meeting east leicestershire and rutland ccg date tuesday...

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Meeting Title

East Leicestershire and Rutland CCG Governing Body meeting – held in Public

Date Tuesday, 14 April 2020

Meeting no. 62 Time 9:30am – 10:50am

Chair Dr Ursula Montgomery ELR CCG Chair

Venue / Location

Via Webex

REF AGENDA ITEM ACTION PRESENTER PAPER TIMING

B/20/1 Welcome and Introductions Dr Ursula

Montgomery 9:30am

B/20/2 Apologies for Absence: Sarah Prema

To receive

Dr Ursula Montgomery verbal 9:30am

B/20/3 Declarations of Interest on Agenda Topics To

receive

Dr Ursula Montgomery

verbal 9:30am

B/20/3

Minutes of the meeting held in December 2019 (approved at the LLR CCGs’ Governing

Body meetings in common)

To approve


verbal 9:35am

B/20/4

Matters Arising: Update on actions following meetings held in common in March 2020

To receive

Dr Ursula Montgomery A

9:35am

B/20/5

To receive written questions from the Public in relation to items on the agenda only

To receive

Dr Ursula Montgomery verbal

9:40am

ITEMS FOR DECISION, ACTION AND ESCALATION

B/20/6 Chair’s Report To approve


B 9:45am

B/20/7 Accountable Officer’s Corporate Report To receive

Andy Williams C 9:55am

B/20/8 Quality Briefing: COVID-19 To

receive Caroline

Trevithick D 10:05am

B/20/9 Leicestershire Better Care Fund Plan for 2020/21

To approve

Cheryl Davenport

E 10:15am

B/20/10 Finance Report: Month 11 update To

receive Donna Briggs F 10:20am

B/20/11 Suspension of Delegated Authority for Continuing Healthcare

To approve

Caroline Trevithick

G 10:30am

B/20/12 Governing Body Board Assurance Framework update 2019/20

To approve

Donna Briggs H 10:40am

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REF AGENDA ITEM ACTION PRESENTER PAPER TIMING

B/20/13 Register of Interests and Register of Gifts and Hospitality 2019/20

To approve

Donna Briggs I 10:45am

ANY OTHER BUSINESS

B/20/14 Items of any other business. To

receive Dr Ursula

Montgomery Verbal 10:50am

The next meeting of the ELR CCG Governing Body will be held in common with LC CCG and WL CCG, which will take place on Tuesday 12 May 2020, venue to be confirmed. The next meeting of the ELR CCG Governing Body will be held on Tuesday 9 June 2020, venue to be confirmed.


Verbal 10:50am

EXCLUSION OF THE PUBLIC

In accordance with the provision of Section 1(2) of the Public Bodies (Admissions to Meetings) Act 1960, to exclude representatives of the press and general public from the meeting due to the confidential nature of the business to be transacted.

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Paper A ELR CCG Governing Body meeting

14 April 2020

NHS EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP

ACTION NOTES

Minute No.

Meeting Item Responsible Officer

Action Required To be completed

by

Progress as at April 2020

Status

B/19/54 11 June 2019

Summary report from the Provider Performance Assurance Group meeting

Tim Sacks To contact and obtain information from WL CCG in respect of the review into the home visiting service.

August 2019

October 2019

December 2019

February 2020

The service is still within the contract terms and the CCG receives detailed information of the utilisation of the home visiting service provided by DHU by ELR practices. As part of the review of services for patients that could be delivered differently e.g. by PCNs this service will be reviewed and any future proposals brought to the Governing body. Request for action to be closed.

AMBER

B/19/86 12 March 2019

Appointment of Secondary Care Clinician (raised under Leicestershire Partnership NHS Trust - Care Quality Commission Inspection Report)

Daljit Bains A new Secondary Care representative to be appointed to the Governing Body.

July 2019 end

September 2019 end

January 2020

February 2020

The Executive Management Team have proposed that this action be deferred until discussions in relation to future form of the CCGs have been determined.

It is requested that this action be closed.

AMBER

Outstanding On-going Completed

Key

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Paper A ELR CCG Governing Body meeting

14 April 2020

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2

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Aligned to Strategic Objectives

Leicester City CCG West Leicestershire CCG East Leicestershire and Rutland CCG

Implications

a) Conflicts ofinterest:

None identified

b) Alignment toBoard AssuranceFramework

Supports the overall risk management and corporate governance arrangements.

c) Resource andfinancialimplications

None identified

d) Quality andpatient safety

None identified

Name of meeting: East Leicestershire and Rutland CCG Governing Body meeting

Date: 14 April 2020 Paper: B

Public Confidential

Report title: ELR CCG Chair’s Report

Presented by: Dr Ursula Montgomery, Clinical Chair, ELR CCG

Report author: Daljit K. Bains, Head of Corporate Governance and Legal Affairs, ELR CCG

Executive lead: Donna Briggs, Interim LLR CCGs’ Executive Director of Finance, Contracts and Corporate Governance

Action required: Receive for information only:

Progress update:

For assurance: For approval / decision:

Executive summary: The purpose of this report is to provide an overview and update of some of the key constitutional and strategic updates that affect the Governing Body and to provide an overview of meetings attended.

Appendices: Appendix 1 – Letter to LLR CCG Practices from LLR CCG Clinical ChairsApril 2020

Appendix 2 - HFMA COVID-19 Financial Governance Considerations

Appendix 3 - A letter from Amanda Pritchard Chief Operating Officer NHSEngland / Improvement - Reducing burden and releasing capacity at NHSProviders and Commissioners to manage the COVID-19 pandemic.

Recommendations: The ELR CCG Governing Body is asked to:

RECEIVE the contents of the report.

AGREE and APPROVE proposed constitutional changes as set out in thereport.

Report history and prior review:

Not applicable

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implications

e) Patient and public involvement

None identified

f) Equality analysis and due regard

Not required

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Chair’s Report

Introduction 1. The purpose of this report is to provide an overview and update of some of the key

constitutional and strategic updates that affect the Governing Body and to provide an overview of meetings that I have attended.

Governing Body members 2. I am pleased to be able to welcome Dr Nikhil Mahatma as our recently elected Member

Practice Representative, who joins the CCG today. Dr Mahatma is a partner at the Kingsway Surgery and brings a wealth of experience across the health sector both primary and secondary care, and across public and private sectors, which will be pivotal as the CCG and Member Practices make the journey towards becoming an integrated care system.

3. Following the appointment of Dr Mahatma, the CCG Governing Body now has the full establishment of five Member Practice Representatives as per the amendments approved by the CCG Membership in September 2019.

Meetings 4. In line with the national guidance in response to the COVID-19 pandemic we continue to

work remotely to support a system wide response to the current situation.

5. To enable clinical and managerial capacity to support the ongoing arrangements some meetings have been postponed, cancelled or take place virtually. Some meetings such as the LLR CCGs’ Clinical Reference Group and meetings with the Primary Care Network Clinical Directors have increased in frequency to ensure clinicians receive up to date information on the current situation. This enables the clinicians to continue to support and provide timely clinical input and advice in relation to changes that may be required to clinical pathways to support the response to the emergency situation, and to ensure clinicians are supported during this period.

6. All staff across the CCG are also working incredibly hard to ensure we can continue to

support the system response and also operate business as usual the best we can during these difficult times.

7. I would like to take this opportunity to thank all NHS colleagues and local partners across

Leicester, Leicestershire and Rutland (LLR) for their continued contributions, commitment and support in fighting coronavirus and delivering a system wide response in these challenging circumstances.

Changes to Chair meetings over the last month 8. In recent weeks I have been working closely with Professor Mayur Lakhani, Chair of

West Leicestershire CCG and Professor Azhar Farooqi, Chair of Leicester City CCG to develop a strategic approach to managing the response of the CCGs to the pandemic.

9. We have instigated the following regular meetings on a weekly basis and will review the frequency as the situation evolves:

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a) Participate in a telephone conference with Dale Bywater (NHS England Midlands Regional Director), Nigel Sturrock (Medical Director and Chief Clinical Information Officer), and CCG Chairs to receive a daily update report on the Midlands region.

b) Update from Caroline Trevithick on the strategic cell.

c) Update from primary care leads assigned to the primary care cell.

d) LLR CCGs’ Clinical Reference Group weekly teleconference meetings with the clinicians on the three Governing Bodies across LLR.

e) Webex with Clinical Directors of Primary Care Networks.

f) Andy Williams, Chief Executive update.

g) NHS England / Improvement telephone conferences for primary care as needed.

h) This week I joined a Webex hosted by Good Governance Institute in partnership with Browne Jacobson solicitors on Keeping focused, safe and legal - running your CCG during the COVID-19 crisis.

i) Clinical directors call between medical directors of Derbyshire Health United (DHU), University Hospitals of Leicester NHS Trust (UHL), Leicestershire Partnership NHS Trust (LPT), East Midlands Ambulance Service (EMAS) and clinical chairs of LLR CCGs.

j) Professor Farooqi represents the clinical chairs at the twice weekly Health Economy Strategic Coordinating Group meetings.

10. We will continue to review these meetings and our involvement regularly to ensure that

we are focused on supporting the CCGs and managing the governance.

11. We have also maintained communication with our member practices by supporting the primary care team messages sent in the daily situation update report (SITREP). This this week we also sent a letter to all our GP Practices thanking them for their professionalism and hard work in responding to the pandemic (a copy appended to this report for information).

Governance arrangements 12. During this challenging period, whilst we need to ensure necessary clinical and

managerial capacity is realised to support the response to the COVID-19 pandemic, it is recognised that, although there is some relaxation of business as usual arrangements nationally, as a CCG we are still required to ensure appropriate governance arrangements are adhered to that enable us to meet our statutory duties and functions.

13. It is also important that we ensure we continue to review our arrangements allowing flexibility wherever possible to act swiftly and make decisions in a timely manner to support the current situation.

14. The Executive Management Team continue to review operational governance

arrangements, operational scheme of delegations and detailed financial policies regularly to ensure operational decisions are taken swiftly while maintaining appropriate governance and controls.

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15. As a Governing Body we will need to ensure we continue to provide oversight and

support as required, and also continue to keep under review constitutional, corporate and financial governance arrangements and support in enabling flexibility where required. The following is an update reaffirming some of the current arrangements, areas which we will keep under regular review, and also areas which we need to agree to amend to enable some flexibility:

i) The CCG Constitution and Scheme of Delegation and Reservation:

At present the CCG Constitution is being updated to reflect the changes as approved by the Membership in September 2019 and the revised collaborative governance arrangements and committee terms of reference as approved by the Governing Body in October 2019. These approvals are recorded and therefore form part of the Constitution. The updated Constitution will incorporate the amendments and will be submitted to NHS England / Improvement in due course.

The delegation of functions and authority to committees and officers are as detailed within the Scheme of Delegation and Reservation, and within the amendments as approved in September 2019 by the Membership and as approved by the Governing Body in October 2019. These delegations will be kept under review as necessary.

ii) Governing Body and Committee meetings:

Meeting remotely: at present decisions are made in line with the CCG Constitution and members of Committees are required to be present. The Constitution is silent on the Governing Body, Committees and their sub-groups meeting virtually by means other than being present geographically in the same place and at the same time. Therefore, the Governing Body is asked to agree to support Committees of the Governing Body and their sub-groups to meet virtually (e.g. video conferencing, teleconferencing) to enable the CCG colleagues and Governing Body members to adhere to national guidance to remain at home and work remotely by means other than meeting in person.

This also means during the current situation we may not have members of the public present for meetings held in public, however we will ensure that questions from members of the public can be provided to the CCG in writing ahead of meetings taking place. A response to the questions will be published following the meeting. Details of this can be found on the CCG website.

Frequency of meetings: at present both the Governing Body and its Committees and sub-groups are required to meet at regular intervals and hold a specific number of meetings during the financial year. Some Committee and sub-group meetings recently have had to be cancelled or postponed to free up clinical and managerial capacity to support the system. However, if possible shorter meetings are being held to enable and support business as usual decisions or statutory requirements. The Governing Body is therefore requested to agree and support any

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postponement or cancellation of Governing Body and Committee meetings during the current situation.

Notice of meetings and papers: the process of giving notice of regular

meetings is detailed within the Standings Orders (within the CCG Constitution) including “special” meetings and “extraordinary” meetings of the Governing Body which can be called with 7 days and 14 days’ notice respectively. At present the agenda and papers for the regular Governing Body meetings and / or Committee meetings may not be prepared in readiness for circulation 7 days in advance of regular meetings. The Governing Body is asked for some flexibility should meetings need to be called urgently for critical business to be considered during the current situation; and to note that some reports may be delayed in being circulated in line with required timelines.

iii) Written resolutions for Governing Body decisions: We will consider whether for instance we could potentially reduce the

burden by amending our Constitution to consider written resolutions during this period to enable swifter decision making for the straightforward items that may not require the Governing Body to convene a formal meeting virtually during this period. This will then enable the focus of meetings that we do convene to consider urgent items of business or items that may require some detailed debate and consideration.

A written resolution allows Governing Body decisions to be made without having to hold a Governing Body meeting. Instead, a written resolution describing the decision can be circulated via email. Should this need to be consideration then the appropriate governance arrangements will be approved by the Governing Body to support this.

At present the Governing Body will continue to meet virtually and we will

continue to review this.

iv) Quroacy of Governing Body meetings and Committee meetings:

we may also consider reducing the quoracy arrangements during this period to release both clinical and management capacity to support the ongoing arrangements for COVID-19. This will be kept under review.

The quoracy arrangements for the Governing Body are detailed in the Standing Orders within the Constitution which has been updated following the reduction in Member Practice Representatives on the Governing Body as approved by the Membership in September 2019. With effect from 1 October 2019 the Governing Body meeting quoracy arrangements are as follows for regular, special and extraordinary meetings, including Annual General Meetings:

- There must be at least 3 Member Practice Representatives

present or 2 Member Practice Representatives and Secondary Care Clinician (Governing Body members will note this is a reduction in proportion to the number of clinical roles on the Governing Body, previously until 30 September 2019 4 GP

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Governing Body members were required to be represent or 3 GPs and the secondary care clinician).

- Where this is not possible, and / or where the Member Practice Representatives are conflicted and voting is required, 50% of persons entitled to vote upon the business to be transacted, shall be a quorum.

- Only those entitled to vote at a Governing Body meeting may cast a vote.

The above confirms the arrangements in place and the Governing Body is

asked to note and be assured that all decisions previously taken prior to the change in number of Member Practice Representatives and following the change, have been taken in line with the agreed quroacy arrangements and governance arrangements.

16. The Governing Body is asked to continue to support in ensuring we continue to adhere

to the principles of good governance in the way we conduct CCG business and in our decision-making processes.

17. National guidance has also been issued to support the necessary arrangements, including:

HFMA COVID-19 Financial Governance Considerations (a copy is appended to this report), and

A letter from Amanda Pritchard Chief Operating Officer NHS England / Improvement - Reducing burden and releasing capacity at NHS Providers and Commissioners to manage the COVID-19 pandemic (a copy is appended to this report).

Recommendations The East Leicestershire and Rutland CCG Governing Body is asked to:

RECEIVE the contents of this report.

AGREE and APPROVE proposed constitutional updates and changes as set out in the report.

Letter from Clinical Chairs to LLR teams

Dear colleagues,

The last week has been among the most difficult any of us can remember for the NHS and for general practice. We know that the next week or two will be even more challenging as we head towards the anticipated peak in demand on local services.

As we build up to that anticipated peak, with demand and numbers of cases likely to increase daily, we wanted to take this opportunity to write and convey our sincere thanks to you and all our colleagues in general practice for the professionalism and care you are continuing to show for our patients during this incredibly difficult time. It has been a real team effort involving medical and clinical teams, practice managers and our administrative and support workers.

Indeed, we are incredibly proud that practices across LLR have risen to the challenge and have shown great dedication and commitment in adapting to the circumstances while continuing to deliver services in very different ways.

They say that necessity is the mother of invention and that has proven to be the case, with the way we work and provide care, changing rapidly in just a few short weeks.

All practices are now operating a telephone triage service for patients and some are also beginning to embrace the potential of online consultations. We would like to thank LHIS colleagues for their support to practices in supplying the additional equipment needed for us to carry on without a pause in services to patients in the overwhelming majority of practices.

These changes have enabled practices to continue meeting the needs of their patients, reducing the risk of spreading coronavirus to patients and staff, while also continuing to provide important non-covid-19 related services such as childhood vaccinations and essential blood tests for cancer patients for example.

Indeed, yesterday’s sit rep (6 April) showed that 98% of practices were able to meet patients’ needs – that is a truly massive achievement given the changes we have had to implement so quickly.

We know there are issues that you are still concerned about, including availability of PPE and testing for staff. Rest assured that we are working hard to take these issues up on your behalf and ensure that essential equipment is available at all practices across LLR. We are also making the point, regularly, of the need to include frontline practice staff for testing at the earliest possible opportunity.

We also know that amid all of this you are undoubtedly concerned about the wellbeing of your staff and your own families and friends.

With that in mind it is impossible to underestimate how grateful we are for your support - particularly with so many practice staff giving up their bank holidays over Easter to ensure essential primary care services can continue over this critical period. We’ve also been overwhelmed by the number of volunteers we have had to staff the ‘hot hubs’ for patients displaying potential coronavirus symptoms.

We recognise that this situation is evolving and changing regularly. Please continue to share with us your queries and concerns so that we can support and escalate them where appropriate. In the meantime, we will continue to share regular updates through the

COVID19 comms each day at 5pm and will adapt this to questions and concerns that you are raising. Once again, thank you for all you are doing. It is greatly appreciated. Thankyou. Dr Ursula Montgomery Chair NHS East Leicestershire and Rutland Clinical Commissioning Group Professor Mayur Lakhani Chair West Leicestershire Clinical Commissioning Group Prof Azhar Farooqi Chair Leicester City Clinical Commissioning Group

HFMA COVID-19 briefing March 2020

Healthcare Financial Management Association www.hfma.org.uk

Covid-19 financial governance considerations Introduction The Covid-19 pandemic is impacting everyone in all parts of their lives. While there has been some relaxation of ‘business as usual’ arrangements, public sector bodies are still required to abide by the stewardship requirements of Managing public money and have a statutory duty to carry out their functions effectively, efficiently and economically. Although it seems a long way off, the NHS will be called to account for its stewardship of public funds once the pandemic is over.

This briefing is intended to identify the issues that finance teams will need to consider as new working arrangements are put in place. It will be updated as necessary. If there are other areas that we can provide useful guidance on, please let us know - [email protected]

Early action needed Some early actions and decisions are needed to enable the speeding up of financial transactions while maintaining appropriate controls and governance. The actions are in relation to:

• schemes of delegation and standing financial instructions (SFIs) • collecting and coding financial information that is auditable and evidenced

https://www.hfma.org.uk/

mailto:[email protected]

HFMA Covid-19 briefing

2

• documentation of key decisions • review of business continuity plans • changes to financial processes/ systems to allow this to work.

Internal communications We are seeing an unprecedented amount of communication about the Covid-19 pandemic1 and it can be difficult to identify the important information.

Locally, the focus of NHS bodies’ staff communication will be clinical and operational, but staff need to be clear what arrangements they need to follow when they are making decisions that incur a cost.

Changes to financial systems and controls need to be communicated to staff quickly and clearly.

Schemes of delegation and SFIs Authorised signatories Actions to take:

• review authorised signatory lists to ensure that there are sufficient signatories so that financial transactions are not slowed down when key staff are unavailable

• allow remote authorisation rather than requiring physical signatures. See below in the section Documenting approval

• consider bank account signatories to ensure that payments can be made when key staff are not available

• amend banking arrangements to avoid any need to go to a bank. For example, it may be possible to bank cheques via an app rather than by physically going to the bank.

Procedure notes and operational rules As staff undertake roles outside of their normal duties procedures and operational rules for key systems must be available and accessible to all staff in a common place, in both hard copy and electronically.

Key systems include payroll and creditor payments.

Any notes to document revised arrangements should also be filed in the same place.

Business continuity plans All NHS bodies should have a business continuity plan or business interruption plan that deals with how the organisation will manage in a situation where normal business arrangements cannot continue. Throughout the pandemic these plans should be:

• tested to ensure that they still work, and key staff are available • kept under review • updated where necessary • shared with all staff members and governing body members. Updates and changes should be quickly and clearly communicated.

See also the section Extending delegated authority.

1 Including this one!


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Schemes of delegation

Governing body powers The governing body of commissioning bodies has the power2 to arrange for the exercise of their functions on their behalf by:

• a non-executive member • any employee, including executive members or • a committee. NHS trusts and NHS foundation trusts have the power to ‘do anything which appears to be necessary or expedient for the purposes of or in connection with its functions’3. This means that the governing body can delegate its functions to staff, executive directors or committees.

For all NHS bodies, the governing body remains accountable for all its functions. Therefore, governing bodies need to put in place arrangements to be kept informed and maintain their monitoring role.

As accountable/ accounting officers, chief executives of provider bodies will be called to account for the decisions made to either Parliament or the Department of Health and Social Care (DHSC).

Consideration must be given to whether the number of members of the governing body required for meeting to be quorate will need to be revised. Meetings should be held remotely/ electronically where possible.

Business critical delegations The delegated limits that need to be considered most urgently include:

• order/ requisition authorisation levels – as discussed above, it may be that more people need to be given the authority to authorise orders and requisitions

• approval of agency/ locum staff – the NHS England and NHS Improvement (NHSE&I) reporting requirements for agency staff remain in place but as permanent staff fall ill or are required to self-isolate, more agency and locum staff will be required

• requirement for quotations/ tenders - most standing financial instructions will require at least two quotations for most purchases, if not a full tender process. In the current situation, this will no longer be possible for supplies relating to Covid-19. New arrangements must be clearly documented

• new suppliers - purchases will probably need to be made from suppliers that are not on the approved list of suppliers, so a process needs to be set up for either approving suppliers quickly or documenting why that supplier is used

• authorisation of overtime and expenses – usually the SFIs will include a level at which personal expenses will be reimbursed including subsistence allowances. Where staff are being asked to stay away from home in order to continue to work, those subsistence allowances may need to be reviewed and need to be clearly communicated. Equally, overtime is likely to have to be worked but must continue to be recorded and authorised, where possible, in advance

2 For NHS England, paragraph 13 of Schedule A1 of the NHS Act 2006; for CCGs, paragraph 3(3) of Schedule 1A of the NHS Act 2006 (subject to the specific arrangements set out in the CCG’s own constitution); for NHS foundation trusts, 3 For NHS trusts, paragraph 14 of Schedule 4 of the NHS Act 2006; for NHS foundation trusts, section 47(1) of the NHS Act 2006 subject to the specific arrangements set out in the foundation trust’s own constitution) Similar arrangements apply in the devolved nations


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• Covid-19 capital spending4 decisions below £15m (for providers) and £10m (for CCGs)5 – usually these would require the preparation of a business case and senior management approval at least. Capital expenditure relating to Covid-19 requirements will need fast decisions so formal business cases will not be prepared but NHSE&I are expecting local delegated authority arrangements to continue. The decision-making process should be documented along with those who made the decision. This may be simply meeting notes with a list of those present (in person and virtually). Where cash funding is needed NHSE&I approval will be required via regional offices and, where necessary, the national team

• Covd-19 capital spending decisions above £15m (for providers) and £10m (for CCGs) – NHSE&I approval is required so the regional office should be contacted. This approval process has been accelerated

• Non-Covid-19 emergency capital will be subject to the same arrangements.

Extending delegated authority Review the scheme of delegation in relation to what should happen in the absence of a director or staff member to whom powers have been delegated. These arrangements should be reviewed to ensure that they are workable in the current climate:

• consider the most appropriate person for powers to be delegated to - it may be more appropriate that a deputy director of finance takes on the responsibilities of a director of finance rather than another director who will be very busy and may not be the most qualified to make the decision

• Consider horizontal delegation - if a ward manager is not available then another ward manager may authorise transactions instead even though they do not work on that ward.

Documenting approval Often, approval is evidenced by a signature on a hard copy document - if staff are working from home, alternative evidence will be needed. Where there is email or electronic authorisation6, it is important to consider the controls around them when deciding on a solution.

There are apps that allow documents to be scanned using mobile phones7.

Where an electronic system is already in place, the process for approval should continue to work. However, where new approval arrangements are made then a decision needs to be made, before the new arrangement is put in place, whether the electronic system hierarchy will be changed or a workaround outside of the system is more appropriate. The core finance staff managing these systems will need to take part in these discussions.

Documenting decisions Once the pandemic is over, the NHS will be asked to account for the resources it has used to tackle Covid-19, so it is important that decisions made in a crisis situation are documented. A practical balance needs to be struck here to ensure that the basis for the decision is documented. but the decision-making process is not slowed down.

Documentation should to be held somewhere where it can be accessed at a later date – on shared drives or in hard copy files rather than on local computer drives or emails (see Procedure notes and operational rules).

4 This must be clearly linked to the pandemic response and expected to be delivered and/ or completed within the expected duration of the outbreak 5 These are the thresholds that are applicable in England, for the devolved nations the appropriate thresholds should be applied but local consideration of delegated limits and approval processes will still be required, 6 DBEIS, Electronic signatures: guide, August 2016. There are many electronic signature solutions available – here is a list of products found via a simple search 7 The HFMA’s IT team has suggested Microsoft Office Lens

https://www.gov.uk/government/publications/electronic-signatures

https://www.capterra.com/sem-compare/digital-signature-software?utm_source=bing&utm_medium=cpc

https://play.google.com/store/apps/details?id=com.microsoft.office.officelens&hl=en_GB


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Financial information Covid-19 expenses The guidance issued by NHSE&I8 and the announcements made by government are clear that the NHS will get the resources necessary to meet the Covid-19 challenge. However, it is also clear that only costs related to Covid-19 will be reimbursed. NHSE&I will be collecting both forecast and actual cost information and will be providing further guidance.

It is therefore vital that unique Covid-19 cost centres and budget codes are set up as soon as possible. Anyone who is part of the purchasing chain must be made aware of the appropriate cost centres and codes.

Consideration should be given to the level of detail that will be required:

• some costs, for example, the purchase of additional ventilators, will be clearly related to Covid-19 and can be coded to a Covid-19 expense code (or capital code) as the purchase is made

• staff costs paid to staff that are not able to work because they are self-isolating and cannot work from home may not be as clearly identifiable but should be captured. This may need to be captured outside of the core financial system

• sickness absence will need to continue to be captured and documented • other Covid-19 related costs, such as the costs of cancelled annual leave should also be

captured so that, if necessary, payment can be made to discharge the liability if the time cannot be given once the pandemic is over.

Ideally, opportunity costs of Covid-19 would also be captured, for example, the costs of staff moved to work on Covid-19 from other areas and income lost from doing other work. A decision should be taken as to whether to try to capture this information in real time or whether to work that out once the pandemic is over.

Appendix 1 contains a list of possible Covid-19 related costs.

Financial reporting 2020/21 The operational planning requirements for 2020/21 and beyond have been suspended5. However, to meet basic financial governance requirements, NHS bodies must be able to report their financial position for months 1 to 4 and beyond.

The 2020/21 budget will need to include:

• for providers: • block income • staff costs will be rolled over from 2019/20 plus any uplift for pay rises • agency and bank costs may exceed budget but normal arrangements for approving these

items will continue. • consultancy costs are unlikely to be incurred but if they are then the usual NHSE&I approval

requirements apply. • for commissioners:

• expenditure will be monitored against the block payments to providers as well as usual payments to primary care services

• allocations have already been provided. Month end processes should continue during this period as far as possible and taking into account materiality.

8 The letter issued by Simon Stevens and Amanda Pritchard on 17 March 2020


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Cash flow This issue is having an impact on the whole economy as well as the health system. It is important that staff are paid but also that suppliers are paid on a timely basis.

In England, from 1 April 2020, the arrangements for payment of NHS contracts have been simplified so NHSE&I does not expect NHS bodies to need interim working capital support, but the usual procedures should be followed if they do.

CCGs have been told to make a payment to providers on 1 April for the anticipated contract income for April and a second payment on 15 April for the May block contract adjusted for any amendments to the first payment. This means that NHS providers should have two months’ worth of cash in their bank accounts. Going forward, CCGs will pay on the basis of the block contract on the 15 th of each month. Providers will not need to invoice CCGs – payments will be made automatically.

It is important that suppliers, particularly small and medium sized companies, are paid promptly during this period. Normal terms and conditions, usually set to the NHS bodies’ advantage, will have to be suspended and faster payments made. The cash arrangements are intended to enable this to happen.

Cash flow forecasting9 will be particularly important.

Inventories and stocks Maintaining control over inventory will become critical as supply chains are under pressure. It will become vitally important that the right consumables are in the right place when they are needed:

• consider whether stock checks should be undertaken more frequently than usual in respect of the inventory and stock that is going to be in high demand or a target for theft, for example personal protective equipment, hand sanitiser and toilet rolls.

• where inventory is held centrally, consider reducing or limiting the quantity of some items that can be requisitioned at any one time to reduce the risk of unused stock being held on some wards while others are running short. This will have to be balanced with the time and administrative effort required to requisition and deliver inventory to the right place

• identify what items will be required and where, especially as wards and theatres are repurposed, to ensure that the supply does not impact on patient care. ‘Usual’ supplies and demand levels are not going to be a useful indication of what is needed during the pandemic

• identify inventory items that will not be in such high demand or needed at all during this crisis. These items may need to be moved off site and/ or securely stored elsewhere for the duration. If some hospitals/ sites are designated non-Covid-19 sites, inventory may need to be transferred those sites to enable them to continue to treat patients without incurring unnecessary additional costs

• patients with on-going conditions who are being seen in different settings - at home or virtually may need consumables (medicines, dressings) that they would normally get when visiting the hospital, these may need to be transferred to other providers or direct to the patients.

If inventory is moved to other NHS organisations, then records will need to be kept of where these items are being sent to ensure that they are appropriately accounted for and are not lost or wasted.

Fraud and irregular expenditure It is becoming clear that there are some people seeking to profit from the pandemic and therefore, it cannot be assumed that there is no risk of fraud or irregular expenditure. As financial controls are relaxed to ensure that finance is not a blocker to the provision of care to patients, it will be important to maintain a sceptical attitude and stop or question transactions which do not feel right.

9 HFMA, Financial forecasting in the NHS, July 2016

https://www.hfma.org.uk/publications/details/financial-forecasting-in-the-nhs


7

The Counter-Fraud Authority10 has suspended some of their activities, for example, the deadline for the self-review process has been pushed back and site visits are no longer taking place, but any frauds must to be reported to them as usual.

Equally, the number of cyber attacks via scamming emails may well increase during this period. Staff, especially those working from home for the first time, should be reminded to be vigilant about opening emails and any known issues should be publicised to all staff as soon as possible11.

Cost improvement programmes (CIPs) 2020/21 2019/20 CIPs will have nearly been concluded so the outturn against the plan should be reported. For the remainder of 2019/20 and the first part of 2020/21, CIPs have been suspended unless they can be useful to the current situation.

Therefore, plans should be reviewed to assess whether those plans can be useful or not. If not, then the programmes should be ceased but will be important that the decisions/ work done so far is clearly documented so the work done so far is not wasted.

Charitable funds There will be opportunities to use charitable funds as part of the Covid-19 response, but the funds will still need to be spent in accordance with their charitable purposes. We are working on a briefing on this.

10 https://cfa.nhs.uk/about-nhscfa/latest-news/covid-19 11 The HFMA’s IT team has produced guidance on how to identify and deal with malicious emails that we will issue for NHS bodies shortly

https://cfa.nhs.uk/about-nhscfa/latest-news/covid-19


8

Appendix 1 – Costs which may be incurred as a result of Covid-19

Staff related costs • bank and agency staff to increase capacity:

• clinical staff at all grades • non-clinical staff such as housekeeping, estates, IT and finance

• bank and agency staff to backfill Covid-19 sickness in other departments • training staff to move to respiratory and Covid-19 related disciplines • training costs for medical students, recently retired healthcare professionals and other

additional capacity staff members • DBS checks and other HR costs for additional staff members • salary and employer costs for additional staff members • impact of cancelled annual leave • accommodation and subsistence costs for staff to remain at work if unable to return home • administrative support to complete Covid-19 returns

Non pay costs

Medical • personal protective equipment • drugs costs for Covid-19 patients12 • oxygen • disposal items such as aprons, gloves and patient clothing • Covid-19 testing

Housekeeping • cleaning supplies for additional cleans and deep cleans • soap and hand sanitiser • food and drink for Covid-19 patients • additional laundry costs for additional beds and as beds are turned over faster than usual

Administrative • funeral costs

IT • laptops and associated technology for staff to work at home (some of this may be capital and

should be dealt with as such) • costs of additional software licences or remote access to systems

Capital • ventilators • Covid-19 pods • amendments to existing estate, for example, to install doors rather than curtains to isolate

patients • additional beds • additional mortuary space

12 High cost drugs will be paid for via the specialised commissioning teams as usual


9

About the HFMA The Healthcare Financial Management Association (HFMA) is the professional body for finance staff in healthcare. For nearly 70 years, it has provided independent and objective advice to its members and the wider healthcare community. It is a charitable organisation that promotes best practice and innovation in financial management and governance across the UK health economy through its local and national networks.

The association also analyses and responds to national policy and aims to exert influence in shaping the wider healthcare agenda. It has particular interest in promoting the highest professional standards in financial management and governance and is keen to work with other organisations to promote approaches that really are ‘fit for purpose’ and effective.

The HFMA offers a range of qualifications in healthcare business and finance at undergraduate and postgraduate level and can provide a route to an MBA in healthcare finance. The qualifications are delivered through HFMA’s Academy which was launched in 2017 and has already established strong learner and alumni networks.

© Healthcare Financial Management Association 2020. All rights reserved.

While every care had been taken in the preparation of this briefing, the HFMA cannot in any circumstances accept responsibility for errors or omissions, and is not responsible for any loss occasioned to any person or organisation acting or refraining from action as a result of any material in it.

HFMA 1 Temple Way, Bristol BS2 0BU

T 0117 929 4789

F 0117 929 4844

E [email protected]

Healthcare Financial Management Association (HFMA) is a registered charity in England and Wales, no 1114463 and Scotland, no SCO41994.

HFMA is also a limited company registered in England and Wales, no 5787972. Registered office: 110 Rochester Row, Victoria, London SW1P 1JP

www.hfma.org.uk

http://www.hfma.org.uk/

NHS England and NHS Improvement

Publications approval reference: 001559

To: Chief executives of all NHS trusts and foundation trusts CCG Accountable Officers Copy to: Chairs of NHS trusts, foundation trusts and CCG governing bodies Chairs of ICSs and STPs NHS Regional Directors

28 March 2020

Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pandemic

We wrote to you on 17 March 2020 setting out important and urgent next steps on the NHS response to COVID-19. Following this letter and detailed guidance to GPs we are writing today to provide further guidance to support you to free-up management capacity and resources.

During this challenging period NHS England and NHS Improvement is committed to doing all it can to support providers and commissioners, allowing them to free up as much capacity as possible and prioritise their workload to be focused on doing what is necessary to manage the response to the COVID-19 pandemic. Further information is provided on the following pages.

We will continue to review and monitor the situation and will remain agile in making further changes where necessary.

We appreciate the incredible amount of commitment and hard work going on across the NHS in these challenging times.

Yours sincerely

Amanda Pritchard

Chief Operating Officer, NHS England & NHS Improvement

1

The system actions

Changing NHS England and NHS Improvement engagement approaches with systems

and organisations

Oversight meetings will now be held by phone or video conference and will focus on critical issues. Teams will also review the frequency of these meetings on a case-by-case basis. For our improvement resource, we have reprioritised their work to focus on areas directly relevant to the COVID-19 response:

• GIRFT visits to trusts have been stood down with resources concentrated on supporting hospital discharge coordination

• The outpatient transformation work is focused on video consultation and patient-initiated follow up

• We have prioritised our special measures support in agreement with CQC to ensure we support the most challenged in the right way to help them manage the COVID-19 pressures.

2

1) Governance and meetings

No. Areas of activity

Detail Actions

1. Board and sub-board meetings

Trusts and CCGs should continue to hold board meetings but streamline papers, focus agendas and hold virtually not face-to-face. No sanctions for technical quorum breaches (eg because of self-isolation) For board committee meetings, trusts should continue quality committees, but consider streamlining other committees (eg Audit and Risk and Remuneration committees) and where possible delay meetings till later in the year. While under normal circumstances the public can attend at least part of provider board meetings, Government social isolation requirements constitute ‘special reasons’ to avoid face to face gatherings as permitted by legislation All system meetings to be virtual by default

Organisation to inform audit firms where necessary

2. FT Governor meetings

Face-to-face meetings should be stopped at the current time1 but ensure that governors are (i) informed of the reasons for stopping meetings and (ii) included in regular communications on response to COVID-19 eg via webinars/emails

FTs to inform lead governor

3. FT governor and membership processes

FTs free to stop/delay governor elections where necessary Annual members’ meetings should be deferred Membership engagement should be limited to COVID-19 purposes

FTs to inform lead governor

4. Annual accounts and audit

Deadlines for preparation and audit of accounts in 2019/20 are being extended. Detail was issued on 23 March 2020.

Organisation to inform external auditors where necessary

5. Quality accounts - preparation

The deadline for quality accounts preparation of 30 June is specified in Regulations. We intend it will be deferred

NHSE/I to inform DHSC

6. Quality accounts and quality reports – assurance

This work can be stopped Organisations to inform external auditors where necessary

1 This may be a technical breach of FTs’ constitution but acceptable given Government guidance on social isolation

3

No. Areas of activity

Detail Actions

7. Annual report

We are working with DHSC and HM Treasury on streamlining the annual report requirements – further guidance forthcoming

NHSE/I and DHSC to prepare guidance in due course

8 Decision-making processes

While having regard to their constitutions and agreed internal processes, organisations need to be capable of timely and effective decision-making. This will include using specific emergency decision-making arrangements.

4

2) Reporting and assurance No. Areas of activity Detail 1. Constitutional

standards (eg A&E, RTT, Cancer, Ambulance waits, MH LD measures)

See Annex B

2. Friends and Family test

Stop reporting requirement to NHS England and NHS Improvement

3. Long-Term Plan: operational planning

Paused

4. Long-term Plan: system by default

Put on hold all national System by Default development work (including work on CCG mergers and 20/21 guidance).

However, NHSE/I actively encourages system working where it helps manage the response to COVID-19, providing support where possible.

5. Long-Term Plan: Mental Health

NHSE/I will maintain Mental Health Investment guarantee.

6. Long-Term Plan: Learning Disability and Autism

As for Mental Health, NHSE/I will maintain the investment guarantee.

7. Long-Term Plan: Cancer

NHSE/I will maintain its commitment and investment through the Cancer Alliances to improve survival rates for cancer. NHSE/I will work with Cancer Alliances to prioritise delivery of commitments that free up capacity and slow or stop those that do not, in a way that will release necessary resource to support the COVID-19 response.

8. NHSE/I Oversight meetings

Be held online. Streamlined agendas and focus on COVID-19 issues and support needs

9. Corporate Data Collections (eg licence self-certs, Annual Governance statement, mandatory NHS Digital submissions)

Look to streamline and/or waive certain elements Delay the Forward Plan documents FTs are required to submit We will work with analytical teams and NHS Digital to suspend agreed non-essential data collections.

10. Use of Resources assessments

With the CQC suspending routine assessments, NHSE/I will suspend the Use of Resources assessments

11. Continuing Healthcare Assessments

Stop CHC assessments. Capacity tracker, currently mandated for care homes, is now also mandated for hospices and intermediate care facilities

12. Provider transaction appraisals

Complete April 2020 transactions, but potential for NHSE/I to de-prioritise or delay transactions appraisals if in the local interest given COVID-19 factors

5

No. Areas of activity Detail CCG mergers Service reconfigurations

Complete April 2020 CCG Mergers but delay work post April 2020. Expect no new public consultations except in cases to support COVID-19 or build agreed new facilities. We will also streamline or waive, as appropriate, the process to review any reconfiguration proposals designed in response to COVID-19

13. 7-day Services assurance

Suspend the 7-day hospital services board assurance framework self-cert statement

14. Clinical audit All national clinical audit, confidential enquiries and national joint registry data collection, including for national VTE risk assessment, can be suspended. Analysis and preparation of current reports can continue at the discretion of the audit provider, where it does not impact front line clinical capacity. Data collection for the child death database and MBRRACE-UK-perinatal surveillance data will continue as this is important in understanding the impact of COVID-19.

15. Pathology services We need support from providers to manage pathology supplies which are crucial to COVID -19 testing. Trusts should not penalise those suppliers who are flexing their capacity to allow the NHS to focus on COVID-19 testing equipment, reagent, and consumables.

6

3) Other areas including HR and staff-related activities

No. Areas of activity Detail 1. Mandatory training New training activities – refresher training for staff and new

training to expand the number of ICU staff – is likely to be necessary. Reduce other mandatory training as appropriate

2. Appraisals and revalidation

Recommendation that appraisals are suspended from the date of this letter, unless there are exceptional circumstances agreed by both the appraisee and appraiser. This should immediately increase capacity in our workforce by allowing appraisers to return to clinical practice. The GMC has now deferred revalidation for all doctors who are due to be revalidated by September 2020. We request that all non-urgent or non-essential professional standards activity be suspended until further notice including medical appraisal and continuous professional development (CPD) The Nursing and Midwifery Council (NMC) is to initially extend the revalidation period for current registered nurses and midwives by an additional three months and is seeking further flexibility from the UK Government for the future.

3. CCG clinical staff deployment

Review internal needs in order to retain a skeleton staff for critical needs and redeploy the remainder to the frontline CCG Governing Body GP to focus on primary care provision

4. Repurposing of non clinical staff

Non-clinical staff to focus on supporting primary care and providers

5. Enact business critical roles at CCGs

To include support and hospital discharge, EPRR etc

7

Annex A

Whilst existing performance standards remain in place, we acknowledge that the way these are managed will need to change for the duration of the COVID-19 response. Our approach to those standards most directly impacted by the COVID-19 situation is set out below:

A&E and Ambulance performance - monitoring and management against the 4-hour standard and ambulance performance (Ambulance Quality Indicators: System Indicators) will continue nationally and locally, to support system resilience. Simultaneously, local teams should maintain flexibility to manage demand for urgent care during the emergency period.

RTT – Monitoring and management of our RTT ambitions will continue, to ensure consistency and continuity of reporting and to understand the impact of the suspension of non-urgent elective activity and the subsequent recovery of the waiting list position that will be required. The wider announcements on suspension of the usual PBR national tariff payment architecture and associated administrative / transactional processes mean that, financial sanctions for breaches of 52+ week waiting patients occurring from 1st April 2020 onwards will also be suspended. Recording of clock starts and stops should continue in line with current practice for people who are self-isolating, people in vulnerable groups, patients who cancel or do not attend due to fears around entering a hospital setting, and patients who have their appointments cancelled by the hospital. The existing RTT recording and reporting guidance is recognised across the country as the key reference point for counting RTT activity and specific clarification of how this should be applied, in the scenarios described above, will be provided in due course.

Cancer – Cancer treatment should continue, and that close attention should continue to be paid to referral and treatment volumes to make sure that cancer cases continue to be identified, diagnosed and treated in a timely manner. Clarification has already been released to the system through the COVID-19 incident SPOC to confirm that appropriate clinical priority should continue to be given to the diagnosis and treatment of cancer with appropriate flexibility of provision to account for infection control. We have also confirmed modifications to v10 Cancer Waiting Times guidance to allow for this to be appropriately recorded. In addition, it has been agreed that the 28-day Faster Diagnosis Standard (which was due to come into effect from Wednesday 1 April) will still have data collected, but will not be subject to formal performance management. The Cancer PTL data collection will continue and we expect it to continue to be used locally to ensure that patients continue to be tracked and treated in accordance with their clinical priority.

8

Annex B

Data collections/reporting

NHS Digital maintains a significant volume of data which is mandated for return from commissioners and providers2. Much of this data is routinely submitted and imposes minimal burden on local systems.

It will be important to maintain a flow of core operational intelligence to provide continued understanding of system pressure and how this translates into changes in coronavirus and other demand, activity, capacity and performance – and in some areas it may be necessary to go further to add to and extend existing collections. For this reason, and to ensure effective performance recovery efforts can begin immediately after the intense period of COVID-19 response activity has subsided, the majority of data collections remain in place.

Notwithstanding the above, a subset of the existing central collections will be suspended, and these returns will not need to be submitted between 1 April 2020 to 30 June 2020:

• Urgent Operations Cancelled (monthly sitrep) • Delayed Transfers of Care (monthly return) • Diagnostics PTL • RTT PTL • Cancelled elective operations • Audiology • Mixed-Sex Accommodation • Venous Thromboembolism (VTE) • 26-Week Choice • Pensions impact data collection • Ambulance Quality Indicators (Clinical Outcomes) • Dementia Assessment and Referral (DAR)

2 https://digital.nhs.uk/isce/publication/nhs-standard-contract-approved-collections

https://digital.nhs.uk/isce/publication/nhs-standard-contract-approved-collections

9

Annex C

Data Security and Protection Toolkit Submission 2019/20

It is critically important that the NHS and Social Care remains resilient to cyber-attacks during this period of COVID-19 response. The Data Security & Protection Toolkit helps organisations check that they are in a good position to do that. Most organisations will already have completed, or be near completion of, their DSPT return for 2019/20.

The submission date for 2019/20 DSPT has been extended to 30 September 2020. However, in light of events NHSX recognises that it is likely to be difficult for many organisations to fully complete the toolkit without impacting on their COVID-19 response. NHSX has therefore taken the decision that:

• Organisations that have completed and fully meet the standard will be given'Standards Met' status, as in previous years.

• Where NHS trusts, CCGs, CSUs, Local Authorities (including Social Careproviders), Primary care providers (GP, Optometry, dentist and pharmacies) andDHSC ALBS do not fully complete or meet the standard because doing sowould impact their COVID-19 response this will be considered sufficient andthey will be awarded 'Approaching Standards' status and will face nocompliance action. It will be possible to upgrade from 'Approaching Standards'status to 'Standards Met' status through the year. The cyber risk remains high. Allorganisations must continue to maintain their patching regimes and Trusts, CSUsand CCGs must continue to comply with the strict 48hr and 14 day requirementsin relation to acknowledgment of, and mitigation for, any High Severity Alertsissued by NHS Digital (allowing for frontline service continuity).

• Organisations that have not taken reasonable steps to complete their toolkitsubmission for 2019/20 will be given 'Standards Not Met' and may facecompliance activity, as per previous years.

For any queries please contact or for further information please go to https://www.dsptoolkit.nhs.uk/News

https://www.dsptoolkit.nhs.uk/News

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group

East Leicestershire and Rutland Clinical Commissioning Group

Aligned to Strategic Objectives Leicester City CCG West Leicestershire CCG East Leicestershire and

Rutland CCG

Implications a) Conflicts of

interest:No conflicts of interest have been identified.

b) Alignment toBoard AssuranceFramework

Not applicable.


Date: 14 April 2020 Paper: C

Public Confidential

Report title: Accountable Officer’s Corporate Report

Presented by: Andy Williams, Chief Executive

Report author: Jo Grizzell, Head of Corporate Affairs Daljit K. Bains, Head of Governance and Legal Affairs Stuart Fletcher, Head of Corporate Governance

Executive lead: Richard Morris, Director of Operations and Corporate Affairs

Action required: Receive for information only: Progress update:


Executive summary: The purpose of this report is to inform the Governing Bodies of key activities with which the Executive Membership Team and Chief Executive have been involved in since the last meeting of the Governing Bodies. The report includes updates on items not covered elsewhere in the Governing body papers, as well as details of achievements and other pieces of useful information.

Appendices: None

Recommendations: The East Leicestershire and Rutland CCG Governing Body is asked to:

• RECEIVE for information the Accountable Officer’s report.


Not applicable

c) Resource and financial implications

There are no financial implications.

d) Quality and patient safety implications

None identified.


Not applicable.


Not applicable.

2

ACCOUNTABLE OFFICER’s REPORT INTRODUCTION

1. This report sets out to the Governing Bodies some of the key activities with which the Executive Leadership Team (ELT) and I have been involved in across Leicester, Leicestershire and Rutland (LLR) since our last meeting of the Governing Bodies. It includes updates on items not covered elsewhere in the Governing Body papers, as well as details of achievements and other pieces of useful information.

Leicester, Leicestershire and Rutland (LLR) NHS Long Term Plan and 2020/21 System Operational Plan update

2. To ensure full organisational (both NHS Commissioners and Providers) focus on responding to the COVID-19 crisis, NHS England/Improvement has taken the unprecedented decision to suspend all strategic and operational planning. This suspension applies to the further refinement, sign off and publication of the Leicester, Leicestershire and Rutland (LLR) NHS Long Term Plan as well as the 2020/21 System Operational Plan. More specifically, development of the 2020/21 financial plan, performance trajectories and system efficiencies (formally QIPP/CIP) have all been paused. At present, no duration has been applied to the suspension of strategic and operational planning. However, initial indications would suggest that planning will remain suspended for the first two quarters of 2020/21.

3. Prior to the suspension of strategic and operational planning, LLR received formal

feedback on the draft 2020/21 System Operational Plan. This feedback highlighted the presence of clear evidence of full system involvement in the development of the LLR NHS Long Term Plan and 2020/2021 System Operational Plan. Also highlighted within the LLR feedback was a request for further operational delivery detail on how the system would meet the requirements within the NHS Long Term Plan and deliver on the necessary efficiencies.

Covid-19 Update

Declaration of major incident

4. On 24th March representatives from the Leicestershire Police force, local authorities, public health and the NHS declared the outbreak of COVID-19 a major incident.

5. LLR NHS is now working within an overall structure established by the Leicester, Leicestershire and Rutland Local Resilience Forum under the strategic command of Leicestershire’s chief constable. The LRF is the multiagency partnership for the management and co-ordination of responses to emergencies in LLR. A Strategic Co-ordination Group of lead officers from each of agencies provides the overall direction for responding to the outbreak.

LLR NHS Incident Management Arrangements

6. We have established a Strategic Co-ordination Group to provide the overall system wide direction for the NHS in LLR. The Strategic Group is supported by the Health Economy Tactical Co-ordination Group (HETCG). The tactical response to the Covid – 19 is delivered through several cells covering organisations and particular activities:

3

• DHU • Discharge Cell • EMAS • EPRR • Independent Sector Hospital Capacity cell • IPC • LPT Cell • Media & Comms Cell • Medicines Cell • Primary Care Cell • Public Health England • Social Care • UHL Tactical • Urgent & Emergency Care • Workforce

Overview of response

7. Underpinning our response has been the need to increase capacity to enable the NHS to cope with the anticipated increase in numbers of people who need to be admitted to hospital and adapting services in line with national guidance to minimise face to face contact and avoiding, unless medically necessary.

8. Examples of the actions taken are: • Focus on discharging those patients medically fit to be discharged, working closely

with social care to ensure arrangements are in place for appropriate support; Increasing critical care capacity in UHL Critical care beds are increasing from 50 to 150 and with the potential to create around 300.

• Clinical staff are having intensive refresher training to enable them to look after the numbers of patients requiring respiratory support and we have received nearly 500 expressions of interest from retirees and leavers who want to come back to help their colleagues.

• Temporary changes to the way patients are seen at the Adult’s and Children’s Emergency Departments at UHL. The departments are now split into two separate areas: The Blue Department - for patients without symptoms of COVID-19 and The Red Department - for patients with symptoms of COVID-19.

• A 70% increase in community hospital in-patient beds for step down and end of life care through the phased introduction of 75 Independent sector beds and an extra 72 beds on LPT additional wards. Overall community beds will increase from 222 to around 350;

• new Mental Health Urgent Care Hub to triage urgent mental health patients to reduce demand at the emergency department at LRI.

• Changes to urgent and emergency care pathways to reduce the movement of patients and consolidate clinical staff on to fewer sites and to reflect fewer face to face consultations between patients and health staff currently taking place as a precaution against COVID-19 (coronavirus):

4

o all out of hours face to face consultation are now delivered from Loughborough Urgent Care centre.

o Temporary closure of Enderby, Melton Mowbray, Lutterworth, Oakham and Market Harborough

o Temporary closure of the two GP extended access sites in West Leicestershire area - Coalville and Hinckley and two of the Healthcare Hubs in Leicester City – Belgrave (Brandon Street) and Saffron

o The creation of ‘hot hubs’ at Loughborough Urgent Care Centre and Oadby to see Covid-19 symptomatic patients

• In primary care all practices are now operating a telephone triage service for patients

and embrace the potential of online consultations. These changes have enabled practices to continue meeting the needs of their patients and providing non-covid -19 related care, whilst reducing the risk of infection.

Looking after NHS colleagues

9. Staff testing having initially been prioritised for those in critical roles in emergency care and ambulance Trusts is being extended to primary care, community staff and care home staff.

10. Colleagues are working incredibly hard in difficult circumstances so looking after their welfare is essential. Locally we continue to develop resources and support for our people, making them aware of services available.

11. Two joint CEO thank you letters have been sent to staff in appreciation of the hard

work and commitment shown in response to Covid-19. The response has been astonishing, staff have shown the highest levels of dedication to the best for the people of LLR.

12. Regular bulletins have been provided to colleagues to keep them informed of

developments local on Covid-19.

Personal Protective Equipment (PPE)

13. Members will be fully aware of the difficulties with the supply of PPE. There is now a focus on ensuring that an adequate supply of appropriate PPE is available for different care settings.

14. New guidance has also been issued to respond to concerns about the level of PPE required in different settings.

Public information

15. Working with colleagues in UHL and LPT, the CCG communications team has been ensuring information is available promoting the national messages on Stay home, Protect the NHS, Save Lives campaign but also to ensure people are aware of service changes locally. Activities include:

5

• Media interviews describing the response of the NHS • An initiative with community radio stations to enable us to reach BAME communities • Regular stakeholder bulletins • Social media posting • Creation of a multi – agency LLR Covid-19 public information hub called One

Prepared Conclusion

16. The response of the NHS in LLR to the Covid-19 outbreak has demonstrated the NHS at its best. Working across boundaries the focus has entirely been on doing what is best for our patients and ultimately to save lives.

17. We have achieved this through effective partnership working both within the NHS

and with other public, private and voluntary organisations and sheer determination and hard work.

18. The public is showing its appreciation of our response every Thursday through the

Clap for Carers, a moving tribute to all key workers.

19. Whilst it is truly sad that for some Covid-19 is fatal, it is heartening to hear the testimonies of recovered patients who have praised the care they have received.

20. We should rightly be proud of what we have achieved.

Recommendation: The East Leicestershire and Rutland CCG Governing Body is asked to:

• RECEIVE for information the Accountable Officer’s report

.

6

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Aligned to Strategic Objectives

Leicester City CCG West Leicestershire CCG East Leicestershire and Rutland CCG

Implications

a) Conflicts of interest:

None identified

b) Alignment to Board Assurance Framework

Currently there are processes in place, as described within each Terms of Reference, to ensure timely escalation of high risks and concerns to the Health Economy Strategic Co-ordinating Group (HESCG). Further details in manging risk are outlined in the update.


Decisions made by both the HESCG and the HETCG need to demonstrate that consideration has been given to impacts on quality, safety, finance and operational issues and that appropriate review by primary and secondary care clinicians has taken place.

Name of meeting: East Leicestershire and Rutland Governing Body (public)

Date: 14 April 2020

Paper: D

Report title:

LLR CCGs - monitoring for quality and safety concerns as part of the COVID-19 response

Presented by: Caroline Trevithick – Executive Director of Nursing, Quality & Performance

Report author: Chris West, Director of Nursing Elaine Thompson, Interim Lead Nurse

Executive lead: Caroline Trevithick – Executive Director of Nursing, Quality & Performance

Action required: Receive for information only: Progress update: For assurance: For approval / decision:

Executive summary: The following paper provides details of the monitoring processes being undertaken for quality and safety during the COVID pandemic including the governance arrangements for decision-making and the way the CCGs are working with providers to ensure that quality and safety is paramount.

Appendices: LLR Health COVID 19 infrastructure Recommendations:

The Governing Body is asked to discuss this paper to ensure board members are assured by the processing place at this time to monitor quality and safety during the COVID-19 period.


d) Quality and

patient safety implications

Addresses the CCG’s statutory duty for quality during the COVID-19 pandemic


Not applicable to this update


Not applicable to this update

LLR CCGs - monitoring for quality and safety concerns as part of the COVID-19 response

1. Introduction

In light of the fact that the system is working differently we have undertaken a review of the CCGs’ systems and processes in place to monitor quality and safety as part of business as usual in order to appropriately refine the processes during the extraordinary period of COVID-19. NHSE/I have issued guidance to the NHS to reduce the burden of bureaucracy and release capacity into the system, but the requirement to ensure oversight of quality and safety is still paramount. The following information highlights the arrangements in place across LLR. The CCGs’ nursing team members are working to support the system in facilitating discharges and ensuring safe packages of care for ages of patients across mental and physical health pathways. This has resulted in a smaller workforce focussing on monitoring quality and safety. The decision has been made to ensure that the Integrated Quality and Governance Committee continues to meet to monitor key areas, this will ensure that any quality concerns are reported through the CCGs’ governance processes.

2. Emergency Preparedness 2.1 Health response (Appendix 1)

In line with the Emergency Preparedness, Resilience and Response infrastructure across LLR the LLR CCGs have established a strategic and tactical infrastructure to managing the current situation. The 2 groups are led by the CCGs and have multi agency representation from health and social care. The Health Economy Strategic Control Group (HESCG) has replaced the LLR Strategic Executive and meets twice a week and the Health Economy Tactical Control Group (HETCG) meets 3 times per week. Feeding into the HETCG are a number of subgroups leading on the wide range of issues being addressed to meet the challenges during the pandemic. CCG teams have been redeployed where necessary to focus on the COVID 19 work to support the NHS and wider public sector.

2.2 Governance Processes Each group has a Chair, Deputy Chair and agreed Terms of Reference and membership is drawn from key agencies, including Health, Social Care and wider partners. Clinical representation from CCGs and the Primary Care Networks (PCNs) has also been identified (Appendix 2). There are clear processes in place, as described within each Terms of Reference, to ensure timely escalation of high risks and concerns to the Health Economy Strategic Co-ordinating Group (HESCG). Decisions made by both the HESCG and the HETCG need to

demonstrate that consideration has been given to impacts on quality, safety, finance and operational issues and that appropriate review by primary and secondary care clinicians has taken place. Changes to pathways as a result of COVIC-19 are being collated from a clinical perspective through the Transferring Care Safely mechanism. This will ensure that there is effective communication across UHL, LPT, primary care and other providers regarding changes to services. The CCGs’ contracting teams are collating the information regarding changes to pathways to report into Collaborative Commissioning Committee. This will ensure that there is a central governance process monitoring the changes. Regular communications regarding pathway changes are been sent to wider stakeholders and the public. Work is underway to establish a recovery group to ensure that we reinstate pathways as soon as is safe to do so ensuring that we pick up the learning from the changes in working arrangements across health and social care to ensure maximum learning for the system takes place. It should be noted that the CCGs are committed to ensuring that no permanent changes will be implemented without due process regarding consultation and undertaking quality and equalities impact assessments.

3. Quality and safety 3.1 Quality Metrics

There are agreed Quality and Safety Metrics in place for each commissioned provider; these are outlined within an agreed Quality Schedule. Under normal circumstances the CCG would have regular face-to-face meetings with commissioned providers to review and discuss these metrics, however due to the COVID-19 crisis these face-to-face meetings have been put on hold so as to allow providers to concentrate on the delivery of their COVID-19 work. The CCGs’ Quality Contracting Teams are maintaining regular contact with our commissioned providers in order to effectively track any additional concerns within the system. The reporting of serious incidents through the STEIS system remains in place, and the CCG continues to use the information and learning from these serious incidents, and their resulting investigations to gain assurance improvements to patient safety and clinical quality are being identified and embedded.

3.2 Ongoing surveillance and monitoring of Quality Issues

Within the CCG we have established a Quality and Patient Safety Concerns log which will enable us to ensure effective tracking and oversight of any identified quality or patient safety concerns. This log is reviewed on a daily basis by a senior staff member within the CCG and escalated to as appropriate to the Executive Director of Nursing, Quality & Performance. Utilising a Quality and Patient Safety Concerns log in this manner will enable the CCG to be effectively sighted on any growing concerns within the wider system,

and therefore take timely and responsive action(s). The CCGs have written to all commissioned providers asking them to consider what quality and patient safety data they will be able to reasonably share during the current COVID-19 crisis and asking them to report any significant quality and patient safety issues they are experiencing to the CCGs so that so that we are not only sighted on the challenges organisations are facing, but also that we can explore wider solutions to such challenges. All commissioned providers have responded to this communication and many have also confirmed the level of quality and patient safety data they will be able to continue sharing with the CCGs during this current crisis. Work is currently taking place to ensure regular telephone conferences with commissioned providers to support regular and ongoing quality and patient safety monitoring.

3.3 Quality monitoring within Care Homes During the current COVID-19 crisis all visits to Nursing and Residential Care Homes has been suspended, however the CCG Care Homes Team continues to monitor quality and patient safety through maintaining regular and ongoing contact with Home Managers. The CCGs’ Care Homes Team is currently making telephone contact with all Nursing and Residential Care Homes with Nursing across the LLR to ascertain how these Homes are managing through the current COVID-19 crisis. In addition to this an Infection Prevention and Control Advice Helpline has been established for Nursing and Residential Care Homes across the LLR. This Advice Helpline provides Homes with additional guidance to support them to manage the care of residents with actual or potential cases of COVID-19. Work has also been undertaken to update a resource website for Nursing and Residential Care Homes across the LLR which supplies a range of up-to-date information concerning the management of actual or potential cases of COVID-19. This website also provides a comprehensive range of Frequently Asked Questions to support Care Home Managers and staff to have both a greater understanding of COVID-19, and also practical steps that they can take locally with their Homes to support residents.

3.4 Safeguarding The LLR Safeguarding teams across health and social care have come together to ensure that there are appropriate mechanisms in place to ensure children and vulnerable adults are identified and plans are in place to undertake face to face monitoring. The LLR safeguarding group is chaired by the CCGs and reports to the Safeguarding Board’s Office(s) and also is aligned with the work of the children’s sub-group; these escalate to the social care cell. The CCG Safeguarding team are currently working on information for primary care to ensure that they are aware of at risk patients on their caseloads and what

actions are required. There is heightened awareness amongst ED and Midwifery to identify safeguarding risks during the lockdown.

4. Cancer The Cancer Board has met to ensure that there is regular communication across the system to ensure that the risks associated with reducing services are fully understood. Measures are being taken to monitor that we have coordinated updates in PRISM 2ww templates to reflect the new measures, and the CCGs and UHL have reopened the Transferring Care Safely reporting process specifically for referral issues to help with implementation and further modifications. The following has been submitted to NHSE to provide assurance regarding cancer services

What is the current status of cancer provision (against business as usual levels) and key risks:

Current Position Comments /Support Required

a) Management of 2ww referrals

• National guidance has been discussed/ reviewed and UHL have confirmed that it is being applied

• Patients are safety netted onto the Patient tracking list (PTL) in the event that decision is made not to proceed to diagnostics , patient is fully involved in the decision and provided advice on escalating problems or worsening or new symptoms

• Referred patient who are not available or because of shielding, chose not to attend diagnostic or outpatient are retained on PTL list to ensure appropriate follow up and review

• In the event that a GP following discussion with the patient decides not to refer the patient under NG12 guidance because of the Clinical risks relating to Covid-19, The general practice will ensure the patient is safety netted Primary-care are currently developing a system to improve co-ordination of safety netting.

• System to ensure individual cases are escalated has been agreed and being developed

• There has been a significant reduction in 2 week wait referrals which the system will need to understand and compare to other systems

• Key risk remains staffing and Workforce

b) Outpatient activity

• All tumour sites have been instructed to employ telephone triage and stream patients straight to test where this is possible and appropriate

• This will continue to be discussed at weekly Cancer Board meeting.

• All tumour sites are looking to see how to risk stratify patient follow ups.

• Looking at Virtual support in the community through (IHope)

c) MDT meetings

• MDTs are continuing virtually where possible

d) Screening patients

• In terms of Cancer Screening we are following national guidance

• Patient Covid -19 screening in place, tests sent to Nottingham

• Staff at home are tested to see if can return to work

• Full protective measures are being taken.to protect against Covid-19

• Support to increase testing capacity and return is required.

• Staff at greater risk of Covid -19 Sequelae can these staff be used differently within East Cancer alliance to support greater resilience?

What are the plans for maintenance of all cancer services, in line with the updated Covid national guidance?


a) Links to tertiary services

• Joint MDTs continue to be provided to ensure joint decisions are made

• Tertiary referrals continue to be accepted for Treatment at UHL

• LLR would be keen to engage in any discussion which helps to manage capacity across a Cancer Alliance footprint

b) How are you ensuring that the independent sector is fully utilised, and what’s been utilised to date? For example, tumour sites / types of cases / location

• A considered system decision made to use the private sector for medical step down. This decision has been made for a number of reasons:

o Workforce availability i.e. anaesthetist, surgeons, nurses.

o Need for ventilators o Expected medical capacity

required. Decision was made through the Strategic Group working with the Independent Sector Cell

• Two to three theatres have been designated for cancer care.

• It is currently impossible to create a cold site for cancer services at UHL given that planning has been reliant on accessibility to suitable facilities for covid-19 patients i.e. oxygen therapy and critical care facilities.

• Discussion are currently ongoing to consider the private sector for chemotherapy patients

• Guidance stipulates that a central MDT demand and capacity process be employed/considered to triage appropriate patients and maximise access to capacity across a Cancer Alliance footprint. LLR would be keen to engage/ discuss such an option.

• LLR would be keen to understand and link up with specialised commissioners and developments involving the private sector.

• Consideration to system is now required in partnership with the Cancer Alliance.

How do you plan to continue to deliver urgent and time critical chemotherapy and radiotherapy?


• UHL continue to provide Systemic Anti Cancer Treatments (SACT) whilst following Societies guidance – risk assessing each patient.

• Radiotherapy is being delivered in accordance with advice from the RCR (royal college of Radiotherapy) and any change to treatment is being recorded to ensure review of possible harm.

• UHL have developed a Radiotherapy Covid-19 response plan which details planned procedures for treating suspected and known positive patients.

• In the event of staff shortage RCR guidance will be followed

What are the governance arrangements, including safety netting, to ensure patients are kept safe and changes to treatment plans are recorded and any

harm review processes? Current Position Comments /Support

Required • At system level weekly cancer board meetings are taking

place to review latest position/guidance and required solutions which ensures joined up working and support between primary and secondary care. EMCA are an inclusive member of the board.

• All tumour sites are reviewing pathways according to best clinical advice and Primary care pathway group has been established to support, understand and mitigate any risks to patients.

• Cancer changes are included in the daily primary care briefing where appropriate.

• Cancer board feeds into system strategic and tactical processes.

• Patients are kept on PTL lists to ensure appropriate monitoring and reviews

• Primary care is developing a safety netting process whilst General practice ensures patients are safety netted.

• Follow up appointments are risk stratified where possible (emerging process) and follow up carried out by phone where possible.

• Support via CNS workforce continues through telephone contact and follow up.

• McMillan information and support Centre at Leicester Royal infirmary continue to offer telephone advice Monday to Friday. Patients are directed to relevant specialist nurses where and when appropriate.

• As detailed above all Tumour sites have reviewed their pathways and made adaptations based on current National and Society Guidelines these have been agreed by the clinical lead for cancer and a deputy Medical Director. All changes are shared via the weekly cancer Board as detailed above.

• Work is commencing on looking at potential long term Harm to patients following unavoidable decisions which are having

• National / Regional approach/Guidance to understanding and mitigating potential Harm would be welcomed

5. Information sharing

An information sharing agreement has been agreed to ensure that information regarding at risk/shielded patients can be shared across all agencies.

6. Performance monitoring 6.1 COVID-19 monitoring

A daily sit-rep report has been established to monitor the incidence of COVID-19 across LLR and the impact on critical care capacity and staffing. This is being refined to include primary care and social care data. Work is also underway to use modelling data to identify surge capacity requirements and capacity requirements in primary and social care. Board members are receiving this information daily.

6.2 Wider population monitoring

The CCGs will continue to monitor key performance indicators as identified in the NHSE/I letter Reducing the burden/Releasing Capacity. This will be reported through the Performance and Assurance Committee monthly. Work has started to consider how to review the impact of COVID-19 and the impact of this on the wider health of our population. M&LCSU Business Intelligence are working with Public Health colleagues to identify the mechanisms for developing this. Further discussion will be had through IQCG and PFAC.

Recommendation The Governing Body is asked to discuss this paper to ensure board members are assured by the processing place at this time to monitor quality and safety during the COVID-19 period.

to be made due to Covid-19 decisions which have emerged following local and National guidelines.

What arrangements are in place for oversight of the backlog – tracking and profiling?


• Tracking profiling continue to be monitored through the weekly cancer Board meeting.

• Any future or emerging Monitoring requirements will be discussed and agreed at the weekly meeting.

• Information will need to feed into planning for recovery

Strategic Co-ordinating Group (SCG) Chair: Rob Nixon Membership: Chief Execs or Senior Managers from all LRF partners Support: LLR Prepared Office

Tactical Co-ordinating Group (TCG)

Chair: Martyn Ball Membership: Tactical Managers and Resilience Practitioners from all LRF partners Support: LLR Prepared Office

Media & Comms Cell

Chair: Katie Pegg (LCC) and Dave Rowson (CCG) Membership: Comms representatives from all LRF partners Support: Resilience Partnership Team

Health Economy Tactical Co-ordinating Group (HETCG)

Chair: Caroline Trevithick Membership: Tactical Managers and Resilience Practitioners from Health Partners Support: LLR CCG UEC Team

Local Authority Sub-Group

Chair: Elaine Bird (HDC) Membership: Senior / Tactical Managers for all LLR Local Authorities Support: Resilience Partnership Remit: Coordination of LA issues

Excess Deaths Cell

Chair: Tom Purnell (LCC) / Professor Mason HM Coroner Membership: As per Excess Deaths Plan – local authorities, Coronial Services, UHL, Coronial Services and Funeral Directors Support: Resilience Partnership Remit: Planning for and management of excess deaths

Community, Voluntary and faith engagement Cell

Chair: Leicestershire County Council Membership: Tactical/Operational Managers from local authorities, community, voluntary and faith groups Support: Resilience Partnership Remit: Planning for support to vulnerable self-isolated people NOT requiring specialist health/social care support

Health Economy Strategic Co-ordinating Group (HESCG)

Chair: Andy Williams Membership: Chief Execs or Senior Managers from all health partners Support: LLR CCG UEC Team

Faith Engagement

Independent sector

capacity Cell Rachel

Bilsborough

Food Support

Volunteer &Community engagement

Support for Self-Isolation

Sub Group

Discharge Cell

Rachna Vyas Tamsin Hooton

UHL Tactical Cell

Fiona Lennon

UEC Cell AEDB

Yasmin Sidyot

Workforce Cell

Hazel Wyman

Primary Care Cell

Tim Sacks

Equipment and PPE Prioritisation Cell

Chair Sam Phillips – Mahon Remit: To support the coordination and distribution of critical supplies of equipment and PPE.

LPT Cell Anne Scott

Business Cell LEPP

Chair: Fiona Baker

Health Multi-agency COVID-19 Response

Medicines Cell

Claire Ellwood

ASC Cell Martin

Samuels

26 March 2020

Blank Page



Name of meeting: East Leicestershire and Rutland CCG Governing Body

Date: 14 April 2020 Paper: E

Public Confidential

Report title: Leicestershire Better Care Fund Plan 2020/21

Presented by: Cheryl Davenport, Director of Health and Care Integration (Joint Appointment)

Report author: Jude Emberson, Health and Care Manager, Leicestershire County Council

Executive lead: Tamsin Hooton / Paul Gibara

Action required: Receive for information only: Progress update:


Executive summary: 1. The purpose of this report is to seek approval for the interim Leicestershire Better Care Fund (BCF) expenditure plan for 2020/21.

2. At the time of writing this report, the national BCF policy framework andtechnical guidance for 2020/21 is still awaited. The timetable forsubmission will be confirmed when the guidance is published.

3. Ahead of the national documentation being released, work commenced inJanuary 2020 to refresh the BCF expenditure plan, in line with the annualfinancial planning arrangements for the CCGs and Leicestershire CountyCouncil.

4. The report sets out the changes made to the BCF expenditure plancompared to 2019/20.

5. It is anticipated that later in 2020/21, NHS England will request a formalsubmission of the BCF plan, which along with the expenditure plan willinclude a supportive narrative, the BCF metrics and a submission againstthe high impact model for the transfers of care.

Appendices: A – Draft BCF Expenditure Plan 2020/21

Recommendations: • Approve the interim BCF expenditure plan for 2020/21 for inclusion in Leicestershire County Council, WLCCG and ELRCCG financial plans.


• Integration Finance and Performance Group (25th Feb 20)• Joint Commissioning Group (26th Feb 20)• Health and Wellbeing Board (30th March 20 via email for approval by

Members)


Rutland CCG


interest: No


Yes


Yes


No


Previously worked with Healthwatch on the overall plan.


No

2

LEICESTERSHIRE BETTER CARE FUND PLAN 2020/21 Purpose of report 1. The purpose of this report is to provide an overview of the progress to refresh the

Leicestershire Better Care Fund (BCF) plan and seek approval for the interim BCF expenditure plan for 2020/21.

Policy Framework and Previous Decisions 2. Nationally, it has been confirmed that the 2020/21 BCF Policy Framework will be

published in due course but with systems needing to focus effort into dealing with Covid-19, local areas will not be asked to produce BCF plans for submission to NHS England at this time.

3. The national BCF team has confirmed that although BCF plans from April 2020 will not

have been formally approved, for the duration of the current outbreak of Covid-19, systems should assume that spending from ringfenced BCF funds, particularly on existing schemes from 2019/20 and spending activity to address demands in community health and social care, is deemed approved and local plans should prioritise continuity of care, maintaining social care services and system resilience.

4. Two national reviews of the BCF policy are taking place over the next few months, which will look at the overall policy framework and operating model for April 2021 onwards.

5. It is anticipated that while the BCF policy framework and guidance for 2020/21 will essentially be a continuation per the guidance of 2019/20 (with possible minor adjustments). BCF arrangements from April 2021 will be informed by the outcome of the national review. Given the Covid-19 situation the outcome of the review is now likely to be published at a later time in 2020.

6. In the meantime, the government has given an indication that the BCF policy is likely to continue for a further three years through to 2023/24, although the content of the policy framework over this period is not yet determined.

BCF National Conditions 7. The four national conditions set by the government in the policy framework for 2019/20

are expected to remain the same, and are:

a. That a BCF plan, including at least the minimum mandated funding to the pooled fund specified in the BCF allocations and grant determinations, must be signed off by the Health and Wellbeing Board, and by the constituent local authorities and CCGs.

b. A demonstration of how the area will maintain the level of spending on social care services from the CCG minimum contribution in line with the uplift to the CCG minimum contribution.

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c. That a specific proportion of the area’s allocation is invested in NHS commissioned out of hospital services, which may include seven-day services and adult social care.

d. A clear plan on managing transfers of care (and improving delayed transfers of care), including implementation of the national high impact change model for managing transfers of care.

Current Position 8. Work commenced locally in January 2020 to refresh the BCF expenditure plan for

2020/21 in line with the annual planning arrangements for the CCGs and local authority.

9. The focus of the refresh has been on the expenditure plan, ensuring it keeps pace with commissioning intentions of partners in relation to the next phase of the transformation of health and care, for example changes to community services such as the Home First Model that have recently been implemented, or the introduction of care coordination as part of neighbourhood teams.

10. A working session was held on 29th January with Leicestershire County Council (LCC), ELRCCG and WLCCG partners to review and make recommendations against the expenditure plan and to consider options and priorities for the unallocated spend arising from the annual uplift to the allocations as set out by government (see BCF income below).

11. The Integration Finance and Performance Group, which includes Finance and Strategy Leads from LCC and the CCGs, reviewed the outputs from this session at its meeting on 25th February and agreed a draft BCF expenditure plan for 2020/21, subject to a number of final actions being followed up by the Joint Commissioning Group.

12. It is anticipated that later in 2020/21, NHS England will request a formal submission of the BCF plan. In previous years this has entailed the expenditure plan, supporting narrative, an overview of the BCF metrics and a submission against the high impact model for the transfers of care. These elements will be brought to the Board for consideration in line with the national timescales, once known.

Budget Income 13. Allocations for the various elements of the BCF pooled budget comprise the CCG

minimum contribution, the Improved Better Care Fund (IBCF), and the Disabled Facilities Grant (DFGs) allocations. These were published in February. The following information on the different funding components was announced:

a. The CCG minimum contribution into the BCF has been increased nationally by 5.3%. As in the previous year, this varies for each CCG. For Leicestershire, the increase is:

• ELRCCG – 5.3% • WLCCG – 5.7%

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b. The existing IBCF funding (adult social care allocation) will continue at the same financial levels as 2019/20 with the same national conditions (to meet social care needs, reduce pressure on the NHS, and ensure that the local social care provider market is supported).

c. The winter pressure grant will continue in 2020/21 but will no longer be ringfenced for alleviating winter pressures on the NHS. Instead it will be incorporated into the IBCF and be subjected to the same national conditions referred to in the above point.

d. DFGs will continue to be allocated through the BCF. The funding remains at the same level as 2019/20.

14. The table below provides an update of the income for the total BCF plan in 2020/21

compared to the income for 2019/20.

2019/20 £000

2020/21 £000

Variance £000

BCF (CCG minimum contribution) 39,177 41,350 2,173 IBCF Funding 14,757 17,171

0 Winter Pressures Grant 2,414 - Disabled Facilities Grant 3,919 3,919 0 TOTAL 60,267 62,440 2,173

BCF Expenditure Plan 15. The BCF expenditure plan, provided at Appendix A, sets out the line items/service

areas funded by each element of the BCF pooled budget along with a comparison in planned spend against 2019/20.

16. The individual line items show the apportionment of the financial contributions across ELRCCG and WLCCG. For the majority of the items, this is divided in the proportions of 42.87% for ELRCCG and 57.13% for WLCCG. (Note that the CCG percentage split used for each CCG has been updated to reflect the proportional change in the CCG minimum allocations).

17. In some cases, there are line items that are specific only to one CCG or the usual proportions have been varied, due to other service specific factors. All of these apportionments have been confirmed and assured by the respective parties including their finance teams.

18. The IBCF schemes are highlighted on the expenditure plan and are subject to Local Authority determination and the associated grant conditions.

19. The DFG allocation is automatically passported to each District Council per the apportionment set out by government and is shown by each District in the expenditure plan.

5

20. The expenditure plan was reviewed to ensure the plan takes account of the national

conditions (detailed in para 7), any imminent changes to models of care affecting elements of the BCF funding streams in 2020/21, pressures on existing service lines, application of growth and inflation across the plan in line with CCG and Local Authority assumptions, and specific confirmation of the CCGs position with respect to the social care investment lines.

21. The following amendments have been recommended to the existing BCF expenditure plan:

Inflationary Increase

a. LCC schemes – 3% increase to all schemes that employ LCC staff.

b. NHS schemes – various percentage increase applied to all NHS schemes (detailed provided in the notes section in the expenditure plan).

c. Schemes assigned to ‘Adult Social Care (ASC) Protection’ – increased by 5.3% for ELRCCG and 5.7% for WLCCG to match the inflationary increase to the CCG minimum contribution. It was also agreed that the Joint Commissioning Group would review the schemes that are covered by the ASC protection lines within the plan at a future meeting, in particular to consider how the nursing resources could be redesigned in line with emerging service models.

d. No increase to the Dementia Support Service – the service is planned to be re-procured in 2020/21. Currently not expecting a change to the county contribution but this will be monitored in-year.

e. No increase has been applied to the health and social care protocol training line. The protocol is currently being reviewed which includes reviewing the training aspect. This will be monitored in-year.

f. No increase anticipated for the Data Warehousing Tool line.

Other Changes

g. In August 2019, it was agreed to transfer the existing mental health section 256 agreements (total value £168k) in to the BCF plan non-recurrently for 2019/20 only. This has therefore been removed from the BCF plan for 2020/21 and will be funded directly from the CCGs.

h. The BCF plan funded a Vista grant in 2019/20 on behalf of the CCGs. This grant has now ended and been removed from the expenditure plan.

i. The Housing (Hospital) Enablement Team was funded through the IBCF during 2019/20. Following CCG approval of the business case, this scheme has been transferred to the CCG minimum allocation. The costs over the next three years has been included in the Service Level Agreement to reflect salary profile/ inflation.

6

22. Following the changes detailed above, there was £646k of unallocated spend within the

BCF plan. The split between area of spend was £480k on NHS spend and £166k for social care spend. A number of priorities and options were considered, and the final recommendation is that:

a. The NHS spend would be directed to fund the increase to LPT capacity to deliver

Home First and Core Community Nursing.

b. The social care spend to be directed to the following three areas: • Care Coordinators Team Leader • Transforming Care service development • Commissioning capacity

23. The Joint Commissioning Group was supportive of the social care areas of spend and

requested further information to be shared with the CCGs to help make an informed decision. This was due to be reviewed during March but has been delayed whilst focus on the Covid-19 situation. This will be reviewed retrospectively by the Joint Commissioning Group at a future meeting.

Next Steps 24. Following the publication of the BCF policy framework and technical guidance, the BCF

expenditure plan will be reviewed to ensure that it meets the national conditions. The narrative plan, BCF metrics and high impact change model will be reported to the relevant Board meeting for approval.

Recommendation 25. The CCG Governing Body is asked to:

a. Approve the interim BCF expenditure plan for 2020/21 for inclusion in LCC,

WLCCG and ELRCCG financial plans.

7

Appendix A - BCF Expenditure Plan 2020/21

Variance Commentary

Scheme Name West Leics CCG East Leics & Rutland CCG

Leics County Council

Total Budget West Leics CCG East Leics & Rutland CCG

Leics County Council

Total Budget

Unified Prevention OfferFirst Contact Plus s 87,874 66,146 0 154,020 90,638 68,002 0 158,641 4.6 LCC - assumed pay award (3%)Total UPO 87,874 66,146 0 154,020 90,638 68,002 0 158,641

Integrated Community ServicesPrimary Care Coordinator n 19,581 14,739 0 34,320 20,263 15,202 0 35,465 1.1 LLR Planning Assumptions (E 3.17% W 3.46%)Community Hospital Link Workers s 121,628 91,552 0 213,180 125,453 94,123 0 219,575 6.4 LCC - assumed pay award (3%)Improving Mental Health Discharge s 159,638 120,164 0 279,802 164,658 123,538 0 288,196 8.4 LCC - assumed pay award (3%)

Lightbulb - Housing (Discharge) Enablement Team s 0 0 100,000 100,000 61,202 45,918 0 107,120 7.1 Via Business Case - agreed to fund through CCG minimum contribution. Assumed pay award (3%)

GP Link Workers (ELRCCG) (Part of Care Coordination) s 0 430,000 0 430,000 0 442,900 0 442,900 12.9 LCC - assumed pay award (3%)Care Coordination (WLCCG) s 209,510 0 0 209,510 215,795 0 0 215,795 6.3 LCC - assumed pay award (3%)Link Workers (to support community & out of county discharges) w 0 0 100,000 100,000 0 0 120,000 120,000 20.0 IBCFLLR Community Integrated Neurology & Stroke Rehabilitation Service (CINSS) n 161,624 121,658 0 283,282 167,249 125,482 0 292,731 9.4 LLR Planning Assumptions (E 3.17% W 3.46%)

Non-weight bearing pathway (case management function) s 49,699 37,409 0 87,108 51,261 38,460 0 89,721 2.6 LCC - assumed pay award (3%)Discharge Pathway 3 Contract n 233,636 262,562 0 496,198 238,636 267,419 0 506,055 9.9 LLR Planning Assumptions (E 1.85% W 2.14%)Discharge Pathway 3 - Case Management s 22,822 17,178 0 40,000 23,540 17,660 0 41,200 1.2 LCC - assumed pay award (3%)Integrated Community Nursing n 3,635,939 2,248,541 0 5,884,480 3,761,742 2,319,820 0 6,081,562 197.1 LLR Planning Assumptions (E 3.17% W 3.46%)Home First, Nursing & Therapies n 1,980,062 1,481,046 0 3,461,108 2,323,223 1,733,544 0 4,056,767 595.7 LLR Planning Assumptions (E 3.17% W 3.46%) +

increase in funding for 2020/21Home First Integrated Reablement s 240,364 180,928 0 421,292 247,923 186,008 0 433,931 12.6 LCC - assumed pay award (3%)HTLAH - Community Based Review Team (2 week review team) s 240,054 180,696 0 420,750 247,604 185,769 0 433,373 12.6 LCC - assumed pay award (3%)HTLAH Reablement - HART (Step Down) s 358,002 269,478 0 627,480 423,377 317,647 0 741,023 113.5HTLAH - Independent Providers (Step Up) n 52,250 39,710 0 91,960 0 0 0 0 -92.0HTLAH Back Office Support s 58,195 43,805 0 102,000 60,025 45,035 0 105,060 3.1 LCC - assumed pay award (3%)Crisis Response Service (CRS) - Social Care s 332,468 250,258 0 582,726 342,923 257,285 0 600,208 17.5 LCC - assumed pay award (3%)Home First Programme Team i 0 0 274,800 274,800 0 0 285,000 285,000 10.2 IBCFHome First Team Leaders i 0 0 110,000 110,000 0 0 110,000 110,000 .0 IBCFIntegration of health and social care rehab/reablement services i 0 0 64,085 64,085 0 0 100,000 100,000 35.9 IBCFDischarge Response Team i 0 0 274,334 274,334 0 0 244,000 244,000 -30.3 IBCFCare Homes Support / Trusted Assessor w 0 0 70,000 70,000 0 0 70,000 70,000 .0 IBCFRedesign of reablement offer (TOM) w 0 0 400,000 400,000 0 0 250,000 250,000 -150.0 IBCFAdult Mental Health Step Down Beds w 0 0 30,000 30,000 0 0 30,000 30,000 .0 IBCFAssessment and Reablement Pilot w 0 0 0 0 0 0 280,000 280,000 280.0 IBCFTotal ICS 7,875,472 5,789,724 1,423,219 15,088,415 8,474,873 6,215,809 1,489,000 16,179,682

ASC Sustainability, Workforce, Market DevelopmentHome Care Service (ASC protected) s 6,538,919 4,922,027 0 11,460,946 6,910,102 5,184,429 0 12,094,532 633.6 5.7% (WL) and 5.3% (ELR) inflationAssessment and Review (ASC protected) s 935,627 704,273 0 1,639,900 988,739 741,818 0 1,730,557 90.7 5.7% (WL) and 5.3% (ELR) inflationResidential Respite Service (ASC protected) s 423,682 318,918 0 742,600 447,733 335,920 0 783,653 41.1 5.7% (WL) and 5.3% (ELR) inflationNursing Care Packages (ASC protected) s 2,053,542 1,545,758 0 3,599,300 2,170,112 1,628,165 0 3,798,277 199.0 5.7% (WL) and 5.3% (ELR) inflationCare Coordination Team Leader sTransforming Care Service Development sCommissioning Capacity sMulti-disciplinary review team for top 100 high cost placements i 0 0 186,946 186,946 0 0 200,000 200,000 13.1 IBCFDevelopment of External Workforce i 0 0 156,798 156,798 0 0 206,000 206,000 49.2 IBCFAssistive Technology i 0 0 729,600 729,600 0 0 730,000 730,000 .4 IBCFSocial Integration Programme i 0 0 0 0 0 0 250,000 250,000 250.0 IBCFCommissioning Brokerage Team w 0 0 0 0 0 0 80,000 80,000 80.0 IBCFStabilising the social care provider market i 0 0 12,091,731 12,091,731 0 0 13,837,503 13,837,503 1,745.8 IBCFTotal ASC 9,951,770 7,490,976 13,165,075 30,607,821 10,605,329 7,966,998 15,303,503 33,875,830

Care ActCare Act Support Pathway s 259,025 194,975 0 454,000 267,171 200,449 467,620 13.6 LCC - assumed pay award (3%)Care Act Enablers s 42,847 32,253 0 75,100 42,908 32,192 75,100 .0 No changeProvision for enhanced carer support services i 0 0 103,628 103,628 0 0 106,000 106,000 2.4 IBCFTotal Care Act 301,872 227,228 103,628 632,728 310,079 232,641 106,000 648,720

Integrated CommissioningHealth & Social Care Protocol Training s 58,375 43,941 0 102,316 58,458 43,859 102,317 .0 No changePost Diagnostic Community & In-Reach Service for people affected by Dementia

s 164,263 123,645 0 287,908 160,790 120,636 0 281,426 -6.5

Post Diagnostic Community & In-Reach Service for people affected by Dementia

n 29,496 29,496 0 58,992 29,496 29,496 0 58,992 .0

LD Lead Commissioning Arrangements s 88,434 66,566 0 155,000 78,845 59,155 138,000 -17.0 LCC - assumed pay award (3%) plus adjustment to Pooled Budget

LD Short Breaks n 598,525 260,583 0 859,108 619,294 268,870 0 888,163 29.1 LLR Planning Assumptions (E 3.18% W 3.47%)Transforming Care Programme - Implementing Actions from the TCP Recovery Plan

s 119,813 90,187 0 210,000 72,160 54,140 126,300

Positive Behaviour Support Team s 51,421 38,579 90,000Improving Quality in Care Homes s 298,773 224,895 0 523,668 308,169 231,209 0 539,378 15.7 LCC - assumed pay award (3%)Vista Grant n 7,327 6,272 0 13,599 0 0 0 0 -13.6 Non-recurrent 2019/20CHC Commissioning Capacity i 0 0 64,000 64,000 0 0 159,000 159,000 95.0 IBCFContribution to TCP Coordinator Role (ELRCCG) i 0 0 20,000 20,000 0 0 8,000 8,000 -12.0 IBCFCase managers for TCP to support inpatient reductions i 0 0 120,933 120,933 0 0 50,000 50,000 -70.9 IBCFTotal Integrated Commissioning 1,365,006 845,585 204,933 2,415,524 1,378,633 845,943 217,000 2,441,576

Mental Health S256MH Care Management & Rehab s 53,346 45,668 0 99,014 0 -99.0MH Welfare Rights s 11,613 9,941 0 21,554 0 -21.6MH Hospital Inreach s 11,360 9,724 0 21,084 0 -21.1MH Day Centres s 14,174 12,133 0 26,307 0 -26.3Total MH s256 90,493 77,466 0 167,959 0 0 0 0

Urgent CareNight Nursing Service n 232,301 174,859 0 407,160 239,875 179,970 0 419,845 12.7 LLR Planning Assumptions (E 2.95% W 3.24%)Loughborough Urgent Treatment Centre n 905,931 0 0 905,931 935,283 0 0 935,283 29.4 LLR Planning Assumptions (W 3.24%)Home Visiting Service n 1,301,385 633,643 0 1,935,028 1,343,550 652,335 0 1,995,885 60.9 LLR Planning Assumptions (E 2.95% W 3.24%)Urgent Care Centres (ELRCCG) n 0 1,338,771 0 1,338,771 0 1,378,265 0 1,378,265 39.5 LLR Planning Assumptions (E 2.95%)Total Urgent Care 2,439,617 2,147,273 0 4,586,890 2,518,708 2,210,571 0 4,729,278

Data IntegrationData Integration Tool s 36,229 27,271 0 63,500 36,280 27,220 0 63,500 .0 No changeTotal Data Integration 36,229 27,271 0 63,500 36,280 27,220 0 63,500

Programme Resources/EnablersIntegration Programme Management s 203,799 153,405 54,594 411,798 210,208 157,712 55,000 422,920 11.1 LCC - assumed pay award (3%)2019/20 IBCF Schemes Only i 0 0 404,807 404,807 0 0 0 0 IBCF2019/20 Winter Pressures Grant Schemes Only w 0 0 1,814,247 1,814,247 0 0 0 0 IBCFTotal Enablers 203,799 153,405 2,273,648 2,630,852 210,208 157,712 55,000 422,920

Disabled Facilities Grant (DFG)Blaby DC d 0 0 585,028 585,028 0 0 585,028 585,028 .0Charnwood BC d 0 0 992,908 992,908 0 0 992,908 992,908 .0Harborough BC d 0 0 451,561 451,561 0 0 451,561 451,561 .0Hinckley and Bosworth BC d 0 0 510,231 510,231 0 0 510,231 510,231 .0Melton BC d 0 0 303,802 303,802 0 0 303,802 303,802 .0North West Leicestershire BC d 0 0 670,314 670,314 0 0 670,314 670,314 .0Oadby and Wigston BC d 0 0 405,615 405,615 0 0 405,615 405,615 .0Total DFGs 0 0 3,919,459 3,919,459 0 0 3,919,459 3,919,459 .0

TOTAL BCF EXPENDITURE 22,352,132 16,825,074 21,089,962 60,267,168 23,624,748 17,724,897 21,089,962 62,439,606

CCG BCF Minimum Funding Allocation 22,352,132 16,825,074 39,177,206 23,624,748 17,724,897 41,349,645 2,172.4IBCF Allocation 17,170,503 17,170,503 17,170,503 17,170,503 .0DFG Allocation 3,919,459 3,919,459 3,919,459 3,919,459 .0

Total Allocation 22,352,132 16,825,074 21,089,962 60,267,168 23,624,748 17,724,897 21,089,962 62,439,607

Over/ -Underspend Commitment 0 0 0 0 0 0 0 -1

Breakdown of BCF Spend Areas

Maintaining Social Care Spend s 13,194,075 10,213,194 0 23,407,269 13,946,137 10,754,493 0 24,700,631

NHS Commissioned Out of Hospital Spend (from CCG min) n 9,158,057 6,611,880 0 15,769,937 9,678,611 6,970,403 0 16,649,014Disabled Facilities Grants d 0 0 3,919,459 3,919,459 0 0 3,919,459 3,919,459Improved Better Care Fund Spend i 0 0 14,756,256 14,756,256 0 0 16,340,503 16,340,503ASC Winter Pressures Funding w 0 0 2,414,247 2,414,247 0 0 830,000 830,000

22,352,132 16,825,074 21,089,962 60,267,168 23,624,748 17,724,897 21,089,962 62,439,606

0 165,308 165.30 0 0 0 88,643 76,665

Non-recurrent 2019/20

No Change

2019/20 SPENDING PLAN DRAFT 2020/21 SPENDING PLAN

Step up reablement moving to HARTLCC - assumed pay award 3%

No change

LCC - assumed pay award (3%)-6.3

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East Leicestershire and Rutland Clinical Commissioning Group Name of meeting: LLR CCGs’ Governing

Body meetings in common Date: 14th April 2020 Paper: F

Public Confidential Report title:

Finance Report Month 11

Presented by: Donna Briggs, Interim LLR Executive Director of Finance, Contracting and Corporate Governance

Report author: Gill Killbery, Deputy CFO, Helen Ellis, Deputy Director of Finance.

Executive lead: Michelle Iliffe, Director of Finance; Donna Briggs, Chief Finance Officer; Spencer Gay, Chief Finance Officer.


Executive summary: Context: The 19/20 financial Plan requires delivery of an “in year” £1.42m surplus across LLR CCGs. This plan was considered challenging and included the anticipated delivery of identified gross savings of £68.4m (net £54.5m) and a further £11.2m unidentified savings. As part of the month 11 reporting to NHS E/I LLR CCGs reported a variance of 20.6m against the original plan. LC CCG is continuing to forecast delivery of the planned surplus of £1.42m giving an in year forecast position for LLR CCGs of £19.175m overspend. The LLR QIPP programme is currently (as at Month 11) delivering £19.675m less than originally planned. This includes £9.9m non delivery of unidentified QIPP. This variance is forecast to increase to £21.76m by the year end against an original budget of £65.7m, representing delivery of 67% of the originally identified QIPP. This gap is more than mitigated by delivery of £29.25m from the financial recovery plan (FRP). A year-end financial agreement has been reached with UHL to the value of £562m. This is a positive step for the system as it means that there is certainty for commissioners and providers of the final value of this contract. It enables the system to focus on preparing for the 2020/21 contract year For the last 8 months the CCGs have been discussing the risks around delivery of the planned position with Governing Bodies and NHS E/I. A likely adverse variance of £20.6m has been recognised as part of FRP and has been shown in these reports and declared in submissions to NHS E/I. At month 11, the underlying position is £27.2m. The underlying position shows that recurrent items are being funded from non-recurrent resources,


Rutland CCG


interest: Not applicable


Aligned to the corporate risk in relation to finance.


As at month 11, LLR CCGs are reporting an adverse £20.595m variance against plan across LLR.


Not applicable


Not applicable


Not applicable

which indicates the level of financial pressure that the CCGs will take into the 2020/21 financial year.

Appendices: • Appendix 1 – Year to date position as at Month 11 • Appendix 2 - Forecast Position as at Month 11 • Appendix 3 - Balance sheet • Appendix 4 - BPPC

Recommendations:

The LLR CCGs’ Governing Bodies are asked to:

• NOTE the financial performance at Month 11 • NOTE the adverse forecast position of £20.6m • NOTE the underlying pressure of £27.2m on the 2020/21 plan


Reported to the LLR Performance, Finance and Activity Committee on 26th March 2020.

2

Finance Report Month 11

Context:

The 19/20 financial Plan requires delivery of an “in year” £1.42m surplus across LLR CCGs. This plan was considered challenging and included the anticipated delivery of identified gross savings of £68.4m (net £54.5m) and a further £11.2m unidentified savings.

Questions:

1 What is the financial performance for the period ending 31st January 2020 (Month 11)?

LLR CCGs have reported a year to date adverse expenditure variance of £24.28m against a break even plan.

The main areas of overspend are acute services, £29.69m (of which UHL accounts for £20.89m), prescribing at £7.45m and the unwinding of unidentified QIPP at £9.9m.

These are countered slightly by favourable variances against continuing care of £6.47m, release of contingency, £2m, and underspend against reserves and investment slippage of £8.7m.

2 What is the performance against the LLR QIPP programme?

The LLR QIPP programme is currently (as at Month 11) delivering £19.675m less than originally planned. This includes £9.9m non delivery of unidentified QIPP.

This variance is forecast to increase to £21.758m by the year end against an original budget of £65.963m, representing delivery of 67% of the originally identified QIPP.

This gap is more than mitigated by delivery of £29.249m from the Finance Recovery Plan (FRP).

3 What is the financial Forecast for the full year?

As part of the month 11 reporting to NHS E/I the LLR CCGs submitted a combined forecast of £19.175m in year deficit. This is a variance of £20.6m against the original plan.

Areas of overspend include:

• Acute services (£31.4m) mainly due to NHS providers. The majority of this is UHL (including the Alliance UHL Pillar) over-performance of £21.4m; the pressure is being seen across all areas. The remaining pressure is attributable to QIPP non delivery and the out of county providers (mainly Derby and Burton Hospital and University Hospital Nottingham.) Non NHS has an overspend of £4m, predominantly due to Independent sector over activity.

• Prescribing (£7.7m) is the result of a combination of slipped QIPP delivery and national changes to drug prices.

3

These are countered in part by the release of contingency £6.8m, Better Care Performance Fund £2m and reserves.

A yearend financial agreement has been reached with UHL to the value of £562m. This is a positive step for the system as it means that there is certainty for commissioners and providers of the final value of this contract. It enables the system to focus on preparing for the 2020/21 contract year.

At month 11, the underlying position is £27.2m. The underlying position shows that recurrent items are being funded from non-recurrent resources, which indicates the level of financial pressure that the CCGs will take into the 2020/21 financial year.

4 What are the key risks to delivery of this forecast?

For the last 8 months the CCGs have been discussing the risks around delivery of the planned position with Governing Bodies and NHS E/I. A likely adverse variance of £20.6m has been recognised as part of FRP and has been shown in these reports and declared in submissions to NHS E/I.

This position is not risk free. Remaining risks can be summarised as:

• Prescribing costs are volatile, actual data is not available in real time and costs can be significantly affected by national actions.

• Activity pressures arising from out of county providers and independent sector. • Final QIPP delivery, although significantly less QIPP is relied on to achieve the likely

financial position, there is still some expectation in relation to smaller contracts. • Continuing Health Care and Section 117 growth, although this has been minimal so

far in 19/20, there is the potential for increased growth in the final month of the year. • Areas of dispute with UHL and LPT regarding finalisation of year end positions. Again

relatively small in value and expected to be resolved over the next two weeks.

Risks will be mitigated through continued effort to achieve FRP and system working to contain activity.

5 Are we delivering the Better Payment Practice Code?

All three CCGs are delivering on the Better Payment Practice Code (BPPC) across all four metrics. (Minimum 95% payment within 30 days both in month and cumulatively for NHS and Non NHS providers).

6 Is Cash remaining at month end within national tolerances?

Each CCG is expected to hold minimal cash balances at the end of each month, (maximum 1.25% of cash drawn down in the month); all CCGs are meeting this expectation.

7 Is Capital spending within allocation limits?

4

A small in year capital allocation has been received by ELR and WL CCG’s to be spent on corporate IT equipment. Assets held on behalf of alliance have now been transferred (with effect from 31st December 2019) on a ‘no impact’ basis to UHL.

8 Are the CCGs operating within the Running costs allocation?

The CCGs received running cost allocations totalling £23.541m. The financial plan anticipated an underspend against this allocation of £1.7m, thereby releasing funds to spend on health care. Actual spend is forecast at £21.8m.

The CCGs are therefore showing a small overspend against plan of £0.026m but an underspend against running cost allocation of £1.7m.

Summary:


• NOTE the financial performance at Month 11 • NOTE the adverse forecast position of £20.6m • NOTE the underlying pressure of £27.2m on the 2020/21 plan

5

SUMMARY FINANCIAL POSITION 2019/20 - MONTH 11 Appendix 1

East City West LLR East City West LLR East City West LLR£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's

Acute - NHS 192,043 216,234 220,870 629,147 198,233 225,256 230,935 654,425 6,190 9,022 10,065 25,278 Acute - Non-NHS 7,591 7,331 7,632 22,554 9,451 8,961 8,201 26,613 1,860 1,629 570 4,059 Acute - Urgent Care 878 617 2,853 4,349 923 627 3,151 4,701 45 10 297 352 Total Acute 200,513 224,182 231,355 656,050 208,608 234,844 242,288 685,739 8,095 10,661 10,933 29,688

Mental Health - NHS 28,799 53,825 34,964 117,588 28,740 54,089 35,107 117,936 (59) 264 143 349 Mental Health - Non-NHS 5,327 10,444 6,666 22,437 6,281 10,729 7,439 24,449 954 285 773 2,012 Total Mental Health 34,126 64,269 41,630 140,024 35,021 64,818 42,546 142,385 895 549 916 2,360

Community Health - NHS 29,366 32,836 34,131 96,333 29,584 33,181 34,096 96,861 218 344 (35) 528 Community Health - Non-NHS 1,677 2,973 227 4,878 1,321 2,526 182 4,028 (357) (447) (45) (849) Total Community Health 31,043 35,809 34,358 101,211 30,905 35,706 34,278 100,889 (138) (103) (80) (321)

Total Continuing Care 25,259 28,586 29,552 83,396 23,568 26,512 26,851 76,931 (1,691) (2,074) (2,701) (6,466)

Primary Care Services 12,909 12,027 12,553 37,489 11,062 10,524 10,755 32,341 (1,847) (1,503) (1,798) (5,148) Prescribing 44,005 47,692 50,946 142,643 47,105 49,994 52,993 150,091 3,100 2,301 2,047 7,448 Total Primary Care 56,914 59,719 63,499 180,132 58,167 60,517 63,748 182,432 1,253 798 249 2,301

Total Primary Care Co-Commissioning 39,462 49,643 43,484 132,589 39,676 48,940 44,856 133,472 214 (704) 1,372 883

Total Corporate 6,145 7,133 6,764 20,043 6,120 6,881 6,782 19,783 (26) (252) 18 (259)

Reserves (859) 5,154 739 5,034 3,215 (1,044) 3,454 5,625 4,074 (6,198) 2,715 591 Other - Acute 2,909 3,698 3,492 10,098 2,712 4,070 3,779 10,560 (197) 372 287 462 Other - Non Acute 13,348 19,681 15,562 48,591 12,946 17,070 14,597 44,613 (402) (2,611) (965) (3,979) Programme Infrastructure 879 4,622 517 6,018 677 3,844 515 5,037 (202) (778) (2) (981) Total Other 16,278 33,155 20,309 69,742 19,550 23,939 22,345 65,835 3,273 (9,215) 2,036 (3,907)

Total CCG Expenditure 409,739 502,497 470,951 1,383,187 421,614 502,157 483,695 1,407,466 11,875 (340) 12,744 24,279

Surplus

YEAR TO DATE

Budget Spend Variance

SUMMARY FINANCIAL POSITION 2019/20 - MONTH 11 Appendix 2

East City West LLR East City West LLR East City West LLR£000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's £000's

Acute - NHS 209,346 235,785 240,885 686,016 216,484 244,175 252,353 713,012 7,138 8,390 11,468 26,996 Acute - Non-NHS 8,291 7,976 8,359 24,626 10,175 9,565 8,900 28,639 1,884 1,589 541 4,014 Acute - Urgent Care 958 674 3,118 4,749 1,007 684 3,437 5,129 49 11 320 379 Total Acute 218,595 244,435 252,361 715,391 227,666 254,424 264,690 746,780 9,071 9,990 12,329 31,390

Mental Health - NHS 31,470 58,718 38,143 128,330 31,378 58,884 38,176 128,437 (92) 166 33 107 Mental Health - Non-NHS 5,820 11,394 7,272 24,486 6,597 10,516 7,939 25,051 776 (878) 667 565 Total Mental Health 37,290 70,111 45,414 152,816 37,974 69,400 46,114 153,488 684 (712) 700 672

Community Health - NHS 32,119 35,855 37,259 105,233 32,357 36,249 37,198 105,803 237 394 (61) 571 Community Health - Non-NHS 1,864 3,243 248 5,356 1,473 2,744 178 4,394 (391) (500) (70) (961) Total Community Health 33,983 39,098 37,507 110,588 33,829 38,993 37,376 110,198 (154) (105) (131) (391)

Total Continuing Care 27,583 31,252 32,253 91,088 25,641 29,042 28,900 83,583 (1,942) (2,210) (3,353) (7,505)

Primary Care Services 14,483 13,238 13,702 41,422 12,112 11,735 11,836 35,683 (2,371) (1,503) (1,866) (5,740) Prescribing 48,186 52,250 55,794 156,230 51,472 54,696 57,734 163,902 3,286 2,447 1,940 7,673 Total Primary Care 62,669 65,488 69,496 197,652 63,584 66,431 69,570 199,585 915 943 74 1,933

Total Primary Care Co-Commissioning 43,077 54,441 48,598 146,116 43,360 53,446 50,115 146,921 283 (995) 1,517 805

Total Corporate 6,683 7,759 7,379 21,821 6,854 7,592 7,402 21,848 170 (167) 23 26

Reserves 2,414 3,142 3,138 8,694 4,028 (826) 3,444 6,646 1,615 (3,969) 306 (2,048) Other - Acute 3,175 4,035 3,809 11,019 2,965 4,440 4,122 11,527 (211) 405 313 507 Other - Non Acute 14,557 21,470 16,971 52,999 13,993 18,915 16,108 49,016 (564) (2,555) (863) (3,983) Programme Infrastructure 961 5,042 564 6,567 775 4,417 562 5,755 (186) (625) (2) (813) Total Other 21,107 33,690 24,482 79,279 21,761 26,946 24,236 72,943 654 (6,745) (246) (6,336)

Total CCG Expenditure 450,987 546,274 517,490 1,514,751 460,669 546,274 528,403 1,535,346 9,682 (0) 10,913 20,594

Surplus 2,462 13,899 7,295 23,656 - - - - (2,462) (13,899) (7,295) (23,656)

Variance

ANNUAL POSITION

Budget Forecast Outturn

BALANCE SHEET (STATEMENT OF FINANCIAL POSITION) Appendix 3

19/20 - MONTH 11

Mar-19 Jan-20 Feb-20 In Month Movement

Movement since opening

positionMar-19 Jan-20 Feb-20 In Month

Movement


positionMar-19 Jan-20 Feb-20 In Month

Movement


position

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000Non Current Assets:Property Plant and Equipment 1,100 188 181 (7) (919) 77 61 60 (2) (18) 1,045 84 82 (2) (963)TOTAL Non Current Assets 1,100 188 181 (7) (919) 77 61 60 (2) (18) 1,045 84 82 (2) (963)Current Assets: 0 0 0 0 0 0Trade & Other Receivables 6,189 3,891 4,326 435 (1,863) 3,665 3,048 3,576 529 (89) 7,630 4,304 3,771 (533) (3,859)Cash and Cash Equivalents 40 98 60 (38) 20 49 25 62 36 13 150 19 34 15 (116)TOTAL Current Assets 6,229 3,990 4,386 396 (1,843) 3,714 3,073 3,638 565 (76) 7,780 4,323 3,805 (518) (3,975)

0 0 0 0 0 0TOTAL ASSETS 7,329 4,178 4,567 389 (2,762) 3,791 3,134 3,698 564 (94) 8,825 4,407 3,887 (520) (4,938)

0 0 0 0 0 0Current Liabilities: 0 0 0 0 0 0Trade & Other Payables (20,751) (25,463) (24,837) 626 (4,086) (35,915) (35,039) (35,035) 5 880 (24,969) (21,943) (20,722) 1,221 4,247Provisions (94) (140) (212) (72) (118) (224) (109) (109) 0 115 (56) (201) (96) 105 (40)Total Current Liabilities (20,845) (25,603) (25,049) 554 (4,204) (36,139) (35,149) (35,144) 5 995 (25,025) (22,144) (20,818) 1,326 4,207

Non Current Liabilities:Provisions 0 0 0 0 0 (375) (533) (533) 0 (158) 0 0 0 0 0TOTAL Non Current Liabilities 0 0 0 0 (375) (533) (533) 0 (158) 0 0 0 0 0

0 0 0 0 0 0TOTAL LIABILITIES (20,845) (25,603) (25,049) 554 (4,204) (36,514) (35,682) (35,677) 5 837 (25,025) (22,144) (20,818) 1,326 4,207

0 0 0 0 0 0ASSETS LESS LIABILITIES (Total Assets Employed) (13,516) (21,425) (20,482) 943 (6,966) (32,723) (32,547) (31,979) 568 744 (16,200) (17,737) (16,931) 806 (731)

0 0 0 0 0 0TAXPAYERS EQUITY 0 0 0 0 0 0General Fund (Opening Balance, Fixed) (9,089) (13,473) (13,473) (0) (4,384) (31,731) (32,723) (32,723) 0 (992) (17,445) (16,200) (16,200) 0 1,245Income & Expenditure (year to date) (434,020) (384,473) (421,614) (37,141) 12,406 (518,793) (457,113) (502,157) (45,044) 16,636 (497,413) (442,039) (483,695) (41,656) 13,718Parliamentary Funding (year to date) 429,637 376,520 414,605 38,085 (15,032) 517,801 457,289 502,900 45,612 (14,900) 498,658 440,502 482,964 42,462 (15,694)Total (13,473) (21,425) (20,482) 943 (7,009) (32,723) (32,547) (31,979) 568 744 (16,200) (17,737) (16,931) 806 (731)

East Leicestershire & Rutland CCG Leicester City CCG West Leicestershire CCG

Statement of Financial Position

BETTER PAYMENT PRACTICE CODE Appendix 4

19/20 - MONTH 11

A B C D E F G A B C D E F G

No of Bills Paid Within

Period


Target

% of Bills Paid Within

Target

Value of Bills Paid Within

Period


Target

% Value of Bills Paid

Within Target

Cumulative Value of Bills paid within

Target


Period


Target


Target


Period


Target


Within Target


TargetMonth No. No. % £'000 £'000 % % No. No. % £'000 £'000 % %

Apr 219 216 98.63 22,383 22,330 99.77 99.77 478 473 98.95 3,067 2,993 97.58 97.58May 205 205 100.00 18,001 18,001 100.00 99.87 616 615 99.84 3,482 3,474 99.77 98.75Jun 343 341 99.42 22,986 22,962 99.90 99.88 602 598 99.34 4,250 4,233 99.60 99.08Jul 323 321 99.38 24,701 24,620 99.67 99.82 569 561 98.59 4,245 4,208 99.13 99.10Aug 193 193 100.00 22,465 22,465 100.00 99.86 638 635 99.53 3,500 3,494 99.83 99.23Sep 300 298 99.33 23,066 23,059 99.97 99.88 649 648 99.85 3,435 3,433 99.95 99.35Oct 279 273 97.85 23,407 23,178 99.02 99.75 594 584 98.32 3,971 3,857 97.13 99.01Nov 266 266 100.00 24,078 24,078 100.00 99.78 577 569 98.61 2,951 2,942 99.70 99.08Dec 300 295 98.33 23,411 23,374 99.84 99.79 603 603 100.00 4,173 4,173 100.00 99.19Jan 182 181 99.45 29,819 29,818 100.00 99.82 560 559 99.82 4,524 4,523 99.97 99.29Feb 344 344 100.00 24,037 24,037 100.00 99.83 621 619 99.68 3,731 3,729 99.95 99.35

Total 2,954 2,933 99.29 258,355 257,922 99.83 99.83 6,507 6,464 99.34 41,328 41,058 99.35 99.35

A B C D E F G A B C D E F GNo of Bills Paid Within

Period


Target


Target


Period


Target


Within Target


Target


Period


Target


Target


Period


Target


Within Target



Apr 256 255 99.61 21,157 21,157 100.00 100.00 556 547 98.38 5,061 4,983 98.47 98.47May 369 368 99.73 23,308 23,304 99.98 99.99 715 711 99.44 4,004 3,827 95.59 97.20Jun 190 189 99.47 27,123 27,121 99.99 99.99 608 604 99.34 6,013 6,009 99.93 98.29Jul 292 291 99.66 30,816 30,816 100.00 99.99 591 588 99.49 5,448 5,317 97.60 98.11Aug 323 320 99.07 25,303 25,302 100.00 99.99 581 578 99.48 3,945 3,939 99.85 98.39Sep 297 292 98.32 28,538 28,343 99.32 99.87 488 488 100.00 4,530 4,530 100.00 98.64Oct 314 313 99.68 28,257 28,257 100.00 99.89 683 676 98.98 4,763 4,659 97.82 98.52Nov 305 304 99.67 29,326 29,325 100.00 99.91 850 846 99.53 4,706 4,686 99.59 98.65Dec 353 348 98.58 28,550 28,522 99.90 99.90 526 526 100.00 8,588 8,588 100.00 98.90Jan 252 250 99.21 36,378 36,377 100.00 99.92 548 537 97.99 4,118 4,062 98.63 98.88Feb 281 280 99.64 28,148 28,131 99.94 99.92 855 853 99.77 6,059 6,058 99.99 99.00

Total 3,232 3,210 99.32 306,904 306,656 99.92 99.92 7,001 6,954 99.33 57,235 56,660 99.00 99.00

A B C D E F G A B C D E F GNo of Bills Paid Within

Period


Target


Target


Period


Target


Within Target


Target


Period


Target


Target


Period


Target


Within Target



Apr 192 187 97.40 19,945 19,943 99.99 99.99 524 522 99.62 3,173 3,161 99.61 99.61May 319 318 99.69 20,129 20,126 99.99 99.99 1,926 1,926 100.00 9,593 9,593 100.00 99.90Jun 290 289 99.66 26,312 26,288 99.91 99.96 707 705 99.72 10,272 10,272 100.00 99.94Jul 297 295 99.33 28,246 28,243 99.99 99.97 695 690 99.28 7,912 7,845 99.15 99.74Aug 326 324 99.39 28,543 28,539 99.99 99.97 1,911 1,911 100.00 8,903 8,903 100.00 99.80Sep 255 255 100.00 28,347 28,347 100.00 99.98 1,784 1,784 100.00 9,048 9,048 100.00 99.84Oct 365 364 99.73 29,530 29,428 99.65 99.92 2,198 2,196 99.91 12,128 11,890 98.04 99.48Nov 338 336 99.41 27,655 27,647 99.97 99.93 1,912 1,912 100.00 10,527 10,527 100.00 99.56Dec 364 363 99.73 27,406 27,406 100.00 99.94 1,739 1,738 99.94 10,751 10,726 99.77 99.58Jan 223 216 96.86 33,341 33,288 99.84 99.93 2,244 2,236 99.64 11,378 11,216 98.58 99.46Feb 305 304 99.67 27,267 27,265 100.00 99.93 1,846 1,846 100.00 6,581 6,581 100.00 99.50

Total 3,274 3,251 99.30 296,720 296,519 99.93 99.93 17,486 17,466 99.89 100,266 99,762 99.50 99.50

West Leicestershire CCGNHS CREDITORS NON-NHS CREDITORS

East Leicestershire & Rutland CCGNHS CREDITORS NON-NHS CREDITORS

Leicester City CCGNHS CREDITORS NON-NHS CREDITORS

Blank Page

Name of meeting: LLR CCGs’ Governing Body meetings in common

Date: 14 April 2020 Paper: G Public Confidential

Report title:

Paper to consider and approve the suspension of the Delegated Authority Process for approval of health funds in response to the COVID-19 Emergency

Presented by: Caroline Trevithick - Executive Director of Nursing, Quality and Performance

Report author: Julie Croysdale. PHB Service Delivery Manager and Nick Hey Senior Contracts Manager

Executive lead: Caroline Trevithick - Executive Director of Nursing, Quality and Performance Paul Gibara - Chief Commissioning and Performance Officer


Executive summary: This report sets out the proposals for the suspension of the Delegated Authority Process for approval of health funds in response to the COVID-19 Emergency. In line with:

• The Hospital Discharge Service Requirements for all NHS trusts, community interest companies and private care providers of acute, community beds and community health services and social care staff in England, who must adhere to the requirements from Thursday 19th March 2020.

• The Government agreement that NHS CHC assessments for individuals on the acute hospital discharge pathway and in community settings will not be required until the end of the COVID-19 emergency period.

• The Government agreement that the NHS will fully fund the cost of new or extended out- of-hospital health and social care support packages, referred to in this guidance. This applies for people being discharged from hospital or would otherwise be admitted into it, for a limited time, to enable quick and safe discharge and more generally reduce pressure on acute services.

• The introduction of a single discharge to assess model across England.

The requirements detailed in the COVID-19 Hospital Discharge Service Requirements guidance included as appendix B

Appendices: Appendix A - Current Process for CHC Approval Appendix B - COVID-19 Hospital Discharge Service Requirements

Recommendations:


• Note the requirements detailed in the COVID-19 Hospital Discharge Service Requirements guidance included as appendix B

• Note the transfer of responsibility for funding care from local assessment

and approval processes to the central government COVID-19 response budget.


Rutland CCG


interest: None


In relation to corporate governance processes.


Yes


Yes


Yes


Yes

• Support the proposal for the suspension of the Delegated Authority Process for approval of health funds in response to the COVID-19 Emergency


N/A

2

To suspend the Delegated Authority Process for approval of health funds in response to

the COVID-19 Emergency

Purpose of the Report

The purpose of this report is to inform the panel of the proposals for the suspension of the Delegated Authority Process for approval of health funds in response to the COVID-19 Emergency

Background

Midlands and Lancs have been our strategic partner for Continuing Healthcare and Continuing Care for Children since April 2017 and in that time we have developed a strong relationship and worked to develop the service specification and service delivery. As part of this arrangement MLCSU have also been the gateway for the processing, approval and commissioning of health funded care in the community.

As part of the current funding approval process Midlands and Lancs CSU rely on oversight and approval of funding decisions to be made the CCG through the Nursing and Quality teams. These include:

• CHC Eligibility for all cases including Joint funded cases who become CHC eligible; • Annex A decisions for Funded Nursing Care; • Funded Nursing Care; • Fast Track Eligibility; • S117 funding approval less than £50,000; • Alternative Hospital Placement approval; • Personal Health Budget decisions outside of panel.

This approval process takes the form of the delegated authority and high risk and complex care panel processes which are detailed in Appendix A.

As part of the NHS emergency response to the COVID-19 crisis the Government has agreed that the NHS will fully fund the cost of new or extended out-of-hospital health and social care support packages, referred to in the COVID-19 hospital discharge service requirements guidance (Appendix B). This applies for people being discharged from hospital or would otherwise be admitted into it, for a limited time, to enable quick and safe discharge and more generally reduce pressure on acute services. Local LLR plans on how the Finance support and funding flows will be established are currently under development, however the expectation is that all care commissioned in the community will be commissioned by the Local Authority on behalf of the CCGs and recharged against the CHC budget. However these charges will then be reimbursed by the Government through COVID-19 financial reporting requirements.

Proposal for approval

As part of these temporary discharge measures, in relation to NHS Continuing Healthcare, NHSE have informed CCGs of the need to suspend any new assessments of eligibility for NHS CHC funding to help expedite patients out of acute and community hospitals beds in the most time efficient method possible. With the NHS nationally accepting the cost of all discharge packages of care during the emergency period to help expedite discharge, there is a need to remove any local processes which will delay the commissioning and approval of care packages.

3

https://www.england.nhs.uk/coronavirus/publication/covid-19-hospital-discharge-service-requirements/

The current local LLR CCG approval process for health funding of packages, although as efficient as it can be, does implement additional steps in the commissioning of care which do cause delay. The new process being implemented during the emergency period will require care decisions to be made and commissioned without an approval process for the spend of NHS funds. This is supported by the agreement that the funding to support the care will be centrally allocated and therefore removes the need for a local governance process to approve spend, as the care will not be funded through local CCG funds.

Conclusions

• The Hospital Discharge Service Requirements guidance makes it’s clear that all NHS trusts, community interest companies and private care providers of acute, community beds and community health services and social care staff in England, must adhere to the requirements from Thursday 19th March 2020.

• The Government has agreed that NHS CHC assessments for individuals on the acute hospital discharge pathway and in community settings will not be required until the end of the COVID-19 emergency period.

• The Government has agreed that the NHS will fully fund the cost of new or extended out-

of-hospital health and social care support packages, referred to in this guidance. This applies for people being discharged from hospital or would otherwise be admitted into it, for a limited time, to enable quick and safe discharge and more generally reduce pressure on acute services.

• Current governance process for the approval of health funds causes an additional level of

delay in the discharge process and will need to be amended during the COVID-19 emergency period.

• During the emergency period is no longer a requirement for Local CCGs to put in place

local governance processes for the approval of health funds

Recommendation

The panel is asked to:

• Note the requirements detailed in the COVID-19 Hospital Discharge Service Requirements guidance included as appendix B

• Note the transfer of responsibility for funding care from local assessment and approval processes to the central government COVID-19 response budget.

• Support the proposal for the suspension of the Delegated Authority Process for approval of health funds in response to the COVID-19 Emergency

List of Appendices

Appendix A - Current Process for CHC Approval Appendix B - COVID-19 Hospital Discharge Service Requirements

4

Appendix A

Current Process for CHC Approval

LLR CCG staff attend bimonthly panels for adults in order to approve High Risk and Complex Care presented by Midlands and Lancashire CSU (MLCSU) and the Section 117 team for S117 cases above £50,000.

The applications considered by panel are adults over 18 with -

• NHS Continuing Healthcare placements over £50K. MLCSU approve cases less than£50k;

• Alternative hospital placements with a primary diagnosis of mental illness;• Section 117 of the Mental Health Act applications for health funding;• Those who require a placement for ongoing non acute neuro rehabilitation following an

acquired brain injury;• Support Plans which have been identified as high risk by the PHB Team or which contain

elements that the LLR CCGs consider need to be individually risk managed;• All Indicative Budgets (IB) and Final budgets (FB) for PHBs.

By way of explanation; the indicative budget for Continuing Healthcare Cases is set via a Resource Allocation System (RAS) designed for PHBs. This includes the need based profile and has the local domiciliary care rate to determine the budget. The calculation is based on an algorithm which attaches money to tasks. The monetary value is calculated using the domiciliary care rates. This value is then shared with the patient and the support plan is worked up and a final budget agreed.

Appendix B

200318 - COVID-19 Discharge Guidance (H

5

COVID-19 Hospital Discharge ServiceRequirements

ContentsCOVID-19 Hospital Discharge Service Requirements ..................................................... 1

1. Summary .............................................................................................................. 32. What does this mean for patients? .......................................................................... 73. What are the actions for acute care organisations and staff?..................................... 84. What are the actions for providers of community health services? ........................... 115. What are the actions for Councils and Adult Social Care services?.......................... 126. What are the actions for Clinical Commissioning Groups? ...................................... 147. What are the actions for the Voluntary Sector? ...................................................... 158. What are the actions for Care Providers? .............................................................. 179. Monitoring and increasing rehabilitation capacity.................................................... 2010. Finance support and funding flows ..................................................................... 22

Proposed finance route from CCGs for additional discharge support services ............. 23

Reimbursement routes and cashflow ........................................................................ 24

Enhanced discharge support – cessation process ..................................................... 25

11. Reporting and performance management ........................................................... 2612. Additional resources and support ....................................................................... 27

Webinars ................................................................................................................ 27

Supporting guidance ............................................................................................... 27

Published 19 March 2020

COVID-19 Hospital Discharge Service Requirement

2

Annex A: The Discharge to Assess Model ................................................................ 29

Annex B: Maintaining good decision making in acute settings .................................... 32

Annex C: COVID-19 Trusted Assessor guidance....................................................... 34

Annex D: Patient discharge choice leaflet ................................................................. 36

Annex E: Homelessness.......................................................................................... 37

Annex F: Community rehabilitation & hospice bed capacity – Capacity Tracker ........... 38

Annex G: NHS Continuing Healthcare and COVID-19 Planning ................................. 40

Annex H: Overview of decision making and escalation .............................................. 42


3

1. Summary 1.1 This document sets out the Hospital Discharge Service Requirements for all NHS

trusts, community interest companies and private care providers of acute, community beds and community health services and social care staff in England, who must adhere to this from Thursday 19th March 2020. It also sets out requirements around discharge for health and social care commissioners (including Clinical Commissioning Groups and local authorities).

1.2 Unless required to be in hospital (see Annex B), patients must not remain in an NHS bed.

1.3 Based on these criteria, acute and community hospitals must discharge all patients as soon as they are clinically safe to do so. Transfer from the ward should happen within one hour of that decision being made to a designated discharge area. Discharge from hospital should happen as soon after that as possible, normally within 2 hours.

1.4 Implementing these Service Requirements is expected to free up to at least 15,000 beds by Friday 27th March, with discharge flows maintained after that. Acute and community hospitals must keep a list of all those suitable for discharge and report on the number and percentage of patients on the list who have left the hospital and the number of delayed discharges through the daily situation report.

1.5 The current legislation does not describe a specific timeframe for carrying out NHS CHC assessments of eligibility, or for individual requests for a review of an eligibility decision (i.e. Local Resolution and Independent Review). Therefore, NHS CHC assessments for individuals on the acute hospital discharge pathway and in community settings will not be required until the end of the COVID-19 emergency period. Planned legislative change, as part of the COVID-19 Bill, will further support the NHS in relation to this.

1.6 The Government has agreed the NHS will fully fund the cost of new or extended out-of-hospital health and social care support packages, referred to in this guidance. This applies for people being discharged from hospital or would otherwise be admitted into it, for a limited time, to enable quick and safe discharge and more generally reduce pressure on acute services.


4

1.7 Discharge requires teamwork across many people and organisations and the funding and eligibility blockages that currently exist cannot remain in place during the COVID-19 emergency period. Therefore, a discharge to assess model will be introduced across England.

1.8 The discharge-to-assess model is based on using four clear pathways for discharging patients as shown below

1.9 Acute hospitals will be responsible for leading on the discharge of all patients on pathway 0, ensuring that the 50% of patients that can leave the hospital and only need minimal support do so on time.

1.10 Providers of community health services will lead on pathways 1-3 as they will play a lead role in assessing and providing care for patients once they are home. Community health providers will need to set up a single coordinator in each acute centre, accountable to a named Executive Board lead in their own organisation, to ensure accountability for delivering the change. The co-ordination team will ensure all patients (irrespective of their address) are discharged on time and are provided with the follow up support as needed. The Discharge Service needs to operate at a minimum 8am-8pm, seven days a week. This approach applies to discharges from all NHS community and acute beds.

Figure 1: Discharge to Assess model


5

1.11 The discharge to assess pathways 1-3 will only be successful if NHS organisations work hand in glove with adult social care colleagues, the care sector and the voluntary sector.

1.12 Whilst most people will be discharged to their homes, a very small proportion will need and benefit from short or long term residential or nursing home care. The Discharge Service will be able to access live information from a national community bed tracker system. The existing North of England Commissioning Support (NECS) care home tracker will be extended to cover all care home places, all NHS community hospital beds and hospice beds. All providers must sign up and start using the tracker by 23 March 2020 (see Annex F).

1.13 The following sections detail what these changes mean for all health and care sectors with a role in hospital discharge and provide clarity on the actions organisations needs to take straightaway. This information will be supplemented by specific action cards outlining how key roles should work differently during this period, which will be published separately and discussed as part of webinar sessions on these changes (see section 12).

1.14 There needs to be clear accountability and escalation mechanisms at each stage of the discharge-to-assess process in each locality (see Annex H).

1.15 The diagram on the following page describes the discharge to asses process that should be undertaken in acute and community hospitals and once the patient is home.

1.16 NHS England and NHS Improvement are grateful for input from The Academy of Medical Royal Colleges and the Association of Directors of Adult Social Services into this guidance.


6

Discharge to Assess

Acute Setting Community Setting

Ne

w P

ath

way

Brief assessment of function e.g. transfers and

mobility

Clear clinical plan and EDD within 14

hrs

Not acutely unwell

Patient arrives in Hospital

Collect pre-morbid functional

information as soon as possible after

admission in majority of people

Alert the Single point i) basic information and ii) level of care needs in last 24hrs

Home

50%

Immediate health and social care

assessment in home environment

Care needs agreed with person

Person in community bed

(14-21 days)

Alert the single point i) basic information and ii) level of care needs in last 24hrs

4%

45%

The Single Point: Takes referrals from providers to support people at home

Reablement support (urgent

response)

Equipment(urgent

response if required)

Ongoing Health

intervention as required.

Access to community

beds if in crisis

Signposting and

advocacy

Review of care needs

Safe?

Discharge

Ongoing case management

Longer term interventionYes

No


7

2. What does this mean for patients? 2.1 Patients will still receive high quality care from acute and community hospitals, but

will not be able to stay in a bed as soon as this is no longer necessary. For 95% of patients leaving hospital this will mean that (where it is needed), the assessment and organising of ongoing care will take place when they are in their own home. Leaflet A, describing these COVID-19 arrangements, is provided in Annex D and should be shared with all patients on admission to hospital.

2.2 On the day a patient is to be discharged patient, (following discussions with the patient, their family and any other professionals involved in their care using leaflets B1/B2 in Annex D), within one hour the ward will arrange to escort the patient to the hospital discharge lounge, so their acute bed can be immediately used by someone being admitted who is acutely unwell.

2.3 Within two hours of arriving in the discharge lounge, transport home, any volunteer and voluntary sector support and immediate practical measures, such as shopping and the heating turning on, will be organised by the discharge co-ordinators for those who have no one else to do this.

2.4 A lead professional or multidisciplinary team, as is suitable for the level of care needs, will visit patients at home on the day of discharge or the day after to arrange what support is needed in the home environment and rapidly arrange for that to be put in place. If care support is needed on the day of discharge from hospital, this will have been arranged prior to the patient leaving the hospital site, by a care coordinator.

2.5 For patients whose needs are too great to return to their own home (about 5% of patients admitted to hospital) a suitable rehabilitation bed or care home will be arranged. During the COVID-19 pandemic, patients will not be able to wait in hospital until their first choice of care home has a vacancy. This will mean a short spell in an alternative care home and the care coordinators will follow up to ensure patients are able to move as soon as possible to their long term care home.

2.6 During the COVID-19 pandemic, all of the above support will be paid for by the NHS, to ensure patients move on from their acute hospital stay as quickly as possible.


8

3. What are the actions for acute care organisations and staff?

‘Why not home, why not today?’

Acute providers need to rapidly update their processes and ways of working to deliver the discharge-to- assess model.

3.1 Ward level:

• Clinically-led review of all patients at an early morning board round. Any patient meeting the revised clinical criteria will be deemed suitable for discharge

• At least twice daily review of all patients in acute beds to agree who is not required to be in hospital, and will therefore be discharged

• Ensure professional and clinical leadership between nursing, medicine and allied health professions for managing decisions and use prompts in the box below:

• All patients who are not required to be in hospital and are therefore suitable for discharge will be added to the discharge list and allocated to a discharge pathway. Discharge home today should be the default pathway

• On decision of discharge, the patient and their family or carer, and any formal supported housing workers should be informed and receive the relevant leaflet (see Annex D).

➢ Does the person require the level of care that they are receiving, or can it be provided in another setting?

➢ What value are we adding for the person balanced against the risks of being away from home?

➢ What do they need next? ➢ ‘Why not home, why not today’ for those who

have not reached a point where long-term 24-hour care is required.

➢ If not home today, then when? – Expected date of discharge from bed.


9

• Individuals and their families must be fully informed of the next steps

• Transfer off the ward into a discharge lounge within one hour of decision to discharge

• Social care colleagues should be involved in daily ward reviews. This will help with the early identification of any possible support, placement or housing issues with discharge and allow the MDT to undertake arrangements in good time.

3.2 Hospital Discharge Teams:

• Arrange dedicated staff to support and manage all patients on pathway 0. This will include:

• co-ordinating with transport providers • local voluntary sector and volunteering groups helping to ensure

patients are supported (where needed) actively for the first 48 hours after discharge

• ‘settle in’ support is provided where needed

• Train discharge staff (potentially those who no longer have to undertake CHC assessments) to operate ‘Trusted assessments’ for patients in hospital from

care homes, so they can return to their care home promptly, and support all care homes with these new discharge arrangements.

3.3 Hospital clinical and managerial leadership team:

• Create safe and comfortable discharge spaces for patients to be transferred to within one hour of decision to discharge, ensuring enough space for increased numbers of discharges.

• Maintain timely and high quality transfer of information to General Practice and other relevant health and care professional on all patients discharged.

To create a safety-net and increase confidence in discharging, consider:

✓ Patient initiated follow up - give patients the direct number of the ward discharged from to call back for advice. Do not suggest going back to their GP or coming to A&E.

✓ Telephone the following day after discharge to check and offer reassurance/advice.

✓ Call them back with results of investigations and any changes or updates to a patient’s management plan

✓ Bring them back under the same team / speciality. ✓ Request community nursing follow up with a specific clinical need ✓ Request GPs to follow up in some selected cases


10

• Use change 9 within the High Impact Change Model (see section 12) to ensure planning and discharge for people with no home to go to and that no-one is discharged to the street. See Annex E for further details on homelessness.

• Senior clinical staff to be available to support ward and discharge staff with appropriate risk-taking and clinical advice arrangements

• Where applicable to the patient, COVID-19 test results are included in documentation that accompanies the person on discharge

• Ensure all patients identified being in the last days or weeks of their life are rapidly transferred to the care of community palliative care teams who will be responsible for co-ordinating and facilitating rapid discharge to home or a hospice.


11

4. What are the actions for providers of community health services?

4.1 Providers of community healthcare are expected to update their processes and ways of working to deliver the discharge to assess model. Community health services will take overall responsibility for ensuring the effective delivery of the discharge service and for pathways 1,2 and 3. As part of this they should:

• Identify an Executive Lead to oversee the implementation and delivery of the Discharge to Assess model in the acute hospitals in their area. The model should operate at least 8am-8pm 7 days a week

• Release staff from their current roles (see separate Community Health Service prioritisation guidance) to co-ordinate and manage the discharge arrangements for all patients from community and acute bedded units on pathways 1, 2 and 3

• Have an easily accessible single point of contact which will always accept assessments from staff in the hospital and source the care requested, in conjunction with local authorities

• Deliver enhanced occupational therapy and physiotherapy 7 days a week to reduce the length of time a patient needs to remain in a hospital rehabilitation bed

• Use multi-disciplinary teams on the day they are home from hospital, to assess and arrange packages of support for patients on pathways 2 and 3.

• Co-ordinate the care for patients discharged on pathways 1-3

• Ensure provision of equipment to support discharge.

• Ensure patients on all three pathways are tracked and followed up to assess for long term needs at the end of the period of recovery

• Maintain the flow of patients from community beds including re-ablement and rehabilitation packages in home settings, to allow the next sets of patients to be discharged from acute care

4.2 For patients identified being in the last days or weeks of their life Community Palliative Care teams will be responsible for co-ordinating and facilitating rapid discharge to home or hospice. This supersedes the current fast track end of life process


12

5. What are the actions for Councils and Adult Social Care services?

5.1 As part of implementing the discharge to assess model, local authorities are asked to:

• Agree a single lead local authority or point of contact arrangement for each hospital or Trust, ensuring each acute trust and single local coordinator for local discharge to assess pathways has a single point to approach when coordinating the discharge of all patients, regardless of where that person lives

• Work together and pool staffing to ensure the best use of resources and prioritisation in relation to patients being discharged, respecting appropriate local commissioning routes. During this period, funding will be made available for all patients being discharged and local authorities are enabled by the Care Act (Section 19) to meet urgent needs where they have not completed an assessment and regardless of the person’s ordinary residence

• Coordinate work with local and national voluntary sector organisations to provide services and support to people requiring support around discharge from hospital and subsequent recovery

• Take the lead contracting responsibilities for expanding the capacity in domiciliary care, care homes and reablement services in the local area paid for from the NHS COVID-19 budget.

5.2 Specific responsibilities for Adult Social Care

• Identify an Executive Lead for the leadership and delivery of the Discharge to

Assess model.

• Redeploy social work staff from the hospital setting to community settings to support discharged patients. Safeguarding investigations should continue to take place in a hospital setting if necessary.

• Ensure there are robust tracking mechanisms to track care placements so that care users do not get lost in the system at a time of very rapid response.

• Suspend need for funding panels for hospital discharge during the level 4 incident, with additional funding available to Local Authorities to cover any increased costs during this period.

• Provide social care capacity to work alongside local community health services to provide a single point of contact for hospital staff.


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• Support real time communication between the hospital and the single point of contact, not just by email.

• Provide capacity to review care provision and change if necessary, at an appropriate point.

• Work closely with community health providers over the provision of equipment.

• Ensure there is 7 day working for community social care teams (to be commissioned by local authorities).

• Deploy adult social care staff flexibly in order to avoid an immediate bottlenecks in arranging step down care and support in the community and at the same time focusing on maintaining and building capacity in local systems


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6. What are the actions for Clinical Commissioning Groups?

6.1 CCGs supported by Integrated Care Systems (ICSs) or System Transformation Partnerships (STPs) need to support the coordination of activities set out in this framework. Specifically, they must:

• Coordinate local financial flows for NHS COVID-19 spend, including monitoring all local spend, coordinating local funding arrangements and work in partnership with local Government to support them in their lead contracting role in the local system.

• Comply with NHS England and NHS Improvement financial controls and reporting as set out in Section 10.

• CCGs should follow the guidance on NHS Continuing Healthcare in line with the detail found in Annex G.

• Free up staff resource from NHS Continuing Healthcare assessment processes to support the discharge-to-assess activities and transfer staff to local providers to support these new discharge arrangements.

• Arrange for community health end of life teams to take responsibility for any “fast track patients” end of life care patients needing support and step down.

• Co-ordinate and lead the rapid implementation of the Capacity Tracker (see Annex F) and NHS mail in care homes and hospices throughout their local area (see Section 8.3).


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7. What are the actions for the Voluntary Sector?

Many systems already work with the voluntary sector to facilitate swift and safe discharges. In the current situation immediate consideration should be given to increasing the capacity of these services

7.1 The sector should:

• mobilise quickly and focuses on safety and positive experiences for patients on the discharge process, enabling patients to feel supported at home. They can also help reticent patients feel much more comfortable about being discharged

• Provide a range of practical support to facilitate rapid discharge, including transport home and equipment such as key safes

• Support discharged patients with home settling services to maintain wellbeing in the community (e.g. safety checks and essential food shopping)

• Provide ongoing community-based support to support emotional wellbeing, such as wellbeing daily phone calls and companionship

• Engage with NHS providers (particularly discharge teams) to provide solutions to operational discharge challenges, freeing-up clinical staff for other activities – focusing on the patients on pathway 0

• Utilise embedded local voluntary organisations in discharge pathways and enhance with input from large voluntary organisations

• Coordinate support between voluntary organisations and existing volunteers within NHS providers.

• In advance of discharge be at the patient's home to accept equipment

• St John Ambulance can also provide assisted discharge where conveyance by ambulance is required

7.2 Voluntary sector assisted discharge scheme extension

• Over the winter months of 2019/20, the British Red Cross Age UK and St John Ambulance have been providing discharge support to 42 hospitals between them. The charities provide practical and emotional support for both inpatients and those attending A&E, then assist frail and vulnerable people home from hospital. This service can remove practical barriers to discharge


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by freeing up the time of NHS staff to focus on clinical tasks, providing transport or escort home to resettle, and undertaking follow up safe-and-well checks once home. This service will now be extended to support up to 100 hospitals

7.3 NHS volunteers to support hospital discharge

In addition to the support being offered by charities as part of the response to COVID-19, hospitals should consider how to deploy their NHS volunteers to volunteering roles that can most reduce pressure on services. Many hospitals utilise volunteers to assist people in getting ready to go home from hospital, ensuring they have everything they need and that everything is in place at their place of residence. They can greatly speed up the discharge process and also reduce the likelihood of readmission by ensuring that the person has the right support and resources in place at home. Volunteers can also provide advice and signposting to community support services and increase patient’s

confidence about leaving hospital and going home.

• 7.4 NHS England and Improvement is setting up a new scheme to identify additional volunteers able to support the NHS led by the Royal Voluntary Service using the GoodSAM app as the digital platform.


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8. What are the actions for Care Providers?

8.1 Care Home providers:

• Maintain capacity and identify vacancies that can be used for hospital discharge purposes

• Adopt from Monday 23rd March 2020 and implement the Capacity Tracker during the COVID-19 outbreak to make vacancy information available to NHS and social care colleagues in real time

• Providers of Care Homes, in partnership with their local Primary care Networks and Community Health Provider, should consider how best to support residents, and where already in place, embed the Enhanced Health in Care Home Framework in line with timescales already outlined by NHSEI which have been communicated to primary care providers. This will ensure their residents are better supported (7 days a week) by the NHS.

• Implement NHSmail in their care home from Monday 23rd March, to ease communication between NHS and social care colleagues. From Monday 23rd March 2020, faster NHSmail roll-out will be available to all care providers, to support safe and secure transfer of information. NHSmail is accredited for sharing patient identifiable and sensitive information, meaning it meets a set of information security controls that offer an appropriate level of protection against loss or inappropriate access.

To improve communication between health and social care during the COVID-19 outbreak, NHSX is speeding-up the roll-out of NHSmail and temporarily waiving the completion of Data Security Protection Toolkit (DSPT) to allow for quicker on boarding. This is in-line with information governance guidance for COVID-19.

These are temporary measures to improve communication during COVID-19. NHSX is committed to enabling care providers to choose the right communication solutions for them. Providers will be asked to give their own assurance that they are secure and post-COVID-19, afterward NHSmail regional teams will take providers through the full DSPT process, supporting them to accredit their secure email system or NHSmail for sharing in future.

• Where ‘Trusted assessor relationships and arrangements are not in place with

Acute providers, rapidly work with the discharge team to implement these rules and processes


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8.2 Domiciliary care providers:

• Identify extra capacity to adult social care contract leads, that can be used for hospital discharge purposes or follow on care from reablement services.

8.3 Patient Transport:

Patient Transport Services (PTS) are a critical resource in moving non-emergency patients from one care setting to a more appropriate setting on another site. Demand for PTS will increase through this period, and services will need to be more responsive.

• All PTS providers, across the NHS, independent and voluntary sector, will be expected to provide support to enable the transfer of patients as part of the discharge process and to support transfers and discharge as a priority in order to maintain flow and maximise patient safety.

• Additional guidance on how PTS will be enabled to deliver through this incident, including adjustments to KPI monitoring and reimbursement models will follow.

• Organisations should also consider alternative transport options. This could include:

• Local Authority owned or contracted vehicles • Volunteer cars • Voluntary sector resources • Taxi services • Use of patient / relatives’ own car.

8.4 Equipment and assistive technology

The single coordinator will need to ensure there is access to sufficient equipment to support discharge of people with reablement or rehabilitation needs at home.

As part of this, the local commissioner for NHS and Social Care Equipment must ensure:

• Local equipment services (across the NHS and local government) have a sufficiency of supply of the more common items of equipment used to support people with reablement or rehabilitation or longer-term care needs

• Access to such equipment can be quickly (same day where needed) and easily facilitated seven days a week (utilising mutual aid with neighbouring areas or redeployment of community based staff if required). This may include the


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purchase of additional equipment and the recycling, cleaning and reuse of equipment

• Providers are prepared for rapid implication of increased volumes of rehabilitation equipment, including same day delivery requests

• The availability of equipment that can be used to reduce the need for two carers to provide care to individuals, releasing workforce capacity

• Providers have access to adequate stocks of Personal Protective Equipment (PPE).

• Simple approval process for more complex patients requiring hospital beds, pressure relieving equipment and hoists. This should be through discussion and verbal approval to order. Current senior clinician approval process and equipment prescription matrices will be stood down

• Regular review and tracking of issued equipment to reduce over prescription of equipment. The responsibility for review of equipment once a patient is discharged will sit with the receiving care organisation

• Photographs supplied by family/carers/community staff including District Nurses as an alternative to completing access and risk assessment visits for more complex patients. If a visit is required, this will need to be arranged within 4 hours of decision to discharge

• Discharge tracking information is used to ensure regular restocking of buffer/satellite stores to maintain supply

• There is a comprehensive range of assistive technology items that can support people to live safely and independently at home with next day access to support if required. This goes significantly beyond falls pendants.

• Stock includes gas, carbon monoxide, smoke alarms including devices that supports people who are blind and/or deaf, and temperature detectors. Movement detectors, bed/chair occupancy detectors and flood detectors.

• There are enuresis sensors, epilepsy sensors and medication dispensers covering a 28-day period.

• Equipment can be made available at low-cost and can be simple to fit without hardwiring..


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9. Monitoring and increasing rehabilitation capacity

9.1 After the first phase of discharging existing patients who do not meet the criteria for being in an acute hospital, it will be essential to maintain this approach in any rehabilitation and step down facilitates and broader care-at- home services. This will avoid creating blockages in the community facilities/services and stop the next sets of patients being discharged from acute care.

9.2 Pathways 1, 2 and 3:

• Of those patients discharged to short-term reablement/rehabilitation pathways approximately 35% are likely to require long term care at home or placement in a 24-hour residential or nursing setting.

• It is essential that people on these pathways are tracked and assessed after a period of recovery. Longer-term care or placement must be made available at the right time to ensure that the pathways are not blocked for future patients needing discharge from hospital.

9.3 Community Hospitals

It is vital that discharges from community hospitals are increased and delays eradicated with the same approach and action taken in acute settings. This includes:

• A daily clinical review of the plan for every patient focusing on three questions

• Why not home?

• What needs to be different to make this possible at home?

• Why not today?

• The review process should explore why people require rehabilitation in a bedded setting. It is accepted that the majority patients will be medically stable in this setting.

• All patients should have an expected date of discharge (EDD) and be fully involved with their discharge planning. Essential that expectations are set at the point of transfer or admission


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• The review should specifically look at whether people can be supported at home. The default assumption will be discharge home today

• All actions from the review should be noted and aimed to be completed by the end of the day.

9.4 Short-term placement for people who require 24-hour supervision and care

• For people who need a 24-hour care setting it is essential they are assigned a case manager (social worker, discharge team nurse or CHC nurse) who will review them regularly using the same questions as for community hospitals.

• Discharge should be arranged as soon as possible to their own home and packages of support made available.

9.5 Short term rehabilitation/reablement-at-home review • Using a professional supervision/case management model the service must

review all people on their caseloads daily. The team identifies all patients who have been on caseloads for an extended period.

• These patients are discussed using the following questions:

o What is our current aim of support?

o Have we met this? If not, what is going to change to enable us to meet this aim?

o Are we best placed to support this need? Is there an alternative?

o Can we safely discharge this person?

• Actions from the discussion are recorded and actions followed up daily.


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10. Finance support and funding flows 10.1 The Government has agreed to fully fund the cost of new or extended out-of-

hospital health and social care support packages, referred to in this guidance, for people being discharged from hospital or would otherwise be admitted into it for a limited time, to enable quick and safe discharge and more generally reduce pressure on acute services. There will be separate announcements on local government resilience funding for social care.

10.2 This section sets out the financial support available for this care and support capacity and enhanced discharge support services from NHS England and Improvement; how finance support will to flow to CCGs; and how the relevant commissioning budgets should be managed locally.

10.3 There will be a suspension of usual patient funding eligibility criteria while this process in in place. NHSE&I will ensure there is sufficient funding to support CCGs and their local authority partners to commission the enhanced discharge support outlined in this guidance. CCGs are expected to ensure that an appropriate market-rate is paid for this support. This includes liaising with their local authorities to agree an approach to ensuring the market can sustain a rapid and significant increase in supply. This appropriate market-rate may need to reflect that some patients and the capacity being utilised would previously have been self-funded.

10.4 This NHSE&I funding support will commence from 19th March and will reimburse, via CCGs, the costs of out-of-hospital care and support that arise as a result of the approach outlined in this document (both new packages and enhancements to existing packages), where it is provided to patients on or later than this date. Any patients already receiving out of hospital care and support that started before this date will be expected to be funded through usual pre-existing mechanisms and sources of funding.

10.5 This funding agreement will be kept under review. CCGs and local authority partners will be notified by NHSE&I or DHSC when this no longer applies to new patients.


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Proposed finance route from CCGs for additional discharge support services

10.6 In order to expedite the most appropriate flow of funds and minimise administrative

burden, the following process should be followed.

10.7 Procurement and contracting rules continue to apply. Local commissioners should agree the most appropriate route to deliver the enhanced discharge support in their area. Additional financial support provided to CCGs and local authorities should be pooled locally using existing statutory mechanisms. Under section 75 of the NHS Act 2006, CCGs and local authorities can enter into partnership agreements that allow for local government to perform health related functions where this will likely lead to an improvement in the way these functions are discharged.

10.8 Where systems decide that an enhanced supply of out of hospital care and support services will be commissioned via the local authority, the existing section 75 agreements can be extended or amended to include these services and functions and the local authority should commission the health and social care activity on behalf of the system. Similarly, where a CCG is already acting as a lead commissioner for integrated health and care, partners can agree that existing section 75 arrangements can be varied to allow them to commission social care services.

10.9 Where CCGs and local government agree, BCF section 75 agreements can be extended or varied for this purpose[1]. A model template for a variation to a section 75 agreement is available on the NHS England website[2].

10.10 The funding provided should be separately identified within the agreement and monitored to ensure funding flows correctly. It should be pooled alongside existing local authority planned expenditure on discharge support. Support provided and agreed budgets from this funding should be recorded at individual level. Where care is

[1] The Better Care Fund Policy allocations for the CCG minimum contribution and the improved Better Care Fund have been made public.

Although BCF plans from April 2020 will not have been formally approved, for the duration of the current outbreak of COVID-19, systems should assume that spending from ringfenced BCF funds, particularly on existing schemes from 2019-20 and spending on activity to address demands in community health and social care, is approved and should prioritise continuity of care, maintaining social care services and system resilience.

[2] https://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/risk-sharing/

https://www.england.nhs.uk/publication/minimum-allocations-for-the-better-care-fund-from-ccgs-in-2020-21/

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/864033/Core_Spending_Power_Supporting_Information_2020_to_2021.xlsx

https://www.england.nhs.uk/ourwork/part-rel/transformation-fund/bcf-plan/risk-sharing/


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most appropriately commissioned directly by NHS commissioners, this should be placed under existing contractual arrangements with providers but invoiced separately to ensure that enhanced discharge support funding is identifiable. This care should be paid for from the additional funding set out in this section.

10.11 Where a patient has been admitted to secondary care and had previously been in receipt of a funded care package (either in a care-home or in their own home) this guidance and additional funding is intended to support the restart of such a package also. I.e. restarted care following discharge will be counted as covered by this additional funding.

10.12 CCGs and local authorities should work with the trusts from which patients are being discharged, and with their community services and voluntary sector partners, to ensure that the most appropriate enhanced discharge services are being provided and that these align with the needs of patients that the trusts are seeing.

10.13 Commissioners should work with providers of discharge services to ensure that extending existing contracts will be financially sustainable for those providers, and consider mitigating actions where there is a risk that they will not be.

Reimbursement routes and cashflow

10.14 CCGs should ensure that both they and any local authorities commissioning on their behalf reimburse their providers in a timely fashion, reflecting differing cash-flow requirements of those providers – paying particular consideration to smaller providers. Local authority and CCG commissioners should refer to guidance published by the Local Government Association, ADASS and the Care Provider Alliance on social care provider resilience during COVID-19.

10.15 NHSE&I expect ordinary financial controls to be maintained with respect to invoicing, raising of purchase orders and authorising payments. However, CCGs should ensure that there is not an undue administrative burden that slows down the commencement of the enhanced discharge support services. Where necessary, retrospective approvals and approaches to the degree of detailed financial scrutiny appropriate to achieving this aim should be undertaken.


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10.16 NHSE&I will reimburse CCGs through the monthly allocation process. CCGs should, from the commencement date, maintain a record of the costs and activity associated with the enhanced discharge process so that they can submit a claim for additional payment for this from NHSE&I using a centralised approach that will be separately communicated.

10.17 Whichever model is followed CCGs should record the costs associated with this and link in with other wider COVID-19 financial reporting requirements. CCGs should expect to be asked for monthly updates on the costs of these services.

Enhanced discharge support – cessation process

10.18 Commissioners should plan throughout the period that the enhanced discharge support process is running to ensure appropriate processes are in place for the period following cessation of the enhanced discharge support process. As part of this, planning conversations should be taking place with patients and their families about the possibility that they will need to pay for their care later, as appropriate.


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11. Reporting and performance management

11.1 Current performance standards on DTOC monthly reported delays will be suspended from 19 March 2020.

11.2 Trusts should continue to report DTOC figures through the usual process, but will not be performance managed on them during the period of the incident.

11.3 Providers of community rehabilitation beds must start reporting DTOC figures on a daily basis to NHS Digital from Monday 23rd March.

11.4 NHS providers will be required to report the following during the Incident:

(1) Bed occupancy in hospitals – via daily sitrep

(2) Number of patients on daily discharge list

(3) Number and percentage of patients successfully discharged from discharge list

(4) Bed availability in community settings, via the Capacity Tracker Tool

11.5 Clinical Commissioning Groups will be required to submit the monthly financial spend to NHS England for reimbursement.


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12. Additional resources and support Webinars 12.1 To support implementation, NHS England will be running webinars to run through

the guidance and provide local areas with the opportunity to ask questions. This will be supported by Frequently Asked Questions which will be regularly updated.

12.2 The webinars are for all those involved in discharge, at all levels and from all organisations -CCGs, local government, health and care providers, housing, voluntary and community sector and social care providers. The webinars will be the same content run over four different sessions during the weeks commencing 16 March and 23 March 2020.

12.3 To register for the webinars, the web link is: http://www.supportingdischarge.eventbrite.co.uk

12.4 Over the next few days and weeks we will also be running virtual support clinic sessions to answer specific local queries. Further details on these clinics will be available on the webinars noted above.

Supporting guidance 12.5 This document should be read alongside the 2015 NICE guideline, Transition

between inpatient hospital settings and community or care home settings for adults with social care needs. https://www.nice.org.uk/guidance/ng27/resources/transition-between-inpatient-hospital-settings-and-community-or-care-home-settings-for-adults-with-social-care-needs-1837336935877

12.6 Discharge to Assess also forms part of the High Impact Change Model (HICM) for hospital discharge. https://local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-resilience/refreshing-high

12.7 For further detail on discharge to assess, please see the D2A Quick Guide https://www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-discharge-to-access.pdf

https://www.nice.org.uk/guidance/ng27/resources/transition-between-inpatient-hospital-settings-and-community-or-care-home-settings-for-adults-with-social-care-needs-1837336935877



https://local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-resilience/refreshing-high

https://local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-resilience/refreshing-high

https://www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-discharge-to-access.pdf

https://www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-discharge-to-access.pdf


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12.8 Shared guidance to local authority commissioners from the Association of Directors of Adult Social Services (ADASS), the Local Government Association (LGA) an the Care Provider Alliance (CPA) https://www.local.gov.uk/social-care-provider-resilience-during-covid-19-guidance-commissioners

https://www.local.gov.uk/social-care-provider-resilience-during-covid-19-guidance-commissioners

https://www.local.gov.uk/social-care-provider-resilience-during-covid-19-guidance-commissioners


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Annex A: The Discharge to Assess Model

This model, based on best practice, assumes that:

95% of people can go straight home on discharge:

• 50% can go home with minimal or no additional support (Pathway 0)

• 45% can go home with a short or longer-term support care package (Pathway 1)

5% of people will require residential or nursing care setting:

• 4% require rehabilitation support (Pathway 2)

• 1% require nursing home care (Pathway 3).

Figure 1: Discharge to Assess model

There are three stages to the discharge to assess model:

Stage one

Review patients daily and identify patients for discharge to leave that day

✓ Clinically-led review of all patients at an early morning board round, any patient meeting the revised clinical criteria will be deemed suitable for discharge

✓ At least twice daily review of all patients in acute beds to agree who is not required to be in hospital, and will therefore be discharged:

✓ All patients who are not required to be in hospital and are therefore suitable for discharge will be added to the discharge list and allocated to a discharge pathway.


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✓ Discharge home should be the default pathway ✓ The discharge list will be managed by the community

provider with the lead responsibility for ensuring the Discharge Service Requirements are met – this provider will be the single coordinator

Stage two

The details of how to discharge patients

✓ On decision of discharge, the patient and their family or carer, and any formal supported housing workers should be informed and receive the relevant leaflet (see Annex K)

✓ Community health, social care and acute staff need to work in full synchronisation (and include housing professionals where necessary) to ensure patients are discharged on time.

✓ The delineation of responsibility to coordinate and manage the discharge arrangements are expected to be:

o Pathway 0 – acute discharge staff lead o Pathways 1, 2 and 3 – community health staff lead

✓ On decision of discharge, all patients will be allocated a case manager by the single coordinator

✓ All patients must be transferred to an allocated discharge area/lounge within one hour of decision to discharge

✓ The case manager will be responsible for ensuring:

o Individuals and their families are fully informed of the next steps

o Patient transport home is available, where needed

o ‘Settle in’ support is provided where needed

✓ Senior clinical staff should be available to support staff with positive risk-taking and clinical advice

✓ Where applicable to the patient, COVID-19 test results are included in documentation that accompanies the person on discharge

Stage three

Assessment and care planning at home

✓ Post discharge, the single coordinator will need to ensure the staff and infrastructure is available to provide immediate care needs, review and assess for longer-term care packages or end support where it is no longer needed.


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✓ The single coordinator should draw on all available local resources, including the voluntary and community sector and social care staff no longer undertaking assessment work in the acute units.

➢ Coordinated home assessments between health and social care, including equipment and reablement support, take place ideally on the same day of discharge, led by a trusted assessor

Important considerations for all pathways:

• Duties under the Mental Capacity Act 2005 still apply during this period. If a person is suspected to lack the relevant mental capacity to make the decisions about their ongoing care and treatment, a capacity assessment should be carried out before decision about their discharge is made. Where the person is assessed to lack the relevant mental capacity and a decision needs to be made then there must be a best interest decision made for their ongoing care in line with the usual processes. If the proposed arrangements amount to a deprivation of liberty, Deprivation of Liberty Safeguards in care homes arrangements and orders from the Court of Protection for community arrangements still apply but should not delay discharge.

• For patients identified being in the last days or weeks of their life Hospital or Community Palliative Care teams will be responsible for co-ordinating and facilitating rapid discharge to home or Hospice. This supersedes the current fast track end of life process.


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Annex B: Maintaining good decision making in acute settings

Every patient on every general ward should be reviewed on a twice daily board round to determine the following. If the answer to each question is ‘no’, active consideration for discharge to a less acute setting must be made.

Requiring ITU or HDU care

Requiring oxygen therapy/ NIV

Requiring intravenous fluids

NEWS2 > 3

(clinical judgement required in patients with AF &/or chronic respiratory disease)

Diminished level of consciousness where recovery realistic

Acute functional impairment

in excess of home/community care provision

Last hours of life

Requiring intravenous medication > b.d. (including analgesia)

Undergone lower limb surgery within 48hrs

Undergone thorax-abdominal/pelvic surgery with 72 hrs

Within 24hrs of an invasive procedure

(with attendant risk of acute life threatening deterioration)


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Clinical exceptions will occur but must be warranted and justified. Recording the rationale will assist meaningful, time efficient review.

Review/challenge questions for the clinical team:

• Is the patient medically optimised? – (Don’t use ‘medically fit’ or ‘back to baseline’).

• What management can be continued as ambulatory - e.g. heart failure treatment?

• What management can be continued outside the hospital with community / district nurses? e.g. IV antibiotics?

• Patients with low NEWS (0-4) scores – can they be discharged with suitable follow up?

• If not scoring 3 on any one parameter e.g. – pulse rate greater than 130

• If their oxygen needs can be met at home.

• Stable and not needing frequent observations every 4 hours or less

• Not needing any medical / nursing care after 8pm.

• Patients waiting for results – can they come back, or can they be phoned through?

• Repeat bloods – can they done after discharge in an alternative setting?

• Patients waiting for investigations – can they go home and come back as out patients with the same waiting as inpatients?

Criteria- ed discharge:

• Can a nurse or allied health care professional discharge without a further review if criteria are well written out?

• Can a junior doctor discharge without a further review if criteria are clearly documented?

• How can we contact the consultant directly if criteria are only slightly out of range and require clarification?


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Annex C: COVID-19 Trusted Assessor guidance 12.9 This guidance is an interim supplement to CQC’s Guidance on Trusted Assessor

Agreements. It has been written to support NHS and social care providers and Trusted Assessor schemes during the COVID-19 pandemic. It will apply until further notice.

12.10 This update seeks to further remove and reduce delays in decision-making processes that can stop patients who are ready to be discharged from leaving NHS acute or community beds. Shifting to this revised approach will require hospital staff, providers and other partners to work in new and different ways.

12.11 The Government is bringing forth legislation to allow CCGs to delay assessments for CHC until after the conclusion of the coming period, including for individuals being discharged from hospital. This means the priority can be on timely discharges, with eligibility assessments and funding decisions taking place afterwards.

12.12 ‘Trusted Assessor’ schemes are a national initiative designed to reduce delays

when people are ready for discharge from hospital. Providers adopt assessments carried out by suitably qualified ‘Trusted Assessors’ working under formal, written

agreements.

12.13 Assessments and care planning can be undertaken by Trusted Assessor schemes in a way that meets both people’s needs and legal requirements on providers.

12.14 Providers accepting trusted assessments must have access to a process by which they can escalate concerns when a person has been discharged to their service with needs they are unable to meet. The process must be able to respond to those concerns promptly. Where a concern is raised about the appropriateness of the placement, CQC will expect this to be considered promptly.

12.15 Key changes from existing arrangements:

(1) All hospitals will train additional discharge staff to operate as ‘Trusted assessors’.

Trusted Assessors will continue to support care providers with discharge arrangements. The additional staff will supplement Trusted Assessors in existing schemes.

(2) Most hospitals already use trusted assessor schemes for discharges to care homes and care at home services in their areas. These should be kept up to date in local NHS Discharge to Assess (D2A) arrangements. This should be prioritised.

(3) Over this period CQC’s priority is to continue to check that people are safe. Where we have serious concerns, we will use inspection and other processes to do so.

https://www.cqc.org.uk/sites/default/files/20180625_900805_Guidance_on_Trusted_Assessors_agreements_v2.pdf

https://www.cqc.org.uk/sites/default/files/20180625_900805_Guidance_on_Trusted_Assessors_agreements_v2.pdf


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(4) Registered providers and managers will need to have confidence that legal requirements for assessments will be met, and that particular consideration will be given to safety and infection control-related needs during this heightened period.


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Annex D: Patient discharge choice leaflet It is recognised that issues of patient choice and engagement can often be significant barriers to hospital discharge where there are ongoing social care needs after discharge (particularly if moving to a residential or nursing home). During the COVID-19 response there will be suspension of choice protocols for this particular issue. The following leaflets have been produced to support the communication of this message.

Leaflet A – to be shared and explained to all patients on admission to hospital

Leaflet B – to be shared and explained to all patients prior to discharge, this is split into leaflets:

• Leaflet B1 for patients who are being discharged to their usual place of residence

• Leaflet B2 for patients moving on to further non-acute bedded care


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Annex E: Homelessness o The requirements of the homeless and people living on the streets, also need to be

reflected in any local framework to support the Government’s COVID-19 emergency. o Practices that have been developed in systems to support homeless persons need to

be maintained and enhanced to reflect the need to support the needs of those who are without a home and living on the street. It is already known that this group has a high level of mortality, and support needs including mental ill-health and substance misuse which may present a barrier to self-isolation.

o NHS trusts have a statutory duty under the Homelessness Reduction Act (2017) to refer people who are homeless or at risk of homelessness to a local housing authority. This statutory duty remains.

o To prevent homelessness from delaying discharge, the following should be followed: • Referrals should be made at the earliest opportunity as soon as it has been

identified that a person may be homeless on discharge as this provides more time for the housing authority and other support services to respond. The person must give consent and can choose which authority to be referred to.

• People who are homeless also need to be able to safely self-isolate to also prevent the need for greater care and reduce transmission risks.

• Systems should be vigilant in spotting symptoms – using organisations and staff to spot potential COVID-19 positive persons who are homeless and have access to rapid triage to cohort people accordingly.

• Local systems need to plan and provide for multiple venues to cohort and care for homeless people who are COVID-19 positive, thereby still managing people in the community where there needs to be spaces to keep people separate with provision on the street; accommodation, water, food, sanitation.


38

Annex F: Community rehabilitation & hospice bed capacity – Capacity Tracker As part of current discharge planning there is an imperative to understand bed occupancy and vacancies in the community. The Capacity Tracker produced and operated by NHS North of England Commissioning Support (NECS) is to be used by all systems nationally to record their care home, community and hospice bed capacity.

The Capacity Tracker is an established web-based tool providing the opportunity to easily track bed capacity and vacancies to support system wide bed and discharge planning. It has been successfully operating to support care home bed planning for some time.

To support current discharge planning Capacity Tracker will maintain support to organisations already registered, but will be expanded to capture bed capacity data in all care homes, all hospices (including children’s hospices) and from all providers of

inpatient community rehabilitation and end of life care.

This is not intended to replace current information systems already being used in some localities to track bed / room vacancies, but to run in parallel

All the above providers are required to use Capacity Tracker to report the following vacancies and broader status information (in care homes only at this stage) to ensure consistency of approach and availability of a real-time single source of truth across England.

Data being collected will be:

i. Number of beds ii. Number of bed vacancies iii. Current status i.e. Open / Closed to Admissions (care homes only), including

number of COVID-19 residents iv. Workforce / staffing levels (care homes only)

This essential information will be included in daily national SitRep reporting to support capacity planning and response. It should also be used by localities to understand their bed base and support system wide discharge planning. To support reliable real time discharge planning when using Capacity Tracker it must be updated as close to real time as practicable – e.g. as and when any occupancy changes or at least once per day if there has been no change. Accurate and timely data is essential for effective management of the response to the COVID pandemic bot locally and nationally System activities/requirements


39

There needs to be rapid system wide adoption of the Capacity Tracker. It will go live on 23rd March, with comprehensive support for registration and operation being developed. The full support offer to enable organisations will include a call centre, online tools, and webinars to enable users to understand what they need to input and how.

All care homes, all hospices (including children’s hospices) and all providers of inpatient community rehabilitation and end of life care are required to be fully using Capacity Tracker by 1st April 2020.

For current support please visit Capacity Tracker website address at: https://carehomes.necsu.nhs.uk/. This weblink will signpost to wider resources when they are available to be released.

Prior to Capacity Tracker going live and to make this happen in the required timescale, CCGs must take the responsibility to each nominate a group of System Champions (more than one person is required to cover in the case of absence) who will oversee the rapid implementation of Capacity Tracker in their locality. Their name(s) and email address must be notified to NHS NECS via [email protected] as soon as practicable.

https://carehomes.necsu.nhs.uk/

mailto:[email protected]


40

Annex G: NHS Continuing Healthcare and COVID-19 Planning NHS Continuing Healthcare as referred to throughout this document relates to individuals aged 18 or over.

NHS Continuing Healthcare COVID-19 emergency preparedness Temporary Arrangements

Temporary arrangements for NHS Continuing Healthcare (NHS CHC) need to be implemented for the duration of the COVID-19 emergency period. These arrangements cover:

• The assessment of eligibility for NHS CHC funding; • Individual requests for a review of an eligibility decision (i.e. Local Resolution and

Independent Review); and, • Three- and twelve-month reviews of NHS CHC packages of care

Objectives

The objectives of implementing any temporary arrangements for NHS CHC are:

• to expedite safe discharge of patients from acute hospital beds under EPPR arrangements.

• to reduce the NHS CHC assessment burden in and out of hospital settings; and • to release clinical and support staff to support the system to manage the COVID-19

outbreak.

Emergency Measures to be implemented for NHS CHC during the COVID-19 Emergency Period

• The current legislation does not describe a specific timeframe for carrying out NHS CHC assessments of eligibility, or for individual requests for a review of an eligibility decision (i.e. Local Resolution and Independent Review). Therefore, NHS CHC assessments for individuals on the acute hospital discharge pathway and in community settings will not be required until the end of the COVID-19 emergency period. Planned legislative change, as part of the COVID-19 Bill, will further support the NHS in relation to this.

• Individuals can still make requests for a review of an eligibility decision (i.e. Local Resolution and Independent Review) however the time frame for a response will be relaxed.


41

• There is an expectation that CCGs will take a proportionate view to undertaking three- and twelve-month reviews to ensure that the individual’s care package is meeting their needs and to ensure that any concerns raised are addressed as appropriate.

• Commissioning end of life services remains important therefore, and the Fast Track pathway tool can still be used for clinical assessments or other local tools as appropriate. However, to remove decision making delays, the responsibility to co-ordinate the arrangements for care at home or a hospice bed should be passed to local Community palliative care teams during this period.

• During the COVID-19 emergency period, CCGs will not be held to account on the NHS CHC Assurance Standards nor timeframes for dealing with NHS CHC individual requests for reviews of eligibility decisions.

• These measures set out for NHS CHC are only in place for the duration of the COVID-19 emergency period.

• Local systems need to ensure that they have some method of monitoring actions taken during the COVID-19 emergency measures, for example using the NHS CHC Checklist, so that individuals are assessed correctly once business as usual resumes.

Implications for Adopting the COVID-19 Emergency Measures for NHS Continuing Healthcare

• If NHS CHC full assessments of eligibility are deferred, a backlog of circa 5,000 assessments per month will be created which will have future workload implications for CCGs, NHS and Local Authority staff. The same will apply to individual requests for a review of an eligibility decisions (i.e. Local Resolution and Independent Review). A handling plan will need to be developed to enable the system to ‘normalise’ following the COVID-19 emergency period;

• There may be a financial impact upon CCGs funding under discharge to assess arrangements as part of the hospital discharge pathway for longer periods than usual and the COVID-19 emergency money can be used for this purpose.

• Where social care has been provided free at the point of delivery for the emergency period, the expectations of individuals in receipt of funded care packages that may not continue to be funded after the COVID-19 emergency period, this will need to be managed, as some individuals will need to return to usual funding arrangements, which will mean they may have to contribute or fully fund their care.

• Although NHS CHC is effectively a “funding stream”, the clinicians involved in NHS

CHC assessment and review are required to assess the specific needs of highly vulnerable individuals and to commission the relevant care. Therefore, it is still important to ensure that care packages are commissioned that meet the needs of these individuals.


42

Annex H: Overview of decision making and escalation


43

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Date: 14 April 2020 Paper: H


Governing Body Assurance Framework 2019-20

Presented by: Donna Briggs, Interim LLR CCGs’ Executive Director of Finance, Contracts and Corporate Governance

Report author: Daljit K Bains, Head of Corporate Governance and Legal Affairs, ELR CCG



Executive summary: 1. This report is requesting the Governing Body’s approval to support the year end risk management and governance processes in relation to the Board Assurance Framework (BAF).

2. The report provides the Governing Body with an update on the corporate risks contained within the East Leicestershire and Rutland CCG’s Board Assurance Framework (i.e. corporate risk register). The report aims to demonstrate that the Board Assurance Framework is a key document that supports the review of corporate risks across the CCG, and it is underpinned by a process of regular review of risks at various levels throughout the organisation. Thus demonstrating that effective processes are in place for the management of principal risks in order to support the achievement of the strategic aims of the CCG.

3. Next steps are detailed noting work underway to align risk management processes across the three Leicester, Leicestershire and Rutland CCGs.

4. Governing Body members will be aware that risks are mapped to strategic

objectives and that the collaborative strategic objectives have yet to be defined. The process of identifying these will initially be the responsibility of the senior Executive Management Team and these will be developed during 2020/21.

Appendices: • Appendix 1 – East Leicestershire and Rutland Governing Body Assurance Framework 2019/20.

Recommendations:

The East Leicestershire and Rutland CCG is asked to: • APPROVE the Board Assurance Framework as at Appendix 1 for 2019/20

year-end and as the starting point for 2020/21 noting the actions supported by the Audit Committee to ensure alignment of strategic risks and processes across the LLR CCGs.


• ELR CCG Executive Management Team during 2019/20 • EL RCCG Audit Committee meeting throughout 2019/20 and the current

version in December 2019 • LLR CCGs’ Audit Committee meetings in common held in January 2020.


Rutland CCG


interest: None identified


The Board Assurance Framework provides an overview of all strategic risks identified in relation to delivering the CCG’s strategic aims and statutory duties.


None identified


None identified


Not applicable


Not applicable

2

Governing Body Assurance Frameworks Introduction 1. This report provides the Governing Body with an update on the corporate risks contained

within the East Leicestershire and Rutland CCG’s Board Assurance Framework (i.e. corporate risk register). The report aims to demonstrate that the Board Assurance Framework is a key document that supports the review of corporate risks across the CCG, and is also underpinned by a process of regular review of risks at various levels throughout the organisation. Thus demonstrating that effective processes are in place for the management of principal risks in order to support the achievement of the strategic aims of the CCG.

2. The Board Assurance Framework provides a structure for the evidence that supports the Annual Governance Statement that the Accountable Officer is required to sign as part of the statutory accounts and annual report. This places an emphasis on the need for the Governing Body to be able to demonstrate that it has been properly informed about the totality of the risks, both clinical and non-clinical.

3. The Board Assurance Framework (BAF) has been regularly reviewed by the Executive Management Team throughout 2019/20 and also the Audit Committee. Following the changes to the collaborative arrangements in 2019/20, the BAF is currently under review in terms of content and format to ensure it remains current and fit for purpose and aligned to the new strategic objectives when developed.

Board Assurance Framework (BAF) 4. During 2019/20 the Board Assurance Framework has been reviewed and updated at

regular agreed intervals from April 2019 – January 2020. This included reviewing the risk profile of the CCG, and level of risks to escalate following feedback from the Audit Committee, Governing Body members and the Executive Management Team. The Executive Management Team is responsible for ensuring corporate risks facing the CCG are current; have been captured and evaluated appropriately; and actions undertaken in a timely manner.

5. The Executive Management Team and members of the Governing Body in the main

identified the risks considering the political, economical, social, technological environment (PEST analysis) in which the CCG operates. In the regular review of the Board Assurance Framework, risks identified from “bottom-up” are also considered, for example, review of directorate level risk registers, cluster of incidents, cluster of complaints, through performance management arrangements.

6. The identification, evaluation and review of the risks within the Board Assurance Framework have been in line with the CCG Risk Management Strategy and Policy. At its regular review of the BAF, EMT is asked to consider if the actions for the risks are still the correct actions and / or whether the risk appetite score remains the correct level of risk appetite for the CCG. The EMT agreed with the risk appetite scores and reviewed the residual risk scores.

7. The content of the Board Assurance Framework will continually be reviewed to ensure the changing risk profile of the CCG is captured, including the changing financial challenges, potential risks across the system for the organisation in line with the Operational Plan; the Sustainability and Transformational Partnership arrangements; and strategic commissioner arrangements.

3

8. The Governing Body will recall that an update was received in October 2019 where the

Governing Body supported the recommendations from both EMT and the Audit Committee to close a number of risks and to include a couple of new risks at time. Accordingly the BAF was updated and reviewed further by EMT and the Audit Committee in December 2019 and this was also presented at the LLR CCGs’ Audit Committee meetings held in common in January 2020.

9. The updated BAF 2019 – 20 (Version 3, draft 8 – as at November / December 2019) is

appended at Appendix 1.

10. In December 2019 the Audit Committee received the BAF and agreed with the proposal from management to pause further updates until the single executive management team was in place so that risks could be reviewed and aligned across the three LLR CCGs. The Audit Committee is supportive of the work being undertaken across the three LLR CCGs to harmonise risk management systems and processes, including a review of strategic objectives, review of the Risk Management Strategy and Policy, and review of the format and content of the BAF.

11. In January 2020, in conjunction with the Audit Committees from LC CCG and WL CCG,

the ELR CCG Audit Committee agreed to adopt a consistent format of the BAF which mirrors the current ELR CCG format. This will be developed further in 2020/21 once the new strategic objectives have been agreed across the LLR CCGs and corporate risks aligned. The work to progress these further will continue, however senior managerial capacity at present is focusing on the current system wide response to COVID-19.

12. In the meantime, directorates have continued to review risks at an operational level and

also risks have been reviewed at project and programme level across the organisation in collaboration with LC CCG and WL CCG.

13. Appendix 1 is the current Board Assurance Framework for 2019/20 as last reviewed, and

will provide the starting point for the BAF for 2020/21 as a number of these risks remain applicable and current across the collaborative e.g. financial risk, organisational capacity, failure to deliver quality of services etc noting that the current position against them may have changed and will be reflected in 2020/21 BAF. In addition, a corporate risk in relation to cyber security will be included as agreed by the Audit Committee and this will be evaluated and incorporated into the 2020/21 BAF.

Recommendations The East Leicestershire and Rutland CCG Governing Body is requested to: • APPROVE the Board Assurance Framework as at Appendix 1 for 2019/20 year-end and

as the starting point for 2020/21 noting the actions supported by the Audit Committee to ensure alignment of strategic risks and processes across the LLR CCGs.

4

Appendix 1 NHS East Leicestershire and Rutland CCG Board Assurance Framework 2019 – 2020

(Version 3, draft 8 – as at November / December 2019)

To be read in conjunction with the Risk Management Strategy and Policy

Version Control Version and Date Version number and description of changes / review Version 3, draft 1 Amendments made by lead officers incorporated within the update to the Audit Committee in May 2019. Version 3, draft 2 Circulated to EMT members and ‘Head of’ to review and update in June 2019 for July. Version 3, draft 3 Presented for discussion and review at EMT meeting on 5 August 2019. Version 3, draft 4 Amendments made following discussion at EMT meeting on 5 august 2019.

Presented to the Audit Committee on 25 September 2019. Version 3, draft 5 Comments from the Audit Committee meeting (25 September 2019) incorporated into version 5, in particular agreement to

archive risks as detailed in v5 and to include some further detail in BAF 9 in respect of staff capacity. Governing Body agreed amendments in October 2019.

Version 3, draft 6 BAF risk 16 updated following discussion at EMT and Governing Body meeting in October 2019. Further update presented to EMT 28 October 2019.

Version 3. Draft 7 Updated as per discussion at EMT on 28 October 2019 and by EMT members following EMT meeting. Version presented to Audit Committee in November 2019 (Audit Committee rescheduled for December 2019). Version presented to the LLR CCGs Audit Committee meetings in common in January 2020.

Version 3, Draft 8 Some udpates provided in December 2019 incorporated in January 2020.

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2

CONTENTS

Page

Strategic Aims 4

Definitions and risk matrix 5

Summary of the Board Assurance Framework 6

Detailed version of the Board Assurance Framework 9

3

Strategic Aims 2019/20

1. Transform services and enhance quality of life for people with long-term conditions 2. Improve the quality of care – clinical effectiveness, safety and patient experience 3. Reduce inequalities in access to healthcare 4. Improve integration of local services between health and social care; and between acute and primary/community care. 5. Listening to our patients and public – acting on what patients and the public tell us. 6. Living within our means using public money effectively

4

Definitions (as within the Risk Management Strategy and Policy, March 2018)

Areas Definitions Risk Description Articulate the risk:

what could happen? how could it happen? What would the effect be?

Risk Category Clinical – e.g. clinical care issues, medicines management. Organisational – e.g. corporate governance, human resources, health and safety, reputation, competition. Financial – e.g. poor financial control, ineffective insurance arrangements, fraud. Information – e.g. theft / loss of personal information, damage to computer systems.

Risk Appetite / Tolerance Level

This is the level of exposure to the risk the organisation is willing to accept. The risk appetite provides a baseline to monitor each risk against i.e. the net risk / residual risk will be reviewed against the risk appetite to monitor the effectiveness of controls and whether actions are being addressed to ensure that the risk remains below the tolerance level. Use 5 x 5 risk matrix:

the impact = describes the impact or outcome component of risk i.e. the outcome or the potential outcome of an event. There may be more than one impact / consequence of a single event.

the likelihood = describes the probability or frequency of a consequence occurring i.e. how probable it is

that the risk (the event or outcome) will occur. Gross / Inherent Risk

This is the risk evaluation before controls are applied. The higher the score the more attention the risk will require and more likely the Board would seek assurance as to how it was being managed whether directly or via sub-committee. Use 5 x 5 risk matrix.

Key controls “Internal control” is the response which is initiated within the organisation to manage a risk and may involve one or more of the following treatment options to manage the risk: terminate / avoid risk, treat / reduce risk, transfer risk, or tolerate / accept the risk.

Net / residual risk This is the risk evaluation once the controls have been applied to reduce / manage the risk identified. This evaluation of a risk compared with the tolerance level is useful as a guide for prioritising risks and determines the appropriate level of managerial supervision and action. Use 5 x 5 risk matrix.

Source of assurance

Need to identify sources of assurance which inform the organisation that the controls are effective.

Gaps in controls and / or assurance

Controls: Where are the gaps in our control / systems? Where are we failing to make them effective? Assurance: Where is the CCG failing to gain evidence that the controls / systems are effective?

5

5 x 5 Risk Assessment Matrix (Risk Management Strategy and Policy)

LIKELIHOOD IMPACT

1 RARE

1 MINOR

2 UNLIKELY 2 MODERATE / LOW

3 MODERATE / POSSIBLE

3 SERIOUS

4 LIKELY 4 MAJOR

5 ALMOST CERTAIN 5 FATAL / CATASTROPHIC

This will result in risks being rated in one of the following four categories:

Risk score Category 1 - 3 Low risk (green) 4 - 6 Moderate risk (yellow) 8 - 12 High risk (amber) 15 - 25 Extreme risk (red)

Key: KE = Karen English, Managing Director TS = Tim Sacks, Chief Operating Officer TB = Tracy Burton, Acting Chief Nurse and Quality Officer DE = Donna Enoux, Chief Finance Officer PG = Paul Gibara, Chief Commissioning and Performance Officer

IMPA

CT

5 5 10 15 20 25 4 4 8 12 16 20 3 3 6 9 12 15 2 2 4 6 8 10 1 1 2 3 4 5

1 2 3 4 5

LIKELIHOOD

Summary of the Board Assurance Framework content (as at November / December 2019) (Summary to be completed by the Corporate Affairs Team)

Risk Ref and Description: Exec Lead

Initial / Inherent

risk score

Risk Appetite / tolerance

score

Current / residual

risk score

Current / residual risk score trend

since last month

Comments (e.g. new risk escalated, de-escalate, close

etc) impact x likelihood = risk score BAF 1: QUALITY – ACUTE: The quality of care provided by acute providers does not match commissioner’s expectation with respect to quality and safety.

TB 16 6 16

BAF 2(a): QUALITY – NON-ACUTE: The quality of care provided by non-acute providers does not match commissioner’s expectation with respect to quality and safety.

TB 16 6 16

BAF 2(b): QUALITY – NON-ACUTE: The quality of care and service delivery provided by emergency patient transport services does not match commissioner’s expectation with respect to quality and safety

TB 16 6 12

BAF 2(c): QUALITY – NON ACUTE: The quality of care and service delivery provided by non-emergency patient transport services does not match commissioner’s expectation with respect to quality and safety - mobilisation of TASL not providing service in line with expectations.

TB 20 6 20

BAF 3: QUALITY – PRIMARY CARE: The quality of care provided by primary care providers does not match commissioner’s expectation with respect to quality and safety.

TB 16 6 9

BAF 5(a): QIPP – CCG QIPP programme, comprising CCG, Better Care Fund (BCF) and Better Care Together (BCT) / Sustainability Transformation Partnership (STP) initiatives fail to deliver against the CCG QIPP Plan resulting in failure to deliver in-year efficiencies and transform delivery for sustainable efficiency.

PG 16 4 9

BAF 5(b): QIPP – Robust systems and processes are not in place to support the CCG QIPP Programme comprising of CCG, (BCF) and BCT / STP initiatives

PG 16 4 9

BAF 6(a): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Primary Care Commissioning – ability to perform delegated duties whilst maintaining member relations and Clinical Engagement.

TS

Risk archived (August 2019).

BAF 6(b): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Primary Care transformation – the workforce and capability of general practice and CCG to develop transformation.

TS


Page 7 of 33

Risk Ref and Description: Exec Lead

Initial / Inherent

risk score

Risk Appetite / tolerance

score

Current / residual

risk score

Current / residual risk score trend

since last month

Comments (e.g. new risk escalated, de-escalate, close

etc) impact x likelihood = risk score BAF 6(c): OUT OF HOSPITAL – PRIMARY CARE: Risk in relation to Out of Hospital Services – Primary Care: Finance – budget inherited from NHS England covers current costs / service and therefore new development and transformation will require additional funding (e.g. premises).

TS


BAF 7: OUT OF HOSPITAL – COMMUNITY SERVICES: Failure to agree service model for future Out of Hospital Services further to consultation and engagement

TS


BAF 8: URGENT CARE: Increased pressure on the Emergency Department which could result in sub-optimal care due to ability to access urgent care services.

TS Risk archived (August 2019).

BAF 9: ORGANISATIONAL CAPACITY: Organisation is at risk of not being able to meet its statutory functions due to capacity within teams.

KE 16 6 12

BAF 10: FINANCE: Non achievement of 2018/19 year end control total surplus which is dependent on achievement of c£19.645m (4.6%) QIPP schemes

DE Risk archived (August 2019) - Audited outturn confirms CCG has achieved against all its financial duties for 2018/19. BAF 10 is therefore recommended to be archived. See BAF 15 below.

BAF 11: EPRR: Lack of systematic and continuous processes in place for Emergency Preparedness, Resilience and Response (EPRR)

TS 20 6 9

BAF 12: COMMISSIONING SUPPORT: Commissioning Support Provider fails to deliver contracted standards, KPIs and outcomes.

PG Risk archived as forms part of contract management of new provider. On directorate risk register (December 2017).

BAF 13: CONTINUING HEALTH CARE (CHC): Lack of engagement from current Provider during procurement of CHC.

PG Risk archived now that new provider in place (September 2017).

BAF 14: EU EXIT: inability to implement the Department of Health and Social Care’s EU Exit Operational Readiness Guidance (published 21 December 2018)

KE 20 9 20

BAF 15 FINANCE: Non achievement of 2019/20 year end control total surplus which is dependent on achievement of c£26.6m (6%) QIPP schemes (NEW) DE 20 6 20

NEW 2019/20 QIPP plan contains a significant proportion of unidentified or red/amber rated QIPP. Significant potential for Acute overspend also exists.

BAF 16: Specifically relating to the maturity and management of PCNs within the CCG and the need to establish positive working relationships with the new ACD roles (NEW)

TS 16 8 16 NEW

Page 8 of 33

BAF 1: QUALITY – ACUTE: The quality of care provided by acute providers does not match commissioner’s expectation with respect to quality and safety.

Section A A1. Corporate Objective /

Strategic Aim the risk is aligned to:

A3. Risk to be treated,

confirm frequency of review by lead?

Section B

Section C Risk rating (impact x likelihood = risk score (see pages 3 and 4 above)

Strategic Aim 2

Monthly ☐

Quarterly ☒

B1. Executive Lead (risk owner):

Tracy Burton C1. Initial / inherent risk score: 4 x 4 = 16 R

A2. Date Risk identified: A4. Risk Category: B2. Officer Lead (action owner):

Amanda Bland C2. Risk appetite / tolerance score: 3 x 2 = 6 Y

2016/17 initially Clinical ☒ B3. Date last reviewed: January 2020 (next review February 2020)

C3. Current / residual risk score: 4 x 4 = 16 R Organisational ☐

Finance ☐ B4. Committee / group with oversight for risk?

Integrated Governance Committee

C4. Date current / residual risk score assessed:

January 2020 Information ☐

Section D: Key Controls What key controls / systems does the CCG have in place to manage the risk?

Section E: current risk score trend

• Clinical quality schedules and contracting performance monitoring arrangements in place. • Integrated Governance Committee oversight. • Collaborative Commissioning Board (Joint Committee) in place and Provider Performance

Assurance Group (PPAG) (meetings in common) for contracting and performance monitoring of collaborative contracts which includes details of UHL and all out of county acute contracts and Independent Sector contracts.

• Contract lead organisation oversight and contracting arrangements, including clinical lead oversight.

• Membership of and ability to escalate to Quality Surveillance Group (QSG). • Triangulation of data to inform unannounced quality visits in place. This includes incidents,

serious incidents and feedback from GPs via GP concerns / transferring care reporting. • RTT/Cancer Board oversee improvement plans. Breach / harm reporting in place for Cancer

100+ day waits. • 2018/19 Quality Assurance Framework. 2019/20 Quality Schedule. • Management of sepsis pathway improving.

(Corporate Affairs Team to update graph showing trend current risk score against risk appetite score)

Brief rationale for any change in current risk score:

Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Summary report from Integrated Governance Committee to Governing Body. ☒ ☐ • PPAG deep dives into specific provider performance risk areas and PPAG assurance report to Governing Body ☒ ☐ • Quality Surveillance Group (NHS England) minutes and public reporting to Governing Body. ☐ ☒

0

5

10

15

20

Nov

-18

Dec

-18

Jan-

19Fe

b-19

Mar

-19

Apr-1

9M

ay-1

9Ju

n-19

Jul-1

9Au

g-19

Sep-

19O

ct-1

9N

ov-1

9

Risk Appetite

Current / ResidualRisk

Page 9 of 33

• CQC inspection report in March 2018 reported Sepsis care as an area of outstanding practice ☐ ☒ Section G:

G1: Gaps in Controls and / or Assurance Where are the gaps in our control / systems? Where are

we failing to make them effective? Where is the CCG failing to gain evidence that the

controls / systems are effective?

G2: Detail the actions to be taken (including brief note on updates / progress where appropriate

and confirm when action completed) What actions are required to bridge the gaps in controls and /

or assurance?

G3: Action to be

completed by (date)

G4: Will the action reduce impact of risk score or

likelihood or both? Impact Likelihood Both

Despite controls in place risks remain with regard to achievement NHS Constitutional targets for: RTT, Cancer and A&E.

• Despite ongoing actions in place performance remains of concern and therefore no change on impact or likelihood.

• 4 Hour performance continues outside of expected levels • Cancer 62 day backlog continues

Ongoing

☐ ☐ ☒

CQC Improvement notice issued to UHL following inspection visit in December 2015. Highlighted quality concerns regarding:

• Ambulance handovers • overcrowding in ED • management of sepsis

• Ambulance handover delays improved • New Emergency Department floor has improved patient

experience in terms of environment. • CQC inspection in February 2018 – requires improvement. • UHL have introduced their new Quality Strategy from April 2019

which focuses on learning and improvement. Implemenetation is work in progress.

• UHL continues to participate in the national Culture and Leadership programme (NHSI and The Kings Fund).

• Regular meetings between the CCG’s Director of Nursing and Quality; UHL Chief Nurse and UHL Medical Director continue.

• The 2019/20 Quality Schedule has been developed in partnership with UHL with a stronger focus on outcome measures of quality and patient experience and continues to underpin ongoing quality and safety discussions at CQRG.

• LLR STP Urgent and Emergency Care Transformation Plan forms basis of improvement actions re A&E

Ongoing

☐ ☐ ☒

Contract Performance Notice in place regarding ‘Never Events’

• Despite ongoing actions in place, Never Events continue to occur within UHL, although the Trust is not an outlier.

• The Never Event Remedial Action Plan reviewed through CQRG. Underlying issue around culture and leadership discussed with the UHL Director of Nursing and Director of Safety and Risk

• Quality visits have been undertaken at Glenfiled and LRI theatres, accompanied by UHL and NHS E representatives. Quality visits will be formally evaluated in September, but early findings have been fed-back to UHL.

• A Board to Board discussion between the CCG and UHL took place in June 2019.

• UHL launched their Quality Strategy in April 2019 which focusses on learning and improvement. Safer Surgery is one of six priority areas. The Head of Nursing for Theatres presented to CQRG in October on the work undertaken so far under the Safer Surgery workstream.

• The Contract Performance Notice for Never Events has now been closed.

Page 10 of 33

BAF 2(a): QUALITY – NON-ACUTE: The quality of care provided by non-acute providers does not match commissioner’s expectation with respect to quality and safety.





Section B


Strategic Aim 2

Monthly ☒

Quarterly ☐





2016/17 Clinical ☒ B3. Date last reviewed: January 2020 C3. Current / residual risk score: 4 x 4 = 16 R

Organisational ☐ Finance ☐ B4. Committee / group with

oversight for risk? Integrated Governance Committee


January 2020 Information ☐



• Clinical quality schedules and contracting performance monitoring arrangements in place.

• Collaborative Commissioning Board (Joint Committee) in place and Provider Performance Assurance Group (PPAG) (meetings in common) for contracting and performance monitoring of collaborative contracts with ELR clinical oversight.

• Integrated Governance Committee oversight. • Triangulation of data to inform unannounced quality visits in place. • Membership of and ability to escalate to Quality Surveillance Group (QSG). • Regular meetings re Quality – Clinical Quality Review Group (CQRG), CAMHS Quality,

Performance and Service Improvement group (QPSIG); Sustem Improvement and Assurance (SIAM)



Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Summary report from Integrated Governance Committee to be presented to the Governing Body. ☒ ☐ • PPAG deep dives into specific provider performance risk areas and PPAG assurance report to Governing Body. ☒ ☐

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• QSG minutes and public reporting to Governing Body. ☐ ☒ Section G:

G1: Gaps in Controls and / or Assurance Where are the gaps in our control / systems? Where are we failing to make them effective?

Where is the CCG failing to gain evidence that the controls / systems are effective?



or assurance?

G3: Action to be

completed by (date)

G4: Will the action reduce impact of risk score or likelihood or

both? Impact Likelihood Both

Despite key controls in place, concern remains with respect to service provided by Leicestershire Partnership Trust:

- the quality of care provided by community services to ELR CCG residents, due to gaps in staffing and clinical leadership within community nursing teams

- staffing levels in place within inpatient adult mental health services

- staffing levels in place within adult community mental health services

- Number of patients placed in out of county MH beds. - Service provision for children and young people with mental

health illness.

• Continued oversight via CQRG: o Specific oversight of staffing across physical and mental

health services o Triangulation of data to review hot spots and seek assurance

with regard to LPT Board oversight of risk. • Length of stay on AMH slowly reducing. • AMH DTOC and CHS DTOC under review to improve pace. • Enhanced surveillance agreed by LNR Quality Surveillance Group

continues. • New acute mental health bed model introduced in May 2019 to

improve patient flow and reduce out of area placements.

ongoing

☐ ☐ ☒

• Staffing issues in CAMHS community service. • Waiting times for CAMHS

- Wait time for Initial Assessment - Wait time for further assessment / treatment

• Focused recovery action plan in place to improve CAMHS community service access including review of all long waits. Some improvement noted in waiting lists for access and treatment due to actions taken following CQC inspection and published report (report February 2019).

• CAMHS Quality, Performance and Service Improvement Meeting • The number of children and young people waiting over 12 months

for CAMHS has reduced, however improvement plans continue

ongoing

☐ ☐ ☒

• CQC report published against Inspection carried out Q3 2018/19 (October/ November 2018); Overall rating for Trust – ‘Requires Improvement.’

• Domains assessed: - Safe; requires improvement - Effective; requires improvement - Caring; Good - Responsive; Requires improvement - Well-led; Inadequate

• 5 services inspected: - Acute wards for adults of working age and psychiatric

intensive care units; Inadequate () - Community based mental health services for older people;

Good () - Specialist Community mental health services for children and

young people; Requires improvement (=) - Long stay/ rehabilitation mental health wards for working age

adults; Inadequate () - Wards for people with a learning disability or autism; Requires

improvement (=)

• Enhanced surveillance status as agreed by LNR Quality Surveillance Group to continue.

• Quality Risk review meeting by NHSE/ NHSI held June 2019. • System Improvement and Assurance Meetings (SIAM) with NHSE/I,

supported by ELR CCG, established to monitor and oversee improvement and progress against actions required by CQC and improvement plan.

• Programme of Quality Visits by Commissioning team planned in collaboration with all agencies.

• Quality schedule for 2019/20 revised to focus on improvement. • The CQC undertook unannounced re-inspection visits to the inadequate

rated services in June 2019. Re-inspection report published August 2019 acknowledged that improvements had been achieved in some areas, however noted that further improvement was required. As this was a focussed visit, the overall rating did not change.

ongoing

☐ ☐ ☒

Page 12 of 33

BAF 2(b): QUALITY – NON-ACUTE: The quality of care and service delivery provided by emergency patient transport services does not match commissioner’s expectation with respect to quality and safety.





Section B


Strategic Aim 2

Monthly ☒

Quarterly ☐





Escalated from WL CCG September 2016 (risk description amended December 2017)

Clinical ☒ B3. Date last reviewed: October / November 2019

C3. Current / residual risk score: 5 x 4 = 20 R




October / November 2019 Information ☐



• Routine reporting of serious incidents / incidents review and sign off at regional level by EMAS and Hardwick CCG and LLR level.


• Range of actions in AEDB High Impact Action plan aimed at reducing handover delays, ECIP support, charting protocol in escalation protocols.

• Escalation to QSG to understand wider impact.


Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • PPAG deep dives into specific provider performance risk areas and PPAG assurance report to Governing Body. ☒ ☐

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• The CQC Inspection - CQC acknowledge that the Trust has made significant improvements as required by the July 2016 warning notice, however there continue to be concern around response times.

☐ ☒

• AEDB meeting (fortnightly). ☐ ☒ • Quarterly QAG meetings and monthly EMAS CCM meetings. ☐ ☒ Section G:






or assurance?

G3: Action to be

completed by (date)



• Quality Improvement Plan at both Regional and County levels through the agreed meeting structure and assurance groups.

• Monitor delivery of the improvement plan – noting the revised national targets impact on ability to review local delivery.

• Review ECIP recommendations, consider rapid handover protocol.

• Continue to implement HIA Plan. • Monitor delivery of Quality Improvement Plan at both Regional

and County levels through the agreed meeting structure and assurance groups.

ongoing

☐ ☐ ☒

• Performance against national standards has deteriorated.

• Category 2 delivery largest gap.

Actions as above. Additional monies have been agreed to help improve response times against the Ambulance Response Programme standards. Monitoring of ARP standards continues via PPAG and Integrated Governance Committee and then reported to the Governing Body. • EMAS had introduced ‘Releasing Time to Care’, which they believe has

impacted upon their improved performance status • CQC Inspection report published July 2019, Good overall and good in 4

domains with outstanding in caring domain. • NHSE / NHS I have reduced theirsurveillance rating to routine

surveillance. • EMAS performance has overall improved in conjunction with a significant

increase in demand across LLR, with reduced response times signifying greater efficiency and performance

• management. However, concerns still remain regarding EMAS’s failure to meet the Ambulance Response Programme (ARP) Standards

• The National Framework for Healthcare Professional Ambulance Responses and National Framework for Inter-facility Transfers implemented across all English ambulance services and new processes launched 1 October 2019

• The first Strategic Delivery Board meeting held - it was agreed that each county would carry out a deep dive to better understand the demand for EMAS.

ongoing

☐ ☐ ☒

Page 14 of 33

BAF 2c:

QUALITY – NON ACUTE : The quality of care and service delivery provided by non-emergency patient transport services does not match commissioner’s expectation with respect to quality and safety - mobilisation of TASL not providing service in line with expectations.





Section B


Strategic Aim 2

Monthly ☒

Quarterly ☐





Escalated from WL CCG December 2017 Financial aspect escalated in July 2018.


C3. Current / residual risk score: 5 x 4 = 20 R

Organisational ☐ Finance ☒ B4. Committee / group with






• Bi-Weekly Interface meetings between WLCCG, TASL, UHL and LPT. • Renal meetings with UHL and TASL as required. • Regional commissioner teleconferences as required. • Quarterly Commissioner Meetings with Lincolnshire and Northamptonshire. • Monthly contract and quality meetings with TASL. • Daily sitrep reports submitted for call centre activity. • Additional support to the CQC action plan as well as providing the oversight to the

operational plans. • UEC Director and TASL CEO fortnightly teleconferences. • Transport Improvement Group meetings



Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective?

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Current / Residual Ris

Page 15 of 33

Internal External • PPAG deep dives into specific provider performance risk areas and PPAG assurance oversight and reports to Governing Body ☒ ☐ • Routine single item update to Governing Body ☒ ☐ • ☐ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



• Financial Stability of provider. • Regular risk review meetings taking place with NHS England. • Review of funding against demand taking place to determine if

appropriately funded for the service. • Contingency plans drawn up by the lead CCG i.e. WL CCG. • Funding (£0.528m) Transferred to TASL for winter pressures

2018/19 • TASL received additional funding for 2019/20, due to the service

not being sustainable without additional funding potentially leading to the collapse of the service

ongoing

☐ ☐ ☒

• Performance and Quality continue to be short of contracted levels.

• CQC report published against Inspection carried out Q3 2018/19 (October 2018); Overall rating for Trust – ‘Inadequate.’ • Domains assessed:

- Safe; Inadequate - Effective; Inadequate - Caring; Good - Responsive; Inadequate - Well-led; Inadequate

• CQC report published against Inspection carried out Q1 2019/20 (May 2019); Overall rating for Trust – ‘Requires Improvement.’ • Domains assessed:

- Safe; Requires Improvement - Effective; Inadequate - Caring; Good - Responsive; Requires Improvement - Well-led; Requires Improvement

• Information monitored at interface meetings and QARG. • Quality submission reviewed monthly and discussed at monthly

contract and performance meetings. • Updates at bi-weekly interface meetings. • Regular meetings with quality team to improve standard of

information being submitted. • NHSE oversight group ceased meeting from May 2019 –

ongoing quality monitoring by commissioners via the revived tripartite quality assurance review processes with Lincolnshire and Northamptonshire CCGs.

• LLR quality team visit to TASL in May 2019 • CQC re-inspected in May, showed some improvement. • Announced quality visit to the Lincoln Head Office in July 2019

ongoing

☐ ☐ ☒

Page 16 of 33

BAF 3: QUALITY – PRIMARY CARE: The quality of care provided by primary care providers does not match commissioner’s expectation with respect to quality and safety.





Section B


Strategic Aim 2

Monthly ☒

Quarterly ☐






C3. Current / residual risk score: 3 x 3 = 9 A


oversight for risk? Integrated Governance Committee / PCCC





• Oversight of Primary Medical Care commissioning undertaken through the Primary Care Commissioning Committee (PCCC) and quality through Integrated Governance Committee.

• Primary Care quality dashboard place. • Risk sharing arrangements in place with NHS England. • General Practice support framework in place. • GP QIPP schemes in place and delivery reviewed regularly. • Reporting to QSG of high risk practices.



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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Summary reports from the Primary Care Commissioning Committee to the Governing Body.

☒ ☐

• Quarterly self-certification completed and returned to NHS England relating to delegated functions in particular primary care commissioning and risks / issues and conflicts of interest. Quarterly self-certification for delegated primary care functions no longer required as covered within CCG assurance review process.

☐ ☒

• Locality meetings and reporting to the Governing Body.

☒ ☐

• CQC Practice Inspection outcomes, work ongoing with CQC

☐ ☒

• Internal Audit review in 2018/19 on primary care delegated functions. ☐ ☒ Section G:






or assurance?

G3: Action to be

completed by (date)



• Collaborative work underway across LLR to ensure consistency of approach of escalation to NHS E.

• Consistent approach to quality reviews across LLR to be developed linked to 5 Year Forward View.

• Quality Strategy approved at ELRCCG Governing Body in April 2019

End March 2019 ☐ ☐ ☒

• Internal Audit Review on primary care delegated functions as required to undertake by NHS England.

• Audit to be undertaken in line with audit plan by end March 2019, Audit completed.

End March 2019 (ACTION COMPLETE, DKB)

☐ ☐ ☒

Page 18 of 33

BAF 5(a): QIPP – CCG QIPP programme, comprising CCG, Better Care Fund (BCF) and Better Care Together (BCT) / Sustainability Transformation Partnership (STP) initiatives fail to deliver against the CCG QIPP Plan resulting in failure to deliver in-year efficiencies and transform delivery for sustainable efficiency.





Section B


Strategic Aim 6

Monthly ☒

Quarterly ☐


Paul Gibara C1. Initial / inherent risk score: 4 x 4 = 16 R


Spencer Gay, WL CCG

C2. Risk appetite / tolerance score: 2 x 2 = 4 Y

2018/19 Clinical ☐ B3. Date last reviewed: August 2019 C3. Current / residual risk score: 3 x 3 = 9 A

Organisational ☐ Finance ☒ B4. Committee / group

with oversight for risk?

Financial Turnaround Committee


August 2019 Information ☐



• Programme Dashboard - demonstrating delivery against finance and activity plan delivery against individual scheme plan.


• Review of QIPP schemes via QIPP Delivery Group meetings and via the established Financial Turnaround Committee.

• Mitigation plans are in place • QIPP Plan forecasting under delivery of £400k at Month 10. • Schemes are reviewed by the SRO, PMOs and Finance Team. • Confirm and Challenge occurs through agreed Committees (i.e. QAG and FTC). • New consolidated system wide QIPP process put in place. • Standardised reports across LLR – presented to CCB by LLR QIPP Lead, WL CCG

CFO. See PMO risk register.


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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Assurance report on QIPP presented to the Governing Body captured within the monthly finance report. ☒ ☐ • Minutes of the QAG, CCB, JMT and EMT. ☒ ☐ • QIPP presented at FTC, QAG and CCB; Financial delivery presented at Governing Body as part of the finance report. ☒ ☐ ☐ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



Robust plans required for some QIPP schemes to ensure delivery e.g. planned care.

• To review in detail the plans in place to support the delivery of the planned care QIPP to determine robustness of plans – initial review of planned care QIPP schemes complete, LLR QAG continue to review other QIPP schemes.

End March 2019

(COMPLETE) ☐ ☐ ☒

☐ ☐ ☐

Page 20 of 33

BAF 5(b) : QIPP – Robust systems and processes are not in place to support the CCG QIPP Programme comprising of CCG, (BCF) and BCT / STP initiatives.





Section B


Strategic Aim 6

Monthly ☒

Quarterly ☐


Paul Gibara C1. Initial / inherent risk score: 4 x 4 = 16 R


Spencer Gay, WL CCG C2. Risk appetite / tolerance score: 2 x 2 = 4 Y

2017/18 Clinical ☐ B3. Date last reviewed: August 2019 C3. Current / residual risk score: 3 x 3 = 9 A

Organisational ☒ Finance ☐ B4. Committee / group

with oversight for risk?

Financial Turnaround Committee





• Detailed approved QIPP Plan. Leads for schemes identified. Weekly report to EMT. • Scope work and QIPP development at Financial Turnaround Committee and weekly

QPDM meetings. • PMO arrangements in place i.e.:

- Programme dashboard developed – reporting monthly to Financial Turnaround Committee

- Finance and activity dashboard developed for monitoring delivery by scheme reporting to Financial Turnaround Committee

- Revised programme documentation in draft to be signed off for development of new schemes.

See PMO risk register.



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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Programme dashboard reports presented to Financial Turnaround Committee.

☒ ☐

☐ ☒ ☐ ☐ ☐ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



See dashboard reports and action plans as reported to QIPP meetings.

Actions and progress within QIPP reports. ongoing ☐ ☐ ☒

☐ ☐ ☒

Page 22 of 33

BAF 9: ORGANISATIONAL CAPACITY: Organisation is at risk of not being able to meet its statutory functions due to capacity within teams.





Section B


Strategic Aims 1 - 6 Monthly ☒

Quarterly ☐


Karen English (Donna Briggs)

C1. Initial / inherent risk score: 4 x 4 = 16 R


Chief Officers C2. Risk appetite / tolerance score: 3 x 2 = 6 Y

2016/17 Clinical ☐ B3. Date last reviewed: October / November 2019

C3. Current / residual risk score: 4 x 3 = 12 A Organisational ☒


Executive Management Team





• System working across LLR CCGs to ensure matrix working is maximised, cross cover, reducing duplication and following vacancy approval process at joint management team.

• New single Accountable Officer across LLR CCGs has been appointed, subject to Treasury approval, and structures for the new strategic commissioner is being developed.



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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Chief Officer oversight and scrutiny ☒ ☐ • Governing Body has oversight of the appointment process to appoint single accountable officer. ☒ ☐ ☐ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



• Running costs are being contained within the allocation. Whilst there is a vacancy control in place it does allow for us to review the structure to ensure we are fit to respond to the requirements of the CCG and the wider LLR issues.

• Ensure there is a defined process to agree how LLR system plans are taken forward if ELR CCG is a lead for specific work programme.

ongoing

☒ ☐ ☐

• Need to consider roles and responsibilities. - Review of capacity and roles underway across LLR CCGs.

ongoing ☐ ☐ ☒

• Consider impact of financial position which adds further pressure to the challenge of recruitment and vacancy control processes (see above additional financial resource to be received from NHS England).

ongoing

☐ ☐ ☒

Impact on staff morale of impending change and as capacity within some teams across the CCG is limited due to vacancy controls etc.

• Regular updates at Staff Briefing and in the ELR CCG newsletter.

• Vancany review process in place.

ongoing ☐ ☐ ☒

Assurance in respect of staff capacity to develop and implement collaborative working arrangements across LLR CCGs and ensuring that there is sufficient capacity within the CCG to meet the CCG specific remit an responsibilities.

• To be discussed further with the CCG Executive Management Team.

ongoing

☐ ☐ ☒

Page 24 of 33

BAF 11: EPRR: Lack of systematic and continuous processes in place for Emergency Preparedness, Resilience and Response (EPRR)





Section B


Strategic Aims all 6 Monthly ☐

Quarterly ☒


Tim Sacks C1. Initial / inherent risk score: 5 x 4 = 20 R


Daljit K. Bains C2. Risk appetite / tolerance score: 3 x 2 = 6 Y

Clinical ☒ B3. Date last reviewed: December 2019 (next review Jan 2020)

C3. Current / residual risk score: 3 x 3 = 9 A Organisational ☒


Executive Management Team


December 2019 Information ☐



• CCG Business Continuity Policy and Plan in place, and LLR Incident Response Plan in place.

• Compliance against the EPRR core standards. • Participation in Local Health Resilience Partnership at executive and working

group level. • Contributing through LHRP to risk management through LHR Forum. • Testing of business continuity plans and emergency planning coordinated via

WL CCG hosted function. • Annual self-assessment return completed and submitted to NHS England in

October 2018. Outcome of assessment received from NHS England, actions being completed.

• EPRR LLR CCGs’ Group in place to ensure oversight and implementation of requirements and the core standards assurance for NHS England.


• Brief rationale for any change in current risk score:

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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • External verification of level of compliance provided by NHS England on annual basis (expected in September /October

2019). ☐ ☒

• 6 monthly / annual report on EPRR core standards to the Governing Body (approved by Governing Body in September 2019).

☒ ☐

• NHS England quarterly Checkpoint meeting to review CCG performance. NHS E review of CCG core standards. ☐ ☒ • LHRP work plan and meetings with NHS England. ☐ ☒ • Directorate on-call training. ☒ ☐ • ☐ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



• Table-top exercise to be arranged to test the ELR CCG updated Business Continuity Policy and Plan. Table-top exercise being arranged to test the Business Continuity Plans across LLR CCGs as agreed by the EPRR Group.

Exercise to be arranged by the hosted team in WL CCG. December 2019 / January 2020 ☐ ☐ ☒

Page 27 of 33

BAF 14: “EU EXIT”: inability to implement the Department of Health and Social Care’s EU Exit Operational Readiness Guidance (published 21 December 2018)





Section B


Strategic Aims all 6 Monthly ☒

Quarterly ☐


Karen English C1. Initial / inherent risk score: 5 x 4 = 20 R


(in conjunction with hosted team in WL CCG)

C2. Risk appetite / tolerance score: 3 x 3 = 9 A

December 2018 Clinical ☒ B3. Date last reviewed: August 2019 C3. Current / residual risk score: 5 x 4 = 20 R

Organisational ☒ Finance ☒ B4. Committee / group with

oversight for risk? Executive Management Team





• Further to recent national discussions on EU Exit and a potential “no deal” scenario, a discussion took place at the Emergency Planning, Resilience and Response (EPRR) meeting on 31 July 2019 and the Head of Corporate Governance and Legal Affairs requested that the EPRR team at WL CCG review the risk in light of recent discussion and revise the risk accordingly. The current risk score will remain the same until further information is received from the team at WL CCG to ensure consistency in risk description and evaluation across LLR CCG. An update is expected in mid-October 2019.



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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • ☐ ☐ • ☐ ☐ • ☐ ☐ • ☐ ☐ • ☐ ☐ • ☐ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



• ☐ ☐ ☐ • ☐ ☐ ☐ • ☐ ☐ ☐

Page 29 of 33

BAF 15: FINANCE: Non achievement of 2019/20 year end control total surplus which is dependent on achievement of £26.6m (6%) QIPP schemes





Section B


Strategic Aim 6 Monthly ☒

Quarterly ☐


Donna Enoux C1. Initial / inherent risk score: 5 x 4 = 20 R


Colin Groom C2. Risk appetite / tolerance score: 2 x 3 = 6 Y

May 2019 (NEW)

Clinical ☐ B3. Date last reviewed: November 2019 C3. Current / residual risk score: 5 x 4 = 20 R

Organisational ☐ Finance ☒ B4. Committee / group with

oversight for risk? Financial Turnaround Committee / Governing Body


November 2019 Information ☐



• Previously documented financial processes including monthly finance and QIPP confirm and challenge processes, detailed finance reviews, monthly budget holder meetings and involvement in contract setting and performance monitoring processes.


• Enhanced system working with UHL and LPT to progress schemes that will take cost out of the system.

• Continued close working with NHS E turnaround team to identify additional cost saving opportunities.

• Continued Challenge by finance team to hosted finance teams producing the provider financial positions. Increased LLR wide collaboration to ensure consistency and share workload and drive efficiency within the finance function. Use of virtual teams within finance to share expertise and knowledge and increase efficiency

• Monthly reports from ML CSU providing assurance on outsourced Financial Accounting function.

• CFO / Deputy CFO reviewed log of all existing risk (and flexibilities) quantified where possible.

Brief rationale for any change in current risk score: Note the risk now relates to 2019/20.

• 2019/20 Financial plan completed consistently wherever possible across LLR to ensure all possible cost pressures, investment requirements and QIPP can be projected as accurately as possible.

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Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Challenge of financial position at the Financial Turnaround Committee and challenge of position at monthly Governing Body

meetings. ☒ ☐

• Regular ELR and LLR QIPP meetings to monitor relevant QIPP schemes and identify further schemes. ☒ ☐ • Challenge at quarterly Checkpoint and monthly operational meetings with NHS England. ☐ ☒ • Internal Audit Review on Key financial systems awarded an opinion of significant assurance for 2017/18. 2018/19 review

being planned. ☐ ☒

• External audit of value for money. External Service Auditor Reports on financial service provision of the CSU, Capita, SBS and other national systems/service providers.

☐ ☒

• Dedicated PMO resource in place across LLR to support the identification and implementation of QIPP programme. ☒ ☐ Section G:






or assurance?

G3: Action to be

completed by (date)



• Potential delays in obtaining assurance for certain QIPP programmes

• Confirm and challenge through Q1 30/06/2019 COMPLETE ☐ ☐ ☒

• Significant proportion of QIPP programme currently unidentified or rated Amber or Red

• Confirm and challenge of QIPP through Q1 to confirm deliverability of major schemes and new schemes to deliver currently unidentified target.

• System working with UHL / LPT to identify further cost release

30/06/2019 COMPLETE ☐ ☐ ☒

• Q1 review has confirmed approximately £8m of QIPP risk for ELR, of which £6m is original unidentified balance.

• System leadership group, QIPP Assurance Group and JMT reviewing potential mitigating QIPP schemes/cost reduction actions to include any opportunities for delaying existing investment proposals.

30/09/2019 COMPLETE

☐ ☐ ☒

• Acute contracting information received for April and May 2019 is already indicating material likelihood of overspend driven not just by activity overperformance but also material casemix/price increases.

• Acute contracts team to undertaken deep dive into information received from providers to confirm any issues with activity coding or any other reporting issues that would need to be challenged with the providers. Escalation to NHSE/NHSI is likely to be required as the current values being reported cannot be accommodated within the current LLR CCG finances and are significantly increasing the likelihood of control total breaches by County CCGs if not all 3 CCGs in LLR.

30/09/2019

☐ ☐ ☒

Page 31 of 33

BAF 16: Specifically relating to the maturity and management of PCNs within the CCG and the need to establish positive working relationships with the new ACD roles





Section B


Strategic Aim Monthly ☐

Quarterly ☒


Tim Sacks C1. Initial / inherent risk score: 4 x 4 = 16 R


Paula Vaughan C2. Risk appetite / tolerance score: 4 x 2 = 8 Y

July / August 2019 (NEW)

Clinical ☐ B3. Date last reviewed: November 2019 C3. Current / residual risk score: 4 x 4 = 16 R

Organisational ☒ Finance ☐ B4. Committee / group with

oversight for risk? PCCC and Governing Body


November 2019 Information ☐



• Dedicated management capacity for ACD and PCN development (Corporate Affairs Team to update graph showing trend current risk score against risk appetite score)

• Implementation of an LLR ACD Forum

• Inclusion of ACDs in the operational meeting supporting PCN development • CCG management support for all PCN meetings •


•

0

10

20

30

Jul-19 Aug-19 Sep-19 Oct-19 Nov-19


Risk Appetite

Page 32 of 33

Collaborative Risks - current high risks for information

See Corporate Performance Report and also Provider Performance Assurance Report for details.

Section F: Internal and / or External Assurances Where can we gain evidence that our controls / systems on which we are placing our reliance are effective? Internal External • Challenge at PCCCs ☒ ☐ • Challenge and confirmation at Primary Care Group ☐ ☒ • Opportunities for direct dialogue with ACDs including PLT events, ACD Forum and other development events ☒ ☒ • Review of ACD membership and involvement with the key decision making and design groups within the ICS ☒ ☒ • Enabling a regular feedback mechanism with the ACD team ☒ ☐ • Joint development of the PCN and ACD Development Plan across LLR ☐ ☒ Section G:






or assurance?

G3: Action to be

completed by (date)



• Loss of focus on relationships with individual practices as focus on ACDs and PCNs increases

• To be agreed at PCDG Dec 19 ☒ ☒ ☒

• Risk of loss of alignment between ICS Strategic Planning and PCN development plans led by ACDs

• Delivery of the ACD and PCN development plan Dec 19 ☐ ☒ ☒

• Complexities arising as ACD of different CCGs potentially lead with varying priorities

• Delivery of the ACD and PCN development plan across LLR

• Delivery of a move towards a single approach to commissioning from primary care

Dec 19 March 20 ☐ ☒ ☒

• • ☐ ☐ ☒

Page 33 of 33

Blank Page




Date: 14 April 2020 Paper:


Register of Interests 2019/20 and Register of Gifts and Hospitality 2019/ 2020

Presented by: Donna Briggs, Interim LLR CCGs’ Executive Director of Finance, Contracts and Corporate Governance

Report author: Daljit K Bains, Head of Corporate Governance and Legal Affairs, ELR CCG



Executive summary: 1. All Governing Body members and senior employees of the East Leicestershire and Rutland CCG have a legal obligation to act in the best interests of the Clinical Commissioning Group (CCG) and have a duty to conduct NHS business with probity. The Code of Accountability for NHS Boards; Standards for members of Boards and CCG Governing Bodies; and the LLR CCGs’ Conflicts of Interest, Gifts and Hospitality and Sponsorship Policy (as approved in March 2020), which is in line with NHS England’s guidance, set out the requirement that chairs and all Governing Body members should declare any conflict of interest that arises in the course of conducting NHS business.

2. Governing Body members, committee members and CCG staff are expected to demonstrate high standards of corporate and personal conduct including impartiality, integrity and objectivity in the execution of their roles and responsibilities. This also means adherence to the standards of probity outlined in the ‘Seven Principles of Public Life’ (i.e. the Nolan Principles).

3. All members and senior employees of the CCG are therefore expected to

declare any personal or business interest which may influence, or may be perceived to influence, their judgement in line with the updated CCG Policy. This includes, as a minimum: financial interests, non-financial professional interests; non-financial personal interests; and indirect interests which includes such interests of close family members.

4. As detailed within the CCG Constitution, the Accountable Officer is

responsible for an annual review of the declarations of interest register. The updated register is as at Appendix 1 and which will be published on the CCG website. The register of interests relates to declarations as at 31 March 2020 and continues to be updated on a regular basis in line with the Policy. Governing Body members are asked to review the content to ensure the declaration are an accurate reflection, and if any further amendments are required to inform the Head of Corporate Governance and Legal Affairs by Friday 17 April 2020.


Rutland CCG


interest: None identified specifically in relate to the report. Details in relation to individual Governing Body member declarations are contained within Appendix 1.


Aligned to risk relating to implementation of corporate governance and legal arrangements.


None identified


None identified


Not applicable


Not applicable

5. The register containing staff declarations of interest and conflicts is held within the Corporate Office. In addition, there is also a more detailed register documenting how conflicts of interest have been managed at the Primary Care Commissioning Committee meetings.

6. Furthermore, all Governing Body members, senior employees and staff

are also required to declare any gifts or hospitality received or offered in connection with their role in the CCG. A register is maintained by the Head of Corporate Governance and Legal Affairs and updated on a regular basis. The current register has been reviewed and is as at Appendix 2.

7. This report provides assurance to the Governing Body that systems and

processes are in place to demonstrate compliance with the CCG’s governance arrangements as outlined within its Constitution.

Appendices: • Appendix 1 – ELR CCG Register of Interests as at 31 March 2020 • Appendix 2 – ELR CCG Register of Gifts and Hospitality reviewed as at 31

March 2020. Recommendations:

The East Leicestershire and Rutland CCG is asked to: • RECEIVE and APPROVE the report and the register of interests as at

Appendix 1 and the register of gifts and hospitality at Appendix 2 ahead of publishing these versions as at 31 March 2020.


• None

2

EAST LEICESTERSHIRE AND RUTLAND CLINICAL COMMISSIONING GROUP

Declarations of Interest - 2019 - 2020 (v4, 31 March 2020)N.B. including dates "to", "from" or both as per guidance relating to the interest where new or circumstances have changed through the year.

Name Job Title Financial Interests Non-financial professional interests

Non-financial personal interest Indirect Interests Actions to be taken to mitigate the risks (see Conflicts of Interest Policy for details)

Mr Andy Williams (from 11 November 2019)

LLR CCGs' Accountable Officer

Director of Phase 3 Management Team. Trustee of brap - charity working in the rights and equality field.

Deputy Warden of Birmingham Cathedral - non remunerated position.Foundation Governor of St Matthews Primary School, Smethick - non remunerated position.

Wife is Acting Director at Dudley and Walsall Mental Health Partnership NHS Trust.

If consultancy firm required Andy would not be part of the procurement process. Remaining interests are non-financial interests. However, if a direct potential or actual conflict of interest arises then appropriate action to be taken in line with the Policy.

Mrs Karen English (until 17 November 2019)

Managing Director

N/A

Member of Chartered Institute of Public Finance and Accountancy.

N/A

Husband is the owner of Graham English Consultancy Ltd.

If consultancy firm required Karen would not be part of the procurement process.


(from 22 October 2018)

CCG Chair GP Partner at Central Surgery and South Wigston Health Centre.

Practice is a member of the East Leicestershire and Rutland GP Federation.

Minor Shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd).

Husband is an employee of Phillips Healthcare.

Indirect interest in respect of discussions and decisions made relating to GP Practice property. Dr Montgomery is a property owning partner of Central Surgery. South Wigston Health Centre has a lease with NHS property services however Dr Montgomery is not named on the lease at present, other partners are.

In relation to financial interests, to ensure individual does not participate in the decision-making process in committee meetings (e.g to absent themselves from meetings at the relevant point on the agenda); during procurement processes individuals to seek advice if and up to which part of the process individuals can be involved in, or not involved with at all etc.

Dr David Andrew James Ker

(until 30 August 2019)

GP Governing Body Member, Clinical Vice Chair

GP Partner in Oakham Medical Practice and Market Overton and Somerby Surgery.

Practice is a provider of minor injury services.

Practice is a member of the East Leicestershire and Rutland GP Federation. Partner at the Practice is a Board member on the ELR Federation Board.

Minor Shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd).

Oakham Medical Practice and Market Overton and Somerby Surgery are minority shareholders in The Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd).

Member of the British Medical Association and Royal College of General Practitioners.

N/A

Wife was a partner at Oakham Medical Practice and Market Overton and Somerby Surgery (25 March 2019 confirmed wife now retired and no longer Partner).

Indirect interest in respect of discussions and decisions made relating to GP Practice property. Dr Ker is part owner of the Oakham Medical Practice property . Oakham Medical Practice lease the on-site pharmacy building to Boots the Chemist. Dr Ker is also the part owner of the two sugeries properties wihtin the Market Overton and Somerby Surgery.


Dr Nicholas Glover

GP Governing Body Member, South Blaby and Lutterworth Locality Lead

GP Partner at Northfield Medical Centre, Blaby.

GP Trainer, East Midlands Deanery.

Member of the Leicester, Leicestershire and Rutland Local Medical Committee.


The Northfield Medical Centre is a minor shareholder in Leicester, Leicestershire and Rutland Provider Company Ltd. (LLR Provider Company Ltd).

Member of the Royal College of General Practitioners and British Medical Association.

N/A

Indirect interest in respect of discussions and decisions made relating to GP Practice property, however does not own the Northfield Medical Centre premises. Dr Glover is one of three partners who lease the building from an independent company.



Non-financial personal interest Indirect Interests Actions to be taken to mitigate the risks

Dr Simon Vincent

(from 1 November 2018 - until 30 June 2019)

GP Governing Body Member, North Blaby Locality Lead

GP Partner at The Limes Medical Centre, Narborough. In addition to usual GP services the Practice holds the contract for the Medical Services to Stewart House, Mill Lodge and the Violent Patient Service.

As a GP Partner at The Limes Medical Centre in receipt of rental income from the on site pharmacy, Peak Pharmacy.


The Limes Medical Centre is a shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd).

Fellow of the Royal College of General Practitioners and Member of the British Medical Association

N/A N/A


Dr Girish Purohit GP Governing Body Member, Syston, Long Clawson and Melton Locality Lead

Director Holiday Club 4 Kids Services Ltd and Nurseries 'R' Us Ltd - child care and nursery manned by wife.

Dr Purohit and his wife are Directors of Purohit Property Ltd (from 1st May 2018).

GP Partner at The Jubilee Medical Practice, Syston Health Centre, Syston, Leicestershire.

The Practice is also the Jubilee Medical Practice Academy and Training Hub.


The Jubliee Medical Practice is a shareholder in The Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd).

Dementia Lead for East Midlands Clinical Mental Health Network (from 23 May 2018).

N/A N/A

Indirect interest in respect of discussions and decisions made relating to GP Practice property, however does not own the Syston Health Centre as currently leasing the practice premises within the health centre.


Dr Vivek Varakantam

GP Governing Body Member, Oadby and Wigston

GP Partner at The Croft Medical Centre, Oadby, Leicester.Director Bushby Lodge Medical Personal Health Services (Out of Hours)

Resigned Director - LLR Provider Company.

The Practice is also the Jubilee Medical Practice Academy and Training Hub.

Undertakes examination of medical students at the University of Leicester.

The Croft Medical Centre is a shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd).

FY2 Trainer in general practice (Health Education East Midlands)

Member of the Royal College of General Practitioners and British Medical Association member.

Academic Champion / Research Fellow for University of Leicester.

N/A

Wife is shareholder in Bushby Lodge Medical (medical services company).

Wife commenced post in Interserve in care at home (therefore conflicted with e.g. CHC) - March 2015.

Indirect interest in respect of discussions and decisions made relating to GP Practice property, however does not own the Croft Medical Centre premises.


Dr Tim Daniel(until 31 March 2020)

Consultant in Public Health Medicine

Consultant in Public Health Medicine – Leicestershire County Council (from 01.04.2013); East Midlands Public Health Foundation Programme Director for LNR; Salaried GP Kegworth and Gotham Medical Practice; Sessional GP for Nottingham Emergency Medical Services and Rushcliffe CCG Extended Access Primary Care Scheme.

Member of Royal College of General Practitioners and British Medical Association. Fellow of Faculty of Public Health

N/A

Wife appointed as Non-Executive Director at Derby Hospitals Foundation Trust (October 2014).

Wife is Professor of Healthcare Research at University of Nottingham .




Dr Katherine Packham

Public Health Consultant

Public Health Consultant - Leicestershire County Council (from 13 August 2018)

Fellow of Faculty of Public Health, Member of British Medical Association

N/A

Husband is a Consultant Anaesthetist at University Hospitals of Leicester NHS Trust.


Dr Anuj Chahal

(from 1 December 2017 - 31 December 2019)

GP Governing Body Member, Harborough Locality Lead

GP Partner at the Two Shires Medical Practice, Kibworth, Leicestershire.

Resigned Director - LLR Provider Company.Resigned Director - ELR GP Federation

The Two Shires Medical Practice is a sharehodler in the Leicester, Leicestershire and Rutland Provider Company Ltd (LLR PRovider Company Ltd).Practice is a member of the East Leicestershire and Rutland GP Federation.GP Trainer, East Midlands Deanery.

Member of the British Medical Association and Royal College of General Practitioners.

N/A N/A


Dr Hilary Fox (from 3 January 2019 - 30 November 2019)

GP Governing Body Member, Rutland Locality Lead

Salaried GP (i.e. employed) at Market Overton and Somerby Surgery (part of the same partnership as Oakham Medical Practice), Oakham, Rutland, Leicestershire.

Accountable Clinical Director of the Rutland Health Primary Care Network from 1 July 2019.

GP Appraiser and Senior Appraiser for NHS England Central North Midlands (Senior Appraiser from Janury 2019).

Markey Overton and Somberby Surgery is a member of the East Leicestershire and Rutland GP Federation.

The Market Overton and Somerby Sugery is a shareholder in the Leicester, Leicestershire and Rutland Provider Company Ltd (LLR Provider Company Ltd).

Fellow Royal College of General Practitioners and British Medical Association member.

N/A N/A


Dr Andrew Ahyow (from 1 January 2020)

Member Practice Representative

Senior Partner at Forest Medical Group (Forest House Medical Centre).

GP Trainer, FY2 trainer, Health Education East Midlands.

Practice is a member of the ELR GP Federation.

Practice is a member of the Jubilee medical Practice Academy and Training Hub.

Forest House Medical Centre is a shareholder in the Leicester, Leicestershire and Rutland Provider Company Lrd. (LLR Provider Company Ltd.).

Member of the Royal College of General Practitioners.

N/A

Wife is a Public Health Consultant (CCDC) for LLR.




Mr Warwick Kendrick

Independent Lay Member N/A

Member of Chartered Institute of Management Accountants (CIMA). N/A N/A N/A

Mr Clive Wood Independent Lay Member

N/A

Vice President Section UK, International Police Association (until end May 2018).

President Section UK, International Police Association (from 9 June 2018).

N/A

Son is employee of Total Community Care Ltd which provides specialist care services for individuals with spinal cord injury and other neurological conditions.


Mr Alan Frederick Smith(until 30 June 2019)

Independent Lay Member

N/A

Member of the Chartered Institute of Public Finance and Accountancy.

N/A N/A N/A

Ms Fiona Barber(from 5 August 2019)

Deputy Chair / Independent Lay Member

N/A

Lay Member on the General Pharmaceutical Council (from 2017).

Patient Public Voice Advisor NHS England (from 2016). Primary Care Oversight Group, NHS England (from 2016).Clinical Priorities Advisory Group, NHS England (from 2016).Trustee Royal Air Force Association (from 2018).

N/A

Note that interest is not a direct financial interest. However, if a direct potential or actual conflict of interest arises then appropriate action to be taken in line with the Policy.

Mr Tim Sacks Chief Operating Officer N/A N/A N/A

Wife was a partner at Oakham Medical Practice (from 1st July 2013 - end February 2015).

N/A

Tracy Burton(from 1 April 2018 - February 2020)

Interim Chief Nurse and Quality Officer N/A

Registered with the Nursing Midwifery Council. N/A

Husband is a lay member with South West Lincolnshire CCG . N/A

Ms Donna Briggs (nee Enoux)

Chief Finance Officer and Deputy Managing Director (until end February 2020)

Interim LLR CCGs' Executive Director of Finance, Contracts and Corporate Governance

N/A

Member of the Chartered Institute of Management Accountants.

N/A

Registered as a patient at The Jubilee Medical Practice, Syston Health Centre, Syston, Leicestershire, which is the Practice of one of the Governing Body members.

Note that interest is not a direct financial interest, and as a member of the CCG Executive Team and a member of the CCG Governing Body it may not be possible for the individual not to participate in the decision-making process in committee meetings relating to this Practice. However, if a direct potential or actual conflict of interest arises then appropriate action to be taken in line with the Policy.

Mr Paul Gibara(from 24 July 2017)

Chief Commissioning and Performance Officer N/A N/A N/A N/A N/A

Ms Sarah Prema(from January 2020)

LLR CCGs' Executive Director of Strategy and Planning

Local Public Sector Director at Leicester LIFT Co.

N/A N/A N/A

Appropriate actions to be taken as necessary and dependent on the nature of the conflict.

Mrs Caroline Trevithick(from January 2020)

LLR CCGs' Executive Director of Nursing and Quality

NICE Expert Advisor Panel. Royal College of Nursing

Nurse & Midwifery Council N/A N/A




Prof Azhar Farooqi

Clinical Chair (Leicester City CCG)

Partner at the East Leicester Medical Practice.

Part owner and shareholder of "A Farooqi Ltd" and Director of Clinical Research and Quality Services.

Member of the National Institute of Healthcare Research, East Leicester Medical Practice is in receipt of NHS England research funding via NIHR.

Practice is a shareholder in the LLR Provider Company Ltd.

Clinical Director of the Clinical Research Network.

Practice is a member of the Leicester City Health Federation.

Honorary Professor at University of Leicester, Department of Health Sciences

Fellow at the Royal College of General Practitioners

Member of the British Medical Associations

Member of the Leicester Medical Society.

N/A N/A

Appropriate actions to be taken as necessary and dependent on the nature of the conflict. In relation to financial interests, to ensure individual does not participate in the decision-making process in committee meetings (e.g to absent themselves from meetings at the relevant point on the agenda); during procurement processes individuals to seek advice if and up to which part of the process individuals can be involved in, or not involved with at all etc.

Dr Avinashi Prasad

Deputy Clinical Chair (LC CCG)

Partner at the Clarendon Park Medical Centre.

Part of the Leicester Federation.

Practice is a shareholder in LLR Provider Company Ltd.

Dr Prasad is a Board member on the LLR Provider Company Ltd Board.

Director of the Clarendon Medical Centre Property Limited.

Clarendon Park Medical Centre is a secondary provider of the Vasectomy Services.

Son is a partner at Clarendon Park Medical Centre.

Member of the British Medical Associations

N/A

Dr Rishabh Prasad(Son) is a partner at The Willows and Willowbrook Primary Care.


Mr Zuffar Haq Independent Lay Member (LC CCG)

Vice Chair of the Leicester Children's Hospital Charity Campaign.N/A N/A

Brother employed as a procurement manager at George Eliot Hospital.


Ms Sue Lock Managing Director (LC CCG)

N/A

N/A N/A

Niece employed by Voluntary Action Leicester.

Registered as a patient at Downing Drive Surgery (Dr Bentley from this Practice is a member of the LC CCG Governing Body).


Mrs Michelle Iliffe Director of Finance and Depiuty Managing Director N/A Member of the Chartered Institute

of Management Accountants.

Two sister-in-laws employed at the Melton Community Hospital in Intermediate Care Service (ICS)


Ms Sarah Prema Directtor of Strategy and Implementation

Local Public Sector Director at Leicester LIFT Co.

N/A N/A N/A


Prof Mayur Lakhani

Clinical Chair (WL CCG)

Undergraduate teaching at University of Leicester and University of Nottingham.

Highgate Medical Centre is part of South Charnwood Federation

Highgate Medical Centre is a member of LLR Provider Company Ltd.

Spouse is a Practice Manager and non-clinical partner at Highgate Medical Centre and director of South Charnwood Federation (Network)

Professional Membership Details Royal College of General Practitioners

Professional Membership Details British Medical Association

Professional Membership Details Fellow of Royal College of GPs

Professional Membership Details Member of the Faculty of Medical Management & Leadership

N/A N/A


Commissioning Collaborative Board (CCB) (which will be superseded by Collaborative Commissioning Committee (CCC)) is a joint committee of the East Leicestershire and Rutland CCG, West Leicestershire CCG and Leicester City CCG. Declarations for CCB (and CCC) members as follows (please note individuals who are part of ELR CCG Governing Body and serve as a member of the CCB (and CCC) are mentioned above only, below is a list of non-ELR CCG members who are members of the CCB (and CCC):

Dr Nick Pulman Deputy Clinical Chair (WL CCG)

GP Senior Partner - Dr Pulman & Partners, Long Lane Surgery.

Long Lane Surgery is a member of North West Leicestershire Federation

Long Lane Surgery Ltd has a contract to provide vasectomies

A member of LLR Provider Company

Professional Membership Details Royal College of General Practitioners

Professional Membership Details British Medical Association

Professional Membership General Medical Council

N/A N/A


Mrs Gillian Adams Independent Lay Member (WL CCG)

Director - Gillian Adams Consultancy Ltd.

Husband is employed by Loughborough University - Pro Vice Chancellor (Research)

Appointed as Lay Member for the Registration Council of Chartered Physiologists from July 2017 (paid role).

Lay Member on the Midlands & East RMOC (Regional Medicines Optimisation Committee).

Member of the National Medicines Optimisation Prioritisation Panel

Patient Participation Group (PPG) of the Loughborough University Practice.

N/A N/A


Mrs Caroline Trevithick

Interim Managing Director (WL CCG)

NICE Expert Advisor Panel. Royal College of Nursing

Nurse & Midwifery Council N/A N/A


Ms Tamsin Hooton

Director of Urgent and Emergency Care N/A

Voluntary work with Age UK Rutland.

N/A N/A


EAST LEICESTERSHIRE & RUTLAND CLINICAL COMMISSIONING GROUP

Register of Gifts & Hospitality 2019-20 v4 as at 31 March 2020)

Ref Name of receipient and job

title

Date of offer / receipt of

gift / hospitality

Description of gift / hospitality Estimated Value

£

Supplier / Offeror Name and

Nature of Business

Details of Previous Offers

or Acceptance by this

Offeror/ Supplier

Details of the officer

reviewing and approving

the declaration made and

date

Declined or

accepted and date

Reason for declining or

accepting

Other Comments

1 Karen Wood, Clinical Quality

Lead

17 December 2019 Hotel Chocolat box of chocolates £22.95 Langdale House Care Homes

(Langdale Group)

Received chocolates last

Christmas.

Amanda Bland, Interim

Deputy Chief Nurse,

19 December 2019

Accepted

17 December 2019

In line with CCG policy, item

shared with the Nursing and

Quality Team.

2 Vishal Mashru, Head of

Prescribing

19 December 2019 Room hire and tea/coffee for

Pharmacists' Protected Learning

Time event.

£247 + VAT Gary Carver, Ethypharm None Tim Sacks, Chief Operating

Officer,

24 December 2019

Accepted

19 December 2019

In line with CCG policy and

value for money.

3 Vishal Mashru, Head of

Prescribing

19 December 2019 Lunch for Pharmacists' Protected

Learning Time event.

£252 + VAT Lewis Bell, Thornton & Ross

(T&R)

T&R sponsored a protected

learning time event in June

2018.

Tim Sacks, Chief Operating

Officer,

24 December 2019

Accepted

19 December 2019

In line with CCG policy and

value for money.

4 Mental Health Team and case

managers

17-Dec-19 Hotel Chocolat box of chocolates £22.95 Langdale House Care Homes

(Langdale Group)

None Mark Whotmore, Senior

Commissioning Manager,

3 January 2020

Accepted

17 December 2019

in line with CCG Policy, item

shared with the Mental

Health Team and case

managers.