as the ‘Supervisory Body’. If the LA believe that the DoL is in the persons best interest they will authorise the ‘Managing Authority’ to apply the deprivation of liberty safeguard.

1. Challenges to Local Authority authorised DoLS

It is some of these authorised DoLS that the CCG funds via CHC that the patients’ relevant persons representatives (RPR) are challenging under the legal framework known as section 21a of the MCA. In 2016/17 and 2017/18 the total cost for legal representation across the 4 CCGs for CoP21a challenges alone came to £131,737.40 (£76,247.50 & £55,489.90 respectively) and this doesn’t include the cost in time of the CCG Safeguarding Adults Managers and CHC Nurse being engaged in this work. It is not possible to predict whether or not these cases will continue to be bought, and in what numbers.

N.B. CoP21a challenges are currently eligible for non-means tested legal aid which could be a possible explanation for the increase in these challenges over the last two years.

2. Fully Funded by CHC Court of Protection authorised DoL

The ‘Cheshire West’ judgement also extended the concept of deprivation of liberty to include patients in supporting living environments whether that be in their own home, or a supported living placement.

For those patients in their own home or supported living placements a different process for authorisation is required via a streamlined Court of Protection (CoP) process for uncontested cases known currently as the Re X process. A set fee has been agreed with the CCGs solicitors Browne Jacobson LLP for each case and this is currently at £1,500 + VAT and £400 for the Court fee. We have recently submitted the first 8 Re X DoL cases to Browne Jacobson to take to the CoP on behalf of the Derbyshire CCGs. These 8 include at least one case residing in North, South and Hardwick CCGs to spread the risk (currently reviewing a case for Erewash CCG). We have not been charged to date for the work any of these cases has generated. Once the case has been heard by the CoP the invoice will be raised.

The Quality and Performance Committee should note that for the CoP cases the authorisation is only valid for up to 12 months, the CCG is then required to go back to court for further authorisation each year so the costs will increase year on year as more cases are identified and authorised, until such time that the law changes.

3. Joint Funded CHC Court of Protection authorised DoL

For joint funded cases where we share responsibility for the DoL with Derbyshire County Council we have previously paid Browne Jacobson on a case by case basis to represent the CCGs in Court. Being mindful of trying to minimise legal costs the Safeguarding Lead for MCA/DoL and the Chief Nurse recently met with colleagues

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from the Derbyshire County Council legal team to discuss arrangements for how to progress with joint funded cases requiring CoP authorisation for a DoL. There is an opportunity for the DCC legal team to undertake this work on behalf of the CCGs across Derbyshire where there is no conflict of interest between our joint positions, both agreeing that the DoL is in the persons best interest. The DCC legal team will identify relevant cases with the intention that the CCGs pay 50% of the costs to the DCC legal team (the LA picking up the other 50% share). Based on the figures they are proposing there will be cost savings to the CCGs who are currently paying Browne Jacobson LLP on a case-by-case basis. The fixed fee proposal from DCC for new applications to court is:

£200 which is 50% of the Court fee, plus £400 which is 50% of the cost of the officer time VAT not chargeable. The fixed fee proposal for subsequent annual reviews £200 which is 50% of the Court fee, plus £300 which is 50% of the cost of the officer time VAT not chargeable

In the event that the matter becomes particularly complex it may be that an additional charge is made. This will reflect a charge for the additional time taken to advise and will be limited to 50% of the cost of additional officer time. If the Quality and Performance Committee decide to recommend to Governing Bodies that we work with DCC in this way on the joint funded cases, then following a 6 month trial period the CCGs may wish to consider approaching the DCC legal team to look at costings for processing fully funded Re X DoL cases on our behalf as there may be further cost savings. Browne Jacobson LLP declined to put forward their costings for the joint funded work on behalf of the CCGs, it is safe to assume that these would have been higher than DCC’s proposed costs. Figures from DCC for the legal work on our fully funded cases can be obtained if the Quality and Performance Committee and Governing Bodies wish to pursue this. N.B. This paper only covers the proposals for the joint funded case within Derbyshire. For Derby City residents the City Council would need to be approached. Conclusion

Following two recent third party challenges to the Derbyshire CCGs questioning the lack of a DoLS for two patients in supported living settings it is right that we progress this work under the current legal framework to lessen the risk of reputational damage to the CCGs.

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N.B. Any litigation against the CCGs for failure to present the case for a court hearing would currently be met by the NHS Litigation Authority.

There may be light on the horizon, the Mental Capacity Act (amended) Bill started its journey through Parliament on July 3rd, 2018. The draft Bill changes the term ‘Deprivation of Liberty’ to ‘Liberty Protection Safeguards’ as proposed by the Law Commission. This is happening sooner than first thought and therefore may receive royal ascent in the next 12 months. The reason for this happening sooner than first thought is partially related to the backlog of cases now accumulating at the Court of Protection.

This will further impact on the work of the CCGs Adult Safeguarding Team (AST) as currently the amendments propose that the CCGs would become the ‘Supervisory Body’ and be able to authorise DoL for all CCG fully funded patients only, for joint funded cases with the LA this is less clear. If this does become practice the CCGs will benefit from a reduced financial burden in respect of court costs however the additional work for the CCG AST would need to be considered. The final version of this Bill may look different after any amendments as it makes its way into law. The AST will keep the Quality and Performance Committee advised of its progress and implications.

Recommendations

1. The current arrangements for joint funded packages are only applicable toCounty residents. Derby City Council legal team should be approached tosee if we can work together in a similar way to reduce legal costs.

2. The CCG should put a ‘hold’ on any further fully funded cases being passedto Browne Jacobson until the initial cases have gone through the Court ofProtection hearings and judgements have been made by the Court whether ornot to authorise the DoL, or if they think the case does not meet the thresholdfor DoL.

3. The AST would not propose that the CHC Nurse leading this work stopsidentifying cases which she feels meet the DoL threshold while the revision tothe DoL process makes its way through parliament. However by holdingthese cases within the CCG until we have judgements on our first cases weare mitigating legal costs via Browne Jacobson LLP as the courts have abacklog of cases pending. The AST will monitor the CCGs position as thenew draft bill is reviewed and any changes to the legislation comes into effect.

4. The Quality and Performance Committee support the proposal to work withthe DCC legal team on our joint funded cases for the trial period of sixmonths. If this is successful the CCG considers any future proposal for ourfully funded cases.

Michelle Grant Adult Safeguarding Manager

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Joint Governing Body

13th December 2018

Report Title Better Care Closer to Home Programme – Location of the Specialist Rehabilitation Bed Provision (Pathway 3 beds)

Author(s) Louise Swain – Interim Deputy Director of Joint and Community Commissioning

Sponsor (Director) Kate Brown – Director of Joint Commissioning and Community Development

Paper for: Decision X Assurance Discussion X Information Recommendations

1. The CCGs Governing Bodies Committee in Common, are asked to note the Better Care Closerto Home Implementation Board’s report (Paper A) on the location of the specialist rehabilitationbeds (pathway 3) in the north of Derbyshire. The Board considered two options and have putforward option 1 as the preferred location:

i. Option 1 - (baseline – current provision) three community hospitals – Cavendish,Whitworth, Clay Cross

ii. Option 8 – three facilities, Cavendish Community Hospital, Chesterfield Royal HospitalNHS FT (CRH) and Clay Cross.

2. The CCGs Governing Bodies Committee in Common are asked to agree the BCCTH Board’srecommendation of option 1 as the location of the P3 beds.

Report Summary

1. Introduction

The Better Care Closer to Home programme aims to provide more care closer to home specifically for:

• Older people receiving inpatient care in a community hospital, usually following a spell in anacute hospital because of an illness or accident, and

• Older people with dementia who currently receive services in community hospitals.

It is a programme that has enabled the transformation of the existing provision from a largely bed based model into a model providing high quality care closer to home, integrating health and social services through a joint team approach. This has resulted in the consolidation of 32 community rehabilitation beds, development of 44 community support beds (delivered in DCC care homes)

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and enhanced joint health and social care integrated community services. In addition the programme has also developed a 30 bedded specialist dementia unit at Walton Hospital, two dementia rapid response teams and a workable model for the delivery of the ‘living well with dementia’ programme that is aligned to place alongside other day services. The roll out of clinically proven models of home-based care in northern Derbyshire is part of a national move to provide more care at the right time and in the right place.

The Better Care Closer to Home business case set out the requirement for 32 beds to meet the bedded community rehabilitation needs of the populations. Multiple options for the configuration of these beds were considered and the final agreed option was for there to be a 24 bedded ward on the Chesterfield Royal Hospital NHS FT (CRH) site to be run by Derbyshire Community Health Services NHS Trust (DCHS) with the remaining 8 beds provided in Buxton at the Cavendish Community Hospital through a change of use.

Initial plans for the new ward at CRH were developed at the time of the consultation and once the proposals put forward in the BCCTH business case were agreed, more detailed implementation planning could begin as until this point proposals were formative. The detailed planning that followed the decision making meeting saw estates experts at Chesterfield Royal Hospital NHS Foundation Trust and Derbyshire Community Health Services NHS Foundation Trust come together with clinicians and operational managers to work on the design of the proposed ward at Chesterfield Royal Hospital. Guidance on the planning and design of the specialist rehabilitation facilities were based on the ‘In-patient care Health Building Note 04-01: Adult in-patient facilities’ (DoH: 2013). The team considered many different permutations in order to meet the required standards and design criteria set out in the planning guidance.

However, the detailed design proved a more complex piece of work than was anticipated and once the BCCTH Implementation Board became aware of this, they recommended that the team cease pursuing this option, review the implications of this finding and undertake an options appraisal of the benefits, costs, risks and opportunities of alternative options. The appraisal would need to take full account of the BCCTH business case aims and original evaluations.

2. The Options

2a. Original Options When the business case was originally completed multiple configurations of provision were assessed and consolidated into 7 options.

Option 1 - three community hospitals – Cavendish, Whitworth, Clay Cross (current provision) Option 2 - one facility at Chesterfield Royal Hospital (CRH) Option 3 - one facility at Whitworth Option 4 - two facilities Cavendish and CRH (the original agreed implementation proposal) Option 5 - two facilities Cavendish and Whitworth Option 6 - two facilities Cavendish and Clay Cross Option 7 - two facilities Cavendish and Bolsover

Taking into consideration that although the original 24 bedded option at CRH had now been shown to not be feasible, the available space at CRH would allow for a smaller, 12-bedded unit, therefore a further option was added to the original 7. The 8th option put forward a solution whereby there would be a 12-bedded unit at both CRH and Clay Cross hospitals as well as an 8 bedded-unit at Cavendish hospital. Option 8 – three facilities, Cavendish, CRH and Clay Cross

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2b) Revised Options At their September meeting, the BCCTH Implementation Board were presented with the sum of the review they had requested. The Board considered the eight options detailed above and agreed that options one and eight should be evaluated further using a clinical confirm and challenge approach. The reasons for excluding the other six options were as follows: OPTION DESCRIPTION REASON FOR EXCLUSION Option 2

one facility at Chesterfield Royal Hospital Option does not include Cavendish which is part of the agreed Model

Option 3 one facility at Whitworth Option does not include Cavendish which is part of the agreed model

Option 4 two facilities Cavendish and CRH Available space at the CRH ward does not allow for a 24 bedded unit

Option 5 two facilities Cavendish and Whitworth Available space at Whitworth does not allow for a 24 bedded unit

Option 6 two facilities Cavendish and Clay Cross Available space at Clay Cross does not allow for a 24 bedded unit

Option 7 two facilities Cavendish and Bolsover Bolsover scheduled for closure

3. Clinical Confirm and Challenge A clinical confirm and challenge meeting took place on 9th October 2018 where option one and option eight were considered. Delegates were asked to look at the following areas to help assess the deliverability of the options presented. A summary of the options is included here: (the full appraisal is available in the attached report – Paper A)

Summary The following table summarises that draft ratings across each of the categories. Table 5.

Option Deliverability Clinical Travel Finance Resilience 1.Cavendish/ Whitworth/Clay Cross.

G G G A G

8.Cavendish/ CRH/Clay Cross

A G G R G

Are there any Resource Implications (including Financial, Staffing etc)? Financial Summary

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a. Finances Both options have increased running costs above those modelled in the business case which totalled £3,408k across Cavendish and CRH. The financial and contracting committee are reviewing the overall programme costs for 19/20. As the wards at Clay Cross and Whitworth are scheduled for closure there is an element of backlog maintenance.

Table 3. Option Staffing(total) Capital (total) Economic appraisal

20 years Rating

1. Cavendish, Whitworth/Clay Cross.

£3,859k £30,000 – backlog Whitworth and Clay Cross

£61.442M A

8.Cavendish, CRH/ Clay Cross

£4,157k £10,000 – backlog Clay Cross £1.25M CRH Refurbishment costs

£63.404M R

Economic appraisal A small multi-agency finance group conducted an economic appraisal on the 2 options. The group used the STP allocations Tranche 2: Value for Money Assessment methodology based on ‘The Green Book appraisal and evaluation in central government – GOV UK. The outcome of the appraisal was as follows: Option 1. (all 32 beds located on DCHS sites) at a cost of £61.442m over a contract life of 20 years Option 8. (20 beds located on DCHS sites + 12 beds located on CRH site) at a cost of £63.404m over the same contract life A difference of £1,962M with Option 1 providing the cost effective option. Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? Full Due regard and EIA undertaken within original business case. Have you involved patients, carers and the public in the preparation of the report? Indirectly through service provider responses. Have any Quality and Compliance issues been identified/ actions taken

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None identified. Have any Conflicts of Interest been identified/ actions taken? None identified Governing Body Assurance Framework N/A Identification of Key Risks

1. A challenge is made that we are not compliant with the initial decision made as a result of the consultation. However the option that has been recommended by the Implementation Board is one that a high proportion of consultation recipients put forward as a preferential location of the P3 beds.

2. In potentially moving the location of the P3 beds from CRH, there may be an impact to residents living in the Chesterfield area, who may have to travel further from their home to access the P3 beds if option 1 is agreed.

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Joint Governing Body

13th December 2018

Report Title Better Care Closer to Home Programme – Location of the Specialist Rehabilitation Bed Provision (Pathway 3 beds)

Author(s) Louise Swain – Interim Deputy Director of Joint and Community Commissioning & Kate Brown – Director of Joint Commissioning and Community Development

Sponsor (Director)

Zara Jones – Executive Director Commissioning Operations

Contents

1. Introduction2. The Options3. Clinical confirm and challenge4. Summary5. Recommendation

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Specialist Rehabilitation Bed Provision – Option Appraisal Report

1. Introduction The Better Care Closer to Home programme aims to provide more care closer to home specifically for:

• Older people receiving inpatient care in a community hospital, usually following a spell in an acute hospital because of an illness or accident, and

• Older people with dementia who currently receive services in community hospitals. It is a programme that has enabled the transformation of the existing provision from a largely bed based model into a model providing high quality care closer to home, integrating health and social services through a joint team approach. This has resulted in the consolidation of 32 community rehabilitation beds, development of 44 community support beds (delivered in DCC care homes) and enhanced joint health and social care integrated community services. In addition the programme has also developed a 30 bedded specialist dementia unit at Walton Hospital, two dementia rapid response teams and a workable model for the delivery of the ‘living well with dementia’ programme that is aligned to place alongside other day services. The roll out of clinically proven models of home-based care in northern Derbyshire is part of a national move to provide more care at the right time and in the right place. The Better Care Closer to Home business case set out the requirement for 32 beds to meet the bedded community rehabilitation needs of the populations. Multiple options for the configuration of these beds were considered and the final agreed option was for there to be a 24 bedded ward on the Chesterfield Royal Hospital NHS FT (CRH) site to be run by Derbyshire Community Health Services NHS Trust (DCHS) with the remaining 8 beds provided in Buxton at the Cavendish Community Hospital through a change of use. Initial plans for the new ward at CRH were developed at the time of the consultation and once the proposals put forward in the BCCTH business case were agreed, more detailed implementation planning could begin as until this point proposals were formative. The detailed planning that followed the decision making meeting saw estates experts at Chesterfield Royal Hospital NHS Foundation Trust and Derbyshire Community Health Services NHS Foundation Trust come together with clinicians and operational managers to work on the design of the proposed ward at Chesterfield Royal Hospital. Guidance on the planning and design of the specialist rehabilitation facilities were based on the ‘In-patient care Health Building Note 04-01: Adult in-patient facilities’ (DoH: 2013). The team considered many different permutations in order to meet the required standards and design criteria set out in the planning guidance. However, the detailed design proved a more complex piece of work than was anticipated and once the BCCTH Implementation Board became aware of this, they recommended that the team cease pursuing this option, review the implications of this finding and undertake an options appraisal of the benefits, costs, risks and opportunities of alternative options. The appraisal would need to take full account of the BCCTH business case aims and original evaluations.

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2. The Options

2a. Original Options When the business case was originally completed, multiple configurations of provision were assessed and consolidated into 7 options:

Option Number of facilities

Description

Option 1 Three facilities Cavendish, Whitworth, Clay Cross (baseline – current provision)

Option 2 One facility Chesterfield Royal Hospital

Option 3 One facility Whitworth

Option 4 Two facilities Cavendish and CRH (the original agreed implementation proposal)

Option 5 Two facilities Cavendish and Whitworth

Option 6 Two facilities Cavendish and Clay Cross

Option 7 Two facilities Cavendish and Bolsover

Taking into consideration that although the original 24 bedded option at CRH had now been shown to not be feasible, the available space at CRH would allow for a smaller, 12-bedded unit, therefore a further option was added to the original 7. The 8th option put forward a solution whereby there would be a 12-bedded unit at both CRH and Clay Cross hospitals as well as an 8 bedded-unit at Cavendish hospital. Option 8 Three facilities Cavendish, CRH and Clay Cross

2b) Revised Options At their September meeting, the BCCTH Implementation Board were presented with the sum of the review they had requested. The Board considered the eight options detailed above and agreed that options one and eight should be evaluated further using a clinical confirm and challenge approach. The reasons for excluding the other six options are as follows: Option Number

of facilities

Description Reason for exclusion

Option 2 One

facility

Chesterfield Royal Hospital Option does not include Cavendish

which is part of the agreed model.

Option 3 One

facility

Whitworth Option does not include Cavendish

which is part of the agreed model.

Option 4 Two

facilities

Cavendish and CRH (the original

agreed implementation proposal)

Available space at the CRH ward

does not allow for a 24 bedded unit

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Option 5 Two

facilities

Cavendish and Whitworth Available space at Whitworth does

not allow for a 24 bedded unit

Option 6 Two

facilities

Cavendish and Clay Cross Available space at Clay Cross does

not allow for a 24 bedded unit

Option 7 Two

facilities

Cavendish and Bolsover Bolsover scheduled for closure

3. Clinical Confirm and Challenge A clinical confirm and challenge meeting took place on 9th October 2018 where option one and option eight were considered. Delegates were asked to look at the following areas to help assess the deliverability of the options presented.

• Deliverability

• Clinical impact

• Travel impact

• Finance

• Resilience

The Confirm and Challenge Group comprised GPs, GP Chair of NDCCG, DCHS Deputy Medical Director/ GP, CRH Medical Director, DCHS Group Manager (Nurse), DCHS transformation Director, DCHS Contracts and finance manager, Estates manager and DCC direct care group manager, DCC operations manager and CCG Deputy Director of Community Commissioning. The group were given a PowerPoint presentation which documented the original workings from the business case and provided the option appraisal results relating to deliverability, clinical impact, travel impact, financials and resilience for the 2 options. A summary of the presentation is seen below:

a. Deliverability The following table shows the deliverability of the options. Table 1 Option Deliverability Rating 1. Cavendish, Whitworth and Clay Cross.

Immediately available and provides certainty which is anticipated to support staff stability. Minor backlog maintenance required on wards that were scheduled for closure.

G

8. Cavendish, CRH and Clay Cross

Extended implementation timeline which is anticipated would not be available until Autumn 2020. *NB

A

*In order to refurbish the CRH ward to the rehabilitation ward standards, CRH would have to close 3 wards. As part of the hospitals’ capital programme they try and minimise disruption by

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carrying out all necessary ward changes at the same time. Whilst this programme is only interested in the rehabilitation ward, CRH would want to refurbish the non-rehab wards as well.

b. Clinical Impact

The location of the beds will not impact upon overall clinical benefits of the transformation as the model of care remains the same for all of the potential options.

During the consultation and in the public meetings there were references made to there being an advantage to having beds located at CRH as it provides easy access to advanced diagnostic facilities and there is an obvious benefit of proximity for discharge into the rehabilitation beds. This was balanced with concerns about protection of access to rehabilitation beds at times of significant stress in the acute environment and the fact that some acute discharges in the area are from hospitals other than CRH. There was always a plan for the model of care to blend and expand the reach of support across the acute/community boundary and all of the options still require this approach.

In terms of diagnostics the same benefits would be gained should the beds be located on a site with the relevant facilities. The minor injuries units (MIU) have x-ray facilities and some near patient testing. There is an MIU at Whitworth Hospital and one in Buxton which is not on the same site as the beds currently, but plans are underway to create a single facility in Buxton, at which point beds and diagnostics would be co-located.

c. Travel Impact

The approved model with beds only at CRH and Cavendish was assessed to improve access for some of the population but the loss of local hospitals was a major concern to the public in terms of travel impact.

Table 2 Option Travel Impact Rating 1. Cavendish, Whitworth and Clay Cross No impact as this is the current

configuration but a lost opportunity to reduce travel for population where CRH is the nearest hospital

G

8. Cavendish, CRH and Clay Cross Benefit to population living closest to CRH but negative impact on Dales population

G

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d. Finances During implementation some of the costs have proven to be different from the original planning assumptions. The BCCTH Implementation Board has a multi organisational finance sub group supporting implementation. Across the whole programme currently there is a forecast imbalance between released costs and new service costs. Work is underway to close that gap (fully mitigated in 18/19 however there is still a significant gap for 19/20). Selection of the lowest cost option will support the mitigation plan to ensure delivery of the programme is cost neutral. Table 3. Option Staffing(total) Capital (total) Economic appraisal

20 years Rating

1. Cavendish, Whitworth/Clay Cross.

£3,859k £30,000 – backlog Whitworth and Clay Cross

£61.442M A

8.Cavendish, CRH/ Clay Cross

£4,157k £10,000 – backlog Clay Cross £1.25M CRH Refurbishment costs

£63.404M R

Economic appraisal

A small multi-agency finance group conducted an economic appraisal on the 2 options. The group used the STP allocations Tranche 2: Value for Money Assessment methodology based on ‘The Green Book appraisal and evaluation in central government – GOV UK.

The outcome of the appraisal is as follows:

Option 1. (all 32 beds located on DCHS sites) at a cost of £61.442m over a contract life of 20 years

Option 8. (20 beds located on DCHS sites + 12 beds located on CRH site) at a cost of £63.404m over the same contract life

Identifying that option 8 would cost £1,962M more over the contract life, option 1 emerged as the most cost effective and therefore is the preferred option.

e. Resilience The table below shows no difference between the two options’ ability to flex the bed capacity throughout the year (Cavendish provision is the same in each option), both offer the ability to support seasonal resilience and longer term capacity planning. There is a distinct clinical advantage in splitting the 24 bed provision in the case of a Noro-virus or similar outbreak where containment and separation is likely to keep more beds open than in the case of a single unit.

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Finally, consideration has been given to the sustainability of two wards at Clay Cross and Whitworth. It is assumed that these sites will be key within the wider Place/Health and Well Being hub provision for the areas. Given the substantial numbers of outpatient appointments, the location of community team bases and the co-location of some Local Authority services, the concern regarding sustainability is mitigated.

Table 4. Option Bed flexibility Rating 1. Cavendish, Whitworth andClay Cross.

High – can retain space for additional beds on all sites

G

8.Cavendish, CRH and ClayCross

High – can retain space for additional beds on all sites

G

4. Summary

The following table summarises the draft ratings across each of the categories.

Table 5. Option Deliverability Clinical Travel Finance Resilience 1.Cavendish,Whitworth/Clay Cross.

G G G A G

8.Cavendish/CRH/Clay Cross

A G G R G

5. Recommendation

The BCCTH Implementation Board considered the clinical impact to be the most significant factor in its review of the options. The Clinical Confirm and Challenge Group concluded that there was no clinical difference between the two options. The BCCTH Board evaluated the other factors and agreed that the recommendation to the CCGs Governing Bodies Committee in Common should be option 1 on the basis that this gives stability for the position now; is cost effective; has no clinical impact; and has minimal patient impact in terms of transport.

The Board noted that many people are likely to welcome the proposal to provide specialist rehabilitation beds across Cavendish, Whitworth and Clay Cross as feedback gathered during the consultation on this area of the programme indicated a preference to keep specialist rehabilitation provision across community hospitals.

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Governing Body Meetings in Common

13th December 2018

Report Title Update on Operating Plan for 2019/20

Author(s) Zara Jones – Executive Director of Commissioning Operations


Paper for: Decision Assurance X Discussion X Information X Report and Recommendations

At the September Governing Body Meeting in Common, a summary of the CCGs commissioning and contracting intentions were provided. The commissioning intentions have the following underpinning strategic principles, which were communicated to our providers on 28 September 2018:

1. Put patients’ needs before organisational needs and make sure the systemcan continue to deliver safe and effective health care, improving patientoutcomes and making the best use of the resources available to us.

2. Support people to live independently for longer, stay well and recover quicklycloser to home.

3. Encourage and support patients to be active participants in their own care;4. Commission services in local community settings (Place) – where it is safe,

sustainable and achieves improved outcomes and patient experience.5. Provide holistic care co-ordinated around the patient that is delivered by

multidisciplinary teams working around groups of GP practices.6. Work with our Partners to implement alternative methods of providing care

and support, that deliver the outcomes people need using the best use of ourfinancial resources.

Planning Approach

At the time of writing this paper, we are still awaiting the detailed Planning Guidance from NHS England. However in communications we have received to date we understand the following is required for 2019/20:

• Individual organisations will submit in year operational plans for 2019/20 thatwill be aggregated by STP

• These plans will form a year 1 baseline for strategic systems• Commissioners can expect 5 year allocations in December 2018 giving

greater financial certainty on which to plan

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• Detailed planning guidance will follow in December 2018.

Appendix 1 provides more detail of the requirements which have been jointly set out by NHS England and NHS Improvement.

There are a number of significant changes that have been signalled for inclusion in the 2019/20 NHS Standard Contract that present key opportunities for Commissioners to work with Providers to move into transformational models to deliver efficiencies by, for example, utilising new blended tariffs to support reductions in non-elective activity and reducing follow up attendances to share financial responsibility for levels of hospital activity.

The CCGs are working with system partners as part of the STP Joined up Care Derbyshire, to plan and map opportunities for mutual development next year to improve outcomes and drive greater efficiencies. This will include sharing QIPP plans and understanding provider plans linked to areas of national best practice such as initiatives and the Model Hospital Programme and Getting it Right First Time.

We know through data analysis and benchmarking that there are particular pathways and disease groups where the local population has poorer outcomes than peer group CCGs. Clinical transformation schemes will be worked up in collaboration with our providers to drive improvements in identified opportunity areas. Our QIPP programme as part of our 2019/20 plan will therefore be a balance of transformational and transactional initiatives to support the CCGs objectives of Better Health, Better Care, Better Value.

Activity Planning

As part of the planning process the CCGs have been required to submit a first cut of activity data which indicates our anticipated forecast outturn for 2018/19; to support baseline setting for 2019/20 and also our initial assessment of 2019/20 activity; demonstrating activity levels pre and post-QIPP activity reductions. As set out above, the CCGs and wider system are still developing plans which will have an impact on activity; therefore the submission is very much a first cut ahead of the first national planning submission due on 14th January.

The detailed planning timetable is set out below.

Contracting Approach 2019/20

The CCG Contracting Intentions underpin the 2019/20 contract to support delivery of the Commissioners QIPP programme to improve outcomes and drive efficiency. We have reiterated to providers our intention to work towards affordable, balanced models for contracts and this must be underpinned by a transparent and rigorous contract management framework.

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The CCGs began contract negotiation meetings with our main acute, community and mental health providers in early November and have agreed the following meeting architecture for negotiations:

Initial negotiation meetings have set out the direction of travel per contracting intentions; i.e. that there remains an intention to negotiate a different form of ‘affordability’ contract with providers, but as we work towards the final arrangements, we will need to agree all the separate components to be included. Initial discussions around draft activity plans have started, and we have already shared a first-cut forecast baseline activity position with University Hospitals Derby and Burton Foundation Trust (UHDB). A detailed contract work programme has been designed and shared to deliver signed contracts by the national deadline of 21st March 2019. Work is also underway with Staffordshire commissioners to agree the contracting and commissioning approach to adopt for the recently merged Derby and Burton Trusts to form UHDB. The former Burton NHS Trust had East Staffordshire CCG as its lead Commissioner and Southern Derbyshire CCG is the lead commissioner for Derby. This work will include alignment of commissioning priorities, policies, quality metrics and reporting requirements. Detailed work with providers around quality and performance schedules will be progressed following publication of the detailed operational planning guidance.

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Are there any Resource Implications (including Financial, Staffing etc)? Effective planning and robust finance and activity plans required to ensure affordable contracts are agreed. Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? N/A for overall process described, however individual QIPP schemes and commissioning plans as part of our operational planning for 2019/20 will follow our statutory duties including compliance with the Equality Act. Have you involved patients, carers and the public in the preparation of the report? N/A for overall process described but patient groups have been involved in QIPP planning and the CCGs will follow statutory duties for commissioning plans as

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required. Have any Quality and Compliance issues been identified/ actions taken N/A Have any Conflicts of Interest been identified/ actions taken? N/A Governing Body Assurance Framework Effective planning and commissioning Identification of Key Risks Delivery of affordable contracts within required timescales.

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To: CCG AO Trust CE CC: NHS Improvement and England Regional Directors NHS Improvement and England Regional Finance Directors Publications Gateway Reference 08559 16 October 2018

Approach to planning

The Government has announced a five-year revenue budget settlement for the NHS from 2019/20 to 2023/24 - an annual real-term growth rate over five years of 3.4% - and so we now have enough certainty to develop credible long term plans. In return for this commitment, the Government has asked the NHS to develop a Long Term Plan which will be published in late November or early December 2018.

To secure the best outcomes from this investment, we are overhauling the policy framework for the service. For example, we are conducting a clinically-led review of standards, developing a new financial architecture and a more effective approach to workforce and physical capacity planning. This will equip us to develop plans that also:

improve productivity and efficiency; eliminate provider deficits; reduce unwarranted variation in quality of care; incentivise systems to work together to redesign patient care; improve how we manage demand effectively; and make better use of capital investment.

This letter outlines the approach we will take to operational and strategic planning to ensure organisations can make the necessary preparations for implementing the NHS Long Term Plan.

Collectively, we must also deliver safe, high quality care and sector wide financial balance this year. Pre-planning work for 2019/20 is vitally important, but cannot distract from operational and financial delivery in 2018/19.

NHS Improvement and NHS England

Wellington House 133-155 Waterloo Road

London SE1 8UG

020 3747 0000

www.england.nhs.uk

www.improvement.nhs.uk

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Planning timetable

We have attached an outline timetable for operational and strategic planning; at a high-level. During the first half of 2019-20 we will expect all Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to develop and agree their strategic plan for improving quality, achieving sustainable balance and delivering the Long Term Plan. This will give you and your teams sufficient time to consider the outputs of the NHS Long Term Plan in late autumn and the Spending Review 2019 capital settlement; and to engage with patients, the public and local stakeholders before finalising your strategic plans.

Nonetheless, it is a challenging task. We are asking you to tell us, within a set of parameters that we will outline with your help, how you will run your local NHS system using the resources available to you. It will be extremely important that you develop your plans with the proper engagement of all parts of your local systems and that they provide robust and credible solutions for the challenges you will face in caring for your local populations over the next five years. Individual organisations will submit one-year operational plans for 2019/20, which will also be aggregated by STPs and accompanied by a local system operational plan narrative. Organisations, and their boards / governing bodies, will need to ensure that plans are stretching but deliverable and will need to collaborate with local partners to develop well-thought-out risk mitigation strategies. These will also create the year 1 baseline for the system strategic plans, helping forge a strong link between strategic and operational planning. We will also be publishing 5-year commissioner allocations in December 2018, giving systems a high degree of financial certainty on which to plan.

We are currently developing the tools and materials that organisations will need to respond to this, and the timetable sets out when these will be available.

Payment reform

A revised financial framework for the NHS will be set out in the Long Term Plan, with detail in the planning guidance which we will publish in early December 2018. A number of principles underpinning the financial architecture have been agreed to date, and we wanted to take this opportunity to share these with you.

Last week we published a document on ‘NHS payment system reform proposals’ which sets out the options we are considering for the 2019/20 National Tariff.

In particular, we are seeking your engagement on proposals to move to a blended payment approach for urgent and emergency care from 2019/20. The revised approach will remove, on a cost neutral basis, two national variations to the tariff: the marginal rate for emergency tariff and the emergency readmissions rule, which will not form part of the new payment model. The document will also ask for your views on other areas, including price relativities, proposed changes to the Market Forces Factor and a proposed approach to resourcing of centralised procurement. As in

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https://improvement.nhs.uk/resources/201920-payment-reform-proposals/

previous years, these proposals would change the natural ’default’ payment models;

local systems can of course continue to evolve their own payment systems faster, by local agreement.

We believe that individual control totals are no longer the best way to manage provider finances. Our medium-term aim is to return to a position where breaking even is the norm for all organisations. This will negate the need for individual control totals and, in turn, will allow us to phase out the provider and commissioner sustainability funds; instead, these funds will be rolled into baseline resources. We intend to begin this process in 2019/20.

However, we will not be able to move completely away from current mechanisms until we can be confident that local systems will deliver financial balance. Therefore, 2019/20 will form a transitional year, in which we will set one year, rebased, control totals. These will be communicated alongside the planning guidance and will take into account the impact of distributional effects from any policy changes agreed post engagement in areas such as price relativities, the Market Forces Factor and national variations to the tariff.

In addition to this, we will start the process of transferring significant resources from the provider sustainability fund into urgent and emergency care prices. The planning guidance will include further details on the provider and commissioner sustainability funds for 2019/20.

Incentives and Sanctions

From 1 April 2019, the current CQUIN scheme will be significantly reduced in value with an offsetting increase in core prices. It will also be simplified, focussing on a small number of indicators aligned to key policy objectives drawn from the emerging Long Term Plan.

The approach to quality premium for 2019/20 is also under review to ensure that it aligns to our strategic priorities; further details will be available in the December 2018 planning guidance.

Alignment of commissioner and provider plans

You have made significant progress this year in improving alignment between commissioner and provider plans in terms of both finance and activity. This has reduced the level of misalignment risk across the NHS. We will need you to do even more in 2019/20 to ensure that plans and contracts within their local systems are both realistic and fully aligned between commissioner and provider; and our new combined regional teams will help you with this. We would urge you to begin thinking through how best to achieve this, particularly in the context of the proposed move to blended payment model for urgent and emergency care.

Good governance

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We are asking all local systems and organisations to respond to the information set out in this letter with a shared, open-book approach to planning. We expect boards and governing bodies to oversee the development of financial and operational plans, against which they will hold themselves to account for delivery, and which will be a key element of NHS England’s and NHS Improvement’s performance oversight. Early engagement with board and governing bodies is critical, and we would ask you to ensure that board / governing body timetables allow adequate time for review and sign-off to meet the overall timetable.

The planning guidance, with confirmation of the detailed expectations, will follow in December 2018. In the meantime, commissioners and providers should work together during the autumn on aligned, profiled demand and capacity planning. Please focus, with your local partners, on making rapid progress on detailed, quality impact-assessed efficiency plans. These early actions are essential building blocks for robust planning, and to gauge progress we will be asking for an initial plan submission in mid-January that will be focussed on activity and efficiency (CIP / QIPP) planning with headlines collected for other areas.

Thank you in advance for your work on this.

Yours sincerely

Simon Stevens Chief Executive NHS England

Ian Dalton Chief Executive NHS Improvement

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Annex

Outline timetable for planning Date

NHS Long Term Plan published Late November / early December 2018

Publication of 2019/20 operational planning guidance including the revised financial framework Early December 2018

Operational planning

Publication of CCG allocations for 5 years Near final 2019/20 prices Technical guidance and templates 2019/20 standard contract consultation and dispute resolution

guidance 2019/20 CQUIN guidance Control totals for 2019/20

Mid December 2018

2019/20 Initial plan submission – activity and efficiency focussed with headlines in other areas 14 January 2019

2019/20 National Tariff section 118 consultation starts 17 January 2019

Draft 2019/20 organisation operating plans 12 February 2019 Aggregate system 2019/20 operating plan submissions and system operational plan narrative 19 February 2019

2019/20 NHS standard contract published 22 February 2019

2019/20 contract / plan alignment submission 5 March 2019

2019/20 national tariff published 11 March 2019

Deadline for 2019/20 contract signature 21 March 2019

Organisation Board / Governing body approval of 2019/20 budgets By 29 March

Final 2019/20 organisation operating plan submission 4 April 2019 Aggregated 2019/20 system operating plan submissions and system operational plan narrative 11 April 2019

Strategic planning

Capital funding announcements Spending Review 2019

Systems to submit 5-year plans signed off by all organisations Summer 2019

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NHS Derbyshire Governing Bodies Meetings in Common

Report Title Summary Finance Report 1st April – 31st October 2018

Author(s) Louise Bainbridge/Sandy Hogg Sponsor (Director) Louise Bainbridge/Sandy Hogg

Paper for: Decision X Assurance X Discussion Recommendations The Governing Body is recommended to:

• NOTE the month 7 financial position• NOTE the use of contingencies and budget flexibilities to manage savings under-delivery and cost pressures • NOTE the month 7 savings forecast of £43.7m (month 7+ £45.0m)• NOTE the month 7 level of risk on the 2018/19 savings programme of £1.1m (month7+ £1.6m)

Report Summary As at month 7 the Derbyshire CCG’s year to date financial position is ahead of plan and the full year forecast remains in line with the plan.

The significant forecast variances are within Acute, CHC and Prescribing. The forecast overspend has been managed through the use of budget flexibilities following the detailed budget review earlier in the year.

The risks identified within the savings programme, potential further acute and CHC pressures can be mitigated through contingency.

Are there any Resource Implications (including Financial, Staffing etc)?

n/a

Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report?

Attach completed Equality Impact Assessment if available or explain how Due Regard has taken place if required.

Have you involved patients, carers and the public in the preparation of the

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report? n/a

Have any Quality and Compliance issues been identified/ actions taken n/a Have any Conflicts of Interest been identified/ actions taken? None identified

Governing Body Assurance Framework

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Summary Finance and Savings Report 1st April 2018 – 31st October 2018

Finance Summary 1. Introduction The purpose of this report is to inform Governing Body members of the financial performance of the Derbyshire CCGs, including delivery of the savings plan for the seven month period ending 31st October 2018. The detailed Finance and Savings Delivery reports were presented to the Derbyshire Finance Committees in Common on 29th November. This report summarises the key messages from those reports. Sections 2 to 4 of this report are based on month 7 savings information provided by the PMO on the 7th November 2018. These sections are consistent with the information provided to NHS England through the monthly Non-ISFE submission and to the Finance Committee via the Finance Report. The work scrutinising and assessing savings delivery and forecasts continued after the month 7 financial position was finalised and a second cut of month 7 data (called Month 7+) has been used in section 5 which is an extract from the month 7 Savings Delivery Report produced by the PMO. 2. Statement of Financial Duties At month 7 all CCG’s are continuing to report year to date and forecast positions in line with their financial plans. The CCGs are collectively reporting forecast achievement of the CSF adjusted control total of £28.6m (original control total of £44.0m less the CSF allocations received to date of £15.4m). £4.5m of the £7.8m contingency has been used in reporting this position. Table 1 – Summary of performance against key CCG financial duties

Statutory Duty Target Erewash Hardwick North

Derbyshire Southern

Derbyshire Hold a 0.5% risk reserve (incl PCCC) £7.778m

Forecast achievement of control total in-year deficit (original plan) (£43.994m)

Forecast achievement of control total in-year deficit after Q2 CSF adjustment

(£28.593m)

Forecast delivery of the Savings Target £50.841m

Forecast - remain within the Running Cost Allowance £22.470m

Remain within cash limit

Greatest of 1.25% of

Drawdown, or £0.25m

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Achieve BPPC (Better Payment Practice Code)

>95% across 8

areas

The red crosses indicate the target is forecast to be missed. At month 7 the full year savings savings programme is expected to deliver £43.7m. 3. Financial Position and Key Variances

Table 2 – Summary Operating Cost Statement – Combined Derbyshire CCG

Within the forecast outturn position the key overspends are:

Acute Services The year to date position shows an underspend of £0.62m and a forecast overspend of £2.83m. This is an improvement of £0.33m year to date and a deterioration of £1.00m on the forecast from month 6. The main reasons for the movements are;

Chesterfield Royal Hospital – the forecast overspend of £1.01m remains broadly consistent with the value reported at month 6 whilst the year to date position has improved slightly. However, the CCGs have had early sight of the uncoded activity for month 7. The activity is above plan but the price is unknown. The CCGs have therefore increased the forecast to reflect this information.

Derby Teaching Hospitals – improvement in forecast of £0.88m taking the forecast underspend to £2.73m. Planned and unplanned activity continue to underperform at the Trust and underspends are also being seen on high cost drugs.

£1.6m of queries have been reflected in the forecast position. There are a total of £5m queries still to be resolved.

East Midlands Ambulance – the forecast underspend of £0.26m remains broadly consistent with month 6.

Sheffield Teaching Hospitals – the contract continues to underperform in line with previous forecasts. The previous forecast underspend of £0.78m is unchanged at month 7.

Prior Year Balances – deterioration of £0.24m – The CCGs continue to assess all 2017/18 accruals. The 2017/18 Derby Hospitals position has been finalised and the under-accrual has been reflected in the updated forecast. This reduces the overall benefit from prior year.

Annual Budget

YTD Budget

YTD Actual

YTD Variance

Forecast Outturn

Forecast Variance

Forecast Variance

due to Savings Under

Delivery

Forecast Variance

Other incl Price and Acitivity

YTD Variance as a % of YTD

Budget

FOT Variance as

a % of Annual Budget

M6 Forecast Variance

FOT Variance Change from M6

£'000's £'000's £'000's £'000's £'000's £'000's £'000's £'000's % % £'000's £'000'sAcute Services 777,334 452,839 452,221 617 780,165 (2,830) (998) (1,832) 0.14 (0.36) (1,831) (1,000)Mental Health Services 165,737 96,814 97,249 (435) 166,681 (945) (126) (819) (0.45) (0.57) (473) (471)Community Services 132,353 77,433 78,573 (1,139) 134,643 (2,289) (1,571) (718) (1.47) (1.73) (590) (1,699)Continuing Health Care 92,872 54,162 55,879 (1,717) 94,414 (1,543) 444 (1,987) (3.17) (1.66) (1,169) (374)Primary Care 184,732 107,932 105,088 2,843 183,870 862 300 562 2.63 0.47 (495) 1,357Co-Commissioning 137,592 77,355 74,512 2,843 135,008 2,584 0 2,584 3.68 1.88 1,615 969Other Programme 66,747 39,040 38,175 866 66,601 147 (5,266) 5,413 2.22 0.22 2,670 (2,523)Total Programme Resources 1,557,367 905,575 901,697 3,879 1,561,381 (4,014) (7,217) 3,203 0.43 (0.26) (273) (3,741)

Operational Costs (Running Costs) 20,079 10,755 9,752 1,003 19,837 242 200 42 9.33 1.20 228 14

In-Year Allocations 7,695 2,948 2,758 190 7,664 31 0 31 6.44 0.40 45 (14)0.5% Contingency (excl co-comm) 7,010 0 0 0 3,268 3,742 0 3,742 53.38 0 3,742

In year Planned Deficit (Control Total) (43,372) (25,043) 0 (25,043) 0 (43,372) 0 (43,372) 100.00 100.00 (43,994) 622CSF Received 14,778 14,778 0 14,778 0 14,778 0 14,778 100.00 100.00 4,401 10,377

Total In-Year Resources 1,563,558 909,014 914,207 (5,193) 1,592,151 (28,593) (7,017) (21,576) (0.57) (1.83) (39,592) 10,999

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Acute Savings – deterioration of £1.5m. The Lucentis savings scheme will not deliver due to a legal challenge on the national price change.

Mental Health Mental health is forecasting an overspend of £0.9m (underspend of £0.5m forecast at month 6). The adverse movement is due to: £0.1m increase in IAPT referrals, £0.1m PICU and £0.3m as Transforming Community Partnership (TCP) costs are higher due to increased costs in CHC and High Cost Patients.

Community The forecast overspend on Community of £2.3m (£0.6m over forecast at month 6). The change recognises under-delivery of savings of £1.5m. The remainder of the overspend relates to high cost patients, ophthalmic and audiology.

Continuing Healthcare The CHC position is forecast to overspend by £1.5m (month 6 £1.2m). The deterioration is due to the recognition of £0.2m for retrospective claims and an increase of £0.2m across adult and children’s CHC.

Primary Care and Prescribing The forecast underspend of £0.9m (month 6 overspend of £0.5m) relates to the following areas: Recognition of prior year accrual benefits of £4.5m, savings are forecast to be £0.3m better than plan. These benefits are then partially offset by £1.1m overspend on Cat M and NCSO and £2.7m overspend on cost and volume.

4. Underlying Position

The CCG’s underlying (UDL) position compares the recurrent funds available against the recurrent expenditure baseline. The difference between the two will result in either an underlying surplus or deficit for the CCG. This is an indicator of the underlying financial health of any organisation. The CCG’s underlying position is directly affected by the delivery of recurrent savings (improvement in position) or non-delivery (deterioration).

The movement in the Derbyshire CCGs underlying position at month 7 is shown below:

Table 3 – Underlying Position Movement from Month 6 to Month 7

Month 6 Month 7 Movement £m £m £m

Total Recurrent Allocations 1,538.7 1,538.7 - Total Recurrent Expenditure 1,600.3 1,600.2 0.1 Forecast 2018/19 Exit Underlying Position (61.6) (61.5) (0.1) Full Year Effect of 2018/19 Savings Schemes (8.8) (7.6) (1.2) Forecast Opening 2019/20 Underlying Position (52.8) (53.9) 1.1 % of Recurrent Allocation -3.4% -3.5% 0.1%

The movement in the Derbyshire CCGs underlying position from the planned in-year deficit of £44.0m is shown below in Table 4. This shows the forecast underlying position as at 31st March 2019 and excludes the full year effect of savings schemes started part year in 2018/19 of £7.6m:

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Table 4 – Underlying Position

£m Planned In-year Deficit (44.0) Non-Recurrent Allocations (excluding CSF) (9.4) Non-Recurrent Spend against Non-Recurrent Allocations 9.0 Non-Recurrent benefit from prior year accruals & unused Contingency (12.1) Non-Recurrent planned transactions 2.0 Non-Recurrent QIPP in 2018/19 (7.0) Forecast Exit Underlying Position 31/03/2019 (61.5)

2018/19 Savings Delivery Summary

5. Savings Programme year to Date and Forecast Outturn Position at Month 7

The Governing Body Meeting in Common of the four Derbyshire CCGs formally agreed the 2018/19 Savings Programme on 17th August 2018. The CCGs planned to deliver £50.8m of savings in 2018/19 as part of the overall financial plan, in order to deliver the £44m deficit control total agreed with NHS England (NHSE).

The CCG’s are required to report delivery to NHSE against the original savings plan submitted in April 2018. It has not been possible to update the NHSE plan to reflect the final CCG plan, given the impact on the overall NHSE plan. As a result the CCGs will continue to report to NHSE against the April plan, whilst also closely monitoring delivery against the finalised CCG savings plan, and using this for accountability purposes within the CCG. The year to date profile in the NHSE plan is £25.7m for month 7; the year to date actual savings is £22.5m, an adverse variance of £3.2m; reported to NHSE in early November.

At month 7+ the year to date savings delivery is £22.5m against the CCG’s plan of £21.8m, an over-performance of £0.7m, with an improved forecast outturn of £45.0m against a plan of £50.8m, an under-performance of £5.8m. Of the forecast outturn £7.0m is non-recurrent, and there is a full year effect of £7.6m in 2019/20.

The savings delivery reported to NHSE and the Finance Committee via the Finance Report used the month 7 information and showed forecast savings delivery of £43.7m.

At month 7+ there is a total savings risk of £7.4m. The reported financial position in sections 2 and 3 recognises savings under delivery of £7.1m and additional financial risk of further slippage of £1.m, a total of £8.2m.

The confirmed level of risk of £7.4m, on the 2018/19 savings programme of £51m, is significant and would impact on delivery of the 2018/19 control total agreed with NHSE if it was not mitigated. At month 7 the CCGs are forecasting to use £9m of mitigations to offset the forecast savings under-delivery and other cost pressures.

6. Summary and Recommendations

144

As at month 7 the Derbyshire CCG’s year to date position is ahead of plan and the full year forecast remains in line with the plan after CSF adjustments. The significant forecast variances are within Acute, Mental Health, Community Services and CHC. Included within those areas are forecast savings under delivery of £7.1m. The forecast overspends have been managed through the use of contingencies and budget flexibilities. A reported forecast financial position in line with the plan has only been possible through the use of £4.5m of contingencies, out of the available £7.8m, and from using £4.5m of budget flexibilities, out of the available £6.9m. Risks of £3.7m, which include £1.1m for potential further savings under-delivery, is being managed across the Derbyshire CCGs through the use of the remaining contingencies. The risks at Southern Derbyshire CCG exceed their available mitigations therefore this risk is being mitigated by the other 3 CCGs. The month 7+ information shows an updated forecast savings delivery of £45.0m. The Governing Body is recommended to:

• Note the month 7 financial position • Note the use of contingencies and budget flexibilities to manage savings under-

delivery and cost pressures • Note the month 7 savings forecast of £43.7m (month 7+ £45.0) • Note the month 7 level of risk on the 2018/19 savings programme of £1.1m (month

7+ £1.6m)

145



Derbyshire CCGs Governing Body Meeting in Common

13th December 2018

Report Title Quality and Performance Report

Author(s) Adam Sutherst, Assistant Director of Performance and BI Helen Hipkiss, Deputy Director of Quality

Sponsor (Director) Zara Jones, Executive Director of Commissioning Operations Brigid Stacey, Chief Nurse


X Discussion X Information

Recommendations The Governing Body meeting in Common are asked to:

• NOTE the key performance and quality highlights and risks as set out in the executivesummary.

• NOTE the CCG position against the CCG Assurance Framework Dashboard and identify anyareas of concern that require information or analysis that the Committee feels necessary inthe next report.

• NOTE the providers performance against the dashboard and identify any areas of concernthat require information or analysis that the Committee feels necessary in the next report

Report Summary This report covers the period of September 2018 unless more current information is available at the time of writing the report and includes the following items:

• Executive Summary• Derbyshire wide CCG Assurance Dashboard• Derbyshire wide CCG Provider Performance Dashboards (Main / Associate Contracts/other)• Quality Dashboard• Main Contracts – Contract Information / Quality and Performance• Associate Contracts• Contract Performance Notices Issued• Appendix 1: Main Provider Exception Reports


There is no direct financial impact on the CCGs with regards this report, however it should be noted that should the CCGs not achieve a number of the key performance indicators contained within the CCG Assurance Framework there will be a reduction in the Quality Premium available to the CCGs in 2018/19.

Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report?

Not applicable for this report.

Have you involved patients, carers and the public in the preparation of the report?

Item No: 62

146

No patients, carers or public have been involved in the publication of the report. However the impact of the issues raised in the report are considered from the perspective of all these individuals. Have any Quality and Compliance issues been identified/ actions taken Not applicable for this report. Have any Conflicts of Interest been identified/ actions taken? Not applicable for this report. Governing Body Assurance Framework

Better health outcomes for all

This report provides the Committee with an effective performance management mechanism that will ensure the CCGs delivers national and local standards by commissioning safe, quality care for patients that improves outcomes, secures access and ensures an excellent patient experience.

Improved patient access and experience

This report provides the Committee with an effective performance management mechanism that will ensure the CCGs delivers national and local standards by commissioning safe, quality care for patients that improves outcomes, secures access and ensures an excellent patient experience.

Empowered, engaged and well-supported staff This report ensures that through effective performance management the CCG’s staff will be empowered, engaged and supported to deliver.

Inclusive leadership at all levels This report ensures that the CCG commission’s services from providers that demonstrate the values and behaviours encouraged within the CCG.

Identification of Key Risks

Reference

Number: BAF/ RR * Current Risk Score

ND CCG R22,R37 15 (Extreme), 12 (High)

H CCG R3, R10 12(medium), 20 (Extreme)

SD CCG R07, R03 12(medium, 20 (Extreme)

E CCG FIN05 20 (Extreme)

147

NHS North Derbyshire CCG NHS Southern Derbyshire CCG NHS Erewash CCG NHS Hardwick CCG

1


Month 6 Quality & Performance Report

2018/19

148


2


Contents Page

Page

Executive Summary 3

Quality & Performance Proposed Deep Dive Schedule 4

Performance Overview 5-7

Quality Overview & Narrative 8-12

Urgent and Emergency Care

A&E

DTOCs

NHS 111

Ambulance

14-15

16

17

18

Planned Care Referral to Treatment Patients & Waiting 52+ weeks

Diagnostic Waits

Cancer

Referral to Treatment Recovery Trajectory

20-23

24-26

27-30

31-34

Derbyshire CCG Operational Activity v Plan 35-37

Appendix Trust Performance Overview 39-40

149


Key Messages • The tables on slides 5 and 6 show the latest validated CCG data against the constitutional targets. A more detailed overview of performance against the specific targets and the associated actions to manage performance is included in the body of this report. This is reported at a Derbyshire and individual CCG level

Urgent &

Emergency Care

• A&E standard was not met at a Derbyshire level, with both main providers failing to achieve the 95% target, CRH at 87.3% and UHDB at 89%. CRH performance reduced from the previous month (91.2%) but UHDB had improved (85.6%).

• The number of 12 hour trolley breaches in October was 5 – all at UHDB relating to unavailability of mental health beds. All breaches took place within a period of five days during the month.

• EMAS is non-compliant in 4 out of 6 national standards for Derbyshire which has not changed since the previous month.

Planned Care • 18 Week Referral to Treatment (RTT) for incomplete pathways continues to be non-compliant at 90.0% which is a slight decrease on the August figure (90.9%). Both main providers in Derbyshire (UHDB & CRHFT) failed to meet the 92% standard. Contract Performance Notices are currently in place for both CRH and UHDB. Actions within the recovery plan form part of the RTT recovery plan which aims to reduce the total waiting list size back to the March 2018 positon.

• 52+ week waiters has increased in September to 27. Of the 18 reported for Derbyshire CCGs, 11 of them were for our two main acute providers (7 x Derby, 4 x CRH), there were 7 for providers out of the area.

Cancer • 6 of the 9 standards were non compliant at a Derbyshire level in September 18. • 2wk Breast symptoms was 90.3% due to non-compliance at CRH (90.6%) • First treatment within 31 days was non compliant due to breaches at STH and NUH. Both UHDB and CRH achieved this standard. • 62 day performance continues to be non-compliant at Derbyshire level (75.5%) a significant decrease from August (81.1%) with both CRH(81.3%) and UHDB

(79.7%) failing to achieve • Both Trusts were non compliant for 62 day to treatment from screening service referral with CRH (72.2%) and UHDB (89.5%). Derbyshire was non compliant at

82.5% • The number of patients waiting over 104 days for treatment during September was 12 a reduction from 15 in August. 8 of the patients were treated at Derby and

3 at CRH. The remaining patient was treated at STH. RCA’s have been requested for these patients.

Quality - Derbyshire Community Health Services FT

Use of Restraint Practices within Ashgreen Hospital: Following increased national media coverage SoS for Health asked CQC to undertake urgent investigation into use of seclusion and restraint methods within ATU’s . The response received from DCHS showed multiple use of restraint practices for all four patients currently in Ashgreen hospital over last 6 months which has included prone restraint. Actions taken: Weekly updates to commissioners regarding the level of violent behaviour displayed within the unit. Trust closed the unit to new admissions early September 2018 due to risks to both staff and other patients regarding the levels of violence and aggression. Formal letter to Director of Nursing sent 07/11/18 for confirmation that all of the patients currently receiving care have detailed PBS plans in place, confirmation of general training in place for staff to the use of positive behavioural support and details of action plans in place to reduce the use of restrictive practices and progress made .

Quality - East Midlands Ambulance Trust

Complaints /PALS Backlog: Due to a number of vacancies within the Patient Safety team the trust were reporting a backlog of 202 overdue /ready for response cases. Actions taken: Temporary staff employed to reduce the backlog of cases. Vacant staffing positions within the patient safety team have been advertised and recruited into Monitoring through quality assurance meetings with updates/progress Trust is on target to clear backlog by the end of December 2018.

3

EXECUTIVE SUMMARY

150


4

Area Data Elements Overview Schedule

Profile of Derbyshire Cancer Performance and Activity

Cancer activity vs plan Referrals by trust and tumour site Conversion to Treatment Trust capacity & demand Profile of long waiters Cancer measure performance

Provide a profile of Derbyshire Cancer activity and the impacts upon performance. The deep dive will analyse what are the changes in referral patterns by tumour site. What has been the overall change in activity levels? How does this impact on the trust? Understanding the secondary care capacity and demand. Impacts on provider operational issues and performance. Review of CCG transformation / network plans / schemes.

Dec-18

A&E - 4hr Standard

A&E / MIU attendances growth and attendance patterns (Time / Day / Adults/ Peads) CCG Activity vs plan Contract Activity vs plan Conversion to admission Inappropriate or frequent attendances Support Services activity - primary care streaming, MIU, DUCC

The deep dive paper intended to analyse the A&E departments of Derbyshire providers in order to asses how the activity can impact on A&E performance. This will be done by analysing the flow of patients through A&E and other urgent care support services such as streaming, DUCC and MIUs. Data will also be reviewed to identify the conversion rate from A&E attendance to admission. Links will then be drawn between activity and performance. This can then be mapped to current and expected winter pressures and the current / Planned work in regards to Urgent Care transformation.

Jan-19

RTT Recovery Plan

Referrals (GP and Other vs Plan / Year on year) Conversion to FOP Elective activity (vs plan / year on year) RTT incomplete position vs March 18 by CCG and Provider Review of 40+ Week waiters 52+ week Waiters Progress vs plan

Review CCG and trust progress against the RTT recovery plan ahead of reaching March 19. The report will detail the CCGs current position against plan and outline the actions taken and action remaining. As part of this long waiters will be analysed as well as the numbers of 52+ week waiters. The report will also asses the current referral and elective activity demand and how this could impact the performance against the recovery plan.

Feb-19

EMAS (Quality & Performance)

Performance against the Ambulance response programme and local trajectories Ambulance System Indicators Ambulance Clinical Quality Indicators Prolonged Waits Review of Demand (Duplicates, Incidents and on scene average) Hospital Handovers

The deep dive paper provides members of the Quality & Performance Committee with a deep dive into the urgent and emergency ambulance contract with East Midlands Ambulance Service (EMAS) NHS Trust. The paper covers all aspects relating to delivery of a regional urgent and emergency ambulance service, along with background information on the Ambulance Response Programme, and the key changes following its introduction.

Mar-19

Mental Health - CQC Inspection Waiting times for psychological therapies and other data requirements for issues raised by CQC

Highlight the issues raised following the recent CQC inspection, identifying the mitigating actions being taken by both the CCG & Trust i.e. waiting time for psychological therapies Apr-19

Derbyshire CCG performance against the IAF metrics

IAF indicators by performance area and metric group firstly focusing on areas which do not meet the assesment citeria in 2017/18 and updating where possible to the lastest position. Further detailed analysis to be done in areas or indicators which are in the lowest interquartile range

A detailed review of Derbyshire CCGs performance against the IAF metrics in order to determine key areas of good and poor performance. Areas which are outlying in the group will be reviewed as well as a detailed review of the areas which are in the lowest interquartile range. Scalability will be included to highlight the level of increase or decrease for Derbyshire to be in line with the next interquartile range and England average. Details from commissioning to be included to explain what the issues are and what actions are being taken in order to improve the position.

May-19

2019/20 Derbyshire CCG Operational Plan Indicators included in the CCG operational and activity plan Overview of the methodology used and the agreed CCG operational plan 2019/20, identifying the expectations in relation to activity & performance for the Derbyshire CCGs as outlined in the NHSE planning Guidance

Jun-19

Note: Activity has been removed from the above schedule as it will be covered in all aspects of the deep dives. In addition to this RTT recovery has been included as a separate deep dive.

QUALITY & PERFORMANCE COMMITTEE DEEP DIVE SCHEDULE

151


5

PERFORMANCE OVERVIEW MONTH 7 – URGENT CARE Key: Performance Meeting Target Performance Improved From Previous Period h

Performance Not Meeting Target Performance Maintained From Previous Period g

Indicator not applicable to organisation Performance Deteriorated From Previous Period i

Direction

of Travel

Current

MonthYTD

consecutive

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fa i lure

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Area Indicator Name StandardLatest

Period

Ambulance - Category 1 - Average Response Time 00:07:00 Oct-18 i 00:07:31 00:07:43 15 00:08:15 00:08:41 7 00:09:14 00:09:12 7 00:07:51 00:08:09 7 00:06:53 00:07:04 0

Ambulance - Category 1 - 90th Percentile Respose

Time00:15:00 Oct-18 i 00:13:30 00:13:43 0 00:12:32 00:13:22 0 00:14:23 00:13:56 0 00:15:34 00:15:16 4 00:11:47 00:12:38 0

Ambulance - Category 2 - Average Response Time 00:18:00 Oct-18 g 00:25:03 00:27:26 15 00:25:49 00:27:51 7 00:27:48 00:30:49 7 00:25:51 00:28:10 7 00:23:58 00:26:19 7


Time00:40:00 Oct-18 g 00:50:41 00:58:06 15 00:47:17 00:53:33 7 00:57:42 01:02:34 7 00:55:05 01:00:42 7 00:48:14 00:53:55 7


Time02:00:00 Oct-18 g 02:10:04 02:22:52 8 02:18:46 02:37:53 7 02:02:23 02:34:09 6 02:05:03 02:15:15 6 02:13:05 02:21:32 7


Time03:00:00 Oct-18 g 01:56:21 02:21:16 0 01:12:19 01:53:21 0 01:54:07 01:48:04 0 01:14:28 01:37:38 0 02:49:25 02:37:19 0


PeriodAccident &

Emergency

A&E Waiting Time - Proportion With Total Time In A&E

Under 4 Hours95% Oct-18 h 89.3% 91.1% 37 87.9% 89.7% 37 90.6% 93.9% 4 88.4% 92.7% 5 89.7% 90.5% 37

East Midlands Ambulance Service

Performance (Derbyshire CCGs

only - National Performance

Measure)

EMAS - Erewash CCG

Local Performance

EMAS - Hardwick CCG

Local Performance

EMAS - Southern

Derbyshire CCG Local

Performance

Ambulance

System

Indicators

Derbyshire Wide CCG Performance Erewash CCG Hardwick CCG North Derbyshire CCG Southern Derbyshire CCG

EMAS - North Derbyshire

CCG Local Performance

152


6

PERFORMANCE OVERVIEW MONTH 6 – PLANNED CARE

Key: Performance Meeting Target Performance Improved From Previous Period h



Direction

of Travel

Current

MonthYTD

consecutive

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fa i lure

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PeriodReferrals To Treatment Admitted Patients - % Within

18 Weeks90% Sep-18 i 78.6% 80.0% 18 81.3% 81.6% 18 82.3% 81.6% 18 80.8% 83.7% 18 76.3% 77.4% 18

Referrals To Treatment Non-Admitted - % Within 18

Weeks95% Sep-18 i 89.8% 90.7% 18 91.2% 92.5% 18 87.6% 89.4% 18 88.5% 89.9% 18 90.7% 91.1% 18

Referrals To Treatment Incomplete Pathways - %

Within 18 Weeks92% Sep-18 i 90.0% 91.2% 8 92.8% 92.6% 0 89.7% 91.0% 3 88.2% 90.5% 7 90.8% 91.4% 2

Number of 52 Week+ Referral To Treatment Pathways -

Incomplete Pathways0 Sep-18 i 20 111 22 2 9 2 1 12 3 8 37 13 9 53 18

DiagnosticsDiagnostic Test Waiting Times - Proportion Over 6

Weeks1% Sep-18 i 2.80% 1.61% 4 1.16% 0.59% 1 4.86% 1.99% 4 5.26% 2.90% 17 0.67% 0.65% 0

All Cancer Two Week Wait - Proportion Seen Within

Two Weeks Of Referral93% Sep-18 h 95.8% 96.2% 0 93.7% 95.0% 0 93.2% 95.0% 0 93.3% 95.1% 0 95.8% 96.2% 0

Exhibited (non-cancer) Breast Symptoms – Cancer not

initially suspected - Proportion Seen Within Two Weeks Of Referral93% Sep-18 i 90.3% 93.7% 1 92.9% 94.0% 1 100.0% 96.1% 0 75.5% 90.9% 1 94.7% 94.7% 0

First Treatment Administered Within 31 Days Of

Diagnosis96% Sep-18 i 93.9% 96.3% 1 93.2% 95.3% 1 92.9% 96.3% 1 92.1% 95.4% 2 95.3% 97.2% 1

Subsequent Surgery Within 31 Days Of Decision To

Treat94% Sep-18 h 97.9% 93.5% 0 100.0% 88.1% 0 100.0% 91.1% 0 100.0% 92.6% 0 96.2% 91.3% 0

Subsequent Drug Treatment Within 31 Days Of

Decision To Treat98% Sep-18 h 99.5% 99.3% 0 100.0% 99.3% 0 100.0% 100.0% 0 100.0% 99.7% 0 99.0% 99.0% 0

Subsequent Radiotherapy Within 31 Days Of Decision

To Treat94% Sep-18 i 96.6% 95.1% 0 95.2% 97.8% 0 100.0% 92.0% 0 95.8% 91.9% 0 96.7% 97.0% 0


Urgent GP Referral85% Sep-18 i 66.2% 73.1% 5 75.0% 78.9% 1 100.0% 68.3% 0 61.9% 72.2% 5 64.7% 73.5% 10

First Treatment Administered - 104+ Day Waits 0 Sep-18 h 12 73 30 0 6 0 1 9 1 5 23 5 6 35 30


Screening Referral90% Sep-18 i 82.5% 90.5% 2 100.0% 95.5% 0 100.0% 95.5% 0 68.8% 85.4% 2 89.5% 92.7% 1


Consultant UpgradeN/A Sep-18 i 88.4% 87.2% 100.0% 97.1% 100.0% 88.0% 94.1% 86.7% 81.0% 84.3%

Derbyshire Wide CCG Performance Erewash CCG Hardwick CCG North Derbyshire CCG Southern Derbyshire CCG

Referral to

Treatment for

planned

consultant led

treatment

2 Week Cancer

Waits

31 Days Cancer

Waits

62 Days Cancer

Waits

153


7

PERFORMANCE OVERVIEW MONTH 6 – PATIENT SAFETY & MENTAL HEALTH Key: Performance Meeting Target Performance Improved From Previous Period h



Direction

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PeriodMixed Sex

Accommodatio

n

Mixed Sex Accommodation Breaches 0 Sep-18 h 7 34 18 0 1 0 1 1 1 2 8 3 4 24 18

Healthcare Acquired Infection (HCAI) Measure: MRSA

Infections0 Sep-18 g 0 5 0 0 0 0 0 0 0 0 1 0 0 4 0

Plan 150 12 24 0 60

Actual 122 0 7 0 20 0 0 0 48 0

Healthcare Acquired Infection (HCAI) Measure: E-Coli - Sep-18 i 104 486 10 46 10 61 28 132 56 247

Healthcare Acquired Infection (HCAI) Measure: MSSA - Sep-18 g 26 117 1 8 5 16 5 29 15 64

Plan 1.58% 9.50% 1.58% 9.50% 1.58% 9.50% 1.58% 9.50% 1.58% 9.50%

Actual 1.83% 12.17% 0 1.75% 14.29% 0 1.64% 11.35% 0 1.69% 12.71% 0 1.94% 11.71% 0

IAPT - Proportion Completing Treatment That Are

Moving To Recovery50% Sep-18 i 52.2% 56.2% 0 61.2% 55.1% 0 55.2% 54.7% 0 52.8% 58.7% 0 50.2% 55.3% 0

IAPT Waiting Times - The proportion of people that

wait 6 weeks or less from referral to entering a course

of IAPT treatment75% Sep-18 i 82.7% 83.3% 0 93.5% 87.9% 0 93.1% 88.3% 0 84.0% 86.7% 0 79.2% 79.9% 0

IAPT Waiting Times - The proportion of people that

wait 18 Weeks or less from referral to entering a

course of IAPT treatment95% Sep-18 i 100.0% 99.9% 0 100.0% 100.0% 0 100.0% 99.9% 0 100.0% 99.9% 0 100.0% 100.0% 0

Early Intervention In Psychosis - Admitted Patients

Seen Within 2 Weeks Of Referral50.0% Sep-18 h 84.2% 85.0% 0 50.0% 69.2% 0 100.0% 91.7% 0 100.0% 95.0% 0 88.9% 76.4% 0

Early Intervention In Psychosis - Patients on an

Incomplete Pathway waiting less than 2 Weeks from

Referral50.0% Sep-18 h 90.9% 90.9% 0 n/a 60.0% 0 100.0% 100.0% 0 100.0% 100.0% 0 83.3% 86.8% 0

Dementia Diagnosis Rate 67.0% Aug-18 i 71.5% 71.3% 0 83.4% 83.4% 0 74.6% 74.7% 0 68.3% 67.7% 0 70.7% 70.7% 0

Care Program Approach 7 Day Follow-Up 95.0% 18/19 Q1 h 98.1% 98.1% 0 100.0% 100.0% 0 100.0% 100.0% 0 97.1% 97.1% 0 98.0% 98.0% 0

Me

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IAPT - Number Entering Treatment As Proportion Of

Estimated Need In The PopulationSep-18 i

Early

Intervention In

Psychosis

Mental Health

Pa

tie

nt

Sa

fety

Incidence of

healthcare

associated

Infection

Healthcare Acquired Infection (HCAI) Measure: C-Diff

Infections

Erewash CCG Hardwick CCG North Derbyshire CCG Southern Derbyshire CCG

Sep-18 h

Derbyshire Wide CCG Performance

154


Quality Overview

8 155


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Area Indicator Name Standard

Inspection Date N/A

Outcome N/A

Staff 'Response' rates 15%18-19

Q1h 1.2% 4.2%

18-19

Q1h 10.8% 12.8%

18-19

Q1i 38.0% 38.0%

18-19

Q1h 32.8% 21.4%

Staff results - % of staff who would recommend the

organisation to friends and family as a place to work

18-19

Q1i 54.9% 53.0%

18-19

Q1h 69.4% 67.4%

18-19

Q1i 70.0% 70.0%

18-19

Q1h 61.4% 59.7%

Inpatient results - % of patients who would

recommend the organisation to friends and family

as a place to receive care

90% Sep-18 h 98.2% 97.5% Sep-18 i 95.2% 96.6% Oct-18 h 97.4% 98.5%

A&E results - % of patients who would recommend

the organisation to friends and family as a place to

receive care

90% Sep-18 h 82.5% 76.1% Sep-18 i 85.5% 84.5% Oct-18 i 99.1% 99.5%

Number of formal complaints received N/A Sep-18 i 32 168 Sep-18 h 63 387 Sep-18 h 9 78 Sep-18 i 20 99

Number of formal complaints responded to within

agreed timescaleN/A Sep-18 h 97.0% 90.4% Sep-18 i 35 244 Sep-18 i 58.0% 74.5% Sep-18 h 2 17

Number of complaints partially or fully upheld by

ombudsmanN/A Sep-18 1 0 1 Dec-17 0 3 Sep-18 h 0 2 Sep-18 1 0 0

Stage 2 - Number of pressure ulcers developed or

deteriorated N/A Sep-18 i 7 23 Sep-18 h 10 45 Sep-18 h 82 668 Sep-18 1 0 0


deterioratedN/A Sep-18 1 6 18 Sep-18 i 6 17 Sep-18 h 40 342 Sep-18 1 0 0


deterioratedN/A Sep-18 1 0 1 Sep-18 1 0 0 Sep-18 i 4 16 Sep-18 1 0 2

Number of pressure ulcers which meet SI criteria N/A Sep-18 i 4 9 May-18 i 1 1 Sep-18 i 2 13 Sep-18 1 0 0

Number of falls N/A Sep-18 i 88 507 Sep-18 h 2 22 Sep-18 h 44 287 Sep-18 h 28 201

Number of falls resulting in SI criteria N/A Sep-18 i 3 7 Sep-18 1 0 7 Sep-18 1 0 0

Medication Total number of medication incidents ? Sep-18 h 66 371 Sep-18 1 2 13 Sep-18 1 0 0 Sep-18 h 41 324

Never Events 0 Sep-18 h 0 2 Sep-18 1 0 3 Sep-18 1 0 1 Sep-18 1 0 0

Number of SI reports overdue 0 Sep-18 i 3 4 Sep-18 i 9 36 Jan-18 1 0 0 Sep-18 1 0 0

Number of avoidable cases of hospital acquired VTE Sep-18 1 3 16 Sep-18 1 0 0

% Risk Assessments of all inpatients 90%18-19

Q1i 98.2% 97.3%

18-19

Q1h 96.3% 96.4%

18-19

Q1i 99.4% 99.8%

Hospital Standardised Mortality Ratio (HSMR)Not Higher Than

Expected Sep-18 h 105.6 Nov-17 h 99

Summary Hospital-level Mortality Indicator (SHMI):

Ratio of Observed vs. Expected

17-18

Q4i 0.98677

17-18

Q4h 0.966

Crude Mortality Sep-18 h 1.01% 1.38% Jul-18 h 0 0

Derbyshire Wide Integrated ReportDashboard Key:

CCG assured by the evidence Performance Improved From Previous Period

Provider Local Quality Indicators CCG not assured by the evidence Performance Maintained From Previous Period

Performance Deteriorated From Previous Period

Part B: Acute & Non-Acute Provider Dashboard for Local Quality

Indicators

Chesterfield Royal Hospital FT Derby Teaching Hospitals FT Derbyshire Community Health Services Derbyshire Healthcare FT

Jun-16

Good Good Good Requires ImprovementRatin

gs

CQC RatingsFeb-17 Mar-15 Jun-16

Adul

t

FFT

Complaints

Pressure

Ulcers

Falls

Serious

Incidents

VTE

Mortality

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ent P

erio

d

YTD

Late

st P

erio

d

Dire

ctio

n of

trav

el

See

Sect

ion

D fo

r

Com

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Curr

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erio

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YTD

Late

st P

erio

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Dire

ctio

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trav

el

See

Sect

ion

D fo

r

Com

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Curr

ent P

erio

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Late

st P

erio

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Dire

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See

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D fo

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YTD

Sect

ion

Area Indicator Name Standard

Antenatal serivce: How likely are you to recommend

our service to friends and family if they needed

similar care or treatment?

Sep-18 g 100.0% 97.6% Sep-18 i 96.0% 97.7%

Labour ward/birthing unit/homebirth: How likely are

you to recommend our service to friends and family

if they needed similar care or treatment?

Sep-18 i 97.1% 93.1% Sep-18 i 95.9% 97.4%

Postnatal Ward: How likely are you to recommend

our service to friends and family if they needed

similar care or treatment?

Sep-18 i 95.5% 96.4% Sep-18 i 94.6% 97.6%

Postnatal community service: How likely are you to

recommend our service to friends and family if they

needed similar care or treatment?

Sep-18 g 100.0% 99.0% Sep-18 h 98.5% 98.3%

Stillbirth Stillbirth rate per 1,000 births May-18 1 0 0 Aug-18 i 2.57 2.324

Smoking at

DeliverySmoking at time of delivery (%) May-18 i 19.47% 17.46% Aug-18 h 17.23% 17.07%

Dementia Care - % of patients ≥ 75 years old

admitted where case finding is applied90% Aug-18 i 99.0% 99.4% Aug-18 h 91.3% 88.9%

Dementia Care - % of patients identified who are

appropriately assessed90% Aug-18 i 100.0% 100.0% Aug-18 i 81.0% 35.7%

Dementia Care - Appropriate onward Referrals 95% Aug-18 i 100.0% 98.8% Aug-18 i 100.0% 20.6%

Inpatient

AdmissionsUnder 18 Admissions to Adult Inpatient Facilities 0 Sep-18 1 0 0

Staff turnover (%) Sep-18 h 10.0% 9.9% Sep-18 i 14.5% 14.5% Sep-18 i 8.8% 8.6% Sep-18 i 10.2% 10.0%

Staff sickness - % WTE lost through staff sickness

* Staff Attendance Rate provided by CRHFT≤3.5% Sep-18 h 4.71% 4.40% Sep-18 h 3.9% 3.9% Sep-18 i 4.9% 4.5% Sep-18 h 6.7% 6.1%

Vacancy rate by Trust (%) Sep-17 i 1.9% 1.3% Sep-18 h 0 0 Sep-18 1 0 0 Sep-18 h 0 0

Target

Actual 51 212 0 0

Agency nursing spend vs plan (000's) Sep-18 i £148 £921 Sep-18 h 0 3632 Sep-18 i 51 212

Agency spend locum medical vs plan (000's) Sep-18 i £570 £4,020

% of Completed Appraisals 90% Sep-18 h 86.7% 54.9% Sep-18 i 90.5% 90.5% Sep-18 i 89.4% 90.0% Sep-18 i 75.5% 79.2%

Mandatory Training - % attendance at mandatory

training90% Sep-18 i 91.4% 91.4% Sep-18 i 96.9% 94.7% Sep-18 i 82.8% 83.7%

Is the CCG assured by the evidence provided in the last

quarter?CCG assured by

the evidence

CCG assurance of overall organisational delivery of

CQUIN CCG not assured

by the evidence

Agency usage

Part B: Acute & Non-Acute Provider Dashboard for Local Quality

Indicators cont.

Chesterfield Royal Hospital NHS

Foundation TrustDerbyshire Healthcare FT

Mat

erni

ty

FFT

Men

tal H

ealt

h

Dementia

Derby Teaching Hospitals FT Derbyshire Community Health Services

Training

Quality Schedule CCG assured by the evidence CCG assured by the evidence CCG assured by the evidence CCG assured by the evidence

i

Wor

kfor

ce

Staff

CQUIN CCG assured by the evidence CCG assured by the evidence CCG not assured by the evidence CCG assured by the evidence

157


Trust Key Issues

Chesterfield Royal Hospital FT

• CQC: The Well Led part of the CQC inspection is now complete and informal feedback was given to the Trust early November 2018.The final report will be shared with the Trust at the end of December 2018 with publication due in January 2019.The Trust will share the feedback with the CCG and will be an agenda item at the next QAG scheduled for January 2019.

• MSA breaches: Two mixed sex accommodation breaches were reported to the CCG on the 9th November. Both caused by delays transferring patients out of HDU & ITU. Full details will be provided in the reports submitted to the CCG.

• Friend & Family Test (FFT) ED: Although the score for ED remains below target the Trust has seen an improvement in the score for the 3rd month in a row. The September score is the highest they have seen in the last 12 months. The Trust has developed a number of patient experience initiatives in the ED department which is reflected in the improved scores. Next step is continued monitoring of results.

• Never Events : Two Never Events occurred in June & August .One report has been submitted and reviewed. The CCG are happy with the report and that incident is now closed. The report on the second incident has been received recently. Next steps are to review the report and feedback to the Trust.

• Serious Incidents overdue: The 3 reports overdue in September have now been submitted, there are currently no overdue reports.

• Appraisals: The Trust adopted for the first time an appraisals season approach taking place April- September 2018 .Their internal target was to be at 95% by the end of September they have achieved 86.7%. Next step: The trust is now undertaking a review and evaluation of this approach.

University Hospitals of Derby and Burton NHS FT

• Mixed Sex Accommodation (MSA): There were seven MSA breaches reported in August, all were reported in the ICU/HDU. The Lead Nurse for ICU actively speaks with each patient as part of the follow up care. Next steps: An audit is planned over 2 months to gain patient experience of mixed sex accommodation breach in ICU/HDU, results will be shared in December.

• Never Events: There were no new Never Events reported by the Trust in August, ongoing action plans are being monitored. All Never Events are monitored via the CQRG meetings with the Trust. No further actions required.

• Getting it Right First Time (GIRFT): The Trust had a visit from the national GIRFT Diabetes Team and were praised for having one of the most integrated diabetic foot services nationally. They also perform well nationally having fewer diabetic patients who have complications post repair of #NOF at the Trust. The Trust is reviewing all the feedback from the national GIRFT team and producing an action plan. Action plan will be monitored via CQRG as the next step.

11

QUALITY OVERVIEW M6

158


Trust Key Issues

Derbyshire Healthcare FT

• CQC Section 29a Warning Notice: In July CQC issued a Section 29a Warning notice in relation to the recording of patient observations within an appropriate timescale. The Trust developed and implemented a number of actions. CQC Inspectors revisited the ward on the 5 September and the Warning Notice was lifted on the 15 September 2018.

• CQC Inspection: The Derbyshire Healthcare FT CQC Inspection report was published on the 28th September 2018. Overall the trust were rated as Requires Improvement (RI) with four core services rated as RI, one service as Inadequate (Acute Wards for Adults) and four core services were rated as Good. The Trust have submitted their action plan to CQC and progress will be monitored through the Quality Assurance Group.

Derbyshire Community Health Services FT

• Use of Restraint Practices within Ashgreen Hospital: Following increased national media coverage SoS for Health asked CQC to undertake urgent investigation into use of seclusion and restraint methods within ATUs . The response received from DCHS showed multiple use of restraint practices for all four patients currently in Ashgreen hospital over last 6 months which has included prone restraint. Weekly updates to commissioners regarding the level of violent behaviour displayed within the unit. Trust closed the unit to new admissions early September 2018 due to risks to both staff and other patients regarding the levels of violence and aggression. As next steps a formal letter was sent to the Director of Nursing on the 07/11/18 for confirmation that all of the patients currently receiving care have detailed PBS plans in place, confirmation of general training in place for staff to the use of positive behavioural support and details of action plans in place to reduce the use of restrictive practices and progress made.

East Midlands Ambulance Trust

• Complaints /PALs Backlog: Due to a number of vacancies within the Patient Safety team the Trust were reporting a backlog of 202 overdue/ready for response cases. Temporary staff have been employed to reduce the backlog of cases and vacant staffing positions within the patient safety team have been advertised and recruited into. The next step is monitoring through quality assurance meetings with updates and progress. The Trust is on target to clear backlog by the end of December 2018.

12

QUALITY OVERVIEW M6 continued

159


Urgent & Emergency Care

13 160


Performance Analysis During October 2018 the trust did not meet the 95% standard, achieving 87.3%. Performance has been declining from July 2018 and is currently at it lowest since March 2018. Attendances have shown a 4% (208) increase in October as well as a 50% increase in breaches. Primary care streaming activity has shown a small increase, currently 15% of A&E attendances are seen within the primary care streaming service.

What are the issues? The trust are experiencing pressures in the service which we would expect to see in December;

• Activity levels are +30 patients on average a day. • Batching of patients attending ED between 6pm and 7pm, with the trust

seeing on average 25 patients per hour compared to the planned 12 patients and hour average.

• High Acuity of patients attending ED with Respiratory and Cardiology conditions,

• Occasions when all 3 adult resus bays are full, each requiring a ED doctor which reduces doctor capacity to see minors.

What actions have been taken?

What are the next steps and when will they impact? • After the review of the capacity and demand in relation to Consultant and Middle

grade doctors by Meridian, new medical shift patterns will be introduced during December that reflect the activity surges.

• The trust are awaiting a report from a Critical friend visit in October which has identified new ways of working and improvement of IT systems.

• The Head of Nursing is currently reviewing capacity and demand of nursing staff with in ED

14

CCG Actions • CCG issued a Contract Performance

Notice which requested • Recovery action plan received but no

recovery trajectory and this has been requested at the next CMB on 5th December.

Provider Actions • The trust have now recruited 5

doctors from India starting in Jan 19, and a further doctor from Manchester starting in Dec 18.

• Locums currently in place for the vacancies and the ED department is fully staffed.

• An additional 18 winter beds have been opened

August September October

A&E attendances 5961 5867 6075

Breaches 657 646 967

Primary Care Streaming 1574 1503 1556

MIU attendances 3214 3173 3055

CRHFT A&E PERFORMANCE – PERCENTAGE OF PATIENTS SEEN WITHIN 4 HOURS (95%)

161


What are the issues? • High occupancy (over 95%) on a number of days during the month and the acuity of

the patients attending ED who needed an hospital admission caused delays in flow through the hospital, particularly when patients were to be moved to MAU.

• Focus remains on early decision making and correct level of escalation for outflow delays.

What are the next steps • CPN has been re issued. This recovery trajectory has been rejected and further

meetings will now take place to negotiate the date for recovery. • ‘Perfect 5 days’ initiative took place between 23/11/2018 and 27/11/2018. Outcomes

are to be shared with commissioners. • CCG await revised action plan from NHSE from meeting held on 7th September with

regard to 12 hour trolley breach processes.

15

UHDBFT A&E - PERCENTAGE OF PATIENTS SEEN WITHIN 4 HOURS (95%) Performance Analysis During October 2018 the trust did not meet the 95% standard, achieving 89.0%. This is however an improvement to the position reported in September. Type 1 attendances have shown a 2% (204) increase in October 18 although breaches have shown a -23% (620) reduction. There were 5 x 12 hour trolley breaches during October, all of which were as a result of delays in securing a suitable mental health bed.


CCG Actions • As a result of the CPN meetings

commissioners have now received a revised recovery action plan.

• The recovery trajectory has been rejected due to March 2019 position being non compliant.

• Through the provision of winter monies additional support at the Acute Front Door at UHDB for 4 months to start in December to support delivery of 4 hour standard (part of winter plan)

Provider Actions As part of the remedial action plan the following actions have been completed during October 18: • Appointment of duty escalation

manager. Interviews October 2018 and expected start date 19th November for six months.

• FEAT expansion to ED and ward 101. • Audit on 5th October completed by

NHSI of 70-80 patients attending with Mental health conditions. Trust awaiting the action plan.

Metric August September October Acutal

change

%

change

A&E attendances (Type 1) 10566 11197 11401 204 2%

A&E Breaches (Type 1) 1622 2678 2058 -620 -23%

Primary Care Streaming Attendances

1156 1177 1235 58 5%

DUCC attendances 3485 3487 3815 328 9%

MIU attendances 5532 5530 5737 207 4% 162


Performance Analysis

The DTOC standard was met by three of our four main providers during September. DCHS were the only provider who failed this standard with a performance of 7.8% which is an increase on the August figure of 5.1%

What are the issues? As previously highlighted in the performance analysis section the issues are currently at DCHS. • The over performance is attributable to discharging patients with highly complex needs

from the OPMH beds at Walton Unit. • Within Derbyshire there are a limited number of beds designated to provide care for

patients with very challenging behaviour. • Care homes appear to be experiencing recruitment and retention of staff issues. • There are also a number of delays which are attributable to the patient or family choice • Overall there is a lack of placements for these patients with complex needs.

What are the next steps • The trust will continue with their weekly health and social care conference call which

reviews all patients in delay and now reviews any potential delays which may affect a timely discharge.

• A forecasted October 18 position by the trust indicates non-compliance.

16

DELAYED TRANSFERS OF CARE (<3.5%)


CCG Actions • Delayed transfers of care continue

to me monitored and reviewed as part of the monthly contract management board meetings.

Provider Actions • The trust are monitoring the admission of

patients to community bed to ensure that the right patients are getting the necessary care and support.

• A standard operating procedure for pathways 2 beds has been introduced to improvement the management of access and use of the beds. This has been implemented via a series of training events.

163


What are the issues? • DHU111 reported for September that five counties received 19,848 more calls than September 2017

(+19.4%) which is 16,229 more than contracted (+15.3%). • September is the last month of Year 2 of the 5 year contract and therefore the agreed activity uplift for

Year 3 is not reflected in the above figures. • A significant NHSE media campaign started on 01.10.18 and will continue throughout most of

November. Early indications show an increase in call volumes of 11.8%. • The contract was procured to deliver average speed of answer and not calls answered in 60 seconds.

The contractual standard of average answer time is currently being met however answered in 60s is not. Delivering 95% of call answered in 60seconds requires more staffing resource and is therefore more expensive to deliver.

What actions have been taken? • The Year 3 IAP is based Year 2 outturn with a growth rate based on the last three years. This

increase has enabled DHU111 to recruit with the confidence of the income associated with the expected call volumes. An additional 309,635 calls offered and increase of 22.9%. Year 3 started in October this year.

• The significant shift in performance seen from mid-August is largely due to an increase in workforce of circa 790 hours of Health Advisors and Service Advisors. The early introduction of Pathways V16 and the new IVR structure has meant that Service Advisors can now answer calls giving significant additional capacity and ability to meet contractual standards. The approximate cost of this staffing and associated audit, training and IT infrastructure is circa £1m.

• The recruitment and training campaign is still in progress and numbers in the pipeline/in employment checks/booked onto training at the end of September are 2583 hours of Health Advisors, 909 hours of Service Advisors and 277 hours of clinical Advisors.

• Detailed winter planning has been completed. • A staff attendance bonus commenced in October. • DHU111 have explored the use of Conduit to take calls on DHU111’s behalf, however the idea is not

to be progressed, DHU111 recruitment and retention plans will continue. • NHS111 Online use has increase by 4.4% month on month.

What are the next steps • DHU 111 are undertaking two pieces of work which will be presented to the DHU111 CMB on 28th

Nov 18: 1. The level of performance that can be delivered with the Year 3 agreement. 2. The cost to CCGs to consistently deliver 95% of calls answered in 60s.

• New management roles to support mentorship of staff and analyst role to be approved. • Implementation of Phase 3 for NHS111 Online. • Continuation of all actions contained within the Recovery Action Plan.

17

Performance Analysis • DHU111 performance has shown improvements mid-

August 2018 leading and September and October 18 performance against the measure calls answered in 60 seconds has moved to partial compliance.

• The percentage of calls answered in 60 seconds remains below the 95% full compliance level but has shown improvements in September and October despite an increase in calls.

Indicator Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18

Calls Answered (Volume)

Actual 27964 30400 27256 31153 29262 30467 29760

Full Compliance 1% 1% 1% 1% 1% 1% 1%

Partial Compliance 2% 2% 2% 2% 2% 2% 2%

Actual 5% 5% 9% 12% 6% 2% 1%

Full Compliance 95% 95% 95% 95% 95% 95% 95%

Actual 91% 90% 91% 81% 85% 90% 90%

Abandoned Calls

Calls Answered Within 60 Seconds

NHS 111 – Month 7

164


What are the issues? • Incident and on scene demand was lower than commissioner plan during M7. • Pre-clinical handover times for local acute trusts are all above the 15 minutes national standard.

The total number of hours lost to the Derbyshire Division was 640 hours, which equates to c. 53 12-hour shifts lost, a reduction from M6.

• In M7 the Derbyshire Division were 177 hours (2.6%) down on the planned level of total vehicle hours. Although PAS provision has been increased and sickness has reduced to 5.2% in October, the division remain under plan on recruitment, and have seen a significant increase in vehicle off road (VoR) hours which impacts on delivery of performance.

What actions have been taken? • Regular meetings take place between the division and RDH and CRH with regards improving

handover times. EMAS now have a base in both CRH and RDH EDs to work with the Trusts to improve processes and reduce delays. Daily Opel reports are being shared with all acute trusts which include forecasts for ambulance arrivals.

• Sickness is being managed by the divisional team and the position has seen improvement. The M7 position saw a further improvement down to 5.2% against a M6 position of 5.8% and a M5 position of 7.2%.

• EMAS implemented a change to their Capacity Management Plan (CMP) in October, which is to now clinically triage lower acuity activity (within defined parameters) when in CMP level 2 or above. This is to increase Hear and Treat rates and reduce ambulance dispatches.

• The Derbyshire Mental Health hub is now live and feedback from the division has been positive. • EMAS continues to review individual post handover times and VoR times to identify where any

additional training and support may be required. Individual conveyance rates are also reviewed with mentorship offered if appropriate.

• EMAS have ongoing recruitment processes in place and additional training courses have been put in place to ensure EMAS deliver against the recruitment plan. The division are confident they will be on plan by early Q4 18/19.

What are the next steps • The regional Care Home process will be distributed early November which aims to reduce

demand from care homes. Work is ongoing reviewing high intensity service users and demand in from 111.

• EMAS are undertaking a review of their electronic patient record form (ePRF) completion as the division believe this is what is increasing the VoR times. Discussions are taking place with the software supplier regarding a “ePRF light” version to enable a more streamlined and efficient form.

• Through the recent commissioning intentions letter to EMAS commissioners have requested that EMAS adopt call scripts for all calls, with the exception of C1 calls, to manage patient expectation regards how long the wait will be to support a reduction in duplicate calls which have increased significantly.

• Work in relation to reducing handover delays will be taken through the relevant A&E Delivery Boards to ensure system actions are put in place

October 2018 Category 1 Category 2 Category 3 Category 4

Average 90th centile Average 90th centile 90th centile 90th centile

National standard 00:07:00 00:15:00 00:18:00 00:40:00 02:00:00 03:00:00

EMAS Actual 00:07:37 00:13:31 00:29:46 01:01:52 02:45:50 02:16:13

Derbyshire

October

indicative

trajectory 00:07:20 00:15:00 00:21:39 00:47:56 02:43:24 03:56:42

Actual 00:07:31 00:13:30 00:25:03 00:50:41 02:10:04 01:56:21

October 2018 NTPS Activity

DERBYSHIRE 2018/19 Actual

17/18 Actual

18/19 Actual vs

17/18 Actual

Commissioner Plan

18/19 Actual vs Commissioner

Plan

EMAS Plan

18/19 Actual vs EMAS

Plan

Calls 16,817 17,459 -3.7% 17,150 -1.9%

Total Incidents 13,925 13,838 0.6% 13,969 -0.3%

Total Responses 11,483 11,140 3.1% 11,669 -1.6%

Duplicate Calls 2,892 3,621 -20.1% 3,181 -9.1%

Hear & Treat 2,442 2,698 -9.5% 2,300 6.2%

See & Treat 3,263 3,064 6.5% 3,319 -1.7%

See & Convey 8,220 8,076 1.8% 8,350 -1.6% 8,731 -5.9%

October 2018

Pre Handovers Post Handovers Total Turnaround

Average Pre Handover Time

Lost Hours Average Post

Handover Time Lost hours

Average Total Turnaround

Lost hours

Burton Queens 00:19:46 48:57:09 00:13:21 23:08:20 00:33:07 53:36:10

Chesterfield Royal 00:18:48 214:31:45 00:13:12 112:36:08 00:32:00 218:24:38

Macclesfield District General Hospital 00:25:13 13:37:49 00:11:02 1:08:36 00:36:15 10:29:32

Royal Derby 00:16:09 234:01:04 00:15:18 300:42:53 00:31:27 392:38:08

Sheffield Northern General Hospital 00:27:59 34:47:44 00:13:23 7:35:15 00:41:22 34:26:31

Stepping Hill 00:29:04 94:23:32 00:12:10 15:04:37 00:41:14 84:56:58

Derbyshire TOTAL 00:18:06 640:19:03 00:14:19 460:15:49 00:32:25 794:31:57

AMBULANCE – EMAS PERFORMANCE

18 165


Planned Care

19 166



During September 2018, only Erewash CCG achieved the 92% standard for the percentage of patients seen within 18 weeks. Overall the Derbyshire position was 90% during September. The Derbyshire waiting list in September 18 is at 64,037 which is currently 2,878 above the March 18 position. At a Derbyshire level there are a number of specialities which are performing below the standard and have shown the largest movement. These include T&O (87%), General Surgery (84%) and General Medicine (87%).

What are the issues? The Derbyshire CCG position is representative of all of the patients registered within the CCG area attending any provider nationally. 70% of Derbyshire patients attend either CRHFT (25%) or UHDB (45%). Currently both providers are failing the 92% standard and the impact of this has resulted in the Derbyshire CCGs failing the standard. Other out of area providers such as East Cheshire, Stockport and Sherwood Forest are facing difficulties delivering the standard. Erewash CCG are currently achieving the standard and this is likely as a consequence of NUH achieving the standard in September (92.91%). The NHSE Planning Guidance states that the total number of incomplete pathways at March 2019 should be above the March 2018 level. This is being measured at CCG level. What actions have been taken?

What are the next steps and the point of impact? The CCGs will continue to work closely with their main providers to ensure progress against the recovery plan by way of weekly performance calls. Associate providers will continue to be monitored. It is anticipated that recovery will not be realised until March 19 as per the RTT recovery plan.

20

CCG Actions • Derbyshire CCGs have an agreed

recovery plan with both CRHFT and UHDB to reduce the waiting list position and bring performance in line.

• Additional activity has commenced at Nuffield and is confirmed at Barlborough.

• An in-sourced Medinet solution is being explored for ophthalmology and rheumatology.

Provider Actions • Please see page 21 & 22 for CRHFT

and UHDB provider actions. • Recovery plans / Trajectories are in

place at Stockport (recovery by Q3), Sherwood Forest Hospital (recovery end of October 18) and NUH (TBC).

April May June July August SeptemberTrend

Line

North Derbyshire CCG 91.5% 91.7% 91.2% 91.1% 89.3% 88.2%

Hardwick CCG 90.5% 91.8% 92.1% 91.3% 90.3% 89.7%

Erewash CCG 92.4% 92.7% 92.4% 92.7% 92.3% 92.8%

Southern Derbyshire CCG 90.7% 91.4% 91.5% 92.2% 91.7% 90.8%

Derbyshire CCGs Combined 91.1% 91.7% 91.5% 91.8% 90.9% 90.0%

Treatment Function Name

Total

Incomplete

Waiting List

Number

< 18

Weeks

Backlog

(+18

Weeks)

%

<18

Weeks

March

2018

Waiting

Movement

from March

18

General Surgery 5186 4347 839 83.82% 4883 303

Urology 3580 3204 376 89.50% 3788 -208

Trauma & Orthopaedics 9685 8450 1235 87.25% 8806 879

ENT 3549 3137 412 88.39% 3523 26

Ophthalmology 6082 5622 460 92.44% 5774 308

Oral Surgery 0 0 0 1 -1

Neurosurgery 361 337 24 93.35% 317 44

Plastic Surgery 461 413 48 89.59% 378 83

Cardiothoracic Surgery 129 122 7 94.57% 124 5

General Medicine 1192 1041 151 87.33% 1583 -391

Gastroenterology 3709 3323 386 89.59% 3618 91

Cardiology 2715 2456 259 90.46% 2396 319

Dermatology 4153 3963 190 95.42% 3343 810

Thoracic Medicine 14291 13068 1223 91.44% 14111 180

Neurology 1239 1157 82 93.38% 1263 -24

Rheumatology 1829 1688 141 92.29% 1596 233

Geriatric Medicine 1619 1405 214 86.78% 1448 171

Gynaecology 453 440 13 97.13% 609 -156

Other 3804 3490 314 91.75% 3598 206

All specialties 64037 57663 6374 90.05% 61159 2878

DERBYSHIRE COMMISSIONER – INCOMPLETE PATHWAYS (92%)

167


TABLE 52+ WEEK WAITERS – Trust Trajectory

What are the issues? • Increase referrals seen in Urology and Breast 2wk urgent referrals. • Increase in demand seen in Dermatology over the summer, compounded by annual leave. • Staff vacancies in Respiratory, Gastro, Cardiology, General Med, ENT and Vascular Surgery. • Capacity Issues in Respiratory, Orthopaedics, Ophthalmology and Gynaecology. • Validation backlog due to the vacancy of 1.5 wte

What are the next steps • Validation work planned for Oral Surgery and Cardiology outpatients. • Reviewing patient pathways in Rheumatology, Ophthalmology and Cardiology • Plan to pilot one stop straight to MRI this will commence in November for Urology.

21

Performance Analysis During September CRHFT failed to achieve the incomplete pathway standard (92%) achieving only 88.5%. The September 18 position has deteriorated when compared to August 18 and is the lowest since October 17.

What actions have been taken? • Clinical Haematology – Locum consultant made substantive to provide additional support in

clinic and wards. Vacant consultant posts now appointed, one will start mid November with 10 PA’s and the other one starts in January to work 7 PA’s. Locum consultants continue to provide support through-out September, October & November

• Endocrinology -Locum Consultant provided additional capacity until mid September to see 20 new and 22 follow ups..

• Cardiology – Appointed to vacancy on 10th September, locum was in place covering until appointment. Further validation be undertaken on follow ups.

• Gastro - Fibro scanning nurse to shadow in clinic with a view to implementing specific clinics. Endoscopy nurse completed training and undertaking endoscopy sessions.

• Gen Med – New Consultant appointed, new clinics in the process of being set up. • Respiratory - Options for locum support being explored, modelling the possibility of additional

capacity. • Urology – Additional Consultant evening and weekend sessions to clear the backlog, additional

theatre capacity being investigated. Plan to pilot one stop straight to MRI this will commence in November.

• Orthopaedics - Work is being undertaken to move patients between colleagues where possible, working with clinical team to increase the number of lists.

• Breast Surgery - Locum consultant post now out to advert with middle grade cover planned for the interim period.

• ENT - Locum continues to cover vacancy, extra capacity in October. • Vascular - Regular weekly clinic now supported by Derby enabling a reduction in waiting times

for new • Ophthalmology - Locums are covering essential clinics with extra capacity planned during

October. • Clinical Validator appointed, starting in October with a 4 month training timeline. Existing staff

working overtime on weekends and evening to provide additional capacity.

CRHFT Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Actual 6 4 7 6 5 4 12

Trajectory 6 9 6 4 1 0 0 0


Total

Incomplete

Waiting List

Number < 18

Weeks

Backlog

(+18 Weeks)

%

<18 Weeks

March 2018

Waiting List

Movement

from March

18

General Surgery 2392 2046 346 85.54% 2169 223

Urology 1007 846 161 84.01% 1148 -141

Trauma & Orthopaedics 1266 1090 176 86.10% 1282 -16

ENT 1159 1046 113 90.25% 1205 -46

Ophthalmology 1367 1249 118 91.37% 1390 -23

Oral Surgery 360 328 32 91.11% 366 -6



Cardiology 589 525 64 89.13% 564 25

Dermatology 1407 1329 78 94.46% 1002 405


Rheumatology 355 327 28 92.11% 323 32

Gynaecology 1073 926 147 86.30% 1062 11

Other 1608 1351 257 84.02% 1859 -251

All specialties 15133 13183 1950 87.11% 14908 225

CRHFT – INCOMPLETE PATHWAYS PERFORMANCE (92%)

168


TABLE 52+ WAITERS – Trust Trajectory

What are the issues? • General Surgery –Waiting list backlog from cancellation of elective surgery and issues

with thyroid and bariatric waiting lists. • T&O – Waiting list backlog from cancellation of elective surgery and loss of beds

during Winter is continuing to impact although the backlog is reducing. The overall size of the waiting list has increased due to increased referrals.

• Rheumatology – Referrals have increased and struggling with capacity. The waiting time for booking has reduced from 30 to 27 weeks.

• Max Fax – Have consultant surgeon vacancies. Team also supporting Nottingham and Leicester with their cancer referrals.

What actions have been taken? • General Surgery – Trust continue to run additional lists to reduce the backlog. Thyroid

consultant capacity is hoping to be increased by reducing outreach clinics. Additional weekend operating in planned for bariatrics.

• T&O – Additional waiting list sessions are being offered for consultants who have long waiters. Use of independent sector capacity to reduce the backlog. New appointment has commenced in September to cover some of the work due to a consultant retiring.

• Rheumatology – An additional consultant is now in post as well as the appointment of a speciality doctor. 2 part time nurses are currently under recruitment.

What are the next steps • Rheumatology – Speciality doctor recruited but unable to start in post until

December/January. • Max Fax – Recruit 2 surgeons. A further surgeon will be retiring and this will impact on

the RTT benign work. • The waiting list reductions planned as part of the CCG RTT waiting list recover plan will

positively impact on the delivery of overall trust and speciality delivery against the 92% national standard

22

UHDB Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Actual 24 19 19 18 14 12 12

Trajectory 22 20 18 15 15 10 10 10 10 10 10 0


Total

Incomplete

Waiting List

Number < 18

Weeks

Backlog

(+18 Weeks)

%

<18 Weeks

March 2018

Waiting List

Movement

from March

18

General Surgery 3372 2838 534 84.16% 3531 -159

Urology 2469 2258 211 91.45% 2246 223

Trauma & Orthopaedics 8632 7551 1081 87.48% 7704 928

ENT 3519 3176 343 90.25% 3155 364

Ophthalmology 5414 4836 578 89.32% 4935 479

Oral Surgery 806 666 140 82.63% 0 806

Neurosurgery 96 90 6 93.75% 0 96

Plastic Surgery 258 238 20 92.25% 225 33

Cardiothoracic Surgery 15 14 1 93.33% 0 15



Cardiology 2321 2235 86 96.29% 1691 630

Dermatology 3495 3433 62 98.23% 2831 664


Neurology 1379 1306 73 94.71% 1101 278

Rheumatology 1489 1293 196 86.84% 1230 259

Geriatric Medicine 274 260 14 94.89% 240 34

Gynaecology 3345 3145 200 94.02% 2914 431

Other 12644 11465 1179 90.68% 11342 1302

All specialties 52796 47935 4861 90.79% 48003 4793

UHDB – INCOMPLETE PATHWAYS PERFORMANCE (92%)

Performance Analysis During September UHDB failed to achieve the incomplete pathway standard (92%) achieving 90.79%. The September 18 position has shown improvement however when compared to August 18.

169


What are the issues? • Due to the cancellation of elective surgery earlier in the year a number of

patients were seen quite late in their pathway and there were a number of patient choice issues during the Summer months.

• The national requirement is that the CCGs will half the number of patients waiting over 52 weeks by March 2019 of that reported at the end of March 2018 (20). The number of CCG patients at the end of September was 20.

What actions have been taken? • The CCG are receiving weekly reports from our main providers and a number of

associate contracts for all patients over 40+ weeks and enquiries are being made each week to understand why patients have not received TCI’s.

• UHDB hold weekly meetings which review all patients over 40 weeks ensuring that any difficulties are escalated.

• UHDB have put on additional capacity at weekends in an effort to clear the oral surgery patients.

• CRH, with NHSE, have implemented Electronic referral for Oral surgery, this has reduced the number of referrals as expected and this speciality is now compliant with no 52 week waiters.

What are the next steps • The waiting list reductions planned as part of the CCG RTT waiting list recovery

plan will reduce the number of patient waiting over 52 weeks. • Additional Saturday theatre lists will be booked to enable additional theatre lists

to be undertaken for OMF patients. This reduced the OMF patients waiting for surgery during the Summer and it is hoped that this will have the same effect.

• Locum consultant to operate on a specific group of TMJ arthroscopy patients to reduce the backlog further.

23

Performance Analysis During September there were 27 Derbyshire patients waiting over 52 weeks

CCG Trust No

ECCG Nottingham 1

UHDB 1

HCCG CRH 1

NDCCG CRH 6

Oxford Hospital 1

STOCKPORT NHS FT 1

SDCCG UHDB 4

North Midlands Trust 2

NUH 1

Sherwood Forest 1

Oxford Hospital 1

NHSE - Max Fax UHDB 6

CRH 1

Total 27

DERBYSHIRE COMMISSIONER - 52+ WEEK WAITERS

Of the 27 patients, 4 patients had not been treated at the start of December. 3 x Maxillofacial patients at UHDB with no TCI date and one T&O patient with a TCI date of 4.12.18

CCG patients - Trend

CCG Name Mar-18 Jun-18 Jul-18 Aug-18 Sep-18 Year end target

ECCG 1 2 0 4 2 1 HCCG 4 0 1 1 1 2 NDCCG 6 6 6 5 8 3 SDCCG 9 13 10 8 9 5 Derbyshire 20 21 17 18 20 10

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24

ELECTIVE CARE - REFERRAL TO TREATMENT CCG AND TRUST RECOVERY PLANS Performance analysis

• Baselines were set for the RTT recovery plan using the July 2018 position and overall for Derbyshire the position was required to be reduced by 3,192 patients.

• In September 2018 there has been a reduction of 314 pathways (2,878). • SD CCG has the largest reduction required at 1,653 but has only shown a

reduction of 14 pathways when compared to the July to March 18 gap. Whilst DTHFT have shown an increase in the position this highlights the use of independent sector providers to stabilise the list.

• ND CCG have shown a reduction of 333 pathways which is likely as a result of CRHFT reductions. CRHFT have shown a reduction in incomplete pathways between September and July 2018 (-522). CRHFT are now 225 pathways from achieving the March 18 position.

• DTHFT are currently shown a increase in the gap from the March 18 position by 1,393 pathways. The reduction required to meet March 18 is now 4,793.

What are the issues? NHSE mandate to reduce the total number of incomplete pathways from referral to treatment to below the March 18 reported position by March 19. This must be delivered at a CCG level and will require University Hospitals of Derby & Burton FT (UHDB) and Chesterfield Royal FT (CRH) to: Recover the March 2018 waiting list position by March 2019 and to deliver elective activity to plan by March 2019. • Recovery actions plans received from both UHDB and CRH have identified at total reduction in

patients on the waiting list by 4,884 by March 19. • Using the July 2018 position there was 3,192 Derbyshire patients above the March 18 waiting

list position. • The trust reductions have then been apportioned by Derbyshire CCGs, recognising that not all

trust patients will be resident within Derbyshire. If the agreed reductions are delivered Derbyshire CCGs will be back in line with the March 18 position.

What are the next steps • Weekly performance calls continue with providers to track progress against the RAP and trajectory. • Barlborough additional Capacity – Whilst the trust are looking to start operating core lists from January there

is the possibility for ad hoc work in December.

-314

-522

+1,393

Mar-18 Jul-18Movement From

March 18

CRHFT

CCG @

provider

CRHFT CCG

apporitoned

Change

(Based on

recovery

trajecory)

UHDB

CCG @

provider

UHDB CCG

apporitone

d Change

Additional

Provider

Impacts

Total ImpactsDistance from

March 18

NHS Erewash CCG (03X) 5247 5420 173 0% 0 4% 139 34 173 0

NHS Hardwick CCG (03Y) 6636 7004 368 23% 324 1% 20 24 368 0

NHS North Derbyshire CCG (04J) 18669 19653 984 69% 983 1% 18 1001 -17

NHS Southern Derbyshire CCG (04R) 30607 32274 1667 2% 30 52% 1782 1812 -145

Derbyshire CCGs 61159 64351 3192 93% 1337 57% 1959 3354 -162

Total CRHFT 14908 15979 1071 1433 1433 -362

Total UHDB 48003 51454 3451 3451 3451 0

Commissioner Positon Trust Recovery Trajectory CCG ImpactsTotal Impacts

What actions have been taken? CRHFT: Commissioners have received the trusts detailed recovery action plan (31.10.18). RAP is underpinned by 4 key priority areas and includes a speciality specific action plan and weekly recovery trajectory. Actions completed include training of internal teams with in month validation of the waiting lists and monitoring and reporting of speciality level recovery plans. Some risk remains around gastro due to increased demand) and within diagnostics (IS provider dropped lists). UHDBFT: Additional activity has commenced at Nuffield (October 2018) and is confirmed at Barlborough. E-RS capacity alerts are being implemented supported by comms to GPs, to redirect referrals at source (starting with Orthopaedic referrals into the Derby site, with further specialities to be confirmed). The alert will suggest for the GP to refer into Circle / Nuffield or Barlborough. An in-sourced Medinet solution is being explored for ophthalmology and rheumatology. Commissioners have facilitated the initial phases and is being developed between providers. The trust have confirmed that additional validation resource would enable them to validate the entire waiting list and reduce the overall incomplete position. A business case is being written to secure additional capacity and the Trust is currently quantifying the impact on the list size.

171


Performance Analysis Derbyshire CCG diagnostic performance during September 18 was 2.8% (1%). Southern Derbyshire CCG met the 1% standard. The key tests in Derbyshire which are performing above the 1% standard include Echocardiographs (16.7%) and Urodynamics (14.7%). There are further tests which are currently performing above the 1% standard. It is likely that these are due to associate provider over performance which is impacting on the CCG position. The 2nd table below highlights the total provider diagnostic performance by test. It is however important to note that performance is only monitored at an overall “total” position and that test

level has been supplied in order to understand the issues further.

What are the issues? As CCG flows into a provider will be based on geographical location of the patients, likely over performance will be present in the test level provider position. The 2 main providers in Derbyshire have large issues with Echocardiographs (CRHFT) and Urodynamics, Cystoscopy and DEXA scans (UHDB). Further to this the associate provider East Cheshire is having large performance issues across a range of specialities including Echocardiographs and Urodynamics. The issues include demand being higher than capacity available. Sherwood Forest Hospitals are also having an issue with cystoscopy. 28 out of 112 waiting list waited above 6 weeks.


What are the next steps and the point of impact? The CCGs will continue to work closely with their main providers within Derbyshire to ensure improvement in the position. Associate providers continue to be closely monitored.

25

CCG Actions • Please see page 24 and 25 for the

CCG actions relating to CRHFT and UHDB.

• CRHFT – Trajectory for recovery is being agreed w/c 12.11.18.

• Lead commissioners East Cheshire CCG have issued a Contract Performance Notice on the 10.10.18 in relation to Diagnostic performance at East Cheshire. Further work is underway to ensure sight of the recovery plan and timescales.

Provider Actions • Please see page 24 and 25 for the

CCG actions relating to CRHFT and UHDB.

• East Cheshire Hospital are looking to maintain productivity at 90%, ensure compliance with access policy to maintain DNAs and validation of the waiting list.

DERBYSHIRE COMMISSIONER – 6 WEEK DIAGNOSTIC WAITING TIMES (Less than 1%)

Test

North

Derbyshire

CCG

Hardwick

CCG

Souther

Derbyshire

CCG

Erewash

CCG

Derbyshire

CCGs

Cardiology - Echocardiography 25.7% 29.2% 2.6% 1.5% 16.7%

Urodynamics - Pressures & Flows 0.0% 16.7% 22.9% 25.0% 14.7%

Colonoscopy 14.4% 0.0% 0.0% 1.6% 6.2%

Cystoscopy 0.0% 0.0% 8.2% 0.0% 5.3%

Flexi Sigmoidoscopy 12.3% 0.0% 0.8% 6.7% 4.9%

DEXA Scan 0.0% 1.6% 2.8% 23.8% 2.5%

Respiratory Physiology - Sleep Studies 0.0% 0.0% 2.2% 0.0% 1.2%

Neurophysiology - Peripheral Neurophysiology 2.3% 0.0% 1.0% 0.0% 1.1%

Audiologyy 0.0% 0.0% 1.7% 10.0% 1.0%

Gastroscopy 1.2% 0.0% 0.4% 0.0% 0.5%

Magnetic Resonance Imaging 0.3% 0.9% 0.0% 1.3% 0.3%

Computed Tomography 0.1% 0.0% 0.0% 0.0% 0.1%

Non-obstetric Ultrasound 0.0% 0.0% 0.0% 0.0% 0.0%

Total 5.3% 4.9% 0.7% 1.2% 2.8%

Diagnostic Test Name

Chesterfield Royal Hospital NHS Foundation Trust

University Hospitals Of Derby And Burton NHS Foundation Trust

East Cheshire NHS Trust

Stockport NHS Foundation Trust

Sheffield Teaching Hospitals NHS Foundation Trust

Sherwood Forest Hospitals NHS Foundation Trust

NUH

Cardiology - Echocardiography 31% 25% 1%

Urodynamics - Pressures & Flows 16% 48% 5%

Colonoscopy 49% 2% 2%

Cystoscopy 6% 33% 2% 16% 2%

Flexi Sigmoidoscopy 44% 1% 1% 5%

DEXA Scan 4% 1% 1% 39%

Respiratory Physiology - Sleep Studies 2%

Neurophysiology - Peripheral Neurophysiology 2% 7%

Audiology - Audiology Assessments 5%

Gastroscopy 13% 4%

Magnetic Resonance Imaging 1%

Computed TomographyNon-obstetric UltrasoundTotal 6% 1% 18% 0% 0.4% 1% 3%

172


Performance Analysis CRH did not meet the diagnostic waiting times for the proportion over 6 weeks to be less than 1%. They have failed this measure for the last three months.

What are the issues?

• Diagnostic Referrals have risen averaging 1000 per month more than March

2018. • Echocardiography waiting list has increased from June and capacity has not been

able to be increased. • There has been a long term staff vacancy and long term sickness. The vacancy is

being covered by a locum who had 1.5 weeks of unplanned leave in August.


• Permanent recruitment to the vacant post has now been successful. Home Office

approval has been received and the candidate is now waiting for a Visa • Additional agency staff have been identified from 22/10/18 • Existing staff have agreed to provide additional weekend sessions • Discussions are taking place with an additional 3rd party provider • An additional MRI scanner was installed in September and is being brought into

service.

What are the next steps

A CPN has been raised and Recovery Action Plan received which includes • Demand & Capacity modelling • Outsourcing activity • Sustainable workforce • Additional on-site capacity including equipment

26

CRHFT DIAGNOSTICS - 6 WEEK DIAGNOSTIC WAITING TIMES

Diagnostic Test Performance above 1% standard - September 18

Diagnostic Test Name Chesterfield Royal Hospital NHS Foundation Trust

Cardiology - Echocardiography 31.4%

Total 5.8%

173


Performance Analysis UHDB have achieved the diagnostic standard every month since September 2017. There are a number of test level performance issues which are highlighted in this report.

What are the issues? Cystoscopy – Remains challenging with capacity on Consultants lists. There are a lot of DNA’s and patient choice issues. DEXA Scans - Currently compliant at the Derby site, non compliant at the Burton site. Issue is due to the department not having an IT solution for there referral process. Breaches are generally occurring due to delays in the paper referral reaching the registration team. Neurophysiology – 7 patients were seen after 6 week and the issue is still under investigation to establish why. Urodynamics – Urology do not have control of booking patients or managing slots. This along with staff sickness has contributed to the failure of this target.

What actions have been taken? Cystoscopy – Generic code is now used for consultants to book multiple consultants patients on one list instead of dedicated lists per consultant. This should allow for more flexibility in booking patients. There have been 2 weekend lists in an effort to clear backlog. DEXA Scans – As the trusts have now merged, Burton are looking to implement an IT solution. Urodynamics – Urology have taken over this service from 1st October and currently only have a couple of outliers over 6 weeks.

What are the next steps Cystoscopy – Undertake review of DNA’s and Patient choice. As the generic code is

working well look at whether this can be used further to give greater flexibility. Urodynamics – Trying to recruit an HCA to support the urodynamic sessions.

27

UHDB DIAGNOSTICS - 6 WEEK DIAGNOSTIC WAITING TIMES

Diagnostic Test Performance above 1% standard - September 18

Diagnostic Test Name

University Hospitals Of Derby And Burton NHS Foundation Trust

Cystoscopy 6.1% DEXA Scan 3.9% Neurophysiology 1.6% Urodynamics 15.9% Total 1%

174


Performance Analysis During September 2018, Derbyshire was non compliant in 5 out of the 9 cancer standards. All of the 4 CCGs failed the 62day standard (85%) and NDCCG also failed the 2wk Breast Symptom standard (93%). Patients continue to wait over 104 days for first treatment at all CCGs except Erewash.

What are the issues? Performance data reflects the complete cancer pathway which for many Derbyshire patients will be completed in Sheffield and Nottingham. The 62 day performance is reflective of non compliance at CRHFT, UHDBFT, STHFT, ECFT, Stockport FT and NUHFT. The only Trust achieving the standard is SFHFT. CRHFT failed to achieve the 2ww Breast Symptoms standard which resulted in both HCCG and NDCCG also being non compliant


What are the next steps and the point of impact? CCGs will be agreeing realistic recovery dates with CRHFT and UHDBFT early in December which will then be monitored on a monthly basis through the contacting process.

28

CCG Actions A Contract Performance notice was issued to CRHFT for delivery of the 62 day standard in Jan 2018. The Trust has failed to deliver recovery as predicted and were asked to submit a revised RAP w/c 11/11 A CPN was also issued to UHDB and the CCG received the RAP w/c 11/11. Further discussions with the Trust were held on 5/12 as the proposed recovery date, supported by NHSI, is March 2020. The CCGs are seeking an earlier date for compliance

Provider Actions Please see pages 28-30 for CRHFT and UHDB provider actions.

DERBYSHIRE COMMISSIONER – CANCER WAITING TIMES

175


What are the issues? • Current shared pathway for Urology with Sheffield Teaching Hospital is resulting in

delays in treatment. Agreed revised pathway with Sheffield from January 2019. • 2 week referrals have risen since February in both Breast (+40) and Urology (+50) on

average a month, which then track through the pathway which impact on the 62 day deliver standard.

• 2 out of the 3 Breast Consultants at the trust were off sick for 3 months, locums employed to cover but unable to perform complex surgery impacting on the 62 day delivery.

• The trust have seen a rise in Diagnostic referral from February to July for Colonoscopy (+84) and MRI (+95) which is causing a delay the decision to treat which is impacting on the patients being seen within 62 day.

• 6 Head & Neck patients were not seen within 62 days due to lack of capacity at STH (3 patients), Delay waiting for MRI results (2 patients) and 1 complex pathway

What actions have been taken? • Newly appointed radiologist utilised for MRI prostate reporting only as another member

of staff has left leading to delay in other diagnostic results. With an additional MRI scanner available from September.

• Full complement of Breast Consultants at the Trust. • An updated electronic Urology referral form has been introduced into Primary Care in

November, formalising the information required and reducing the number of enquiries back to GP practice before the 1st O/Pat apt could be made. Primary Care has also requested to delay a referral if the patient is not available for tests and treatment over the following 2 months.

• Urology pathway activity with STH has now been formally agreed to transfer to STH from the date the information is available for the Sheffield Consultant from 7th January 2019.

• 104 day breach reports have been analysed by the Quality Manager, breach reasons are multi factorial and many if these patients are very complex, there are clearly capacity issues which the team will discuss with the Trusts to agree action to address them.

What are the next steps • CCG contracts team requested a revised RAP • Capacity review of the Head & Neck Pathway at CRH and STH


62 day performance breached the standard in September at 81.29%. The Trust has now been non-compliant for 4 out of 6 months in 2018/19.Early indications for October are for non-compliance. The 104+ day wait target continues to breach recording 3.5 in September. This related to 5 patients in total, 3 of which were on a shared pathway with STH.

29

Tumour Type Total Pts Seen +62 days %

Performance

Breast 12.5 4.5 64.00% Gynaecological 4 1 75.00% Haematological (Excluding Acute Leukaemia) 7 1 85.71% Head and Neck 3.5 3 14.29% Lower Gastrointestinal 4.5 0 100.00% Lung 2.5 0.5 80.00% Skin 18 0 100.00% Upper Gastrointestinal 2.5 0.5 80.00% Urological (Excluding Testicular) 15 2.5 83.33% Totals 69.5 13 81.29%

CRHFT - CANCER WAITING TIMES (62 Day Waits)

176


What are the issues?

• 2 out of the 3 Breast Consultants at the trust were off sick for 3 months, locums

employed to cover but unable to perform complex surgery impacting on the 62 day delivery.

• 2 week referral have risen since February in Breast (+40) and May saw a spike of 79. This has impacted on both diagnostic, In Patient and Out Patient capacity.

• As expected patient availability over the summer is reduced due to holidays • The trust have seen a rise in Diagnostic referral which is causing a delay for the

decision to treat which then impacts on the patients being seen within 62 day.


There is now a full complement of Breast Consultants at the Trust. Planned Maternity Leave in November has already been resolved securing a Locum Consultant for that period.

30


62 day screening performance breached the standard in September at 72.2%. The Trust has now been non-compliant for 3 out of 6 months in 2018/19. The main tumour site which is effecting the performance is breast (61.54%) all other tumour sites within the measure are currently compliant.

Tumour Type Total pts seen +62 days % Performance Breast 13 5 61.54% Gynaecological 1.5 0 100.00% Lower GI 3.5 0 100.00% Totals 18 5 72.22%

CRHFT - CANCER WAITING TIMES (62 Day Screening)

What are the next steps?

CCG contracts team will be requesting a revised RAP week commencing 12/11/2018.

177


What are the next steps • UHDB have provided a recovery action plan in response to the contract performance noticed

raised by the CCG on the 10th October 2018 which has identified March 2020 for recovery against the 62d national standard. The CCG have asked the trust to review the recovery timescale and identify actions to ensure recovery sooner than March 2020. Actions include:

• Engagement programme for all clinical and operation teams based on an agreed and optimised understanding of the Cancer waiting times guidance.

• Sustained recruitment of oncologists and oncology medical workforce review by 01/04/19. • Review MDT and Tracking processes in response to increased demand and ensure

correct infrastructure in place to quickly diagnose and discuss patients by 01/03/19 • Pathway redesign for optimal Lung, RAPID prostate and Colorectal pathways by 01/04/20

Performance Analysis –

62 day performance for September was 79.7%. This is the fifth successive month that the trust have failed this standard.

31

Tumour Type Total pts seen +62

days

%

Performance

Breast 23 0 100.00% Gynaecological 12 2 83.33% Head and Neck 4 1 75.00% Lower Gastrointestinal 20 2 90.00% Lung 10 5 50.00% Other 2 0 100.00% Sarcoma 1 0 100.00% Skin 35.5 3 91.55% Testicular 2 0 100.00% Upper Gastrointestinal 15 6 60.00% Urological (Excluding Testicular) 45.5 15.5 65.93% Totals 170 34.5 79.71%

UHDB - CANCER WAITING TIMES What are the issues? • Urology referrals - Increase during Q1 has severely affected performance. During Q1

17/18 the number of urology referrals was 452. Over During Q1 18/19 this had risen steadily to 602 referrals. This number of referrals has caused delays in clinic capacity as well as increased waits for diagnostic procedures. QHB are no longer referring patients to Birmingham.

• Imaging- There are delays for Truss Biopsies which is delaying Urology patients. • Head and Neck services are also supporting Nottingham and Leicester patients. There

is only one surgeon currently who undertakes cancer surgery so capacity is an issue, but currently being managed. Particular issues if the patient requires robotic surgery as currently the head and neck service have one theatre session per month.

• Gynaecology has received 10% more referrals over the last year (cancer and benign) and an increase in more complex patients who require ultra radical treatment.

• Upper GI. A recent increase in referrals has resulted in capacity issues.

What actions have been taken? • 2 locum oncologists commenced in post during September. • Two new Head and Neck consultants commence in November. • General Gynaecology patients are now being offered treatment over at the Burton site to

reduce waiting times at the Derby site. This will give additional capacity for the complex gynaecology patients. Unfortunately out of 80 patients offered this alternative only 34 agreed.

• Urology - there is an extra double clinic on a Saturday to pull Truss Biopsies cases in, with the aim to get back to a 1 week wait. MRI capacity under review.

• Upper GI Capacity is currently being increased, benefits will be seen in the following months

• Lung -Extra 2ww clinics have been put on to manage demand.

178


Activity

32 179


33

Indicator Issues Actions

Referrals GP / Other referrals for Derbyshire remain above plan at Month 6 (1.8%) with North Derbyshire CCG having largest variance to plan (4.3%). GP Referrals: The plan for 18/19 was set using a low activity year as well as a low level of national growth (c.0.69%) which has resulted in a high year on year position as well as activity above plan. Using a local proxy for GP referrals (FOP Appointments), Derbyshire is showing a similar increase in activity to the MAR referral data (c.4%) year on year. Main providers UHDB (7%) and CRHFT (4% )continue to show increases year on year in GP referrals. Specialities which have shown increases include Gastroenterology (43%) and Urology (12%). Other Referrals: Overall Derbyshire is currently 0.8% below plan. Both Erewash and Southern Derbyshire CCG are below plan whilst North and Hardwick CCGs are above plan. The plan was set using national growth which for Derbyshire was 4.6%.

(1) Work continues with all Derbyshire practices to establish practice networks and drive down unwarranted variation.

(2) Place data packs are in development and draft packs have now been shared with 5 out of 8 places. An initial meeting took place on 31.10.18 to scope out the requirements for referral reporting and monitoring at practice level as well as reviewing. A further meeting has taken place to discuss the requirements for the primary care team as well as the process to identifying priority areas e.g. specific specialities.

.

Elective

Ordinary Total Elective Admissions - Ordinary for Derbyshire continue to be below plan at M6 (6.6%). Largest variances were shown at Hardwick (8.2%), ND CG (6.4%) and SD CCG (7.2%). Year on year activity has also shown a decrease (5%) and this is due to the cancelled operations in January 2018. The trend in activity is increasing and if it continues CCGs will be at planned levels– at month 6 activity was up by 4% when compared to month 5. Compared to last year CRHFT SUS activity has shown a 3% increase year on year and DTHFT has shown a -8% decrease year on year. Additional use of independent sectors is also apparent with the increase in Nuffield health activity up by 25% year on year.

The Derbyshire CCG Elective ordinary position against plan is consistent with the contract position at DTHFT and the position is below contract plan at M6. The contract position at CRHFT is currently -2 below plan showing an increasing activity when compared to the M5 position. Within both contracts the position is likely to increase due to the work ongoing to reduce waiting list sizes. This is likely to bring Derbyshire CCGs closer to plan. Please see page 32 for further detail on the issues and actions.

Day Case Day Case activity for Derbyshire are above plan at Month 5 (1.9%) and year on year activity has shown a 6% increase. Hardwick CCG (2.4%) and Southern Derbyshire CCG (2.8%) have shown the highest variances against plan. Both DTHFT and CRHFT have shown increases year on year in day case activity. Compared to last year main increase was seen in General Surgery (22%) and Clinical Haematology for Hardwick CCG. At Erewash CCG Gastroenterology (13%) has an increased when compared to last year.

The Derbyshire CCG Day case position within the operational plan, is consistent with the contract position at both CRHFT and DTHFT which is above plan at M6. Increases at Erewash and SD CCG within Gastroenterology are consistent with the DTHFT contract. This has seen an increase in Diagnostic Flexi Sigmoidoscopy activity. This is currently being challenged and has been escalated to CMDG (1/12/2018 resolution date).

Planned Care Activity – Month 6

Actual Activity vs Plan - Cumulative Month 06 2018/19

NHS

Erewash

CCG

NHS

Hardwick

CCG

NHS North

Derbyshire

CCG

NHS

Southern

Derbyshire

CCG

Derbyshire

CCG

Referrals

E.M.07: Total Referrals for a First Outpatient Appointment (G&A) 0.1% 5.5% 4.3% (0.2%) 1.8% E.M.07a: Total GP Referrals for a First Outpatient Appointment (G&A) 4.3% 4.1% 4.4% 1.9% 3.1% E.M.07b: Total Other Referrals for a First Outpatient Appointment (G&A) (7.3%) 8.3% 4.2% (3.9%) (0.8%)

Outpatients E.M.08: Consultant Led First Outpatient Attendances (Specific Acute) (7.1%) (5.3%) (5.6%) (4.6%) (5.2%) E.M.09: Consultant Led Follow-Up Outpatient Attendances (Specific Acute) (3.6%) (1.7%) (1.3%) 4.8% 1.5%

Electives

E.M.10: Total Elective Spells (Specific Acute) 1.5% 0.8% (0.7%) 1.3% 0.6% E.M.10a: Total Day Case Elective Admissions (Spells) (Specific Acute) 1.9% 2.4% 0.2% 2.8% 1.9% E.M.10b: Total Elective Admissions - Ordinary (1.2%) (8.2%) (6.4%) (7.2%) (6.6%)

180


ELECTIVE CARE - ELECTIVE ACTIVITY (DAY CASE AND ELECTIVE ORDINARY) ACTIVITY VS OPERATIONAL PLAN

Performance Analysis NHSE allow a 2% tolerance above or below contracted activity. Derbyshire wide 4 out of the 4 CCGs are below plan or within the NHSE 2% tolerance for variance for total Elective activity. Activity is currently within tolerances due to elective activity performing below plan and contracted activity levels. In contrast to this Day case activity is currently above plan and contracted activity levels. Individual CCGs rated as amber (local rating) is due to the focus from NHSE to increase elective activity in order to reduce the waiting list position). SD CCG are currently rated as green as they are within NHSE 2% thresholds and also that the increase has increased in M6 when compared to month 5.

34

Actual vs CCG Plan

Movement Month to month

YTD Actual vs Plan:

Actual vs combined CCG

Plan


YTD Actual vs Plan:

l i 1.50% l i 0.80%


Plan


YTD Actual vs Plan:


Plan


YTD Actual vs Plan:

l i -0.70% l h 1.30%

NHS North Derbyshire CCG NHS Southern Derbyshire CCG

NHS Erewash CCG NHS Hardwick CCG

Derbyshire Commissioner (SD CCG, ND CCG, Hardwick CCG and Erewash CCG)EM10a and EM10b Day Case and Ordinary Elective Admissions Source: DM01OP Trajectory = Operational Plan TrajectoryOperational Plan

0

200

400

600

800

1,000

1,200

1,400

2018-19 2017-18

0

200

400

600

800

1,000

1,200

1,400

1,600

2018-19 2017-18

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

2018-19 2017-18

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

2018-19 2017-18

181


GP REFERRAL ACTIVITY MONITORING VS OPERATIONAL PLAN


All 4 Derbyshire CCGs are currently above plan for GP referrals. Across Derbyshire, there has been a c.6% increase in GP referrals year on year. MAR data which is used to measure GP referral activity in the operational plan is a limited data source which can only show the position by CCG and trust. In order to analyse the position further a SUS proxy is used, based on GP first outpatient appointments. Key specialities which have shown increases year on year include Gastroenterology (43%) and Urology (12%).

What are the issues? Analysis of GP referrals across Derbyshire Practices shows significant variation including variations within Places. There will always be some variation in healthcare due to the complexity of the variables that produce it e.g. characteristics of the individual patient, disease complexity and unpredictability of symptoms. Further work is required at a place and practice level in order to understand how much of the variation is unwarranted and the driving factors behind it. This is required in order to review and improve the CCG position for GP referrals. GP referrals are above plan by 3.1% which is the same reported variance at M5. 3 out of 4 Derbyshire CCGs are above plan by c.4% with only SD CCG within the NHSE threshold (2%). The 18.19 plan for GP referrals was set using a c.0.69% growth for Derbyshire CCGs and was applied to the 17/18 forecast outturn position. At month 6 the change year on year in referral activity is c.6%. 2017/18 saw an overall decrease in referrals when compared to the 2016/17 m6 position (-7%). When compared to 16/17 at M6 activity is down by -2%.

What actions have been taken? • Supported practices to establish practice networks in Place • Developed a draft data pack using RAIDR (Reporting Analysis and Intelligence

Delivering results, a Healthcare intelligence tool) data to allow discussion, peer review and reflection within practice networks (geographical area) around variation and to support the practices using RAIDR as a tool.

• Identified outlying practices in terms of overall referral cost and begun work with practices to understand what is driving variation, and to co-produce and implement a turnaround plan.

What are the next steps? An outline action plan is in development for the CCG covering current and next steps. As part of this a draft referral management plan is in development as part of an overall project opportunity document for General Practice. The aim would be to begin work during Q4 18.19 and throughout 19.20.

35

Actual vs Plan YTD

(+/- 2%)


YTD Actual vs Plan:

Actual vs Plan YTD

(+/- 2%)


YTD Actual vs Plan:

l i 4.4% l i 1.9%

Actual vs Plan YTD

(+/- 2%)


YTD Actual vs Plan:

Actual vs Plan YTD

(+/- 2%)


YTD Actual vs Plan:

l i 4.3% l i 4.1%

EM7a: Total GP Referrals Made for a First Outpatient Appointment (G&A)Source: Monthy Activity Return

NHS North Derbyshire CCG NHS Southern Derbyshire CCG

NHS Erewash CCG NHS Hardwick CCG

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

2018-19 2017-18 Plan

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

2018-19 2017-18 Plan

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

2018-19 2017-18 Plan

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000Ap

r-18

May

-18

Jun-

18

Jul-1

8

Aug-

18

Sep-

18

Oct-1

8

Nov-

18

Dec-

18

Jan-

19

Feb-

19

Mar

-19

2018-19 2017-18

182


36

Indicator Issues Actions

Total A&E

Attendances Both Erewash and SD CCG remain below plan at Month 6. The largest variance is seen at Southern Derbyshire CCG which continues to be below plan (-6.6%). Year on year the activity for SD CCG has shown a -2% reduction in activity. All other CCGs have shown an increase year on year. Reviewing the Derbyshire activity at provider level DTHFT has shown a -2% reduction year on year whilst CRHFT have shown a 7% increase year on year. A large reduction is identified at the Derby Urgent Care Centre (-20%). This is due to the provider missing the M6 deadline for submission. In contrast to this MIU activity at DCHS has shown a 21% increase.

The M6 contract position at DTHFT is currently below plan for A&E attendances, whilst at CRHFT the position is above plan. The CRHFT position is currently under review due to duplicate streaming activity which could be inflating the position. This is reflected in the Hardwick and North Derbyshire position which is continues to be above plan. DUCC have now submitted the M6 but missed the national deadline. This is currently being raised through the contract.

Total Non-elective: Total Non-Elective activity for Derbyshire is above plan (0.3%) at Month 6. The largest variance against plan and year on year is at Hardwick and Erewash CCGs. For Erewash CCG the largest increases year on year are within General Surgery (35%) and Geriatric Medicine (16%). At Hardwick CCG the largest increases year on year are within Paediatric (15%) and Accident and Emergency (18%) which is being coded from Doncaster and Bassetlaw Hospital.

The M6 contract position at CRHFT and DTHFT is currently below plan for Non-elective admissions.

URGENT CARE ACTIVITY M06

Actual Activity vs Plan - Cumulative Month 06 2018/19 NHS Erewash

CCG

NHS

Hardwick

CCG

NHS North

Derbyshire

CCG

NHS Southern

Derbyshire

CCG

Derbyshire

CCG

Non-Electives

E.M.11: Total Non-Elective Spells (Specific Acute) 2.5% 3.6% (0.4%) (1.8%) (0.3%) E.M.11a: Total Non-Elective Admissions - 0 LoS 2.7% 10.3% 1.2% (4.8%) 0.4% E.M.11b: Total Non-Elective Admissions - +1 LoS 2.4% 0.8% (1.1%) (1.1%) (0.6%)

A&E

Attendances

E.M.12: Total A&E Attendances (Excluding Planned Follow-Up Attendances) (2.8%) 2.6% 5.9% (6.6%) (2.0%)

E.M.12a: Type 1 A&E Attendances excluding Planned Follow Ups (6.4%) (11.8%) (11.7%) (7.6%) (9.1%)

183


Appendix

37 184


PERFORMANCE OVERVIEW M6 – MAIN PROVIDER CONTRACTS

38

Key:

Part A - National and Local Requirements

Provider Dashboard for NHS Constitution Indicators

Dir

ecti

on

of T

rave

l

Current

MonthYTD

consecutive

months of

fa i lure Dir

ecti

on

of T

rave

l

Current

MonthYTD

# months

of failure Dir

ecti

on

of T

rave

l

Current

MonthYTD

consecutive

months of

fa i lure Dir

ecti

on

of T

rave

l

Current

MonthYTD

consecutive

months of

fa i lure Dir

ecti

on

of T

rave

l

Current

MonthYTD

consecutive

months of

fa i lure


Period

A&E Waiting Time - Proportion With Total Time In A&E Under 4

Hours95% Oct-18 i 87.3% 92.5% 5 h 89.0% 89.6% 37 h 100.0% 100.0% 0 h 89.1% 89.5% 37

A&E 12 Hour Trolley Waits 0 Oct-18 g 0 1 0 h 5 21 8 g 0 0 0 h 212 1226 37

Ambulance Handover Delays > 30 Minutes Sep-18 i 230 1135 i 364 1842

Ambulance Handover Delays > 60 Minutes Sep-18 h 9 44 h 12 101

DToC Delayed Transfers Of Care - % of Total Bed days Delayed 3.5% Sep-18 i 1.44% 1.06% 0 i 3.20% 3.50% 0 i 7.8% 4.8% 2 h 0.8% 1.6% 0 i 4.1% 3.9% 42

Referrals To Treatment Admitted Patients - % Within 18 Weeks 90% Sep-18 i 81.03% 83.52% 18 i 72.57% 74.35% 18 i 93.5% 95.3% 0 i 73.1% 73.6% 69

Referrals To Treatment Non-Admitted Patients - % Within 18

Weeks95% Sep-18 i 89.89% 90.88% 18 i 90.58% 91.43% 18 i 92.1% 91.4% 13 i 89.8% 93.3% 7 i 87.3% 88.7% 39

Referrals To Treatment Incomplete Pathways - % Within 18

Weeks92% Sep-18 i 87.1% 90.2% 4 i 90.8% 91.3% 9 i 95.2% 95.8% 0 h 94.3% 93.5% 0 i 86.7% 87.5% 31


Incomplete Pathways0 Sep-18 h 9 38 19 g 12 95 11 g 0 0 0 g 0 0 0 i 3156 19527 137

Diagnostics Diagnostic Test Waiting Times - Proportion Over 6 Weeks 1% Sep-18 i 6.04% 2.51% 4 h 0.53% 0.61% 0 g 0.00% 0.17% 0 h 2.67% 2.77% 43

All Cancer Two Week Wait - Proportion Seen Within Two Weeks

Of Referral93% Sep-18 i 93.4% 95.6% 0 i 95.7% 96.0% 0 i 91.2% 91.5% 6

Exhibited (non-cancer) Breast Symptoms – Cancer not initially

suspected - Proportion Seen Within Two Weeks Of Referral93% Sep-18 i 90.6% 94.5% 2 i 95.1% 94.2% 0 h 91.8% 86.8% 7

First Treatment Administered Within 31 Days Of Diagnosis 96% Sep-18 i 95.3% 97.2% 1 i 96.6% 97.2% 0 i 96.2% 97.1% 0

Subsequent Surgery Within 31 Days Of Decision To Treat 94% Sep-18 i 100.0% 96.2% 0 i 96.2% 96.6% 0 i 92.6% 93.9% 3

Subsequent Drug Treatment Within 31 Days Of Decision To Treat 98% Sep-18 i 100.0% 100.0% 0 h 99.3% 99.1% 0 i 99.5% 99.4% 0

Subsequent Radiotherapy Within 31 Days Of Decision To Treat 94% Sep-18 i 94.7% 94.0% 0 i 96.5% 97.0% 0

First Treatment Administered Within 62 Days Of Urgent GP

Referral85% Sep-18 i 81.3% 84.1% 1 i 79.7% 81.9% 5 i 78.2% 79.7% 33

First Treatment Administered - 104+ Day Waits 0 Sep-18 i 3 14 5 h 8.0 59 30

First Treatment Administered Within 62 Days Of Screening

Referral90% Sep-18 h 72.2% 86.6% 2 i 89.5% 90.0% 1 i 88.9% 89.0% 1

First Treatment Administered Within 62 Days Of Consultant

UpgradeN/A Sep-18 i 90.9% 90.2% i 85.4% 93.4% i 84.7% 85.6%

Mixed Sex

AccommodationMixed Sex Accommodation Breaches 0 Sep-18 g 0 0 0 h 0 30 0 g 0 0 0 g 0 0 0 h 1728 10044 18

Healthcare Acquired Infection (HCAI) Measure: MRSA Infections 0 Sep-18 g 0 0 0 g 0 1 0 i 0 0 0

Plan 18 28

Actual 9 0 29 1 6816

Healthcare Acquired Infection (HCAI) Measure: E-Coli - Sep-18 h 28 149 i 81 324 h 3791 22316

Healthcare Acquired Infection (HCAI) Measure: MSSA - Sep-18 g 1 5 h 2 17 h 979 5012

Early Intervention In Psychosis - Admitted Patients Seen Within 2

Weeks Of Referral50.0% Sep-18 h 84.2% 84.9% 0 h 76.1% 75.5% 0

Early Intervention In Psychosis - Patients on an Incomplete

Pathway waiting less than 2 Weeks from Referral50.0% Sep-18 h 90.9% 90.8% 0 h 53.1% 50.0% 0

CPA Care Program Approach 7 Day Follow-Up 95.0% 18/19 Q1 i 98.1% 98.1% 0 h 95.8% 95.8% 0

Key:

Performance Meeting Target Performance Improved From Previous Period

Derbyshire Wide Provider Assurance Dashboardh



Men

tal H

ealth Early

Intervention In

Psychosis

2 Week Cancer

Waits

31 Days Cancer

Waits

62 Days Cancer

Waits

Patie

nt S

afet

y

Incidence of

healthcare

associated

Infection

Plan

ned

Care

Healthcare Acquired Infection (HCAI) Measure: C-Diff Infections Sep-18

Accident &

Emergency

Chesterfield Royal Hospital FT

Urg

ent

Care

Ambulance

Handovers

Referral to

Treatment for

non-urgent

consultant led

treatment

h

NHS England Performance

h i

University Hospitals of Derby & Burton FTDerbyshire Community Health

Services FTDerbyshire Healthcare FT

185


PERFORMANCE OVERVIEW M6 – ASSOCIATE CONTRACTS

39

Part A - National and Local Requirements

Provider Dashboard for NHS Constitution Indicators

Dir

ect

ion

of

Trav

el

Current

MonthYTD

# months

of failure

Dir

ect

ion

of

Trav

el

Current

MonthYTD

# months

of failure

Dir

ect

ion

of

Trav

el

Current

MonthYTD

consecutive

months of

fa i lure Dir

ect

ion

of

Trav

el

Current

MonthYTD

consecutive

months of

fa i lure Dir

ect

ion

of

Trav

el

Current

MonthYTD

consecutive

months of

fa i lure


Period

A&E Waiting Time - Proportion With Total Time In A&E Under 4

Hours95% Oct-18 i 76.9% 85.4% 4 i 75.2% 78.7% 40 h 89.4% 88.2% 30 i 94.4% 95.4% 1 i 70.8% 79.3% 41

A&E 12 Hour Trolley Waits 0 Oct-18 h 6 6 1 i 0 3 0 g 0 0 0 i 0 4 0 h 18 33 3

Ambulance Handover Delays > 30 Minutes Sep-18 h 433 2537 h 175 2004 i 147 577

Ambulance Handover Delays > 60 Minutes Sep-18 h 39 222 h 8 92 i 26 46

DToC Delayed Transfers Of Care - % of Total Bed days Delayed 3.5% Sep-18 h 5.44% 5.74% 17 i 3.08% 2.71% 0 h 5.42% 5.49% 11 h 3.93% 4.49% 13 h 3.05% 3.87% 0

Referrals To Treatment Admitted Patients - % Within 18 Weeks 90% Sep-18 i 54.17% 59.83% 18 i 75.66% 75.58% 18 i 85.95% 87.10% 9 i 67.72% 68.12% 18 i 70.83% 73.66% 18

Referrals To Treatment Non-Admitted Patients - % Within 18

Weeks95% Sep-18 h 87.94% 88.91% 15 i 94.92% 95.41% 2 i 91.30% 93.00% 8 i 85.44% 87.01% 18 i 75.25% 79.16% 18

Referrals To Treatment Incomplete Pathways - % Within 18

Weeks92% Sep-18 i 81.6% 83.6% 13 i 92.9% 93.6% 0 i 92.0% 94.4% 0 i 90.6% 90.2% 13 i 83.4% 86.2% 8


Incomplete Pathways0 Sep-18 g 0 1 0 h 14 56 9 g 0 0 0 h 21 143 30 h 8 25 5

Diagnostics Diagnostic Test Waiting Times - Proportion Over 6 Weeks 1% Sep-18 h 18.36% 14.26% 6 i 2.90% 1.30% 2 h 0.39% 2.37% 0 i 0.84% 0.91% 0 h 0.29% 0.84% 0

All Cancer Two Week Wait - Proportion Seen Within Two Weeks

Of Referral93% Sep-18 h 96.1% 93.8% 0 i 95.3% 95.4% 0 i 94.3% 95.2% 0 h 95.4% 95.8% 0 i 82.3% 90.9% 4

Exhibited (non-cancer) Breast Symptoms – Cancer not initially

suspected - Proportion Seen Within Two Weeks Of Referral93% Sep-18 h 96.4% 69.1% 0 i 96.8% 97.6% 0 i 89.9% 93.3% 1 i 97.5% 95.8% 0 i 17.4% 85.5% 2

First Treatment Administered Within 31 Days Of Diagnosis 96% Sep-18 i 100.0% 99.7% 0 i 93.3% 95.3% 1 i 90.8% 93.2% 9 h 99.1% 98.9% 0 h 96.3% 95.8% 0

Subsequent Surgery Within 31 Days Of Decision To Treat 94% Sep-18 i 91.7% 98.1% 1 i 84.6% 90.0% 5 i 92.9% 93.9% 3 i 100.0% 100.0% 0 i 100.0% 100.0% 0

Subsequent Drug Treatment Within 31 Days Of Decision To Treat 98% Sep-18 i 100.0% 100.0% 0 i 98.7% 99.1% 0 i 100.0% 99.8% 0 i 91.7% 96.6% 1 i 100.0% 100.0% 0

Subsequent Radiotherapy Within 31 Days Of Decision To Treat 94% Sep-18 i 97.6% 98.3% 0 i 92.0% 93.9% 1

First Treatment Administered Within 62 Days Of Urgent GP

Referral85% Sep-18 h 81.7% 80.9% 5 h 79.9% 81.4% 4 i 69.4% 76.3% 37 h 85.1% 79.3% 0 h 81.6% 80.1% 5

First Treatment Administered - 104+ Day Waits 0 Sep-18 i 2.0 7.0 5 h 8.0 44.0 30 i 22.0 84.5 30 h 1.5 13.5 5 h 0.5 15.0 9

First Treatment Administered Within 62 Days Of Screening

Referral90% Sep-18 i 90.3% 97.2% 0 i 91.4% 95.8% 0 i 85% 85.9% 4 i 88.9% 96.4% 2 i 0% 89% 1

First Treatment Administered Within 62 Days Of Consultant

UpgradeN/A Sep-18 i 72.2% 91.7% i 88.7% 92.8% h 91.4% 81.9% i 74.2% 88.7% h 93.4% 93.6%

Mixed Sex

AccommodationMixed Sex Accommodation Breaches 0 Sep-18 h 40 178 3 g 0 0 0 g 0 0 0 g 0 0 0 g 0 4 0

Healthcare Acquired Infection (HCAI) Measure: MRSA Infections 0 Sep-18 g 0 0 0 g 0 1 0 h 0 1 0 g 0 0 0 g 0 0 0

Plan 7 48 44 24 10

Actual 4 0 40 0 47 2 17 0 10 0

Healthcare Acquired Infection (HCAI) Measure: E-Coli - Sep-18 i 12 58 h 49 343 h 52 359 h 20 170 h 10 93

Healthcare Acquired Infection (HCAI) Measure: MSSA - Sep-18 i 1 5 i 15 70 h 4 25 h 3 12 h 0 4

Derbyshire Wide Provider Assurance Dashboard

Nottingham University Hospitals

Accident &

Emergency

East Cheshire Hospitals

Urg

ent

Car

e

Ambulance

Handovers

Pati

ent

Safe

ty

Incidence of

healthcare

associated

Infection

2 Week Cancer

Waits

62 Days Cancer

Waits

Plan

ned

Care

31 Days Cancer

Waits

Healthcare Acquired Infection (HCAI) Measure: C-Diff Infections Sep-18

Referral to

Treatment for

non-urgent

consultant led

treatment

gh

Sheffield Teaching Hospitals FT

h

Sherwood Forest Hospitals FT

Key:

h

h

g

i

Performance Improved From Previous Period

Performance Maintained From Previous Period

Performance Deteriorated From Previous Period

Performance Not Meeting Target

Indicator not applicable to organisation

Performance Meeting Target

Stockport FT

h

186



GOVERNING BODY MEETINGS IN COMMON 13th December 2018

ITEM/PAPER NO. 63

TITLE November Governance Committee Assurance Report

PRESENTER Jill Dentith – Lay Member Audit and Governance NHS Hardwick and NHS North Derbyshire CCGs

AUTHOR Richard Heaton – Head of Governance Erewash CCG

SPONSOR Helen Dillistone – Executive Director Corporate Strategy and Delivery

IS THIS PAPER FOR: Decision Assurance X Discussion X

RECOMMENDATIONS The Governing Body is asked to:

NOTE the contents of this report for assurance.

REPORT SUMMARY

This report provides the Governing Body with highlights from the November meeting of the Governance Committee in Common. Discussions took place around all the agenda items and the Committee felt assured by the detail that was presented to them.

BUSINESS CONTINUITY & EMERGENCY PLANNING RESILIENCE AND RESPONSE (EPRR)

An update was provided on the EPRR Assurance Process for the CCGs and Providers within Derbyshire. Since the last meeting a comprehensive “confirm and challenge” process has taken place facilitated by the CCG’s and NHSE EPRR Team. The Derbyshire Providers were all confirmed as either full or substantially compliant and the Derbyshire CCGs as substantial. A debate took place around what it would take to ensure full compliance in the future and it was it was noted that the on-call training agreed with the Executive team would greatly assist in progressing the action plan towards full compliance.

INFORMATION GOVERNANCE (IG), GENERAL DATA PROTECTION REGULATIONS (GDPR) and FREEDOM OF INFORMATION (FOI)

The IG Framework, IG Framework Appendix 1 and IG Assurance Group Team Terms of Reference were presented for approval. Changes to the structure of the CCGs have required a review of the arrangements for meeting the CCGs information governance obligations. It

187



was agreed that a new group, the Information Governance Assurance Group (IGAG), would be established to replace the current IG Committee. This group along with the IG team will continue to progress policies and procedures, work towards meeting the requirements of the revised IG Toolkit (Data Security and Protection Toolkit), and continued compliance with the requirements of GDPR. It was noted that the CCGs Privacy Notices have been updated and that IG training is continuing to be rolled out to meet the requirements. The Committee agreed to approve the Information Governance Management Framework (IGMF) and IGAG Terms of Reference subject to some minor amendments and future additions to the appendices of the IGMF.

FREEDOM OF INFORMATION REPORT – QUARTER 2

It was reported that FOI’s are now being handled across the whole of Derbyshire and policies have been merged to create one procedural document. The target for responding to FOI’s has been met throughout the reporting period with 100% completed within the timeframe. It was noted that there had been a sharp rise in the number of FOI’s during August 2018 but there was no identified pattern that could explain the increase.

ORGANISATIONAL DEVELOPMENT

CCG – MERGER UPDATE

It was reported that the merger plan was progressing well and regular meeting were being held with NHSE. The merger is supported by NHSE with some caveats at the moment including appointing a replacement for the Chief Finance Officer, agreeing on a name for the merged organisation following consultation with key stakeholders and the appointment of a Clinical Chair.

PROCUREMENT SERVICE

The Committee approved the proposal to bring the Procurement Service in-house in line with other services that have transferred in from Arden & GEM Clinical Support Unit (AGCSU). A discussion took place around the benefits of the proposal, including savings in future years.

ESTATES

There was nothing of significance to report for this quarter.

HEALTH, SAFETY, FIRE AND SECURITY

The CCGs are continuing to work with third party supplier and a quarterly report will be presented to the next meeting of the Governance Committee in Common. Members of the Committee asked for information regarding compliance with training and this will be provided at the next meeting.

188



CORPORATE POLICIES

Three policies, Derbyshire CCG Fraud, Corruption and Bribery Policy; Derbyshire Gift and Hospitality Policy; and Derbyshire Standards of Business Conduct & Managing Conflicts of Interest Policy were presented for agreement. It was highlighted that although the policies appear to be similar in nature setting the detail out separately assists the CCGs in meeting certain requirements such as NHS Protect Counter Fraud Standards and NHSE Statutory Guidance for managing conflicts of interest in CCGs. The Committee agreed the policies.

PROCUREMENT

Four reports were presented for each of the CCGs highlighting current risks and the mitigations in place for active contracts, those in the pipeline and those subject to ongoing procurement. Following a discussion all four reports were received by the Committee for assurance.

RISK MANAGEMENT

The same report was presented to the committee as went to the last meeting of the Governing Body and detailed the numbers and types of risk across the CCGs. Risk 004 – Lack of clarity on Derbyshire CCGs organisational changes was discussed in detail to establish whether the score should be reviewed. Due to the reorganisation still ongoing it was decided that the score should remain at its current rating and will be reviewed at the next meeting. Risk 016 - Lack of robust intelligence and or system unavailability from IT provider, was reviewed and Committee members agreed to remove this risk at the end of November 2018 but asked to be informed how the risk has been further mitigated. The Committee also agreed to leave risks 018, Implementation plan for GDPR, and 019 Cyber Attacks, at the current level of scoring.

GOVERNING BODY ASSURANCE FRAMEWORK (BAF) 2018-19

There are currently 9 high risks on the BAF. It was reported that a Risk Management Workshop had been held in August to work through the risks and there are further development sessions being planned with the Executive team members. The Committee were assured with the information provided to support the BAF.

IS THERE A FINANCIAL IMPACT? None specifically identified relating to this report. HAVE ANY QUALITY & COMPLIANCE ISSUES BEEN IDENTIFIED/ACTIONS TAKEN? See report above.

189



HAVE ANY CONFLICTS OF INTEREST BEEN IDENTIFIED/ACTIONS TAKEN? The discussion regarding the Procurement Service did not include the Senior Procurement Manager due to a conflict of interest.

CCG IMPROVEMENT & ASSESSMENT FRAMEWORK Please describe how this report and/or the services described within it supports CCG performance in the following domains: Better health outcomes for all Improved patient access and experience Empowered, engaged and well-supported staff Inclusive leadership at all levels

CLINICAL PRIORITY AREAS (please tick) Mental Health Dementia Learning Disabilities Cancer Diabetes Maternity

PRIVACY IMPACT ASSESSMENT NOT APPLICABLE

QUALITY IMPACT ASSESSMENT NOT APPLICABLE

PATIENT, PUBLIC AND STAKEHOLDER INVOLVEMENT NOT APPLICABLE

EQUALITY AND DIVERSITY IMPACT

Due Regard to the proactive duties of the Equality Act 2010 has been taken in development of this paper and: It is judged that it is not proportionate on the basis that the report does not directly impact any single group. This completes the due regard required.

NOTE: Policies/decisions may need to be adjusted in line with any equality analysis or due regard that is brought back at a future date. Any decision that is finalised without being influenced by appropriate due regard could be deemed unlawful.

190



Governing Body Meetings in Common

13th December 2018

Report Title Governing Body Assurance Report for the Audit Committees in Common held on 19th September.

Author(s) Stuart Fletcher, Governance Manager Sponsor (Director) Helen Dillistone, Executive Director Corporate Strategy &

Delivery


X Discussion Information X

Recommendations Governing Body is asked to NOTE the Governing Body Assurance Report for the minutes of the Audit Committees in Common held on 19th September. Report Summary The Governing Body Assurance Report is presented to the Governing Body to inform them of any decisions that have been made at Committees in Common or any CCG-specific items that were discussed or directly impact the CCG.

The following items were received and noted by the Audit Committees in Common:

Internal Audit Reports – Derbyshire wide Counter Fraud The Counter Fraud Team, 360 Assurance presented their Progress Report and discussed their approach to producing an annual report for each of the CCGs.

Within the annual report is the NHS Counter Fraud Authority Self Review Tool which is an assessment of the standards that have to be adhered to. All Derbyshire CCGs are currently standing at a green rating.

The Counter Fraud Team is preparing for Counter Fraud Awareness month in November and will liaise with the Corporate Delivery Team to support its rollout.

360 Assurance - 360 progress report Internal Audit presented its update on the progress of the work undertaken in 2017/18 and the outcomes of the planned audit assignments. A number of audits have commenced, including the Stage 1 HOIAO which has been issued in draft form. A piece of work around COI has been issued as stage one in draft and stage two will be issued later in the year.

Other items discussed included:

• Forthcoming primary care commissioning audit• 360 primary care post payment verification service

Item: 64

191

• Mersey internal audit agency paper – assurance framework benchmarking 2017 External Audit It was noted that there are no new messages following the Internal Audit Letters which were issued at the May Audit Committee Meeting. The Annual Audit letters conclude the 2017/18 audit. Finance report – Derbyshire wide Louis Bainbridge presented the Month 5 Finance Report to committee members. The Derbyshire CCGs are reporting YTD on the financial plan and forecasting delivery on financial plan. At the time of reporting the M5 financial position all risks identified at that point could be mitigated through contingencies and budget reserves. Following a Deep Dive into the QIPP verification this position has now changed. At M5 the risk of QIPP delivery was £6m this has now moved to £9m. Other reports received and noted included:

• Exception risk register report • Derbyshire strategic risks and objectives update • Statutory registers – Derbyshire wide

o Derbyshire gifts and hospitality register o Derbyshire procurement register

Governing Body assurance The implications of the decisions reached by each Audit Committee (meeting in common) are to support the governing bodies by critically reviewing and seeking assurances on the relevance and robustness of the governance processes in place as relied on by each governing body. Are there any Resource Implications (including Financial, Staffing etc)? Not required as part of this update Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? Due Regard is not found applicable to this update. This report is for assurance and information Have you involved patients, carers and the public in the preparation of the report? Not applicable to this update. This report is for assurance and information.

Have any Quality and Compliance issues been identified/ actions taken Not required for this update. Notwithstanding this, where issues/risks have identified from Quality Impact assessment and Data Protection Impact Assessments (DPIA) as part of the work being reported into the Audit Committees in Common, appropriate actions taken should be taken that accord with the principles of risk management. Have any Conflicts of Interest been identified/ actions taken?

192



Not applicable to this report. Governing Body Assurance Framework The Exception Risk Report and GBAF provide an update and progress on the arrangements to develop and embed the Derbyshire Risk Management Framework arrangements.

Risks recorded in the Risk Register are aligned to the appropriate Strategic Risk recorded in Governing Body Assurance Framework. Identification of Key Risks The Exception Risk Reports provides a summary of the high scoring risks recorded during that month.

193

NHS Derbyshire CCGs Governing Body Meeting in Common

13th December 2018

Report Title Exception Risk Register Report - December Author(s) Stuart Fletcher – Governance Manager Sponsor Helen Dillistone – Executive Director Corporate Strategy &

Delivery

Paper for: Decision Assurance √ Discussion √ Information √ Recommendations

The Governing Body meeting in common is asked to:

• RECEIVE and NOTE the Exception Risk Register Report;• NOTE and RECEIVE Appendix 1 as a reflection of the high

risks facing the organisation as at 05th December 2018;• APPROVE the decision from Governance Committee in Common to close Risk

016. • CONSDER whether the GB wish to deep dive any of the risks on Risk Register

with the relevant lead in more detail at the next meeting for further assurance.

Report Summary This report presented to the Governing Body (GB) meeting in common is prepared as an exception report to highlight the areas of organisational risk that are recorded in the Derbyshire Corporate Risk Register (RR) as at 05th December 2018.

The RR is a live management document and it enables the organisation to understand its comprehensive risk profile, and brings an awareness of the wider risk environment.

For the purpose of this report, only those current risks rated as very high (15-25) and high (8-12) to the organisation are presented to the GB. These risks are allocated to a committees incommon as they relate to the business areas of that forum. This approach acknowledges that some operational risks are capable in damaging the long-term viability or reputation of the organisation as the strategic risks.


The Derbyshire CCG attaches great importance to the effective management of risks that may be faced by patients, members of the public, member practices and their partners and

Item No 65

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staff, CCG managers and staff, partners and other stakeholders, and by the CCG itself.

Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? Due Regard is not found applicable to this update; however, addressing risks will impact positively across the organisation as a whole. Have you involved patients, carers and the public in the preparation of the report? Not applicable to this update.

Have any Quality and Compliance issues been identified/ actions taken Not required for this paper. Notwithstanding this, where any issues/risks that have been identified from a Quality Impact Assessment and Data Protection Impact Assessment (DPIA) appropriate actions will be taken to managed the associated risks. Have any Conflicts of Interest been identified/ actions taken? Not applicable to this report.

Governing Body Assurance Framework Risks recorded in the Risk Register are aligned to the appropriate Strategic Risk recorded in Governing Body Assurance Framework. Identification of Key Risks The paper provides a summary of the high scoring risks as at 05th December 2018.

195

NHS Derbyshire CCGs Governing Body Meeting in Common

Exception Risk Register Report – December 2018

1. Introduction

The Risk Register (RR) is a live management document and it supports the organisation to understand its comprehensive risk profile, and brings an awareness of the wider risk environment.

For the purpose of this report all very high (15-25) that have been highlighted by the organisation are attached in summary form in Figure 1 to show their movement since the last report. These risks are also detailed along with the high risks (8 -12) within the RR attached in Appendix 1. All risks in the RR are allocated to a committees in common. This approach recognises that these risks relate to the business areas of those particular committees in common which has an opportunity to review these further. In order to prepare the monthly reports for the various committees in common, updates are requested from the Senior Responsible Officers (SRO) for that period. All updates received during this period are highlighted in red within the RR attached in Appendix 1. In readiness for December report, the RR was circulated to SROs at throughout November seeking clarification as to whether the risk that has been described:

• remains relevant, and if not to be closed; • if relevant, to update the controls in place to reduce the likelihood/mitigate the impact of

the risk • review the risk score

2. Derbyshire Risk Profile – as at 05th December

The table below provides a summary of the current Derbyshire risk profile. Please refer to the Appendix 1, which details all very high scoring risks (15-25) that have been highlighted by the organisation and informs the RR.

Derbyshire Risk Register (December position)

Risk Profile Very High

(15-25)

High

(8-12)

Moderate

(4-6)

Low

(1-3)

Total

Position reported to GB on 1st November

7 14 1 0 22

Total number on Risk Register to be reported to GB in December

6 14 1 0 21*

* Please refer to the Sections 3 and 4 below regarding the key actions taken during this period. This information is to inform the GB of the movement in the Derbyshire RR profile.

196

3. Committees in Common (CIC) – November/ December overview of assigned risks

Quality & Performance CiC - Very High Risks

At the December meeting the QPCiC received 10 quality and performance risks with 2 risks rated very high (15-25). Risk leads have provided updates to mitigations and assurances where appropriate, and are reflected in Appendix 1 and the summary table in Figure 1.

• Risk 002: The Acute providers may breach thresholds in respect of the A&E operational standards. The risk rating remains the same as October 18 (Probability 5, impact 4 = 20) which is impacted by:

o the lack of middle grade doctors in ED at CRH with vacancies not being filled until December 18/ January 19.

o Going into winter without a clear understanding from the trust around plan to address the vacancies, capacity issues or flow within the trust.

o UHDB have not delivered against the national 95% standard for the last 36 months, and there is no clear plan or trajectory from the trust to provide assurance that an improvement will be seen during 2018/19.

• Risk 006: Approximately 50% of NDCCG residents in care homes are placed within non AQP homes:

o Risk score remains the same. o Window 4 has closed and has resulted in 3 new providers being awarded new

contracts subject to GB approval (still outstanding). This has been approved through FRG and CLCC.

Governance CiC - Very High Risks

The number of assigned risks reported in November was recommended to decrease to 4 with the proposal to close risk R016.

• Risk 016: This risk concerned the migration of the IT service across the Derbyshire CCGs to a new provider, and the lack of system availability would impact on Business Informatics and corporate IT services. Although the risk was agreed to be closed with a recommendation made to the GB, the Governance CiC, which supported the closing of this risk has asked for an additional brief to provide further assurance to their meeting in January. (See 4.3)

Finance CiC – Very High Risks

At the November meeting the Finance CiC received 3 assigned risks, which includes Risk 023 around the cost of acute care. This risk is also reported into the Quality & Performance CiC from a performance perspective; however, the financial risk implication requires that it is reviewed by the FCiC. Although no assigned finance risks have been closed, there have been changes to risk scores, which are noted in 4.2 below.

Primary Care Co-commissioning CiC – Very High Risks

At the November meeting the CiC received 2 assigned risks (Risk 009 and 015), which both highlight particular threats around general practice. It was considered at the meeting whether the two risks can be combined, but was found that although these two are interrelated they are separate. It was noted that there are overlaps with regard to the controls in place to manage these risks, which are further detailed in Appendix 1.

197

4. Key changes and updates

4.1 Increased risk(s) since last month

• No risks have increased since the last report to the Governing Body

4.2 Decreased risk(s) since last month

• Risk 001: ‘CCG failing to meet their statutory financial duties in 2018/19’ This was reviewed in November and its score has been reduced down from 20 to 15, which reflects the reported financial position at Month 7. Assurances around the financial position, QIPP delivery and associated action plan continue to be provided to the Finance Committees in Common. Further details are found in Appendix 1. This still remains a very high risk.

• Risk 014: Psychiatric intensive care Unit beds (PICU) This risk was reviewed in November by the risk lead. The overall score has been lowered to a high risk (red) to amber at a score of 12. It was highlighted that this matter is still predicting an overspend by yearend; however, the PICU use has stabilised and has seen the drop in use over a few months. On this basis this risk going forwards has been downgraded from extreme to high and therefore is reflected in the register. Further details are found in Appendix 1.

4.3 Closed risk(s) since the last report

• Risk 016 (IT migration) has been reviewed and is proposed to be closed. This risk concerned the migration of the IT service across the Derbyshire CCGs to a new provider, and the lack of system availability would impact on Business Informatics and corporate IT services.

This risk has been mitigated as the migration work was completed during Q1 and is recommend by the Associate Director of Digital Development to be closed. The committee agreed to support closure of this risk, but has sought further assurance from the lead that will return to the January meeting.

4.4 Embedding at an operational level - all staff As part of our ongoing commitment to embed risk management across the organisation, a monthly Risk Group has been scheduled for 4th December to meet for 1 – 1 ½hr at the beginning of each month with a view to:

• provide a regular review of all existing CCG risks • review all newly identified risks • provide a challenge to risk descriptors and scoring • ensure that risks are scored consistently with the CCG risk matrix, including initial,

residual and target ratings • review actions plans, where appropriate • ensure financial and resource implications and impact are properly represented • ensure each risk has a nominated Risk Owner and Risk Manager • provide a cross cutting review of the risk register

The chair of the Risk Group will be the Director of Corporate Delivery with membership informed by the Functional Directors, and/or relevant Deputy, and Leads from across the directorates who currently support this agenda.

198

The aim of the meeting is to ensure that the organisation has an updated position to help embed the management of the risk across the organisation. This will help to provide assurances to the Executive Team, the committees in common and ultimately to the Governing Body.

The first meeting was scheduled for 4th December and provided an opportunity to talk through the role of the Risk Group and how risk management relates to the work of the teams.

The key outputs from colleagues who attended the session included:

• agreement for teams to hold/manage their own local risk registers; • coordinate a rollout of training/development around describing and scoring risks, and

understanding controls and assurances; • Risk Group offering an opportunity to map themes arising across teams that need

exploring such as provider concerns; • Support that this is an appropriate time to commence this work that can mature to support

the needs of a strategic commissioner.

199

Figure 1

Summary: Movement of very high scoring risk since the last report

Probability

Impact

Rating

Probability

Impact

Rating

001 There is a risk that the CCGs fail to meet their statutory financial duties in 2018/19

4 5 20 3 5 15

002

The Acute providers may breach thresholds in respect of the A&E operational standards of 95% to be seen, treated, admitted or discharged within 4 hours, resulting in the failure to meet the Derbyshire Wide CCGs constitutional standards and quality statutory duties.

5 4 20 5 4 20

004The lack of clarity on the Derbyshire CCGs organisational changes will have a detrimental effect on staff morale and productivity, this will result in losing existing staff, impacting on capacity to deliver CCG objectives

4 4 16 4 4 16

006 Approximately 50% of residents in care homes are placed within non AQP homes. This may result in financial and quality assurance implications.

4 4 16 4 4 16

009 Failure of GP practices across Derbyshire results in failure to deliver quality Primary Care services resulting in negative impact on patient care.

4 4 16 4 4 16

014

There is a national shortage of Psychiatric intensive care Unit beds PICU . This has resulted in delayed transfers (12hour breaches) in ED for RDH and CRH and in police custody. It is also a concern for prison release where there is a significant MH problem and community risk. This has resulted in an Increased use of PICU over last three years locally, which is impacting on CCG and DHcFT budget overspend.

5 3 15 4 3 12

015Due to the increased pressures around workload, workforce and financial concerns, there is a risk to General Practice in providing quality primary care services to patients.

4 5 20 4 5 20

Previous Rating Residual/ Current Risk Monthly C

hanges

Risk R

eference

Risk Description

200

Appendix 1

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act

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Pro

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001There is a risk that the CCGs fail to meet their statutory financial duties in 2018/19

Fin

an

ce

Fin

an

ce

5 5 25

• A Turnaround Director has been appointed to manage delivery of the financial turnaround required

to support the CCGs in achieving the agreed control totals and delivering its statutory financial duties . • A weekly Executive led Finance Recovery Group has been convened to oversee progress on

delivery and instigate actions where necessary. • The CCGs budgets are aligned to Executive Directors ensuring senior oversight and management

of budgets.• There is a budget escalation process in place overseen by the FRG and the Derbyshire Finance

Committees in Common.• At plan stage all CCGs are holding a 0.5% uncommitted risk contingency

• Develop 18/19 Derbyshire Financial Recovery Plan

• Standardise finance and QIPP reporting across 4 CCGs

• Continual development of further QIPP schemes

An 2018/19 control total action plan is in place to manage and monitor key actions, overseen by the Financial Recovery Plan. The Finance Committee receives a standardised Derbyshire wide report to provide information and assurance on the CCGs financial positions, QIPP delivery and actions being taken. The Finance Committee receives action plans on areas where forecast overspends are greater than 0.5% of the budget. Work is being undertaken now to identify 2019/20 QIPP schemes with an assessment being made on which schemes can start in 2018/19 .At month 7 the CCG is reporting • The

reported year to date financial position is ahead of plan at month 7 • The forecast outturn position remains in line with plan

• The year to date and forecast position includes non-recurrent benefits from

finalising prior year balances • There is a forecast £7.1m under-delivery of savings , this can be mitigated in

the financial position• The 0.5% contingency remains uncommitted at month 7, but is forecast to be

utlised by the year end.

4 5 20 3 5 15 0 0 0

Objective 4 linked to S

trategic Risk 6.

BA

F Appetite S

core = 6 (low risk appetite) and O

bjective 4 linked to S

trategic Risk 6. B

AF A

ppetite Score = 6 (low

risk appetite)Nov-18 Dec-18

Louise Bainbridge - Chief Finance

Officer

Niki Bridge - Deputy Chief Finance Officer

002

The Acute providers may breach thresholds in respect of the A&E operational standards of 95% to be seen, treated, admitted or discharged within 4 hours, resulting in the failure to meet the Derbyshire Wide CCGs constitutional standards and quality statutory duties.

Perfo

rman

ce

Co

nstitu

tion

al S

tan

dard

s/ Q

uality

3 4 12

Derbyshire wide performance to the end of October 18 is 89.3% (YTD 91.1%), with Chesterfield Royal Hospital NHS Foundation Trust (CRH) reporting 87.3% (YTD 92.5%) and Derby Teaching Hospital FT (DTHFT) reporting 89.0% (YTD 89.6%) for the same period. This is system level performance not individual trust 4hr performance, reporting agreed at the A&E Board.

Un-validated performance received from the trust shows as at 18th November 2018;CRH Trust level 4hr, MTD (87.72%), QTD (85.41%) & YTD (90.27%) and System, MTD (93.28%), QTD (91.82%) & YTD (94.34%). The main contributing factor to the underperformance at Chesterfield Royal is due to a lack of middle grade doctors, with the trust currently identifying 4 vacancies out of the 8 doctor posts and a higher acuity of patients attending ED with Respiratory and Cardiology conditions.

Unvalidated performance as at as at 18th November 2018: UHDB Trust level 4hr, MTD (78.06%), QTD (80.05%) & YTD (82.93%) and System, MTD (88.5%), QTD (89.9%) & YTD (90.7%). The CPN at Derby remains in place and a revised RAP has been recieved although the recovery date has not yet been agreed . The main issues impacting on performance delivery are high occupancy (95%) and a high conversion rate from attendance to admission.

• Awaiting plan from collective providers inc. social care to fund:

keeping people out of hospital; flow; primary and community capability and capacity; and dementia• Develop and implement new integrated care model starting with

practical measures to reduce avoidable admissions• Data requested from both trusts to monitor the Minor A&E

performance. CCG's will work with providers to drive the performance improvement in this area.• CCGs working through the Urgent Care Minimum Standards

Checklist

CRH Key actions include: The trust have recruited 5 additional middle grade staff from India starting in January 19 and a further middle grade doctor from Manchester starting in December 18. Locums are in place for the vacancies and the department is fully staffed. The CCG have issed a CPN o understand the issues impacting on ED service delivery and to ensure the correct actions are being taken to mitigate and ensure delivery against the 95% standard. A recovery action plan has been recieved by the CCG and disucssions are taking place around the recovery date.

UHDB key actions include: Appointment of duty escalation manager and an additional 30 non acute beds to be opened in November at London Rd Community Hospital to help improve flow. The CCG have raised a CPN on the 10th October to understand the issues impacting on ED service delivery and to ensure the correct actions are being taken to mitigate and ensure delivery against the 95% standard

Risk rating remains the same as October 18 (Probability 5, impact 4) due to the lack of middle grade doctors in ED at CRH with vacancies not being filled until December 18 / January 19. Going into winter without a clear understanding from the trust around plan to address the vacancies, capacity issues or flow within the trust. UHDB have not delivered against the national 95% standard for the last 36 months, and there is no clear plan or trajectory from the trust to provide assurance that an improvement will be seen during 2018/19.

5 4 20 5 4 20 3 3 9


trategic Risk 3.

BA

F Appetite S

core = 9 (high risk appetite)

Nov-18 Dec-18

Lynn Matthews - Director of

Contracting and Performance

Adam Sutherst - Assistant Director – Planning &

Performance

003

If the Derbyshire CCGs do not take the lead on the Derbyshire STP to deliver the Derbyshire Commissioning Strategy, this will result in the Derbyshire STP being Provider influenced

Go

vern

ing

Bo

dy

ST

P

4 4 16

• Chief Officer and Executives input the STP process

• Support and input into the development of the business cases

• STP Meetings and governance set up

• STP Plan (1st submission and 2nd Submission end of October 2016)

• STP discussed at CDG, Quest and extraordinary membership meeting

• Establishment of PLACE meetings and relationships in place.

• STP is now public and communicated

• Chairs and Chief Officers STP meeting in place

• Joint CCG HR Strategy in development

• Ongoing discussions on STP planned for future Governing Bodies

and CDG meeting• Development of strategic commissioning function across the 4

CCGs• Close working with Derbyshire CCGs

• Ongoing STP Board Development

• External STP Lead Executive in post

• Further development of STP Plan and governance

• Derbyshire CCG Strategic Commissioner Programme Board being

established from April 2018

• STP Board Plans for 2018/19 at low levels of maturity

• CCG FRP / QIPPs embedded in STP governance.

• Agreed direction of travel is for a system control total. On-going discussions

for block contract arrangements with DTHFT and CRH (in place with DHcFT and DCHS). Regular STP DoF and CEO / DoF are held to progress the joint agenda. Substantive Director of Commissioning Operations has been appointed and will start in post on 03/09/18. Interim arrangements have been put in place and commissioning development work is on-going with STP SROs. • Permanent Executive Director of Commissioning Operations in post

• Permanent Derbyshire STP Director in post

• CCGs working under one management structure

• Strengthened working as Governing Bodies in common with consistent

commissioning approach• Single Commissioning Strategy developed and included within merger

submission to NHSE• Regular CEO / CFO focused on strategic agenda

3 4 12 3 4 12 0 0 0


trategic Risk 5.

BA

F Appetite S

core = 6 (low risk appetite)

Nov-18 Dec-18

Zara Jones Executive Director of Commissioning

Operations

Kate Brown - Director of Joint Commissioning and Community Development

Action Owner

Resp

on

sib

le C

om

mitte

e in

Co

mm

on

Date Reviewed

Derbyshire CCG High Scoring Risk Register - December 2018

Review

Due

Date

Ris

k R

efe

ren

ce

Risk Description

Typ

e - C

orp

ora

te o

r Clin

ical

Initial Risk

Rating

Mitigations

(What is in place to prevent the risk from occurring?)

Actions required to treat risk

(avoid, reduce, transfer or accept) and/or identify assurance(s)

Targ

et D

ate

Executive Lead

Target Risk

Progress Update

Previous

Rating

Residual/

Current Risk

Lin

k to

Bo

ard

Assu

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Fra

mew

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Page 1 of 6201

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004

The lack of clarity on the Derbyshire CCGs organisational changes will have a detrimental effect on staff morale and productivity, this will result in losing existing staff, impacting on capacity to deliver CCG objectives

Go

vern

an

ce

Co

rpo

rate

4 4 16

• Open and transparent communications in relation to STP

• Regular staff briefings

• Away Days and regular weekly briefings

• Arrangements in place to manage CCG transition

• Outstanding results published for staff survey

• Staff Away Days

• HR framework agreed and being worked through

• AO and CFO secured and started October & November 2017

• Executive/Director post confirmed and appointed subject to REMCOM May/June.

• Single organisational structure to be presented to Governing Body meeting 29th June, consultation

to be launched 2nd July.• Turnaround Director in post.

• Comprehensive HR framework and Comms Plan to support staff

through any period of change• FAQs will be developed for staff

• Structures likely to be consulted on when new AO is in place, for 45

days• Transition Plan developed and being worked through

• Executive/Director post confirmed and appointed subject to

REMCOM May/June.• Single organisational structure to be presented to Governing Body

meeting 29th June, consultation to be launched 2nd July.• Turnaround Director in post.

• The staff consultation closed on 3 August and a further report was tabled for

decision and assurance at GB in Common on 17th Aug and at Erewash GB on the 23rd Aug. The decision was taken to proceed to implement those structures were only minor revisions have occurred and to begin a further 30day consultation during September for those structures subject to more major changes which would impact upon staff.• Following feedback from staff and Trade Unions it was agreed to implement

all structures at the same time, following the closure of the consultation on the 9th October, The exec team have agreed to release only business critical vacancies in the meantime and any new external secondments will not be agreed during this period. • The staff consultation is due to close as planned on the 9th October with the

outcomes presented to GB Committee in Common on 1st November. 4 4 16 4 4 16 2 3 6


trategic Risk 2.

BA

F Appetite S


Nov-18 Dec-18

Helen Dillistone - Executive Director

of Corporate Strategy and

Delivery

Beverley Smith - Director of Corporate Strategy &

Development

005

Changes to the interpretation of the Mental Capacity Act (MCA) and Deprivation of Liberty (DoLs) safeguards, results in greater likelihood of challenge from third parties, which will have an effect on clinical, financial and reputational risks of the CCGs

Qu

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inan

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3 3 9

• Midlands and Lancs CSU continue to re-review and identify care packages that potentially meet

the ‘Acid Test' and the MCA/DoLS staff member is preparing the papers for the CCG lawyers to take

to the Court of Protection.• CCG DoL policy has been agreed across 4CCG’s and is now agreed with Midlands and Lancs

CSU. • Priority to be given to those care packages that are 100% health funded that require Court of

Protection (CoP) authorisation• The DoLS proposal paper from Derbyshire re Joint Funded cases is going CCGs Executive and

Derby City has been contacted to see if they would consider a similar proposal.The Mental Capacity Act (Amended) Bill is still going through the House of Commons still no implementation due until at least 2020, therefore reputational risk to CCG remains if found guilty of an unauthorised DoL with additional compensation costs.• 8 cases have been identified that require Re X DoL Court process for the CCGs and are currently

with Browne Jacobson. • The CCGs Safeguarding Adults Managers continue to meet regular with Midlands and Lancs to

discuss ongoing management of cases.

The Quality and Performance Committee have received the Re X DoLS Options Paper and agreed for it go to the November Governing Body meeting.

The first 8 Re X DoLS CCG cases are with Browne Jacobson to date 5 have been taken to the Court of Protection for authorisation. There is a 4 month backlog of cases at the CoP

3 4 12 3 4 12 0 0 0


trategic Risk 1.

BA

F Appetite S


Nov-18 Dec-18Brigid Stacey - Chief Nursing

Officer

Ed Ronayne - Safeguarding Adults

Manager

006

Approximately 50% of residents in care homes are placed within non AQP homes. This may result in financial and quality assurance implications.

Qu

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4 4 16

• Hardwick CCG Quality Monitoring Team are alerted by either the Local Authority or CQC if any

concerns are raised regarding care in a non AQP home. The team work with the LA as lead and follow the quality monitoring process with the home until assurance is gained. • A total of circa 71 homes across Derbyshire are now on the AQP list. 10 providers have chosen

not to extend their contact, 6 of those are not in Derbyshire There is a risk in relation to capacity, quality and cost. It has been agreed to extend the current AQP contract for a further 2 years and whilst there is a risk that current Providers won’t sign up (which

will affect capacity) the agreed increase in the care home tariff go some way to mitigating this risk.. .Quality in the care homes market is of concern as there is a risk where there is a high level of agency nurses used.

A window 4 has been opened to enable new providers to be added to the AQP. This window is now closed and only 3 providers have applied to join the AQP contract

Window 4 has closed and has resulted in 3 new providers being awarded new contracts subject to GB approval (still outstanding). This has been approved through FRG and CLCC.

4 4 16 4 4 16 3 3 9


trategic Risk 3.

BA

F Appetite S

core = 9 (high risk appetite) and O

bjective 3 linked to Strategic R

isk 4. BA

F Appetite

Score =9 (high risk appetite)


Officer

Steph Austin - Head of Clinical Quality

007

Achieve and sustain the performance, pace and change required to achieve the TCP national outcomes. The Adult TCP is on recovery trajectory and rated amber with confidence whilst CYP TCP is rated Green, concern is around maintaining the performance required to avoid reputational damage and increased scrutiny

Qu

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/ Rep

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3 4 12

• The TCP has identified executives for the TCP exec Board.

• TCP have developed a new sustainability plan,

• TCP forensic core team in place.

• DHcFT Chief Nurse has approved the new QS for TCP.

• Investment in Speech and Language Therapist for mental health wards to improve formulation in

mental health care.• Agreement reached to review bed base use with regard to ATU style bed functionality

• New SRO confirmed - Mick Burrows. Brigud Stacy CCG Executive lead.

• Succession of Letters NHSE Stuart Poyner and recently NHSE Chief Nurse who restated faith in

the rigour of TCP commissioners • TCP has assured by NHSE as AMBER and CYP as Green

• Weekly system pressures meetings in place with CCG and system partners.

• NHSE assurance meetings continue monthly.

* TCP Executive Board meets Bi-monthly* TCP Delivery Group meets monthly

• A Trajectory Recovery Plan agreed with NHS E in August - Programme

delivered against recovery trajectory for Q2.* Programme anticipating to deliver against required trajectory March 2019 (Q4).

2 5 10 2 5 10 3 4 12


trategic Risk 1.

BA

F Appetite S

core = 6 (low risk appetite) and O


trategic Risk 2. B

AF A

ppetite Score = 9 (high risk appetite)


Officer

Jennifer Stothard - Transforming Care

Delivery Manager for Learning Disabilities and/or

Autism Programme Derbyshire Partnership

Page 2 of 6202

Appendix 1

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Rating

Mitigations




Targ

et D

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Executive Lead

Target Risk

Progress Update

Previous

Rating

Residual/

Current Risk

Lin

k to

Bo

ard

Assu

ran

ce

Fra

mew

ork

008

The new CHC provider has created a backlog of cases requiring review, which may have an impact on clinical and financial risks to the CCGs.Potential that the delivery of CHC packages are not meeting the National Standard Contract.

Qu

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an

d P

erfo

rman

ce

Qu

ality

3 4 12

Contract Performance Notice issued - Backlog clearence trajectory in place Recovery Action Plan in place. Additional staff recruited by provider. Monthly reporting against trajectory and staffing. Continue working with provider to determine any unmitigated Risk.

Nov 18 - Trajectory in place to complete reviews on all backlog cases by June 2019. Plan in place to ensure a further backlog does not emerge.Dedicated review team now in place. 14 additional staff members recruited. Concern raised with provider regarding impact of backlog clearence in terms of 'backlog' of full DST assessments required following review.

2 4 8 2 4 8 0


trategic Risk 6.

BA

F Appetite S



Officer

Helen Hipkiss - Deputy Director of Quality

009

Failure of GP practices across Derbyshire results in failure to deliver quality Primary Care services resulting in negative impact on patient care.

Prim

ary

Care

Co

Co

mm

issio

nin

g

Prim

ary

Care

5 4 20

Development and implementation of Derbyshire wide Primary Care StrategyImplementation of Derbyshire plan to deliver GPFV and 10 point plan for nursing including:- Additional resources - securing additional funding from NHS England to support delivery of the workstreams.- Support to practices through GP provider networks to support practice resilience via the NHS Engalnd GP Resilience Programme allocations.- collaborative work with the LMC GP Taskforce to support Practice Management development, GP recruitment and retention, Practice Nurse recruitment and retention- Develop 'at scale' collaborative working (GP Federation, Primary Care Groups).

Primary Care Quality and Performance Committee to oversee support to practices (CQC, GP contract, Quality) to identify and monitor individual practice risks at an early stage.Robust supportive contract management approach for practices rated as "Inadequate" or overall "Requires Improvement".Extended Access Hubs and shared IT arrangements to support business continuity and resilience for individual practices (major / unforeseen incidents).

NHS England funding schemes available to support GP practices under pressureCCG drawing down vulnerable practice scheme support as availableContinued intensive work with one practiceGP 5-Year Forward View Plan Derbyshire has now been completed and is being implemented

Development and implementation of Derbyshire wide Primary Care Strategy.Implement STP/Derbyshire wide plans to invest in and develop practices at scale Continue to work with LMC, Federations and emerging groups to support sustainability of general practice. Primary Care Team to continue to work closely with practices to understand and respond to early warning signs including identification of support / resources available including practice support in discussions around workload transfer from other providers.Derbyshire wide Primary Care Co Commissioning Committee to oversee commissioning, quality and GPFV workstreams.Assurance provided to NHS England / JUCD through monthly returns and assurance meetings.

4 4 16 4 4 16 0


trategic Risk 3.

BA

F Appetite S


Nov-18 Dec-18 Dr Steve Lloyd - Medical Director

Clive Newman - Director of GP Development

Page 3 of 6203

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Mitigations




Targ

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Executive Lead

Target Risk

Progress Update

Previous

Rating

Residual/

Current Risk

Lin

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Bo

ard

Assu

ran

ce

Fra

mew

ork

010

EMAS remains within CQC domain of 'requires improvement' overall. This impacts on the CCG to commission services that are supportive of and deliver good outcomes in line with operational plans.

Qu

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3 4 12

• EMAS Quality Governance Committee and other internal governance processes

• Collaborative Commissioning Meetings monthly

• Partnership Board monthly

•Quality Assurance Group (QAG) Bimonthly

• Engagement with regional health scrutiny leads

•Currently subject ot Deep Dive process overseen by NHS England and NHS Improvement - next

meeting October 2018• Quality Improvement Plan delivery to be monitored internally by QGC and externally through QAG

Monitor delivery of Quality Improvement Plan at both Regional and County levels through the agreed meeting structure and assurance groups

• Following a long and challenging contracting round EMAS are to receive

additional funding to assist in addressing the resource gap identified that will support delivery of agreed performance trajectories.• Monitoring continues on a monthly basis with additional assurance meetings

and reviews as identified by concerns raised and quality issues identified.The CQC improvement plan is a standing agenda item at the bi-monthly QAG

3 4 12 3 4 12 3 4 12


trategic Risk 6.

BA

F Appetite S

core = 6 (low risk

appetite)

Nov-18 Dec-18


Operations

Sharon Fitton - Quality Lead

012

There is a risk that the 21st Century/ Joined Up care Programme do not achieve their objectives. This will result in the CCGs being unable to transact significant elements of the Plans, or transacted but not within the agreed implementation principles.

Go

vern

ing

Bo

dy

Co

rpo

rate

4 4 16

• Decision made by Governing Body 24.7.17

• Implementation team meeting weekly. Implementation Board and governance structure

established• All key stakeholders associated with the 21C Programme (Commissioners and Providers) met on

the 11 September 17. Under the individual delegated powers of the CCG, Accountable Officers and the Clinical chairs agreed to urgent changes due to quality and staffing concerns, namely establish beds with care, expand integrated care teams, consolidate community hospital beds at Clay Cross Hospital and close the Hudson Ward at Bolsover Hospital • Informed key stakeholders of change

Governance arrangements approved by GBProgramme plan developed by implementation team to be agreed by implementation boardFull implementation board to meet monthly Establish local implementation groups at place level to ensure changes made are effectively implemented.Run a workshop to finalise specialist rehabilitation site and design.

Implementation Board meeting regularly

Project plan in place

17/18 changes complete and being embedded and monitored

18/19 changes being planned to begin April 2018

Model for community support beds ('beds with care') being developed and rolled out including the medical support model to these beds.The programme continues to implement changes in line with the original principles. Detailed planning is underway regarding the remaining phases of the plan. The financial plan is balanced for 2018/19 but shows a potential cost pressure for 2019/20. The mitigations for this are being identified.

3 4 12 3 4 12 0 0 0


trategic Risk 8.

BA

F Appetite S


Nov-18 Dec-18


Operations

Kate Brown - Director of Joint Commissioning and Community Development

Louise Swain Interim Deputy Director

Community

013

Due to consultancy vacancies and service capacity and Inpatient staffing absence/vacancies has a result in increased waiting times for DHcFT services (in particular outpatients & psychology which impacts on patient experience.

Qu

ality

an

d P

erfo

rman

ce

Patie

nt E

xp

erie

nce/ Q

uality

4 3 12

Skill Mix review conducted in January 2017Introduction e-rostering for staffing predication allows for concerns to be highlighted and mitigated againstOngoing use of bank staff and substantive staff taking on additional shiftsOngoing recruitment of occupational therapists (OTs) and medicine optimisation technicians (MOTs)Exploration of the role of advanced clinical practitionerAll campus services have access to Paris and are in the process of embedding electronic recording into their practiceA review of psychology service undertakenCommissioners monitoring through contractual meetings

Continue to monitor through contractual meetingsOutcome of Psychology service review and mitigationsReview of Consultants Annual Leave PolicyOngoing recruitment of all skill levels

Brexit may cause pressure on staffing. Regular monitoring of staffing in place at QAGsCommissioners have received the Psychology review and associated mitigations being taken by DHcFT.Scheduled to receive an Action Plan re outpatients and have the Consultant lead attend CAP to report on this.Recruitment has improved after a difficult summer. There is evidence of a skill mix review resulting in wider recruitment e.g. OTs rather than being over-reliant on nurses. All recruitment continues. More detailed staffing review for all psychotherapies including Psychology started by Commissioners .A new model of service delivery may need to be produced. CQC inspection report requires improvement plans to be produced by December for wait times and this has negated need to issue a contractual notice. The CQC plan will be monitored and will inform our Review .

4 3 12 4 3 12 3 3 9


trategic Risk 2.

BA

F Appetite S


Nov-18 Dec-18

Director of Mental Health, Learning

Disabilities & Children’s

Commissioning

Dave Gardner - Assistant Director of Procurement &

Commissioning

014

There is a national shortage of Psychiatric intensive care Unit beds PICU . This has resulted in delayed transfers (12hour breaches) in ED for RDH and CRH and in police custody. It is also a concern for prison release where there is a significant MH problem and community risk. This has resulted in an Increased use of PICU over last three years locally, which is impacting on CCG and DHcFT budget overspend.

Fin

an

ce

Fin

an

ce

5 3 15

Appointment of a coordinator for PICU to help bring LOS down, build relationships with providers and bring data togetherProvide challenge in system and more robust control of gatewayNew contract agreement with DHcFT means PICU will be directly commissioned by Hardwick CCG from 1 April 2017Escalated performance management from NHSE/I. Action plan in placePICU protocol adopted and in use

Explore regional options for procurement

Consider dedicated beds to assist with cherry picking by independent providers

Review Enhanced care unit and strengthen its ability to manage complex patients reducing need for PICU

Case Management to deliver local solution.

• Recent reduction in PICU usage but still above the block contracts in place.

Regional data shows Derbyshire did well compared to region . But national trend is up. Reprocurement process now in place. Statistical process control used to identify beds needed. rate of increase slowed but activity remains volatile. Analysis showed multifactorial no one factor at play. Remains at same risk level due to uncertainty.Procurement launched and is due award in December. Good expressions of interest for commissioned beds from independent and NHS sectors. Aiming to stabilise at 10 beds for next 12 months .

5 3 15 4 3 12 2 3 6


trategic Risk 6.

BA

F Appetite S


Nov-18 Dec-18

Director of Mental Health, Learning

Disabilities & Children’s

Commissioning

Dave Gardner - Assistant Director of Procurement &

Commissioning

015

Due to the increased pressures around workload, workforce and financial concerns, there is a risk to General Practice in providing quality primary care services to patients.

Prim

ary

Care

Co

Co

mm

issio

nin

g

Prim

ary

Care

4 5 20

Development and implementation of Derbyshire wide Primary Care StrategyImplementation of Derbyshire plan to deliver GPFV and 10 point plan for nursing including:- Additional resources - securing additional funding from NHS England to support delivery of the workstreams.- Support to practices through GP provider networks to support practice resilience via the NHS Engalnd GP Resilience Programme allocations.- collaborative work with the LMC GP Taskforce to support Practice Management development, GP recruitment and retention, Practice Nurse recruitment and retention- Develop 'at scale' collaborative working (GP Federation, Primary Care Groups).

Primary Care Quality and Performance Committee to oversee support to practices (CQC, GP contract, Quality) to identify and monitor individual practice risks at an early stage.Robust supportive contract management approach for practices rated as "Inadequate" or overall "Requires Improvement".Extended Access Hubs and shared IT arrangements to support business continuity and resilience for individual practices (major / unforeseen incidents).



4 5 20 4 5 20 0 0 0


trategic Risk 3.

BA

F Appetite S


Nov-18 Dec-18 Dr Steve Lloyd - Medical Director

Clive Newman - Director of GP Development

Marie Scouse - Assistant Chief Nurse Primary Care

Page 4 of 6204

Appendix 1

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Targ

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Previous

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018

If the organisation does not have a robust implementation plan to comply with The General Data Protection Regulation. The organisation will not be able to demonstrate its compliance when the Regulation comes into force on 25th May 2018. This will expose the organisation to significant legal/regulatory action, which may be imposed for any infringement of the GDPR and not just data security breaches.

Go

vern

an

ce

Sta

tuto

ry

3 4 12

GDPR Gap analysis undertaken and action plan put in placeAction plan monitored by Strategic GDPR working group.Key areas for compliance highlighted which have now been completed areIdentifying legal basis for processing under GDPRUpdating Fair Processing noticeCompiling a record of processing activitiesIdentifying any processing of Children’s data.

Updated the Data Protection Impact Assessment Template – raising awareness through a DPIA

presentation as part of operational meeting and embedding the DPIA process within the PMO. GDPR webpage populated to include DPIA templates, mandatory breach notification and timescales, updated incident reporting procedure, staff privacy notice, DPO contact details, guidance and links from the ICO and Information Governance Alliance.

• Continue to apply the principles of the GDPR to all aspects of the

CCGs business. • Ensure that PIAs become embedded practice for all new projects or

changes in processing data • Develop the role of the IG Committee.

• Ensure DPO, Caldicott Guardian and SIRO are visible and

influencing and supporting the IG Agenda • Network and learn from the wider IG community and apply best

practice within the CCGs• Develop and refine policies, procedures and codes of practice

• Ensure that those undertaking senior Information Governance roles

are trained and developed in order to provide relevant support, advice and guidance. • Work towards compliance with the Data Security and Protection

Toolkit

Good progress has been made against implementing the required changes to comply with the requirements of the GDPR. Teams and leaders within the CCGs need to continue to identify where there are risks inherent within the service they provide to ensure continued compliance. Projects need to have a DPIA carried out at an early stage and supportive policies, procedures and codes of proactive developed and promulgated. The interim PMO Operations Manager has developed a PMO operations manual, currently in draft, which includes a section on DPIAs. Once approved this manual will further embed the requirement to undertake a DPIA.

CCG Data Protection Officer is an active member of the Derbyshire Wide Information Governance Workstream meeting which will support the CCG in applying best practice and learning from the wider IG community.

A gap analysis between the IGTKV14.1 and the new DSPT is in progress.

The Derbyshire Governance Committee meetings in common at the meeting on 8th November 2018 approved the latest version of the information Governance Framework (2018).

3 4 12 3 4 12 2 3 6

To be determined

Nov-18 Dec-18



Delivery

Falu Bharmal - Director of Corporate Delivery

019

There is an organisational risk that cyber attacks are becoming common. This impacts upon the integrity and security of key information assets and use of IT and clinical systems, which may lead to Information Governance breaches.

Go

vern

an

ce

Co

rpo

rate

3 4 12

• Information Governance Policies training for all staff

• Compliance with Information Governance Toolkit and audited annually by Internal Audit

• Derbyshire-wide Information Governance Committee

• NECS IT counter measures against cyber-attacks and assurance on safeguards in place against

cyber-attacks, with regular reporting • Incident reporting tool

• HSCIC undertake monitoring of email traffic to identify potential threats

• The CCG has sight of the Local Health Resilience Partnership Strategic Risk Register, which

contains two risks on Cyber Security: NM15 (Cyber Attacks: Infrastructure) and NM22 (Cyber Attacks: Data Confidentiality) • 360 Assurance report on Cyber Security delivered 'Significant Assurance' and Action Plan in place

• Positive 360 Assurance Cyber Security Review Follow-up Report received

• Cyber Security Week completed across Derbyshire CCG's.

• Periodic testing of staff awareness around Cyber Attacks

Require assurance linked to mobilisation plan

Reporting on CARECERT commenced

• All GP servers upgraded to Windows 2003 completed April 18.

NAO report recommendations to be followed up

NECS contract mobilisation complete - active monitoring in place

• Server replacement complete•

3 4 12 3 4 12 3 4 12


trategic Risk 7.

BA

F Appetite S


Nov-18 Dec-18



Delivery


020

If there is a failure to maintain and review existing business continuity contingency plans and processes (Inc EPRR), this will impact on the known risks to the Derbyshire CCGs, which may lead to an ineffective response to local and national pressures.

Go

vern

an

ce

Co

rpo

rate

4 4 16

• CCG active in Local Health Resilience Partnership (LHRP)

• On-call staff are required to receive Met Office Weather Alerts. These will be cascaded to relevant

teams who manage vulnerable groups • The CCG is aware of and contributes to Derbyshire wide Risk Registers which contains risks

relating to Emergency Planning and Business Continuity. • Executive attendance at multi agency exercises.

• Internal Audits have evaluated Business Continuity preparedness.

• BC Leaflet includes Derbyshire On-Call number - circulated to staff

• Derbyshire-wide Incident Plan in existence

• Joint Emergency Services Interoperability Protocol (JESIP) training made available to on-call staff

• CCG EPRR Core Standards for 2018 completed, presented to Governance Committee and

forwarded to NHSE EPRR Team ahead of Confirm & Challenge session to be held in October 2018• Staff member trained in Business Continuity and member of professional body

• Derbyshire CCGs are holding two full days to carry out Confirm & Challenge sessions with

Derbyshire providers scheduled for 8 /9 October 2018• Paper to Governance Committee September 2018 setting out work towards the Core Standards

and seeking approval for EPRR 2018/19 Work Plan, Strategy Document and guidance for providing Situational Reports (SitReps)• Derbyshire CCGs represented on LHRP and LRF sub-groups including, HEPOG, Training and

Exercising sub-group. Risk Assessment Working Group and Derbyshire Health Protection Response Group.• On-call rota being revised to introduce two tier system with improved resilience

• Comprehensive training planned for On-call staff

Practices updating Business Continuity Plans to include consistent contact details for CCG in-hours and out of hours.

Derbyshire CCG's to develop a single Business Continuity Plan to support proposed merger. CCG on call arrangements currently being reviewed including training. Derbyshire CCGs EPRR core standards reviewed as part NHSE confirm and challenge process (October 2018) as SUBSTANTIAL compliant.

NARU review of EMAS's national capabilities 23-26 October. Report received from EMAS along with action plan. There will be quarterly updates provided at Partnership Board.

2 3 6 2 3 6 2 2 4


trategic Risk 4.

BA

F Appetite S

core = 9 (high risk appetite) and Objective 5 linked to S

trategic R

isk 9. BA

F Appetite S

core=9 (high risk appetite)

Nov-18 Dec-18



Delivery


022

There is a lack of community nursing staff in Derbyshire, which is an integral element in developing 'place'. This increases the likelihood of clinical risk as well as impacting on patient experience.

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5 4 20

• As the provider of the service DCHS are responsible for managing the clinical risk, and report on

this risk through formal contracting mechanisms with commissioners.• DCHS / practice communication is clear with a link nurse for each practice.

• Development of new nursing care model in 'place'

Continue to monitor staffing levels

Discussion needed and consider new models of working.

This issue is forming part of discussion re development of places

Contract negotiations reduced overall funding to DCHS (November 2017)

Additional staff recruited to ICT April 2017

CCG identified gaps between primary care nursing & community nursing (e.g. wound care). Begun a review of community nursing specification to quantify gap and determine who should cover it, ahead of a discussion about how to resource this cover.• Meeting with LMC 20th June 2018 to discuss way forward. Outcomes to be

presented directly to Excess.

3 4 12 3 4 12 0


trategic Risk 7.

BA

F Appetite S

core = 9 (high risk appetite) and O


trategic Risk 8. B

AF A

ppetite Score=6

(low risk appetite)


Officer

Laura Moore - Deputy Chief Nurse

Page 5 of 6205

Appendix 1

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Targ

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Progress Update

Previous

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Residual/

Current Risk

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Fra

mew

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023

There is a risk that the cost of acute care is higher than the contracted value, either through additional activity or higher than planned average costs. This would could lead to the CCG missing its statutory responsibility in meeting it's agreed control total.

Qu

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4 3 12

Contracts monitored monthly via FRG and Finance Committee/Standardised data checks/Coding and counting checks/Internal contract management process/revised contract governance - including introduction of a finance and activity group/demand management schemes in place - PLCV/C2C/MSK/Practice

Timely close down of contract challenges/Implementation and monitoring of delivery of demand management schemes to inform further actions

Month 7 reported position is a forecast overspend of £2.8m (0.36%) which is being managed within the financial position. The forecast includes the required investment to meet the RTT planning requirements of maintaining the elective waiting list at the March 2018 level.

3 4 12 3 4 12 3 4 12


trategic Risk 6.

BA

F Appetite S


Nov-18 Dec-18Louise Bainbridge -

Chief Finance Officer

Lynn Matthews - Director of Contracting and

Performance

024

If the CCGs fail to engage with the membership and does not put in place succession planning this will lead to gaps in the organisation and decrease in performance.

Prim

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3 3 9

• Governing Bodies received report on current GB members’ contracts for decision to agree process

to for future changes to contract end dates . Roles of GB members GPs to be reviewed in light of committees in common and closer working proposals across Derbyshire.

• The Chairs have just completed their nominations for the new committees

and we will then be looking to review hours and remuneration etc., but there remains outstanding the triumvirate and clinical leadership roles to decide and agree on and that is now being progressed.• The Triumvirate and Clinical Leadership roles are being considered both as

part of The Organisational Development Board and the wider CCG Clinical Commissioning Strategy due for discussion at the GB Development Session on the 27th September.• The GB Development session focused on the key areas and following this

meeting the Transition Working Group has been re constituted and meets in between each GB meeting. Recruitment to new GB in place.

3 3 9 3 3 9 2 2 4


trategic Risk 8.

BA

F Appetite S

core = 6 (low risk

appetite) and Objective 5 linked to

Strategic R

isk 9. BA

F Appetite S


Nov-18 Dec-18 Helen Dillistone/Beverley Smith

Helen Dillistone/Beverley Smith

25

The changes to the Special Educational Needs and Disability (SEND) Tribunal Process from the 3rd April 2018 may have a negative financial and reputational impact on the Derbyshire CCGs should the appropriate commissioned services not be in place.

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4 3 12

• The designated clinical officer (DCO) for SEND (Jayne Hankins) and Children’s Commissioning

Lead for SEND (Georgie Hill) along with representatives from both Derbyshire County and Derby City Local Authorities have attended briefing events on the trial and have more detailed information on the Tribunal process.• DCO and children’s commissioners to share information with adult commissioning colleagues.

• Briefing for CCG executive board and CCG governing bodies.

• Tribunal themes and commissioning implications are being analysed via the Derbyshire County

SEND Commissioning Hub and the Tribunal work stream in the city.• The changes to be raised at both County and City SEND strategic Boards.

• The information on this trial has already been shared with health providers across Derbyshire via

their SEND leads. This paper will also be shared with providers via formal contracting routes and via the SEND health footprint meeting (under the Children’s STP workstream).

• “DCO has drafted a “ 1st Tier Tribunal Implications for CCG’s Framework document” that

children’s commissioner & DCO are working through to address gaps and mitigate against risks.

• DCO and children’s commissioners will work with both the City and

County Local Authorities to integrate the health contribution into the Tribunal process and identify if there is any additional resource required or further implications from health to support the process. •

There has been specific Tribunal workstream set up in the city & similar work in the county- with clear plan & actions required. Risks highlighted to adult MH/LD commissioners to ensure providers are able to engage

Specialist legal advice has been sought to understand the implications for commissioners. 4 cases have been lodged via the single route of redress in the. County -implemented new tribunal panel - liaison with LA & providers identifying mitigating actions required

4 3 12 4 3 12 3 2 6


trategic Risk 6.

BA

F Appetite S



Officer

Jayne Hankins - Head of Children's Therapy

Services, Derbyshire

Page 6 of 6206

CONFIRMED MINUTES

Derbyshire Quality and Performance Committee 4th October 2018

2.00 – 5.00 Conference Room, Toll Bar House

Present: Dr Buk Dhadda (Chair) Steph Austin Helen Henderson-Spores

DB SA HHJ

Q&P Chair/GP Governing Body Member, SDCCG Head of Quality, Derbyshire CCGs Healthwatch Derbyshire

Helen Hipkiss Zara Jones

HH ZJ

Deputy Director of Quality, Derbyshire CCGs Executive Director of Commissioning Operations, Derbyshire CCGs

Nicola MacPhail Karen McGowan

NM KM

Deputy Chief Nurse, ECCG Assistant Director of Quality & Assistant Chief Nurse, SDCCG

Laura Moore Rachel Murfin Bill Nicol

LM RM BN

Deputy Chief Nurse, Derbyshire CCGs Patient Experience Lead, ECCG Assistant Director of Adult Safeguarding, Derbyshire CCGs

Gillian Orwin GO Lay Member, Patient & Public Participation, HCCG Suzanne Pickering Dr Alla Praveen Michelina Racioppi Ed Ronayne

SP AP MR ER

Head of Governance, NDCCG Governing Body GP, NDCCG Designated Nurse for Safeguarding Children, SDCCG Adult Safeguarding Manager, SDCCG

Brigid Stacey Isabella Stone

BS IS

Chief Nursing Officer, Derbyshire CCGs Lay Member, Patient & Public Involvement, NDCCG

Phil Sugden PS Deputy Director of Quality, HCCG Adam Sutherst Dr Merryl Watkins Pamela Watson Martin Whittle Lynne Matthews

AD MW PW MWH LMt

Assistant Director of Planning and Performance, NDCCG GP Lead SDCCG Lay Member, Patient & Public Involvement, ECCG Lay Member, Patient & Public Involvement, SDCCG Director of Contracting & Performance, Derbyshire CCGs

In Attendance: Lucinda Frearson LF Clinical Quality Administrator, SDCCG (Minutes)

Item No.

Item Action

Q&P 1819/81

Welcome and Apologies Dr Buk Dhadda (BD) as Chair welcomed all to the meeting and introductions were made around the table.

The following apologies were noted: Steve Hulme - Director of Medicines Management, SDCCG

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Karen Ritchie – Chief Executive, Healthwatch Derbyshire Stuart Fletcher – Governance Manager, SDCCG Karen Holgate – Designated Nurse Looked After Children Derbyshire Heather Peet – Designated Nurse, SDCCG Juanita Murray – Designated Nurse Safeguarding Children

Q&P 1819/82

Declarations of Interest The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of the CCGs. No declarations of interest were declared.

Q&P 1819/83

Quality and Performance Committee Minutes The Minutes of the previous meeting held on 6th September 2018 were agreed as an accurate record with the following amendments: Page 4: Word corrected in the last paragraph. Page 9: Individual Case Reviews: Word amended in second paragraph. Action: Confirmed minutes to be submitted to the Derbyshire Governing Body meetings.

HH/LR

Q&P 1819/84

Matters Arising Action Log requires dates adding. If the topic is on the Agenda then the word agenda needs to be entered on the action log. Action Log BAF & Risk Register – Item Q&P 1819/36 – Item now closed Various Checks – Item Q&P 1819/44 – All items now closed Safeguarding Adults DOLs – Item Q&P 1819/45 – Item now closed. DTHFT Performance – Item Q&P 1819/58 – Item now closed. Various – Item Q&P 1819/72 – Item now closed Various Reports – Item Q&P 1819/73 – All items closed with Jackie Jones EMAS, invited to the November meeting to give an overview. Various – Item Q&P 1819/74 – Care Homes are on the Agenda for the November meeting. Children’s section complete with Patient Experience and Maternity remaining open. Scheduled Performance Reports – Item Q&P 1819/75 – Item now closed.

Q&P 1819/85

Quality & Performance Report INTEGRATED REPORT

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Chesterfield Royal Hospital (CRH) Adam Sutherst (AS) gave an update on the key areas from the report which showed CRH had missed the ED 4 hour target again in August at National with 91.3%, however, un-validated data is showing an improvement to 93.7%. At the moment the Trust are running with 4 out of 8 vacancies for middle grades and have appointed 5 doctors from India that are due to start January 2019 and one doctor from Manchester who is due to start December 2018. As we go into the winter period and new appointments will not start until December/January, on the 28th September the Clinical Commissioning Group (CCG) raised a Contract Performance Notice (CPN) to understand how CRH expect to recover leading up to and through the winter period and are currently awaiting an action plan. It was queried what could be done in the meantime prior to the appointments starting as they are currently underperforming at a time of year when they should not be, an understanding of their actions moving forward is required. Even after the new doctors have been appointed there will still be a settling in period. Zara Jones (ZJ) raised the breach analysis, obviously other issues are happening. Understanding performance trajectory was required as this targeted approach around workforce would not be seen until January or middle of winter. Last week there were 85 breaches and 75 of those were down to waiting to see a doctor. BD highlighted that there was a need for the committee to fully understand - what they are doing to recover the position and do we have systems in place for 90% performance for December before the committee can be fully assured. Royal Derby Hospital (RDH) RDH are in the same position as the CRH. Performance meetings and weekly telephone calls are being carried out; there is a need to find out what the issues are and what is being done to solve the problems, again a CPN had been issued. Assurance should be received through the CPN with regard to actions. They have had good performance in the past. RTT Performance In July CRH were performing 90.6% against 92% standard and the un-validated performance progress has shown a dip to 88.6%. Since last month NHS England has written to the CCG to get an elective recovery plan in place to reduce waiting lists which have grown at both CRH and RDH. A paper will be presented at the Finance Recovery Group (FRG) meeting on Monday 15th October and will be brought to this Committee next Month. 52 Week Waits There were 8, which dropped to 4 in August 2018. There is a recovery plan in place with CRH to have none by January and the CCG have made a commitment to NHS England to have none by October 2018. The performance team have begun to collate waiting list reports for patients over 38 weeks from all providers with a member of staff telephoning the Trusts weekly. This information will be given to AS and Lynn Matthews (LMt) to gain a better understanding of why patients have not been treated.

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The CRH trajectory is looking to reduce waiting listings by around 1200 patients and remove 52 week long waits. A new process is being put in place whereby a member of staff will telephone at 38 week and find out why the patient is still on the waiting list, assurance has been given to NHS England that these will be zero by the end of October, it is the ambition of the CCG to be more proactive. Patients Choice means that a patient can have up to 6 appointments if previous appointments were not convenient. In other large Trusts patients are offered just two dates, if for non-clinical reasons they did not take up either of the dates further dates were not offered. The CCG would like to work with our Providers to implement this way of working. Action: AS to share Monday’s report findings with Laura Moore (LM). Diagnostic Waits CRH echo-cardiograph: in July they were reporting 3.4% against 1% standard, our un-validated position is showing an improvement to 1.5%. A recovery plan from the Trust has not been received; therefore, a CPN had been issued. The timeframe under the CPN is they have to meet with us within 10 days of the notice with a recovery plan, the CPN was raised on the 1st October 2018. CRH have had staffing problems and at present there is a national shortage of echo-cardiographers. So it is about understanding what mitigations they are putting in so that this does not happen again. CRH have put on extra clinics at the weekends to try to sustain delivery and are clearing the backlog whilst still having a vacancy. BD asked how confident we are that they will clear the backlog in a reasonable time as the backlog will keep increasing. AS advised that once recovery plan has been received than we can ask the questions. If no response to requests are forthcoming from the Trust then issues such as this ought to be escalated internally to a member of the executive team prior to issuing a CPN. Under NHS England contract a CPN is a severe sanction whereby funding can be withheld and always produces a result. Cancer 62 day at CRH identified performance was at 81% in July un-validated data shows they hit the target of 86.2% but there is still the outstanding issue of the urology clinic which is shared with Sheffield. Some progress has been made in moving the clinic over to Sheffield Teaching Hospital but this will not start happening until the first week in January. A recovery action plan is still awaited from CRH and from the breaches half will be from this clinic. Action: LMt and LM to meet with Cancer Lead, Christine Urquhart, and AS to provide a deep dive report as part of the schedule of reports EXCEPTION REPORTS QUALITY REPORTS CRH had a never event which was wrong sight surgery. The error was noticed and the correct procedure was carried out on the correct leg with no harm to the patient. A full report is awaited, the 72hr report shows everything was done correctly but then there was an interruption, which meant a break in the process.

AS

LM/ LMt/ AS

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In terms of CQC there was an unannounced inspection which took place and the draft report for factual accuracy will not be with the Trust until after Christmas. There has been some information feedback from the Trust and there was no immediate action the Trust would have to make. There may be some feedback given at the next QAG but currently there is a need to wait for the report to be received. With regard to CQUINs there is a detailed schedule that sets out quality indicators which are a statutory requirement of the Trust. The CCG do not pay for anything which is not achieved. Contract intentions were sent out last week. Derby Hospital With regard to A&E a CPN has been issued for a recovery timeline. A verbal agreement has been received for the standard at March. RTT work is being done on electives and with Cancer a CPN has been put in. Recovery was agreed for July but not yet achieved so a request for a revised recovery plan has been made. Joint work was undertaken by the contracting and quality teams, to look at cancer breaches as we are not getting the assurance that actions post breach analysis are being put in place, this was presented internally to the Provider Cancer Programme Board. We are monitoring progress with this. Burton have had issues with regard to Ophthalmology. Since the merger they have been looking together at the backlog and new pathways. The service was put on hold for a while and then recommenced. A new trust manager has taken this on and East Staffs are feeling more confident that they are seeing results. MWH asked if the urology patients were included in the numbers. Patients referred in and given a date to go on the list. Action: AS to check which patients were included in the report figures. The Patient Experience Report was showing an 8 week backlog on clinical letters, but this was only around some services. Discharge data is required to show how quick patients are being discharged and how quick the Trusts getting discharge papers out. Action: AS to follow up and report back to the meeting. LM had had a meeting with NHS England, NHSI and the Trust with regard to the oxygen never events. The Trust have produced a very good action plan which has been agreed. They are holding meetings across the Trust with staff at all levels to get the issue resolved. LM is returning with NHS England and NHSI in November. BD expressed concern that it had taken four never events to put things in place. Other issues were also uncovered at the same time such as different instructions on different wards which have also been resolved. DCHS Children’s Wheelchairs Only 7 children waiting over 18 weeks with overarching trajectory now agreed, have a recovery plan in to get this down.

AS

AS

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DHU Recovery plan is now in place and performance as of Monday was 94.5% against 95% standard, additional funding means they can recruit more staff.

Q&P 1819/86

Scheduled Quality Reports Adult Safeguarding Annual Report 2017-18 BN gave his report on safeguarding adults. One of the biggest challenges is MCA and the implementation of what is a statutory piece of work, the problem is it is aligned with safeguarding and so people think about it when someone is the subject of abuse when actually it is a daily core function of any health profession. The core function of the safeguarding team is to look at functions across the Trusts done in a variety of ways, main way is the safeguarding adults framework where trusts are asked to give a range of evidence which is assessed and work with the trust to develop and work through action plans. A lot of work with colleagues has been done over what we call JSASF, Joint Safeguarding Adult Assurance Framework, for primary care and last year was 100% compliant. Again it was felt there were gaps in the process because there is no resource to go to each GP practice and measure their assessments. A huge amount of work is done through multi agencies and it is important that the CCG shape the agenda rather than it be brought to them. Safeguarding have established a training programme, 14 podcasts, and a MCA DOLs App. This year there has been a drop in the number of calls for advice which is positive and people seem more confident to make a referral rather to have it checked out, the ones we do get are appropriate. These are all great improvements. Policies and Procedures are updated to ensure CCG are in line with national standards and this is ongoing. MARAC and GP information sharing project had 6% compliance to begin with and is now at 84% - the CCG’s paid £1200 into the MARAC administration and from that small investment we are seeing a good return. Another safeguarding issue now becoming more common is hoarding and this sits with self-neglect in abuse category. BN highlighted that at one time work was done with the family and then at the end there was no one to pay for a skip to clear away so the work was for nothing. Now there is a payment of £3000 made by the CCG, Police, Local Authority and Environmental Health and for £60-£90 the problem is being resolved and the person is given a fresh start. Vulnerable Adult Risk Management, the CCG has undertaken a full review of the whole process which has led to a new policy, new customer leaflet and staff guidance. Safeguarding adults continues to be a challenge within the resources that are available but the agenda has moved on a great deal. £30k has been received from NHS England for CCGs to use on Safeguarding

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issues around STPs and this has been used to arrange a Conference on the 1st March 2019 with several speakers lined up to take part. Details will be circulated once finalised. Safeguarding Children and Looked After Children Annual Reports This was presented by Michelina Racioppi (MR). Gillian Orwin (GO) found the report very easy to understand, no questions were presented as it was so informative. The reason for there being four reports is due to their being two Safeguarding Children Boards and two Corporate Parenting Boards. Next year it is hoped there will be one looked after and one safeguarding children board only. Chris Clayton is due to attend a Chief Officer’s meeting to discuss the new partnership arrangements with safeguarding children across Derby City and Derbyshire. This stems from the Wood review and has led to a complete overhaul of safeguarding children’s arrangements across the country but it means that systems and processes imbedded for many years are going to be very different. A task and finish group is to be established to interpret the guidance and implement by September 19. Proposals once agreed and signed by the Chief Officers will go to the Secretary of State to agree. The proposals put forward have had full participation of the Board members who are very engaged. Once presented at Chief Officers’ meeting it will be sent to the Local Authorities, to Q&P Committee and then Executive Body. The CCG, Local Authority and Police will be the three key members and hold significant responsibility. The report gives an overview of the structure, laying out duties and sub groups. With the new arrangements there will also be a reduction in costs made by the CCG. Although, within the new arrangements children’s death overview process will fall heavily with the CCG. CHC A deep dive had been carried out for Finance Committee showing a significant overspend at the end of last year. M3 was recording a £41k underspend and M5 an £84k overspend. CHC Fast Tracks are an issues which is being explored. SDCCG saw services decommissioned and an increase in costs, which saw a £300k underspend and a £800k movement within the month. At M5 the highlights were:

• Funded Nursing Care and High Cost Packages • Fast Tracks needing focus • PWC Action Plan put in place

BD highlighted the need to have the right access to data to be able to deal with concerns. Brigid Stacey (BS) pointed out that reliance on the CSU for the information was an issue, although work around CSU is improving. Finance are currently working through invoices from Local Authorities and once initial analysis and review is complete a discussion will take place with the Local Authority with a cut-off date. Patient Experience Rachel Murfin (RM) informed the meeting that the actual template and structure contents had not changed as yet, as the data content was up to end of June. The

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data for July, August and September to be presented in November will be in the new format. Referencing source of information has been included to demonstrate where the information was gathered and entered and by whom and an overview of the report highlights are given in key bullet points. An additional Section on reassuring patient experience was included informing of the new process and information. It is really good to get all the data together and to share. If any changes required or comments, please forward on. End of Life Treetops quality account has been submitted and Steph Austin (SA) had included for information. During the last meeting SA had informed of changes to the in-patient beds at Ashgate Hospice. Planning permission had now been granted but it had been decided to delay due to the winter period and work will commence in the spring. Work is being undertaken on the palliative care at home to try to remove some of the pressure. There had been a change to the model of how the clinical specialists work, with a more towards hospice at home beds. Ashgate will try to mitigate risks with the quality impact assessment of the work being done and SA is waiting for this to be submitted. Ashgate have this high on their agenda and risk register. MWH highlighted the comment ‘there continues to be late referrals to the day hospital’ on page 2 of the report in the first paragraph. SA advised that support from the day hospice is not as effective if people are not referred early enough as they are too ill to attend, therefore the specialist for hospice at home service would be a better option. ZJ commented on the dashboard and thought it would have been good to see collective performance data. SA informed her that hospices are commissioned and measured differently so are not like for like. High Risk QIAs for Escalation There have been 4 QIA Panels with 9 QIAs submitted.

• 2 were no risk • 4 were low risk • 3 moderate risk

Two were returned not approved as further mitigation was required. Overall none were of high risk. Delivery of QIA workshops has continued with good feedback and improvement in assessments being seen.

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Q&P 1819/87

Breach Report 12 HR Breaches Phil Sugden (PS) had produced a deep dive report on the 12 hr breaches which showed a good example of the work that goes on when getting some of the performance figures and what is happening when they appear red on a dashboard. For the last 12 to 18 months RDH have been under scrutiny around the number of reported 12hr breaches. Work had been done around the cause and around patient harm. Work had been undertaken by both acute trust commissioners and the mental health trust to produce a detailed action plan. Cases from beginning of the year were looked at and when broken down there were only four that were 12 hour breaches due to delays and 3 were out of area so the delay was waiting for a bed in the area they lived. Some delays are due to the national shortage of tier 4 beds which are commissioned by NHS England and Specialised commissioning. Conclusion was that there were 2 overarching factors but its not all around the national shortage of tier 4 beds and there was quite often a delay in the assessment of the patient due to them being in crisis. There are four medium term actions which are being worked through with a Quality Review Meeting taking place with NHS England and NHSI on 17th September. An action plan has been received and then sent back with comments. Currently waiting the final report and this will be monitored through the urgent care board but will also go through necessary QAGs. PS wanted to note that David Gardner’s knowledge and input was invaluable. BS wanted noting that all actions had gone to the Urgent Care Board except one which had gone back to the regulators to understand how Derby were recording the 12hr breaches. Action is for regulators to make a decision and give clarity and is being taken forward by a regional group. BS will be drafting a letter on behalf of Chris Clayton to be sent to the regulators. BD expressed the report was really good and detailed giving a good insight. The underlying issue is how do you prevent those patients getting to that point and providing support services earlier along that pathway. There is a 3 year investment plan that covers this. Partial investment has been received but there are not enough mental health nurses out there. EMAS Following the review from NHSI a C1 harm review was carried out. Leicestershire has been completed but the report is yet to be received. A large proportion look as if they should have been reported as C2s. The review was taken to the Quality Assurance Group and then back to EMAS and an agreement was made to look at Northamptonshire next and the focus will be on C2s rather than C1s. This was felt to be an excellent review.

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Q&P 1819/88

Scheduled Performance Reports: IAF Again the report seemed weighed towards quality, performance requires time to prepare and a quarterly report around performance was suggested. ZJ expressed requirement for a deep dive and would work up a schedule and share. BD highlighted the need to evidence for assurance. Action: ZJ to produce performance report schedule

ZJ

Q&P 1819/89

National / Regional Guidance This is a standing item – Nothing to report.

Q&P 1819/90

Exception Risk Report Since September, a report had gone to Governing Body and changes were highlighted in red. There were 10 risks, 3 were extreme with no increase in the risk score during the month. Safeguarding was also closed last month and approved by the Governing Body. AQP window is now open for anyone on the list, with a report going to FRG and the Clinical & Lay Committee. Action: BS to circulate the report. PS queried what that meant with regard to quantity and there was a need to ask SA what the potential was for extra beds. Action: BS to discuss with SA

BS

BS

Q&P 1819/91

Minutes Received The following minutes were received for information only: DHcFT QAG Diabetes Primary Care Provider Group – 21 06 18 Diabetes Primary Care Provider Group – 02 08 18 JAPAC EMAS PTS CMB PSG North MWH pointed out page 366 of the Minutes (JAPAC) the request to use unlicensed dupilumab for severe atopic dermatitis in adults, and wondered where such things were addressed. He was informed that it is a risk to go off licence and anything without a licence would not be funded.

Q&P 1819/92

Items for Escalation to JCC / GB / QSG None.

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Q&P 1819/93

Any Other Business Derbyshire CQC Inspection Report PS informed the meeting that a full inspection had been carried out and improvements were required although a lot of good work had been done. Radbourne Unit and Hartington had no issues, however, there were safeguarding issues and a whistleblowing incident reported. The CQC report had been received and this will be reviewed and circulated. A follow up inspection date of 19th October had been arranged. Action: PS to circulate CQC Report

PS

Date and Time of Next Meeting

This may be reorganised due to Joint Governing Body Meeting

8th November 2018

2.00 – 5.00 Boardroom, Toll Bar House

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DRAFT MINUTES OFAUDIT COMMITTEES IN COMMON FOR EREWASH, HARDWICK, NORTH DERBYSHIRE AND SOUTHERN DERBYSHIRE CCGS HELD ON 19th SEPTEMBER 2018

ROBERT ROBINSON ROOM, SCARSDALE AT 13.30PM

Present NHS Erewash CCG Margaret Amos (MA)

Shaw Ian (IS) Watson Pam (PW)

Lay Member Audit and Governance, ECCG Audit Chair Lay Member, Governance Lay Member Patient and Public Involvement

NHS Hardwick CCG Dentith Jill, (JD)

Beattie Valerie(VB) Heathcote David (DH) Orwin Gill (GO)

Lay Member Audit and Governance and HCCG Audit Chair Lay Representative Lay Representative Lay Member, Patient and Public Involvement

NHS North Derbyshire CCG

Gibbard Ian(IG)

Apsley Gary (GA) Dentith Jill, (JD) Stone Isabella (ISt)

Lay Member Audit and Governance, NDCCG Audit Chair Lay Member, Patient and Public Involvement Lay Member, Audit and Governance Lay Member Patient and Public Involvement

NHS Southern Derbyshire CCG

Amos Margaret (MA)

Whittle Martin (MW)

Lay Member, Audit and Governance, SDCCG Audit Chair Lay Member, Patient and Public Involvement

In Attendance: Bainbridge Louise (LB) Chief Finance Officer, Derbyshire CCGs Dillistone Helen (HD) Bharmal Falu (FB)

Executive Director Corporate Strategy & Delivery Derbyshire Director, Corporate Governance

Colson Alasdair (AC) External Audit, KPMG Dean Janet (JDe) Internal Audit, 360 Assurance Fletcher Stuart (SF) Governance Manager, SDCCG Hogg Sandy (SH) Director of Turnaround, Derbyshire CCGs

(QIPP Programme item) Morris Ian (IM) Counter Fraud Specialist, 360 Assurance Pearce Joanne (JP) Directorate Administrator, ECCG (Minute Taker) Pickering Suzanne (SP) Head of Governance, NDCCG Stacey Brigid (BS) Chief Nurse, Derbyshire CCGs Stanyer Simon (SS) External Audit, KPMG Thomas Tim Internal Audit, 360 Assurance

Apologies: Gascoigne Sian (SG) 360 Assurance

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AC/1819/47 WELCOME AND APOLOGIES MA welcomed the attendees and noted apologies from Sian Gascoigne, 360 Assurance. It was confirmed that all Audit Committees were quorate.

AC/1819/48 DECLARATIONS OF INTEREST

MA reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of the CCG.

Declarations declared by members of the Audit Committees in Common are listed in the CCG’s Register of Interests and included with the meeting papers. The Register is also available either via the corporate secretary to the Governing Body or the CCGs websites.

Declarations of interest from sub committees

No declarations of interest were declared.

Declarations of interest from today’s meeting

No declarations of interest were declared.

AC/1819/50 INTERNAL AUDITS – DERBYSHIRE WIDE COUNTER FRAUD PROGRESS REPORT SURVEY REPORT 2018 IM presented the papers to the committee members and took the papers as read. This is the first progress report of the financial year. The work plan and risk assessment were approved at the Audit Committee meeting in April 2018. 360 Assurance are required to submit an annual report for each of the CCGs. The reports will be circulated to the Audit Committee members after to today’s meeting, any questions to be directed to IM – ACTION Within the annual report is the NHS Counter Fraud Authority Self Review Tool which is an assessment of the standards that have to be adhered to. All Derbyshire CCGs are currently standing at a green rating.

MA referred to the Anti-Crime initiatives and asked if these were consistent across the county. IM replied that these initiatives are passed to a single point of contact within the four CCGs for circulation.

DH referred to Section 4 of CF survey IM noted there have been 244 responses from Derbyshire and asked if this was an acceptable level. IM confirmed the rate is far superior to other responses he is receiving.

JP

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IM continued to say the Counter Fraud Team are preparing for Counter Fraud Awareness month in November. An animated Counter Fraud presentation is almost complete. Any member of staff viewing the presentation will count towards the standards.

Ideas have been requested from senior members of staff around Counter Fraud Awareness.

SH joined the meeting.

AC/1819/49 QIPP PROGRAMME

SH provided a verbal update on the QIPP programme for 2018/19 which focused on key points. The background to the 2018/19 QIPP programme is the need for a response to the financial crisis within the Derbyshire CCG’s. The QIPP plan started very late in the year and subsequently finished late, it was carried out without the usual systems and processes. The first step in July 2018 was to get the 2018/19 QIPP plan approved by a public Governing Body (GB). A more detailed plan then went to the Confidential GB meeting. The overall 2018/19 QIPP plan was approved at the GB meeting on 17th August 2018. The QIPP target is £51m. There is a deficit of £95m and if the CCGs fully deliver the QIPP savings it will meet its negative deficit control total of £44m which will mean the CCG’s will secure £44m of the Commissioners Sustainability Fund (CSF) allowing the CCG’s to report break even in this financial year. The QIPP programme is split into two key areas. Of the £51m, £39m relates to schemes that can be realised to deliver the savings. The other £12m requires difficult negotiations with providers around removing costs from the contracts and also includes an element on reducing running costs. The next step was to establish SRO accountability arrangements. This is now in place and each scheme has an Executive Lead, a Functional Director and a core team to ensure delivery. In terms of reporting the first full QIPP report was submitted to the Finance Committee on 7th September 2018. The Finance Committee members approved a methodology for reporting on all of the schemes. The M5 QIPP report will be presented at the Finance Committee meeting on 20th September 2018.

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There has been reference through the limited assurance report and also through the Finance Committee that there is not a robust PMO arrangement in place to manage the QIPP programme. This is a significant risk to the CCGs and mainly due to the CCG restructure going through a second period of consultation. To mitigate the risk the Executive Team have agreed on a number of business critical posts that will be progressed and Project Management Office (PMO) is one of those areas. The CCG are actively reviewing the CV’s of agency staff with a view to getting staff into post as soon as possible. HD joined the meeting Another step is the recruitment of a Director of Efficiency (Deputy Turnaround Director) for 6-9 months to support SH. This is not a permanent requirement. There are some potential candidates from NHSE. A PMO manual is currently being developed which will set out the end to end processes of all things related to the QIPP programme. This will be completed by 1st October 2018. Detailed planning for 2019/20 has commenced and a launch event on 3rd October 2018 will take place to start actively planning the QIPP programme for next year. The current QIPP position against £51m is £14.8m delivery to the end of August 2018. This is against the profiled plan within the CCGs. However the risk assessment is key as 66% of the QIPP programme is due to be delivered in the second half of the year. The risk assessment highlighted around £9.1m of risk on the overall £51m. In turn this is forcing the CCGs to look at the actions that need to be taken to ensure delivery of the control total. SH referred to the action plan collated through the Financial Recovery Group (FRG) which ensures all areas are covered. Included in the action plan is contract management and manging the contract hotspots from an operational point of view. In the second half of the year there will be a concerted effort around referral management, reducing Non Electives (NELS) and Out Patient Activity. MA asked SH to confirm whether there will be two Finance Committee meetings per month. SH replied this will be discussed at the Finance Committee on 20th Sept 2018. GA referred to a meeting he attended at which SH has raised the issue

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of performance against QIPP and he reflected that he was aware people were not switched on to the importance and urgency of the job in hand. SH responded to say that within the formal paper there is set out three areas of concern which require urgent improvement. MW asked how long it would be until the PMO infrastructure is in place. SH replied saying the aim is to get and interim structure in place by to mid-October. On a permanent basis the aim is Christmas 2018. MA asked SH if she would be agreeable on returning to the Audit Committee meeting in November to provide and update. ACTION – SF will ensure SH is invited to the Audit Committee meeting in November 2018 to provide a verbal update on the PMO arrangements. IG asked the question on whether the current PMO team have the skills and capabilities to deliver the required QIPP savings. SH replied the focus will be on how the business critical areas can fill the gaps whilst not taking things off people as accountability remains important. Zara Jones has now joined the organisation as executive Director of Commissioning Operations and has extensive experience in how to undertake appropriate commissioning, appoint the right people into post to drive the commissioning processes. TT added the he had a good meeting with SH to review the QIPP report and there is the potential to carry out some independent assurance work if the Audit Committee should require it. MA suggested this is addressed at the meeting in November 2018. ACTION – SF to include on the November agenda for discussion. MW commented that the CCGs should be careful to ensure running costs are not reduced too much. SH replied that the Executive Team are confident that the structure which has been developed is the right structure and will produce savings in the long term. HD supported SH view and confirmed that both running costs and management costs are being reviewed. DH asked how the current level of risk would be described. SH replied that on the £51m there is £9m that must be reported to the GB. SH believes is possible to recover some of the £9m with a possible residual risk of £5-6m. DH asked what would be the consequences in terms of the CSF. LB replied that in M5 the CCGs have reported around £7m contingency available for risks. If individual CCGs cannot hit the control total then part

SF SF

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of the CSF will be lost. The criteria for receipt of the CSF is that it is judged quarterly and the CCG has to report on plan YTD and be able to forecast that it will meet the in year control total. This is one area that is scrutinised at the Finance Committee. The Committee members noted the content of the verbal update provided by SH. SH left the meeting

AC/1819/51

INTERNAL AUDIT REPORTS – DERBYSHIRE WIDE 360 ASSURANCE: 360 PROGRESS REPORT JDe presented the report to the committee members and took the papers as read. Over the last few months the aim has been to complete the 17/18 work. A number of reports have been issued including the QIPP report. At the time of writing the report limited assurance had been issued. The report also includes a summary of the work completed during the year and since the last Audit Committee meeting. A number of audits have commenced, including the Stage 1 HOIAO which has been issued in draft form. A piece of work around COI has been issued as stage one in draft and stage two will be issued later in the year. Referring to the work plan JDe stated the initial plan of 380 days was agreed at the April 2018 Audit Committee, this has now been reduced to 274 days and is included in the papers for approval. Also included in the papers is information on work that 360 Assurance are able to offer around PPV and Benchmarking. MW asked that the CCGs ensure that in terms of the limited assurances issued there is nothing missed that could carry over to the new arrangements. ACTION – MA requested that a review of the areas issued with limited assurance should be discussed at the meeting in November. This item will be added to the agenda. The committee members queried the due date of December for the Derbyshire Wide QIPP review and asked if it would be possible to move this piece of work forward. The committee agreed to a swift review on the processes in place with a formal audit to follow. The timing will be by the

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end of November. DERBYSHIRE CCGS INTERNAL AUDIT PLAN 18-19 (FINAL) JD referred to page 65 of the papers and the Constitution and Terms of Reference (TOR). JD was of the understanding that the CCGs had a common set of TOR. IG referred to the Primary Medical Care Delegated Commissioning Audit and the 40 days allocated to this piece of work. IG expressed his feeling that this was excessive by comparison. JDe confirmed that at the time of the plan being amended it was unsure what this piece of work would entail. Now that guidance has been received the number of days can be reassessed. IS referred to the Communications and Engagement review and asked what the appropriate benchmark was. JDe replied that discussions had taken place with HD and BS with regards to what their review would entail. As the CCGs do not have a strategic approach for this area it was decided that it would be more appropriate to concentrate on QIPP schemes relating to Communications and Engagement.

JDe added that there has been a request to postpone some pieces of work. Lynn Matthews, Interim Director of Contracting & Performance has asked to postpone the work until October as the processes being put into place are not quite complete. Kevin Watkins, colleague at 360 Assurance, is carrying out work around the Sustainability and Transformation Partnerships (STP). After discussions with Vicky Taylor at NHSE it has been suggested that this work is postponed until January / February 2019. The committee members were not in agreement and asked that JDe push challenge the suggestion. ACTION - LB will challenge the suggestion to postpone the STP work with Vicky Taylor, NHSE. 360 PRIMARY CARE POST PAYMENT VERIFICATION SERVICE JDe explained this is a service 360 Assurance are able to offer should it be useful to the CCGs. There were no questions from the committee members. MERSEY INTERNAL AUDIT AGENCY PAPER – ASSURANCE FRAMEWORK BENCHMARKING 2017 JDe stated that 360 Assurance will be issuing particulars on

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benchmarking across their client base. JD commented that this would give a sense check from colleagues that similar issues are being covered. The Committee noted the paper and approved the internal audit plan.

AC/1819/52 AUDIT TRACKER – DERBYSHIRE WIDE SF presented the paper to the Committee Members. The document is a collation of all outstanding audit recommendations to support the progress reports from 360 Assurance. Conversations have taken place with 360 Assurance around software that the CCG may consider adopting to facilitate with the monitoring of any recommendations. LB referred to the audit tracker and noted that it includes the names of colleagues that are no longer employed by the CCGs. JD raised concerns around the number of audit recommendations that were overdue and noted that she was therefore not assured. GA made comment that the information within the tracker has to be accurate; there is not enough detail on what the recommendation is and why it has been included in the tracker. ACTION – SF will update the audit tracker to reflect the appropriate lead. ACTION – A demonstration of the software from 360 Assurance will be brought to the next Audit Committee meeting. The Committee members noted the contents of the paper.

SF JDe

AC/1819/53 EXTERNAL AUDIT – DERBYSHIRE WIDE ANNUAL AUDIT LETTERS FOR: EREWASH CCG HARDWICK CCG NORTH DERBYSHIRE CCG SOUTHERN DERBYSHIRE CCG SS presented the papers to the Audit Committee members. There are no new messages following the Internal Audit Letters which were issued at the May Audit Committee Meeting. SS noted the ISA 260 was written before the Annual Accounts were signed. The Annual Audit letters conclude the 2017/18 audit.

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The Committee members noted the contents of the paper. SS left the meeting.

AC/1819/54 FINANCE REPORT – DERBYSHIRE WIDE LB presented the Month 5 Finance report to the committee members. The Derbyshire CCGs are reporting YTD on the financial plan and forecasting delivery on financial plan. At the time of reporting the M5 financial position all risks identified at that point could be mitigated through contingencies and budget reserves. Following a Deep Dive into the QIPP verification this position has now changed. At M5 the risk of QIPP delivery was £6m this has now moved to £9m. LB also noted the Commissioner Sustainability Fund (CSF) allocated to each Statutory Organisation. At M5 a potential differential position is being seen across the CCGs and as a result SDCCG have had to utilise the majority of their contingency to cover in year and FOT cost pressures. This along with the QIPP risk means there is not enough contingency in SDCCG. However as a Derbyshire Wide Organisation there is. LB has talked to NHSE about the possibility of changing the Control Total and will pursue this conversation and report back to the Finance Committee and Governing Body. Discussions at the Finance Committee being held tomorrow will include the potential to consider a Financial risk share across the CCGs. The Committee members noted the contents of the paper.

AC/1819/55

REVIEW OF LOSSES AND SPECIAL PAYMENTS – DERBYSHIRE WIDE LB confirmed there is nothing to report.

AC/1819/56 RISK MANAGEMENT – DERBYSHIRE WIDE EXCEPTION RISK REGISTER REPORT SF presented the paper to the Committee Members. The paper is a culmination of the risks that have been received by the ACIC during August and September. The report includes a summary of the 22 Derbyshire risks. 9 of which are very high ranging between 15 and 25. HD added the other committees of the Governing Body have assigned

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risks which are managed through the SRO and risk leads. MA referred to risk 15 which relates to GP pensions and noted the need to be clear on this risk. ACTION – SF will clarify this. ISt suggested another column be added to ensure clarity on where the risks sit. ACTION – SF will add another column to include this in the risk register. The Committee members noted the contents of the paper.

SF SF

AC/1819/57 RISK MANAGEMENT – DERBYSHIRE WIDE DERBYSHIRE STRATEGIC RISKS AND OBJECTIVES UPDATE HD presented the paper to the committee members. The Committee Members were asked to receive and note the progress on work recently completed to develop the strategic objectives for 2018/19. GB members are aware of a draft paper presented at the GB meeting in June and further discussed at the GB meeting in July. The suggestion was made for a focus group to work with lay members and GB GP’s to refine the objective descriptions which would start work on the risk descriptions and outline scoring in readiness to present back to the GB at the September meetings for final agreement. The paper has been brought to the ACIC meeting for further comment and to provide assurance. GA asked how the CCGs are reducing, managing or eliminating the risks and how is this being demonstrated and evidenced. There was a discussion around the role of the Lay Member and how involved they should get when concerns are raised. The Committee members noted the contents of the paper.

AC/1819/58 STATUTORY REGISTERS – DERBYSHIRE WIDE DERBYSHIRE GIFTS AND HOSPITALITY REGISTER DERBYSHIRE PROCUREMENT REGISTER FB presented the paper and took the Gifts and Hospitality Register and Procurements Register as read.

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This follows the CCGs policies around managing Gifts and Hospitality and Procurements to ensure openness and transparency. Both registers are available for review publicly. JD commented that she is surprised that the only offers of gifts or hospitality that were accepted are from offers from pharmaceutical companies. JD took assurance that due process is followed in terms of the CCGs policies. IG stated the register of procurement decisions is useful and gives an insight on what is forth coming. FB added that procurement colleagues attend the Governance Committee meetings where the procurement work plan is reviewed across Derbyshire. IM commented that feedback received from the Counter Fraud Survey highlighted 10% of responders answered incorrectly to the question around accepting gifts and hospitality. It is vital that all employees understand their responsibility in this area. MW referred to the Procurement Register and questioned the scale of what should be included. In particular referring to Personal Health Budgets (PHB) and Individual Funding Requests (IFR)’s. BS confirmed that’s are reported to the committees however this is a good point that is being made as ACTION – develop a clear policy around PHB The Committee members noted the contents of the paper.

BS

AC/1819/59 DERBYSHIRE AUDIT CSIC MINUTES OF THE MEETING HELD ON 23RD MAY 2018 DH referred to page 6 of the Audit Committee minutes and noted that it was himself and not GT who observed the QIPP achievement. With this amendment the minutes were agreed.

AC/1819/60 DERBYSHIRE COMMITTEESS IN COMMON MEETING LOG – FOR INFORMATION No questions were raised in relation to the Committees in Common Meeting Log.

AC/1819/61 DERBYSHIRE CCGS COMBINED ACTION LOG MA discussed the current outstanding actions with SF and updates were

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given to the committee members. ACTION – SF will update the action log in preparation for the next meeting on 15th November 2018. The Committee members noted the contents of the paper and the updates provided.

SF

AC/1819/62 ASSURANCE QUESTIONS The Committee members confirmed that they were assured by the discussions that had taken place in today’s meeting and there were no items that should be escalated to the Governing Body.

AC/1819/63 ANY OTHER BUSINESS FB noted for the minutes of the meeting that there are no reports on legal claims for this quarter. 360 ASSURANCE – GOVERNANCE AND AUDIT WORKSHOP SLIDES – FOR INFORMATION The slides from the Audit and Governance Workshop were included in the meeting papers for information. CHC DEEP DIVE BS gave a verbal update on the CHC Deep Dive that has taken place. The paper on the CHC Deep Dive was presented at the FRG meeting on Monday 17th September 2018 where it was challenged by the members of the group. The full deep dive including action plan will be presented to the Finance Committee on 20th September 2018. There are a number of key issues around CHC which were raised at the GB meetings in July and at which point the CCGs were underspent. A review of the CHC was undertaken in terms of the systems and processes and the QIPP plan. A number of issues were highlighted for both the CCGs and the CSU who provide the contract for the CHC assessments. BS gave the view that the contract was not properly managed by the CCG with inconsistencies between CCG and CSU data which resulted in a request for a RAP from the CSU and Finance Team at the CCGs. The outcome is an integrated action plan with the report from Price Waterhouse Cooper. BS added that weekly meetings take place with the Finance and CHC teams and fortnightly with the CSU Director.

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The current position is a reduction in the in-month overspends from M4 to M5. Daily run rates are received from the CSU which reports the number of patients with CHC packages and costs attached as well as the number of packages that are planned. The initial Deep Dive has found that the CCG is in budgetary control for fully funded packages, FNC and Joint funded packages. The area that can demonstrate the overspend is Fast Tracks and the CSU have been asked to complete a Deep Dive on Fast Tracks which should be received imminently. There has also been ongoing inconsistency between the Broadcare and the CCG Finance Teams data however the pattern of the inconsistency is the same. To manage these senior members of the CSU and CCG Finance team and the CCG Nursing and Quality Team will be meeting on Friday 21st September 2018 to scrutinise the reasons why. MA thanked BS for the update and requested attendance at the next meeting in November to present a paper on the findings and lessons learned. ACTION – BS will circulate the paper to the committee members and SF will add a CHC update to the agenda for the November meeting.

BS

DATE AND TIME OF NEXT MEETING The next meeting is: 15th November 2018, 9.30am to 12.30pm, Cardinal Square, Rooms 1 & 2 17th January 2019, 9.30am to 12.30pm, Conference Room, Toll Bar House.

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DERBYSHIRE CCGS Governance Committees

(Meeting as Committees in Common)

Date & Time: Thursday 13th September, 13:30-15:30

Venue: Conference Room, Toll Bar House, 1 Derby Road, Ilkeston, DE7 5FH

Present: Dr Markus Henn – Chair Isabella Stone IS Dr Anne-Marie Spooner AS Falu Bharmal FB

GP ECCG and Deputy Caldicott Guardian Derbyshire CCGs Lay Member, PPI NDCCG GP NDCCG Director of Corporate Delivery Derbyshire CCGs

In Attendance: Suzanne Pickering Richard Heaton RH Stuart Fletcher SF Bronwyn Jackson BJ Lisa Innes LI Leni Robson LR (Minutes)

Head of Governance NDCCG Head of Governance ECCG Governance Manager SDCCG Information Governance Manager Senior Procurement Manager, AGEM (for item GC/1819/81) Office Manager ECCGCCG

Apologies: Jill Dentith JD Helen Dillistone HD Shokat Lal SL Karen Watkinson KW James Lunn JL Chrissy Tucker

Lay Member Audit & Governance HCCG/NDCCG Executive Director of Corporate Strategy and Delivery Lay Member SDCCG Corporate Secretary HCCG Head of People and Organisational Development Deputy Director of Corporate Development

Item Subject GC/1819/69 Welcome & Apologies

Apologies were noted from Jill Denith, Shokat Lal, Helen Dillistone, Chrissy Tucker, James Lunn and Karen Watkinson.

This meeting was chaired by Dr Markus Henn who welcomed everyone to the meeting and introductions made round the table. MH declared that the meeting is quorate.

GC/1819/70 Declarations of Interest

MH reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with

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the business of the CCG.

Declarations declared by members of the Governance Committees in Common are listed in the CCG’s Register of Interests and included with the meeting papers. The Register is also available either via the corporate secretary to the Governing Body or the CCG website.

It was agreed that Exec Directors and Senior Managers on the Committee would be included on the Declarations of Interest for the next meeting. Action: Exec Directors and Senior Managers to be included on the next DoI There were no amendments to the Declarations of Interest register and none declared for any item on the agenda.

LR

BUSINESS CONTINUITY & EMERGENCY PLANNING RESILIENCE AND RESPONSE

GC/1819/71 Draft Derbyshire CCG EPRR submission 2018/19 and supporting documentation for approval. RH talked through the paper submitted. This is the first year this has been done across of all four CCGs. A Derbyshire wide approach has been taken and one set of assurance standards have been set. All CCGs have assessed themselves as fully compliant in 38 of the 43 standards. It is therefore classed as “SUBSTANTIALLY” compliant as it is just above the 98-99% compliant for that rating. The following key milestones have been set.

• Assurance returns should be made to Regional EPRR Teams by 31 October 2018.

• Regions to have completed confirm and challenge meetings and submitted their Regional EPRR assurance report by 31 December 2018.

• National EPRR Team to have completed confirm and challenge meetings with Regional teams by 28 February 2019.

• National EPRR assurance reported to the NHS England (NHSE) Board by 31 March 2019.

The forward plan accompanying this report is a refresh on an already existing document. IS asked for clarification on what the Governance Committees in Common was being asked to approve and where the assurance for this was. RH stated that the reason for bringing this paper to the Committees was to ensure that the Committees were aware of the paper and where there were any gaps in the plan. RH will meet with any committee member who has concerns outside of this meeting and invited all to the Confirm and Challenge meetings if they wished to attend. It was noted that the EPRR does not fit with Commissioners, and therefore certain

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process have to be gone through to provide assurance to NHSE. The process had highlighted the need for on-call training and funding was required for this. The training had been developed and provided to other providers. There was also free training available to those involved in the on-call rota. It was noted that the on-call arrangements have been part of the staff consultation which has delayed the implementation of the training plan. The assurance was in the supporting the framework and NHSE process. It was noted that the Standard Operating Procedure does not name any member of staff. Helen Dillistone will be named going forward. Action: Helen Dillistone’s name will be included in the Standard Operating Procedure as the senior member of staff The Governance Committees in Common:

• NOTED the contents of this report for information and assurance. • APPROVED the draft EPRR Core Standards submission for 2018/19

subject to any amendments made as part of the Confirm and Challenge process with NHSE.

• AGREED to recommendation to send details of recommendation to a Public Governing Body meeting for final APPROVAL.

• APPROVED the EPRR Work Plan for 2018/19 • APPROVED the EPRR Policy Statement • NOTED the Standard Operating Procedure for completion of Situation

reports (SitReps)

RH

GC/1819/72 Severe Weather Structured Debrief - Final Report RH provided an update. This had been well-attended. There are 27 action points but these are minor. The recent risk of water shortage had shown lessons had been learnt from the weather in October. The Governance Committees in Common NOTED the update.

SERIOUS (NON-CLINICAL) INCIDENTS GC/1819/73 Serious (non- clinical) update

There has been a Data breach as a result of the CCGs publishing a paper that had identifiable information relating to Derbyshire Healthcare staff as part of the public Governing Body meeting. Due process is being followed and the action plan has been shared with Derbyshire Healthcare. The incident had been reported to the Information Commissioner’s Office (ICO) who do not view this as an incident.

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As part of the action plan there are 4 action points within recommendations. One of which is that all staff around the tables at meetings are reminded of their responsibility with regards to Information Governance and confidentiality. There was some discussion, and it was agreed that without very clear information this could be very confusing as to where the responsibility would rest, such as the author of the report or the lead SRO. As a way forward it was noted that the Governance team would continue checking papers, particularly around the public governing body papers, and that there were several points in the preparation and distribution process where this can be picked up such as at the draft minute stage. It was agreed that action is closed off from the action plan as there protections in place to reasonably present this from happening again. The Governance Committees in Common NOTED the update.

INFORMATION GOVERNANCE & GDPR GC/1819/74 GDPR Update

BJ talked through the GDPR update. GDPR came into force on 25th May this year. A strategic group and operational meeting have been put into place. Key issues have been identified. Assurance has been received from providers that they have appropriate protection in place The need to be transparent with data processes has been embedded within the project management office. As a result risks are being identified at source. Privacy notices have been updated. BJ has been meeting with individual teams to ensure this is done. The processing contract has been updated and is in place. All contract variations are compliant with GDPR. The Subject Access Request process has been put into place. The Governance Committees in Common NOTED the update.

GC/1819/75 IG/DSP Toolkit Update: BJ talked through the report and update. NHS Digital expects that most organisations would comply with the required standards. The Information Governance Committee met on 12th September to discuss how to move forward. A ToR is being put into place for this group. The Information Governances Committee will be the working group for the Governance Committee. Draft ToRs will be circulated virtually to the GC for agreement. ACTION: BJ to circulate Draft ToR to GC virtually. The Governance Committees in Common agreed that policies could be circulated

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virtually if approval required prior to the next meeting. NHS Digital has removed relevant online training and there are no plans to reinstate this. The Committee supported new information asset owners receiving training going forwards. Incidents There have been no significant incidents in the period since the last meeting. IS asked that the front sheet is made clearer for the Committee.

BJ

GC/1819/76 Policy Schedule Data protection impact assessment was submitted for review. It was noted that this will go to the IG Committee going forward. The Governance Committee approved the amendments to the Data Protection Impact Assessment.

ORGANISATIONAL DEVELOPMENT

GC/1819/77 Derbyshire CCGs Improvement Plan – Governance Work stream update Stuart Fletcher talked through report. The recommendations have been updated for the purpose of submitting to NHS England. This is an ongoing live document and will be informing a bigger piece of work. The Governance Committees in Common stated that it was vital that the learning was taken on board and the actions were taken forward. This will be a standing agenda item for the Committees in Common. The Governance Committees in Common NOTED the work outlined in the Governance Work stream as part of the Derbyshire CCGs Improvement Plan.

Agenda item

ESTATES

GC/1819/78 Estates and facilities update This was highlighted to be a standing agenda item. No update provided at this time.

HEALTH, SAFETY, FIRE AND SECURITY

GC/1819/79 Health & Safety update

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The Q2 report will be submitted to the next meeting. It was highlighted to the committees in common that since the last meeting the team have been ensuring policies and procedures were up to date to reflect a Derbyshire-wide position. The Governance Committees in Common NOTED the update.

RESEARCH GOVERNANCE

GC/1819/80 Research Forum – draft minutes from July-18 meeting Going forward only ratified minutes will be submitted. It was noted that there was no escalation process for the Research Forum. A meeting will be arranged for FB, SL and Dr Tim Parkin, Chair of the Research Forum. IS queried whether this would be better suited to be reviewed by the Clinical and Lay Committee. FB confirmed that while aspects will go to the CLC statutory responsibility lies with the Governance Committee. The Governance Committees in Common NOTED the minutes.

FB

PROCUREMENT

GC/1819/81 Procurement Highlight Reports LI presented an update on current procurement status for each CCG. The highlighted projects are being managed through the Arden & Greater East Midlands CSU. It was explained that the overall service status is green; however each individual project has been ‘RAG’ rated along with a reason for any variance or comment to progress of the individual project. LI confirmed that there were no major risks that need to be escalated to the Governance Committees in Common. Nonetheless, LI highlighted two minor risks, which are: V Spa – Due to financial pressures the funding stream is being withdrawn which has raised some political issues. This risk is due to the fact this has been under proof of concept. This is outside of a contracting term but presents a risk as it should be going out to market. Services are currently continuing as normal but there are no contracts in place. Tier 3 weight management services – There has been a direct award to a provider without suitable market testing. The contract has been issued on a Fixed term and will formally go to market at the end of this term. The Governance Committees in Common NOTED the updated and status for each CCG.

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RISK MANAGEMENT

GC/1819/82 Exception Risk Report The exception report was presented to the committees in common highlighting that these risks are aligned to the business areas of the committee. It was noted that there are 5 governance risks with 4 risks rated between 15-25 (very high). The number of assigned risks reported in September remained the same. The committees in common were informed of the wider developments since the last meeting and that a Risk Workshop took place on 17th August and was attended by a number of GB GP and Lay Members from across the CCGs. The workshop touched upon Risk Appetite and the definitions of ‘likelihood’ and ‘impact’ in order to understand the achievement of an Objective within the context of risk management. A proposed set of Derbyshire Strategic Risks will be taken to the September GB meeting as a ‘committees in common’ on 27th September 2018 for agreement. This will inform the Governing Body Assurance Framework. IS queried the lack of detail in Risk 004 within the register and whether this is a Governing Body issue. The risk relates the lack of clarity on the Derbyshire CCGs organisational changes that will have a detrimental effect on staff morale and productivity. It was confirmed that Helen Dillistone is the lead executive and that whilst the Governing Body will have ownership of this the Governance Committees in Common is required to have an understanding to support the risk and process. It was noted that assigned risk will return as an item on the next agenda. The Governance committees in Common RECEIVE the governance risks assigned to the committees in common.

MINUTES / ACTION LOG / MATTERS ARISING

GC/1819/84 Minutes of the meeting held on: • 12th July 2018

These minutes were accepted as a true and accurate record.

GC/1819/85 Action Log For the purposes of an audit trail, the actions highlighted in grey have been closed off and will be removed from the Action Log for the next meeting.

• GC/1819/30 Conflicts of Interest training: an update on the training figures

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to be brought to the November meeting.

• GC/1819/34 Derbyshire CCGs Health and Safety Quarter 1 report: training figures to be highlighted in the Q2 report

COMMITTEE BUSINESS

GC/1819/86 Future meetings – dates and times Meeting dates have been circulated with venues. The Governance Committees in Common requested that the March 2019 date was changed from Cardinal Square to Tollbar House.

GC/1819/87

01 02 03

AOB Governance committees in Common Terms of Reference (ToR) and Quoracy. There was discussion around the ToR and required Quoracy. It was agreed that quoracy would remain at 4 members. It was agreed that the Chair must be a lay member. FB will e-mail Jill Dentith and ask if she would be willing to chair, with Shokat Lal being asked if he will be Vice-Chair. SF will ensure that all members are aware they have been included in the ToR and LR will recirculate the dates of the meetings. Reporting of Performance. FB highlighted whether where the reporting of performance should sit. This is currently reported to Finance Committees in Common but the Governance Committees in Common is required to be assurance on performance. It was highlighted that the Quality and Performance Committees in Common receives this report and therefore it does not need to come to this meeting. Improvement and Assessment Framework CC sent out in the Improvement and Assessment Framework. This has been reviewed. This will go before the Governing Body members however it is a requirement that this will also go to Governance Committees in Common for information.

FB SF/LR

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Agenda Item 2

MINUTES of a meeting of the DERBYSHIRE HEALTH AND WELLBEING BOARD held at County Hall, Matlock on 4 October 2018.

PRESENT

Councillor C Hart (Derbyshire County Council) (In the Chair)

C Clayton Derbyshire CCGs Councillor A Dale Derbyshire County Council H Dill stone Derbyshire CCGs H Jones Derbyshire County Council I Fleming Derbyshire County Council P Mitchell Derbyshire Fire & Rescue H Henderson -Spoors Healthwatch Derbyshire G Smith Tameside & Glossop CCG D Swaine Bolsover District Council & NEDDC V Taylor Derbyshire STP D Wallace Derbyshire County Council Councillor J Wharmby Derbyshire County Council P Wood South Derbyshire CCG

Also in attendance – W Downes (Derbyshire County Council), Lucy Gavens, (Derbyshire County Council), G Harry (Derbyshire Healthcare PCT), A Kemp (Shift) J Lawther (DAAS/Stand To) A Scott (DAAS/Stand To) and Councillor S Swann (Derbyshire County Council),

Apologies for absence were submitted on behalf of L Allison, H Bowen, Dr A Dow, B Milton, S Morritt and T Slater.

The Chair welcomed Helen Jones, Strategic Director, Adult Social Care & Health to her first meeting of the Health & Wellbeing Board

28/18 MINUTES RESOLVED that the minutes of the meeting of the Board held on 12 July 2018 be confirmed as a correct record.

29/18 STAND TO EX ARMED FORCES PROJECT Alison Scott, Derbyshire Alcohol Advisory Service attended the meeting and gave a presentation on the ‘Stand To’ Ex Armed Forces project.

As background Alison informed members that a 2012 study had indicated that an estimated 50,000 ex-armed Forces personnel were living in the county of Derbyshire, with around 60,000 family members.

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67% of men and 49% of women in the UK Armed Forces had an audit score representative of hazardous drinking compared to 38% of men and 16% of women in the general population. In both sexes, for all ages, the military had a higher prevalence of hazardous drinking.

Research also suggested that the ex –armed forces community were less

likely to access “generic” support services Derbyshire had historically expressed commitment and recognition of a

need to ensure that the needs of ex-armed forces were met (DCC cabinet paper 2012) and signing of the Military Covenant.

The ‘Stand To’ embraced the belief that there was a debt of gratitude

owed to the sacrifices made by the armed forces and that ex-armed Forces personnel should gain speedy access into services dedicated to their specific needs.

Details were given of the key project milestones between 2015-18 and

what had been learnt throughout this period. - Stand To clients respond more favourably and were more likely to

engage if their worker was ex armed forces or had first hand knowledge or experience;

- Once engaged ST clients respond well to CBT focussed work, however for many longer term talking therapy was needed;

- ST clients remained in treatment longer than clients in generic caseloads

- Working together with the ST client and family members improved engagement and outcomes;

- Links into mental health support were not currently managing to meet the needs of ex-armed forces;

- Issues for ST clients were often complex, and there was a need for a dedicated counselling service;

- Links made into recovery support such as ITS, RTN and the recovery network was developing well and was much needed; and

- A high percentage of ex-armed forces were drinking to high dependent levels.

Details were given of the most recent progress made and what the next

steps were:- - Work on attracting increased referrals from women; - Continuing to develop family support (CRAFT model); - Develop a veteran specific counselling service; - Source further funding beyond 2020;

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- Continuing to develop and strengthen self help network (The MESS); and

- More Volunteers would be recruited.

Members were given the opportunity to make comments and observations and ask questions, which were duly noted or answered The Chair thanked Alison for a most informative and interesting presentation. RESOLVED to note the update report. 30/18 DERBYSHIRE AND DERBY FUTURE IN MIND LOCAL TRANSFORMATION PLAN UPDATE Isobel Fleming, Service Director, Countywide Commissioning, attended the meeting and provided Members with an update. The national Future in Mind (FiM) Strategy and Derbyshire and Derby Local Transformation Plan (LTP) 2015-2020 had a strong system-wide strong focus on children and young people having access to high quality mental health care when they needed it. Governance was via a Derbyshire footprint-wide Future in Mind Board that was accountable to both Derby City and Derbyshire County Health and Well Being Boards. As part of the presentation, Isobel, informed members that the local Plan was currently being refreshed in line with annual NHS England (NHSE) assurance requirements and set Key Lines of Enquiry. This must be submitted to NHSE by 12th October 2018. Local plans would be published on Clinical Commissioning Group (CCG) and Local Authority websites on 31st October 2018. The strategic priorities identified by the Derby and Derbyshire Children and Young People’s Future in Mind Health Needs Assessment (2017) are: Strategic Priority 1: To further develop our engagement and support to

parents and carers; Strategic Priority 2: To develop further a whole-school approach to

prevention and early help; Strategic Priority 3: To develop a new care model responding to children and

young people exhibiting complex needs; Strategic Priority 4: To increase the workforce offer including blended

learning approaches across professional groups; and Strategic Priority 5: To develop a place-based approach to interventions and

care supporting Primary Care, developing the Voluntary and Community Sector, linking to schools, and offering digital interventions

Members were also presented with the progress in 2017/18 (year 3) against these strategic priorities and the proposed plans for 2018/19 (year 4).

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As part of a wider consultation process for the refresh, members were invited to give their views on progress to date and proposed plans. After a period of discussions in the meeting these comments were duly noted and Isobel thanked members for their input. The Future in Mind Health Needs Assessment will continue to inform the remaining 2 years of the plan, particularly ensuring that the needs of vulnerable children and those at risk of poor mental health. The Future in Mind plan linked to the Health and Wellbeing Strategy ‘supporting the emotional health and wellbeing of children and young people.’

RESOLVED (1) to note the update of the Future in Mind Local Transformation Plan.

(2) to agree that the sign-off of the refreshed Plan be delegated to the

Chair on behalf of the Board once consultation is complete and prior to its submission to NHSE.

31/18 JOG DERBYSHIRE Andrea Kemp, Shift, attended the meeting and shared a Jog Derbyshire promotional video with Health and Wellbeing Board Members, to increase awareness of the programme and the health and wellbeing benefits it brought to participants. Jog Derbyshire was a programme that worked with people in communities to support them to become more active through jogging. It currently ran 137 sessions every week and had over 6,500 members. New groups were being set up all the time and there were plans in development to expand some existing groups, e.g. by starting groups for children and young people. Jog Derbyshire was run by Shift (formerly the Community Sports Trust). The programme was currently funded by Public Health (for 2 years from 1st September 2018) with an ambition to get people into jogging through setting up groups in different communities and new settings (e.g. workplaces and from GP practices). Shift had also secured Action Grant funding to develop a Family Mile in 10 communities across Derbyshire and were continuously exploring other opportunities to support people to become more active. There remained strong links to the Health and Wellbeing Strategy and Jog Derbyshire contributed to two of the five Health and Wellbeing outline priorities agreed by the Health and Wellbeing Board in July 2018:

1. Enable people in Derbyshire to live healthy lives 2. Build mental health and wellbeing across the life course

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Members were given the opportunity to make comments and observations and ask questions, which were duly noted or answered. Members also discussed, how, both as individual organisations and collectively they could support the continued success of the programme. The Chair thanked Andrea for a most informative and interesting presentation. RESOLVED to note the presentation and promotional video 32/18 DERBYSHIRE BETTER CARE FUND 2018-19 QUARTER 1 STATUTORY RETURN The Board was presented with an update on progress of the Derbyshire Integration and Better Care Fund (BCF) 2017-19 through reporting of the required statutory quarter one return for 2018-19. The Department of Health and Social Care’s Better Care Support Team published the Q1 2018-19 National Return template on 11 June 2018 with the requirement that completed templates be returned by 20 July 2018, following sign-off from respective local Health and Wellbeing Boards (HWBs). The quarterly reporting dates for 2018-19 did not correlate with the meeting dates for the Derbyshire Health and Wellbeing Board. Therefore, submissions were approved via the Joint BCF Programme Board (a delegated sub-group of the Health and Wellbeing Board) and signed-off for submission by the Health and Wellbeing Board Chair. The reporting requirements of the Q1 template were largely unchanged from previous reporting periods in 2017-18. The main change had been the inclusion of improved Better Care Fund (iBCF) monitoring information into the same template so that there was now only one return to be provided each quarter. It should be noted that iBCF monitoring returns were issued separately by the Ministry for Housing, Communities and Local Government in 2017-18 and were not required to be reported to the Health and Wellbeing Board. (The iBCF was an additional grant provided directly to Local Authorities with Social Care responsibilities and was announced in the Spring Budget 2017). It should be noted that the submission deadlines for the reporting periods in 2018-19, as in 2017-18, were earlier than in previous years. As such, full data will not be available for the reporting period which meant that performance assessments included in the returns were subject to change throughout the year. The BCF and iBCF Q1 2018-19 return was appended to the report RESOLVED (1) to receive the report and note the responses provided in the Quarter 1 Statutory Return; and

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(2) to continue to receive regular updates on the progress of the Integration and Better Care Fund throughout 2018-19. 33/18 HEALTH PROTECTION BOARD UPDATE Dean Wallace, Director of Public Health had provided HWB members with an overview of the key messages arising from the Derbyshire Health Protection Board, which met on the 24th July 2018. The Board was a formal sub group of the Derbyshire County Health and Wellbeing Board and the Derby City Health and Wellbeing Board. Specific reference was made to The Bowel Health Equity Audit, which aimed to determine the equality of access and uptake outcomes from the Derbyshire Bowel Cancer Screening Program, was now being overseen by the Derbyshire Cancer work stream of the Sustainability and Transformation Partnership (STP). A comprehensive work plan was being developed. RESOLVED to note the information contained in the update report. 34/18 HEALTH AND WELLBEING BOARD ROUND-UP REPORT Helen Jones had provided HWB members with a written report rounding up key policy announcements in relation to health and wellbeing issues. RESOLVED to note the information contained in the round-up report.

35/18 HEALTH AND WELLBEING STRATEGY – 2018 ONWARDS Lucy Gavens, Speciality Registrar in Public Health attended the meeting to ask members to review, discuss and seek the approval of the Board to adopt the proposed ‘Health and Wellbeing Strategy 2018 Onwards’.

Appendix 1 presented the Derbyshire ‘Health and Wellbeing Strategy 2018 Onwards’. The strategy identified 5 priority areas:

Enable people in Derbyshire to live healthy lives Work to lower levels of air pollution Build mental health and wellbeing across the life course Support our vulnerable populations to live in well-planned and healthy homes Strengthen opportunities for good quality employment and lifelong learning

For each priority the strategy described:

Why this is a priority for Derbyshire. What we want to achieve. How we will achieve our ambitions.

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The Strategy also identified a number of specific ways in which Board Members, as representatives of organisations and collectively, could work together to address complex health challenges in Derbyshire. This new ‘Health and Wellbeing Strategy 2018 Onwards’ both built on previous strategies and identifies new priorities based upon factors including data on wellbeing, health and social care needs in Derbyshire and understanding of priority areas for the local population.

Lucy explained to members that the purpose of the presentation was to - Discuss and adopt the proposed Health and Wellbeing Strategy 2018 Onwards.

- Should it be a rolling strategy with a review each Spring? Or fixed time period e.g. 2018-2021.

- To decide a name for the strategy? Proposal: ‘Our Lives, Our Health’ - The possibility of Board champions? One for each priority?

The general consensus amongst those present was that the Strategy should operate on a rolling basis with regular annual reviews. The new proposed strap line was considered to be along the right lines although some further thought would be given to it before finalising it. Board Champions for priority areas was felt to be a good idea and people were invited to put forward the names of people to fill these roles and contact the Chair. RESOLVED to adopt the attached ‘Health and Wellbeing Strategy 2018 Onwards’ taking into account the suggestions and comments made above. 36/18 HOUSING & HEALTH UPDATE Vicky Smyth, Public Health Lead for Wider Determination provided the Board with an overview of Housing and Health related work across Derbyshire. Healthy housing was key to preventing ill health and enabling people to live independently into old age. The presentation outlined current housing and health related work across Derbyshire that aimed to support residents to live well.

“All vulnerable populations are supported to live in well-planned and healthy homes” is proposed as Outcome 4 in the refreshed Derbyshire Health and Wellbeing Strategy. The Board was asked to note the significant amount of housing and health related work currently being undertaken by partners in Derbyshire and discussed the proposed priority area, to ascertain and support planning of future housing and health related work. Board members were also asked to consider

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can support this agenda moving forward by identifying opportunities for co-ordinating and collaborating across different strategic areas of work. Members were given the opportunity to make comments and observations and ask questions, which were duly noted or answered. RESOLVED to note the report 37/18 DATES OF FUTURE MEETINGS RESOLVED to note the following future meeting dates:- Thursday 31 January 2019 Thursday 4 April 2019 H:\New Democratic Arrangements\Health and Wellbeing Board\Minutes\2018\2018.04.19.docx

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Time Commenced: 1.07pm Time finished: 3.35pm

Health and Wellbeing Board 13 September 2018

Present:

Chair: Councillor Poulter

Elected members: Councillors Ashburner, Care, Hudson and Repton and Councillors Webb – Cabinet Member for Adults, Health and Housing and Williams – Cabinet Member for Children and Young People

Appointed officers of Derby City Council: Cate Edwynn (DCC - Director of Public Health), Andy Smith (DCC – Strategic Director of People Services)

Appointed representatives of Derbyshire Clinical Commissioning Groups: Richard Crowson

Appointees of other organisations: Gavin Boyle (Derby Hospitals NHS Foundation Trust), Chris Clayton/Helen Dillistone (Derbyshire CCGs), Steve Studham (Healthwatch Derby), Kath Cawdell (Community Action Derby), Vikki Taylor (Joined Up Care Derbyshire), Bill Whitehead (University of Derby)

Substitutes: Phil Mitchell (Derbyshire Fire and Rescue Service)

Non board members in attendance: Nigel Brien (DCC – Network Management Group Manager), Robyn Dewis (DCC – Consultant in Public Health Medicine), Isobel Fleming (Senior Responsible Officer - Future in Mind), Sheila McFarlane (Acting Deputy Head of Integrated Commissioning for Children and Young People (Health) – Derbyshire CCGs/DCC), Kirsty McMillan (DCC - Service Director – Integration & Direct Services), Lynn Wilmott-Shepherd (Derbyshire CCGs), Alison Wynn (DCC, Assistant Director of Public Health)

12/18 Apologies for Absence

Apologies were received from Councillor J Khan and Pervez Sadiq.

13/18 Late Items

There were no late items received.

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14/18 Declarations of Interest Councillor Webb wished it to be noted that in relation to 17/18 – Joined up Care in Derbyshire, he was the Chair of a local care home. 15/18 Minutes of the meeting held on 19 July 2018 The minutes of the meeting held on 19 July 2018 were agreed as a correct record. 16/18 Rules and Procedures of the Health and Wellbeing

Board The Board received a report of the Strategic Director of Corporate Resources on Rules and Procedures of the Health and Wellbeing Board. The report was presented by Alison Wynn – DCC - Assistant Director of Public Health and Steven Mason - Democratic Services Officer. The Assistant Director of Public Health outlined the amendments to the Terms of Reference. Members put forward some further amendments. The Democratic Services Officer reported that all Council Committees must follow established committee procedure as set out in the Committee Procedure Rules, attached at Appendix 3 of the report. It was also reported that there were, however, a number of anomalies between existing council procedures and the Health and Social Care Act 2012 and that to ensure the spirit of the Health and Social Care Act 2012 was implemented, there were a number of Committee Procedure Rules that were waived or amended to reflect the requirements of the HWB. It was noted that these rules related to the use of substitutes, the appointment of the Chair and Vice Chair and the quorum. It was reported that under the Localism Act 2011, all Councillors and co-opted members of Council committees were required to comply with a Code of Conduct, attached at Appendix 4 of the report. It was also reported that as part of this, Committee Members were required to declare Disposable Pecuniary Interests (DPIs) affecting them and their partners, and the Council was required to publish this information. It was noted that it was the duty of Members to complete and return a DPI form, attached at Appendix 5 of the report, and a declaration form confirming compliance with the Code of Conduct, attached at Appendix 6.

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Resolved:

1. to approve the amended Terms of Reference as detailed in Appendix 2, subject to further amendments as outlined at the meeting;

2. to note the council’s established rules relating to committee procedures, detailed in full in Appendix 3;

3. to note the waivers/ amendments to the Committee Procedure Rules incorporated within the ToR detailed in 4.4; and

4. to note paragraphs 4.5 to 4.7, detailing the council’s Code of Conduct for members of committees and the requirement for all members of the Health and Wellbeing Board, including council officers and representatives of external organisations, to comply with it and declare any Disclosable Pecuniary Interests (DPIs).

17/18 Joined Up Care Derbyshire Update The Board received a report of the Service Director of Adult Social Care Services/Derbyshire STP Director on Update on Joined Up Care Derbyshire – Derbyshire's STP. The report was presented by Vikki Taylor – Joined Up Care Derbyshire. Members were provided with an update on the progress of Joined Up Care Derbyshire (JUCD) – Derbyshire’s Sustainability and Transformation Partnership (STP) and this included an overview of the latest news and progress of JUCD as a whole. In addition, Members received and update on the development of the Place Alliances and particularly the establishment and progress of Derby Place Alliance. Members discussed the funding of health and care and the implementation of JUCD. It was agreed that the Board should make representations to the Secretary of State, in relation these matters, and that Councillors Dhindsa, Repton and Webb would come up with a form of wording on behalf of the Board. Members wanted to know what work the Local Government Association was doing in relation to JUCD and any representation to central government. The Board agreed that an update report should be brought to a future meeting of the Board. Members discussed the work of the STP in relation to frailty and work 'upstream'. It was agreed that an update report be brought to a future meeting of the Board.

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Resolved:

1. to note the update on Joined Up Care Derbyshire and the establishment and progress of Derby Place Alliance;

2. to agree that representations should be made to the Secretary of State from the Health and Wellbeing Board, in relation to the funding of health and care and the implementation of Joined Up Care Derbyshire;

3. to request that a report be brought to a future meeting of the Health and Wellbeing Board on the work of the Local Government Association in relation to any representations to central government on funding of health and care and support of Sustainability and Transformation Partnerships; and

4. to request an update report on Derbyshire’s Sustainability and Transformation Partnership at the next meeting of the Health and Wellbeing Board, focused on the work in relation to frailty and work ‘upstream’.

18/18 Derbyshire CCGs Proposals to Merge The Board received a report of the Chief Executive, Derbyshire CCGs on Derbyshire CCGs Proposals to Merge. The report and a presentation were presented by Chris Clayton and Helen Dillistone – Derbyshire CCGs. Members were provided with an overview of the plans and required process and this included:

• Key principles • Strategic direction • Derbyshire Places • Local decision making and influence • Membership voting and public engagement

The Board were asked to recommend a name for the merged Derbyshire CCGs and agreed to recommend the name NHS Derby and Derbyshire CCG. Resolved:

1. to note Derbyshire CCGs proposals to merge and the progress achieved to-date;

2. to continue to support the work for the merger and also recommend the name NHS Derby and Derbyshire CCG; and

3. to agree to receive regular updates on proposed merger through to 2019.

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19/18 Integration and Better Care Fund Update The Board received a report of the Strategic Director of People Services on Integration and Better Care Fund Update. The report was presented by Kirsty McMillan – DCC - Service Director – Integration & Direct Services. It was reported that in September 2017, Board Members approved and endorsed the Integration and Better Care Fund (BCF) plan for Derby for 2017 – 2019. It was also reported that the plan was subsequently approved by NHSE. Members noted that Health & Wellbeing Boards were required to have oversight of the Integration and BCF in their localities to ensure that the required outcomes and performance that was expected was being delivered. It was also noted that the BCF was collaboration between NHS England, the Ministry of Housing, Communities and Local Government (MHCLG), Department of Health and Social Care (DHSC) and the Local Government Association to help local areas plan and implement integrated health and social care services across England, in line with the vision outlined in the NHS Five Year Forward View. Members received a narrative summary on:

• Residential Admissions per 100,000 population 65+ • Reablement – still at home 91 days after discharge • Delayed Transfers of Care (DTOC) per 100,000 population 18+ • Non Elective Admissions to hospital

Members discussed the Improved Better Care Fund (the specific grant to Council’s for social care). Resolved to note the progress being made against the Derby Integration and Better Care Fund (BCF) 2017-19. 20/18 Update Reducing Roadside Nitrogen Dioxide – Air

Quality The Board received a report of the Strategic Director of Communities and Place on Update Reducing Roadside Nitrogen Dioxide – Air Quality. The report was presented by Nigel Brien – DCC – Network Management Group Manager. It was reported that on 17 May 2018 a report was presented to the Board setting out the main objectives of the government’s policy and the tasks set for Local Authorities to achieve compliance. Members noted that the Council launched a public consultation on 30 July 2018

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and this icluded three options, and indicated which of the options was preferred and that this conformed to the general advice provide by DEFRA. It was also noted that the consultation would be open until 24 September. It was reported that the Council was due to make a submission of an outline business case, to demonstrate progress before 15 September. It was noted that this would not be complete as the results of the consultation would not have been analysed. It was also noted that officers had been discussing what would be submitted in September and the future refinement of the project towards the delivery of a full business case. It was reported that the three options in the consultation included:

• Option 1 – A traffic management plan, along with vehicle replacement and retirement plans, promotion of ultra-low emission vehicles, and other sustainable measures

• Option 2 – A chargeable Access Restriction for non-compliant vehicles, within the inner ring road. This would also include some traffic management measures, a scaled up vehicle replacement plan, along with the promotion of ultra-low emission vehicles and other sustainable measures.

• Option 3 - A chargeable Access Restriction for non-compliant vehicles, within the outer ring road. This would also include some minor traffic management measures, a much larger vehicle replacement plan, along with the promotion of ultra-low emission vehicles and other sustainable measures.

Members noted that the Council had suggested that option 1 was the preferred option. Resolved:

1. to support the Council’s developing proposals for a package of measures to stimulate travel behaviour change and assist in developing campaigns for public awareness of the public health issues; and

2. to support the Council’s developing proposals to address NO2 emissions directly by delivering a scheme to remove polluting vehicles.

21/18 Derbyshire and Derby Future in Mind Local

Transformation Plan Update The Board received a report of the Senior Responsible Officer – Future in Mind on Derbyshire and Derby Future in Mind Local Transformation Plan Update. The report was presented by Isobel Fleming (Senior Responsible Officer - Future in

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Mind), Sheila McFarlane (Acting Deputy Head of Integrated Commissioning for Children and Young People (Health) – Derbyshire CCGs/DCC) It was reported that the national Future in Mind (FiM) Strategy and Derbyshire and Derby Local Transformation Plan (LTP) 2015-2020 had a strong system-wide focus on children and young people having access to high quality mental health care when they needed it. It was also reported that governance was via a Derbyshire footprint-wide Future in Mind Board that was accountable to both Derby City and Derbyshire County Health and Wellbeing Boards. Members noted that the local plan was currently being refreshed in line with annual NHS England (NHSE) assurance requirements and set Key Lines of Enquiry and that this must be submitted to NHSE by 12 October 2018. It was also noted that local plans would be published on Clinical Commissioning Group (CCG) and Local Authority websites on 31 October 2018. Members considered the five strategic priorities identified by the Derby and Derbyshire Children and Young People’s Future in Mind Health Needs Assessment (2017). Resolved:

1. to note the update of the Future in Mind Local Transformation Plan; and

2. to agree that the sign-off of the refreshed Plan is delegated to the Chair on behalf of the Board once consultation is complete and prior to its submission to NHSE.

22/18 Derbyshire Winter Plan 2018/19 The Board received a report on the Derbyshire Winter Plan 2018/19. The report was presented by Lynn Wilmott-Shepherd – Derbyshire CCGs. Members considered and discussed the system wide plan in place for winter 2018/19. Resolved to note the report. 23/18 Influenza: Reflection on 2017/18 Season and

Planning for 2018/19 The Board received a report of the Director of Public Health on Influenza: Reflection on 2017/18 Season and Planning for 2018/19. The report was presented by Robyn Dewis - DCC - Consultant in Public Health Medicine.

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It was reported that levels of influenza like illness were unpredictable and varied annually, resulting in varying levels of associated morbidity and mortality. It was also reported that most cases in the UK tended to occur during an eight- to ten-week period during the winter, however the timing and extent and severity of the ‘season’ could vary. Members noted that in the 2017 to 2018 season, moderate levels of influenza activity were observed in the UK with co-circulation of influenza B and influenza A (H3). It was also noted that very high levels of hospital and Intensive Care Unit (ICU) admissions were experienced during 2017/18 and that the highest number of cases were observed in those aged 65 years and over. Members noted and discussed vaccines used in 2017/18 and the changes to the recommended vaccines for 2018/19, to support improved protection for at risk groups. Resolved:

1. to note the report; and 2. to support the prioritisation of influenza vaccination where possible,

including; • ensuring high coverage of flu vaccination amongst front line

employees within health and social care; • ensuring high coverage of flu vaccination amongst at risk

groups; and • support national flu vaccination communications and

proactive media engagement. 24/18 Health Protection Board Update The Board received a report of the Director of Public Health on Health Protection Board Update. The report was for information. Resolved to note the update report from the meeting of the Health Protection Board on 24 July 2018.

MINUTES END

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13th December 2018

Report Title Psychodynamic Psychotherapy Author(s) Tracy Lee, Senior Commissioning Manager Sponsor (Director) Zara Jones, Executive Director of Commissioning

Operations

Paper for: Decision X Corporate Assurance

Discussion Information X

Recommendations End the current public consultation on the proposal to decommission psychodynamic psychotherapy and instead deliver an engagement programme as part of a wider review of psychological therapies.

Report Summary

A decision was made by the CCGs Executive Team and Chair of the CCGs Clinical and Lay Commissioning Committee to pause the consultation for Psychodynamic Psychotherapy from 4 December 2018. The decision was based upon feedback from a range of sources and is pending a final decision regarding next steps by the CCGs Governing Bodies at its meeting in common on 13 December 2018.

In response to the feedback received, CCG Executives decided to enact this pause and have been working closely with Derbyshire Healthcare NHS Foundation Trust to agree a way forward.

Following these discussions, the CCGs have concluded that in the interests of ensuring that we commission and provide the most appropriate, effective, equitable, streamlined and efficient range of services to our population, we should now review the wider psychological therapy services currently available.

It is proposed that the review should be delivered in conjunction with a comprehensive programme of engagement to ensure that we listen to views and what matters most to our patients and service users, staff and clinicians, partners and stakeholders. This broad ranging review and engagement programme will enable us to understand the full range of potential opportunities that could be available to our service users. An effective partnership approach is critical to the

Item No: 68

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success of this engagement programme and we are already working closely with key partners towards this. Since the pause on 4th December, the CCGs have moved rapidly to inform everyone who has been involved with the consultation to date, including patients and service users, staff and partners and stakeholders. This has included assurance that we will not be making changes to any treatment programmes currently in place and that appointments for service users currently receiving treatment will continue as they are. Subject to Governing Bodies approval, a draft action plan is in place to enable the CCGs to progress to the next stage of an engagement programme as part of a wider review of psychological therapies. Governing Body members are asked to APPROVE the recommendation to end the current public consultation on the proposal to decommission psychodynamic psychotherapy and instead deliver an engagement programme as part of a wider review of psychological therapies. Are there any Resource Implications (including Financial, Staffing etc)? No Has Due Regard to the proactive duties of the Equality Act 2010 been taken into consideration in respect of the proposals within this report? Yes – integral to the consultation process Have you involved patients, carers and the public in the preparation of the report? This report is responding to feedback from these groups Have any Quality and Compliance issues been identified/ actions taken Yes Have any Conflicts of Interest been identified/ actions taken? N/A Governing Body Assurance Framework Identification of Key Risks

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DERBYSHIRE CCG GOVERNING BODIES MEETING IN COMMON Public Session

Held on Thursday 1st November 2018

UNCONFIRMED Present: Derbyshire-wide Executives Dr Chris Clayton (CC) Chief Executive Officer Helen Dillistone (HD) Executive Director Corporate Strategy & Delivery Sandy Hogg (SHo) Turnaround Director Steven Lloyd (SL) Medical Director Laura Moore (LM) Deputy Chief Nurse Clare Williams (CW) Deputy Chief Finance Officer

ECCG Dr Markus Henn (MH) Governing Body GP Ian Shaw (ISh) Lay Member Julie Vollor (JV) Service Director, Derbyshire County Council Pamela Watson (PW) Lay Member

In Attendance Dr Arvind Mistry (AMy) Governing Body GP

HCCG Jill Dentith (JD) Lay Member Gillian Orwin (GO) Lay Member - PPI

NDCCG Dr Ben Milton (BM) NDCCG Chair (Meeting Chair) Dr Praveen Alla (PA) Governing Body GP Ian Gibbard (IG) Lay Member – Audit and Governance Isabella Stone (ISt) Lay Member

In Attendance Helen Hipkiss (HH) Deputy Chief Nurse Pauline Innes (PI) Executive Assistant to Dr Steven Lloyd, Medical Director

SDCCG Margaret Amos (MA) Lay Member Dr Nick Bishop (NB) Governing Body GP Shokat Lal (Sla) Lay Member (Deputy Chair) Martin Whittle (MW) Lay Member - PPI Dr Paul Wood (PW) SDCCG Chair

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Opening of Business Item No.

Item Action

GBIC/1819/31 WELCOME AND APOLOGIES The Chair welcomed Governing Body Members and members of the public to the meeting. Apologies for absence were received from Dr Debbie Austin, Mrs Louise Bainbridge, Dr Avi Bhatia, Mr Bruce Braithwaite, Dr Kathryn Bagshaw, Dr Sudeep Chawla, Dr Richard Crowson, Dr Buk Dhada, Dr Ruth Cooper Dr Duncan Gooch, Dr Andrew Mott, Dr Anne-Marie Spooner, Dr Merryl Watkins, Dr Andrew Maronge, Mr Roger Miller and Mr Dean Wallace in advance of the meeting. The Chair recognised that Hardwick CCG were not fully quorate as no GPs were present. Mrs Dillistone reported that a telephone conversation will take place for any decisions taken today, therefore, members of Hardwick CCG present at the meeting will agree in principle to any decisions taken with the caveat that agreement will be sought from Dr Ruth Cooper following today’s meeting.

GBIC/1819/32 Questions from members of the public The following questions were received from members of the public: 1. Would you be kind enough to explain in detail where the 4 CCGs

plan to save the £50 million? I would really appreciate the detail. 2. When one looks at the members of each CCG Governing Body for

Derbyshire, Chris Clayton, Louise Bainbridge and Brigid Stacey are listed on all of them. Also, just about all other Governing Body members are on various CCG committees, which I understand is a requirement of their post. Who on each Governing Body, if any, is independent of the CCG? With so much overlap between Governing Bodies and CCGs, how can the CCGs be called to account for their actions?

3. At the previous meeting of the Governing Bodies in common on

27th September, which I attended, Item 21 on the agenda recommended the Governing Body to "formally confirm approval of the CCGs financial plan to deliver an in year control total of £44m deficit". This very important item was rushed through and approved with no discussion whatsoever in the last ten minutes of the meeting. Earlier we had heard in great detail and at great length about the proposed cuts to the Discretionary Grants to the voluntary sector, but that only accounts for £1.2 Million. Where are the details about how the other £50 Million of cuts that are presumably already being implemented in order to reach the target by end of March next year? And have these details been given to Derbyshire County Council Health and Scrutiny Committee?

Dr Milton clarified that the answers will be provided in the next 7 days and will be included in the December minutes:

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Response to Question 1 Thank you for your question to our Governing Body in Public meeting on 1 November 2018 regarding the detail of how Derbyshire CCGs plan to save £50 million. Your question was read out at the meeting and we committed to respond to you in writing within seven working days of the meeting. We believe that transparency is extremely important and we have shared our plans through CCG Governing Body meetings in public and other channels. The link below is to a letter we submitted for our meeting with Derbyshire County Council Improvement and Scrutiny Committee on 10 September 2018 and includes a detailed breakdown of our plans. It also reinforces our intentions to minimise any impact upon direct services to patients as less than £5 million of the £51 million plan relates to spend on frontline services: https://www.derbyshire.gov.uk/site-elements/documents/pdf/council/meetings-decisions/meetings/improvement-scrutiny/health/2018-09-10-ccgs.pdf Responses to Question 2 & 3 I think your reference is to our four CCG websites and the reason for three of our Governing Body members appearing on each website is that they hold statutory roles in line with our CCG constitutions and these statutory roles are prescribed nationally. In 2017, as part of our move towards joint working and improved efficiency, we moved from having each statutory role in all four CCGs (12 in total) to one of each for Derbyshire (three in total). The statutory roles held by name are Dr Chris Clayton (Chief Executive Officer), Louise Bainbridge (Chief Finance Officer) and Brigid Stacey (Chief Nursing Officer). The composition of our Governing Bodies are again set out in line with our constitution and comprise executive directors of the CCG, GP members and lay members who bring further independence and a particular specialism, usually patient representation and finance but also others. The Governing Body brings together all of these individual members into a collective group where they can scrutinise plans jointly and one member usually acts as a sponsor for any given issue. In that way the Governing Body members collectively scrutinise issues as they are submitted for a decision. The role of our Governing Body is to hold the CCGs to account for all its actions and you will see from the papers and the meetings in public you have attended that Governing Body members continually challenge the CCGs on recommendations and decisions through robust debate. It is important to recognise that Governing Bodies are only one channel through which CCGs are held to account and that others include the regulator, NHS England who monitor and measure performance and activities. We believe that transparency is extremely important and we have shared our plans through CCG Governing Body meetings in public and other channels. The link below is to a letter we submitted for our meeting with Derbyshire County Council Improvement and Scrutiny Committee on 10 September 2018 and includes a detailed breakdown of our plans. It also reinforces our intentions to minimise any impact upon direct services to patients, as less than £5 million of the £51 million plan relates to spend on frontline services: https://www.derbyshire.gov.uk/site-elements/documents/pdf/council/meetings-decisions/meetings/improvement-scrutiny/health/2018-09-10-ccgs.pdf

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https://www.derbyshire.gov.uk/site-elements/documents/pdf/council/meetings-decisions/meetings/improvement-scrutiny/health/2018-09-10-ccgs.pdf






GBIC/1819/33 Declarations of Interest Dr Milton reminded committee members of their obligation to declare any interests they may have on any issues arising from committee meetings which might conflict with the business of the governing bodies. Any declarations made by the members of the governing bodies are listed in the individual CCGs Register of Interests. Declarations of Interest from today’s meeting: Mr Shaw declared that he is an employee of Nottingham University and requested this be included on the Register. Merger update agenda item 38 where discussions will take place regarding the future Chair of the single CCG, and GPs and Lay Members will have a conflict with this particular agenda item. The Chair was in agreement that those members would remain in the room for this agenda item to ensure quoracy of the meeting however requested that the Nolan Principles are adhered to during this discussion.

CHIEF OFFICERS REPORTS

GBIC/1819/34 Chief Executives Report Dr Clayton provided a verbal update to the Governing Bodies of work undertaken over the last month. Key Points of interest:

• Financial Recovery continues • Merger of the CCGs which is on today’s agenda for discussion; • Commissioning system in Derbyshire - the CCGs have

completed the staff consultation and proposals with regard to the single management team restructure are being progressed. It is anticipated that the staff structures will be in place by Christmas 2018

• Strategic Commissioning strategy for 2019/20 and beyond is developing this will be brought back through a public meeting in due course.

The Governing Bodies NOTED and RECEIVED the Chief Executive verbal update.

DECISION

GBIC/1819/35 Wheelchairs Procurement Contract Award Mrs Wilmott-Shepherd provided background information on wheelchair service. The procurement of a new wheelchair service has been undertaken following a formal review of the service in 2016/17. It was noted that this decision has already been taken via a virtual poll of the Governing Bodies which needed to stay in confidence until the decision has been agreed due to procurement regulations. All public contractual regulations have been followed and the award was given to AJ Mobility Ltd for a period of 3 years commencing from 14th January 2019. This will have a positive impact on patients within

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Derbyshire who require wheelchairs. Patients will receive an improved service with greater accessibility, and improved opening times. Due diligence was undertaken on the company prior to the award of the contract. Mr Shaw questioned the quality of the wheelchair stock asking if this has been improved as part of the contract. Ms Wilmott-Shepherd explained that she is unable to answer the question as this moment in time however agreed to clarify and report back. Mrs Orwin asked from a Governance perspective how the CCGs will ensure that AJ Mobility will deliver services as promised. Ms Wilmott-Shepherd explained that the company will be run under normal contract routes with regular meetings taking place. AJ Mobility will have to meet very clear KPI’s stating that if these are not met the CCG’s would work them to put in remedial action plans through formal contracting routes. The Governing Bodies of Erewash, North and Southern Derbyshire CCGs NOTED the decision and formally AGREED to award the wheelchair contract to AJ Mobility for an initial period of three years effective from 14th January 2019. The Governing Bodies requested clarity on the stock of wheelchairs. Those members of Hardwick CCG present at the meeting RECEIVED, NOTED and AGREED in principle to the recommendations as set out in the paper. Post Meeting Note: Following the meeting Dr Cooper confirmed her agreement with the decisions taken by Hardwick CCG.

Ms Wilmott-Shepherd

GBIC/1819/36 Derbyshire CCGs Scheme of Reservation and Delegation Ms Williams provided an update on a new proposed Derbyshire CCGs Scheme of Delegation which will align the four Derbyshire CCGs, and to move from a culture of financial expenditure approval, to one which is closely monitored by budget holders. The scheme is a simplified scheme to the previous schemes used and is being proposed for an interim period of 3 months commencing from the 19th November 2018 and would see all invoices being approved by the Executive Directors. This would allow sufficient time for budget holders to understand all of the types of expenditure being charged against their budgets. To reduce the level of invoices, it is proposed that CHC invoices would be an exception, and approval would be delegated to budget managers. Following this interim period from the 18th February 2019, invoices below £10k could be delegated to budget managers i.e. Functional Directors. Dr Milton reported that this paper was presented to the Finance Committee in Common for review and received approval at that stage. Ms Dentith referred to the process asking if this paper had been presented through Audit Committee as seen, as a change to the scheme of delegation and further asked if the proposal complies with standard of business conduct policy. Ms Williams explained that this proposal will be presented to the Audit Committee for information in November, once approved by the Governing Bodies.

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Dr Wood enquired about the cycle of Governance asking for assurance in terms of this being a change and the Governing Bodies should be assured that the Audit Committee are content with the proposals. Mr Gibbard stated that the proposals would be presented to the Audit Committee; however the Audit Committee should not be seen as the determining factor for approval. Mrs Dillistone clarified that this paper will be presented to the Audit Committee in November 2018 dependent of the decision taken today. Mrs Orwin felt this proposal should be presented to the Governing Bodies meeting in December once the proposal has been presented to the Audit Committee. Ms Hogg explained that discussions were held at the Finance Committee in terms of the dates clarifying that the Audit Committee will take place on 15th November therefore the implementation date of 19th November could be adhered to. Further context looked at was around the measures to ensure the management of finances appropriately whilst in financial recovery. The Governing Bodies of Erewash, North and Southern CCGs PENDING review and sign off by Audit Committee AGREED the proposed scheme of delegation. Those members of Hardwick CCG present at the meeting RECEIVED, NOTED and AGREED in principle to the recommendations as set out in the paper. Post Meeting Note: Following the meeting Dr Cooper confirmed her agreement with the decisions taken by Hardwick CCG.

GBIC/1819/37 CCGs Derbyshire Governing Body Assurance Framework (GBAF) Mrs Dillistone presented an update on the 2018/19 Derbyshire Governing Body Assurance Framework from the paper previously circulated. The GBAF builds on a conversation over a series of months to agree and formalise the strategic objectives of the organisation moving forwards and the associated strategic risks. Dr Bishop referred to the graphs in each chart which shows the current risk however this does not show the projected trajectory for reducing the target score and the timeline to undertake this, stating that it is difficult for the Governing Body to assess how the organisation is doing with financial risks towards its targets. Mr Dillistone agreed to place additional information in to the graphs. Dr Milton stated there has been a significant amount of work which has got the organisation to this point and wished this to be recognised in the Public session of the Governing Bodies meeting. The Governing Bodies of Erewash, North and Southern Derbyshire CCG NOTED and APPROVED the 2018/19 Derbyshire Governing Body Assurance Framework. Those members of Hardwick CCG present at the meeting NOTED and APPROVED in principle the recommendations as set out in the paper. Post Meeting Note: Following the meeting Dr Cooper confirmed her

Mrs Dillistone

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agreement with the decisions taken by Hardwick CCG.

GBIC/1819/38 Derbyshire CCGs Merger Update There is a conflict of Interest for Lay Members and GPs with this agenda item however, the Chair stated that in the interest of maintaining quoracy those members could remain in the room during this discussion, reiterating the need for GP’s and Lay Members to adhere to the Nolan Principles. Mrs Dillistone provided an update for the Governing Bodies on the next steps for the Derbyshire CCG Merger which forms part of the monthly update to Governing Bodies. Mrs Dillistone talked the Governing Bodies through the paper previously circulated. The Governing Bodies at its meeting on 27th September considered the naming of the CCGs and agreed to ‘NHS Derby and Derbyshire CCG’. However two CCGs wished to seek further assurance around the process being taken and requested that the Membership are asked for their views. The Governing Bodies are asked to agree the process to engage the membership on the CCG name, the process of appointing the new Chair and type of Chair. Dr Milton referred to the name stating it is worth highlighting the name was agreed last month and concern was raised in the room pending membership approval. Discussions took place ahead of the Transition Working Group that raised concern about whether the CCGs would receive the required membership approval for that name. When the Transition Working Group met there were a number of points considered and ‘NHS Derbyshire CCG’ was considered the preferred name. Detailed discussions took place with regards to the renaming of the CCGs. Dr Clayton explained that conversations have taken place with NHSE and their view is that they would welcome ratification of the final name as quickly as possible. Mrs Dillistone stated that guidance is needed as to whether the name decided today is further tested with the Membership. Dr Milton explained that membership approval would be required and suggested that ‘NHS Derbyshire CCG’ be the proposal put forward to the Membership. The Governing Bodies of Erewash, North and Southern CCG AGREED with the proposal of ‘NHS DERBYSHIRE CCG’ Those members of Hardwick CCG present at the meeting AGREED in principle to the recommendations as set out in the paper. Post Meeting Note: Following the meeting Dr Cooper confirmed her agreement with the decisions taken by Hardwick CCG.

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Appointment of the Derbyshire CCG Chair In order to establish the new CCG there are a number of roles that the current GBs need to consider and which will require the views of the current four memberships. The first role that needs to be determined is the appointment of the CCG Chair. It is for local determination whether this is a lay or a clinical Chair. Detailed discussions ensued with regards to the type of Chair; during the discussion the Governing Bodies acknowledged that this role will be an enormous responsibility. Dr Milton summarised the discussions held stating that the proposal is that the Chair will be a GP from within the Membership either a Partner, salaried doctor or Locum GP who undertakes the bulk of work within Derbyshire. Mrs Orwin shared her concerns with regard to a Locum GP being appointed as Chair, due to the challenges of the role. Mr Shaw stated that NHSE guidance is that the “leading clinician” should be one that represents the clinical voice of its members and only a local GP is likely to be able to do this. Dr Clayton stated that caution needs to be taken around the two stage process in terms of eligibility coming from the Membership and suitability to take on the role. The processes will need to be worked through cautiously and undertaken appropriately. Dr Clayton suggested that the search is widened in terms of undertaking an appointment process that is credible in what is going to be a challenging role. Dr Milton clarified that the appointment of a Chair will be a GP from the Membership and that the process of appointing the Chair will be an internal process managed by the HR department without a need to use recruitment consultants. Mrs Dillistone confirmed that Stakeholders would need to be involved in the recruitment process explaining that whilst NHSE have a particular role the CCGs will be looking at convening a panel that is representative of stakeholders and Member Practices. Dr Clayton recommended that the CCG’s seek expressions of interest from those eligible within the Membership against a very clear role description and then appoint against that as opposed to having an appointment process and then going to membership for ratification. The Governing Bodies of Erewash, North and Southern CCG were in AGREED to seek a GP Chair from within Membership Practices. Those members of Hardwick CCG present at the meeting AGREED in principle to seek a GP Chair from within Membership Practices. Post Meeting Note: Following the meeting Dr Cooper confirmed her agreement with the decisions taken by Hardwick CCG.

GBIC/1819/39 Mental Health Together Plan Prior to the update Dr Milton requested that Ms Innes update the website with the embedded papers from the report.

Ms Innes

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Mrs Wilmott-Shepherd reported that this report is brought for assurance and information to ensure that it is brought in to the public domain for transparency. Decommissioning of the the Mental Health Together service was previously agreed but subsequently it was asked that further work be undertaken to engage with the provider and service users to see how this could potentially be taken forward in a different way. This revised service is proposed to be jointly funded with Derbyshire County Council and following the engagement and subsequent work undertaken it has been agreed that the service will be reduced and a contract variation has been produced. The budget will be brought down from £154k to £32k which is to be jointly funded between the two organisations. The revised model has been agreed by Mental Health Together, the CCGs and Derbyshire County Council. The revised model will still allow full involvement in both Place and within the Mental Health STP elements and still provide assistance to volunteers who themselves have mental health issues, which was a key element of this particular service. Even though the service has been reduced it still allows engagement and support as the organisation moves forward with changes in Place and the Mental Health services. The Governing Bodies of Erewash, North and Southern CCG were in NOTED and AGREED the extensive engagement on a proposed re-commissioning of the engagement service. Those members of Hardwick CCG present at the meeting NOTED and AGREED in principle to seek a GP Chair from within Membership Practices. Post Meeting Note: Following the meeting Dr Cooper confirmed her agreement with the decisions taken by Hardwick CCG.

CORPORATE ASSURANCE

GBIC/1819/40 Finance and QIPP Assurance Report Ms Williams provided an update from the Finance & QIPP Assurance Report for Month 6 up until the end of September from the report previously circulated. As at month 6 the Derbyshire CCGs are currently reporting to be on target with the delivery of the control total. Included within this the CCGs are assuming that the 0.5% risk reserve will not be used, however there are risks around the QIPP delivery. The CCGs will receive the Qtr. 2 CSF funding from NHSE. Ms William highlighted the current budget pressures:

• Acute Services are showing a forecast overspend of £1.8m (£2.7m over forecast at month 5).

• Continuing Health Care is forecast to overspend by £1.2m • Primary Care prescribing shows forecast overspends of £0.5m

which is an improvement on month 5. • At month 6 the CCGs forecast underlying position is a deficit of

£52.8m against a plan of £42.0m deficit. Ms Hogg provided an update on the 2018/19 Savings Delivery. The CCGs must deliver £50.7m of QIPP in 2018/19 as part of the

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overall Financial Plan, in order to deliver the £44m Deficit Control Total agreed with NHS England. The CCGs have over performed against the target in the first half of the year, however, the challenge is that 66% of the QIPP target will be delivered in the second half of the year. The risk assessment undertaken suggests that there is a £7.2m risk on QIPP schemes where the organisation potentially will struggle to meet the full targets. Detailed discussion took place at the Finance Committees on this subject and and detailed reports were provided on those schemes by the relevant Directors who are responsible for those schemes. The recommendation of the Finance Committees to the Governing Bodies was that all reasonable actions were being taken to progress those schemes? There is one further area that will be subject to a deep-dive of the sub-committees for assurance purposes. The report mentions one area that was still being investigated at the time of writing, which is where there is an ongoing review of prescriptions for patients who are on repeat prescriptions. Ms Hogg emphasised that there is considerable risk on that scheme which is a £3m QIPP scheme which may under deliver by c£1m and the Finance Committees have requested a deep-dive on that scheme at the November meeting. Dr Mistry referred to the abbreviations being used in reports and requested that all reports include a report of all acronyms used. Dr Milton requested that a glossary of terms is included in future packs of papers. The Governing Bodies NOTED and RECEIVED the Finance and QIPP Assurance Report

Ms Innes

GBIC/1819/41 Quality & Performance Committee Assurance Report Mrs Moore provided an update from the Quality & Performance Committee Assurance report which was discussed in detail at the Quality & Performance Committee. There has been a significant amount of work on the report over the last month, and it was noted that further clarity is provided within the report. Key points to note:

• Cancer 62 day performance continues to be non-compliant at Derbyshire level.

• 2 week wait breast symptoms – although the trust achieved this standard as a whole those patients treated at the Derby site did not meet this standard achieving a standard of 90.68%

• Cancer 31 day performance for subsequent Radiotherapy was not met at a Derbyshire level

• A&E standard was not met at a Derbyshire level, with both main providers failing to achieve the 95% target.

• Never Event at CRHFT the Governing Bodies noted that no harm came to the patient the incident was recognised immediately and the patient was treated.

Ms Wilmott-Shepherd stated that the report has been through a number of iterations highlighting key points for the Governing Bodies to note:

• A&E performance remains to be a concern this area is looked

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at through the A&E Delivery Board which has recently been revamped and further scrutiny will take place on performance.

• CRHFT have had a contract performance notice issued on their A&E;

• Derby Royal has also had a contract performance notice issued and a remedial action plan is in place by March 2019;

• Cancer performance within Chesterfield; a contract performance notice is not being raised as the performance is showing considerable improvement and the CCG’s continue to work with both Trusts on this concern;

• 2 week waits referrals in North Derbyshire; concerns remain with regards to breast referrals to Stepping Hill Hospital. The CCG remain in contact with the CCGs and with the Trusts to ensure the situation does not worsen;

• 18 week referral to treatment; the CCGs are working with both Trusts and there are clear action plans in place. A lot of work has taken place with private providers to ensure patients are seen in a timely way which will allow the CCGs to reach the NHS Constitutional targets.

The Governing Bodies NOTED and RECEIVED the Quality & Performance Report

GBIC/1819/42 Clinical and Lay Commissioning Assurance Report Dr Milton provided an update from the Clinical and Lay Commissioning Assurance Report. The Governing Bodies of NOTED and RECEIVED the Clinical and Lay Commissioning Committee Report

GBIC/1819/43 Governance Committee Assurance Report Ms Stone provided an update from the Governance Committee meeting held in July 2019. The Governing Bodies noted that the Governance Committee has improved and progressed significantly since the first meeting took place. The Governing Bodies NOTED and RECEIVED the Governance Committee Assurance Report.

GBIC/1819/44 Audit Committee Assurance Report Mrs Amos provided an update from the Audit Committee in Common meeting held in May 2018. Key points to note:

• signing off the adjustments to the Annual Accounts, • the internal audit opinions across the four CCGs • the external Audit opinion

The Governing Bodies of NOTED and RECEIVED the Audit Committee Assurance Report.

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GBIC/1819/45 Risk Register Exception Report October 2018 Mrs Dillistone provided an update from the Risk Register Exception Report October 2018. Key Points to note:

• Risk 002 which relates to the concern with A&E where an update has been provided today under Quality & Performance Assurance Report.

Dr Milton referred to Risks 9 and 15 being merged asking if this has happened seeking clarity on whether the Governing Bodies are required to approve this. Mrs Dillistone explained that advice will be sought from Dr Lloyd and agreed to provide an update to the Governing Bodies. The Governing Bodies NOTED and RECEIVED the Risk Register Exception Report requesting clarity on Risks 9 & 15.

Mrs Dillistone

GBIC/1819/46 Committees in Common Minutes (for information only) The Governing Bodies NOTED and RECEIVED the following minutes:

• Quality & Performance minutes from the meeting held on 2nd August and 6th September 2018.

• Audit Committee minutes from the meeting held on 23rd May 2018.

• Governance Committee minutes from the meeting held on 12th July 2018.

GBIC/1819/47 Minutes from other meetings for information Derbyshire Health & Wellbeing Minutes from the meeting held on 12th July 2018 were RECEIVED and NOTED. Derby City Health & Wellbeing Board Terms of Reference were RECEIVED and NOTED.

MINUTES AND MATTERS ARISING

GBIC/1819/48 Minutes of the Derbyshire CCGs GB Meeting in Common meeting held on 27th September 2018 The minutes from the Derbyshire CCG’s Governing Body Meeting In Common meeting held on 27th September 2018 were accepted as an accurate record subject to slight amendment: Minutes to be amended to reflect that Jane Chapman, NHS England was in attendance at the Public Governing Body meeting in Common, Ms Innes to clarify if Ms Chapman was also present for the Confidential Session of the Governing Body meeting.

Ms Innes

GBIC/1819/49 Matters Arising from the Minutes not elsewhere on the agenda Action Log Action 127.17: Gluten Free Consultation – this action to remain open

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to be further considered in December 2018. Action 18/19/39: Quality & Performance Assurance Report - .this action remains to be ongoing with regard to Wound Care, update to be provided in December 2018. Action GBICP 1819/14: Derbyshire Voluntary Sector Review – this action remains to be ongoing an update will be provided in December 2018. Action GBICP 1819/22 Quality & Performance Assurance Report – this action remains open Mrs Stacey to provide an update in December 2018. The Action Log was RECEIVED and REVIEWED.

GBIC/1819/50 Any Other Business Dr Milton referred to Hardwick CCG quoracy requesting that final ratification is sought in terms of the decisions taken and recorded appropriately in the minutes. There were no further items of any other business transacted.

Date and Time of Next Meeting: Thursday 13th December, 2:30pm at Coney Green Business Centre

Signed by: …………………………………………………. Dated: ………………… (Chair)

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GOVERNING BODY MEETING IN PUBLIC ACTION SHEET – November 2018 GBIC meeting

Item / Minute No.

Action Proposed Lead Action Required Action still to be taken Due Date

2017 Actions GBP 127.17 / 027.18

Gluten Free Consultation

Steve Hulme Review of the position to be undertaken in 6 months’ time.

Further considered in February 2018. Original decision to review in 6 months still stands.

Update from September GBIC: 6 months review in November

Update from Steve Hulme 24.10.18: Gluten Free report presented to CLCC in September. Required to be presented to Executive Team and will be presented to Governing Body as part of December agenda.

On December 2018 Agenda

Close

2018 Actions GBP 1819/39

Wound Care Brigid Stacey Further discussion is to be held by the executive team in order to ensure that clear wound care guidelines are implemented.

A Derbyshire wide task and finish group was launched with a teleconference on the 12th September, the group is meeting for an initial workshop on the 19th September with representatives from practices, DCHS and the LMC. Meetings with groups of practices to discuss local issues are happening across the county, with DCHS being invited to meet separately with representatives to try to find interim local solutions

Update from September GBIC: Further update required following discussions with DCHS, practice representatives and the LMC.

Update provided:

September 2018

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Update from Jean Richards 24.10.18: The wound care task and finish group has developed a wound care referral pathway, this includes a definition of simple wounds to be managed in primary care and a clear route into DCHS for complex wound care, how this service is commissioned is still for discussion. The proposed pathway has been circulated to a primary care reference group for comment along with an update of progress, a summary has also been shared with all practices via the primary care newsletter. A productive meeting has been held with CRH, with agreed actions around improving the post-surgical discharge pathway to prevent unnecessary contacts with community and primary care and to increase self-care, the group is now in touch with Derby Hospitals to have the same discussion. Clive Newman is linking with the acute contracting leads to ensure any changes are included in contracts and compliance monitored. The group has proposed a new model for delivery of complex wound care, focused around community hubs, DCHS are in the process of developing plans which we hope to share with practices within the next two weeks, plans for hubs in High Peak and Amber Valley are already underway due to high demand in those areas.

Update from Jean Richards December 2018: Task and finish continues to meet, a joint definition of housebound has been agreed to support the new wound care pathway. Progress continues to be made with the establishment of community dressings clinics in hubs, a further clinic in Chesterfield is expected to be opened week commencing 17th December. Discussions are ongoing around a proposal for practices to support a

November 2018

Updated December 2018

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safe, managed transition plan from December 2018 onwards, with the aim of having the new pathway fully implemented by 31st March 2019. It is proposed that patients are transferred to DCHS in order of risk, while there is scope for local variation the principle will be; Consolidate existing clinics based within practices to the new DCHS place based dressing hubs, practices start to refer all new leg ulcers to DCHS, Practices meet with DCHS individually to discuss their caseload with patient level detail, based on risk assessment practices transfer the most complex leg ulcer patients first and then the remaining complex patients from high to low risk.

GBICP 1819/14 September mtg

Derbyshire Voluntary Sector Review Infrastructure Organisations Discretionary Grants

Zara Jones Zara Jones Zara Jones

Undertake infrastructure review within current financial year aligned with Local Authority partners. This will include further period of engagement with organisations. Undertake a detailed review (including further engagement with individual voluntary sector organisations and proportionate engagement with service users) to enable governing bodies to reach a decision on the most appropriate commissioning arrangements to be put in place form 2019/20.

On agenda December

2018 Close

On agenda December

2018 Close

On agenda December

2018 Close

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GBICP 1819/22 September mtg

Quality and Performance Assurance Report Never events in relation to air and oxygen Cancer services

Brigid Stacey Brigid Stacey

A joint visit was held between the CCG/NHSI/NHSE. A final report will be provided in due course. Deep dive report to be provided to Governing Body Update Dec: Deep dive scrutinised at Dec Quality & Performance Ctte. Highlights from deep dive will be included in Q&P Assurance Report December to GB.

On December 2018

Agenda Close

December 2018 Close

NEW: GBIC 1819/33 November mtg

Declarations of Interest

Rosalie Whitehead

Mr Shaw declared that he is an employee of Nottingham University

Updated for December

2018 Close


Wheelchairs Procurement Contract Award

Lynn Wilmott-Shepherd

Clarity on the quality of the wheelchair stock

Update from Louise Swain December 2018: Louise confirms that the new wheelchair specification is in line with the NHSE guidance in the contract and has a very robust improvement programme which includes quality of wheelchair stock, meeting 100% RTT 18 week waits and will ensure Derbyshire delivers a service that is fit for purpose. This will be assured by rigorous contract management and performance and quality assurance.

Update for December

2018


Finance and QIPP Assurance Report

Pauline Innes Glossary to be included in future Governing Body

December 2018

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papers completed CLOSE


Risk Register Exception Report October 2018

Helen Dillistone

Clarity on whether Risks 9 and 15 are being merged, are GB’s required to approve this? Mrs Dillistone seeking advice from Dr Lloyd

Update Dec from Stuart Fletcher: This will be picked with the relevant lead and reflect where appropriate in the Exception Report.

Updated December

2018

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