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Agenda – Wirral Clinical Commissioning Group – PUBLIC MEETING - 3rd October 2017 of 2

GOVERNING BODY MEETING – A meeting in public

Tuesday 3rd October 2017 Nightingale Room, Old Market House

1.00pm – 2.30pm

AGENDA

Ref No. No Time Item Action Papers GB17-18/0036

1. 1.00pm PRELIMINARY BUSINESS (Chair)

1.1 Apologies for Absence

1.2 Chair’s Announcements To Note

1.3 Declarations of Interest

1.4 Welcome and Comments/questions from members of the public (10 mins)

1.5

Minutes and Action Points of Last Meeting

Minutes 5th September

Action Points

To Approve

2. DRAFT WCCG Governing Body PUBL

3. Governing Body Action Log .pdf

1.6 Matters Arising

GB17-18/0037

2. 1.20pm BUSINESS ITEMS

2.1 Chief Officer’s Report (Simon Banks)

4. Chief Officer Report October 2017.

2.2 Chief Financial Officer Report (Michael Treharne)

Quality Innovation Productivity Performance (QIPP) Update

Finance Update Financial Recovery Plan

To Discuss

5. GB cover sheet for M5 report.docx

5a. Wirral CCG GB Finance Report 17-18

5b. Appendix 1 GB - Board Report Extract.x

5c. Appendix 2 - WUTH M5 Summary.x

2.3 Board Assurance Framework (Paul Edwards)

To Discuss

6. BAF cover sheet.docx

6a. AF October Governing Body narra

Agenda – Wirral Clinical Commissioning Group – PUBLIC MEETING - 3rd October 2017 of 2

Ref No. No Time Item Action Papers

6b. Wirral CCG Assurance Framework

2.4 Winter Planning (Nesta Hawker)

To Discuss

7. Winter Plan cover sheet.docx

7a. Wirral Winter Plan 30 08 17 v14 - Final.do

GB17-18/0038

3. 2.20pm ANY OTHER BUSINESS

4. End DATE AND TIME OF NEXT MEETING

Tuesday 7th November 2017 Nightingale Room, Old Market House

Minutes of the Wirral Governing Body meeting PUBLIC Session 5th September 2017 Page 1 of 9

WIRRAL CLINICAL COMMISSIONING GROUP Governing Body Meeting

Minutes of Meeting – Public Session

Tuesday 5th September 2017 1pm

Nightingale Room, Old Market House Present: Simon Banks (SB) Chief Officer Mike Treharne (MT) Chief Financial Officer Paul Edwards (PE) Director of Corporate Affairs Nesta Hawker (NT) Director of Commissioning Alan Whittle (AW) Lay Member (Audit & Governance) Sylvia Cheater (SC) Lay Member (Patient Champion) Linda Roberts (LR) Lay Member Dr Paula Cowan (PC) (Chair) Medical Director Dr Sian Stokes (SS) GP Lead – Long Term Conditions Dr Helen Downs (HD) GP Lead – Unplanned Care Dr Simon Delaney (SD) GP Lead – Primary Care Graham Hodkinson (GH) Director of Health and Care Dr Richard Sturgess (RS) Secondary Care Doctor In Attendance: Grace Price – Jones (GPJ) Senior Corporate Officer

Ref No.

Minute Action

GB17-18/0027

Preliminary Business 1.1 Apologies for absence: Apologies were received from Dr Sue Wells, Lorna Quigley, Dr Laxman Ariaraj, Julie Webster, Lesley Doherty and Dr James Sowery.

1.2 Chairs Announcements/Opening Remarks Chair welcomed all attendees to the meeting and announced the start of Grace Price – Jones as Senior Corporate Officer. 1.3 Declarations of Interest Chair reminded the Governing Body members of their obligations to declare any interest they may have on any issues arising at committee meetings, which might conflict with the business of NHS Wirral Clinical Commissioning Group. Declarations declared by members of the Governing Body are listed in the CCGs Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link:

GB Agenda Pack - of 70


Ref No.

Minute Action

https://www.wirralccg.nhs.uk/about-us/whos-who/registers-of-interest/ There were no declarations of interest highlighted by the Governing Body members. 1.4 Comments/questions from members of the public The Chair welcomed the five members of the public that were in attendance at the meeting. The Governing Body was addressed in regards to the service changes being made at Eastham Clinic with regards the to the Walk-in Centre facility. A statement was given to the Governing Body with a request that the decision to temporarily close the Walk-in Centre to be reconsidered. The Chair advised that further information in regards to the decision made and the reasoning behind the decision will be addressed in the Chief Officer’s Update. The Governing Body were addressed by another member of the public who highlighted the positive aspects of a ‘Champions’ scheme run at a local acute hospital.. The Champions work with patients in addressing concerns and queries and acting as a liaison with the patients and other members of the general public. The idea was commended to the Governing Body as something that could be adopted on Wirral. The public attendees were thanked for their input and attendance at the meeting. 1.5 Minutes & Action Points from previous meeting held on the 4th July 2017 Minutes The minutes of the previous meeting held on 4th July 2017 were agreed as a true and accurate record notwithstanding grammatical/typographical errors, which will be rectified, with the following exceptions: Amendments to the attendees of the meeting required. Action Points Members reviewed the outstanding actions recorded on the action log and noted the updates provided on the progress to date. AP 15 – The application of reserves is included within the Finance Report. It was agreed that this action point can be closed. ACTION: AP 15 to be closed on the action log. AP 18 & 19 – GPJ advised the members that Fiona Johnstone had provided the following update to the action “Julie Webster and Rachel Musgrove met with PC and as a result they will be attending the Clinical Senate meeting to discuss the variation screening rates. The need to address inequalities will be identified as part of this work”.

GPJ



Ref No.

Minute Action

ACTION: AP 18 &19 to be closed on the action log. All remaining action points were reviewed. 1.6 Matters Arising There were no matters arising. 1.7 Patient Story A short video recording was displayed to the Governing Body promoting the idea of ‘Choosing Well’ so as to ensure patients use the most appropriate services. Members noted the patient story presented today. 1.8 Chief Officer’s Update SB addressed the concerns raised in regards to the service changes made at Eastham Clinic. He acknowledged the concern and the strength of feeling following the changes made at the Walk-in Centre, whereby staff had been moved to the Arrowe Park site to support the pressures facing A&E on the grounds of patient safety. The decision to temporarily suspend the Walk-in Centre at Eastham was made following a meeting held with NHS England (NHSE), NHS Improvement (NHSI), and members of the West Cheshire and Wirral A&E Delivery Board on the 13th July 2017 in which the performance of the Wirral Urgent Care system was scrutinised following its performance deterioration for some months. As a result of this, the partners across the system agreed immediate actions that needed to take place to turnaround the urgent care performance and to expedite the introduction of clinical streaming. On the 10th August the CCG, Wirral Council, WUTH, Wirral Community NHS Foundation Trust (WCT) met with NHSE and NHSI with the proposed improvement plan and it was agreed that the actions outlined required implementing by September. The decision made by the leaders in Wirral to temporarily suspend the Walk-in Centre from Eastham was not made lightly. The changes had to take place quickly, as patient safety was paramount. SB acknowledged the fact that residents of Eastham will concerned about changes made, but the CCG could not allow the poor performance at A&E to continue. It was reiterated that this change is temporary and patients can still attend for planned care such as blood tests and dressings. From November 2017, a full consultation will be taking place in regards to Urgent Care. This consultation was due to take place earlier this year but, due to the general election taking place, public sector organisations are not able to engage or consult on potential service changes. Unfortunately, when the changes were made to the Eastham Clinic, Mersey Travel had made changes to their bus routes within that area. Further to this, in future, consideration will be made to include other agencies such as public transport in service changes.

GPJ



Ref No.

Minute Action

SB gave the Governing Body an update on the activity of the Cheshire and Merseyside Women’s and Children’s Service Partnership. There is a lot of work going on improving choice across Wirral and the requirement of care plans to promote the National Maternity Review. The Governing Body were informed that Andrew Gibson, Chair of Cheshire and Merseyside Five Year Forward View/STP chaired a workshop in Liverpool and re-enforced that Cheshire and Merseyside footprint is going to remain and that will focus in holding local systems to account as the ‘system manager’. On the 13th July 2017 NHS Wirral CCG received the confirmation of the outcomes of the annual Improvement and Assessment Framework for 2016/17. This included a summary of any areas of strength and where improvement was required. The final headline rating for 2016/17 for NHS Wirral CCG was ‘requires improvement’ and the CCG has a recovery plan in which is regularly reported and reviewed at Governing Body. The Governing Body noted the Chief Officer’s.

GB17-18/0028

2.1 Risk Management Risk Register The Governing Body members reviewed the risks on the register. PE appraised the Governing Body of the main risks recently reviewed at the Quality and Performance (QP) Committee and advised of the recommendations to Governing Body: 17-18B – With regard to the SEND inspection, the Governing Body were informed that the proposed likelihood risk agreed by the QP Committee was 4 (likely) and that the consequence was agreed as a 3 (moderate). This was based on the fact that there were likely to be recommendations from the inspection, but their impact was likely to be less significant to the CCG than other partners. 17-18C – With regard to the Dynamic Purchasing System, the Governing Body were informed that the proposed likelihood of the risk agreed by the QP Committee was a 4 (likely) and the consequence agreed as a 4 (major). This was because the system is a key tool in sourcing packages of care and could have an impact on choice, reputation and providers. The members were advised that a presentation on the Dynamic Purchasing System is being given at the Overview and Scrutiny Committee. The risk ratings were agreed by the Governing Body members. There was a lengthy conversation in regards to 14-15G, which focuses on the A&E performance. Given that the Wirral system has been required to change the service provided at Eastham due to patient safety in the A&E department, some members supported raising the likelihood rating to 5. This was based on the assumption that poor



Ref No.

Minute Action

performance against this target would be likely to affect patient safety. AW pointed out that LQ had undertaken a visit to WUTH A&E department and was assured that patients had not come to harm. Members suggested, however, that the score should be raised to 5 until LQ could undertake a follow up visit to provide additional assurance around patient safety. SB suggested that a letter to the Chair of the A&E Delivery Governing Body be written to seek further assurance around patient safety. ACTION: LQ to arrange a patient safety assurance visit to WUTH A&E department. ACTION: SB to write to the Chair of the A&E Delivery Governing Body around the CCG’s concerns regarding patient safety.

LQ SB

GB17-18/0029

3.0 Chief Financial Officer’s Report Finance Report MT highlighted to the Governing Body the main headlines in the Finance report, at Month 4.

For month 4, the CCG is reporting a deficit of £1,272m. NHS Contracts are overspent by £780k. Non NHS contracts have underperformed by £551k. The position at the end of July is £68k overspent based on the May prescribing

data. For 2017/18, the original Quality Innovation Productivity Prevention (QIPP) plan

was set at £12.275m, at the end of July there was an underachievement of £2.4m, this has been reported to NHSE.

The Governing Body was advised that there are meetings being arranged to gain clarity of mitigation and actions with budget holders and QIPP scheme owners. Members of the Governing Body welcomed the extra detail provided within the report. The Governing Body was reminded that the key risks to the CCG in 2017/18 are achievement of a substantial recurrent QIPP programme of £12.275m and ensuring operational/contract expenditure is managed in line with the financial plan set. The Governing Body noted the WUTH summary position for July 2017. The members were drawn to the Non Elective Non-Emergency variance of £71k and it was advised that this may be a “coding and counting” issue. It was agreed that activity from this will be included within the next contract meeting, as it was noted that GP referrals are reducing but activity is rising. It was highlighted that the Procedures of Low Clinical Priority figure of £163k has been identified but has not yet been delivered. Cyber Security The Governing Body were asked to note the ‘Wannacry’ Cyber attack report. Two systems were identified as using Microsoft XP (which was vulnerable); Patient Partner



Ref No.

Minute Action

Telephone Appointment System and Patient Arrival Screens. Further to this, the CCG authorised the upgrade of the Windows operating system within practices. No further comments were made by the Governing Body members. Finance Committee Chair’s Report The Governing Body members noted the report submitted. There were no further comments.

GB17-18/0021

4.0 Performance and Commissioning 4.1 Director of Commissioning Report The Governing Body members noted the report submitted and were advised that the recovery schemes for 2017/18 are discussed in detail at the Financial Recovery Group meetings. An update was given on the identified/planned savings to date. The Learning Disability Review of Funding remains in development, however, this is moving forward at pace and work is being undertaken by the CCG and the Local Authority. Members were advised that on the 19th September 2017, the CCG will be hosting a Stakeholder QIPP Summit, to bring together partners to develop our QIPP ambitions for 2018/19. The members reviewed the performance dashboard, demonstrating the exceptions in performance against the NHS constitutional standards, including a trend analysis from April 2016 to June 2017. The Referral to Treatment (RTT) 18 weeks wait for incomplete pathway was not met in June, but with performance improving to 84.5% from 83.9% in May. The CCG has not met the standard of 92% since December 2015. The underperformance at WUTH is a significant contributing factor to the CCG’s position. WUTH have an agreed STF Trajectory with NHSI, which has been met consistently for the past three months. The underlying cause of RTT failure at WUTH is attributed to poor data within their Patient Administration System, resulting in an unmanaged list of 280,000 open pathways. Considerable work has been undertaken to cleanse this data, with all reviews of pathways exceeding 18 weeks now being concluded. The CCG are working closely with WUTH, NHS England, NHS Improvement and Intensive Support Team to recover the position. Improving Access to Psychological Services (IAPT) Investment Proposal NH presented the proposal for additional investment to Governing Body. The further investment is to clear the existing waiting listing within the IAPT service provider Inclusion Matters Wirral. This is supported by the implementation of interim pathways as recommended by the Intensive Support Team which visited the service in May.



Ref No.

Minute Action

It was queried where the extra funding would come from, and it was clarified that this in national funding that is ring fenced for Mental Health Services. The proposal was approved by the Governing Body 4.2 Alcohol and Tobacco Strategies Gary Rickwood (GR), Senior Public Health Manager and Rebecca Mellor (RM), Public Health Manager, attended the Governing Body to present the strategies developed by Public Health. The CCG were asked to sign up to the priorities within the strategies which are believed will make a significant impact to patients of Wirral. GR pointed out that Wirral currently ranks as number fifteen nationally for alcohol related admissions. The Alcohol Strategy aims to raise awareness and change behaviours regarding alcohol consumption. With regard to the Tobacco Strategy, members were appraised that one in ten women on Wirral smoke while pregnant. The strategy helps target this issue and wider tobacco usage. The Governing Body agreed with the strategies presented and were supportive of their implementation.

GB17-18/0031

5.1 Director of Quality & Patient Safety The Governing Body noted the report submitted within the meeting pack. There were no further comments. Quality and Performance Committee Chair’s Report The Governing Body noted the report submitted within the meeting pack. There were no further comments.

GB17-18/0032

6.1 Director of Corporate Affairs PE advised the Governing Body that as part of the Organisational Development plan, access has been provided to a Coaching programme to provide support to members of staff who wish to develop within the organisation. There is also a Mentoring Scheme in place and members of staff are also offered the opportunity to become Mentors themselves. The Governing Body were informed that the CCG has a number of Apprentices coming to work within the CCG and is supporting Internship programme for young people with learning disabilities. The CCG is also hosting a Graduate Officer jointly with the Local Authority. PE also reported that the CCG is above the compliance rate for Statutory and Mandatory Training. Emergency Planning, Response and Resilience (EPRR) – Compliance Assessment PE talked through the self-assessment for the annual EPRR Core Standards submission process, describing how the CCG complies with core standards as a Category 2



Ref No.

Minute Action

responder. Governing Body supported the overall rating as ‘green’, with an outstanding action being to test the recently updated Business Continuity plan. Finance Committee Terms of Reference The Governing Body were advised that, following the deterioration of the CCG’s financial position is 2016/17, the Governing Body agreed to support the formation of a Finance Committee to increase scrutiny and strengthen governance. To strengthen the grip of QIPP delivery and financial recovery, a Turnaround Group was also established. PE stated that it had become apparent that both Committees are increasingly overlapping. As a result, this paper proposed that the Turnaround Group remit was incorporated into the Finance Committee, as reflected in the amended Terms of Reference presented. Members supported the revised Terms of Reference for the Finance Committee and agreed to cease the Turnaround Group meeting.

GB17-18/0033

7.1 Medical Director’s Report The Governing Body members were updated with regards to the activities that the clinical team. PC advised that the work being undertaken on the Wirral Care Record and this will be presented at a future Protected Learning Time Event. No further comments were made by the Governing Body. 7.2 Clinical Senate Chair’s Report The report was reviewed by the Governing Body members. No further comments were made.

GB17-18/0034

9.1 Committee Meeting Minutes The minutes submitted were noted by the Governing Body members. No further comments were made.

GB17-18/0035

Any Other Business & Communications from this Meeting No further business was discussed by the Governing Body. Communications from this meeting:

The service changes being made to the Eastham Walk in Centre The current Financial position and the plans in place The proposal for additional funding for the IAPT service was approved. The Governing Body agreed the Public Health Strategies. The Finance Committee terms of reference were agreed.

Meeting closed at 15.15pm



Ref No.

Minute Action

Date and Time of Next Public Meeting

Date and time of next meeting: Tuesday 7th November 2017 1pm – 4pm Nightingale Room, OMH Please forward any apologies to [email protected]


Item NoDate

Opened

Agenda

Item NoRef no

Item of

discussion

Action PointsResponsibility Date Due Status Status and progress (including updates)

Closure

dateOutcome of action

Requires

review?

Date of

review

10 02.05.17 6.1 GB17-18/0010

Integration

between Wirral

CCG and and

Wirral Council

ACTION:

Financial Due Diligence report to be submitted to

the Governing Body Board within Quarter 3. MT Nov-17 open 23.08.17: Independent review has been commissioned.

11 02.05.17 6.1 GB17-18/0010

Integration

between Wirral

CCG and and

Wirral Council

ACTION:

Vehicles to support integration to be submitted

to Governing Body Board. PE Nov-17 open 23.08.17: review underway.

12 02.05.17 6.1 GB17-18/0010

Integration

between Wirral

CCG and and

Wirral Council

ACTION:

Draft Terms of Reference for Shadow Strategic

Commissioning BoardPE Nov-17 open 23.08.17: review of best practice is underway

14 06.06.17 3.1 GB17-18/0016

Performance and

Commissioning/Pri

mary Care

Transformation

ACTION:

Develop a plan to report the Operational Plan

progressionof delivery to the Governing BodyNH Nov-17 open 23.08.17: plan to be presented at the November Governing Body Board.

16 04.07.17 4.1 GB17-18/0021 Cancer Strategy

ACTION:

implementation plan to be submitted to the

Governing Body Board Quarter 3NH Dec-17 open


ACTION:

focus group to be developed to address

inequalities within the strategy and the best

forms of engagement.

FJ Sep-17 closed

25.08.17: update received from FJ to advise, Julie Webster and Rachael Musgrave have met with

Paula Cowan, and as a result will be attending the Clinical Senate in October to discuss variation in

screening rates. The need to address inequalities as identified in the Cancer Strategy will be picked

up as part of that work.

25.08.17 not applicable No N/A


ACTION:

SW requested clinical support in the

development on the focus group. LA Sep-17 closed

23.08.17: await update from FJ (as above).

25.08.17: please see action item 18. 25.08.17 not applicable No N/A

22 05.09.17 2.1 GB17-18/0029 Risk Register

ACTION:

LQ to arrange a patient safety assurance visit to

WUTH A&E department. LQ Nov-17 open 21.09.17: LQ to undertake visit and provide report to November Governing Body.

23 05.09.17 2.1 GB17-18/0029 Risk Register ACTION: SB to write to the Chair of the A&E Delivery Board

around the CCGs concerns regarding patient safety.

SB Oct-17 open

21.09.17: update from action requested from SB.

21.09.17: Update received from SB to advise that this became a conversation with the Chair of the

A&E Delivery Board. Winter Plan/A&E Delivery Plan demonstrates how patient safety concerns will be

addressed through system reform.

GOVERNING BODY BOARD - MEETINGS ACTION LOG

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CHIEF OFFICER’S REPORT

Agenda Item: 2.1 Reference GB16-17/GB0037

Public / Private Public Meeting Date 3rd October 2017

Lead Officer/Author of paper

Simon Banks, Chief Officer

Contributors

For Decision

For Information Yes

For Discussion

Executive Summary This report sets out some key areas of work, in addition to their usual duties, for the Chief Officer since the last Governing Body meeting. The report covers the period from 6th September 2017 to 3rd October 2017.

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

Risk Please indicate Detail of Risk Description

High Medium Low Yes

No significant risks or identified in this report

Clinical engagement taken place Y

Patient and public involvement taken place N/A

Equality Analysis/Impact Assessment completed N/A

Quality Impact Assessment N/A


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Strategic Themes

To empower the people of Wirral to improve their physical, mental health and general well being Y

To reduce health inequalities across the Wirral Y

To adopt a health and well-being approach in the way services are both commissioned and provided Y

To commission and contract for services that:

Demonstrate improved person centred outcomes Are high quality and seamless for the patient Are safe and sustainable Are evidenced based Demonstrate value for money

Y

To be known as one of the leading Clinical Commissioning Groups in the country Y

Provide systems leadership in shaping the Wirral health and social care system so as to be fit for purpose both now and in five years time

Y

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

Governance route prior to Governing Body

Meeting Date Objective/Outcome

CCG Governing Body

Quality and Performance Committee

Finance Committee

Audit Committee

Remuneration Committee

Health and Wellbeing Board

Clinical Senate

Quality & Improvement Group


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CHIEF OFFICER’S REPORT

This report sets out some key areas of work, in addition to their usual duties, for the Chief Officer since the last Governing Body meeting. The report covers the period from 6th September 2017 to 3rd October 2017. Working in partnership with other organisations Cheshire and Merseyside Women’s and Children’s Service Partnership The Chief Officer is the Senior Responsible Officer for the Cheshire and Merseyside Women’s and Children’s Services Partnership. The work of the Partnership is incorporated into Delivering the 5 Year Forward View structures across Cheshire and Merseyside as a cross-cutting theme. The Partnership also brings together national funding as a New Care Models Acute Care Collaboration Vanguard, a pioneer site for choice and personalisation in maternity services and as an Early Adopter to deliver the outcomes of the National Maternity Review – Better Births. Activity in the last month has included:

Weekly team meetings with the Partnership team. Charing the Cheshire and Merseyside Women’s and Children’s Services Partnership

Programme Board on 6th September 2017. Attending and participating in Better Births and New Care Models events at Expo 2017 in

Manchester on 11th and 12th September 2017. Attended the High Quality Hospital Care Programme Board on 27th September 2017 to ensure

that the next steps for the Partnership’s work programme are congruent with the wider work about hospital services.

Attended the inaugural Clinical Advisory Group for the Partnership on 27th September 2017, which is chaired by David Richmond, formerly the President of the Royal College of Obstetricians and Gynaecologists.

Attended the North West Neonatal Operational Delivery Network meeting on 27th September 2017.

Presented to the NHS Cheshire and Merseyside System Management Group on 27th September 2017 on the work of the Partnership to date and the plans for the 2017/18 and beyond.

Oversight of the development of the Cheshire and Merseyside Local Maternity System delivery plan.

Delivering the 5 Year Forward View The Chief Officer is due to attend a meeting of the Cheshire and Wirral Local Delivery System Joint Leadership Group (LDS JLG) on 29th September 2017. This paper has been written and submitted in advance of this date and a verbal update can be provided to the Governing Body if required. Monthly Clinical Commissioning Group (CCG) Chief Officers Meetings The meetings are convened by NHS England and chaired by Graham Urwin, Director of Commissioning Operations, NHS England (Cheshire and Merseyside). They are a mechanism through which Graham and his team exchange information and key messages with the Chief Officers from Cheshire and Merseyside CCGs. The Chief Officer attended this meeting on 15th September 2017.


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Cheshire and Merseyside CCGs are working together on developing a proposal to manage mental health out of area placements differently. The aim is to create a framework that delivers better health, better care and better value and repatriates people to placements within Cheshire and Merseyside. The two main priorities for all CCGs in the next 6 months are to have a “good winter” by ensuring that delivery of urgent care services is maintained and that financial balance is achieved. As highlighted later in this report, the Secretary of State for Health has acquired a personal interest in the status of the Wirral health and care economy in regard to A&E performance in Quarter 2 of 2017/18 and will be personally involved in the sign off of our Winter Plan, which is featured elsewhere on the Governing Body agenda for 3rd October 2017. One the key challenge, as well as moving towards achieving the 95% 4 hour standard, is to have clarity around how the whole system, including social care, will manage Delayed Transfers of Care. The Wirral system should expect fortnightly calls on progress against A&E performance and the delivery of the Winter Plan with the whole system moving towards a nationally directed and managed approach. Other issues that were discussed included the introduction of a GP Workload Tool, enhancing cyber security, remuneration of CCG Governing Body members, the establishment of Joint Committees of CCGs and performance in Child and Adolescent Mental Health Services (CAMHS). Cheshire and Wirral CCGs Meetings A meeting of the Cheshire and Wirral CCG Accountable Officers is scheduled for 29th September 2017. This paper has been written and submitted in advance of this date and a verbal update can be provided to the Governing Body if required. Delivering Healthy Wirral The Chief Officer has engaged in a number of activities that are designed to deliver the Healthy Wirral vision, objectives and outcomes by 2020. To deliver Healthy Wirral, NHS Wirral CCG and Wirral Council are on a path to integrating our commissioning functions so that we commission an integrated health and care system in which providers come together and have accountability for using a defined set of resources to provide the best possible quality of care and health outcomes for the people of Wirral. Urgent Care/A&E/Winter Plan Delivery The Chief Officer has established regular communications with the Chief Executives of Wirral Community Health Care NHS Foundation Trust and Wirral University Teaching Hospitals NHS Foundation Trust to ensure that system performance is improved and any improvements are sustained. This has been essential as we have been under considerable national and local scrutiny in regard to A&E performance and the actions we have taken to address this, specifically with the temporary suspension of the walk-in services at Eastham Clinic. On 15th September 2017 the Chief Officer chaired a meeting with local health and care partners and North West Ambulance Service NHS Trust. The purpose of the meeting was to discuss and agree actions as to how NWAS could help the Wirral health and care system in admission avoidance work and improving handover and turnaround. On 18th September 2017 the Chief Officer, together with the Chair and Chief Executive of Wirral University Teaching Hospitals NHS Foundation Trust attended a national summit for challenged health and care economies on A&E and preparations for winter. The event was chaired by Pauline Philip, National Director for Urgent and Emergency Care and featured presentations by:

Rt. Hon. Jeremy Hunt MP, Secretary of State for Health Simon Stevens, Chief Executive, NHS England


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Jim Mackey, Chief Executive, NHS Improvement David Behan, Chief Executive, Care Quality Commission

The key messages were that A&E performance needed to be improved immediately and improvement sustained through the winter, with health and care systems having clear winter plans to support this. This also required action by general practice, in terms of 8am-8pm services seven days a week, 365 days a year, and also by local authorities through the use of Better Care Fund resources to ensure that extra home care and care home packages were in place. There is also a concern about the potential impact of flu on the system, with a big push needed on vaccinations. It was also made clear that A&E performance is seen a barometer for the performance of the whole hospital, trusts who are assessed good or outstanding by the Care Quality Commission do not have A&E departments that require improvement or are inadequate. Poor performance, overcrowding and queuing in corridors or in ambulances should not be normalised as it constitutes poor care and is not safe. There was a clear expectation that the reform of urgent care systems needs to happen at pace at the same time as operational delivery is maintained. The Chief Officer is due to attend the Wirral and West Cheshire A&E Delivery Board on 26th September 2017. This paper has been written and submitted in advance of this date and a verbal update can be provided to the Governing Body if required. Assurance by NHS England Improvement and Assurance Framework The Chief Officer attended an Improvement and Assurance Framework meeting with the four Cheshire CCGs and NHS England on 14th September 2017. The 2017/18 IAF framework is yet to be published but is likely to have significant resonance with that of 2016/17. The agenda for the meeting covered the development of the Cheshire CCG’s Joint Committee and of integrated commissioning in Wirral. The development of place based care approaches, particularly in West Cheshire, was also picked up. The importance of delivery on A&E performance and financial balance was also emphasised. Assurance Teleconferences The Chief Officer has also participated in the following assurance teleconferences:

On 13th September 2017 with Graham Urwin, Director of Commissioning Operations, NHS England (Cheshire and Merseyside) on learning disability out of area placements, which we are required to reduce under the Transforming Care programme.

On 19th September 2017 with Graham Urwin, Director of Commissioning Operations, NHS England (Cheshire and Merseyside) on the Winter Plan and urgent care delivery.

On 21st September 2017 with Richard Barker, Regional Director (North), NHS England and Lyn Simpson, Executive Regional Managing Director (North), NHS Improvement, also on A&E system performance.

Being accessible and accountable to local communities Adult Care and Health Overview and Scrutiny Committee The Chief Officer attended the Adult Care and Health Overview and Scrutiny Committee on 13th September 2017. Amongst the issues that were considered were the temporary suspension of the walk in services at Eastham Clinic, the deployment of the Dynamic Purchasing System for Continuing Health Care (CHC) placements and the Better Care Fund.


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Annual General Meeting The Chief Officer is due to attend NHS Wirral CCG’s Annual General Meeting on 28th September 2017. This paper has been written and submitted in advance of this date and a verbal update can be provided to the Governing Body if required. Margaret Greenwood MP The Chief Officer is due to meet with Margaret Greenwood MP on 29th July 2017. This paper has been written and submitted in advance of this date and a verbal update can be provided to the Governing Body if required.


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GOVERNING BODY BOARD REPORT


High Yes Medium Low

This paper identifies financial risks to the organisation.

Clinical engagement taken place N

Patient and public involvement taken place N

Equality Analysis/Impact Assessment completed N

Quality Impact Assessment N

Strategic Themes




Month 5 Finance Report

Agenda Item: 2.2 Reference GB17-18/0037



Mike Treharne- Chief Finance Officer

Contributors Ken Jones – Deputy Finance Officer Louise Morris - Senior Contracts and Primary Care Accountant

For Decision

For Information Yes

For Discussion Yes

Executive Summary Financial performance as at 31st July 2017 and high level identification of risks for 2017/18.

Recommendations The Finance Committee is asked to: Note the contents of the report Note the risks identified in the report


2/2



Y


Provide systems leadership in shaping the Wirral health and social care system so as to be fit for purpose both now and in five years time

Y


Governance route prior to Clinical Senate


CCG Finance Committee 29th August 2017


GOVERNING BODY REPORT

GOVERNING BODY Report M5 Page 1 of 6

1.0. INTRODUCTION

1.1 This report sets out the financial position for NHS Wirral Clinical Commissioning Group

(Wirral CCG) as at the end of August (Month 5) 2017/18. The main headlines are

£2,167k YTD operational deficit against Resource Limit. Packages of Care have deteriorated £709k in month. QIPP plans need to be delivered in full whilst maintaining financial management

discipline, in order to achieve a balanced financial position at year end as per the CCG plan submission.

2.0. KEY ISSUES/MESSAGES

2.1. For month 5 the CCG is reporting a year to date operational deficit of £2.167m.

2.2. The table below shows the breakdown of the deficit by expenditure area; a more

detailed breakdown is shown in Appendix 1.

2.3. Current indicative forecasts show a predicted pressure/risk of £4.4 million at the end of the financial year mainly in Acute contracts and COOH – packages of care. The risk

Wirral CCG Financial Position as at 31st August 2017 (Month 5)

Expenditure Area M5

YTD

variance

£'000

M4

YTD

variance

£'000

Movement

£'000s

M5

Forecasted

Year End

Outturn

£'000

M4

Forecasted

Year End

Outturn

£'000

Movement

£'000s

NHS 1,120 780 340 2,540 2,183 357

Non NHS (758) (551) (207) (1,339) (1,557) 218

Prescribing 102 68 35 306 103 203

Commissioned out of Hospital 1,321 612 709 3,035 2,063 972

Primary Care (89) (65) (24) (160) (627) 467

Better Care Fund (51) (38) (13) (82) (71) (10)

Other (Incl Contingency/

reserves)

561 447 114 63 (41) 104

Running costs (39) 19 (58) 69 84 (15)

Operational performance 2,167 1,272 895 4,433 2,136 2,297

Report Title Finance Report for the period - 1st April to 31st August 2017

M5 – 2017/18 Financial Year Lead Officer Mike Treharne Recommendations 1. To note financial position of CCG at Month 5.

2. To note high level budget summary for 2017/18. 3. To note risks attached to achieving the 2017/18 planned

breakeven position.




movement this month is across all programme areas. This does not include any under delivery against QIPP schemes. The forecast reported to NHSE is still as per planning submission, being a planned breakeven position for 2017/18. This is discussed further in the risk section.

NHS Contracts

2.4. NHS contracts are overspent by £1.1 million at month 5, an adverse movement of £340k. Of the adverse movement (between M4-M5), £330k is attributable to WUTH and £126k is for Liverpool Heart & Chest, which offset a favourable movement at the Royal Liverpool hospital due to a trust data coding error of an ITU patient.

2.5. Liverpool Heart & Chest over performance is driven by a continued pressure with day case catheters and pacemakers and this is likely to continue for the remainder of the year.

2.6. WUTH data as at the end of August shows an overspend of £330k against a profiled plan including penalties. (See Appendix 2). There is significant increase in non-elective and A&E activity of £3.2 million, which is offset by non-elective driven penalties and a small underperformance in outpatients and maternity. This position does not take into account the risks involved in the Rightcare and referral management assumptions.

Non NHS Contracts

2.7. Non NHS contracts are under spent by £758k at the end of August. This is predominantly due to Spire Murrayfield underspend of £585k at the end of August (£177k favourable move from the July position). This position is based on July data with an estimate for August activity. There is an underperformance against all points of delivery; however these reduced activity levels are not expected to continue. Locally commissioned services are underperforming by £199k at the end of August mainly due to physio.

Prescribing

2.8. The position at the end of August is £102k overspent, based on three months actual prescribing data and two months estimates. This includes a brought forward pressure from 16/17 of £100k.

2.9. There are potential issues in respect of category M pressures (separate presentation to finance committee), and these are still being worked through with the CSU Medicines Management Team and the CCG BI team. Whilst this is a national issue there is a potential significant pressure for the CCG of circa £2 million.

Continuing Healthcare

2.10. As at the end of August, Packages of Care are £1.3 million overspent, an adverse movement of £709k from the July reported position. Of this, fully funded continuing




healthcare packages are £1.026 million overspent. This is due to a large increase in new package approvals, high package costs and fewer ceased packages.

2.12 Joint Funded CHC is £244k over spent year to date, this is an adverse movement of £255k in month. Note 17/18 data for DASS packages is yet to be received pending validation on 2016/17 packages.

2.13 Funded Nursing Care is £206k underspent at month 5, this is now based on the information provided by the CHC team and input into the Broadcare database.

2.14 Personal Health budgets (PHB’s) are £251k over spent.

2.15 CHC Children is showing a small over spend of £674.

Primary Care

2.16 At the end of August Primary Care budgets are £88k under spent. This is due to Think Pharmacy (level 1 only provided) and 16/17 fallouts.

Better Care Fund

2.17 The Better Care Fund pooled budget shows £50k favourable variance at the end of August. This is predominately due to 2016/17 difference between accruals and actuals. Any known slippage or pressures will be managed by the Better Care Fund Board.

Other (Incl QIPP and Reserves)

2.18 Some contingency was utilised in month 2 to fund the prescribing practice budgets. There is circa £1.3m remaining profiled in month 12 for the CCG to utilise as appropriate. (Contract pressures/ QIPP pressures etc).

2.19 Headroom of £2.4m (0.5%) remains set aside profiled in M12 under instruction from NHS England.

2.20 The reported overspend as at the end of August £561k relates to realised 16/17 year-end financial pressures.

2.21 A reserves breakdown as at 31st August is shown below, all reserves are profiled in M12 and all except contingency is committed.




Running Costs 2.22 Running cost budgets are £39k under spent as at the end of August. Vacancies are

offsetting some of the reported pressure, namely the cost of the Deloitte’s report commissioned/ Turnaround Director and PMO lead support.

QIPP 2.23 For 2017/18, the original QIPP plan was set at £12.275m, of this we have reported to

NHSE at the end of August an underachievement of £2.3m. (note this now excludes operational pressures, as opposed to that reported last month). This is predominantly due to an under achievement in referrals management schemes.

2.24 The forecast in the report shows that the achievement will be made later on in the year so the full QIPP programme will be delivered. It should be noted that initial internal calculations indicate a potential £3.8 million QIPP shortfall by year end (£2.8m referrals management risk, £1.0 million Rightcare and Other Programme risk).

2.25 The following table shows the QIPP plan and the forecast against programme areas:

Reserves Analysis as at Month 5 2017/18

£

636261 Contingency 1,349,484 Profiled in M12 ‐ offset contract pressures?

636281 MH5Y4V 554,780 Committed

636281 Risk Reserve 2,483,600 0.5% committed per NHSE

636306 CEOV 506,000 Committed

636306 Packages 897,130 Committed

636306 Contracts 442,670 Use for ADHC/ remainder for T3

636306 Other 129,070

636306 M3/4/5 allocation Adj 3,347,113 IR/ cancer pass through etc ‐ all ringfenced

9,709,847




2.26 QIPP assurance is needed from the next financial recovery group, including details of the schemes needed to ensure appropriate and accurate monitoring as well as robust recovery plans for schemes that are not currently achieving.

Risks

2.27 The key risks to the CCG in 2017/18 are achievement of a substantial recurrent QIPP programme of £12.275m, and ensuring operational/contract expenditure is managed in line with the financial plan set.

2.28 As at month 5, the position reported to NHSE was £2.167m overspend with a consistent message to want to achieve a breakeven position at the end of the financial year but there is a significant risk of this not being achieved if contracts over perform or the QIPP programme fails.

2.29 The total risk value reported to NHSE at month 5 is £8.5 million, detailed below:

£2.3 million Acute SLA £2.0 million Continuing Healthcare £2.2 million QIPP under delivery £2.0 million Prescribing

Underlying Position 2.30 Due to a change in national reporting, the focus for CCG’s is to achieve an in year

surplus. It must be noted that the CCG still has a cumulative deficit of £7.1m.

Cash Management

2.31 The recorded CCG cash book balance at the end of August was £40k. This is in line with current NHSE guidance that CCGs aim towards 1.25% month end cash balance of the drawdown.

2.32 The BPPC monitors public sector organisations on the timeliness of its financial payments in terms of both volume and value. Guidance recommends 95% of payments within 30 days, the CCG performance was 98.78% for August. The following table shows the number of invoices paid against target.




2.33 The total aged debt for the CCG at the end of August is circa £164.5k, of which only 6.18% are current. There is still some old debt in relation to virgin media phone bills that needs to be resolved with Cheshire & Merseyside CSU and WUTH. It is hoped progress can be reported at the next meeting.

2.34 Expenditure incurred above £25k is collected monthly and published on the CCG

website.

3.0. CONCLUSION

3.1. NHS Wirral CCG’s Governing Body is asked to note:

The financial position at month 5 The risks to achieving the planned breakeven position for the financial year

2017/18 The need to identify and implement mitigations for the risks.

Mike Treharne

Chief Financial Officer NHS Wirral Clinical Commissioning Group 19th September 2017

Month Total Number of Invoices Paid

Total Paid Within Target No.

%age Total Value of Invoices Paid £

Value paid w ithin Target £

%age

APRIL 1012 1000 98.81% 38,613,254.16 38,540,194.82 99.81%MAY 1117 1103 98.75% 35,389,099.83 35,333,339.50 99.84%JUNE 1138 1106 97.19% 34,834,832.35 34,473,846.29 98.96%JULY 956 949 99.27% 39,593,683.99 39,543,397.10 99.87%AUGUST 1090 1090 100.00% 34,263,851.07 34,263,851.07 100.00%

5313 5248 98.78% 182,694,721.40 182,154,628.78 99.70%

Performance Against Better Payment Practice Code (BPPC) ALL


NHS Wirral CCG

APPENDIX 1 ‐ Month 5 Board Report Extract

Cost Centre Expenditure Category Annual Budget Budget to

Date

Spend to

Date

Variance Prior Mth

YTD

Variance

Change In

YTD

Variance

Forecast

Variance

Prior Mth

Forecast

Variance

Change In

forecast

Variance

Wirral University Teaching Hospital NHS Foundation Trust Acute 231,999,760 95,917,245 96,247,242 329,997 7 329,991 0 0 0

North West Ambulance Service Ambulance and Other 12,174,208 5,023,551 5,104,902 81,351 65,082 16,269 0 0 0

West Midlands Ambulance Service Ambulance and Other 1,333,242 555,510 565,839 10,329 9,456 872 0 0 0

Royal Liverpool & Broadgreen University Hospitals NHS Trust Acute 7,159,422 2,950,946 2,867,923 (83,023) 60,098 (143,121) 0 0 0

Aintree University Hospitals NHS Foundation Trust Acute 2,582,902 1,076,210 1,165,802 89,592 63,371 26,221 0 0 0

Countess of Chester NHS Foundation Trust Acute 4,708,107 1,965,916 1,980,815 14,899 (727) 15,626 0 0 0

Liverpool Womens NHS Foundation Trust Acute 2,660,949 1,074,300 1,027,447 (46,853) (28,994) (17,859) 0 0 0

Liverpool Heart & Chest NHS Foundation Trust Acute 1,252,679 516,710 1,017,397 500,687 374,741 125,946 0 0 0

Alder Hey Childrens NHS Foundation Trust Acute 1,937,838 807,428 864,356 56,928 37,360 19,568 0 0 0

St Helen's & Knowsley NHS Trust Acute 898,658 369,590 344,558 (25,032) (3,425) (21,607) 0 0 0

CCC Other 851,781 730,591 730,591 0 (1) 1 0 0 0

Central Manchester University Hospitals NHS Foundation Trust Acute 280,050 115,365 58,914 (56,452) (53,657) (2,795) 0 0 0

Warrington & Halton Hospitals NHS Foundation Trust Acute 106,857 44,520 59,243 14,723 10,052 4,671 0 0 0

Wrightington, Wigan and Leigh NHS Foundation Trust Acute 126,814 52,190 79,738 27,548 33,681 (6,133) 0 0 0

University Hospital of South Manchester NHS Foundation Trust Acute 193,439 80,595 101,166 20,571 26,757 (6,186) 0 0 0

Walton Centre NHS FT Acute 2,061,832 861,167 900,177 39,010 (67) 39,077 0 0 0

Christies NHSFT Acute 154,874 63,735 30,873 (32,862) (14,944) (17,918) 0 0 0

Non Contracted Activity (various providers) Mental Health 2,516,384 1,048,490 1,048,490 () 3 (4) 0 0 0

Cheshire & Wirral Partnership NHS Foundation Trust Mental Health 32,678,527 13,454,017 13,457,261 3,244 5,094 (1,850) 0 0 0

South Staffordshire and Shropshire Healthcare NHS Foundation Trust Mental Health 2,560,051 1,053,679 1,053,680 1 1 0 0 0 0

Greater Manchester West MH NHSFT ‐ Military Vets Mental Health 30,000 12,500 12,518 18 15 4 0 0 0

MH NCAs (Various Providers)/ Merseycare NHS Trust Community 95,987 39,990 48,637 8,647 9,412 (764) 0 0 0

Wirral Community NHS Foundation Trust Community 42,197,808 17,365,965 17,373,455 7,490 39,193 (31,702) 0 0 0

Liverpool Community Health NHS Trust Acute 0 (3) 0 3 3 0 0 0 0

Penine Acute Hospitals NHS Trust Acute 0 0 0 0 0 0 0 0 0

Blackpool Teaching Hospitals NHS FT Acute 0 0 0 0 0 0 0 0 0

Lancashire Teaching Hospitals NHS FT Acute 0 0 0 0 0 0 0 0 0

M12 Performance Prior Yr. fallouts for FT's 0 0 159,388 159,388 147,985 11,403 0 0 0

350,562,169 145,180,207 146,300,411 1,120,204 780,495 339,709 0 0 0

Spire ‐ Murrayfield Acute 6,297,264 2,623,860 2,039,015 (584,845) (407,605) (177,240) 0 0 0

Spa Medica Acute 1,421,155 592,145 648,451 56,306 52,598 3,709 0 0 0

One to One Midwifery Acute 815,990 339,990 324,484 (15,506) (12,405) (3,101) 0 0 0

Spire Liverpool Acute 93,777 38,595 50,108 11,513 7,099 4,415 0 0 0

Extended Choice Network Acute 103,616 43,170 43,170 () 3 (3) 0 0 0

Locally Commissioned Services ‐ Minor Surgery (Wallasey&Bebington) Community 138,624 57,760 61,069 3,309 (2,712) 6,021 0 0 0

Peninsula Community 1,891,863 788,275 853,749 65,474 30,595 34,879 0 0 0

Locally Commissioned Services Community 2,503,386 1,043,075 844,364 (198,711) (157,823) (40,888) 0 0 0

Stroke Association Other 135,965 56,650 56,653 3 2 1 0 0 0

Specialist Care / IFR Panel Approvals Other 362,189 150,910 142,988 (7,922) 7,800 (15,722) 0 0 0

Marie Curie Community 125,188 52,160 53,492 1,332 679 652 0 0 0

End of Life Community 329,568 137,315 137,630 315 314 1 0 0 0

St Johns Hospice (Wirral) Community 1,624,448 676,850 672,147 (4,703) (6,455) 1,752 0 0 0

British Pregnancy Advice Service Community 227,152 94,645 108,373 13,728 10,130 3,598 0 0 0

Patient Transport Other 18,147 7,560 10,627 3,067 2,918 148 0 0 0

Mental Health Services Mental Health 68,038 28,172 30,951 2,779 2,223 556 0 0 0

Primary Care Advice Link Other 305,000 127,080 127,083 3 3 0 0 0 0

CAMHS Mental Health 174,000 72,500 0 (72,500) (58,000) (14,500) 0 0 0

Parenting & Prevention 150,000 62,500 22,500 (40,000) (32,000) (8,000) 0 0 0

Homeopathy 0 0 0 0 0 0 0 0 0

Looked After Children 0 0 (11,508) (11,508) (7,871) (3,637) 0 0 0

Prior Yr. fallouts for Non NHS 0 0 19,653 19,653 19,653 0 0 0 0

16,785,370 6,993,212 6,234,999 (758,213) (550,854) (207,359) 0 0 0

Primary Care Prescribing Prescribing 58,588,380 24,415,897 24,569,867 153,970 100,235 53,735 0 0 0

Central Drugs Prescribing 1,705,432 710,591 689,123 (21,468) (17,986) (3,482) 0 0 0

Air Liquide Prescribing 561,766 234,069 203,824 (30,245) (14,595) (15,649) 0 0 0

60,855,578 25,360,557 25,462,814 102,257 67,653 34,604 0 0 0

Continuing Healthcare/ Fully Funded Packages of Care Commissioned Out of Hospital 9,731,787 4,259,329 5,285,718 1,026,389 789,251 237,138 0 0 0

Continuing Healthcare/ Fully Funded Packages of Care Personal HealthCommissioned Out of Hospital 1,144,239 479,639 724,565 244,926 88,485 156,441 0 0 0

Continuing Healthcare/ Joint Funded Packages of Care Commissioned Out of Hospital 18,626,573 8,285,580 8,529,255 243,675 (21,685) 265,359 0 0 0

Continuing Healthcare/ Joint Funded Packages of Care Personal HealthCommissioned Out of Hospital 14,196 5,949 10,865 4,916 3,921 995 0 0 0

Children with Special /Safeguarding Needs Commissioned Out of Hospital 1,696,880 711,081 711,755 674 (848) 1,521 0 0 0

CHC Childrens Personal Health Budgets Commissioned Out of Hospital 33,703 14,128 19,946 5,818 2,467 3,351 0 0 0

Funded Registered Nursing Care Commissioned Out of Hospital 6,114,497 2,563,391 2,357,592 (205,799) (249,688) 43,889 0 0 0

37,361,875 16,319,097 17,639,695 1,320,598 611,904 708,694 0 0 0

LES Budgets Other 2,648,426 1,242,824 1,242,824 () 9,890 (9,891) 0 0 0

Primary Care Development Other 170,000 70,830 70,832 2 2 1 0 0 0

PC Investments Other 0 0 0 0 0 0 0 0 0

Think Pharmacy Other 160,603 66,915 14,853 (52,062) (39,580) (12,483) 0 0 0

WCCG Service Development Other 694,339 289,305 289,305 0 (1,447) 1,447 0 0 0


Cost Centre Expenditure Category Annual Budget Budget to

Date

Spend to

Date

Variance Prior Mth

YTD

Variance

Change In

YTD

Variance

Forecast

Variance

Prior Mth

Forecast

Variance

Change In

forecast

Variance

Interpreting Services Other 75,606 31,500 30,744 (756) 769 (1,524) 0 0 0

Collaborative Fees Other 180,625 75,260 75,260 0 () 1 0 0 0

Phlebotomy Other 152,949 63,725 60,620 (3,105) (1,746) (1,359) 0 0 0

Primary Care prior yr Other 0 0 (32,731) (32,731) (32,856) 125 0 0 0

PCTF Revenue Other 0 0 0 0 0 0 0 0 0

Primary Care GPIT Other 982,308 409,295 409,295 () 0 (1) 0 0 0

5,064,856 2,249,654 2,161,003 (88,651) (64,968) (23,684) 0 0 0

CWP BCF Other 622,572 259,400 259,405 5 4 1 0 0 0

Mental Health Services ‐ Advocacy Other 53,415 22,255 22,255 (1) (1) 0 0 0 0

Dementia CWP Other 221,290 92,200 92,205 5 4 1 0 0 0

Dementia LES Other 71,400 29,750 25,393 (4,358) 1,593 (5,950) 0 0 0

Community Services Other 48,633 20,260 14,212 (6,048) (3,914) (2,134) 0 0 0

Hospices Community 230,035 95,845 95,848 3 3 1 0 0 0

Intermediate Care Other 674,882 281,195 243,074 (38,121) (24,784) (13,337) 0 0 0

Intermediate Care Wiral CT Other 1,115,714 464,875 478,219 13,344 4 13,340 0 0 0

Palliative Care Community 43,782 18,240 18,242 2 2 0 0 0 0

Commissioning ‐ Non Acute Other 16,888 7,035 7,037 2 1 1 0 0 0

Reablement Wirral CT Other 644,516 268,540 268,547 7 6 1 0 0 0

Reablement WUTH Other 400,000 166,665 166,667 2 1 0 0 0 0

Reablement NWAS Green Car Other 282,500 117,710 117,708 (2) (1) (1) 0 0 0

Reablement Other 19,962,373 8,309,730 8,294,298 (15,432) (10,484) (4,948) 0 0 0

24,388,000 10,153,700 10,103,109 (50,591) (37,566) (13,025) 0 0 0

Programme Projects (Diabetes & Respiratory) 55,294 55,294 55,294 () 0 () 0 0 0

CHC Admin Team 859,305 358,041 358,041 0 5 (5) 0 0 0

CHC Admin Team ‐ Other 212,395 88,495 88,495 () 2 (2) 0 0 0

CSU MM Programme charges 873,125 363,800 363,802 2 2 0 0 0 0

Winter Pressures (SRG) 0 0 0 0 0 0 0 0 0

Prior approvals & exceptions 0 0 0 0 0 0 0 0 0

Safeguarding 383,307 159,695 162,847 3,152 1,767 1,384 0 0 0

Safeguarding ‐ other 130,799 31,306 31,000 (306) (245) (61) 0 0 0

Miscodes 0 0 () () 0 () 0 0 0

General Reserve ‐ Programme Reserves 5,321,983 0 557,883 557,883 445,270 112,614 0 0 0

Contingency Reserves 1,349,484 0 0 0 0 0 0 0 0

Rec QIPP Target Reserves 0 0 0 0 0 0 0 0 0

Reserves Reserves 0 0 0 0 0 0 0 0 0

Non recurrent Reserves Reserves 554,780 0 0 0 0 0 0 0 0

1% Headroom Reserves 2,483,600 0 0 0 0 0 0 0 0

12,224,072 1,056,631 1,617,362 560,731 446,801 113,929 0 0 0

507,241,920 207,313,058 209,519,392 2,206,334 1,253,466 952,868 0 0 0

Chair and Non Execs Running Costs 175,460 73,090 63,428 (9,662) (7,873) (1,789) 0 0 0

CEO/ Board Office Running Costs 752,818 313,640 401,201 87,561 85,777 1,784 0 0 0

Strategic Planning & Outcomes Running Costs 0 (9) 0 9 9 0 0 0 0

Clinical Governance Running Costs 342,750 142,790 145,882 3,092 5,181 (2,089) 0 0 0

Contracts Management Running Costs 0 (10) 0 10 10 0 0 0 0

Corporate Costs Running Costs 831,105 346,254 357,603 11,349 9,274 2,075 0 0 0

CSU SLA Running Costs 413,472 172,280 172,279 (1) () () 0 0 0

Business Informatics Running Costs 381,286 158,849 123,120 (35,729) (26,420) (9,309) 0 0 0

EDUCATION AND TRAINING Running Costs 75,081 0 0 0 0 0 0 0 0

Finance Running Costs 909,916 379,105 372,659 (6,446) 7,611 (14,057) 0 0 0

Commissioning Running Costs 1,488,102 619,978 599,251 (20,727) (451) (20,276) 0 0 0

PALS Running Costs 34,000 14,165 14,165 0 1 (1) 0 0 0

CHC Admin Running Costs 0 0 0 0 0 0 0 0 0

Quality Premium Running Costs 0 0 0 0 0 0 0 0 0

Reserves running costs Running Costs 222,203 89,245 20,777 (68,468) (54,609) (13,859) 0 0 0

Total Running Costs 5,626,193 2,309,377 2,270,364 (39,013) 18,508 (57,521) 0 0 0

Total Wirral CCG Spend 512,868,113 209,622,435 211,789,756 2,167,322 1,271,974 895,348 0 0 0

Surplus (Deficit b/fwd) Offset (7,128,000) (2,969,999) 0 2,969,999 2,375,999 594,000 7,128,000 7,128,000 0

Total Wirral CCG Resource 505,740,113 206,652,436 211,789,756 5,137,321 3,647,973 1,489,348 7,128,000 7,128,000 0

* Running costs budget is vired non recurrently each year to cover programme spend ‐ actual running costs expenditure against the original allocation is shown on the line below

Total Running Costs 7,095,020 2,921,367 2,885,508 (35,859) 20,279 (56,138) 0 0 0


Wirral University Teaching Hospital NHS Foundation Trust ‐ NHS Wirral CCG summary position ‐ August 2017

Total ‐ Month 5 2017/18 (based on month 4 1st cut data)

Plan YTD Actual YTD Variance

PBR DC and Elective (including XBDs) 18,536 18,389 (146)

A&E 36,696 37,577 881

Non Elective (including XBDs) 19,797 19,800 3

Non Elective Non Emergency (including XBDs) 2,129 2,533 404

Outpatients First 30,615 30,380 (235)

Outpatients Follow up 65,727 65,649 (78)

Outpatients Procedures 14,540 15,045 505

Unbundled Diagnostic Imaging 10,958 10,792 (166)

Maternity 2,520 2,474 (46)

Back to PbR Plan

201,518 202,638 1,120

Non PbR 626,674 666,117 39,443

BCF (OPAT & Care of the Elderly) 0 0 0

AQP‐ Audiology 501 2,405 1,904

AQP‐ DAD 39,484 39,631 147

AQP‐ Appliances 0 0 0

Back to Non PbR Plan

CQUIN 0 0 0

Contract Performance 868,176 910,791 42,615

Contractual Adjustments Readmissions 0 (257) (257)

Outpatients F/UP Cap 0 (3,248) (3,248)

NEL Threshold 0 0 0

AAU Adjustment 0 0 0

MRSA 0 0 0

VTE 0 0 0

Never Events 0 0 0

Single Accommodation Breaches 0 0 0

Clostridium Difficile 0 0 0

Cancelled Ops

RTT 0 0 0

A&E 4 Hour Wait 0 0 0

Diagnostic Waits < 6 weeks 0 0 0

Ambulance Penalty 0 0 0

Cancer 2WW 0 0 0

Reinvest STP Sanctions 0 0 0

WOA 0 0 0

CCC Diagnostic Imaging 0 0 0

Further Adjustments NHSE ‐ IR

Contract Subtotal (pre rightcare adjustments) 868,176 907,286 39,110

Workstreams agreed NHS Rightcare Transformation 0 0 0

Referrals Management 0 0 0

Procedures of Low Clinical Priority 0 0 0

Additional DAD ‐ other providers 0 0 0

0 (3,505) (3,505)

Contract Performance 868,176 903,782 35,606

Contracts Total (SAC & DAD AQP Additional) 868,176 903,782 35,606

Board Report Total

Activity ‐ Month 5

S:\Gov‐Body\Meetings\Governing Body Board Committee\2017 Meetings\10. October GB Meeting 2017\5c. Appendix 2 ‐ WUTH M5 Summary CCG Profiled Plan (M5 Board)GB Agenda Pack - of 70

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GOVERNING BODY BOARD REPORT COVER SHEET


High Yes Medium Low

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

GOVERNING BODY ASSURANCE FRAMEWORK

Agenda Item: 2.3 Reference GB17-18/GB0037



Paul Edwards, Director of Corporate Affairs

Contributors Governing Body Members, Mersey Internal Audit Agency

For Decision Yes

For Information

For Discussion Yes

Executive Summary The Assurance Framework was developed by the Governing Body in conjunction with Mersey Internal Audit Agency and identifies key risks to NHS Wirral CCG’s Strategic Objectives. When presented at Governing Body in June 2013, key controls and assurances were identified against each risk, with any gaps identified as requiring an action plan to address them. The Assurance Framework has been reviewed a number of times since then (see Report History), with the whole structure of the Assurance Framework structure itself being reviewed at the Informal Governing Body session held on 1st March 2016 where risks were re-aligned to refreshed CCG Strategic Aims. This session also suggested the inclusion of ‘risk appetite’ and this was discussed at July 2016’s Governing Body and was incorporated in the October 2016 iteration of the Assurance Framework. The changes agreed at May 2017 are incorporated here and further proposed changes for consideration at Governing Body in October 2017 are outlined in the supporting paper.

Recommendations The Governing Body is asked to: Discuss risks Agree any potential changes


2/3

Clinical engagement taken place N




Strategic Themes






Y


Provide systems leadership in shaping the Wirral health and social care system so as to be fit for purpose both now and in five years’ time

Y




Governing Body 2nd May 2017 Reviewed scores and agreed amendments

Governing Body 10th January 2017 Reviewed scores and agreed amendments

Governing Body 4th October 2016 Reviewed scores and added risks

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

Governing Body 1st March 2016 Updated to align to new refreshed


3/3

Strategic Aims, facilitated by Mersey Internal Audit Agency


Introduction

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

Changes to the Assurance Framework agreed at May 2017 Governing Body

Extensive engagement exercises added as assurance sources on Risks A1, A2 and D7

Establishment of Finance Committee and Turnaround Group as added control on Risks B2, B3 and C4

Purchase of Browse Aloud as additional control on Risk D4 Lack of consultation and local approval of LDP and STP as gap on Controls

and Assurance on Risk B1 Development of formal governance and structures to support Integrated

Commissioning identified as gap on Controls and Assurance on Risks D6 and F2

New Chief Officer in post as gap on Controls and Assurance on Risks D6 and F2 until role beds in

Approval of Improvement Plan by NHS England as gap on Controls and Assurance on Risks F3

Risk score increased on Risk D5 as a results of 360 results Gap added to Risk D5 related to production of Action Plan in response to 360 Updates to Responsible Committees

All other risks were deemed to be accurate in terms of scores and narrative.

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

Contributors Recommendations Governing Body members are asked to approve the

proposed changes, discuss new risks and assess whether any risk scores need to be modified.


Proposed changes at October 2017 Governing Body

Removing references to historic Healthy Wirral engagement events when related to Vanguard activity on Risk A1

Following the dissolution of Patient Voice (when the group failed to elect a chair and chose to disband), new gap identified whilst CCG supports the creation of a Public/Patient Reference Group. Relates to Risks A1, A2, C5, D1, D2, D3, D4

Updated references to Finance Committee now that Turnaround Group has been disbanded and now incorporated into remit of Finance Committee. Relates to Risks B2, B3

Updated references to ‘Advice and Guidance’ in Risks D5 and E1 in line with recognised term

Lack of consultation and local approval STP/5YFV as gap on Controls and Assurance on Risk B1

Need to develop formal Terms of Reference for Operational Group added to Risks B2, B3 and C4

Updated Key Controls/Assurances in Risk D6 Implementation of agreed formal governance and organisational structures to

support Integrated Commissioning identified as gap on Controls and Assurance on Risks D6 and F2

Development of firm timelines for development of integrated provision identified as gap on Controls and Assurance on Risks D6 and F2

New Chief Officer in post removed as gap on Controls and Assurance on Risks D6 and F2 until role beds in

Action Plan on Risk D5 re: member engagement updated Additional considerations Governing Body Members are asked to consider those risks were ‘risk appetite’ is not currently being achieved and whether:

a) These still reflect the CCG’s ambition b) Other controls need to be considered to achieve the target risk scores

Conclusion


Governing Body members are asked to approve the proposed changes, discuss new risks and assess whether any risk scores need to be modified.


Wirral CCG

Controls Assurances Gaps Responsible CommitteeRisk No

Risk Owner/ Lead Risk DescriptionImpact Rating Key Controls Assurance on Controls

Likelihood Rating

Risk Score

Risk Rating

Status Gaps in Control and Assurance Action plan Target Impact Target Likelihood Target ScoreTarget

DeadlineNarrative

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

A1

Dir

ect

or

of C

orp

ora

te A

ffair

s

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

3

Governing Body Reporting Format incorporating Engagement reports. Expo Event and other

Healthy Wirral events set up to engage with wider public. New Engagement and Experience Strategy approved. Assistant Director of Communications

and Engagement recruited. Implemetation Plan for Engagement Strategy brought to Governing Body

November 2016.

Quality and Performance Committee minutes and reports, Governing Body minutes and reports, including Engagement Report. Feedback captured from Healthy Wirral events. Several extensive engagement exercises evidence through Governing Body papers

2 6 ↔New Public/Patient Reference Group to be established to improve ongoing relationships

New group will be established end of Quarter 3.

Quarter 3 2017/18Lead: Director of Corporate

Affairs

Governing Body 3 2 6 Quarter 4

A2

Dir

ect

or

of C

orp

ora

te A

ffair

s

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

3

PALS, Complaints management, website feedback mechanisms, Communications support systems provided by CSU, Quality and Performance Committee monitoring. Patient Engagement Reports to CCG Governing Body. CQC relationship, Quality Surveillance Group, Complaints Monitoring. Healthwatch links and representation on Governing Body. New Governing Body Reporting Format incorporating Engagement reports. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement Strategy brought to Governing Body November 2016.

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

2 6 ↔NewPublic/Patient Reference Group to be established to improve ongoing relationships



Affairs


B1

Dir

ect

or

of C

om

mis

sio

nin

g

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

4

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

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

3 12 ↔

Sustainability and Transformation (5 Year Forward View) plans yet to be consulted on with patients, the public and clinicians. Also, this is not approved by CCG Governing Body

Engage on and contribute to Sustainability and

Transformation (5 Year Forward View) planQuarter 4 2017/18Lead: Chief Officer


3 2 6 Quarter 4STP5YFV plans not yet consulted on or locally

approved

B2

Dir

ect

or

of C

om

mis

sio

nin

g

Fail to deliver agreed health priorities and objectives.

3

CCG Strategic Plan, NHS England performance monitoring, Patient Feedback, Patient Practice Groups, Quality and Performance Contract meetings, Quality and Performance Committee Monitoring. Refreshed Strategic Plan. Financial Recovery Plan. QIPP Reports. Finance Committee now established and revised to incorporate Turnaround Group functions

Performance reports to Governing Body, Quality and Performance Committee Committee minutes. External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Finance Committee and new Operational Group focus

4 12 ↔Operational Group does not have formal role within the CCG's Governance Arrangements

Terms of Reference to be developed for Operational

Group and Scheme of Delegation to be updated


Affairs


3 3 9 Quarter 4

B3

Ch

ief F

ina

nci

al O

ffice

r

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

4

QIPP Strategy and plans, DASS membership on CCG Governing Body, Health & Wellbeing Board, Quality and Performance Committee Committee monitoring. Joint Strategic Commissioning Group being established. Healthy Wirral finance workstream. Section 75 agreement in place. Development and monitoring of Financial Recovery Plan. QIPP Plan. Finance Committee now established and revised to incorporate Turnaround Group functions

Health and Wellbeing Board, Quality and Performance Committee minutes. Healthy Wirral SLG minutes. Reports to Health and Well Being Board. Pooling arrangements for Better Care Fund. External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Finance Committtee, and new Operational Group focus.





Affairs

Finance Committee/Governing Body

4 4 16 Quarter 4

Risk Appetite

To empower the people of Wirral to improve their physical, mental health and general well being

To reduce health inequalities across the Wirral

To adopt a health and well being approach in the way services are both commissioned and provided

Strategic Aim A

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

assurance

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

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

statutory,

Priority

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

effective. What needs to be done

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

objectives being delivered

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

Strategic Aim B

Strategic Aim C

Page 1GB Agenda Pack - of 70

Wirral CCG



Likelihood Rating

Risk Score

Risk Rating


DeadlineNarrative

Risk AppetitePriority

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

3

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

3 9 ↔Quality and Performance

Committee3 3 9 Quarter 4

C4

Ch

ief F

ina

nci

al O

ffice

r

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

4

CCG Strategic Plan, QIPP Plan with measurable outcome targets, Quality and Performance Committee monitoring. Indicators of success/ failure in demand management and action plans as needed. Quality Surveillance Group. CQUINS monitoring. Clinically led workstreams. 2 year plan in place & refocus of commissioning intentions. New Governing Body Reporting Format. Financial Recovery plan developed. Confirm and Challenge Meetings. Primary Care Quality Scheme introduced, PMO established and Finance Committee established, incorporating functions of Turnaround Group.

Quality and Performance/Finance Committee monitoring of QIPP. Systeme Resilience Group now in place to address economy wide pressures. Governing Body minutes. External CCG Assurance Framework. Monitoring of Financial Recovery Plan through Finance Committee and new Operational Group focus. Monitoring impact of Primary Care Quality Scheme through Quality and Performance Committee





Affairs


4 3 12 Quarter 4

C5

Dir

ect

or

of Q

ua

lity

an

d P

atie

nt S

afe

ty

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

3

Continuing work with community partners in voluntary, community and faith sectors plus representatives of individuals with protected characteristics to ensure their full representation in our commissioning plans . Friends and Family Test. Public Health intelligence. Analysis of provider organisations complaints. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement Strategy brought to Governing Body November 2016

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

2 6 ↔NewPublic/Patient Reference Group to be established to improve ongoing relationships



Affairs


C6

Dire

ctor

of

Com

mis

sion

ing

Failure to adequately benchmark with peers.

3

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

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

2 6 ↔Quality and Performance

Committee3 2 6 Quarter 4

D1

Dir

ect

or

of C

orp

ora

te A

ffair

s

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

3

CCG Strategic Plan, use of JSNA in plans, Lay member for Patient Engagement, Public Health inclusion on CCG Governing Body.Engagement events and activities. Patient Engagement Reports to CCG Governing Body. Healthwatch member at Governing Body. Healthy Wirral work re self care & prevention. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement brought to Governing Body November 2016

Patient Group/Practice feedback, Public Health Reports. Plans based on JSNA presented at Governing Body. Engagement activities reported through Governing Body




Affairs


D2

Dir

ect

or

of C

orp

ora

te A

ffair

s

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

3

Website development, Use of social media, Engagement events and activities, Public CCG Governing Body meetings. Engagement Reports to CCG Governing Body. Links to Healthwatch via Governing Body attendance and ongoing relationship.. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement brought to Governing Body November 2016

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




Affairs


D3

Dir

ect

or

of C

orp

ora

te

Affa

irs Cultural and attitudinal issues skew expectations against self care.

3

CCG Strategic Plan. Integration team work re patient care. Healthy Wirral workstream re self care and prevention. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement brought to Governing Body November 2016

Engagement activities reported through Governing Body




Affairs


To commission and contract for services that: Demonstrate improved person centred outcomes ; Are high quality and seamless for the patient; Are safe and sustainable; Are evidenced based and Demonstrate value for moneyStategic Aim D

Dir

ect

or

of Q

ua

lity

an

d P

atie

nt S

afe

ty

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

C1


Wirral CCG



Likelihood Rating

Risk Score

Risk Rating


DeadlineNarrative


D4

Dir

ect

or

of C

orp

ora

te A

ffair

s

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

3

Website development, Choose Well/ Public Health campaigns, use of social media. Patient Engagement Reports to CCG Governing Body. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement brought to Governing Body November 2016. Purchase of 'Browse Aloud' and newlly designed website that enhanced accessibility

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




Affairs


D5

Ch

air Ineffective engagement from

clinicians 4

New CCG structures enable clinical involvement through the Clinical Senate, Provider Forum and Membership Council as well as clinical membership of other committees and Governing Body New Governing Body Reporting Format. Advice and Guidance established, cycle of Practice Visits established, CCG to introduce locality approach. Review of Clinical Senate, Membership Council and Provider Forum taken place.

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

4 12 ↔360 results require refreshed approach to practice engagement

Proposals to be produced to address member engagement, to be led by member practices

Quarter 1 2017/18Lead: Chair of Membeship

Council


D6

Acc

ou

nta

ble

Offi

cer

/Ch

air

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

4

JSNA and HWB Strategy and Board, development of service specifications and a Commissioning Prospectus which require collaborative approach, Joint CQUIN development, Social Care/Public Health represenentation on CCG Governing Body. Integrated planning processes. Joint Strategic Commissioning Board being developed. Section 75 under consideration for expandsion. Integration Project Board established. Intregrated Target Operating Model being developed. CCG activities to support development of Accountable Care.

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

2 8 ↔

Agree and implement governance and structures for Integrated Commissioning. Target Operation Model to be agreed. Financial Due Diligence report to be considered.

Need to establish timelines and pathway for parallel development of integrated provider development

Develop and Implement Governance and

Organisational arrangementsQuarter 1 2018/19

Lead: Director of Corporate Affairs

Output of AQUA work supporting provider

integration/system lock in planned


D7

Dir

ect

or

of C

orp

ora

te A

ffair

s

Adverse public reaction to decommissioning or reduction in access

3

Public consultation, Engagement through Wirral Voice/PPGs, CSU support, Use of different comms mechansims e.g local press, social media. Engagement Reports to CCG Governing Body. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Commissioning Decision Making process agreed. Implemetation Plan for Engagement brought to Governing Body November 2016

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




Affairs


E1

Me

dic

al D

ire

cto

r/ D

ire

cto

r o

f Co

rpo

rate

Affa

irs

CCG fails to be innovative and deliver sufficient appropriate change

4

AQUA and other membership/subscriptions. QIPP/Commissioning Plan/Urgent Care/Strategic Plan and Healthy Wirral programme all require innovation to change to system. Staff trained in Experience Lead Commissioning. Development of Clinical Senate to drive clinical innovation. Examples of innovation include Think Pharmacy, OPAT, Single Front Door, Advice and Guidance. Delivery against planning guidance and the Five Year Forward View. Review of Clinical Senate, Membership Council and Provider Forum taken place. New Organisational Development Strategy approved. QIPP Plan and Confirm and Challenge meetings

Governing Body minutes. CCG plans. Clinical Senate minutes. Organisational Development implementation plan. Confirm and Challenge meetings and monitoring of QIPP Plan via Finance Committee

3 12 ↔ Governing Body 4 2 8 Quarter 4

E2 Dire

ctor

of

Cor

pora

te A

ffai

rs

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

3

Regular communications with local politicians, open, transparent communication with local media. Staff and community newsletters from CCG , Patient Engagement Reports to CCG Governing Body. New Engagement and Experience Strategy approved. Assistant Director of Communications and Engagement recruited. Implemetation Plan for Engagement brought to Governing Body November 2016

Engagement activities reported through Governing Body


E3

Dire

ctor

of

Com

mis

sion

ing

Failure to deliver QIPP targets 4

Quality and Performance Committee Committee monitoring. Development and monitoring of Financial Recovery Plan. QIPP Plan, Finance Committee. Finance Committee established and PMO established.

Quality and Performance Committee minutes. Finance Committee minutes External CCG Assurance Framework. Monitoring of Financial Recovery Plan through 'Confirm and Challenge' Group and new Operational Group focus

4 16 ↔ Finance Committte 3 3 9 Quarter 4

To be known as one of the leading Clinical Commissioning Groups in the country and locally across Wirral to patients / public

Provide systems leadership in shaping the Wirral health and social care system so as to be fit for purpose both now and in five years timeStrategic Aim F

Strategic Aim E


Wirral CCG



Likelihood Rating

Risk Score

Risk Rating


DeadlineNarrative


F1

Acc

ou

nta

ble

O

ffice

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

3Healthy Wirral Memorandum of Understanding in place

Healthy Wirral Memorandum of Understanding in place.

3 9 ↔ CCG's new Chief Officer to start in post To start in post April 2017 Governing Body 3 3 9 Quarter 4

F2

Acc

ou

nta

ble

Offi

cer/

Dir

ect

or

of C

orp

ora

te

Affa

irs

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

4

Healthy Wirral Memorandum of Understanding in place

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

Healthy Wirral Memorandum of Understanding in place.

Minutes of Integrated Commissioning Project Board

3 12 ↔

Agree and implement governance and structures for Integrated Commissioning. Target Operation Model to be agreed. Financial Due Diligence report to be considered.

Need to establish timelines for parallel development of integrated provider development

Develop and Implement Governance and

Organisational arrangementsQuarter 1 2018/19

Lead: Director of Corporate Affairs

Output of AQUA work supporting provider

integration/system lock in planned


F3

Acc

ou

nta

ble

O

ffice

r Capability and capacity for CCG staff to deliver key objectives and duties

3Independent Assessment of CCG Capability and Capcacity by Price Waterhouse Cooper. Improvement Plan submitted NHS England

Report form Price Waterhouse Cooper and Action Plan in response to recoomendations


F4

Dir

ect

or

or

Co

mm

issi

on

ing

/Ch

ief F

ina

nci

al

Offi

cer Failure to achieve 'good' or

'outstanding' in the external CCG Assessment Framework

3Close monitiring of new clinical domains and other indicators that contribute to overall rating. Clinical Senate in place

Quality and Performance Committee minutes. Finance Committee minutes External CCG Assurance Framework meetings. Monitoring of Financial Recovery Plan through 'Confirm and Challenge' Group and new Operational Group focus

3 9 ↔ 2 2 4 Quarter 4


1/2

GOVERNING BODY BOARD REPORT COVER SHEET


High Yes Medium Low

Failure to deliver this plan could result in an inability for the Wirral Health and Care System to cope with the anticipated demands over the winter period.

Clinical engagement taken place Y




WIRRAL WINTER AND SYSTEM SUSTAINABILITY PLAN 2017-18

Agenda Item: 2.4 Reference GB17-18/0037



Nesta Hawker, Director of Commissioning

Contributors Jacqui Evans, Assistant Director and health and care system partners

For Decision

For Information Yes

For Discussion

Executive Summary This plan outlines the Wirral health and care system’s plan for the forthcoming winter period

Recommendations The Governing Body is asked to note the plan


2/2

Strategic Themes






Y


Provide systems leadership in shaping the Wirral health and social care system so as to be fit for purpose both now and in five years’ time

Y





Wirral Winter and System Sustainability Plan 2017-18

Winter Plan Executive Summary

Wirral has faced a challenging period during the winter of 2016, continuing to date. The acute hospital and A&E saw unprecedented pressure during winter. There has

been little let up on that pressure into the summer months.

Key challenges have included:

Trust and collaboration across the system to deliver the changes within the required timescale

Ability to work across organisational boundaries

Capacity & ability to lead the ‘hearts & minds’ changes required to achieve the necessary behaviour and culture shift

Capacity and ability to make and sustain required system changes at pace

Physical capacity of the system to cope with increased demand

Continued expectations & behaviours of the public

Effectively implementing and sustaining clinical streaming, SAFER, internal flow

Achieving DTOC target of 3.5% as agreed with NHS England

Recruitment & retention of key professionals, especially therapists

Domiciliary care market, experiencing key providers leaving the market at a time of increased demand for services

Ineffective system planning for winter 16/17

Financially challenging position across the system

The above challenges have resulted in consistent non‐achievement of 4 hour target. As such the acute has been in the bottom quartile nationally for performance. This

is a situation owned and recognised as a whole system challenge, requiring collaborate solutions.

The urgent care challenges for Wirral are therefore a priority, acknowledging all organisations have a part to play & that there are opportunities to make better

connections between planned & unplanned care.

Transformational Priorities going forward for 17/19

The system has agreed the following priorities:


of 29

I. Implementation of clinical streaming at the front door

II. Consistent & complete implementation of safer throughout the hospital & community beds

III. Implementation, expansion & embedding of Transfer to Assess (T2A) – own home & bed base including Trusted Assessor, joint assessment and care planning.

IV. Expansion of admission avoidance schemes including Rapid Community Service, Green Car ensuring resilience

V. Investment in domiciliary care & commissioning of alternate models, to ensure responsive & flexible capacity, supporting flow across the system

VI. Support to care homes including tele triage, care home connector training, upscaling of staff with increased access to specialist support

VII. Demand divergence from hospitals: ambulances reducing ambulance conveyances

VIII. Whole system therapy redesign, developing a generic offer and supporting a shift left.

IX. Whole system approach to Business Intelligence, monitoring evaluation, evidencing ROI, VFM & trajectories to achieve KPI’s – overarching dashboard with tight

oversight & evaluation

The system is actively working with ECIP, EY and AQUA to support the transformational programme. EY have undertaken a 6 week evidence based diagnostic to review drivers

of delay and identify and prioritise high impact change opportunities ‐ diagnostic report summary is available in Appendix 1. AQUA are reviewing the effectiveness of A&E

Delivery Board. ECIP are supporting whole system transformational redesign.

The key issue for Wirral partners is to turnaround urgent care delivery in Wirral and ensure performance is significantly improved over the coming winter months .The key

must dos for winter 17/18 to address the current Wirral situation are below and are currently RAG rated against assessment of deliverability with the expectation will move

to green in line with developments. Key risk ‐ workforce


of 29

PRIORITY AREA IMPACT ON 4 HOUR PERFORMANCE DESCRIPTION SCHEMES RAG

RATING

Admission Avoidance & Ambulatory Care Wirral has developed a menu of admission avoidance services providing a response 7 days per week, 8‐8. These include

Review of all schemes with a report into Exec and A&E board October 2017. This will inform review on ROI, impact and outcomes and future prioritisation of resource.

Acute Visiting Scheme

Clinical Assessment Service

Green Car

Rapid Community Response

AMBER

NWAS and 111/OOH Review of data suggests Wirral could improve performance relating to alternatives to ED. This includes cross cutting work between NWAS, 111, GPOOH and application of the DOS ‐ work will be completed for implementation 1 November

Planning and implementation of the new Integrated Urgent Care Service Specification – timescales mandated

GREEN

Primary care (GP) extended access Currently Monday to Friday 8‐8 and Saturday 10am‐2pm in place.

Discussions underway to ensure extended access in place 7 days a week, 8‐8 from November 2017.

AMBER

Ambulatory Care Pathways Establish Ambulatory project group to review all Ambulatory pathways from ED (ACU, Surgery, Other). Review current inclusion criteria for existing ambulatory pathwaysValidate Ambulatory opportunity with group and agree revised opportunity Review GP activity profiles by day / time to identify bottlenecks and

Confirm top 5 pathways and devise clear action plans to target

AMBER


of 29


RATING

suggest scope to smooth demand

Single Point Access (SPA) Revisit pathways in line with transformational process. Sharing best practices across Wirral and Western Cheshire and any changes identified will be implemented by November. Ensuring robust resilient response to maximise diversions for referrals from NWAS/111. Effective communications strategy to ensure all aware of services available. A post will be in place to support this

Optimise next day appointments/ hot slots.

AMBER

ED Processes

Primary Care Streaming Phase 1 commenced 4 September 2017 with GP cover 8am – 7pm Mon‐Fri and additional Advanced Nurse Practitioner (ANP) and Emergency Nurse Practitioner (ENP) cover 7 days a week. This will include disaggregation of minors and zero tolerance on breaches. Phase 2 ‐ preferred model, applying the learning from phase 1, will be fully costed and agreed

Primary Care Streaming to Urgent Treatment Centres.

GREEN


of 29


RATING

by 16th October with supporting implementation plan. This will ensure effective advice and information/ signposting to alternative community services support, supporting delivery of the 4 hour target and prevent minor injury breaches. Phase 3 is in line with National guidance for delivery of Urgent Treatment Centres, public consultation commences November 2017.

Agree who is responsible for over‐arching ED floor coordination at patient level and formalise job description to clarify. Assess capability / capacity gaps to deliver floor coordination in / out of hours – alignment to ensure response for known surges. Explore opportunities to designate medical capacity to focus on non‐admitted’ patients

Devise and launch inter‐professional standards that support 4 hour pathways. Formalise ED MDT huddles membership, structure and objectives

GREEN


of 29


RATING

Test revised medical rotas through a Rapid Improvement week, ensuring that floor cover meets peaks in demand e.g. 6‐10PM Agree longer term ‘optimised’ rotas across all grades and confirm through job planning process

AMBER

Flow and Discharge

Immediate Grip and control Revise membership and structure of Beds meetings to drive accountability at ward level Test this revised approach in a Rapid Improvement week (30/8) Enhance visibility and uptake of available discharge lounge capacity

Launch revised Medically optimised list as a sense check for daily discharge volumes/ to support escalation of internal/external delays

GREEN

Ongoing flow management to accelerate discharges

Conduct RCAs across top 5 highest volume of post 2pm discharge wards to identify delay causes (Internal and external). Re‐calculate ward level discharge targets and communicate / monitor wards against these.

Consistent and complete implementation of SAFER throughout the hospital with a commitment to ensure at least 33% of patients are discharged before midday by March 2018 with clear trajectories to be agreed by the end of August.

AMBER


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RATING

Accelerate roll out of EDDs for every patient. Review inclusion criteria for OPAU and wider Older persons pathways to confirm scope to improve performance for this key cohort. Review use of full capacity protocol / Trust triggers. Update as required.

Re‐establish Golden Patient as a must‐do exercise for all ward areas, agreeing required volume of discharges and performance monitoring.

Transfer to Assess (T2A) Achievement of 3.5% DTOC by December Implementation of Trusted Assessor for care homes and domiciliary agencies by 30th October 2017

T2A in place by 4th September this involves patients being discharged to care home or own home for assessment and care planning building upon learning from pilot. New streamlined T2A discharge pathways and model and supporting integrated structure agreed. Scaling up from September to November. Please see supporting trajectory

AMBER

Community Capacity

Domiciliary Care This is an area of significant challenge. The loss of 4 key providers during 16/17 has negatively impacted on the capacity and flow within the domiciliary care market in Wirral.

A new commissioning model for dom care is under development, being co‐designed with providers due to implement April 2019.

RED


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RATING

Significant work with providers locally to address the position including additional £200k investment. The changes in model and approach (T2A) is increasing demand in this area. It is recognised a significant priority for Wirral is to achieve a ‘shift left’ in order to reduce the reconditioning of patients, therefore reducing the volume of referrals requesting 4 x double up calls per day Interim additional capacity and pilot schemes are being tested to support the system over winter, including enhanced dom care whereby nurses are working as part of the dom care team

Therapy redesign Cross organisation review of therapy services the results in a proposal for integrated community based therapy model enhancing streamlined care pathways directly supporting streaming, internal flow and DTOC.

Identification of quick wins to support the transformational changes above will be presented to UC Operational Group October. Full implementation go live April 2018

RED


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RATING

Initial paper due to be presented to joint exec October 2017.

Demand Modelling Phase 1 modelling indicates we are 50 system beds short based on current system deliverables. The whole system demand modelling exercise to inform reconfiguration of bed capacity is due October 2017. This analysis will be utilised to refine current capacity plans both for this winter and longer term. As a system, Wirral is confident that there is sufficient community bed capacity to support both plans for winter and contingency. There is currently a variable 8‐10% general nursing bed capacity available.

This has been addressed with additional winter beds to be available following capacity trajectory. We also estimate that by improving the current flow of community T2A beds, is equivalent to an additional 11 beds to the system.

GREEN

Support to care homes

Teletriage

Care Home Connector training supporting homes rolling out with Teletriage roll out – timescales as above.

10 homes gone live, additional 20 homes by mid‐October 17, further 10 by Dec 17, 20 more by

AMBER


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RATING

Falls prevention App rolling out with teletriage – timescales as above

March 18 remaining 16 April – June 2018.

Trusted Assessor

Co‐creation with homes 20th Sept – recruitment by end of Sept. Rolling out to Teletriage homes from October 17. Linking with new Discharge Process and Discharge to Assess model

AMBER

Primary Care

Enhanced primary Care support to Care homes – rolling out to all homes April 2018

1,400 care home patients receiving a service through commission currently

AMBER

Improvement Team/CHIP

Improvement team and nurses working with care homes requiring improvement. Priorities action plan being implemented

AMBER

Care Market Strategy

To be developed to draw together all care home schemes and future direction by Dec 17.

AMBER


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RATING

Mental Health

Whole system enabler

Mental health crisis care ‐ working through the crisis care concordat group to focus redesign and five year forward view investment on developing new approaches to tackling crisis and enhancing existing services in order to meet new national access targets. Should impact upon NWAS, police and A&E. To be in place January 2018. Also now bidding for NHSE monies for an extended crisis service for children locally, to be implemented in November 2018.

Psychiatric liaison ‐ core 24 investment looking to reduce both A&E attendances (for repeat attenders) and also reduce LOS for patients with mental health needs. Will be fully implemented by January 2018. Street triage ‐ extending the hours of street triage with the police and setting up a new service to work with NWAS. Staff recruited but currently awaiting enhanced police DBS clearance. Aim to reduce section 136 and A&E attendances for patients in crisis and also reduce NWAS conveyances too A&E – to be in place November 2017. CAMHS ‐ implemented THRIVE model, working with partners, particularly schools to reduce the number of mental health crisis admissions for children at the acute trust by prioritising early intervention, significant reduction already seen and expecting further impact

AMBER


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Delivery of 4hr Performance Trajectory 2017/2018:

TARGET SEPT 2017 OCT 2017 NOV 2017 DEC 2017 JAN 2018 FEB 2018 MAR 2018

Admission Avoidance including Ambulatory Care

2% 1% 2% 2% 2% 2% 2% 2%

ED Process 3% 3% 3% 3% 3% 3% 3% 3

Flow & Discharge 10% 1% 5% 5% 5% 5% 5% 10%

Baseline (80%) 95% 85% 90% 90% 90% 90% 90% 95%


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Whole System Winter Bed Plan

CURRENT BED MODELLING LAST YEAR THIS YEAR ADDITIONAL

SUBJECT TO STAFFING

OPEL 4 CONTINGENCY

ACUTE COMMUNITY ACUTE COMMUNITY ACUTE COMMUNITY

Acute ‐50 705 +86 Nursing IMC beds 705 +7 (Ward 14) +17 (M1 – Clatterbridge)

+86 nursing

+26 (old neuro Clatterbridge)

+27 (Ward 19) Commissioning additional nursing community bed capacity

Community ‐10 Residential T2A beds ‐ 3 Residential EMI T2A Beds ‐ 3 Nursing EMI beds

+12 Respite Beds +10 new T2A beds +3 Residential EMI beds +3 Nursing EMI beds +12 Respite Beds +10 Winter Escalation nursing T2A beds + additional commissioning based on second cut whole system capacity & demand (Oct)

10% achievability in market

Total 705 98 729 124 26 27 Max. potential 75 community beds

Requirement – 869 beds across system

853 (+50) 879 906 981

NB: revised T2A specification model and KPI’s will create equivalent for additional 11x beds in system, due to improved flow in whole system capacity and demand modelling due Oct 2017. Current explorations of additional community bed capacity for flu /demand at St Catherine’s (WCT)


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Whole system action plan

No. Priority Lead(s) Progress Start date and duration

Action

Demand and capacity plans Bed and home Urgent care demand modelling to identify potential peaks will be available 29.09.17

Exec Leads: Janelle Holmes (WUTH) Val McGee (WCT) Jacqui Evans (CCG and WBC)

Business intelligence team profiling peaks in demand to share report

September 17

BI to validate and finalise.

Acute escalation 7 winter beds on ward 14, Arrowe park 17 winter beds on M1, Clatterbridge Hospital (step down as part of T2A pathway), subject to safe staffing

Implementation Leads: Acute escalation Anthony Middleton (WUTH)

24 escalation beds available until April 18

Commenced until April 18

26 winter beds on previously named Wirral neuro unit at Clatterbridge Hospital supported by capital build, requires staffing

26 additional beds available once staffing model and funding agreed

1st Dec TBC until April 18

JE and AM to meet to agree staffing model in September and liaise with providers for delivery. Urgent care Op group to oversee implementation and monitoring

Community beds and wrap around MDT 86 Transfer 2 Assess nursing beds in 4 provider homes, new specification (replaces IMC model) and fee rate agreed, targeting shorter LOS to create extra capacity and improve flow 10 Transfer 2 Assess residential beds to become permanent from 01.10.17

Community bed commission Jacqui Evans Wrap around MDT

96 T2A beds available recurrently with MDT Further 10 available from 1st October, MDT to be identified

Commenced October 2017

12 respite beds for carer support, (6 Res EMI, 4 res, 1 nursing, 1 nursing EMI)

Available recurrently, new commission to be

Currently available

JE with contracts team to commission beds and MDT JE/GT/CO to work up GP cover


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Action

available Nov MDT to be identified until April 2018

however new commission commences 1st Nov (no break in service)

J Ey and AB to scale up MDT to include CWP (SQ) J Ey and AB to implement SAFER across T2A providers, monitored by dedicated contract manager

3 T2A residential EMI beds with MH assessment support

Available from 16th

October, MDT to be identified until April 2018

Meeting required with SQ, AB, SA to agree MDT for the additional 6 EMI beds including specialist input

3 nursing EMI beds step up step down with MDT wrap around and trusted assessor model

Available from 1st November, MDT to be identified until April 2018

Further 10 Transfer 2 Assess nursing beds for 6 month period and MDT funded through BCF as extension to existing capacity See Appendix 1 Additional implementation post for T2A and DToC (6 months)

November 2017 to April 18 September 2017

Meeting required with JEY and AB to shape and confirm additional MDT. CO to contract GP cover

GP capacity Full implementation of GP Access Hubs serving all population of Wirral for evening and weekends appointments and commission an additional circa 5,400 GP appointments over winter 2017/18 (Oct‐March) compared to winter 2016/17. GP access hubs will also

Exec Lead Martyn Kent (WCCG)

Information requested but not available until December 2017

SBS/MK to monitor progress and delivery and connect with UCOG Primary care dashboard in development JE raising info gaps with NHSE JE and MK to discuss funding of additional capacity.


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Action

support any surges in demand in primary care for same day appointment. Extended GP access to ensure 7 day 8‐8 cover in place November across 2 sites.

Implementation plan in development with primary care/ GP Federations

Effective Discharge Processes and T2A and admission prevention Patients own home (Home First) (equivalent to a ward) 7 patients per week from September 13 patients per week from October 20 patients per week from November 27 patients per week from December Enhanced Community Rapid Response 7 patients per week from September 10 patients per week from October 17 patients per week from November 23 patients per week from December The above are in addition to the 500+ patients the service is currently supporting annually.

T2A/Home First Julian Eyre

Scaling up from 1st October to take 27 patients per week by early December

Commenced and available ongoing from 30th September

J Ey recruitment of workforce to be completed by Mid‐October. This connects with implementation of new model and approach for discharge overseen by J Ey and AB

Domiciliary care 16/17 activity indicated at 13,668hrs. Avg. Per Person receives 11.17 hrs. Current position: 110 people waiting x average 11.17 hrs = 1,229 additional per week. Estimated growth required at 3%. This was financially factored in for reablement and dom care for 17/19. This will be revised following the whole system capacity

Jacqui Evans (WCCG & WBC)

To reduce the waiting list to 12 packages of care by 30th September Active recruitment across agencies

20th August for 3 months 16th October From 4th September

Awaiting the whole system capacity and demand modelling, first cut anticipated early October Dom care capacity model will be adjusted based on report


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Action

and demand modelling due oct, considering impact of new T2A models. Revised model from September 2017 to increase capacity and operate within the 4 hub model to meet target of packages available within 24 hours of referral. From 1st August additional £200k pass ported to dom care market to retain packages for 7 days for those admitted to acute and to increase capacity across WirralThis includes additional social work capacity to support provider led reviews Implemented trusted assessor for reablement and dom care This includes dedicated complex/end of life dom care commission

Boo Stone (WCB) Anne Barlow (WCT)

Recruitment underway.

October 2017

Requires the drive to shift left and improve therapy offer Workshop with providers on 20th September to discuss implementation of Trusted Assessor role

DTOC All of the above to support the DTOC target of 3.5% (See appendix 2 for DTOC trajectory)

Exec Leads: Janelle Holmes (WUTH) Anthony Middleton (WUTH) Jacqui Evans (CCG and WBC) Val McGee (WCT)

Trajectories available to reach 3.5% target Requiring: a) Effective single

assessments b) Reduce wait on Dom

care c) Address issues re

home of choice with Age UK dedicated HOC support officer, trusted assessor to improve assessment

T2A model, early MDT, cultural, behavioural shift


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Action

timescales and reduce delays

Front door processes and primary care streaming Implementation of clinical streaming Priority to ensure flexible and fluid protocols and pathways across organisations. Front door processes and streaming will support achievement of zero tolerance type 3 minor breaches. Phase 1

24 hour 7 day cover (GPs M to F 8 to 6pm)

Supporting peaks in demand particularly over weekends and bank holidays

Phase 1 in place with weekly task and finish group meetings.

From 4th September for phase 1 (zero tolerance on minor breaches)

Phase 2 model – fully costed Model to be agreed building on learning from phase 1. This will include signposting to alternative community services (including off site) Phase 3 – Urgent Treatment Centre Public Consultation to commence November 2017. Additional implementation post for streaming (12 months)

16th October 2017 phase 2 Phase 3 – TBD In post

Flow through the UEC pathway NWAS adopted ARP on 7th August 2017 and are making the necessary changes to their dispatch and reporting systems to embed the requirements of ARP. Early

Exec Leads: Janelle Holmes (WUTH) Anthony Middleton (WUTH) Debbie Mallet (NWAS)

Commenced 7th August ongoing over 2 year period

Aug 17

NWAS will continue to feed back to the Lead Commissioner and to local CCGs (via the Ambulance Area Commissioning Groups) on


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Action

feedback from the Trust is that staff in the Emergency Operations Centres have embraced the changes and found ARP to allow more appropriate allocation of the correct response to individual patients, delivering a faster response to time critical incidents. Other feedback from NWAS has indicated that vehicle utilisation rates have improved allowing resource to be protected for patients needing the fastest response.

how implementation of ARP is progressing. Discussions are taking place with the Lead Commissioner on what information can be produced to evidence successful implementation of the ARP requirements.

The implementation of ARP will continue as part of an overall package of changes to implement the overall transformation of the operational delivery of services by NWAS over the next 2 years. This will include reconfiguration of the ambulance fleet, changes to the workforce model and reliance on supporting endeavours around management of patients (e.g. HCP requests, Calls from care homes, closer integration with NHS 111 and working with other stakeholders).

30 minute turnaround of vehicles at APH by 1st October

Oct 17

The ongoing integration of ARP and delivery of performance continues to be predicated on 30 minute turnaround of vehicles at hospital sites. (JH, AM, DM)

4. Focus on improving patient flow Internal Hospital Improvements

‐ E&Y review ‐ Implementation of SAFER throughout APH ‐ Bed reconfiguration of CBH site

Senior Review – by clinician by midday – management

& discharge decision

All patients – expected discharge date & clinical criteria

for discharge set by assuming ideal recovery and assuming no unnecessary waiting

Exec Leads: Janelle Holmes (WUTH) Anthony Middleton (WUTH)

6 week diagnostic completed and action plan developed. See Appendix 1. Detailed plans and interventions to be in place mid October. Prioritised 5 high impact changes to WUTH internal action plans to deliver sustained improvement

Aug 17

Map 5 high impact interventions to current articulated Patient Flow improvement work by week commencing 11th September to include : Timescales Ownership Improvement trajectories


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Action

Flow ‐ earliest opportunity from assessment units to

inpatient wards. Wards will ensure the first patient arrives by 10am

Early Discharge ‐ 33% of patients will be discharged from base inpatient wards before midday. Trajectory: Current: 16%, October 18%, November 25%, December 28%, January 28%, February 30%, March 33%.

Review ‐ systematic multi‐disciplinary team (MDT)

review of patients with extended lengths of stay (>7 days) All partners are working together to produce a refreshed data dashboard that clearly identifies the blocks in the system. Additional project support and BI for urgent care have been identified to support this.

Jacqui Evans (WCCG & WBC)

to the delivery of the 4 hour standard. These are:

1. ED coordination 2. ED senior medical

cover – proof of concept week of 20th Sept to inform future model

3. Ambulatory care Model

4. Patient Flow – Grip & Control

5. Flow Management & Discharge

Post holder identified

Dashboard in place

Early discharge before lunch

Discharge Coordinators funded through BCF commence August 2017.

Integrated Discharge Team to attend board rounds to support decision making and EDD.

Exemplar ward showcase (SAFER)

Expansion of Age UK offer to include support for discharge lounge and home of choice

Extra care navigator posts (Age UK)

T2A pathway expansion – 10 August 2017

T2A residential beds (10) – tender process with beds to be in place 1st September 2017.

Stranded Patients

Weekly stranded patient reviews to commence 10 August 2017

5.


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Action

CHC Wirral CCG and DASS have commissioned Transfer to assess (T2A) beds in a nursing home. MDT support, to ensure timely assessments. IDT (acute) transfer all potential CHC patients to T2A, and checklists are completed outside of the acute. In order to facilitate the process a transfer to assess form has been developed.

Exec Lead: Ian Williams (CCG)

A specification has been written and a dashboard provides monthly information. Wirral has achieved the target of less than 15% of all CHC assessments undertaken in acute hospital setting. Wirral has achieved 80% of cases with a positive checklist and decision made within 28 days.

Continue with good progress. Reviewing process in line with new pathways to embed streamlined assessment process. Liaison with regional team re DPS and effective implementation in Wirral.

6. Flu planning Wirral Seasonal Flu Group which includes representatives of Wirral Health and Social Care organisations, Wirral Council and NHSE meeting throughout the year to facilitate co‐ordination preparedness for seasonal flu. This includes individual organisational planning for staff vaccination, population vaccine programme implementation and communications during the season. This enables sharing of intelligence, good practice and reduces duplication supports effective surveillance. Each organisation locally is responsible for ensuring that plans are in place for effective vaccination of essential staff. This is monitored monthly by NHSE and reviewed in the Flu Group.

Julie Webster Acting DPH (Wirral BC) Rachael Musgrave (WBC)

Meets monthly during Flu season Initial NHSE uptake data will be provided to

ONGOING Sept – Jan 2018

Vaccination programmes for staff have been initiated


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Action

All community and acute paediatric and maternity services to promote uptake of vaccine. Primary Care ensuring adequate stocks of vaccine and promoting with key population groups. All care homes are provided with a Seasonal Flu Resource Pack for how to prepare for flu and to manage in the event of an outbreak. Explore extension of vaccination provision to private care sector staff to protect vulnerable care home residents. GP OOH commissioned to ensure timely access to antivirals in the event of an outbreak in a care home out of hours. Primary care will provide the in hours response. Deliver the school based vaccination programme. Extensive local communications campaign is scheduled to target key groups starting in September to increase vaccination amongst potential transmission groups and ‘at risk’ cohorts. Focus is on pregnant women, young children and people with long term conditions.

All Health and Social Care Organisations CCG COO, MD and DPH Wirral CCG Wirral Council Wirral Community Trust IPC Team Wirral CCG Wirral CCG Wirral Community NHS Trust Wirral Council

illustrate progress in late Autumn. Schedule commences October 2017

October 2017 August 2017 September 2017 September 2017 September – Jan 2018 October 2017 September – January 2018

Action cards to support the packs are also being developed


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Action

7. 7 day Exec cover Agreeing 7 day Exec cover for the urgent care system. Review of daily escalation and conference call. To be implemented mid October.

Exec Leads: Janelle Holmes (WUTH) Anthony Middleton (WUTH) Jacqui Evans (CCG and WBC) Val McGee (WCT)

Mid October 2017 until April 18

Discussions and agreement at Exec with recommendation to A&E Delivery Board

8. Mental Health Services Capacity and demand planning

‐ Staffing and rotas ‐ Escalation process in place ‐ Bed management process (see below)

Bed management CWP has implemented a bed management system in acute care during 2017 which has been adapted but is based on the ECIP safer model used in acute trusts. This system coordinates MH acute bed management across Cheshire and Wirral on a day to day basis. This will be operating in and out of hours by December 2017. The bed management system is focusing on:

‐ Home treatment gatekeeping ‐ Maintaining and improving flow ‐ Removing recurring blockages that lead to

patients being stranded in inpatient care

Exec Leads Suzanne Edwards (SE) Sarah Quinn (SQ)

Also working with economy wide capacity and demand modelling to ensure that the impact of domiciliary care, reablement, care home capacity is factored in for MH specifically. In addition to ensure that delays in funding / CHC decisions are also taken into account for MH.

Completed December 17 Ongoing

Actions to support the wider UEC system October onwards

‐ Additional dementia nurses to support care homes and the telehealth pilot

‐ Increasing the hours of the street triage service with the police

‐ Introducing a street triage service with NWAS

‐ Introducing a new local transport service for patients who have been detained with a 1 hour response time

‐ Focus with WUTH on frequent ED attenders

Recruitment underway, staff expected in post Nov ‘17

9. Contingency plan B – OPEL 4/ non delivery of plan

Exec Leads: Janelle Holmes (WUTH)

Draft report to be reviewed early October

October 2017

Review on a weekly basis to respond appropriately to peaks


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Action

Additional Capacity Additional 27 acute beds on ward 19 (Arrowe Park) Spot purchase additional community nursing beds (currently 10% vacancy across market – up to 75 beds) Prioritisation of temporary ceasing of provision to redirect resource

a) Acute – cancel all non‐urgent clinical activity (electives, diagnostics, Outpatients etc.) excluding cancer and clinically urgent. Restarting theatre/ elective procedures after new year later than 16/17

b) Community based geriatricians to be redirected across system to support pressure points e.g. OPAU/ SPA

c) Community (WCT) – prioritise continuation of palliative, end of life and very complex wound management to free up matrons to support ED and OPAU and stabilise community services.

d) Community (WBC) – reprioritise reablement capacity for dom care maintenance.

e) Mental health – dementia nurses to be redirected to support SPA/ ED

f) Whole system – restrictions on annual leave considering ghost rotas – end Dec/start Jan

g) Plan as if OPEL 4 for first 2 weeks January 2018.

Anthony Middleton (WUTH) Jacqui Evans (CCG and WBC) Val McGee (WCT) Suzanne Edwards (CWP)

Discussions and plans in progress to finalise plans for 1st December to ensure go live possible. Close system wide monitoring of plans to assess risk on a weekly basis.

in demand or loss of traction on any of the above services Ongoing engagement and comms with community care market to ensure effective response over winter and alive to potential request for additional services


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Appendix 1

TABLED Week 6 Diagnostic output 130


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Appendix 2a ‐ Bed capacity September 2017 to April 2018

This excludes 705 core acute beds for 16/17 and 17/18. Please note, 16/17 winter nursing beds were IMC beds with reduced flow due to length of stay. Implementation of

T2A will release equivalent to 11 additional beds.


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Appendix 2b – Community capacity (non‐bed based) September 2017 to April 2018 NB additional capacity re 7 day 8‐8 offer to be added

0

50

100

150

200

250

Winter escalation ‐ T2A Res EMI

Winter escalation ‐ T2A Nurs EMI

Winter escalation ‐ T2A Nursing

Winter escalation ‐ Arrowe Park Hospital

Winter escalation ‐ Clatterbridge Hospital

Existing Respite beds

Existing T2A Res

Existing T2A Nursing

Existing acute escalation (contingency)


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Appendix 3 – DTOC Trajectory

0

200

400

600

800

1000

1200

Sep‐17 Oct‐17 Nov‐17 Dec‐17 Jan‐18 Feb‐18 Mar‐18 Apr‐18

42 42 42 42 42 42 42 4228 40 68 92 92 92 92 920

900900

900 900 900 900 900

28

5280

108 108 108 108 108

Winter escalation ‐ Home First (patients managed)

Winter escalation ‐ GP Additional Appointments

Winter escalation ‐ Enhanced CommunityResponse (patients managed)

Existing ‐ Rapid Community Response (Patientsmanaged)


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14 14 14 13 13 12 12 12 11 11 10 10 10 9 9 9 8 8

5 5 5 5 5 4 4 4 4 4 4 4 4 3 3 3 3 3

9 8 8 8 8 7 7 7 7 7 6 6 6 6 5 5 5 5

13 12 12 12 11 11 11 10 10 10 9 9 9 8 8 8 7 7

33

22

22

22

22

22

22

22

11

43 42 41 40 39 37 36 35 34 33 32 31 29 28 27 26 25 24

0

5

10

15

20

25

30

35

40

45

50

DToC TrajectoryJun‐17 to Nov‐17

Awaiting Assessment Further Non‐NHS Res/Nurs Bed POC Other


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