Title Report concluding the formal handover of functions ... · Report concluding the formal...

Board meeting date: 29 November 2011

Agenda Item number: 3 Enclosure: 1

Title Report concluding the formal handover of functions to Shropshire Community Health NHS Trust from Shropshire County PCT and NHS Telford and Wrekin

Accountable Director: Jo Chambers Author (name & title): Jo Chambers, Chief Executive

Action required from the Board:

Decision / Approval

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Gain assurance

Discussion

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Information

What other Trust Committee has considered this report? Executive Team

Committee

Date reviewed Various up to and including 24 November 2011

Key points or recommendations Ensure there is a clear commitment from both PCTs to resolving outstanding legacy issues within the timescales indicated.

Purpose of the report

To note the contents of the legacy position inherited from NHS Telford & Wrekin and Shropshire County PCT. To note the work to date on clarifying and resolving items that will require on-going management by Shropshire Community Health NHS Trust, that were under the management of NHS Telford & Wrekin and Shropshire County PCT prior to 1 July 2011. To note the need for further work between the two PCTs and the Trust to finalise the conclusion of the work arising from the creation of the Community Trust.

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Summary of Key Issues

The creation of a new NHS provider trust from the two PCT provider arms has been a complex piece of work undertaken in a very tight timescale. The Community Trust received Department of Health approval for legal establishment on 7 April 2011, with a period of shadow running until formal establishment as a separate organisation on 1 July 2011. A number of legacy issues came to light during the period of shadow running, immediately prior to establishment and during the early period as a separate organisation. All three management teams set about resolving the issues as they arose, however, the nature and complexity of some issues required further work and analysis to enable all risks to be identified, mitigated and where possible solutions identified. There have been some particularly complex financial adjustments to make linked in part to re-casting a variety of shared service arrangements across all three organisations, designed to minimise the cost of administration, and the consequent impact on the apportionment of overhead costs to individual services within the Price Activity Matrices; this last piece of work is due for completion in February 2012. The report identifies the progress to date and the items that require further work and agreement at a later date. The following issues remain outstanding but will be completed by the end of November 2011:

o Agreement on financial risk sharing o Agreement on service level agreements o Agreement on baseline position of occupational health

funding transferred from NHS Telford and Wrekin to the Community Trust

o Agreement on aged debtor issues o Community Trust to raise invoice for Freedom of

Information support provided since 1 July 2011 to Shropshire County PCT.

The other issues that will remain outstanding with completion dates post November are:

o Adults with learning disabilities service modernisation o MIU clinician cover and supervision and West Midlands

Quality Review Service review and recommendations

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o Clearing Backlog of NHS Telford & Wrekin entries on the Datix system

o Clarification of the continuation of Datix for other Datix records; e.g. complaints and PALs (PCTs)

o Agreement on the future ownership of Ludlow land (subject to Department of Health final guidance and Strategic Health Authority approval)

o Review of areas of occupation of William Farr House by Shropshire County PCT and the Community Trust

o Clarify the former NHS Telford & Wrekin provider budgets

o Calculation of revised Price Activity Matrices and agreement on the baseline position of each PCT

o Agreement on commissioning arrangements for wheelchair, continence supplies and community equipment services

o Agreement on funding of consultant input from Shrewsbury and Telford Hospital Trust into Minor Injuries Units via contract negotiations for 2012/13

o Agreement on request for stepped cost increase with regards to the Oswestry Primary Care Centre

o Agreement of transfer of funding for emergency planning SLA

o Agreement of SLA for medicines management o PCTs to work with the Community Trust to implement

the relevant recommendations from the RSM Tenon Due Diligence reports.

Additionally, there are some specific areas for joint ongoing review or action by the Community Trust:

o Children’s safeguarding – joint review with PCTs o Adult safeguarding – review by Community Trust and

further discussion if required with PCTs. o Adult safeguarding – continued joint approach to training

and joint processes o CAMHs commissioner review – need to address

shortage of Tier 4 beds locally and impact on service provided by the Community Trust

o Incident Room – Shropdoc – NHS TW to transfer assets to Shropshire Community Health NHS Trust (equipment funded), and Community Trust to negotiate with Shropdoc for continued partnership working to ensure availability of an Incident Control Room in the event of major incident.

In addition, the report also sets out a provision for dispute resolution if these issues are not resolved, or if any material new issues arise subsequent to this meeting.

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Recommendation(s) to Board

1. To note the position in respect of legacy issues

handed over from the Boards of NHS Telford & Wrekin and Shropshire County PCT, as outlined in the report.

2. To accept the assurances of the Boards of NHS

Telford & Wrekin and Shropshire County PCT in relation to ensuring that the responsibilities transferred and the commitment to resolve outstanding issues within the timescales indicated.

3. To take assurance that should any additional issues

that arise subsequently, or known issues become more significant, each party will use best endeavours to resolve the matter through director discussions. In the event of dispute, the issues will be escalated to the Chief Executive of Shropshire Community Health NHS Trust and the Managing Director for Shropshire County PCT and NHS Telford & Wrekin or the Cluster CEO in the first instance, who will use all reasonable endeavours to resolve any such dispute/s. Failure to reach agreement within 28 days will result in escalation to Board level for resolution. If the dispute cannot be resolved at Board level, then any party may refer the matter to the Strategic Health Authority for resolution.

Strategic Objective(s) to which this paper relates: /

To increase quality, safety

and productivity of the services we provide

To explore every

opportunity to innovate and

improve

To build financial strength

and resilience

To develop strong

community links and a

reputation for responsiveness

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Which key standards or assurances does this report relate to?

State specific standard / outcome or BAF risk

CQC

NHSLA

Board Assurance Framework

The aim of the formal handover and documentation is to reduce the risks inherent in the transition from the PCT Boards’ responsibility for services to the Community Trust Board for on-going management.

IMPACTS & IMPLICATIONS Patient safety & experience Ensure that all on-going aspects of patient

safety and experience are appropriately transferred to the management of the Community Trust.

Financial (revenue & capital)

There are a number of areas of potential financial risk which will be subject to further discussion with the two PCTs.

Equality & Diversity

OD/Workforce

What patient & public involvement has there been in this issue?

The Community Service Integration Project, which oversaw the establishment of the Community Trust, included stakeholder representation including CiNCH and LINKs.

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Agenda Item 3

Report concluding the formal handover of functions to the Shropshire Community Health NHS Trust from Shropshire County PCT and NHS Telford

and Wrekin

1. Introduction On 1st July 2011, the Shropshire Community Health NHS Trust was created via a transfer order, and the provider functions of both Shropshire County PCT and NHS Telford and Wrekin were transferred to the new Shropshire Community Health NHS Trust. Despite the extensive due diligence process that both PCTs undertook during the months preceding the transfer, a number of outstanding operational issues were identified during the period of shadow running just prior to the transfer and afterwards, that have required further discussion, assurance and action being taken by all three organisations to resolve them. This report documents these issues and outlines for the Boards of Shropshire County PCT, NHS Telford and Wrekin and Shropshire Community Health NHS Trust the actions that have been, and are being taken to resolve them, in order to complete a formal handover of functions and provide assurance to the Boards that risks and liabilities have been mitigated through a transparent agreement between all the parties. 2. Information The issues that remain outstanding are listed below with the respective action that has already been taken or an assurance on the action that is currently being taken to resolve the issue. 3. Safeguarding 3.1 Children’s Safeguarding This section identifies the key issues relating to Children’s Safeguarding handed over to the Community Trust The PCT Cluster Executive Nurse/Director of Public health identified in March 2011, that investment in health visiting was being made over the next 4 years and it was agreed with the PCT Managing Director of the Shropshire County Provider Arm that the investment would help to provide an opportunity to strengthen safeguarding functions with the Community Trust. An Ofsted review then took place that identified that the designated nurse for Children’s safeguarding was undertaking too much operational work. In June 2011, the Director of Nursing of the PCT Cluster requested the transfer of the Designated Nurse from the shadow Community Trust to commissioning within NHS Telford and Wrekin to address this imbalance in her workload. The request was discussed and agreed by the Community Trust Director of OD & Workforce and the Community Trust Interim Director of Service

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Delivery who held Board responsibility for safeguarding. Therefore, prior to the Community Trust authorisation a gap in capacity had been identified.

Further reviews to assess any residual gap in current capacity occurred with input from the Designated Nurse and Lead Children’s Nurse from the SHA to provide advice and guidance in relation to issues in capacity of the Community Trust. The initial view on the gap was 0.50wte, however further discussion has occurred with the PCT Director of Public Health, PCT Cluster Executive Nurse and the Community Trust and it has been acknowledged and agreed that the residual gap in terms of work is approximately 0.20 whole time equivalent. It has been agreed that through the Clinical Quality review meetings the PCT and the Community Trust will monitor any safeguarding issues and have further discussions should this gap impact on the ability of the Community Trust to deliver its duties in relation to safeguarding.

The Designated Nurse for Safeguarding produced all safeguarding reports for previous Trust Boards/ Professional Executive Committees and respective quality committees. This responsibility will now have to be taken over by safeguarding leads within the provider arm.

The Designated Nurse for safeguarding also had the overall responsibility within provider services for in house training targets, serious incident reporting/ safeguarding incident reporting regionally and locally and safeguarding supervision. New arrangements for safeguarding will need to be put in place within newly configured provider services to ensure local safeguarding systems and processes are robust to protect children and young people. External changes within the Local Authority also impact on the Community Trust due to reorganisation of statutory partners; funding constraints including significant cutbacks in agency budgets; Inspection Reports actions; Serious Case Reviews (SCR)/Individual Management Reviews (IMR) recommendations; Safeguarding risk management and reduction; and the fact that this is a high media attention area. A further risk identified on a national, regional, and local basis is that there is a shortage of Tier 4 Child and Adolescent Mental Health Services (CAMHS) care beds resulting in local delays in service provision. This issue needs to be highlighted with the commissioners as part of the CAMHS review. Nationally, children in care are placed out of county. In Shropshire and Telford & Wrekin there are a number of Looked After Children (LAC) in county and a number of local LAC children placed out of county requiring extensive monitoring. There is significant cross boundary flow from mid-Wales, due to families seeking treatment in Shropshire services such as Minor Injury Units (MIU) and Accident & Emergency Units; this presents on-going challenges in terms of monitoring vulnerable children and safeguarding information sharing. There are also a number of private providers of care for LAC children and young people in the area. Shropshire and Telford & Wrekin also has a number of children home schooled. In addition, there are a number of key work areas from previous incidents and reviews which include safeguarding governance, supervision, training targets, policy and procedures and local systems that the Community Trust will be required to continue to work on. 3.2 Adult Safeguarding The interim PCT Lead Nurse post holder is currently reviewing commissioning safeguarding arrangements in relation to gaps that have been identified following completion of the DH(2011) suite of documents for Adult Safeguarding. The PCTs have advertised a 1.0wte Adult Safeguarding nurse post to work across both PCTs.

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The PCTs have requested that the Community Trust undertakes a similar review based on the DH 2011 Adult Safeguarding provision guidance which relates to responsibilities of healthcare provider organisations. The Community Trust will complete this review by December 2011, and the findings will be shared with commissioners in relation to any future investment required.

A report undertaken by Shropshire County PCT commissioners in August 2011, detailed information sought from the Acting Director of Commissioning and relevant finance lead indicated that in terms of financial resources for Vulnerable Adult Safeguarding there is a budget allocation of £54,000 assigned to the Mental Capacity Act implementation that is ring fenced to support the joint working processes with Shropshire Council, the PCT and the Community Trust. No additional specific financial resources have been allocated for other adult safeguarding posts for 2011/12.

It is recommended that the joint working processes and training between PCT, Community Trust and local authority continue, co-ordinated by the PCT arrangements with Shropshire and Telford and Wrekin Councils.

4. On-going Risk, Risk Registers and Serious Incidents The aim of this section is to identify pre-existing areas of risk which have given cause for concern during the transition period or remain on-going. High risks which appear on the PCT Boards strategic risk registers have been identified. Risk registers have now been split between the PCT’s and Shropshire Community Health NHS Trust (SCH). SCH has developed its own Board Assurance Framework. This was developed from previous provider risk registers. As part of this register 33 risks identified, 1 of which have been identified as high risk. Furthermore, consideration has been given to Serious Incidents (SI’s) which may need to be captured on future risk registers within the community trust. These SI’s remain open at present. The key areas in the Quality Risk Profiles (QRP) for the previous PCTs and Community Trust organisations have been reviewed by the parties. The areas flagged in terms of quality assurance areas of concern/improvement relate mainly to the results from the Staff Survey and it is recognised that this included feedback from staff across all functions of the previous organisations. Whilst offering assurance that there are no specific legacy issues to be handed over, all Boards are asked to note that future QRP data will continue to inform the quality assurance process and will be monitored via the CQR processes.

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Area of concern

Risk Risk Ratin

g

Risk description Considerations Outstanding issues Responsibility& Actions taken.

Residual Risk as of 30.06.11.11

CAMHS Capacity. high Direction of travel. Safe clinical practice.

Emotional wellbeing and mental health services for children for the future

CAMHS review Strategic level planning groups to re-invigorate planning partnerships

Action plan in progress in the PCT and Community Trust

Moderate

Community Hospitals. Ludlow

Adult safeguarding. Standards and safety of care

Moderate As per investigation report on Stretton Ward Ludlow Hospital

Monthly clinical quality review meetings commenced around the delivery of relevant contractual quality schedule requirements

Detailed remedial action plan in place to address recommendations of immediate risks and serious concerns.

Action plan in progress in the PCT and Community Trust

Low

Community Hospitals.

Ward staffing Moderate Current staffing levels were not in line with acute recommended staffing ratios

Additional funds have been identified to remodel the staffing ratios at £438,000 recurring

To ensure that increased staffing levels are assisting the improvement in the delivery of key clinical and quality care aspects. These include falls prevention, Pressure area care, and improved patient experience

PCT to monitor via CQR process

Moderate

Adults with Learning Disabilities

Modernisation of services

High Appropriate clinical pathways. Clinical safety. Community Based Assessments. Appropriate placements

Providers to demonstrate local strategic leadership to drive forward modernisation of healthcare within the local partnership context

To be jointly agreed with providers

PCTs to lead High

Minor Injuries Adequate Moderate Findings of WMQRS Compliance with PCT worked with PCT agreed Moderate

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Unit clinician cover and supervision

review WMQRS standards shadow community trust staff in relation to key issues from WMQRS review.

business case needs to be developed to address the issues, rather than through CQR meetings.

PCT Corporate Risk Register

Risk

Risk descriptions Considerations Outstanding issues Responsibility

SC ref 988 Modernise Community Services

high Modernisation of Community Services and Care Closer to home to ease pressure on acute services and deliver more integrated patient centred pathways.

Threats to this are a possible focus on reorganisation, rather than modernisation. Resource issues, staffing levels, skill levels and clinical engagement. Clinical Quality Review (CQR)

Privacy & Dignity issues, Single Sex Accommodation

Director of Quality and Nursing

high

SC ref 725 Assuring Quality and Safety of Acute Commissioned Services

high Community Hospital Services – Staffing- Agreed Metrics and Methodology

Contracts review. CQR – monitoring SI’s, complaints. Monitoring risk registers. Announced and unannounced visits

CQC - Compliance with essential standards of quality and safety. Health Care Acquired Infections. Falls. Nutrition.


high

SC/T&W ref 2b Availability and use of information to commissioners

High Information may not meet performance monitoring requirements.

Identified as a strategic risk by SCPCT and NHST&W

Negotiations with Commissioner on information processes are ongoing

Director of Finance

High

SC/NHST&W ref 6/6a

Quality patient experience

High Completion and Internal monitoring of patient risk

Pilot risk assessment trialled in community services

Ongoing implementation and monitoring of patient


Low

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and related risk assessments

assessments risk assessments

Serious Incidents

Risk Risk descriptions Considerations Responsibility

2011/12031 Unexpected death of inpatient

Patient admitted from Acute to BC Hospital. Deteriorated over Bank Holiday weekend, returned to Acute where passed away. Family complained

Investigation is complete, actions are being implemented including introduction of Early Warning Score system

Introduction of early warning system.

Implementation to be reviewed at CQR – bank holiday service

2011/10120

Management of pressure ulcers

Pressure Ulcer grade 3/4

RCA Investigation in place

Awaiting RCA Outcome to be reviewed at CQR

2011/6207

Death in Custody Death in Custody. RCA complete.

Awaiting PPO report, inquest will follow some months after.

No major issues for Prison Healthcare

Outcome to be reviewed at CQR – pre-inquest review January 2012

2010/18355

Death in Custody Investigation and PPO report complete.

Awaiting inquest, no date as yet.

No major issues for Prison Healthcare

Outcome to be reviewed at CQR – pre-inquest review October 2011 – no concerns anticipated

2010/7802 Choking incident at Bridgnorth

Investigation carried out.

Remedial actions complete.

Inquest 22nd Nov Outcome to be reviewed at CQR

2010/6500 Death in Custody Natural causes. Investigations complete. Inquest 29th November.

Outcome to be reviewed at CQR

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5. Datix Two issues were raised by the PCTs at the second legacy meeting about the Datix system:

a concern that there appeared to be a backlog of Serious Incident reports to go onto the Datix system;

a concern that the system administrator arrangements meant that the Community Trust system administrator could continue to have sight of entries on the system other than purely Community trust ones. The PCTs will shortly move to a separate Datix system which will remove the problem, but an interim solution was needed to prevent this in the meantime.

Discussions between the Trust and PCTs have now resolved the issues as follows:

named PCT staff have taken full handover of management of SUIs, incidents, purple cards, GP incidents and other risk related records on the system. Trust and PCT staff together have reviewed numbers of records and in which categories, and after this clarification, there are no remaining concerns about significant backlogs. NHS Telford and Wrekin PCT have carried out a final check to ensure there are no T&W provider entries still to be put on the system, which has highlighted 10 datix incidents remaining to be closed.

The Community Trust Risk Manager will no longer have routine system access to commissioner records, unless in exceptional cases for SCPCT this is required in order to assist with a particular query at their request.

The PCTs are aware that there are certain other types of PCT records on the Datix system e.g. complaints and PALs, which will either need migrating to the new system and for the PCTs to ensure in house technical knowledge of Datix. The PCTs have indicated an intention to continue with Datix for these other records. 6. Finance As at 1st July 2011 there were a number of finance issues that required resolution. These included agreeing the quantum for 2011-12, setting up of SLAs for hosted services and a number of issues around estates. There was an apparent discrepancy between the information submitted by NHS Telford & Wrekin provider services for the Long Term Financial Model (LTFM), which informed the authorisation process and indicated an underlying surplus, and the later position revealed in the Stage 3 Due Diligence and Corporate Services Review undertaken by RSM Tenon, indicating an underlying deficit. Since 1st July 2011 a number of issues have already been resolved between the commissioner and provider, i.e. further funding of £192k and the Community Trust has removed £494k establishment (vacant posts agreed by commissioner from the underlying deficit work), but there are still some outstanding issues, e.g. Occupational Health funding to be finalised and the Corporate SLAs.

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Agreed Solutions:

£000

Corporate split corrections (NHSTW) 585 Aged Debtor (All Welsh) (NHSTW) 125 Additional Funding Gap Correction (NHSTW) 192 Establishment Reduction in Community Trust 494 1396 In Discussion:

Creditors (charges) not set up in 2010/11 and Invoices raised incorrectly

379

Occupational Health Establishment 115 494

The PCTs and the Community Trust need to finalise the Corporate SLAs which will require the Lead Directors from the relevant organisations to have shared service specifications and risk sharing arrangements by 22 November. Following detailed discussions between the respective lead directors, final draft documents were issued by the Community Trust on 25 November for review and agreement by the PCTs.

The Tripartite Agreement was that both PCT provider arms would aim to hand over a surplus cash balance. It was identified during July that NHS Telford & Wrekin provider closed down month 3 with an overdrawn balance of £277k, the implications of which were a tight cash position initially, together with implications going forward on Financial Risk Ratings (FRR) which needed to be worked through. Estates As at 1st July, assets were transferred or retained based on knowledge at the point of transfer. Further guidance was received on 4th August 2011, which has changed the original transfer agreement. Financial Accounts 2011-12 have been amended to pre-1st July estates status and further guidance is still awaited on the actual timing of the transfers. Indications are that they are likely to be actioned in 2012-13. There will be implications for the SLA with South Staffordshire and Shropshire Foundation Trust for estates services to be resolved. Headquarters Accommodation – William Farr House (WFH) is identified in the Transfer Agreement as the Headquarters of the Community Trust. The WFH site is also Shropshire County PCT Headquarters. Under the recent DH guidance on estates transfer the WFH site will be retained by the PCT. Discussions are on-going regarding the split of the site between provider and commissioner organisations.

The Shropshire County Clinical Commissioning Group (CCG) is looking at its future accommodation needs. Retaining accommodation on the WFH site is one of the options being considered and the CCG is also looking at off-site options. The Community Trust is looking at potential opportunities to rationalise its estate to make use of the space on the WFH site that would be vacated if the CCG moved off-site. Both parties are working to resolve these matters as soon as possible. Leases and Sub-Leases – as a result of the above, the leases and sub-leases required between the Community Trust and PCTs have not been put in place. It is recommended that these are not actioned pending resolution of the estates transfers in order to avoid duplication and additional (unnecessary) costs. The PCTs and Community Trust met with

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the SHA on 20 October to agree the proposed properties that will be submitted to the DoH for transfer to the Community Trust, with the following key changes: NHS Telford & Wrekin:

Longbow Close have a single lease for units C and D with the only clinical area being ground floor D which equates to 25% of the building therefore to be retained by the PCT.

All Occupational Health properties will now be retained by the PCT, following recommendation/guidance from SHA that these are staff services/income generation and not patient clinical properties.

Shropshire County PCT:

Ludlow land now shown as “transferred” which the SHA are supporting, however are stating that it is likely to require a joint business case.

Oswestry Primary Care Centre – remaining with Shropshire County PCT. Negotiations are on going, both in terms of space occupied and funding arrangements.

Ashwood, Charlesworth and Sweetlake now shown as retained

The PCTs and the Community Trust need to finalise the Corporate SLA’s which will require the Lead Directors from the relevant organisations to agree service specifications, risk sharing, etc. A current list of SLAs required is provided at appendix 1 with indicative financial values (noting estates issues above including WFH). Work to agree the baseline position is continuing with further meetings scheduled to take place between the Director of Finance for the Community Trust, and the respective Chief Finance Officers for both PCTs as necessary. Good progress has already been made in many areas but further work is required to resolve the remaining outstanding issues. The lack of finalisation of these issues is a result of the complexity of the areas under discussion and all parties are actively working to conclude these matters. Work to develop a revised Price and Activity Matrix (PAM) is underway and an initial meeting on the 3rd November, has agreed principles (see attached Appendix 3) and discussions on the corrections of services and activity to be agreed between the Shropshire Community Health NHS Trust the two main PCT commissioners and will require identification of areas of work to be completed first, e.g. Corporate SLAs, etc. to allow the quantum to be agreed. In addition a number of connected financial issues also require risk sharing agreements between the PCTs and Community Trust and these include:

Establishment control

The Due Diligence and Corporate Services Review – Review of Corporate Budgets report completed in May 2011 by RSM Tenon highlighted that the financial position of the provider arm of NHS Telford & Wrekin was an underlying deficit of £494,000. Non pay expenditure was significantly higher than budgeted across a number of areas offset by a large number of vacancies. This report therefore highlighted the need to address the issue of establishment since, if all vacancies were recruited to, the former provider arm would move into a deficit position (overspend). The report recommended that the Trust perform a detailed review of the pay establishment to identify which posts could be removed whilst maintaining safe clinical operating practice, with the aim of addressing the underlying deficit. The Community Trust has undertaken this work and removed approximately £490,000 vacancies and put

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establishment controls in place. It should be noted that the removal of these vacancies reduced the Community Trust’s scope for identifying efficiencies in order to deliver the required level of savings.

Wheel Chair Service, Rheumatology, Equipment Store, Genito-Urinary Medicine (GUM)

Funding for the: Wheelchair Service, Rheumatology Service and the Community Equipment Service are still under review; this work is linked to agreement of the overall financial quantum (item 2 above) and development of the revised PAM. In addition a risk sharing proposal is being developed in respect of the financial impact of Welsh authorities not paying for their usage of these services. This work will be concluded in line with agreement of the overall financial position which is expected to take place during November. GUM - the historical saving target which formed part of the inherited position from a change in funding arrangement with no transformation in the service £260,426.

Occupational Health

As highlighted in the Due Diligence and Corporate Services Review ‘NHS Telford’ “that the reduction in the value of the Occupational Health budget can be attributed to a recently quantified underlying deficit which has arisen through loss of income. The ledger has been adjusted to reflect this with the creation of a negative CRES budget to the value of £157,577” no CRES was initiated before transfer, since 1st July a re-costing and review exercise has been undertaken with regard to Occupational health services which has resulted in a requirement for all the commissioners of the service to identify additional funding and commissioners are currently considering options with regard to future of the services.

MIU. The current informal arrangement with SaTH is for received advice (usually via email) from the A&E Consultant, primarily at request of the Community Trust Clinical Lead for MIU. This may be regarding service developments and MIU protocols. A&E Consultants also provide individual patient advice to all the MIU staff (Whitchurch, Oswestry, Ludlow and Bridgnorth) via telephone in order to avoid inappropriate A&E transfers or to discuss appropriate transfers. This is all on an informal basis. GP cover is available at all the MIU’s. We have been recently advised via the Director of Commissioning at Shropshire County PCT, that SaTH have agreed to continue this consultant cover, and these arrangements will need to be formally recorded to clarify the clinical governance responsibilities of each party. 7. Service Level Agreements between the PCTs and Shropshire Community Health NHS Trust Prior to the establishment of the Community Trust both PCTs provided shared services to each other in order to maximise the expertise available to the health economy and minimise management and support costs. Both PCT Boards agreed to the continuation of shared service arrangements with the Community Trust. The hosting arrangements have been re-organised across three organisations depending upon which organisation is best placed to ‘host’ the service. See attached appendix 2.

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8. Medicines Management At the end of June, NHS Telford and Wrekin raised a concern that there was inadequate medicines management input to community services because of the historic apportionment of time of the two PCT Medicines Management Teams. Discussions commenced immediately with the Community Trust and the SHA to determine an approach for ensuring appropriate input for the new Trust. A Medicines Management Group, incorporating representatives from the two PCTs, SHA and Community trust agreed that the current situation was a major risk to both commissioners and the local provider. It was therefore agreed that the Community trust should recruit a Chief Pharmacist, who in turn would identify and recruit a Pharmacy team to meet local needs and ensure risks were mitigated. Further discussion with commissioners regarding the funding of the medicines management service will be undertaken once the Chief Pharmacist has scoped the Trust’s service requirements; an outline structure was discussed to allow a quantum of cost to be identified. The Community Trust has now appointed a Chief Pharmacist who is scoping the needs of the Trust and developing proposals for medicines management support to the Trust. The Community Trust has now appointed a Chief Pharmacist who will join the Trust at the end of January 2012. the post of deputy Chief Pharmacist is about to go out to advert. The PCTs have confirmed that current support to the Trust will be maintained at least until 31 March 2012. Arrangements from April 2012 will be subject to further discussion once the Chief Pharmacist has completed their review. 9. Emergency Planning This section describes the issues in resolving how the resource of the small and specialist emergency planning service, which prior to the establishment of the Community Trust served both PCTs, including both provider arms, should best be deployed in future. Department of Health Guidelines state that in each NHS organisation, the Chief Executive Officer will be responsible for ensuring that their organisation has a Major Incident Plan in place that will be built on the principles of risk assessment, co-operation with partners, emergency planning, communicating with the public and information sharing. The plan will link into the organisation's arrangements for ensuring business continuity. It is considered good practice for NHS organisations to designate an adequately resourced officer, usually referred to as the Emergency Planning Liaison Officer (EPLO), to support the executive in the discharge of their duties for emergency preparedness. The requirement for the new Community Trust to establish emergency planning resources was clearly indicated in a report to its director lead for emergency planning in October 2010, and in response a service level agreement (SLA) for the provision of the service from the team based in NHS Telford and Wrekin to the Community Trust has been developed through discussion between the team and the Trust. However, agreement still needs to be reached about the commensurate transfer of funding. NHS Telford and Wrekin potentially has a Grade 6 Emergency Planning Officer available and had suggested, subject to HR advice, that this individual could be transferred to the Trust to support emergency planning and business continuity management, but the Trust has signalled that it wishes to proceed with the formal SLA to ensure that they can continue to access a package of service including more senior-level support when necessary. This

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would be different from general advice provided to all local health bodies, and would be a specific SLA service to the Community Trust. Pragmatic advice and support is being provided to the Community Trust pro tem from the PCTs Head of Emergency Planning and his support officer, based at NHS Telford and Wrekin, and the SLA and funding transfer issues will be finalised. 10. Formal arrangement for Shropdoc running emergency incident room There has been an agreement that Shropdoc had always made available to NHS Telford and Wrekin the major incident facilities in exchange for Shropdoc basing its business continuity back up at Mercian House and on call message answering service for PCT Directors and senior managers free of charge. This was a high level agreement between the Managing Director of Shropdoc (Graham fell) and the then CEO of NHS Telford and Wrekin (Simon Conolly) who also funded the equipment based at Shropdoc totally £15k. NHS Telford and Wrekin has no ongoing requirement for an incident control room based at Shropdoc or a requirement to continue the property lease at Mercian House. The PCT is prepared to transfer the ownership of the major incident equipment assets to the Shropshire Community Health NHS Trust. It is suggested that the Shropshire Community Health NHS Trust negotiates with Shropdoc regarding continuing existing arrangements. 11. Inter-Trust arrangements/Differential Commissioning Concerns had been raised by the Community Trust that they had inherited custom and practice issues that raised unexpected funding requests from other NHS Trusts or highlighted marked differences in commissioning decisions between Telford and Wrekin and Shropshire County. It is accepted that commissioners could make differential commissioning decisions and, in the interests of transparency, the current position is stated for information only. Current Differential Commissioning Decisions:

Telford-only services commissioned by Telford and Wrekin PCT: Nurse Consultant; Admiral Nursing; Community Respiratory Nursing**; Community Rheumatology.

(**SCPCT do commission respiratory services but a slightly different model; also, see some Shropshire County patients in rheumatology on a cost-per-case basis.) Telford and Wrekin PCT commissioners pay for use of DAART services on a cost

per case basis. Shropshire-only services commissioned by SCPCT: falls, Virtual Ward, and

Community Matrons Within Children’s services the services are block contracts across the whole of the

county based on a 40% Telford and 60% Shropshire commissioners split. Additionally, there are services of the same name where the service delivery model and pathways differ to reflect localised commissioning or traditional practices. It has been agreed that these are not strictly legacy issues, but form part of the commissioning policies of both PCTs. Therefore the Managing Director of the PCTs will

13

ensure that custom and practice issues highlighted are discussed with relevant providers to agree a set of principles on changing custom and practice and recognition and clarification of any historical commissioning variations between the PCTs. 12. Recommendation

1) The Boards of NHS Telford and Wrekin and Shropshire County Primary Care Trust are recommended to note the position in respect of legacy issues handed over to Shropshire Community Health NHS Trust.

2) The Boards of NHS Telford and Wrekin and Shropshire County Primary Care Trust

are recommended to ensure that operational issues remaining outstanding are resolved within the timescales indicated.

3) The Boards of NHS Telford and Wrekin and Shropshire County Primary Care Trust

are recommended to take assurance that should any additional issues that arise subsequently, or known issues become more significant, each party will use best endeavours to resolve the matter through director discussions. In the event of dispute, the issues will be escalated to the Chief Executive of Shropshire Community Health NHS Trust and the Managing Director for Shropshire County PCT and NHS Telford and Wrekin or the Cluster CEO in the first instance, who will use all reasonable endeavours to resolve any such dispute/s. Failure to reach agreement within 28 days will result in escalation to Board level for resolution. If the dispute cannot be resolved at Board level, then any party may refer the matter to the Strategic Health Authority for resolution.

14

NHS Telford and Wrekin

Expected SLAs with Shropshire Community Health NHS Trust

Annual Value 2011‐12 Value

£ £

HR 41,750 31,313

Financial Services 60,519 45,389

Counter Fraud 31,801 23,851

DEL (workforce) 79,710 59,783

Occupational Health* 12,205 9,154

Occupational Health for GP's 15,840 11,880

Occupational Health for Dentists 14,490 10,868

IT/Informatics (excl Oracle software but includes Oracle suppt) 555,658 416,744

ETD 62,999 47,249

Research Governance 7,032 5,274

Library 22,615 16,961

904,619 678,466

Shropshire County PCT

Expected SLAs with Shropshire Community Health NHS Trust


£ £

HR (incl OD) 78,388 58,791

Financial Services (incl oracle suppt) 70,597 52,948

Counter Fraud 32,245 24,184

Risk Advice/Manual handling 47,880 35,910

Occupational Health* 6,284 4,713

Occupational Health for GP's 34,616 25,962

Occupational Health for Dentists 30,389 22,792

IT/Informatics (excl Oracle software & excl Oracle Suppt) 599,420 449,565

ETD 62,999 47,249

Research Governance 7,032 5,274

Library 25,160 18,870

995,010 746,258

APPENDIX 1

15

Shropshire Community Health NHS Trust

Expected SLAs with Shropshire County PCT


£ £

Medicines Management Support to the Community Hospitals 152,359 114,269 Medicines Management (linked to scoping exercise – see below) * *

Choose and Book (CaB) To be determined To be determined

152,359 114,269

Shropshire Community Health NHS Trust

Expected SLAs with NHS Telford & Wrekin


£ £

Emergency Preparedness To be determined To be determined

Medicines Management 25,000 25,000

‐ ‐

* The medicines management figures are not known yet as this will form part of the scoping exercise that will be undertaken by the Chief Pharmacist (see section 8 of the report). The annual value and the 2011-12 value are not alike for like comparison due to the change from two PCTs inter-trading to a different split across the two PCTs and the Community Trust. During discussion the values for IM&T have changed to include a Band 5 Information Governance post and the Oracle Support for upgrading from the current version Release 11 (which is no longer being supported nationally) to version Release 12 and to bring the hardware management in-house e.g. back-up systems which has been agreed by the five organisations using the system in Shropshire, were recognised.

16

Current Position Regarding Outstanding Issues

Outstanding Issue Actions Required Current Position Date Lead Director

Safeguarding

Ability to deliver key requirements/ standards of delivery

Following move of Designated Nurse to PCTs, scoping of Trust workforce capacity required

Way forward to be agreed with PCTs on risk sharing or additional investment

CT DoN&Q scoped work with input from Designated Nurse and SHA Children’s Lead. Identified residual gap is 0.2wte Band 8A.

Ongoing monitoring regarding safeguarding via the Clinical Quality Review meetings

October 2011

October 2011

completed

Completed

Risk Registers

Risk scores

PCT to provide risk scores for initial issues and risk rating with mitigation in place

DoN&Q to collaborate with PCT Quality Lead to ensure correct information in Legacy Document

7th November 11

Completed

APPENDIX 2

17

Adults with Learning Disabilities (ALD) service modernisation

PCT commissioned review by WMQRS commencing Oct.

Discussions between Service Delivery and NHST&W re best future service employment model (different models between the PCTs)

PCTs awaiting outcome of WMQRS review

Ongoing

March 2012 PCTs

(Director of Integrated Care)

Community Trust

(Director of Service Delivery)

and

NHSTW

(Director of Integrated Care)

MIU clinician cover and supervision, WMQRS review

Business case being updated for consideration by PCTs

Work in progress by Community Trust

31st December 2011

Community Trust (Director of Service Delivery)

Datix System

Backlog of NHST&W entries

NHST&W to complete check of provider entries relating to period before 1.7.11 and identify any backlog

Approximately 10 datix incidents remaining open for HA T&W

14th December 2011

NHSTW

(Medical Director)

Other Datix records

Both PCTs to confirm way forward – continuation with Datix suggested

Meeting has taken place between PCTs and Community Trust where issues and options discussed.

31st December 2011

PCTs

(Head of Governance)

18

PCTs to consider options for continuing with Datix or pursue other solution for PALs, Complaints, non clinical incidents and Health and Safety incidents.

Community Trust

(Director of Governance & Strategy)

Financial Risk

Financial risk sharing

Agree quantum, outstanding contract variances, cost and volume contracts, age debtors

Quantum to be agreed once outstanding SLAs have been finalised. Outstanding aged debtor and creditor issues are to be shared with PCTs w/c 24 October.

Data received by commissioners and response sent back to provider 16th November 2011

See relevant SLAs above/below

Assets

Ludlow land SHA views to be sought on whether land passes to the Trust or written agreement that will transfer at appropriate time

The PCT and SHA have agreed to make this an exceptional item for the DoH return. The SHA have subsequently sent the data to DH and are now awaiting a response.

Response from DH not anticipated before 31st December 2011

Community Trust

(Director of Finance)

and

SCPCT (Chief Finance Officer)

William Farr House HQ Relook at split and areas to be occupied by all parties on site

Initial correspondence between SCPCT/CCG and Trust during Sept/Oct to agree percentage occupancy. Initial meetings commenced

By 25th December 2011

Community Trust (Director of Finance)

and

19

and Shropshire Clinical Commissioning Group also considering an off-site option.

SCPCT (Managing Director/CCG COO)

Revenue Budgets

Budgets initially transferred need correcting and modifying

SLAs needed for hosted services

Value of Occupational Health budget attributed to underlying deficit in NHST&W through loss of income. Ledger adjusted with creation of negative CRES of £157,577, but no CRES initiated before transfer.

Clarify former NHST&W provider budgets

See SLAs below

Service Delivery Managers working with Finance to correct budgets

End Dec 2011

See below

PCTs (Chief Finance Officers)

and

Community Trust

(Director of Nursing & Quality)

Community Trust

(Director of Service Delivery / Director of Finance)

Price Activity Matrices

Calculation for revised PAMs

Identification of correct services and activity levels and baseline position

Commissioning and Provider representatives have met and agreed principles around rebasing.

Actioned - 3rd November 2011

Community Trust

(Director of Service Delivery / Director of Finance)

20

Agree baseline position with PCTs

Services to be identified and included in PAM

Service Delivery Managers working with Finance on outstanding information to ensure costs are correctly allocated to services, provide outstanding information.

Further discussions to clarify how the PAM is to develop to include costs will then be necessary within Finance.

PAMs will be rebased for commissioner sign-off

Early December 2011

End Nov 2011

See below

February 2012

Director of Service Delivery and Directors of Commissioning

Community Trust

and

PCTs (Chief Finance Officers and Commissioning Directors)

Occupational Health

Disparity on funding transferred from previous host NHST&W

Work to agree the baseline position is continuing with further meetings scheduled to take place between Stuart Rees, Laura Boden and Donna McGrath as necessary. Progress has already been made in many

30th November 2011


and

Community Trust

(Director of Finance / Director of Nursing &

21

areas but further work is required to resolve the remaining outstanding issues with the final quantum to be agreed once the outstanding issues are resolved and then the work to finalise the PAM can commence.

Quality)

Cost pressures for staff costs following loss of contracts

No statement of supporting redundancy in event of loss of income within previous contracts.

Scoping impact to the Trust of the loss of the most recent contract. It has been built into the financial modelling by Director of Finance. Reviewed position for all other contracts and risk – data analysed. Redundancy paragraph included in future SLAs.

28th October 2011

Completed

CIP and Underlying Financial Position

Outstanding issues following outcome of Due Diligence by RSM Tenon

Further discussions with RSM Tenon As legacy document

Various

Community Trust

Director of Finance

PCTs

Chief Finance Officers

Community Trust CEO and PCTs MD

Aged debtors Trust to provide further evidence of remaining issues and share with PCTs and agree write-offs, after which time any further liability will sit with the Trust

Trust finance to complete work and share with PCTs for agreement.

Data received by PCTs and responded to on 16th

Community Trust


22

To be shared with PCT

November 2011

22nd November 2011

and

PCTs (Chief Finance officers)

Commissioning Arrangements

Wheelchair, Continence Supply and Community Equipment Services

Funding under review, linked to agreement of overall quantum, contract currency and revised PAM

Further discussions between the Community Trust and PCTs and various other commissioners

End Feb 2012 Community Trust

(Director of Finance / Director of Service Delivery)

and

PCTs and various other commissioners (Finance / Commissioning Leads)

Minor Injuries Units – funding of consultant input from SaTH

Costs currently in SaTH contract value. Commissioners to take up matter with SaTH through next contract negotiations for 2012/13.

Commissioners to progress during contract negotiations for 2012/13

SCPCT

(Commissioning Lead)

Oswestry Primary Care Centre

Commissioners requested to support stepped cost increase to RJAH as result of the need for increased establishment in radiology to support move of MIU to the PCC. Trust needs to identify financial impact regarding MIU diagnostics.

Joint work required to model income generated via MIU tariff related to diagnostics and income that can be redirected for GP direct access. If the modelling work demonstrates a gap

31st December 2011

SCPCT

(Director of Commissioning)

and

Community Trust

23

commissioners would risk share the balance to support on a non recurrent basis until service fully developed.

(Director of Service Delivery)

SLAs (from Trust to PCTs)

IM&T

Trust to agree service specification and costs and SLA with PCTs

An initial SLA has been shared with SCPCT and NHS Telford & Wrekin in respect of the IM&T Shared Service. Financial values were not included within this document, pending agreement of the overall quantum but this information should be available late October to allow negotiations to conclude and formal sign-off of the SLA. With the CCG also looking to make some changes to the service specification in negotiations with the PCT.

22 November 2011


and

Community Trust


OD & Workforce Trust to agree service specification and costs and SLA with PCTs

Specification written, non pay alterations currently underway with manager supported by trust finance and the apportionment over the relevant organisations currently being proposed supported by trust finance.

22nd November 2011

Community Trust


and

PCTs

(Chief Finance Officers)

Fraud, Financial Accounts and Oracle


Initial SLAs have been drafted for Fraud, Financial

22 November 2011

Community Trust

(Director of

24

Accounting and the Oracle System Team and will be shared for agreement following the finalisation of the financial values to be included. To include the new updated requirement for the Health Economy.

Finance)

and

PCTs

(Chief Finance officers)

Occupational Health Trust to agree service specification and costs and SLA with PCTs

Specification developed for PCTs and alterations currently underway with manager supported by finance following the loss of tender and TUPE transfer of staff and resulting loss of income and restructuring of area and the apportionment over the relevant organisations currently be proposed supported by trust finance

22nd November 2011

Community Trust

(Director of Nursing & Quality/Director of Finance)

and

PCTs

(Chief Finance Officers)

Library Services Trust to agree service specification and costs and SLA with PCTs

Specification written for PCTs – indicative budgets already known from previous years and being developed for Ambulance service and Hospice.

Agreed funding available via PCTs waiting to transfer budget form SCPCT. Clarity regarding NHST&E required.

22nd November 2011

Community Trust


and

PCTs

(Director of Public Health for SCPCT) (Chief Finance Officer for NHST&W)

25

Freedom of Information Requests


Specification developed and costed for SCPCT, but the PCT has now indicated it does not require service.

This was confirmed on 21.10.11, with SCPCT acknowledging intention to pay for work completed by Trust in year to date. Trust issuing invoice w/c 24.10.11.

Trust to issue invoice to SCPCT by end of November 2011

Community Trust (Director of Governance & Strategy)

SLAs (from PCTs to Trust)

Emergency Planning Service

PCT to agree service specification and costs and SLA with Trust

Service specification to be agreed that includes more senior level support when necessary.

31st December 2011

PCTs Managing Director

Community Trust Director of Governance & Strategy

Medicines Management PCT to agree service specification and costs and SLA with PCTs

Issue of notional funding from PCTs (£660k which will be split between both PCTs)

PCTs have each provided a letter of intent to continue service to the end of current financial year and these are attached in appendix 4.

PCT to resolve funding to SaTH to support community clinics.

22nd November 2011 – completed for PCTs

Outstanding issue to be resolved in

PCTs

(Directors of Commissioning)

and

Community Trust

(Director of Service

26

PCT to continue funding this year through existing SLA between themselves and SaTH for E Script and Technician support on the community hospital wards for the Community Trust. PCT to transfer budget to the community Trust from 1st April 2012.

Community Trust to resolve funding to SaTH for on costs relating to the supply of drugs for sexual health service (~£35k)

SLAs to then be finalised with input from new Chief Pharmacist (in accordance with Medicines Management Group agreement)

December 2011

New SLA to be developed between SaTH and Community Trust by 1st April 2012

Completion by March 2012

Delivery)

Research Governance

PCT to agree service specification and costs and SLA with PCTs

NHST&W proposed SLA being reviewed by Trust. And agreed.

Shropshire requirements to be identified by Anthony Rathbone who has identified

28th October 2011

22nd November 2011

Completed

SCPCT Medical Director

SCPCT (Anthony

27

the funding to be transferred but still requires understanding of who is holding the budget.

Rathbone)

Choose and Book (CaB)

PCT to agree service specification and costs and SLA with Trust

Proposed SLA being reviewed by the Trust and agreed

22nd November 2011

PCTs

(Directors of Commissioning and Chief Finance Officer)

Community Trust

(Director of Service Delivery and Director of Finance)

28

APPENDIX 3 PAM Principles

Allowing for longer-term planning for improvements, service changes and investment/disinvestment with no service being destabilised in the short-term from that which transferred

Shifting focus away from commissioning WTE, etc. to commissioning of services Shifting focus away from cost more towards other aspects of performance such as outcomes and quality Methods for dealing with uncertainty relating to the outcomes of the PAM Methods for sharing risk (including between PCTs/CCGs) with non-discrimination – the trust will not discriminate between commissioners in

apportionments….recognising the new commissioning landscape (Local Authority; CCGs, etc.) in-year contract and next year implications Service specifications differences. Service specifications should be driven by the needs of the population recognising the differences between the

populations of Shropshire County and Telford & Wrekin and commissioners differential requirements Historical transactions will be superseded by re-setting the PAM baseline Honest, open and transparency relationship from all parties where possible and appropriate.

29

APPENDIX 4 Attached letters of intent from the PCTs for Medicines Management

Medicines Management Team William Farr House Mytton Oak Road

Shrewsbury SY3 8XL

Tel: 01743 277557 Fax: 01743 277558

Our Ref: 111026/letrs/tc/commtrust Date: 26th October 2011 Richard Carroll Shropshire Community Health NHS Trust Somerby Suite William Farr House Mytton Oak Road Shrewsbury SY3 8XL Dear Richard, Re Provision of Medicines Management Services to the Community Health Trust

I would like to confirm that we will continue to offer the same level of service to the Community Health Trust as has been provided in the past under the Service Level Agreement that was drawn up for the PCT Provider Arm, until the end of this financial year. As Rita will only be starting part way through January 2012 we will need to have an early indication from her about the level of future service provision required. Kind regards.

Trish Campbell Head of Medicines Management for Commissioning and Service developments Copy: Dr Julie Davies, Acting Director of Commissioning SCPCT

Halesfield 6

TelfordShropshire

TF7 4BF

Tel: Direct Line:

01952-58030001952-580434

24 October 2011 Richard Carroll Shropshire Community Health NHS Trust William Farr House Mytton Oak Road Shrewsbury SY3 8XL Dear Richard,

Medicines Management Services Thank you for asking me to comment on the draft SLA, unfortunately though, I am writing to inform you that I will not be able to sign the approved SLA. The PCT’s Medicines Management Team simply does not have the capacity to meet your requirements. As you know, I have been concerned about the absence of dedicated Medicines Management support to provider services for a number of years and this has featured on the PCT’s risk register for some time. I am therefore delighted that funding has now been approved to allow the Community Trust to recruit a Chief Pharmacist and a Deputy. I can assure you that I will continue to provide the current level of Medicines Management support to the Community Trust until the end of the current financial year. Much of the support that we provide ensures that your staff are aware of the work that we are doing within general practice and I have no intention of removing or even reducing the current level of communication – this will continue beyond the current financial year. I hope this is helpful! If you have any questions, please do not hesitate to contact me. Yours sincerely

Jacqui Seaton Head of Medicines Management & Controlled Drugs Accountable Officer

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