merton clinical commissioning group governing body … … · 4. 2015 5. 2016 adherence to coi...

MERTON CLINICAL COMMISSIONING GROUP

GOVERNING BODY MEETING

Wednesday 1st May 2019

2.30 to 5.30pm

Chaucer Centre, Canterbury Road, Morden, SM4

AGENDA PART 1

Chair: Dr Andrew Murray

Item Item Description Lead Purpose Att.

Verbal

Time

1. Welcome and apologies for Absence Chair Information Verbal 2.30

2. Declarations of Interest

2.1 Governing Body members are asked to declare if their entry upon the Register of Interest is not a full, accurate and current statement of any interests

AM Information Att.01

2.2 To approve the minutes of Part 1 of the meeting of the Governing Body meeting held on 6.3.19

AM Approve Att.02

2.3 Matters arising from the previous meeting AM Information Verbal

3 Chair’s, Managing Director and Accountable Officer Updates 2.40

3.1 Chair’s Update AM Information Verbal

3.2 Managing Director’s Update JB Information Att.03

3.3 Accountable Officer Update SB Information Verbal

4 Key focus 3.00

4.1 Local Health and Care Plan

JP Discussion Att.04

5 Strategy & Planning 3.30

5.1 Moving Forward Together SB/JB Discussion Att.05

5.2 2019/20 Planning NM Approval Att.06

6 Standing Items 4.00

6.1 Finance Report Month 12 NM Information Att.07

6.2 Governing Body Performance Report JA Information Att.08

6.3 SWL Health and Care Partnership Update SB Information Att.09

7 Reports from Committees 4.15

7.1 Summarised Minutes

a. Finance Committee in Common

b. Integrated Governance and Quality Committee

c. SWL Collaborative and Decision-Making Committee

Information

Att.10

a-c

8 Any Other Business 4.20

8.1 Date of next meeting: Wednesday 3 July 2019, 2.30 to 5.30, The Chaucer Centre, Canterbury Road, SM4 6PX

AM Information Verbal

Meeting Close 4.30

Closure of Part 1

To resolve that the public now be excluded from the meeting, on the basis that publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be

conducted in the second part of the agenda.

Register of Interests (updated April 2019)

Status Name

Current position (s) held in the

CCG i.e. Governing Body member;

Committee member; Member

practice; CCG employee or other

Do you

have any

interests

to

declare?

(Y or N)

Declared Interest

(Name of the organisation and nature of business)

Fin

an

cia

l In

tere

st

No

n-F

ina

nc

ial

pro

fes

sio

na

l In

tere

st

No

n-F

ina

nc

ial

Pe

rso

na

l In

tere

st

Ind

ire

ct

Inte

res

t

Nature of Interest

From To

Action taken to mitigate

risk

Voting Member Dr Andrew Murray Clinical Chair of MCCG

Chair of Merton CCG Governing Body

Co-Chair of Clinical Oversight Group and

Joint Clinical Cabinet

Member of Remuneration Committee

Member of Executive Management

Team

Member of LDU Finance Committee in

Common

Member (non-voting) of Merton Primary

Care Commissioning Committee

Co-Chair of South West London Clinical

Senate

Chair of Merton/Wandsworth Planned

Care Programme Board

Co-Chair Integrated Governance and

Quality Committee

Y

1. GP Partner in The Nelson Medical Practice operating out of the Nelson

Health Centre.

2. Chair of Executive Management Team at Nelson.

3. Wife helped establish Merton Against Trafficking (local anti-people

trafficking) for which I have done some volunteer work.

4. A close friend set up Chapel Street (Charity) – this runs some services

for NHS, but not in Merton.

5. Same friend also set up Good Faith Partnership which has run a

national initiative aimed at supporting refugees moving to UK.

6. Regular attendee of Raynes Park Community Church,which is a

member of Merton Citizens, a community movement whose campaign

areas include mental health services for children and young.

7. Trustee of Health and Hope UK

1

7

6

3

4

5

1. Apr 2015

2. Apr 2015

3. Sept 2008

4. 2010

5. 2016

6. 2016

7. Oct 2012

4. March

2017

7. June 2017

Adherence to COI policy

Voting Member Sarah Blow Accountable Officer

Member of MCCG Governing Body Y

1. Trust Governor for Greenshaw Learning Trust 1 1. 13/09/17 Adherence to COI policy

Voting Member James Blythe Managing Director

Governing Body Member


Team

Member of Primary Care

Commissioning Committee

Member of Finance Committee in

Common

Member of Integrated Governance

Quality Committee

Y

1. Wife is an employee of St George's University Hospitals NHS

Foundation Trust and has a specialist training number with HEE South

London

1 1. May 2017 1. I am not present at

specific discussions relating

to the relevant service.

Voting Member James Murray Chief Finance Officer

Merton CCG Governing Body


CommonY

1. MPL Ltd. (Director)

2. Provek Ltd (Associate Director)

1

2

1. 30/09/03

2. 30/09/03


Status Name





Do you

have any

interests

to

declare?

(Y or N)

Declared Interest


Fin

an

cia

l In

tere

st

No

n-F

ina

nc

ial

pro

fes

sio

na

l In

tere

st

No

n-F

ina

nc

ial

Pe

rso

na

l In

tere

st

Ind

ire

ct

Inte

res

t

Nature of Interest

From To


risk

Voting Member Clare Gummett Governing Body Lay Member for Patient

& Public Engagement

Member of Integrated Governance and

Quality Committee

Chair of Primary Care Commissioning

Committee

Member of Audit & Governance

Committee

Member of Remuneration Committee

Member of Sutton & Merton CCGs

Charitable Trust

Member of Patient Engagement Group

Member of Merton Equality & Diversity

Group

Member of the Patient & PUblic

Engagement Steering Group

Member Quality Sub-Committee

Y

1. Age UK Merton – Chair of Trustees 1. Jan 2014 Adherence to COI policy

Voting Member Andrew Leigh Governing Body Lay Member for Audit &

Governance

Chair of Audit & Governance Committee

Member of Governing Body

Member of Remuneraton committee

Member of Primary Care Commissioning

Committee


Quality Committee

Y

1. Director of Maynard Leigh Associates (MLA), and Chair of Leadership

Team. MLA runs training courses; NHS employees occasionally attend.

2. Manage a non for profit web site called Ethical Leadership.

3. Wife is acting Chair of the voluntary body Sustainable Merton. The

organisation may develop some commecial links with The new Wilson

project.

1

2

3

1. Nov 2017

2. Nov 2017

3. Current

all ongoing 1. Avoid voting on items

about Leadership Training

contracts for which

Maynard Leigh might bid.

2. A not-for profit site; does

not trade commercially.

Voting Member David Smith Merton CCG Lay Member Finance

Merton CCG GB Lay Vice Chair

LDU Finance CIC Joint Chair

SWL Finance CIC Vice chair

Sutton CCG Lay Member Governance

and Audit

Y

1. Director, D Smith Partnership Limited

2. Senior Adviser, Newton

3. Associate, Oxford Centre for Triple Value Healthcare

4. Member, Oxfordshire Sport and Physical Activity Partnership Board

5. Independent Chair of the Joint Committee for the NHS 111 and Clinical

Assessment Service Procurement: Kent, Medway and Sussex.

1

2

3

5

4

1. Jan 2018

2. Jan 2018

3. Jan 2018

4. Jan 2018

5. Feb 2019 5. Feb 2020


Voting Member Dr Tim Hodgson GP Governing Body Member

Deputy Clinical Chair of Governing Body

Joint West Merton Locality Lead


Quality Committee


Common

Member of Clinical Oversight Group


Committee

Y

1. GP Partner – Wimbledon Village Surgery (Member of Merton

Federation)

1 Apr-17 Apr-19 Adherence to COI policy

Status Name





Do you

have any

interests

to

declare?

(Y or N)

Declared Interest


Fin

an

cia

l In

tere

st

No

n-F

ina

nc

ial

pro

fes

sio

na

l In

tere

st

No

n-F

ina

nc

ial

Pe

rso

na

l In

tere

st

Ind

ire

ct

Inte

res

t

Nature of Interest

From To


risk

Voting Member Dr Karen

Worthington

GP Governing Body Member



Quality Committee


Common

Clinical Director for transforming

Primary care

Named GP for Safeguarding Merton

from 1.1.19

Y

1. Part time salaried GP at Central Medical Centre. 2 days per week

2. Part time staff bank member-clinical support to clinical harm review at

St Georges Hospital. Training undertaken but no work done.

1.

2.

1.12/06/16

2. 24/4/17 2. 24/04/18


Voting Member Dr Andrew Otley Clinical Lead for Mental Health


GP Governing Body Member

Member of EMT

Y

1. Member of Cricket Green Practice

2. Practice is a member of East Merton Primary Care Home.

3. GP Trainer

4. Member of the LMC

5. Member of the PMS & LMC Contract Review Board

6. Wife is IT Director of South West London Alliance

7. Merton Health and Wellbeing member

1

4

6


Voting Member Dr Mohan Sekeram Clinical Lead for Social Prescribing


Member of EMT Y

1. GP partner at Wide Way Medical Centre

2. Practice is a member of the East Merton Primary Care Home

3. Trustee of commonside trust , Pollards Hill

4. Member of steering group Merton CPEN

5. Member of Merton LMC

1

4

5

3

3. 2017

4. 2015

5. 2016


Voting Member Dr Mike Greenberg Governing Body Secondary Care

Member


Committee


Committee

Y

1. Medical Director of Barnet Hospital (part of Royal Free London Group)

2. Member of Wellington Diagnostics and Outpatient Centre LLP

3. Wife is a GP in Barnet and a Board member of Barnet Federation of

GPs.

2

1

3

1. 01/04/2018

2. 01/04/2018

3. 01/04/2018


Voting Member Dagmar Zeuner Director of Public Health (LBM)


Director for Preventative and Proactive

Care


Member of CCG Clinical Cabinet

Member of Primary Care CommitteeY

1. Director of Public Health, LBM

In this role potential / perceived conflict of interest re any decision about

future of St Helier’s Hospital.

2. Partner is owner of ZG publishing (publishes the magazine: “Outdoor

Swimmer”).

3. Honorary senior lecturer at the London School of Hygiene and Tropical

Medicine.

4. Research advisor (occasional) for University of London/Institute of

Child Health.

1

3

2

1. Feb 2016

2. Feb 2011

3. Apr 2006

4. Apr 2010

1. Not being a member of

the CIC, being excluded

from any decision making

on the future of St Helier,

which includes circulation

of related unpublished

papers.

Status Name





Do you

have any

interests

to

declare?

(Y or N)

Declared Interest


Fin

an

cia

l In

tere

st

No

n-F

ina

nc

ial

pro

fes

sio

na

l In

tere

st

No

n-F

ina

nc

ial

Pe

rso

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st

Ind

ire

ct

Inte

res

t

Nature of Interest

From To


risk

Voting member Sam Page Registered Nurse

Wandsworth CCG Board member

Merton CCG Board Member

Quality CCG Board

Integrated Governance and Quality

Committee (WCCG Vice Chair)

Quality Sub-committee (Joint Chair)

Safeguarding Committee

Children’s Programme Board

MH & LD Placements Panel (Chair)

MCP Quality Oversight Group

Directly Commissioned Service CQRG

Y

1. Director - Sam Page Consultancy

2. Chair of Board of Trustees for Learning Through Horses

1

2 2. April 2019


Non Voting

Member

Neil McDowell Director of Finance


Member of Finance Committee


Committee


Committee


Committee


Quality Committee

Y

1. Spouse is Chief Finance Officer for Surrey Heartlands CCGs. 1 Adherence to COI policy

Non Voting

Member

Julie Hesketh Director of Quality and Corporate

Governance



Committee


Quality Committee

Member of Audit and Governance

Committee

Y

1. Personal involvement in Richmond Education Network (not for profit

organisation). This is done outside of CCG hours.


Status Name





Do you

have any

interests

to

declare?

(Y or N)

Declared Interest


Fin

an

cia

l In

tere

st

No

n-F

ina

nc

ial

pro

fes

sio

na

l In

tere

st

No

n-F

ina

nc

ial

Pe

rso

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l In

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st

Ind

ire

ct

Inte

res

t

Nature of Interest

From To


risk

Non Voting

Member

Katharine Denton Director of Primary Care Transformation

Member of MCCG Governing Body

Member of WCCG Board

Member of LDU Clinical Oversight Group


Team

Member of Merton Primary Care

Committee

Member of Wandsworth Primary Care

Committee

N

No interests declared Adherence to COI policy

Non Voting

Member

John Atherton Director of Performance Improvement



Committee


Quality Committee


Committee

N


Non Voting

Member

Josh Potter Director of Commissioning Member

of Governing Body


Committee

Member of Primary Care

Commissioning Committee


and Quality Committee

N


Non Voting

Member

Dr Marek Jarzembowski Local Medical Committee

Representative

Chair of Merton Local Medical

Committee

Y

1. Partner in the Nelson Medical Practice partnership, operating from the

Nelson Health Centre.

2. Member of Merton Health Ltd (Federation) by dint of being a partner

in the Nelson Medical Practice.

3. Member of the Board of Directors of Londonwide LMCs.

4. Chair of Merton Local Medical Committee.

1 1. April 2015

3. March 2015

4. 2016


MINUTES MERTON CLINICAL COMMISIONING GROUP

GOVERNING BODY PART 1

Wednesday, 6 March 2019 Raynes Park Library, Station Approach, Raynes Park, SW20

Chair: Dr Andrew Murray

Members

Dr Andrew Murray (AM) CCG Clinical Chair

James Blythe (JB) Managing Director

Dr Mike Greenberg (MG) Secondary Care Member

Clare Gummett (CG) Lay Member Patient & Public Engagement

Dr Tim Hodgson (TH) GP Member and Joint Locality Lead for West Merton

Dr Mohan Sekeram (MS) GP Member and Joint Locality Lead for East Merton

James Murray (JM) Chief Finance Officer

Dr Andrew Otley (AO) GP Member, Clinical Lead for Mental Health and Joint Locality Lead for East Merton

David Smith (DS) Lay Member Finance

Andrew Leigh (AL) Lay Member Governance

Dr Karen Worthington (KW) GP Member and Clinical Lead for Transforming Primary Care

Sam Page (SP) Independent Nurse Member

Dr Dagmar Zeuner (DZ) Director of Public Health, London Borough of Merton

Non-Voting Members

Julie Hesketh (JHe) Director of Quality and Governance

John Atherton (JA) Director of Performance

Katie Denton (KD) Director of Primary Care Transformation

Neil McDowell (NM) Director of Finance

Dr Marek Jarzembowski (MJ) Chair, Local Medical Committee

Katie Thomas (KT) Deputy Director of Acute re-design and pathways

Other Officers in attendance

Frazer Tams (FT) Head of Governance

Yvonne Hylton (YH) Committee Secretary (Minutes)

Members of the Public

Graham Barker (GB) Merton Residents Health Care Forum

Sue Clark (SC) Merton Residents Health Care Forum

Peter West (PW) Chair of Patient Participants Group, Lambton Road Medical Centre

Apologies

Sarah Blow (SB) Accountable Officer SWLA

Josh Potter (JP) Director of Commissioning Operations

No. AGENDA ITEM Action by

1 Welcome and Apologies

The Chair welcomed everyone to the meeting and in particular Dr Sekeram who was attending his first meeting of the Governing Body. Apologies received are noted above. With no further apologies the meeting is quorate.

2 Declarations of interest:

2.1 The register of declared interests was APPROVED as an accurate record.

3 Minutes of the meeting held on 9 January 2019

3.1 The Minutes were APPROVED as an accurate record with the following amendment Page 5: Quality Impact Assessment to be amended to Equality Impact Assessment

4 Action Log and matters arising

4.1 There were no matters arising not on the agenda. Written questions received from members of the public since the last meeting will be responded to by the end of this week. Questions will be invited on matters relating to the agenda items from members of the public at the end of the meeting.

5 Managing Director Update

5.1 The Chair advised that he had no further updates to those in the MD report. The MD update was taken as read and JB provided an update on service integration across Merton. JB advised that the Merton Health and Care Together Programme Board met this week and good progress is being made with all Partners in Merton. The Programme Board has agreed the next steps for engagement. A discussion document is being developed for review by the Health and Wellbeing Board at the end of March, following which engagement will take place with specific groups on the involvement and management of the services we wish to deliver in Merton. The Governing Body NOTED the update

4 Key Focus

4.1 MCCG Operating Plan for 2019/20 JB introduced this item which covered 3 areas, the CCG’s Commissioning Intentions for 2019/20 which is for approval, an update on financial planning and an update on performance trajectories for 2019/20 both of which are for note.

Commissioning Intentions KT presented the Commissioning Intentions. The NHS long term plan has set out the expectations for the NHS over the next 5-10 year and the paper describes how the commissioning intentions support the priorities and goals of the plan.

The schemes can be broken down into 3 main groups

- Out of Hospital, Primary Care and Community Services; - Wellbeing, Empowerment and Education schemes which

includes implementation of the new Primary Mental Health Care Service and Diabetes educational schemes;

- Transformational schemes working with providers to agree how services will be delivered in future.

KT advised that there is a robust assessment process in place which includes a clinical assessment of implementation of schemes and each scheme receives a Quality Impact Assessment. AL asked if the efficiencies from QIPP are re-invested in services. JB said that as can be seen from the financial plan later in the agenda, the efficiencies are needed to re-invest into new clinical pathways to reduce the overall cost base and at the same time improve the experience for patients by reducing appointments to secondary care and supporting people to stay well at home for longer. DS said that the work to deliver the plan is extensive and asked if the CCG had the capacity and capability to do the work. JB said that a benefit of working with Wandsworth is that we have a number of shared schemes and teams working across both boroughs makes the work achievable. Financial Planning update 2019/20

NM introduced the paper which is an extract from the draft submitted to NHSE on 12 February 2019.

For 2019/20 the NHS has been set 5-year allocations and there are changes in financial regimes with the clear intention that all NHS organisations are financially sustainable by the end of 5 years. All CCGs and Trusts have been set individual control totals which are aggregated to give a SWL system control total. Merton’s contribution to the system control total is to breakeven against allocation. To achieve breakeven the CCG has a QIPP plan of £11.5m.

MG said that the transformation of Outpatient Services will result in the loss of income for Acute Trusts and ask how this will be managed.

NM said that as part of the contract negotiations with the Trust we need to agree the funding for transformation in a way which supports the Trust and CCGs to achieve their plans.

JM said that we are now starting to see providers and commissioners being managed as a system and meetings with NHSE, NHSI, Providers and Commissioners are starting to take place.

CG asked if the CCG were confident the QIPP plan could be delivered.

JB said that in comparison with other CCGs in SWL, Merton is in the middle range of QIPPs which for this year is 3-4% of total allocation and for some CCGs the target is much higher. Although it will be difficult it will be no more so than for other CCGs.

DZ asked that given the plan for integrated services when will finance meetings with other providers including the Local Authority start. JB said the delay in the green paper means that social care funding beyond 2021 is unknown, however, the first meeting of the Local Estates Group which includes representatives from social care is taking place next week. The meeting is in two parts and Part 2 is Finance.

Performance Trajectories JA introduced this paper advising that Merton is submitting mostly compliant plans in relation to projected performance. Where performance measures are non-compliant the CCG continues to work with the relevant service providers. JA highlighted 3 areas of non-compliance for note by the Governing Body. A&E and RTT at St. George’s and Personal Health Budgets. Since the paper was drafted there has been some progress on Personal Health Budgets and we now have a compliant trajectory. In response to a question whether the CCG is performance managed on RTT and A&E, JA said that they are not and the role of the CCGs with Wandsworth as the host commissioner is to agree the trajectory which the Trust will be measured against. The performance data is then reported internally to the Integrated Governance and Quality Committee to provide assurance to the Governing Body of the services commissioned by the CCG. The Governing Body

- APPROVED the commissioning intentions for 2019/20 - NOTED the progress in Financial Planning for 2019/20 - NOTED the progress to agree financial trajectories for 2019/20

The final draft financial plan and performance trajectories will be submitted in early April 2019 and will come back to the GB for formal approval in May 2019.

5 Strategy and Planning

5.1 Primary Care Contract KD introduced this item to provide the Governing Body with an overview of the newly published 5-year framework for the GP contract reform which is the mechanism by which the Primary Care elements of the NHS Long Term Plan will be implemented. A key part of the framework involves the development of Primary Care Networks as the catalyst to support wider changes. Further work will be undertaken by the Primary Care Team to review the impact and implementation requirements of the new Network Contract; as well as the other key areas highlighted in the framework.

Proposals for Primary Care Networks are due to be submitted by the 15th May 2019. A Primary Care Commissioning Committee Seminar will take place in April to bring the Committee up to speed on the contract framework and identify the support practices may need to ensure the deadline is met. The CCG will have a role in reviewing and approving the applications to ensure 100% coverage of patients across Merton. A meeting of the PCCC in Public will be convened before the end of May in order to sign off the network proposals. In response to a question on training for clinicians in the new Clinical Director network roles, AM said that the CCG has an established Clinical Leadership Programme which is offered to Nurses as well as GPs. KD concluded saying that there is lots of work to do but the focus now is for the CCG, Federation and the LMC to support Practices to meet the deadline for submissions for PCNs by 15 May. The Governing Body NOTED the update

5.2 NHS Long Term Plan JB introduced the paper which summarises the key messages from the long-term plan. All CCGs will be asked for a response in the Autumn and the proposal for SWL is an aggregation of the six Borough Local Health and Care Plans and system-wide transformation strategies at a Borough and SWL level. AL asked about the aim to support diversity and a culture of respect and how the CCG sees its role in achieving this; in addition, we know that preventing people speaking up has been an issue in other organisations and will be difficult to tackle. JB said that supporting diversity and culture will be different for each organisation but for some it will be about tackling workforce diversity to ensure the Senior Leadership reflects the community in which it serves. In relation to clinical assurance, a lot of work has taken place since mid-Staffordshire around duty of candour and freedom to speak up. To hold Providers to account we have a Joint Quality Committee with Wandsworth CCG to provide assurance to the Governing Body. JHe added that in addition to the local Equality and Diversity we now have a SWL Human Resources and Organisational Development Group which is looking at duty of candour and speak up guardians in each CCG as well as fair recruitment and unconscious bias across SWL. JHe advised that an overview of the work taking place will come back to a future GB meeting. In summary AM said that the NHS Long Term plan reflects the work we are already planning to do and it is good to see that locally we are already aligned to the long term vision; and in creating the plan there has been real engagement from the Centre on the work that we have done at a local and SWL level. The Governing Body NOTED the update

7 Finance

7.1 Finance Report Month 10 NM introduced the Month 10 report which covers the period up to 31 January 2019. At Month 10 Merton CCG continues to forecast to meet its £1.9m surplus target. However, to meet the target the CCG has used non-recurrent reserves which has resulted in a recurrent deficit carried forward to 2019/20. Year-end agreements have been reached with ESH and Kingston Hospital and we are close to securing an agreement with SGH. DS said that the Governing Body can take assurance that the financial position has been scrutinised by the Finance Committee in Common. The Governing Body NOTED the report

7.2 Performance Report Month 9/10 JA introduced the report which covers the period November and December 2018 and highlighted two key points for note by the Governing Body:- Improving Access to Psychological Therapies (IAPT) The new service is on track to mobilise from 1 April 2019. TH asked if a large waiting list would be handed over from the previous provider. JA said that discussions are taking place to identify the patients who could be seen by our additional providers (Big White Wall or IESO) to reduce the residual waiting list which will transfer. MJ asked for assurance that treatment would not stop for those patients already accessing treatment. JHe said that she has asked this question and is awaiting a response and once received will update MJ outside the meeting. SGH Referral to Treatment The Trust returned to national reporting and data for January will be reported to Commissioners for analysis on 14 March 2019. In accordance with the Governance arrangements the January data will be reported to the Integrated Governance and Quality Committee and Governing Body from April 2019. Winter Pressures DZ asked for an update on the pressures over the winter period in particular the recent spike in delayed transfer of care. JA advised that overall the plan performed well. In terms of Adult Social Care all transfers were within the target and have been for some time. There were a small number of patients with very complex health needs which were not within the target. As in previous years we have senior staff working at SGH to support the discharge process and overall this has worked well.

The Governing Body NOTED the Performance Report

8 Governance

8.1 Summarised Minutes This report summarises the key items discussed at the following meetings and are not intended to replace the formal minutes which are available upon request.

- Finance Committee in Common - Integrated Governance and Quality Committee

The Governing Body NOTED the summarised minutes

9 Questions from the Public

9.1 The Chair invited questions from members of the public

Questions and responses are summarised below

Peter West, Chair of the Patient Participation Group at Lambton Road Medical Centre asked the following questions which had not derived from the PPG.

A summary of the questions and responses is detailed below

1. Given that the changes we are now seeing in general practice are probably the largest we have seen, have the changes been piloted by the CCG, SWL Alliance or NHSE before being committed to policy and GP contracts. JB said that the changes, to an extent reflect the work we are already doing in Merton. For example, the Federation governance is made up of 4 networks working across areas of Merton and they have been working in this way for some time. Some of the clinical transformation and other areas of transformation envisaged under the GP contract is based on the experience of work that has happened, such as the overall approach to integrate health and care reflects the work we have been doing with the Council and this work builds on the experience of vanguards such as the Mental Health vanguard in Sutton and also local initiatives such as social prescribing. When taken together we believe that the work we have done has tested the changes before they were committed to policy and the GP contract.

2. How will the demand implications of apps such as Doctor Link on General Practice be managed? KD said there are concerns about workload implications,

however the software has been piloted in a number of areas,

including across a number of practices in Wandsworth. The

experience from this was that if implemented properly, the

system reduces demand on practices in the long term.

However, the capacity to implement the system has been

identified as one of the areas where Practices will need support

and alongside costs of the software, additional funding has been

identified to help practices adapt their systems and processes to

make best use of the software.

TH said that he did have some concerns, but this has lessened

to an extent as most Practices already have a portion of

appointments available for on-line booking and the discussions

now taking place in Practices is how doctor-link generated work

will be managed.

3. With the financial challenges facing the NHS why is the CCG investing £500k in a commissioning support system due to be implemented by 1 July 2019 and is this date realistic KD said that the £500k is not an annual investment for Merton

CCG, it is the combined contract value for Wandsworth and

Merton CCGs over a number of years. Based on a high level

knowledge of the type of systems available, implementation by 1

July is a realistic timeline.

This commissioning support software will form part of the CCG’s

approach to demand management, supporting practices to make

high quality referrals to secondary care by providing practices

with up to date referral forms, guidelines and patient pathway

information during clinical consultations. This tool replaces an

existing piece of software which has not met practice needs and

it is anticipated that the investment will be offset by reduced costs

elsewhere in the system.

10 Any Other Business and the date of the next meeting

There was no further business for discussion. The date of the next meeting is 1 May 2019, 2.30 to 5.30pm at The Chaucer Centre, Canterbury Road, Morden SM4 6PX The Chair thanked the Members of the Public for attending the meeting and closed the Part 1 meeting.

Signed as a full and accurate record of Part 1 of the Merton Clinical Commissioning Group Governing Body Meeting on the 6 March 2019 -------------------------------------------------- --------------------------------- Dr Andrew Murray – Clinical Chair Date

Merton Clinical Commissioning Group Governing Body Part 1 in Public

Date Wednesday, 01 May 2019

Report Title Managing Director Update

Lead Director (Name and Role)

James Blythe: Managing Director

Clinical Sponsor

N/A

Author((s) (Name and Role)

James Blythe: Managing Director

Agenda Item No. 3.2 Attachment No. 03

Purpose Approval Discussion Noting

Executive Summary:

This document summarises issues for the attention of the Governing Body.

Key risks affecting the organisation

The below narrative reflects my views on our key risks as articulated in the current

Board Assurance Framework. These are mostly addressed by the substantive

papers on the agenda.

• STP – Health and care provider integration. Our plans for progressing

this are set out in the Local Health and Care Plan paper, and additionally in

ongoing discussions regarding future place-based decision making

structures.

• Delivery of 20% management cost savings. Our plans for progressing this

are set out in the ‘Moving Forwards Together’ paper.

• Financial balance. Subject to audit, the CCG has delivered its control total

for 2018/19. We have set a balanced plan for 2019/20 which nevertheless

will rely on delivery of transformational change and rigorous budgetary

control. This is set out in more detail in the finance papers on the agenda

• Primary care risks in relation to workforce, capacity and capability. We

discussed these at length at the March GB, in relation to the development of

Primary Care Networks. Discussions with potential PCNs in Merton are

X

continuing and we anticipate securing 100% coverage across our practices.

Later in May the CCG will receive PCNs’ formal applications which it will

consider against the requirements set out in national guidance.

General updates

Contracting Round – the CCG has successfully agreed overall contract terms with

all major providers. These include arrangements with local acute hospitals which

reflect our transformation priorities for 2019/20. Work is now underway to ensure

delivery of these priorities in line with our commissioning intentions as previously

approved by the GB.

Staff survey – the CCG saw an overall improvement from 2017 in its national staff

survey results and was in the top 10 most improved CCGs. Given that the survey

was conducted during the office move process, I am pleased with this improvement

and particularly the improvements in perceived organisational capacity and

capability and recommendation as a place to work. There are still a number of

areas where scores are lower than we would like, particularly around consistency

of line management support and input, and we are working with the CCGs across

SWL to put in place action plans with some local and some shared actions where

common themes emerged.

Digital Accelerator Programme – Merton and Wandsworth CCGs have successfully

secured funding from the Healthy London Partnership to be part of this programme

of work. The programme aims to target greater digital and operational integration to

support an aligned patient unscheduled care pathway and the funding will support

the CCG Federations to develop digital access to primary care services.

Staff changes - a small number of staff joined the LDU team under TUPE from

North East London Commissioning Support Unit on 1st April 2019. These staff

deliver our system resilience and transformation support function, supporting our

planned care and emergency care delivery boards. We anticipate further TUPE

transfers during 2019/20 with the aim of harmonising the functions delivered by

CSUs across the South West London CCGs.

Conflicts of Interest: N/A

Recommendation: The Board is asked to note the report.

Corporate Objectives This paper will impact on the following:

NA

Risk This paper links to the following CCG risks:

NA

Financial Implications NA

Has an Equality Impact Assessment been completed

NA

Are there any known implications for equalities

NA

Patient and Public Engagement and communication

NA

Committees previously considered at

NA

Supporting Documents NA

Cover Sheet Template for Governing Body Part 1 Meetings Final Version 1.2 July 2018 Page 1 of 3

Merton Clinical Commissioning Group Governing Body Meeting Part 1 in Public


Document Title Merton Health and Care Plan


Josh Potter: Director of Commissioning

Clinical Sponsor (Name and Role)

Andrew Murray: Chair

Author(s) (Name and Role)

Josh Potter: Director of Commissioning


Purpose (Tick as Required) Approve Discuss Note

Executive Summary Background: The Merton Health and Care Plan has been in development for the last 6 months as a) the focus of local collaboration between commissioners and providers in Merton and b) the borough-based deliverables of the South West London Alliance STP. The plan is overseen by the Merton Health and Care Together Board, a collaboration of all providers and commissioners in Merton (including voluntary sector representation), and Healthwatch. The current version is a “discussion document” for discussion and comment, ahead of a final version produced in the summer. All partners are taking this document to their Governing Bodies/Boards in the coming weeks. Purpose: The Health and Care Plan is made up of programmes of work that will benefit from a collective approach amongst all providers and commissioners in Merton. The plan does not encompass all the CCG’s commissioning intentions as much of the CCG’s work is through bilateral collaboration for example, outpatient transformation. Reason for Governing Body Review: The Governing Body are asked to discuss the plan in its discussion document format, and any changes and amendments will be incorporated into a final draft in Summer 2019

✓


Key Issues: 1. The Merton Health and Care Plan has been developed in collaboration with all

commissioner and provider partners in Merton 2. Whilst the plan contains high level ambitions and how these will be measured,

the delivery plan will be within the Summer version 3. The plan is currently being shared with constituents and governing bodies of all

partners, therefore could be subject to change between now and the final version in the summer

Conflicts of Interest: NA

Mitigations: NA

Recommendation: The Governing Body is asked to discuss the report and provide feedback

Corporate Objectives This document will impact on the following CCG Objectives:

The Merton Health and Care Plan will impact on all Corporate Objectives

Risks This document links to the following CCG risks:

NA

Mitigations Actions taken to reduce any risks identified:

NA

Financial/Resource/ QIPP Implications

Some schemes within the Health and Care Plan contribute towards the delivery of QIPP, but these are managed and monitored as usual, with assurance via finance committee

Has an Equality Impact Assessment (EIA) been completed?

All schemes within the HCP have been subject to an equality impact assessment.

Are there any known implications for equalities? If so, what are the mitigations?

No, the equalities impact assessments found no adverse impact


Patient and Public Engagement and Communication

The Health and Care Plan has been subject to significant patient and public engagement including:

- c30 meetings with individual groups - A large scale engagement event in November 2018 - Ongoing engagement strategy led by comms and

engagement team

Previous Committees/ Groups Enter any Committees/ Groups at which this document has been previously considered:

Committee/Group Name: Date Discussed:

Outcome:

Click here to enter a date.



Supporting Documents LCHP Presentation

Merton Health and Care Together: Start Well, Live Well, Age Well

A Local Health and Care Plan for Merton

Discussion Document: March 2019

Merton Health and Care Together:

Start Well, Live Well,Age Well

Contents

Chapter Page

Introduction 3

The Vision for Merton Health and Care Together 4

Context and Challenges 5

Our Work 12

Prevention Framework 13

Plan on a page 14

Start Well- Emotional wellbeing and mental health for young people- Community health services- Pathways into adulthood

15

Live Well - East Merton Model of Health and Wellbeing- Diabetes- Primary Mental Health Care (Merton Uplift)- Primary Care at Scale

23

Age Well- Integrated Health and Social Care

36

Creating the Right Environment for Change 40

Delivering the plan 42

Other work 44

2


Start Well, Live Well,Age Well

Introduction

All the partners of Merton Health and Care Together want to ensurethat people enjoy even better health and outcomes than their

parents and live, longer healthier lives.

Within Merton, there is still an unacceptable difference between thelife expectancy of people who are relatively wealthy compared to those who are not. We also know that some of our communities have particular needs that we are not always meeting. There is someexcellent work being carried out across the Borough, but we are aware that:

• Whilst Services do a good job in reacting to people's needs, we need to do better proactive work to avoid ill health

• Some services are not joined up, with a resulting lack of continuity for service users

• Information sharing between services in the whole system is difficult

• There is huge value to be gained through better partnership working between statutory services, carers, communities and the voluntary sector

• We have problems recruiting and retaining the right workforce and getting the best out of them• Both commissioners and providers of care have financial challenges

The Health and Care system is facing very significant challenges. People are living longer but many of us are, or can expect to, live with a series of long term conditions such as dementia, cardiovascular disease and diabetes. We recognise that services need to enable people to live healthy and rewarding lives and as such should take their individual circumstances into account.

We all share a responsibility to continue to ensure that our services are as joined up as they possibly can be in a whole system approach to wellbeing. We have formed a ‘Merton Health and Care Together’ Board to help us all work together in the best interests of Merton residents. Representatives from the NHS, Local Authorities, , and other key health and wellbeing providers will regularly reviewprogress and make sure we are on track to meet the current and future needs of people in Merton.

3

The Vision for Merton Health and Care Together:

“Working together, to provide truly

joined up, high quality, sustainable,

modern and accessible health and

care services, for all people in

Merton, enabling them to start well,

live well and age well”

Supporting independence, good health, and wellbeing: people are enabled tostay healthy and actively involved in their communities for longer, maintainingtheir independence. People will be at the heart of the system, and care will wraparound them. The effective use of technology and data will help us understandpeople and their needs to provide the right advice, support or treatment.

Integrated and accessible person centered care: Joint teams in the communitywill provide a range of joined up services, seven days a week, that help people tounderstand how to take care of themselves and prevent the development orrapid progression of long-term physical and mental health illnesses. People willbe helped by their health and care professionals and wider wellbeing teams, tomake use of a much more accessible and wider range of services.

A partnership approach: Local communities will become more resilient, withvoluntary sector organisations playing an increasingly important role in helpingto signpost vulnerable people to the right service and in some cases providingthat service. Peer support will have a vital role to play in counteracting lonelinessand contributing to people’s overall mental health and wellbeing.

We will deliver this through:

4

Context and challenges

Merton Health and Care Together

Our Context and Challenges

5

Merton Health and Care Plan, in context

The Merton Health and Care

Plan is one element of work in

Merton, and across South West

London, to improve health and

wellbeing

Merton Health and Wellbeing Strategy:Led and owned by Merton Health and Wellbeing Board, this seeksto create a healthy place that enables people to start well, livewell and age well. Whilst health and care services are a partner inthis strategy, it focuses on making significant improvements tothose things that create good health and wellbeing such as thebuilt environment, green spaces, and supporting healthy lifestyles.

The Merton Health and Care Plan seeks to improve services through strong partnershipworking between providers and commissioners of health and care services in Merton.Reporting to the Health and Wellbeing Board, we will do this in the context of, and inconjunction with, the Merton Health and Wellbeing Strategy, and the South West LondonHealth and Care Partnership:

South West London Health and Care Partnership:A partnership of the organisations providing health and care in thesix South West London boroughs, divided into four localpartnerships in Croydon, Kingston and Richmond, Sutton andMerton and Wandsworth. The partnership enablescommissioning and transformation of services where this is bestdone across more than one borough, for example in cancercommissioning, transforming hospital services, and specialistmental health

6

Joint Strategic Needs Assessment: The Merton Story 2018

Key challenges:- Emotional

Wellbeing and Mental Health

- Supporting wellbeing and independence

- Long term conditions

- People with complex needs

- The need to take a holistic approach

7

Merton’s changing population and rising demand for services

Our growing population means that by

2030 there will be:

• 45% more people with diabetes

• 50% more people with heart

disease

• 80% more people with dementia

The number of births in Merton in 2016 was 3,246. There is a general downward trend. By 2025 it is projected that there will be an estimated 2856 births.

By 2025 there will be a 17% increase those aged 11-15 years. East Mertoncurrently has a higher proportion of younger people compared to west Mertonhowever, it is forecast that the number of younger people will decline in eastMerton by 2030

There are 141,000 people of working age in Merton, increasing by 3.1% by 2025

37% of Merton’s population are from a Black, Asian, or Minority Ethnic (BAME)group; remaining unchanged by 2025. English, Polish and Tamil are the mostcommonly spoken languages in Merton. Children and young people from BAMEbackgrounds make up 67.9% of those attending a Merton school

These trends have important, well-reported, impacts on health and care demandas well as public space and housing. Working-age disability, with more disabledpeople surviving longer and the costs of their support increasing, means socialcare for people of working age now costs local authorities as much as that ofolder people.

The over 65 population in Merton is projected to grow by 10.3% by 2025. TheOver 75 population will double

8

Quality, Performance and Financial Context

We have a number of challenges

to the quality and performance of

our current services, in the

context of significant financial

challenges across the public

sector

Quality and Performance Context: the NHS quality agenda sets out the three keyelements for commissioning high-quality care: safety, effectiveness and experience.Through this process there is ongoing work to improve issues of staffing andworkforce, and spread of best practice

There has been an ongoing challenge, in common with the wider NHS, in achievingstandards for hospital waiting times for outpatient care and emergency care. Mertonhas also worked hard to achieve the standards for access to psychological therapies,and will introduce a new service model in order to make this sustainable.Performance against indicators of integrated health and social care perform well inMerton, for example levels of delayed transfers of care are some of the lowest inLondon.

Financial Context: Growth in population, and demand for new treatments andtherapies will outstrip the budget. The NHS in Merton needs to achieve an annualefficiency of £11.5m to live within its means. The London Borough of Merton needs£10.4m in savings over the next 4 years.

Providers of services need to deliver significant service redesign on top of thealready challenging financial position they face, most notably at St Georges Hospital.Local Authorities continue to face significant financial and sustainability challenges,as do many of their suppliers in the care market.

9

What residents tell usContinuity of care remains a priority for people in Merton, with a particular reference to ongoing support

for managing long term conditions such as diabetes.

Accessibility of services is very important to people in Merton, particularly for services they have to use

regularly

There is significant support for better integration of health and social care services. Services do not always

feel person centred and did not always take into account the background and preferences of the individual.

People in Merton place a lot of value in therapy support, and other specialist input. However people did

report concerns about the capacity of these teams and their ability to recruit and retain good staff

People are very positive about the move towards services encouraging wellbeing and independence. The

social prescribing pilot in East Merton has held up as being a particularly good example of this.

Mental Health is a clear priority for people in Merton. Access to mental health services was raised as a

concern, particularly for services for common mental health issues.

10

We held a partnership health and care event on 21st November to get feedback on the areas of focus and come up with ideas to improve our work for people in Merton:

11



Our Work

12

Our Work: Underpinned by The Merton Prevention FrameworkPrevention means helping people stay healthy and independent. It focuses on healthy lifestyles, underpinned by social, emotional and mental wellbeing, and creating a healthy place, where people can flourish and making health choices is easy.

We will focus on the evidence, which shows that support at a personal level is most effective as a core part of services provided by health and care teams, in both the statutory and voluntary sector

Merton Health and Care Together: 5 prevention priorities

1) Wellbeing Digital HubSingle directory for health and wellbeing, for use by residents and front-line staff

2) Network of ‘connectors’ to link patients to wellbeing services and activitiesSupporting the wide community of people providing health and wellbeing adviceand support to do so consistently, accurately, and with an up to date knowledge ofthe community assets within Merton

3) Structured conversations training for front line staffSkills for health and care staff to encourage users of services to engage in healthylifestyles and support people to change their behaviour where required

4) Delivering healthy workplacesSupport our workforce to have good health and wellbeing, knowing that this is goodfor them, and those they support. We will focus on key issues such as mental health,joint health, healthy lifestyles through a common workplace framework

5) Embedding healthy lifestyles in clinical pathwaysFor example; healthy maternity pathway incl smoking, alcohol and maternal obesity

13

Merton Health and Care Plan on a Page

Our Vision:

Working together, to provide truly joined up, high quality, sustainable, modern and accessible health and care services, for all people and partners of Merton, enabling them to start well, live well and age well:

- Supporting Independence, good health and wellbeing

- Integrated, person centredcare

- A partnership approach

Responding to the needs of Merton Residents… …Merton Health and Care Together will Focus on… …to improve the lives of Merton residents

Pre

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Start Well

Integrated support for children and families - More children in need due to abuse, neglect or family dysfunction, than London and England- Greater increase in children with special education needs than London and England . - Higher rate of A&E attendances in children under 18 years of age, than England.

Emotional Wellbeing and Mental Health- Increase in children’s use of substance misuse service, in contrast to a reduction across England- Rate of child admissions for mental health conditions higher than local authority nearest

neighbours and England. - The fifth highest rate in London of emergency hospital admission for self-harm

Emotional Wellbeing and Mental Health: Children and young people to enjoy good mental health and emotional wellbeing, and to be able to achieve their ambitions and goals

Children and Young People’s Community Services:Create an integrated commissioning strategy identifying opportunities for integration

Developing Pathways into Adulthood. Children and young people should continue to receive high quality services as they become young adults

Improved experience of and access to mental health provision

Service tailored to individual and family needs

Reduced need for emergency intervention

Live Well

Wellbeing and Log Term Conditions- The main causes of ill health and premature deaths in Merton are cancer and circulatory disease- Steady increase in diabetes prevalence; an additional 1,500 people in Merton- Fewer than 1 in 5 adults are doing 30 minutes of moderate intensity physical activity a week- 1 in 4 adults are estimated to be drinking at harmful levels- Over half of adults in Merton are overweight or obese- Only 16.5% use outdoor space for exercise/health reasons, lower than London and England- 10% of the working age population have a physical disability

Mental Health and Wellbeing- Higher reported levels of unhappiness and anxiety than in London and England- 16% of adults estimated to live with common mental health disorders like depression and

anxietyHigher rate of emergency hospital admission for self-harm than London and England

East Merton Model of Health and Wellbeing:Developing a wellbeing model that underpins a holistic approach to self-management of long term conditions

Diabetes: life course, whole system approach. Focus on prevention and health inequalities.

Primary Mental Health Care: Single assessment, primary care recovery, wellbeing and Psychological Therapies

Primary Care at Scale: improve quality, reduce variation and achieve resilience and sustainability

Improved wellbeing and independence

Greater LTC control and outcomes

Improved access to primary and community services

Improved access to mental health support

Age Well

Complex health and care needs- More people are living into older age with multiple long-term conditions- An estimated 1,686 older people have dementia in Merton- Merton currently supports around 4,000 adults with social care needs- Fewer people remain at home 3 months after reablement than both London and England- 11% of people have a long term illness, disability or medical condition- 5,900 people aged over 75 live alone. - Emergency admissions due to falls are significantly higher than London and England

Integrated Health and Social Care: Proactive and preventative services, rapid response, improving discharges, enhanced support to care homes, falls prevention, dementia care and high quality end of life care

Improved experience, and control of care

Reduction in falls and ambulance callouts

Fewer emergency admissions and A&E

14


Start Well

Emotional health and Wellbeing for Children and Young People: Mental health issues amongst young people in Merton are on the rise and outcomes can be poor. We will deliver integrated, easily accessible mental health services for children and young people

Community Health Services for Children and Young PeopleWe have an opportunity over the next two years to review our portfolio of children’s community services, and recommission a truly integrated model of care

Developing Pathways into AdulthoodServices should respond to needs without using age as a barrier and it is up to us to facilitate this with flexible commissioning arrangements, so that different rules can apply

Together we will focus on:

15

Why have we chosen emotional wellbeing and mental health for young people as an area of focus?

We have more children admitted for mental health conditions than the average for London and England

We have the fifth highest rate in London for emergency stays in hospital for self-harm by young people

We have very high numbers of children in need of support due to abuse, neglect or family dysfunction, compared with London and England

The number of children with an Education Health and Care Plan or Statement of Special Education Need is growing faster than London, and England

The number of young people accessing substance misuse services is rising, against the national trend

Mental health issues amongst

young people in Merton are on the

rise and outcomes can be poor

Let’s take some facts…

16

What are we doing to improve services?

We will deliver integrated, easily accessible mental health services for children and young people

Increasing children and young people’s access to high quality mental health services, with a focus on the most vulnerable

Develop the local workforce to ensure the capacity and expertise to deliver high quality, and evidence based services

Work in partnership with schools and colleges to deliver a ‘whole school’ approach to emotional health, well-being and mental health

A robust healthcare pathway is in place for children and young people in the criminal justice system, on the edge of offending and antisocial behaviour.

To deliver a high quality Early Intervention in Psychosis service for children and young people from age 14

17

WHATwill the impact be?

Children and young people will receive high

quality support leading to:

• Access to mental health services

improving by over 30%

• Access to support in schools via

Mental Health Support teams

• Improved waiting times for children

and adolescent mental health services

• Improved experience of services

through better advice and support

• Reduction in the rate of hospital

admission

WHOare we trying to help?

Around 64,000 young

people aged 0-24

Around 2400 children with

mental health problems

18

Why have we chosen community health services for children and young people as an area of focus?

‘School readiness’ is a key measure of a child’s development. In 2016/17, 73.94% of children living in Merton achieved this standard, similar to London, but we want to do better

Parental mental health problems, parental misuse of alcohol and drugs and domestic violence are the most significant risk factors that impact on a child’s health and wellbeing. Merton has a higher rate of these issues than London and England

There has been a greater increase in children with an Education Health and Care Plan (EHCP) or Statement of special education needs (SEN) than London and England, driven by increases in diagnosis of autism, but also through an increase in social, emotional and mental health needs.

Childhood immunisations are below the national target of 95%.

4,500 primary school children are estimated to be overweight or obese. One in 5 children entering reception are overweight or obese and this increases to 1 in 3 children leaving primary school in Year 6 who are overweight or obese.

There is a higher rate of A&E attendances for children than the England average

The number of young people in

Merton is set to rise significantly

and we want to give them the

best start in life:


19


We have an opportunity over the next two years to review our portfolio of children’s community services, and recommission a truly integrated model of care

The creation of an integrated commissioning strategy:this will include a focus on joint outcomes for children, young people and their families CYP and families; review of current commissioning arrangements and identifying opportunities for integration in borough aligned with the refresh of the Health and Wellbeing Strategy.

Review of community health services: we will review our community services for children and families, with a view to developing and commissioning an integrated model of care by April 2021

Integrated Model of Care: we will ensure that the commissioning strategy and community services review delivers integration of community paediatrics, child and adolescent mental health services, public health services and community services. These services will address children and young peoples individual needs. We will also seek to embed the Pathways into Adulthood principle that services will be available up to the age of 25 where this is preferable for individual young people

20


Development of truly integrated and person

centred community services for Children

and Young people, resulting in:

• A reduction in children attending A&E

and being admitted as an emergency

• Improvements in school readiness

• Improved health and wellbeing

• Improved experience of services

• Shorter waiting times

• More responsive services for those

with the greatest needs


Around 64,000 young

people in Merton

Around 1600 Children with

an Education, Health and

Care Plan

21

Why have we chosen developing pathways into adulthood as an area of focus?Young people experience significant

difficulties in the “transition” from

children’s to adult services. We need

services that provide support into

adulthood, that focus on the needs of

individual young people, and do not

discriminate based on age.

There is currently a Pathways to Adulthood Board, that exists in the context with children with complex special needs that are likely to be eligible for adult health services once they turn 18yrs, looking at what that transition looks like.

Statutory duties for children’s services go up to the age of 25yrs with a requirement in the Care Act that the planning starts in year 9, or 14 years old. Adult services will need to think about their growth and development and we must collectively seek to smooth this transition.

Care leavers also have a level of care up to the age of 25. They will often have complex mental health needs and may be traumatised but may not meet the statutory criteria of adult social care. Although their legal status changes at the age of 18, they may become adults at different stages/ages. These young adults need an adolescent service to chaperone them through this time rather than being excluded due to artificial boundaries.

Services should respond to needs without using age as a barrier and it is up to us to facilitate this with flexible commissioning arrangements, so that different rules can apply. There is not yet a full and clear understanding yet from children’s and adults services of the legal complications that may arise from this work, but it is our commitment to work in partnership to identify and resolve any challenges that arise

22


Live Well

Primary Mental HealthcareWe will deliver high quality and easily accessible services that take account of peoples wider health and wellbeing

Primary Care at ScaleIncreased demand for care, and changes to national policy and workforce means we must transform how primary care is delivered

East Merton Model of Health and CareDeprivation and need in East Merton demands a new approach to health and wellbeing. We will spread this learning across Merton to help all residents

DiabetesThe number of people with diabetes, or at risk of diabetes is growing significantly in Merton. We will develop primary and community care services to ensure people are supported to manage their condition effectively

Together we will focus on:

23

Why have we chosen primary mental health and wellbeing as an area of focus?

Around 8% of people in Merton reported low levels of happiness, broadly in line with London and England.

A greater number of people in Merton reported high levels of anxiety compared to London and England.

There are an estimated 24,000 adults in Merton with common mental health disorders such as depression and anxiety, around 16% of the adult population, which is lower than London but higher than England

Only 7% of these adults are known about by Merton GPs. This suggests that many adults in Merton experiencing common mental health conditions remain undetected, and potentially unsupported

Common mental health problems are proven to make managing diabetes, and other long-term conditions, much more challenging, with poorer overall health outcomes as a result

Many people with common mental

health problems do not get the care

and support they need, and this

has a significant impact on their

health and wellbeing


24


We will deliver high quality and easily accessible services that take account of peoples wider health and wellbeing

We will deliver a single point of access to adult mental health services to help manage the demand for secondary mental health care

We will commission a Primary Care Recovery service to facilitate discharge from secondary mental health services, provide psychological therapies, and ongoing mental health care support

We will commission a wellbeing service to provide social support, including psycho-social interventions, to people with a range of mental health problems. This may include vocational support, benefits advice, housing advice, information workshops, and social peer group development.

We will commission an expanded Psychological Therapies service to provide clinically effective psychological therapies for common mental health problems. It will be integrated with physical health care pathways to provide targeted psychological therapy to clients with specified long term conditions

25


Increase access rate from 19% to 25% over the

next two years, an additional c1600 people who

will receive psychological therapies support

Around 1,800 people a year recovering from

common mental health problems

Around 1000 more people living with long term

conditions better supported, leading to a 25%

reduction in use of emergency services


Around 140,000 adults living in Merton

Around 24,000 people living with common

mental health conditions

Around 16,000 people living with a long term

condition

26

Why have we chosen primary care at scale as an area of focus?

The primary care workforce has changed with a shift towards more GPs working part time and in a salaried or locum capacity. This can cause gaps in frontline clinical time for consultations but also in a reduction in leadership capacity within practices

National policy demands the provision of primary care 8am-8pm care 365 days a year.

There is an increasing number of elderly and more complex patients needing care in the community.

There are differences in the quality of services between different GP practices in Merton

There are significant health inequalities between the east and west of the borough.

The existing infrastructure (IT & estates) are not always fit for purpose to deliver high quality care

Challenges such as increased

demand and complexity of care,

workforce shortages as well as

changing national policy means

we must transform how primary

care is delivered


27


A new GP contract sees practices increasingly working together to improve resilience and quality, increase capacity and provide local care alongside other local services in the community.

We will improve organisational efficiency by:- Maintaining and scaling up back office functions in practices- Investigating efficiencies of scale could be achieved and also

utilisation of collective purchasing power

We will realise the benefits of the new GP contract by:- Supporting all practices to come together in networks to deliver

a range of new services;- This will include significant new investment for the creation of

new front line posts, embedded at network level- Identifying opportunities to align community contracts and staff

with these network arrangementsWe will work to support our workforce by:- Enhancing skill mix and using community services staff

appropriately; - Training existing practice staff to work in different ways e.g.

receptionists sign posting people to community resources- Delivering economies of scale- Ensuring staff want to work in Merton and are retained

We will continue to improve access by:- Development of the locality access hubs- Embracing opportunities from technology and innovation where

it makes sense to- Explore the possibility of a single point of triage- Joining up urgent care systems with primary care so that patients

are seen in the most appropriate place to meet their needs.- Improving public education in relation to self-care

28


High quality, sustainable Primary Care which is

accessible, pro-active and co-ordinated, delivered

across the Borough.

Over 20,000 more appointments available, including

ability for patients to be seen on the day where clinically

necessary

All Merton registered patients able to access primary

care services online

All patients have access to social prescribing services.

Patient care is holistic and joined up across multiple

agencies


Merton has a GP registered

population of 220,000

Around 140,000 adults

Around 16,000 people living

with a long term condition

29

Why have we chosen the East Merton Model of Health and Care as an area of focus?

Significant social inequalities exist within Merton. Largely as a result, people in East Merton have worse health and shorter lives: There is a gap of 6.2 years in life expectancy for men between the most deprived and least deprived areas in Merton. The gap is 3.9 years for women

Premature mortality (deaths under 75 years) is strongly associated with deprivation, with all wards in East Merton being more deprived and having higher rates of premature mortality than their West Merton counterparts.

Marked social inequalities are important drivers of the health divide. However Merton’s plans for economic growth and regeneration have the potential for improving life chances and securing better health outcomes over time.

Unemployment claimant rates in Merton are lower than London; however rates are more than double in the East of the borough, compared to West Merton. Unemployment in East Merton is higher than London and England

16% of households are overcrowded in Merton, but there are nearly doubled the proportion of overcrowded households in East Merton than West Merton

Deprivation and need in East

Merton demands a new

approach to health and

wellbeing. We will spread this

learning across Merton to help all

residents


30


We will seek to embed wellbeing into health and care services, and make the most of our community assets

At the core of the Wilson Health & Wellbeing Campus will be an enhanced East Merton Primary Care Hub offering significant scope for GP’s working at scale for the whole population of East Merton.

We will deliver a whole health and wellbeing system working together: We recognise that health is about whole people (physical, mental and social) who are part of whole communities

We are working together on the vision for East Merton, driven by a requirement to address health inequality and rationalise and improve estates through the development of the Wilson Hospital site in Mitcham

Social Prescribing supports people to take control and explore behaviour change, as well as building social networks and enhancing community cohesion.

Local people will have access to a wide range of serviceson the site, to include community services, acute specialist consultants, social prescribing, diagnostics and community based voluntary services

31


Social prescribing available in every GP practice

in Merton leading to:

• Improvements in wellbeing of around 25% as

measured by the wellbeing star, for those

referred to the service

• Around 30% reduction in use of GP services

for those referred to the service

• Around 25% reduction in emergency hospital

visits, for those referred to the service

• Greater utilisation of community assets and

voluntary sector groups


Adults and

Children across the

whole of Merton

32

Why have we chosen Diabetes as an area of focus?

Unhealthy diet, smoking, lack of physical activity, and alcohol account for around 40% of total ill health. The main causes of ill health and early death in Merton are cancer and circulatory disease

Six percent of our residents are already diagnosed with diabetes

Over half of adults living in Merton are overweight or obese. One in three children leaving primary school in Merton are overweight or obese

We know type 2 diabetes can be prevented or reversed through better diet and more exercise. Fewer people in Merton exercise regularly than the London and England average

Around £10bn - ten percent of the national NHS budget - is spent on treating diabetes every year in England.

The number of people with

diabetes, or at risk of diabetes is

growing significantly in Merton.

We will develop primary and

community care services to

ensure people are supported to

manage their condition

effectively


33


We will develop primary and community care services to ensure people are supported to manage their condition effectively A new Diabetes Community Service

Establishment of a Diabetes Clinical Advice Service:- Single point of contact for diabetes-related advice and

guidance- Supportive GP visits from Community Services providing

additional clinical capacity, as well as both face-to-face and virtual GP Practice support in the delivery of care.

Consistent and high quality primary care- Register for patients who are pre-diabetic.- All people with pre-diabetes or diabetes receive annual

HbA1C testing, diet, lifestyle advice, social prescribing interventions or referral to structured education

- Population analysis to target high risk patients- Provide primary care diabetes clinical teams with

appropriate education and training- Offer injectable therapy - Annual support from consultant diabetologist and

pharmacists

Supported patient self-care and self-management- Healthy lifestyle, diet and exercise.- Social prescribing.- Mental health/IAPT.- Online resources and local support services information.

34


Better care and support for people living

with diabetes, or who are at risk of

diabetes:

- Increased uptake of diabetes

prevention programme

- Increase proportion of people receiving

the 9 care processes as outlined by

NICE

- 5% reduction in emergency hospital

visits due to diabetes complications

- Reduction in medicines costs


Around 13,500 people with

diabetes

Estimated 2,000 living with

undiagnosed diabetes.

35


Age Well

Integrated Health and Social Care

The population is ageing and increasing numbers are living into older age with multiple long-term conditions such as heart disease, diabetes, and dementia. Complex needs require services that put the person in the centre. We will deliver:- Proactive care for those at highest risk- Improved response to crises and more

effective reablement- Integrated Locality Teams- Support for the most frail and those

with the highest need for services, such as those with dementia, and the end of life, and residents of care homes

We will deliver this through:

36

Why have we chosenIntegrated Health and Social Care as an area of focus?

The population is ageing and increasing numbers are living into older age with multiple long-term conditions such as heart disease, diabetes, and dementia

Merton currently supports around 4,000 adults aged 18 and over with social care needs. Merton performs well for providing social care support to people in the community, higher than comparable local authorities and England

Merton has comparably low rates of delayed transfers of care from hospital to home but the proportion of older people who were still at home 91 days after discharge from hospital following reablement is lower than London and England

10.8% of people in Merton were diagnosed with a long term illness, disability or medical condition

Merton has around 17,000 carers. We know that caring can have a negative impact on the carer’s physical and mental health, and that caring can adversely affect education and employment.

Feeling isolated and lonely has a profound negative effect on physical and mental health and wellbeing. This is particularly important given we have an estimated 5,900 people aged over 75 living alone

Falls are the leading cause of older people being admitted to hospital as an emergency, and rates are very high compared to London and England

The population is ageing and increasing

numbers are living into older age with

multiple long-term conditions such as

heart disease, diabetes, and dementia.

Complex needs require services that put

the person in the centre.


37


We will provide proactive, integrated and responsive care, including particular enhancements for those most frail and in need of services

Proactive care for those at highest risk. This will include the identification of high risk individuals, allocation of a key worker, person-centred planning and a common care plan across organisations

Improved responses to crises and exacerbation of conditions, including rapidly available alternatives to hospital admission, supported hospital discharge, rehabilitation, intermediate care and reablement

Integrated Locality Teams comprising of General Practice, social workers, community health services and mental health professionals. These teams will provide oversight and coordinated care to older people in Merton

Enhanced support for those most frail and those at the end of life. This will include supporting Care Homes with dedicated primary care support, enhanced community services, additional therapy input and dietetics and improved IT infrastructure

38


Provision of preventive, proactive,

holistic and patient centred care,

resulting in:

- Improvements in quality of life and

experience

- Care Homes residents will require

c500 fewer visits to hospital as an

emergency, and will be admitted

less often


Around 25,000 older people

in Merton

Estimated 1700 people in

Merton with dementia

Around 850 care home

residents

39



Creating the right environment for change

40

What needs to be in place to create the right environment for change?

Our current systems do not always talk to each other, and information sharing is inconsistent

Whilst we aspire to person centred care, this can mean different things to different people, and different professionals approach it in different ways.

Whilst we aspire to be able to support people to maintain independence and take care of their health and wellbeing, this requires a shift in mind-set and an appreciation of individuals circumstances and resources

Providers of services do not always work together proactively

The contracts we have in place with providers do not always encourage integrated care, and in some cases make it more difficult

We have a workforce that is ageing, and we have challenges recruiting to certain professions

Certain parts of the health and social care system have critical challenges in remaining sustainable.

Some of the health and care estate is not fit for purpose

There is limited use of technology to improve the delivery of services

The population is ageing and increasing

numbers are living into older age with

multiple long-term conditions such as

heart disease, diabetes, and dementia.

Complex needs require services that put

the person in the centre.


41

What do we need to do to create the right environment for change?

We recognise that we need to make significant changes to the way health and care services work

Common Outcomes: We will ensure that services work together towards a common goal, and have a demonstrable impact on health and wellbeing

Reforming our contracting and incentives: Contracts for services will encourage integration, and reward person centred care

Provider development: We will develop greater collaboration between providers of services, and break down any barriers that get in the way of great care

Market development: We will address current risks in the market of health and care provision

Workforce: We will work with partners across South West London to address workforce gaps and training and development needs

Developing a person centred approach: We will define a common approach to person centred care across and within providers of care in Merton

Digital: We will take the opportunities afforded by the NHS Long Term Plan to incorporate digital approaches to the delivery of services for people in Merton

Estates: We will develop a single estates strategy that supports integration and ensures community based integrated care

42

Delivering the plan: the Merton Health and Care Together Board

Senior leaders from across the local authority, NHS and voluntary sector meet on a monthly basis to ensure improvements are delivered for people in Merton

The Merton Health and Care Together Board oversees the development and delivery of theMerton Health and Care Plan. Every major provider and commissioner of health or careservices in Merton is represented (see right)

The Merton Health and Care Together Board isco-chaired by Merton Clinical CommissioningGroup’s Managing Director, and the Director ofCommunities and Housing of the London Boroughof Merton. Held on a monthly basis, it overseesthe development of the health and care plan,drives delivery, and ensures that the benefitsof the plan are tracked and quantified. Byhaving all of the leaders in the system in oneplace, the Merton Health and Care TogetherBoard can effectively unblock any issues andmanage any risks to successful delivery for peoplein Merton

The Merton Health and Care Together Board reports into the Health and Wellbeing Board ona regular basis. Each partner organisation also takes regular updates back to theirorganisations. Merton Health and Care Together is supported by a small programme team,who oversee and support delivery of the work programme.

43


Other work

44

Acute Transformation: Planned Care and Urgent & Emergency Care

Outside of the Merton Health

and Care Together Programme,

the NHS is working to ensure

the quality and sustainability of

acute hospital services meets

our aspirations

Planned Care• Developing primary care to support people outside of hospital where possible

• Cancer: new diagnostic tests to reduce the need for invasive procedures. Psychological support for people living with and beyond cancer

• Effective Commissioning Initiative, ensuring that procedures are evidence based

• New community services to manage hospital demand e.g. community ophthalmology services

• Clinical Assessment Services

• Outpatient redesign. Development of virtual clinics online and over the phone

• Diagnostic pathway improvement

Urgent and Emergency Care• Ambulatory care. Same day medical support for adults and children to avoid

admissions to hospital

• Integration of primary care expertise and capacity to avoid A&E attendances where possible

• Alternative Care Pathways: working with London Ambulance Services to identify where patients can receive support quickly rather than attend A&E

• Older Peoples’ Advice and Liaison Service: providing tailored support to older people when in A&E

• Integrated Urgent Care (NHS 111)

45

Moving Forward Together in South West London – an information update for The Governing Body

May 2019

We believe in an inclusive and innovative approach to care. www.swlondon.nhs.uk

We have been working together as six CCGs for over a year and are committed to ensuring that we

have successful place based local systems supported “at scale” where necessary. As we move

forward a number of things will impact on how we currently operate – development of primary care

networks; strengthening of local health and care partnerships and the development of the six local

health and care plans; development of system rather than commissioning/ provider split and focus on

the person rather than organisations; and the expectation in the NHS Long Term that we will make a

20% reduction in management costs and will have one CCG across SW London. This gives us the

opportunity to re-focus the way we work. It is therefore vitally important that we move forward together

as individual boroughs and SW London in a planned way.

Introduction – there are a number of new developments which mean we need to review the way we work


What are we doing?

•We are considering merging our 6 CCGs across SW London

•We are at the start of a process and will be engaging our partners as we move forward together

• There is a formal process to follow through our regulators and with our membership

• The Chairs, Senior Management Team and Governing Bodies want to ensure we work with partners, in particular on our local place based approach


Our approach

• We are ensuring that clinical leadership is enhanced and the patient remains at the heart of everything we do

• We are committed to ensuring local accountability including financial delegation

• We are engaging with our GP Members, Local Medical Committees, Local Authorities, Healthwatch and other partners and listening to their views

• We are developing our case for change and considering what this means for local people

• We have received national guidance and are assessing what needs to be done, we would have to submit an application by September if we wish to progress

• We are putting in place a programme to support us with this work

• We are building a bottom up approach to ensure a focus on local people, partners and place


We have created the “moving forward together” programme that:

• Is led by Clinical Chairs in partnership with the SWL Senior Management Team.

• Is supported by a programme structure with 5 clear work streams. Each work stream

has a clinical and managerial lead.

• Place based development is being led locally

• We have already engaged on local health and care plans, now we are ready to

start to engage with our partners


We will maintain our focus on today… We will streamline how we operate… We will design an organisation with the future in mind…

We will move forward together, and engage people in how we do this…

patients will remain at the heart of what we do ensuring that what we do improves our efficiency and effectiveness

recognising the development of Integrated Care Systems and ensuring that patients remain at the heart of what we do

patients will remain at the heart of what we do

keeping the show on the road, and continuing to deliver

achieving a 20% reduction in management costs supporting the shift in regulatory responsibilities from NHS London

with our staff as an equal partner, ensuring their views are heard

maintaining borough level focus and delivery of local priorities

limiting the level of disruption with staff where possible

enhancing transformational change capability across the system

with our partners from the Health and Care Partnership so that their views help guide us

recognising that conversations are already happening about how we work better together and that these should proceed as planned

removing unnecessary duplication to make things easier to get things done

maintaining or enhancing local place relationships and creating an organisation that is open and transparent

ensuring consistent communication to staff and partners through a transparent and open approach

maintaining robust governance across the CCGs whilst undergoing the transformation

to make sure that our functions are in the right place, at the right level and the right scale

being clear where accountability sits and for what - at local and system level

delivering our statutory/mandatory requirements

Our Guiding Principles

Maintaining or enhancing clinical leadership locally and SWL level (whether elected or appointed)


Simple three step process for developing “place” delegation …

Step one: Local

systems to

articulate the place

based delegation and

focus they would

request

Step two: Financial

architecture options

developed

Step three: SWL

System Leaders

seminar held in May

to consider each

delegation outline and

the impact on this as

a system

1 2 3


Neighbourhood: Primary Care network

transformationPartners working together around general practice neighbourhood level to:• Define and drive collaboration initiatives• deliver proactive, integrated care for populations

of 30-50k people• work with community, mental health and

voluntary sector services • strengthen primary care • lead multidisciplinary services and teams around

the person

Complex systems: Partners working across multiple boroughs to:• Set priorities for

transformation of hospitals• Redesign care pathways• Define and drive

collaboration initiatives

A picture of integrated health and care in South West London

Place: Borough level transformation

Partners in each borough working together to:• Define and drive collaboration initiatives• set the “place” strategy• plan and implement local transformation• ensure that the right care is deliver in the right

place for local people• ensure a strong focus on self care, health

promotion and prevention• Lead engagement with the public• tackle the social determinants of health and

reduce health inequalities• integrate health, care and third sector services,

where it is right to do so• support local systems to be financially and

clinically sustainable and ensure delivery of system control total

SWL System: South West London wide transformationPartners working together across South West London to:• Define and drive collaboration initiatives• set the overall SWLHCP strategy, SWL wide

transformation programmes and enabling strategies such as digital

• support transformation and delivery at borough level

• secure maximum investment into SWL boroughs e.g. through regional/national bidding

• maximise resources by working at scale when it is right to do so e.g. Estates strategy

• Ensuring business intelligence, research and best practice are used to improve care and services

• Collaborate at or beyond SWL where it is right to do so e.g. specialist services

• Provide assurance to NHS regulators regarding performance, finances and delivery across all levels in SWL

• Ensure delivery of “place” system control total

Neighbourhood

Place

Complex system

South West London

This diagram is a starter for 10: We recognise that things may issues/things may move across different parts of each area and will undoubtedly change as our system/s develop.


Next Steps

• We will engage as we move forward

• Feedback from all is welcomed through local place based discussions

• Governing Bodies will continue to lead this process and regular

updates will be discussed at all Governing Bodies in SW London

• If we proceed, an application would need to be submitted to

regulators in September 2019

• Any proposed implementation would be April 2020



Document Title Financial Plan 2019/20


Neil McDowell, Local Director of Finance


N/A





Executive Summary This is a detailed summary of the financial plans for Merton CCG that have been submitted to NHS England on the 4th April 2019. The Governing Body is being asked to agree the plan contained within the report and the assumptions used to set it. Overall the plan has been set to achieve an in year break even position and has a QIPP plan of £11.5m net of investment. The majority of acute contracts have now been concluded although final signatures for the contracts are being progressed.

Key Issues: 1.Different contract model in operation with all providers with blocks agreed with Epsom & St Helier and Kingston FT. St Georges has a block for A&E/NEL and outpatients 2.Mental health investment standard met and exceeded. 3. Fully identified QIPP plan although risk now sits within the QIPP plan overall with some schemes to be progressed further 4. Investments have been set aside to deliver the QIPP plan. 5. Running cost allowance has been met but there is an assumption that we will make progress in 2019/20 towards the full achievement of the management cost reduction on 1 April 2020. 6. We have set a contingency as required under NHS business rules.


Mitigations: N/A

Recommendation: The Governing Body is asked to: Approve the plan for 2019/20

✓

XX


Ensure financial balance and achievement of statutory duties.


Risk of failure to achieve control totals and set out in the document


Set out in document


Throughout the report


N/A


N/A


N/A



Outcome:

Board Seminar MCCG Wednesday, 04 April 2018

Noted the issues contained within the plan

Finance Committee Tuesday, 24 April 2018

Noted the issues contained within the plan

Supporting Documents Slide Pack attached

Finance

April 2019

2019/20 Financial Plan

Final Submission

1. Key Deadlines

2. Financial Plan Submission & Assumptions

Appendices:

Appendix 1 – Acute & Non Acute Budgets

Appendix 2 – Corporate, Primary Care & Reserves

Appendix 3 – Mental Health Investment

Merton GB Planning 19/20 Final 2

Contents

APRIL 2019

Item Date

Budgets sent to EMT for recommendation to approve 19/20 budgets 8 April 2019

Date for Finance Committee chairs to meet & agree budgets for approval at Boards 28 April 2019

Draft 2019/20 Organisational Operating plans submitted 12 February 2019

Draft 2019/20 STP aggregate operating plan and contract/plan alignment submission 19 February 2019

National Deadline for signing 2019/20 contracts (Heads of Terms) 21 March 2019

Organisation Board/Governing Body Approval of Budgets* 3 April 2019

Final Date for Organisational level operating plan 4 April 2019

Final date for STP aggregate level operating plan 11 April 2019

*Formal Board approval following sign off at Board seminar in April 1 May 2019


Key:

National

Deadline

Local Deadline

1.1 Key Deadlines

APRIL 2019

Merton GB Planning 19/20 Final4

2. Financial Plan Submission & Assumptions

APRIL 2019

APRIL 2019 5

Merton GB Planning 19/20 Final

2.1 Financial Plan Overview

Merton CCG is required to deliver an in year break even position

Approach:

• Acute contracts are set based on new PbR rules around non elective/A&E activity which has a higher fixed element

• Within SWL, acute contracts have been set as a block with small elements remaining as cost and volume (elective) and pass

through (high cost drugs).

• Outside of SWL contracts will largely be run as cost and volume but with new rules around NEL/A&E in operation.

• QIPP plans taken out of contract have been reduced to acknowledge a risk share on delivery and potential loss of income to

providers where costs cant be removed at the same pace.

• QIPP investments have been planned for although given the tight financial position means we need to look at those schemes that

deliver greatest return on investment.

• Mental health investment standard has been met and has exceeded the minimum level

• Primary care includes the £1.50 per head for primary care networks and assumed that the total primary care growth equals

expenditure.

Risk:

• Because local acute contracts have moved towards a block contract arrangement this means we are unlikely to see the levels of

volatility experienced under a normal PbR contract

• Whilst we still have a large QIPP programme the majority of this has been underwritten in the contract to cover for stranded costs.

• Lower levels of net growth in CHC and prescribing assumes that the QIPP in these areas will deliver.

Conclusion:

• Whilst the level of reserves held by the CCG gives very little headroom in the position this needs to be balanced against acute

contracts with near guaranteed QIPP achievement.

• In addition QIPP delivery was required to achieve our target which meant we had to carry a higher level of reserves

• Further focus on the wider QIPP programme may deliver greater cost savings in year although other than Epsom St Helier we are

not assuming this within the plan but could be a mitigation.

APRIL 2019 6


2.1 Bridge from 18/19 Outturn to 19/20 plan


7

2.2 Summary Financial Plan Submission (Post 4th April 2019) UPDATED

£m Merton

CCG

Revenue Resource Limit (RRL) 296.2

Expenditure 296.2

Surplus/(Deficit) 0

Control Total surplus/(deficit) 0

Gap to Control Total 0

Net Risk 0

Surplus/(deficit) after net risk 0

Outturn 2018/19 1.9

QIPP

QIPP CCG 7.1

QIPP Acute Agreed 2.6

QIPP Not Agreed But Covered by reserves 4.7

Unidentified QIPP 0

QIPP Investment (2.9)

Total Net QIPP Plan 11.5

Total QIPP as a % of RRL 3.9%

Contingencies

0.5% Mandated Contingency 1.5

Key Assumptions

▪ Submitted plan is the required break even for Merton

CCG.

▪ Net QIPP plan set is £11.5m of which £7.3m relates to

acute contracts.

▪ In order to achieve a contract that has a joint risk

share around QIPP we have agreed a lower value of

QIPP in the contract. However the actual QIPP being

aimed for is still the higher value but a recognition

with providers that they are unable to release costs in

the short term

▪ The CCG will work with St Georges and other local

acute providers to achieve the activity reductions so

that for 2020/21 we will be able to take the costs out

of the contracts.

▪ It should be noted that we have a fully identified QIPP

plan but there are some schemes that are currently

rag rated red.

▪ Mandatory 0.5% contingency included in plans

(included in mitigations in net risk position).

▪ Growth assumptions as per section 2.3 applied (or

where contract baseline is agreed, actual baseline

number used).

APRIL 2019


8

2.3 Financial Plan Detail

£m Merton

CCG 18/19

FOT

Merton

CCG

19/20

Acute Services 146.0 148.9

Mental health (Including LD) 28.2 30.2

Community 23.2 23.6

Continuing Care 16.7 15.3

Other non acute 7.8 6.8

Primary care (including prescribing) 26.3 27.0

Delegated Primary Care 28.1 29.1

Total Commissioning services 276.3 280.9

Corporate costs – running costs 4.4 4.3

Corporate Costs – non running costs 7.7 7.3

Contingency & Reserves 0 1.9

Investments (not linked to mental health) 0 1.8

Unidentified QIPP 0 0

Total Expenditure 288.4 296.2

Recurrent Revenue Resource Limit 286.3 296.2

Underlying recurrent Position (2.1) 0

Net Risk 0

Surplus/(Deficit) after net risk 0

• The CCG has an underlying recurrent deficit of circa

£2m as it exits 18/19.

• There was a GP practice move in July 2018 for which

a part year adjustment was made. For 19/20 the full

year impact is now showing but does skew some of

the comparisons between the financial years.

• The plan is inclusive of the QIPP plan which is now

fully identified.

• Investments in mental health and primary care as

required by the operating plan have been included

• Further investments of £1.8m relating to the delivery of

the QIPP plan has been planned for.

APRIL 2019


AREA MERTON RATIONALE

Growth in Allocation 5.65%Based on original notified allocationsActual increase with new funding is just over 3%

Acute Provider Efficiency 3.80% NHSE

Acute Provider Inflation -1.10% NHSE

Acute Growth Varies Based on 3 year compound annual growth rate

Non Acute Provider Efficiency 3.80% NHSE

Non Acute Provider Inflation -1.10% NHSE

Non Acute Growth 1.00% Varies between contracts

Mental Health MHIS and growth 6.30% NHSE

Continuing Care growth 6.80% Local assumption

Prescribing Inflation 6.50% Local assumption

Primary Care Co-commissioning 6.40% Based on growth in allocation

Pay Inflation 1.00% 1% pay increase and zero incremental growth

Non Pay Inflation 1.50% Local assumption

NHS Property services 2.00% Local assumption

Contingency 0.50% NHS Business Rules

Acute reserve 0.75% SWL local rule (utilised to agree contracts)

Healthy London Partnership 0.02% SWL local rule plus HLP advisory

2.4 Planning Assumptions

APRIL 2019


10

2.5 Net Risk

£m Merton CCG 19/20

Acute contract over performance 1.125

Continuing Care 0.375

QIPP slippage/unidentified 0.75

Mental health 0.75

Prescribing 0.375

Total Risks 3.375

Contingency 1.481

Stretch QIPP/release underspends 0.407

Delayed investments for non mental health (due to phasing) 0.737

Bring back investment in mental health in line with minimum

requirement

0.750

Total Mitigations 3.375

Net Risk 0

APRIL 2019

We are currently

expecting to mitigate

all our risks


11

2.6 QIPP

• The total QIPP plan of £11.5m is broken down as follows:

• Total agreed in acute contracts - £2.0m with SGH and

£0.5m with ESH.

• Remaining acute QIPP of £4.8m outside of the

contracts has been underwritten within the plan i.e.

assumed that provider cannot reduce costs in line with

reduced income.

• However any cost saving as a result will be shared with

commissioners

• Total other CCG QIPP (prescribing, CHC, Corporate

etc) - £7.1m

• No unidentified QIPP in plan

• Given that any QIPP outside of the acute contract has

been underwritten from reserves this does not

represent a financial risk in 19/20.

• Investments of £1.8m have been set aside to deliver

QIPP in year outside of acute.

• The difference between the investment in the table

versus the £1.8m is because this has been committed

back to the acute as part of the agreement to recognise

the net QIPP saving.

• However in order to get the system into a financially

sustainable position for 20/21 it is essential that QIPP

schemes deliver in full AND take costs out of the

provider.

APRIL 2019

ProgrammeMerton Gross

Saving

Merton

Investment

Merton Net

Saving

Urgent Care £2,032,881 £742,395 £1,290,486

Integrated Care £2,269,304 £972,437 £1,296,867

Planned Care £3,044,708 £1,240,815 £1,803,893

Sub Total Acute £7,346,893 £2,955,647 £4,391,246

CHC £1,108,000 £ - £1,108,000

Children’s £353,000 £ - £353,000

Mental Health £1,582,661 £ - £1,582,661

Meds

Management £1,736,274 £ - £1,736,274

Corporate £2,341,000 £12,181 £2,328,819

Sub Total Non

Acute £7,120,935 £ - £7,460,935

Total £14,467,966 £2,967,828 £11,500,000

Acute

Non Acute

APRIL 2019 12


APPENDIX 1 – ACUTE & NON ACUTE BUDGETSACUTE

Full Year

Budget

£000's

St George’s University Hospitals NHS Foundation Trust 69,559

Epsom and St Helier University Hospitals NHS Trust 33,345

Kingston Hospital NHS Foundation Trust 12,756

London Ambulance Service NHS Trust 6,977

Epsom and St Helier University Hospitals NHS Trust -SWLEOC 3,213

Moorfields Eye Hospital NHS Foundation Trust 4,021

Guy's & St Thomas' Hospital NHS Foundation Trust 2,223

Croydon Health Services NHS Trust 2,775

The Royal Marsden NHS Foundation Trust 1,749

Chelsea and Westminster NHS Foundation Trust 1,414

St George’s University Hospitals NHS Foundation Trust - QMH SLA 2,331

King’s College Hospital NHS Foundation Trust 1,323

Other Contracts < £1m 4,641

QIPP SCHEMES NOT ATTRIBUTED TO ACUTE SLAs 0

NON CONTRACTED ACTIVITY (net of QIPP) 2,034

Other Acute Non-SLA Services 500

TOTAL ACUTE COMMISSIONING 148,862

NON ACUTE

Full Year

Budget

£000's

Mental Health Contracts 17,101

IAPT 4,381

Mental Health Placements 5,544

Child and Adolescent Mental Health 917

Other Mental Health 2,054

Total Mental Health 29,997

Continuing Care 11,475

Funded Nursing Care 2,551

Total Continuing Care - Adults 14,027

Continuing Care - Children 1,272

Total Continuing Care - Children 1,272

Community Services (SGUH etc) 25,428

Learning Disabilities 159

Hospices / Other EOLC 846

Other Non-Acute (e.g. BCF, AQP) 5,932

Total Community Services 32,365

Total Non-Acute Commissioning 77,660

APRIL 2019 13


RUNNING COST & CORPORATE

Full Year

Budget

£000's

Running Costs

BUSINESS DEVELOPMENT 224

CEO/ BOARD OFFICE 559

CHAIR AND NON EXECS 182

CLINICAL GOVERNANCE 184

COMMISSIONING 320

CORPORATE COSTS & SERVICES 1,871

ESTATES AND FACILITIES 281

FINANCE 316

PATIENT AND PUBLIC INVOLVEMENT 94

PERFORMANCE 141

TRANSFORMING PRIMARY CARE 113

Total Running Costs 4,287

Programme Costs

MEDICINES MANAGEMENT 754

GP IT 716

SAFEGUARDING 487

CLINICAL LEADS 869

MERTON HEALTH AND CARE 111

PROGRAMME STAFF 852

CONTRIBUTION TO SWL HCP 659

Total Programme Costs 4,448

Property Costs Programme

PROPERTY COSTS 1,957

OTHER CSU SLA PROGRAMME CHARGES 708

DEPRECIATION 238

Total Property Costs Programme 2,903

TOTAL CORPORATE 11,637

APPENDIX 2 – CORPORATE, PRIMARY CARE & RESERVESRESERVES

Full Year

Budget

£000's

Reserves

0.5% CONTINGENCY 1,481

ACUTE RESERVE 407

Total Running Costs 1,888

APRIL 2019

Merton

GB

Plannin

g 19/20

Final

14

APPENDIX 3 – MENTAL HEALTH INVESTMENT STANDARD

Mental Health Services (report against Mental Health Investment Standard)

2018/19 Outturn 2019/20

Core Mental Health

Reclassification from other

plan categories

Total - 2018/19 Outturn for

MHIS

Core mental health -

2019/20 Plan

Reclassification from other plan categories

Total - 2019/20 Plan for MHISAcute

Community Services

Continuing CarePrimary Care

ServicesOther

Children & Young People's Mental Health (excluding LD) 1,873 1,873 2,991 2,991Children & Young People's Eating Disorders 216 216 232 232Perinatal Mental Health (Community) 52 52 55 55Improved access to psychological therapies (adult) 1,799 1,799 4,381 4,381A and E and Ward Liaison mental health services (adult) 473 473 507 507Early intervention in psychosis ‘EIP’ team (14 - 65) 849 849 910 910Crisis resolution home treatment team (adult) 1,345 1,345 1,441 1,441Community Mental Health 16,309 16,309 6,066 6,066Mental Health Act - - - -SMI Physical Health - - 112 112Suicide Prevention - - - -Other adult and older adult - inpatient mental health (excluding dementia) 388 388 554 554Other adult and older adult mental health - non-inpatient (excluding dementia) 4,838 4,838 12,410 12,410Mental health prescribing - 1,229 1,229Mental health in continuing care - 1,146 1,146Sub-total - MH Services (exc LD & Dementia) 28,141 - 28,141 29,658 - - 1,146 1,229 - 32,033Learning Disabilities 1,751 1,751 498 1,284 1,782Dementia - - - -

Sub-total - MH services (inc LD & Dementia) 29,893 - 29,893 30,156 - - 2,430 1,229 - 33,815

Mental Health Investment Standard (MHIS)

Required Mental Health Growth

Programme Growth + 0.7%

2018/19 Outturn

2019/20 PlanGrowth in MH

SpendMHIS Achieved

Additional investment required to

achieve MHIS

Mental Health Investment Standard (including LD & Dementia) 6.3% 29,723 33,815 13.8% N/A N/AMental Health Investment Standard (excluding LD & Dementia) 6.3% 28,141 32,033 13.8% Y -

CYP and CYP Eating Disorders 2018/19 outturn 6.9%CYP and CYP Eating Disorders 2019/20 plan 9.5%Increase/Decrease in percentage 2.6%

CYP & CYP ED 2018/19 outturn adjusted for spend against non-recurrent allocations2,089

CYP & CYP ED 2019/20 Plan3,223

Increase/Decrease in CYP and Eating Disorders spend1,134

Indicative CYP and Eating Disorders allocation in CCG baselines68

Increase in CYP and ED spend in line with CCG baseline increases (18/19 corrected for non-recurrent CYP allocation)

Y

This slides shows the CCG has put the

required level of investment into mental

health (6.3%).



Document Title Finance report Month 12




N/A


Robert Hudson, Local Deputy Director of Finance



Executive Summary The report sets out the CCG’s financial position at the end of January 2019. The CCG hit its control total of a £1.86m surplus. However, within this the CCG has recorded significant pressures with an overspend of £7.2m on acute and £1.4m on non-acute being covered by £7.4m of reserves. The use of reserves is reflected in the CCG reporting a recurrent deficit of £2m which will have a knock-on effect into next year. Reason for Governing Body Review: For information

Key Issues:

1. CCG expected to hit its control total 2. Overspend in acute, mental health and CHC 3. Significant use of non-recurrent reserves to balance the position.


Mitigations: N/A

Recommendation: The Governing Body is asked to note the report

✓


Financial balance


Achieving the CCG’s control total and statutory financial duties.


Identified in report


The paper is a report on the financial position.


N/A


N/A


N/A



Outcome:




Supporting Documents Finance report for Month 12

Merton CCG Finance Report March 2019 (Month 12)

Produced By Finance – April 2019

FCIC – February 2019226 April 2019

1. Finance Scorecard

2. Month 12 Financial Position

3. Risks and Mitigations

4. QIPP

Contents

26 April 2019 FCIC - January 20193

1. LDU Finance Scorecard

26 April 2019 FCIC – February 20194

1.1 Merton Finance ScorecardMarch 2019

January 2019Financial Strategy Financial Performance

•SWL Health and Care Partnership programme work is ongoing to deliver system

transformation plan.•MCCG achieved the in-year target surplus subject to audit.

•Merton Health and Care Together has been established to develop the health and

care plans for the Borough.•Acute pressures were observed at St George’s, ESH and Kingston.

•2018/19 is year 3 of the 5 year notification of allocations. New allocations have been

published for a revised 5 year plan from 2019/20 onwards.

•MCCG is reporting an underlying recurrent deficit of £2m. The deterioration at

Merton is reflected in the high use of non-recurrent reserves to support the position

and QIPP in 19/20 will need to be achieved to correct that.

•Contracts have been agreed with minimal QIPP outside of these plans. There is no

unidentified QIPP for either CCG.

•We are forecasting near full achievement of the QIPP plan but this has been

achieved by utilising non-recurrent reserves.

•SWL commissioner control totals have been issued. The Merton contribution is in

line with our planned targets.•We have met the running cost target.

•We have achieved the Better Payment Practice Code (BPPC) target of paying 95%

of invoices in total within 30 days.

Financial Governance Financial Risk

•Annual internal audit plan for 2018/19 has been agreed with all audits now

completed or close to completion•The high level of acute spend is covered by reserves.

•Local Counter Fraud Service plan has been agreed as well.•QIPP delivery represented a significant risk due to size of the programme and the

emerging delivery issues.

•Corporate objectives agreed and board assurance framework being updated.•We were able to cover any risks that emerged with mitigations as set out in the risk

table reported to the Finance Committee

•The whole governance around QIPP development and reporting has been

refreshed for 2018/19 with the Finance Resource Oversight Group (FROG) being the

key meeting. This is scheduled twice a month to ensure that there is focus on each

programme area at least once each month.

•Work has started to clear the RTT backlog at St George’s, and this remains a

significant area of financial risk into 19/20.

•We completed a Q1 finance control and governance assessment at the end of July.

Neither CCG was required to complete the assessment for Q2 or Q3.

•Due to the underlying recurrent deficit the financial risk assessment is amber as we

move into 19/20

•The first SWL Audit Committees in Common took place in February and it is

anticipated that these will take place 4 times a year.


2. Financial Position


Merton CCG

• For acute year end deals have been concluded for Epsom St Helier, St Georges and Kingston Hospitals.

• All other values for acute providers have been accrued in line with the agreement of balances exercise.

• Overall acute position had a deterioration of £0.5m compared to month 11 FOT.

• This was a combination of a number of providers having a slight deterioration from the previous months forecasts possibly due

to year end catch up because there was any one single provider that moved significantly.

• We did a shift of £0.2m on the non contracted acute activity due to a larger number of invoices received for year end than we

have seen in previous months. These will need to be validated as normal but for now we have accrued to be prudent and as

required by the agreement of balances exercise.

• For Non acute there was a small favourable movement overall largely driven by the Merton Integrated Community Equipment

Store (ICES) coming in lower than expected. There was also a favourable shift in some of the termination service budgets.

• There was also a presentational change in that we moved patients previously reported under learning disability continuing care

to the main continuing care line.

• In addition there was a deterioration in personal health budgets as we saw a increase in these.

• Overall continuing care remained in line with previous forecast.

• For primary care there was a deterioration in the prescribing position in month 12 (based on month 10 data) but overall the

prescribing position was just about break even.

• Delegated commissioning showed a slight improvement that mitigated the increase in the prescribing expenditure.

• Under corporate/running costs some of the expenditure was moved around to ensure better coding for year end. However

most of this was offset within the budgets.

• We were holding back some HLP funding in reserves which has now been released into the position. This was the final

uncommitted reserve we were holding.

• QIPP achievement was in line with the plan although to note that to achieve this we had to put some further mitigations in

place due to the slow start to some of the transformation schemes.

2.4 Month 12 Financial Position – LDU overview (2)March 2019


2.6 Summary Financial Position – Merton CCGMarch 2019

PERIODS TO DATE FULL YEAR

Budget Actual Var

Total

Budget Actual Var

£000s £000s £000s £ 000s £000s £000s

Resource Limit 286,494 286,494 0 286,494 286,494 0

EXPENDITURE

Acute Commissioning 139,581 146,770 (7,189) 139,581 146,770 (7,189)

Non Acute Commissioning 72,216 73,648 (1,431) 72,216 73,648 (1,431)

Primary Care & Prescribing 57,243 56,602 641 57,243 56,602 641

Running Costs 4,475 4,473 2 4,475 4,473 2

Programme Costs 5,578 4,990 588 5,578 4,989 589

Property Costs 2,578 2,578 0 2,578 2,578 0

Reserves 2,963 (4,425) 7,388 2,963 (4,426) 7,389

Total Applications 284,634 284,635 -1 284,634 284,634 0

Surplus/(Deficit) 1,860 1,859 -1 1,860 1,860 0

Movement

from last

month


3. Risks and Mitigations


3.2 Risks and Mitigations – MertonMarch 2019

£'000 £'000 £'000

Risks

Forecast at

M12

Forecast at

M11

Movement

Fav/(Adv)

Acute overperformance (6,258) (5,736) (522)Acute QIPP (931) (931) 0Mental Health (1,401) (1,430) 29Continuing Care (3,334) (1,544) (1,790)Other (39) (62) 23Prescribing (64) (64)

Total Risks (12,027) (9,703) (2,324)

MitigationsForecast at

M12

Forecast at

M11

Movement

Fav/(Adv)Prescribing 79 (79)Other Primary Care 744 693 51Non Acute Commissioning 3,303 1,256 2,047Running Costs 2 81 (79)Other Corporate 589 363 226Other reserves/balance sheet 7,389 7,231 158

Total Mitigations 12,028 9,703 2,325

Total Reported Position 1 0 1

REPORTED POSITION (M12 FOT)

• This table shows the service

line variances that we

reported at month 11 as the

forecast outturn and what it

has ended at.

• The narrative on slide 7 gives

some of the detail behind

these movements but the

largest shift has been

presentational where we

have moved LD continuing

care reported under non

acute commissioning into the

main continuing care line


4. QIPP

• The purpose of this report is to provide the Governing Body with an update

on the QIPP position for Merton CCG, as at Month 12 for 2018/19.

• At M12, Merton CCG is reporting a breakeven FOT position of £10.15m.

• QIPP under delivery was mainly in Planned Care and Integrated Care

schemes, predominantly due to delays in start. This has been offset by

stretch in Urgent Care and Mental Health schemes and budget efficiencies.

• QIPP under delivery was mainly in Planned Care and Integrated Care

schemes, predominantly due to delays in start. This has been offset by

stretch in Urgent Care and Mental Health schemes and budget efficiencies.

4.1 Executive Summary - MertonMarch 2019

4.2 Merton CCG 2018/19 QIPPMarch 2019

• QIPP is reported one month in arrears.

• Overall Merton is reporting a breakeven FOT actual of £10.15m at month12.

• We saw slippage in the original plan mainly due to the delivery of planned care transformational

schemes. However this was offset by over performance in Mental Health and budget efficiencies.

2018-19 Full Year

PLAN ACTUAL VARIANCE %

CHC 1,200 1,200 0 0%

Corporate 243 93 -150 -62%

Integrated Care 2,484 1,080 -1,404 -57%

Medicines Management 1,230 905 -325 -26%

Mental Health 375 902 527 141%

Planned Care 2,781 1,744 -1,037 -37%

Urgent Care 1,770 1,358 -412 -23%

Contract Efficiencies 2,069 4,306 2,237 108%

Investments -2,000 -1,436 564 -28%

Total 10,152 10,152 0 0%



Document Title Governing Body Performance Report – (M10&11) Jan/Feb 2019


John Atherton – Director of Performance Improvement



Lee Lewis – Senior Performance Manager



Executive Summary Background: The Governing Body Performance Report brings together a range of national and local reporting metrics and benchmarking information to provide an overview of the CCG’s performance against statutory standards and frameworks. Purpose: The report highlights current performance against NHS Constitution standards and the Improvement and Assessment Framework standards, key issues and actions taken by providers and the CCG in managing performance across acute, community and mental healthcare. This report provides information on metrics that are not currently meeting target and addresses: a) current performance levels; b) Root cause of performance issues; c) Mitigating actions; d) Residual concerns / assurances. This update focuses on the January and February 2019 positions. Reason for Governing Body Review: Review and note the month 10&11 (January & February 2019) performance information.

Key Issues: 1. Please refer to the summary page (page 3 & 4) for an overview of current performance.

Conflicts of Interest: None

Mitigations:

✓

Not applicable

Recommendation: The Governing Body is asked to: Review and note the performance information within the report.


Meeting our performance and financial objectives: Make the best use of our resources to benefit our patients and communities.


Failure to achieve performance aspirations set out in the 2017/19 CCG Improvement and Assessment Framework and the 2018/19 Operating Plan. Failure to deliver 'Constitutional pledges' and other priority performance goals.


• Active leadership and participation in acute and mental health contract monitoring and performance management meetings.

• Effective contract management arrangements.

• Manage and monitor improvement plans and recovery trajectories through Performance Meetings and Quality Committees.


None


N/A


N/A


Performance reports shared with the Governing Body are published and available to the public.

Previous Committees/


Outcome:

Groups Enter any Committees/ Groups at which this document has been previously considered:

Integrated Governance and Quality Committee

Tuesday, 16 April 2019



Supporting Documents IAF (CCG Improvement & Assessment Framework), information related to the CCG can be viewed on the NHS England website.

NHSMerton Clinical Commissioning Group

Governing Body

2018/19 Performance Report

Reporting Period: January/February 2019 (Month 10 & 11)

right careright placeright timeright outcome

ContentsPage

Summary / Key Highlights 3-4

Domain 1: Performance Indicator Summary 2018/19 NHS CCG Merton Performance Measures 6-8

Domain 2: Exception Reports IAPT (Improving Access to Psychological Therapies) Access Rate 10

IAPT (Improving Access to Psychological Therapies) Recovery Rate 11

RTT (Referral to Treatment) within 18 weeks 12

Percentage of patients admitted, transferred or discharged from A&E within 4 hours *trust level* 13

31 day cancer wait for second or subsequent treatment: Chemotherapy 14

62 day cancer wait from urgent GP referral to the first treatment for cancer - all cancer types 15

Delayed Transfers of Care (delayed bed days) - Attributable to NHS DELAYS ONLY 16

Delayed Transfers of Care (delayed bed days) - Attributable to ADULT SOCIAL CARE DELAYS ONLY 17

Delayed Transfers of Care (delayed bed days) - OVERALL (all delays ASC/NHS/JOINT) 18

LAS Response Time 19

Ca

nc

er

Key Performance HighlightsIm

pro

vin

g A

cc

es

s t

o P

sy

ch

olo

gic

al T

he

rap

ies

(IA

PT

)

Improving Access to Psychological Therapies (IAPT) is a national programme that aims to make evidence based, clinically effective, talking therapies available to the (adult) population of England with ‘mild’ to ‘moderate-severe’ forms of depression and anxiety. To meet both national and locally set requirements for the service, the CCG monitor performance levels being achieved across a number of service areas, key areas detailed as follows:

'Access Rate' (the number of people entering treatment)Month 11 (February 2019) reporting period showed that the number of people entering treatment continued to increase (from 379 in Jan-19 to 415 clients), but remained below the monthly target of 436 clients (-21 clients). The main driver for the under performance remains issues outlined below:

'Performance is below target due to capacity issues with the main provider, caused whilst the service is transitioning to the new service provider on 1 April 2019. The current main service provider recruited additional interim staff during March to improve capacity and increase the number of people entering treatment. Despite these corrective actions to improve performance, provisional March data suggests this measure will fall just short of the year end access rate target of 4.75%.

'Recover Rate' (the number of people who have finished treatment and are moving to recovery)Latest data available M11 (Feb-19: 50.0%) shows compliance with the national target, The main service provider have struggled to maintain the monthly recovery rates it achieved at the end of 2017/2018, partly because of the new treatment modalities that were introduced, which needed amendment throughout the year. The initial analysis is that lower recovery rates are being achieved in the newer group interventions delivered by Addaction, particularly because a relatively high proportion of patients receiving such treatment withdraw from treatment without completing. A number of measures have been introduced, with a view to rectifying this. The length of the group interventions is such that it is as yet too early to be certain the remedial actions have had the desired effects.

Treatment waiting times (the number people referred to the service that begin treatment with 6 and 18 weeks)Both the 6 week and 18 week wait time targets for the service have been met for February 2019 and year to date performance also remains above target.

The IAPT service transferred to South West London St Georges Mental Health Trust effective from 1 April 2019. The CCG continue to work closely with both the legacy and new provider to mitigate risks and minimalise any negative impact to services during the mobilisation period.

Performance levels for cancer services are monitored by the CCG through a set of ten combined constitutional and IAF (Improvement and Assessment Framework) performance indicators. Latest data currently available M11 (February 2019) reporting period which has been listed below in accordance with compliance against targets:

Six indicators met target (M11): All cancer types - within 2 weeks Breast symptoms - within 2 weeksFirst definitive treatment - within 31 daysSubsequent treatment (radiotherapy) - within 31 days Subsequent treatment (surgery) - within 31 days First treatment following screening within 62 days

Two indicators unbanded (no national target/and/or no activity) M9:Cancer wait times: 104+ days to first treatment - not currently available.Consultant upgrade to first treatment within 62 days

Two indicators fell below target (M11):Subsequent treatment (chemotherapy) - within 31 days Urgent GP referral to treatment- within 62 days Further details of these M9 indicators are available on page 14-15 of this report [exception report]

Page 3

(A&

E)

Em

erg

en

cy

Ca

reE

lec

tiv

e A

cc

es

sKey Performance Highlights (continued)

Performance measure: Percentage of patients admitted, transferred or discharged from A&E within 4 hours shows that during February 2019 (at trust level) St George's Hospital achieved 82.2%, this positions remains below the 95% national target. The Emergency Department saw more than a 10% increase in emergency attendances, treating an additional 45 patients per day with the increases coming in patients self-presenting, compared to the same period last year.

Four key metrics, as recommended by the national Emergency Care Improvement Programme, continue to be tracked: 1) ambulance handover, 2) time to treatment, 3) Four Hour Operating Standard (admitted and discharged patients) and 4) stranded patients (Length of Stay over 7 and 21 days).

A performance “deep dive” data led process is now underway, with the first meeting having taken place on the 4 April. The key focus of the deep dive is to establish an understanding through the data of the reasons driving current performance and increased activity, including a review of the winter schemes. The deep dive will access the impact on performance from the following service areas: NHS 111; Diabetes; LAS; DTOCs; Primary Care; Workforce; Comms; GP OOH; Front Door; Paediatrics; AEC; Mental Health; Contract Model; QIPP/CIP. Further details of this indicator are available on page 14 of this report [exception report]

All eight local performance indicators that monitor the South West London St George's Mental Health services show good Historically the CCG have monitored the London Ambulance Service (LAS) emergency response times via performance measure: Ambulance wait times (red 1) 8 minute response. However, during the quarter three of 2017/18 the LAS implemented the new Ambulance Response Programme (ARP) effective from 1 November 2017. From that point forward, the response key performance measure (red 1 - 8 minute response) is no longer operational (and cannot be measured). The new ARP category 1 is now available at CCG level (measured in minutes), for February 2019 the 7minute target was met with performance for Merton at 05:50 minutes.

Performance measure: Delayed transfers of care (delayed days) for people aged 65+ per 100,000 population attributable to NHS shows that (M11 / Feb-19) number of delayed days attributable to NHS did not meet the monthly target of 131 delayed days for this reporting period. The year to date performance (Apr-Feb) shows that it will not be possible for this measure to meet the year end target of 1,572 delayed days (Apr-Mar).

Whilst performance levels were not able to meet target for 2018/19, this is not necessarily an indication of poor performance and more a reflection of the stretching target set for 2018/19. Merton are currently placed within the top 10 best performing London CCGs (Year to date per 100,000 population).

St George's reported the highest number of NHS delayed days (91), of which however 61 of the delayed days were due to 'patient/family choice'. Further details of this indicator are available on page 18 of this report [exception report]

Performance measure: Patients waiting 18 weeks or less from referral to hospital treatment (RTT ) to measure performance levels of patients waiting to start a non-emergency consultant led treatment who were waiting 18 weeks or less. M11 Feb-19 position shows that the CCG remains below the RTT standard of 92% with monthly position of 88.1%. There were a total of 28 breaches greater than 52 weeks (of which, 26 originated from St Georges / 1 patient Croydon Health Services / 1 patient Guys & St Thomas').

St George's: The trust returned to national reporting in February by submitting Jan-19 data.

The number of patients waiting over 18 weeks without a 1st appointment booked fell to the lowest level standing at 90 patients, a substantial reduction when compared to November 2018 when the number of patients exceeded 1,000.

Moorfields Eye Hospital M11 / Feb-19 89.5% performance levels remain below target (92%), There were 117 breaches out of 1112 total pathways; 0 patients exceeded 52 weeks.

The main driver for the current underperformance for Moorfields at St George’s Hospital is due to the admitted patient pathway. This is due to reduced theatre capacity following the closure for refurbishment work of the inpatient ward and the two operating theatres that Moorfields use at the St George’s site.

A comprehensive action plan has now been received from the Trust which is available on request and indicates that the South Division will achieve the 92% incomplete pathway target by the end of Q2 2019/20.Further details of this indicator are available on page 13 of this report [exception report]

Page 4

Merton CCG

2018/19 NHS CCG Merton Performance Indicator Overview


PI Service Area IAF

Co

nstitu

tio

na

l

Be

tte

r C

are

Fu

nd

Qu

alit

y P

rem

ium

Lo

ca

l m

ea

su

re

Description

London

Average

Previous

reported

position 2018/19

Target

122b Cancer wait times: urgent GP referral to treatment- within 62 days(Feb-19)

81.8%

(Jan-19)

84.4%Feb-19 78.1% (>) 85%

c5 Cancer wait times: subsequent treatment (chemotherapy) - within 31 days(Feb-19)

99.5%

(Jan-19)

100%Feb-19 96.8% (>) 98%

c9 Cancer wait times: first treatment following screening within 62 days(Feb-19)

80.9%(Jan-19)

100%Feb-19 100% / (>) 90%

c1 Cancer wait times: all cancer types - within 2 weeks(Feb-19)

94.7%

(Jan-19)

95.8%Feb-19 95.6% (>) 93%

c2 Cancer wait times: breast symptoms - within 2 weeks(Feb-19)

92.6%

(Jan-19)

99.0%Feb-19 94.9% (>) 93%

c3 Cancer wait times: first definitive treatment - within 31 days(Feb-19)

98.2%

(Jan-19)

95.6%Feb-19 98.6% (>) 96%

c6 Cancer wait times: subsequent treatment (radiotherapy) - within 31 days(Feb-19)

98.2%

(Jan-19)

100%Feb-19 96.8% (>) 94%

c4 Cancer wait times: subsequent treatment (surgery) - within 31 days(Feb-19)

96.9%

(Jan-19)

92.3%Feb-19 100% (>) 94%

c10 Cancer wait times: consultant upgrade to first treatment within 62 days(Feb-19)

83.6%(Jan-19)

75.0%Feb-19 90.0% -

c11 Cancer wait times: 104+ days to first treatment not available not available Feb-19 0

127c Percentage of patients admitted, transferred or discharged from A&E within 4hours (SGH TRUST LEVEL

ONLY)-

(Jan-18)

84.2%Feb-19 82.2% (>) 95%

127d Ambulance response times (Category 1: 7 minute response) expressed in minutes (mean average)(Feb-19)

06:21

(Jan-18)

06:09Feb-19 05:50 (<) 7min

BCF2 {NHS ONLY excl. Joint} DTOC (delayed transfer of care) delayed days per 100,000 population(Feb-19)

125.2

(Jan-19)

54.4Feb-19 91.9 (<) 81.9

BCF1 {OVERALL} DTOC (delayed transfer of care) number of delayed days per 100,000 population (Feb-19)

192.4

(Jan-19)

123.8Feb-19 156.3 (<) 161.9

BCF3 {ASC ONLY} DTOC (delayed transfer of care) delayed days per 100,000 population(Feb-19)

58.9

(Jan-19)

50.0Feb-19 47.5 (<)74.4

123a

(2) IAPT Improving Access to Psychological Therapies - access rate (%) rolling quarter not available

(Jan-19)

4.10%Feb-19 4.10% / (>) 4.75%

123a IAPT Improving Access to Psychological Therapies - recovery rate not available(Jan-19)

44.0%Feb-19 50.0% (>) 50%

123a

(3) IAPT Improving Access to Psychological Therapies - treatment within 6wks of referral not available

(Jan-19)

92.0%Feb-19 98.0% (>) 75%

123a

(4) IAPT Improving Access to Psychological Therapies - treatment within 18wks of referral not available

(Jan-19)

100%Feb-19 100% / (>) 95%

2018/19 NHS CCG Merton Performance Measures - Latest Reporting Period

CCG

Merton

Latest

Performance

Monthly Performance Measures

not available

Emergency care

Delayed Transfers

of Care

IAPT

Cancer

6

PI Service Area IAF

Co

nstitu

tio

na

l

Be

tte

r C

are

Fu

nd

Qu

alit

y P

rem

ium

Lo

ca

l m

ea

su

re

Description

London

Average

Previous

reported

position 2018/19

Target

CCG

Merton

Latest

Performance

105aPersonalisation &

choice Utilisation of the NHS e-referral service to enable choice at first routine elective referral

(Jan-19)

82.7%

(Dec-18)

78%Jan-19 82.0% (>) 80%

123b EIP People with first episode of psychosis starting treatment with a NICE-recommended package of care

treated within 2 weeks of referral (reported month in arrears)n/a

(Jan-19)

33.3%Feb-19 83.3% (>) 53.0%

N2 (SWL SGH MH): 7 Day Follow Ups: Proportion of Service Users followed up within 7 calendar days of

discharge

(Feb-19)

SWL:93.8%

(Jan-19)

90.5%Feb-19 91.3% (>) 95%

N3 (SWL SGH MH):MH RTT - within 18 weeks (month in arrears, 2 appointment proxy for community services)(Feb-19)

93.8%(Jan-19)

92.6%Feb-19 90.5% (>) 92%

N1 (SWL SGH MH): Mixed Sex Accommodation Breach(Feb-19)

SWL: 0(Jan-19)

0Feb-19 0 / 0

N5 (SWL SGH MH): Completion of a valid NHS Number field (Feb-19)

SWL:100%(Jan-19)

99.8%Feb-19 100% (>) 99%

N6 (SWL SGH MH): Completion of Mental Health Minimum Data Set ethnicity coding (Feb-19)

SWL:98.5%

(Jan-19)

98.8%Feb-19 98.2% (>) 90%

N9 (SWL SGH MH): Duty of Candour Breach(Feb-19)

SWL:0(Jan-19)

0Feb-19 0 / 0

126a Estimated diagnosis rate for people with dementia(Feb-19)

SWL:70.9%(Jan-19)

73.5%Feb-19 73.2% (>)66.7%

N4 (SWL SGH MH): Zero Tolerance for RTT waits >52 wks: Number of Service Users waiting over 52 weeks

for Treatment (2 appointment proxy, month in arrears)

(Feb-19)

0(Jan-19)

0Feb-19 0 / 0

129a RTT (Referral to Treatment) within 18 weeks(Feb-19)

87.4%

(Jan-19)

87.5%Feb-19 88.1% (>) 92%

D1 Percentage of patients receiving their diagnostic test within 6 weeks not available(Jan-19)

99.2%Feb-19 99.6% (>) 99%

104a Injuries from falls in people aged 65 and over (17/18 Q3)

1857.4

(17/18 Q2)

2,773

2017/18

Q32,817 -

127b Emergency admissions for urgent care sensitive conditions (per 100,000 registered patients)(18/19 Q1)

2085.9(17/18 Q4)

2537.3

2018-19

Q12538 -

127f Population use of hospital beds following emergency admission (per 1000 population)(18/19 Q1)

491.9(17/18 Q4)

536.2

2018/19

Q1548.5 -

124c Completeness of the GP learning disability register2017/18

0.36%

(2016/17)

0.32%2017/18 0.33%

124b Proportion of people with a learning disability on the GP register receiving an annual health check(2018/19 Q3)

40.7%

(Q2 18/19)

31.3%

2018/19

Q347.0% /

2019/20

75.0%

124a Reliance on specialist inpatient care for people with a learning disability and/or autism (number of inpatients

on CCG of origin basis per million GP registered population)

(Q2 18/19)

41.1

(Q1 18/19)

35.0

2018/19

Q230.0 / -

125d Maternity Maternal smoking at delivery(18/19 Q2)

5.2%

(18/19 Q1)

3.7%

2018/19

Q25.1% -

Learning

disability

Emergency &

Urgent care

Quarterly & Annual Performance Measures

Mental Health

Elective access

7

PI Service Area IAF

Co

nstitu

tio

na

l

Be

tte

r C

are

Fu

nd

Qu

alit

y P

rem

ium

Lo

ca

l m

ea

su

re

Description

London

Average

Previous

reported

position 2018/19

Target

CCG

Merton

Latest

Performance

105b Personal health budgets (18/19 Q2)

22

(18/19 Q1)

0

2018/19

Q24 -

105c Percentage of deaths which take place in hospital2017

6.5%

2016

7.1%2017 6.5% -

131aContinuing

Healthcare People eligible for standard NHS Continuing Healthcare (per 50,000 population)

(17/18 Q2)

28.0

(17/18 Q2)

18.3

2017/18

Q341.2 -

128c Primary care access (extended access to GP services on a weekend & evening)(Oct-18)

100%

Sep-18

100%Oct-18 100% / -

128d Primary care workforce (number of GPs and Practice Nurses (FTE) per 1,000 patients)(Mar-18)

SWL: 0.9

(Sep-17)

0.9%Mar-18 0.90% / -

106a Health inequalities Inequality in unplanned hospitalisation for chronic ambulatory care sensitive conditions (per 100,000

population) ASC & UCSC

2018/19 Q1

1,642

2017/18 Q4

2,343

2018/19

Q12,305 -

122c One-year survival from all cancers(2015)

72.7%

(2014)

73.9%2015 74.9% -

122d Cancer patient experience (survey) average score (scale 0=very poor / 10=very good)(2017)

8.7

(2016)

8.52017 8.6 -

122a Cancers diagnosed at early stage(2016)

52.1%

(2015)

52.8%2016 54.2%

125b Women's experience of maternity services - survey (three-yearly reporting process)(2017)

80.7%

2015

75.3%2017 83.1% -

125c Choices in maternity services - survey (three-yearly reporting process)(2017)

63.0

2015

67.3%2017 68.6% -

125a Neonatal mortality and stillbirths (rate per 1,000 births)(2016)

4.9

(2015)

5.02016 4.6% -

103a Diabetes patients that have achieved all the NICE-recommended treatment targets: Three (HbA1c,

cholesterol and blood pressure) for adults and one (HbA1c) for children

(2017/18)

40.4%

(2016/17)

38.8%2017/18 37.6% -

103b People with diabetes diagnosed less than a year who attend a structured education course2017/18

7.2%

2016/17

5.2%2017/18 9.0% -

102a Child obesity Percentage of children aged 10-11 classified as overweight or obese(14/15>16/17)

37.4%

(13/14>15/16)

35.6%2014/15

>16/1734.8% -

126b Dementia Dementia care planning and post-diagnostic support(2017/18)

79.7%

(2016/17)

77.5%2017/18 72.6% -

128b Primary care Patient experience of GP services (Survey)(2018)

80.7%

(2017)

80.2%2018 81.7% -

Maternity

Diabetes

Personalisation &

Choice

Primary care

Cancer

8

Merton CCG

Performance & Exception Reports


(Table. 1.1): 2018/19 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTDTarget

(YTD)

Total number of referrals 347 395 381 445 463 461 588 571 420 668 591 5,330 -

Provider 1: Addaction 327 366 345 360 419 418 496 428 294 439 400 4,292 4,763

Provider 2: IESO 20 29 36 85 44 43 78 85 74 146 114 754 -

Provider 3: BWW n/a n/a n/a n/a n/a n/a 14 58 52 83 77 284 -

(n) Entering first treatment 256 290 293 305 338 359 387 418 333 379 415 3,773 4,262

Provider 1: Addaction 250 279 277 266 298 323 358 367 274 280 292 3,264 3,575

Provider 2: IESO 6 11 16 39 40 36 29 36 35 40 57 345 -

Provider 3: BWW n/a n/a n/a n/a n/a n/a n/a 15 24 59 66 164 -

National target variance (%) -32% -23% -22% -19% -10% -5% 3% 11% -12% -13% -5% -11% -

First treatment within 6 weeks (%) 92% 92% 96% 98% 95% 97% 98% 95% 95% 92% 98% 95% >75%

First treatment within 18 weeks (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% >95%

First treatment (waiting list) 129 154 184 221 252 269 306 310 262 293 267 267 -

3.4% 3.3% 3.0% 3.2% 3.4% 3.6% 3.9% 4.2% 4.1% 4.1% 4.1% 13.7% 15.5%

(Table. 1.2): 2017/18 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Y/EndTarget

(YE)

Total number of referrals 255 310 300 335 335 300 365 390 265 350 394 414 4,013 -

Provider 1: Addaction 255 310 300 335 335 300 365 390 265 347 348 377 3,927 -

Provider 2: IESO - - - - - - - - - 3 46 37 86 -

Provider 3: BWW - - - - - - - - - - - - - -

(n) Entering first treatment 120 145 140 215 175 235 270 290 285 281 310 362 2,828 4,630

Provider 1: Addaction 120 145 140 215 175 235 270 290 285 280 305 328 2,788 3,852

Provider 2: IESO - - - - - - - - - 1 5 34 40 -

Provider 3: BWW - - - - - - - - - - - - - -

National target variance (%) -68% -61% -62% -42% -53% -36% -27% -22% -23% -24% -16% -2% -34% -

First treatment within 6 weeks (%) 89% 93% 91% 87% 82% 84% 71% 68% 74% 80% 85% 91% 84% >75%

First treatment within 18 weeks (%) 100% 99% 99% 100% 100% 100% 99% 100% 100% 100% 100% 100% 100% >95%

First treatment (waiting list) 271 307 347 353 402 305 259 278 135 142 126 96 96 -

10.7% 16.8%

123 (A) Pt.2 IAPT (Improving Access to Psychological Therapies) Access Rate

Polarity:

bigger is better

This indicator measures the proportion of people that enter treatment against the level of need in the general population i.e. the

proportion of people who have depression and/or anxiety disorders who receive psychological therapies.

Rolling quarter access rate(%)

Quarter access rate (%) 1.5% 2.4% 3.2% 3.6%

Current performance

Root cause/s of performance

Latest data available (M11/Feb-19) shows that the number of people entering treatment continued to increase (from 379 in Jan-19 to 415 clients), but remained below the monthly target of 436 clients (-21 clients).

The underperformance of the Merton IAPT service is attributable to: (1) historical contract provisions with the main provider Addaction (the number of clients entering treatment) below the national target level; (2) demand and capacity issues with the main provider (Addaction) delivery model; (3) an overstated denominator (estimated prevalence rate of the population).

Mitigating action/s:

Residual concern/s /

The service moved to the new provider from 1 April 2019. The CCG are working closely with both the legacy and new provider tomitigate risks and minimalise any negative impact to services during this period.

5.4

%

5.3

%

5.3

%

5.1

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5.0

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5.0

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4.9

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4.8

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4.6

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4.5

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4.5

%

4.4

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4.4

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4.4

%

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4.3

%

4.3

%

4.2

%

4.2

%

4.1%

4.1

%

3.8

%

3.7

%

3.7

%

3.7

%

3.6

%

3.6

%

3.5

%

3.3

%

3.0

%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

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Graph 1.4: 2018/19 Access Rate - Benchmarking (latest)

25

6

29

0

29

3

30

5

33

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35

9

38

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41

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376

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050

100150200250300350400450500

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

Graph 1.2: 2016/17 - to date entering first treatment

2018/19 2017/18 2016/17 2018/19 National Target

The main provider recruited additional interim staff during March to improve capacity and submitted revised trajectories for theremaining weeks of March. Despite these corrective actions to improve performance, provisional March data suggests this measurewill fall just short of the year end access rate target of 4.75%.

Page 10

(Table. 1.1): 2018/19 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target

(n) Total moving to recovery 77 95 86 81 99 89 81 61 62 59 82 872 -

of which: (Main Provider: Addaction) 68 83 82 77 89 89 77 55 57 45 66 788 -

of which: (Sub-contractor: IESO) 9 12 4 4 10 0 4 6 4 10 10 73 -

(d) Total completed treatments 147 192 209 158 208 198 194 142 139 134 164 1,885 -

of which: (Main Provider: Addaction) 135 178 204 149 192 198 188 131 130 111 135 1,751 -

of which: (Sub-contractor: IESO) 12 14 5 9 16 0 6 10 7 18 18 115 -

Treatment within 6 weeks (%) 92% 92% 96% 98% 95% 97% 98% 95% 95% 92% 98% 95% >75%

Treatment within 18 weeks (%) 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% >95%

Second treatment (waiting list) 650 615 516 404 418 394 441 499 535 565 481 481 -

CCG Merton Recovery Rate (%) 52.4% 49.5% 41.1% 51.3% 47.6% 44.9% 41.8% 43.0% 44.6% 44.0% 50.0% 46.3% >50%

(Table. 1.2): 2017/18 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Y/End Target

(n) Total moving to recovery 46 82 75 65 54 45 47 40 44 57 65 71 691 -

of which: (Main Provider: Addaction) 46 82 75 65 54 45 47 40 44 57 65 71 691 -

of which: (Sub-contractor: IESO) - - - - - - - - - - - - - -

(d) Total completed treatments 98 174 153 157 102 98 98 79 85 125 128 139 1,436 -

of which: (Main Provider: Addaction) 98 174 153 157 102 98 98 79 85 125 128 139 1,436 -

of which: (Sub-contractor: IESO) - - - - - - - - - - - - - -

Treatment within 6 weeks (%) 89% 93% 91% 87% 82% 84% 71% 68% 74% 80% 85% 91% 84% >75%

Treatment within 18 weeks (%) 100% 99% 99% 100% 100% 100% 99% 100% 100% 100% 100% 100% 100% >95%

Second treatment (waiting list) 44 30 27 30 38 53 78 131 244 331 471 505 505 -

CCG Merton Recovery Rate (%) 46.9% 47.1% 49.0% 41.4% 52.9% 45.9% 48.0% 50.6% 51.8% 45.6% 50.8% 51.1% 48.1% 50%

123 (A) Pt.1 IAPT (Improving Access to Psychological Therapies) Recovery Rate

Polarity:

bigger is

better

This indicator measures the percentage of people who complete treatment and who are moving to recovery (the

number of people who have finished treatment having attended at least two treatment contacts and are moving to

recovery).

Current performance

Root cause/s of performance issues:

Latest data available M11 (Feb-19: 50.0%) shows that performance levels returned to a compliant position for the month, however YTD performance (46.3%) remains below the 50% target threshold. The waiting list for people awaiting their second and subsequent treatments has decreased from 565 in Jan-19 to 481 for Feb-19.

Recovery rate: The main service provider have struggled to maintain the monthly recovery rates it achieved at the end of 2017/2018, partly because of the new treatment modalities that were introduced, which needed amendment throughout the year. The initial analysis is that lower recovery rates are being achieved in the newer group interventions delivered by Addaction, particularly because a relatively high proportion of patients receiving such treatment withdraw from treatment without completing. A number of measures have been introduced, with a view to rectifying this. The length of the group interventions is such that it is as yet too early to be certain the remedial actions have had the desired effects, although in February 2019, therecovery rate for all Merton IAPT services shows improvement and achieved the standard.


In order to improve the recovery rate the main provider (Addaction) will ensure the problem descriptor guidance is followed to ascertain which workshop will be best suited for the client and ensure the problem descriptor matches the intervention offered.Addaction have also worked to ensure clients are booked in into workshops with sufficient notice and that information regarding the workshops has been shared.

Concerns / assurance:

Whilst performance levels improved during Feb-19 it is likely maintaining a compliant position will be challenging as the service transitions to the new provider from 1 April 2019.

52

.4%

49

.5%

41

.1%

51

.3%

47

.6%

44

.9%

41

.8%

43

.0%

44

.6%

44

.0%

50

.0%

0%10%20%30%40%50%60%


Graph 1.2: CCG Merton (recover rate) 2016/17 - to date

2016/17 2017/18 2018/19 2018/19 National Target

60

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58

%

57

%

57

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56

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56

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48

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46

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200

300

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600

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2018/19 2017/18

Graph 1.1: 2nd treatment (waiting list)

Graph 1.4: 2017/18 Recovery rate - Published Benchmarking (latest)

Page 11

2017/18 (by Main Provider/s) Apr-18 May-18 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-19 Feb-19 Mar-19 YTD Av. Target

Epsom & St Helier Hospitals 87.4% 88.7% 88.0% 88.4% 88.1% 88.1% 89.0% 88.9% 88.4% 88.1% 88.2% 88.3%

St George's Hospital 85.5% 86.4% 85.9%

Moorfields Eye Hospital 88.0% 91.5% 90.9% 85.2% 83.5% 83.7% 85.2% 89.4% 89.9% 89.5% 89.5% 87.8%

Kingston Hospital NHS Trust 93.4% 92.2% 91.7% 93.9% 94.5% 93.6% 93.4% 94.5% 95.3% 94.0% 93.5% 93.6%

SWL & St Georges MH 96.1% 96.2% 94.4% 94.9% 93.5% 94.5% 93.6% 95.3% 93.2% 91.2% 90.5% 93.9%

CCG Merton Compliance 89.5% 90.7% 90.1% 90.1% 89.6% 89.5% 89.9% 90.7% 89.9% 87.5% 88.1% 89.6%

2016/17 (by Main Provider/s) Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Av. Target

Epsom & St Helier Hospitals 91.4% 92.1% 91.9% 91.1% 89.6% 89.1% 89.8% 89.5% 88.8% 87.4% 85.9% 87.2% 89.7%

St George's Hospital 93.0% 92.3% 91.5% 89.5% 87.4% 86.2% 83.1% 81.5% 83.7% 82.9% 84.1% 85.1% 86.7%

Kingston Hospital NHS Trust 96.0% 96.0% 94.0% 92.8% 94.1% 94.2% 93.0% 94.4% 93.7% 93.4% 93.9% 93.6% 94.1%

Guys & St Thomas' Hospitals 97.0% 98.0% 97.3% 98.7% 99.1% 99.4% 99.2% 98.7% 98.5% 99.2% 99.6% 98.1% 98.6%

CCG Merton Compliance 91.7% 92.0% 91.4% 91.2% 90.3% 90.1% 89.8% 89.8% 89.3% 88.6% 88.4% 89.0% 90.1%

R1 RTT (Referral to Treatment) within 18 weeks

Polarity:

bigger is better

Incomplete pathways, often referred to as waiting list times, are the waiting times for patients waiting to start treatment, as at the end of each

month. The volume of incomplete RTT pathways is often referred to as the size of the RTT waiting list. The incomplete waiting time standard

was introduced in 2012 and states that the time waited must be 18 weeks or less for at least 92% of patients on incomplete pathways.

92%

92%

Current performance

Root cause/s of performance

The CCG did not meet the RTT standard of 92% for the reporting period M11 (Feb-19) due to 1,844 breaches out of 15,464 pathways equating to a monthly position of 88.1%. Whilst performance fell short of the 92% national standard, performance levels remain above the London Average of 87.4%. There were a total of 28 breaches greater than 52 weeks (of which, 26 originated from St George s / 1 patient from Croydon Health Services / 1 patient from Guy's and St Thomas' NHS Trust) . *It should be noted that St George's Hospital returned to national reporting during Jan-19.

(Epsom & St Helier): 382 breaches out of 3243 total pathways; 0 patients exceeded 52 weeks.Moorfields): 117 breaches out of 1112 total pathways; 0 patients exceeded 52 weeks.(St Georges): 1037 breaches out of 7,604 total pathways; there were 26 patient breaches that exceeded 52 weeks.


(Epsom & St Helier): Activity to maintain the RTT incomplete waiting list has been agreed in the 2018/19 contract. The Trust has agreed business cases for additional Consultant staff in several specialties, and is putting in place a range of actions in the interim until those staff are in post including use of Locums, in-sourcing and additional ad hoc sessions to increase capacity in the short term. Work is being expedited to consider a range of outpatient transformation initiatives, as alternative approaches to traditional follow-ups including virtual reviews.(Moorfields): The admitted pathway is the main driver for underperformance, a detailed recovery plan has been implemented that will focus on addressing the current capacity shortfall whilst the refurbishment works are taking place on Duke Elder. This recovery plan proposes that the South Division will achieve the 92% incomplete pathway target by the end of Q2 2019/20.(St Georges): At trust level a further reduction on the number of 52 week breaches will be seen at closed-month end March 2019.

Residual concern/s / assurance:

(St George's): The number of patients waiting over 18 weeks without a 1st appointment booked was at the lowest level standing at 90 patients, a substantial reduction when compared to November 2018 when the number of patients exceeded 1,000.

The trust returned to national reporting in February by submitting Jan-19 data, unfortunately due to a technical issue with the data the PTL list was incorrectly reported, NHSE have been informed of the error and a statistical press notice will be issued with the Feb-19 data to explain the differences in reported PTL sizes.

92.0%

76.0%78.0%80.0%82.0%84.0%86.0%88.0%90.0%92.0%94.0%96.0%98.0%


Epsom & St Helier Hospitals Moorfields Eye Hospital Kingston Hospital NHS Trust

SWL & St Georges MH St George's Hospital National Target

89

.5%

90

.7%

90

.1%

90

.1%

89

.6%

89

.5%

89

.9%

90

.7%

89

.9%

87

.5%

88

.1%

92.0%

80%

82%

84%

86%

88%

90%

92%

94%


2018/19 CCG Merton 2017/18 CCG Merton National Target 2018/19 London Region

Graph 1.1: 2017/18 - 2018/19 NHS CCG Merton Performance compliance

Graph 1.2: 2018/19 Main Provider/s Performance compliance

Page 12

2017/18 (by Main Provider/s) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Av Target

St George's Hospital 88.4% 93.3% 93.6% 93.3% 91.1% 90.3% 90.1% 85.5% 85.6% 84.2% 82.2% 88.9%


Kingston Hospital NHS Trust 88.9% 91.9% 92.1% 90.4% 90.3% 88.4% 91.9% 87.6% 88.3% 86.8% 86.7% 89.4%

2016/17 (by Main Provider/s) Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 YTD Av Target

St George's Hospital 90.5% 89.7% 92.1% 89.8% 90.0% 90.0% 88.0% 87.2% 85.0% 83.0% 83.5% 81.6% 87.6%


Kingston Hospital NHS Trust 90.4% 89.0% 90.2% 92.9% 91.3% 91.7% 92.6% 89.5% 86.3% 87.3% 84.8% 83.9% 89.2%

127(C) Percentage of patients admitted, transferred or discharged from A&E within 4 hours *trust level*

Polarity:

bigger is better

The number of patients admitted, transferred or discharged from A&E within 4 hours as a percentage of the total

number of attendances at A&E (for all types of A&E). *Data for this indicator is currently reported at trust level.

95%

95%

Current performance

Root cause/s

At trust level, the four hour standard was not achieved by any of the main providers during Feb-19 (M11). It should be noted that data reported in the tables below represent 'trust level' compliance.

SGH: Performance against the Four Hour Operating Standard in February 82.2%, which was below the monthly improvement trajectory of 90%. The trajectory requires improvement in both the admitted and non admitted pathways. The Emergency Department saw more than a 10% increase in Emergency Attendances, treating an additional 45 patients per day with the increases coming in patients self-presenting, compared to the same period last year.


SGH: Actions underway: The Trust has enacted an Emergency Care Enhanced Support Plan with effect from 5 February 2019 to remain in place until the end of March. A daily meeting has been established to track key metrics against targets which indi cate good flow within the organisation (e.g. no. patients in the ED (target <70), time to treatment (target >60% within 60mins), A MU bed occupancy (<80%), Trust wide bed occupancy (<92.5%) and no. patients with a section 5 with a date that has passed (<25). Theoutput of the daily meeting includes focused actions to be carried out, with the aim of delivering real time improvements in flow and performance on a daily basis. MADE Event (Multi -Agency-Discharge-Event) planned for April with Local Health and Social Care System Partners.


88.4%

93.3% 93.6% 93.3%91.1% 90.3% 90.1%

85.5% 85.6% 84.2% 82.8%

90

.5%

89

.7%

92

.1%

89

.8%

90

.0%

90

.0%

88

.0%

87

.2%

85

.0%

83

.0%

83

.5%

81

.6%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018/19 2017/18 Target

Graph 1.1: 2017/18 - 2018/19 St George's compliance

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%


St George's Hospital Epsom & St Helier Hospitals

Kingston Hospital NHS Trust Target

Graph 1.2: 2018/19 Main Provider/s Performance compliance

Page 13

2017/18 (by Main Provider/s) Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD Target

St Georges's Hospital 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Royal Marsden Trust 98.3% 98.4% 98.6% 98.7% 98.1% 98.1% 98.0% 99.3% 99.3% 98.1% 98.2% 98.4%

CCG Merton Compliance 96.6% 100% 100% 100% 100% 97.3% 100% 100% 100% 100% 96.8% 98.7%


St Georges's Hospital 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Royal Marsden Trust 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

University College London - - - - - 100% - 100% 100% - 100% 100% 100%

CCG Merton Compliance 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

C4 31 day cancer wait for second or subsequent treatment: Chemotherapy

Polarity:

bigger is better

This performance indicator measures the compliance (expressed as a percentage) of patients seen within a

maximum of 31 days for all subsequent treatments for new cases of primary and recurrent cancer where an anti-

cancer drug regimen (Chemotherapy) is the chosen cancer treatment.

98%

98%

Current performance


The CCG did not meet the 98% national target for the current reporting month 11 (February 2019) with a monthly position of 96.8%. This is only the second time that this measure has been non-compliant in the within the last two years. The year-to-date position remains compliant.

This performance measure fell short of compliance due to 1 patient breach out of 31 patient pathways. %



96

.6%

10

0.0

%

10

0.0

%

10

0.0

%

10

0.0

%

97

.3%

10

0.0

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10

0.0

%

10

0.0

%

10

0.0

%

96

.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


2017/18 Merton 2018/19 Merton Target

Graph 1.1: 2017/18 - 2018/19 NHS CCG Merton Performance compliance

10

0.0

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10

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99.5%

97

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96.8%

94

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94

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75%

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90%

95%

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Graph 1.2: 2018/19 - London CCG Benchmarking Performance - February 2019

Not applicable.

The current 2018/19 year to date (YTD) shows that performance levels for this performance indicator remain compliant.

Page 14


St Georges's Hospital 92.3% 85.9% 89.6% 85.7% 85.7% 80.6% 87.8% 87.8% 94.8% 86.1% 77.8% 86.7%


Royal Marsden Trust 74.2% 80.7% 79.1% 73.3% 76.3% 75.7% 76.7% 78.6% 82.8% 68.8% 79.6% 76.9%

Kingston Hospital NHS Trust 91.4% 99.3% 97.6% 97.2% 94.9% 96.7% 95.9% 95.7% 97.5% 92% 92.0% 95.4%

CCG Merton Compliance 82.1% 96.7% 85.3% 77.3% 92.1% 80.0% 84.2% 80.0% 95.5% 84.4% 78.1% 85.1%


St Georges's Hospital 89.0% 87.5% 85.4% 77.8% 75.6% 76.7% 85.6% 80.6% 86.2% 78.4% 80.8% 88.1% 82.6%


Royal Marsden Trust 74.3% 76.9% 77.1% 77.3% 74.1% 74.2% 73.2% 79.3% 64.4% 70.5% 77.2% 81.0% 74.9%

Kingston Hospital NHS Trust 93.9% 100% 93.2% 94.6% 92.3% 94.6% 88.2% 91.4% 89.0% 91.0% 92.9% 92.4% 92.8%

CCG Merton Compliance 95.2% 82.1% 88.9% 75.9% 85.7% 89.7% 83.9% 93.5% 88.5% 76.5% 70.0% 85.2% 85.4%

C5 62 day cancer wait from urgent GP referral to the first treatment for cancer - all cancer types

Polarity:

bigger is better

This performance indicator measures the compliance (expressed as a percentage) of patients seen within a

maximum of 62 days from urgent GP referral to first treatment for all cancer types. Shorter waiting times can help to

ease patient anxiety and, at best, can lead to earlier diagnosis, quicker treatment, a lower risk of complications, an

enhanced patient experience and improved cancer outcomes.

85%

85%

Current performance


The CCG did not meet the 85% national target for the current reporting month 11 (February 2019), due to 7 patient breaches out of 32 pathways, equating to a monthly position of 78.1% and year to date average of 85.1% for Merton CCG. Trust data is reported at 'provider level' rather than Merton specific patients, however the overall headline figure (Merton CCG 78.1%) is reported at CCG level.

(St Georges): At trust level the standard was not met for M11 due to 14 patient breaches out of 63 pathways and performance levels have dipped to the lowest point this financial year.

The trust confirmed that the main drivers for the current performance during Feb-19 was associated to a cohort of complex patients together with capacity issues. Additionally, the trust have confirmed that they were able to maintain the standard during December and January periods when patients tend to reschedule appointments, but that in-part patient choice affected the Feb-19 position due to rescheduled appointments.


Not applicable.


The current 2018/19 year to date (YTD) shows that performance levels for this performance indicator remain compliant.

89

.0%

87.5

%

85.4

%

77

.8%

75.6

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76.7

%

85

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85.7

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85

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St George's Hospital Merton CCG Target

Graph 1.1: 2017/18 - 2018/19 NHS CCG Merton Monthly Performance

95

.8%

91

.9%

91

.3%

91

.3%

91

.3%

90

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89

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89

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88

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85

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84

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81

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81.8%

81

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81

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79

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78

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68

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64

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50%55%60%65%70%75%80%85%90%95%

100%

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Graph 1.2: 2018/19 - London CCG Performance Benchmarking - February 2019

Page 15

BCF1

Smaller is

better


YTD

Total Merton Average Bed/s 8.0 8.0 5.0 3.0 5.0 6.3 5.6 5.5 5.8 3.8 6.3 62 -

Of which: NHS 7.0 7.0 4.0 3.0 5.0 6.3 5.3 4.9 5.2 2.8 5.3 56 -

Of which: Joint 1.0 1.0 1.0 0.0 0.0 0.0 0.3 0.6 0.6 1.0 1.0 7 -

NHS ONLY total delayed days 215 216 132 90 151 188 163 148 161 87 147 1,698 1,441

CLCH HEALTHCARE NHS TRUST 10 0 0 5 31 25 0 0 0 2 0 73 -

EPSOM AND ST HELIER HOSPITALS 30 35 38 4 11 1 26 8 7 3 17 180 -

KINGSTON HOSPITAL 30 48 31 51 28 22 19 38 1 9 3 280 -

ST GEORGE'S MENTAL HEALTH 63 72 12 0 11 24 12 30 19 0 2 245 -

ST GEORGE'S UNIVERSITY HOSPITALS 75 47 51 30 70 103 90 67 103 69 91 796 -

BARTS HEALTH NHS TRUST 0 0 0 0 0 0 0 0 0 0 6 6

OXLEAS FOUNDATION TRUST 0 0 0 0 0 0 0 0 31 0 0 31

CROYDON HEALTH SERVICES 0 0 0 0 0 13 16 5 0 4 28 66 -

THE ROYAL MARSDEN 7 14 0 0 0 0 0 0 0 0 0 21 -

Joint delayed days 30 41 23 11 0 10 10 17 19 31 27 219 99

acute delays 142 144 120 55 105 139 150 118 67 63 125 1228 -

non-acute delays 73 72 12 35 46 49 13 30 94 24 22 470 -

NHS ONLY delayed days per 100k 134.4 135.0 82.5 56.3 94.4 117.5 101.9 92.5 100.6 54.4 91.9 1061.4 900.8

Overall total per 100k (incl. Joint) 153.2 160.7 96.9 63.1 94.4 123.8 108.1 103.1 112.5 73.8 108.8 1198.3 962.7

Delayed Transfers of Care (delayed bed days) - Attributable to NHS DELAYS ONLY

A delayed day occurs when a patient has been delayed one day after they were medically fit to be transferred/discharged. If the

patient is delayed for a further day, then another delayed day occurs. The total number of delayed days for a single patient is the

number of days from when they were medically ready to be transferred to the date they were transferred or discharged.

Current performance

Latest published data available (M11 / Feb-19) shows that Merton's number of delayed days attributable to NHS did not meet the monthly target of 131 delayed days for this reporting period. The year to date performance (Apr-Feb) shows that it will not be possible for this measure to meet the year end target of 1,572 delayed days (Apr-Mar).

Whilst performance levels were not able to meet target for 2018/19, this is not necessarily an indication of 'poor performance' and more a reflection of the stretching target set by NHSE for 2018/19. Merton are currently placed within the top 10 best performing London CCGs (Year to date per 100,000 population).

St George's reported the highest number of NHS delayed days (91), of which however 61 of the delayed days were due to 'patient/family choice'.


Monthly BCF meetings continue take place between the CCG and LA Merton to review data and work together to reduce the number of DTOC bed days.

0 10 20 30 40

A_COMPLETION_ASSESSMENT

B_PUBLIC_FUNDING

C_FURTHER_NON_ACUTE_NHS

DII_NURSING_HOME

E_CARE_PACKAGE_IN_HOME

I_HOUSING

BARTS NHS TRUST

CROYDON HEALTH SERVICES

EPSOM AND ST HELIER

KINGSTON HOSPITAL

SWL AND ST GEORGE'S MENTAL HEALTH

ST GEORGE'S UNIVERSITY HOSPITALS

1,484.1

1,061.5

0.0

500.0

1,000.0

1,500.0

2,000.0

2,500.0

Bre

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21

5

21

6

13

2

90

15

1

18

8

16

3

14

8

16

1

87

14

7

12

4

17

3

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14

1

24

6

16

2

16

5

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71

16

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18

7

19

0

25

4

29

9

31

1

24

4

21

6

18

2

13

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61

18

3

Target 131

274

288266

241

255 243259 252

243266

239

0

100

200

300

400

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018/19 NHS Delays 2017/18 NHS Delays

2016/17 NHS Delays 2018/19 Target

Graph. 1.4: 2018/19 DTOC (NHS) YTD London Benchmarking (rate per 100k)

Graph. 1.3: 2018/19 DTOC actual number of delayed days (per month) - NHS Graph. 1.2: Current reporting periodNHS reason for delay (by provider)

Page 16

BCF2

Smaller is

better


YTD


Of which: ASC 1.0 1.0 1.0 2.5 3.0 2.5 1.0 0.9 3.1 2.6 2.7 21 -

Of which: Joint 1.0 1.0 1.0 0.0 0.0 0.3 0.3 0.6 0.6 1.0 1.0 7 -

ASC ONLY total delayed days 39 29 42 77 88 75 32 28 97 80 76 663 1,309


CROYDON 0 0 0 0 11 17 0 0 0 0 0 28 -



MAUDSLEY 0 0 0 0 0 0 0 0 31 31 28 90



Joint delayed days 30 41 23 11 0 10 10 17 19 31 27 219 99

acute delays 28 6 41 47 86 71 28 21 25 30 41 424 -

non-acute delays 11 23 1 30 2 4 4 7 72 50 35 239 -

ASC ONLY delayed days per 100k 24.4 18.1 26.3 48.1 55.0 46.9 20.0 17.5 60.6 50.0 47.5 414.4 818.3


Delayed Transfers of Care (delayed bed days) - Attributable to ASC DELAYS ONLY




Current performance

Latest data available (month 11 / Feb-19: 76 delayed days) continues to demonstrate good performance levels being achieved that remain compliant with the BCF target (no more than 119 delayed days per month). Performance levels also remain below the London Average .

The highest number of delayed days were recorded at ST GEORGE'S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST (33 delayed days), all of which 31 were related to patients 'awaiting care package in home'.

The current performance trajectory implies that the year end target will be achieved.


Monthly BCF meetings take place between the CCG and LA Merton to review data and work together to reduce the number of DTOC bed days.

654.5

414.5

0.0200.0400.0600.0800.0

1,000.01,200.01,400.01,600.01,800.02,000.0

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29 42

77

88

75

32

28

97

80

76

99

11

7

13

7

23

5

25

4

11

7

14

8

14

5

69

35

91

70

84

90

12

8

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97

13

4

10

8

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2

24

6

16

8

74

14

6

138118

110

135150

134 125 126

99117 117

Target: 119

0

50

100

150

200

250

300

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018/19 ASC Delays 2017/18 ASC Delays2016/17 ASC Delays 2018/19 ASC London Av.2018/19 Target

Graph. 1.4: 2018/19 DTOC (ASC) YTD London Benchmarking (rate per 100k)

Graph. 1.3: 2018/19 DTOC actual number of delayed days (per month) - ASC

0 10 20 30 40


DI_RESIDENTIAL_HOME

DII_NURSING_HOME


EPSOM AND ST HELIER

KINGSTON HOSPITAL

SOUTH LONDON AND MAUDSLEY

ST GEORGE'S UNIVERSITY HOSPITALS

Graph. 1.2: Current reporting periodASC reason for delay (by provider)

Page 17

BCF3

Smaller is

better


YTD


Of which: ASC 1.3 1.0 1.0 2.5 3.0 2.5 1.0 0.9 3.1 2.6 2.7 22 -

Of which: NHS 7.2 7.0 4.0 2.9 5.0 6.3 5.3 4.9 5.2 2.8 5.3 56 -

Of which: Joint 1.0 1.0 1.0 0.0 0.0 0.3 0.3 0.6 0.6 1.0 1.0 7 -

Total delayed days 284 286 197 178 239 273 205 193 277 198 250 2,580 2,849




OXLEAS 0 0 0 0 0 0 0 0 31 0 0 31

MAUDSLEY 0 0 0 0 0 0 0 0 31 31 28 90



BARTS HEALTH NHS TRUST 0 0 0 0 0 0 0 0 0 0 6 6

CROYDON HEALTH SERVICES 0 0 0 0 0 30 16 5 0 4 28 83

THE ROYAL MARSDEN 7 14 0 0 41 0 0 0 0 0 0 62 -

(of which) Joint delayed days 30 41 23 11 0 10 10 17 19 31 27 219 99

acute delays 170 173 181 102 191 217 178 139 92 93 172 1708 -

non-acute delays 114 113 16 76 48 56 27 54 185 105 78 872 -


Delayed Transfers of Care (delayed bed days) - OVERALL (ASC+NHS+JOINT)




Current performance

Latest data available (month 11 / Feb-19: 250 delayed days) shows the monthly target of no more than 259 delayed days was met for this reporting period. YTD performance also remains compliant with the target and performance remains considerably below the London average, an indication of good performance.

The highest number of delayed days were recorded at St Georges (130 delayed days), of which 61 related to 'patient/family choice'.

The current performance trend implies that the year end target will be achieved for this overall measure.


Monthly BCF meetings take place between the CCG and LA Merton to review data and work together to reduce the number of DTOC.bed days.

2209.81,612.8

0.0500.0

1,000.01,500.02,000.02,500.03,000.03,500.04,000.04,500.05,000.0

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Graph. 1.4: 2018/19 DTOC (all) YTD London Benchmarking (rate per 100k)

28

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6

19

7

17

8

23

9

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20

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Target: 259

0

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Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2018/19 ALL Delays 2017/18 ALL Delays

2016/17 ALL Delays 2018/19 ALL London Av.

Graph. 1.3: 2018/19 DTOC actual number of delayed days (per month)

0 50 100


B_PUBLIC_FUNDING

C_FURTHER_NON_ACUTE_NHS

DI_RESIDENTIAL_HOME

DII_NURSING_HOME


G_PATIENT_FAMILY_CHOICE

I_HOUSING

BARTS HEALTHCROYDON HEALTH SERVICESEPSOM AND ST HELIERKINGSTON HOSPITALSOUTH LONDON AND MAUDSLEYSWL AND ST GEORGE'S MENTAL HEALTH

Graph. 1.2: Current reporting periodALL reason for delay (by provider)

Page 18

LAS (London Ambulance Service) - Ambulance Response Programme (ARP) Performance - Feb-19

Overview and Guidance

Performance and Benchmarking - as at February 2019

Page 19

of 2



Document Title South West London Health and Care Partnership Update


Sarah Blow, Senior Responsible Officer for the SWL HCP Karen Broughton, Director of Transformation and Strategy

Clinical Sponsor


Nikki Fountain, Business Manager to Karen Broughton, Director of Transformation and Strategy, SWL HCP


Purpose (Tick as Required)

Approve Discuss Note

Executive Summary: The Health and Care Partnership News has been developed as a monthly update to provide stakeholders across South West London with the latest developments, announcements and news. This edition of the update includes:

• Local Health and Care Plans

• New perinatal mental health service for mums

• Jobs that Care - work in schools encouraging health and social care career choices for pupils.

• Connecting your Care – sharing records.

• Diabetes Book & Learn Service.

• More GP appointments and online consultations.

• Partnership successful bids for funding.

• HSJ award shortlisting for November engagement events

Key Issues: 1. We have been successful in securing bids of £200,000 for the Partnership for falls

prevention therapists and to develop a programme to support senior commissioning staff making the cultural shift from individual commissioning, to system-wide working and integrated care

2. All our “extended access” GP hubs providing an 8am to 8pm service are now open across south west London meaning an extra 21,000 appointments are available to our residents each month.

Conflicts of Interest: Non-Applicable – There are no conflicts of interest raised with the following update

Mitigations: Non-applicable

XX

✓

of 2

Recommendation: The Committee is asked to: note the first STP update and to provide feedback to the STP relating to the content, whether additional items should be included and whether the detail is too detailed / too high-level or sufficient.



There are no associated risks with the contents within the attached paper


n/a


n/a


n/a


n/a



Committee/Group Name: Date Discussed: Outcome:




Supporting Documents South West London Health and Care Partnership News – April 2019

Governing Body Update – April 2019 Since the publication of the NHS Long Term Plan in January, partners across our south west London system have been discussing how we govern our partnership at both a local and south west London level, as we move towards an integrated care system. This update sets out our progress as health and care partners work together to support the people in our six boroughs to start well, live well and age well. We hope you find this update helpful and would welcome your feedback. Do let us know if this update gives you the right level of information. In this issue • Local Health and Care Plans • New perinatal mental health service for mums • Jobs that Care - work in schools encouraging health and social care career choices for

pupils. • Connecting your Care – sharing records. • Diabetes Book & Learn Service. • More GP appointments and online consultations. • Partnership successful bids for funding. • HSJ award shortlisting for November engagement events Local Health and Care Plans We have been working with partners at borough level to develop local health and care plans since we published “The Refresh” of our south west London strategy in November 2017. We held an engagement event in each borough in November with front-line health and care staff, local people, community and stakeholder groups to help us develop our plans.

These were innovative and energetic events that generated huge enthusiasm and many fresh ideas for our partnership working. You can watch a film that has a glimpse of all six events here or watch each borough’s film. Each of the six-local health and care plans will be published during April as a "discussion document" and final version issued in the summer.


New perinatal mental health services for mums

New and expectant mums in south west London now have access to specialist mental health teams, thanks to £1.6 million funding secured by South West London Health and Care Partnership. Working together in teams that can be made up of doctors, nurses, social workers, psychologists, psychiatrists, occupational therapists and nursery nurses, we provide a comprehensive service to mums, tailored to their individual needs. These teams will offer psychiatric and psychological assessments and care for women with complex or severe mental health problems during the perinatal period. At the end of March 2019, the service had seen over 60 perinatal women since September 2018. These are women that prior to the service would have ended up in A&E or community mental health services, both of which do not adequately meet the needs of a perinatal woman experiencing ill mental health.

Jobs That Care - work in schools encouraging health and social care career choices for pupils To support local students in making their career decisions, the South West London Health and Care Partnership has developed the ‘Jobs That Care’ Programme in partnership with Health Education England. It helps pupils consider careers in health and social care. The programme launched in January 2019 and includes a play that takes the audience through three realistic scenes based in a GP surgery, a community setting and a hospital. There is also a ‘Jobs That Care’ game, which is designed so pupils can learn about different roles within health and care. We have also developed an app and website. In phase one, ‘Jobs That Care’ play was performed to year 8 pupils in 20 schools across south west London, reaching around 5,000 students. Connecting your Care - sharing records The South West London Health and Care Partnership has been working with NHS providers and local authorities to connect health and care records across our six boroughs into a single, shared view for patient care. 'Connecting your Care' means that professionals involved in care such as GP, hospital doctors, nurses and social workers will be able to access records from other health and care organisations when needed, through a secure system, helping them to make the best decisions about the care they provide. The first practices and hospitals to go live on the system will be able to use the Connecting your Care viewer in April 2019, with all practices, NHS providers and social care providers in Kingston and Sutton to follow later this year – with Merton, Wandsworth, Kingston and Richmond expected to adopt this year as well. We launched the Partnership’s ‘Connecting your Care’ privacy notice campaign in February 2019, to inform 1.6 million patients across south west London about the changes. Digital and social advertising has been seen over 750,000 times. To date, we have received only 12 requests to opt-out from the system.

Diabetes Book & Learn Service People living with diabetes in south west London are being offered a new and easy way to access diabetes education. The Diabetes Book & Learn service allows patients to book educational courses, wherever they live or work, in the evenings and weekends using an online booking service. The website also provides on-line courses on how to manage diabetes. 30% of men with diabetes choose not to attend educational courses when referred, so it is hoped that hosting education events in a non-clinical environment such as major sporting venues from April 2019 will increase attendance. More GP appointments and online consultations Significant progress has been made within the GP-online consultations programme and the rollout is on track to have 80 practices live by April 2019. All our “extended access” GP hubs providing an 8am to 8pm service are now open across south west London meaning an extra 21,000 appointments are available to our residents each month. Partnership successful bids for funding

• £100,000 has been secured from Health Education England for falls prevention therapists working in care homes in Merton, Sutton, Wandsworth and Richmond to prevent London Ambulance Service callouts and trips to the hospital for falls.

• £100,000 has been secured from the London Leadership Academy to support a development programme that will be rolled out across the five London ICS areas to support senior commissioning staff making the cultural shift from individual commissioning, to system-wide working and integrated care.

HSJ award shortlisting for November engagement events We are pleased to announce that the six events held jointly by health and care organisations in south west London boroughs, have been shortlisted for a HSJ Value Award. The nomination is recognition of the value and importance of engaging residents and frontline staff when bringing together health and care services. At the events, held in November 2018, almost 1,000 health and care frontline staff, local people and representatives from lots of different community organisations talked about how people in the boroughs of Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth, could “start well, live well and age well”. The ideas generated during the events are being used to develop the Local Health and Care Plans for each borough.




Document Title Summarised Minutes of the Finance Committee


Neil McDowell, Finance Director


N/A


Yvonne Hylton, Committee Secretary

Agenda Item No. 7.1 Attachment No. 10A


Executive Summary This report summarises the minutes of the Finance Committee meeting held on 19 February 2019.

This summary is not intended to replace the formal minutes of this meeting which are available on request.

Key Issues: As detailed within the report.


Mitigations: N/A

Recommendation: The Governing Body is asked to: note the summarised minutes


N/A

✓



N/A


N/A


N/A


N/A


N/A


N/A



Outcome:

LDU Finance Committee in Common

Tuesday, 23 April 2019

Approved

Supporting Documents Summarised Minutes


SUMMARISED MINUTES

Committee: Merton and Wandsworth Finance Committee in Common (Merton)

Meeting date: 19 February 2019

Members Present

James Blythe, David Smith, Dr Karen Worthington, James Murray, Robert Hudson

Main Items Discussed:

Finance Report Month 10

Financial Planning Draft Submission 2019/20

SGH Referral to Treatment (RTT) update

Points to Note:

Finance Report Month 10 At Month 10 Merton CCG continues to forecast to achieve its control total of a £1.9m surplus for 2018/19 Key risks are related to acute over-performance and non-delivery of QIPP which are covered by reserves and the non-recurrent funds. The Committee NOTED the report

Merton and Wandsworth Draft Plan submissions for 2019/20 The Draft Plan for 2019/20 was submitted to NHSE on 12 February 2019. For 2019/20 SWL CCGs will be set individual control totals which will be aggregated up to a single SWL system control total. Merton’s contribution to the system is to achieve breakeven against total allocation. To deliver breakeven MCCG is required to deliver a QIPP plan of £11.5m. Final submission of the draft plan is 4 April 2019 following which the finalised plan will be presented to the Governing Body meeting held in Public for formal approval. The Committee NOTED the update

SGH Referral to Treatment (RTT) update WCCG as the host commissioner for SGH gave conditional support for the Trust to return to reporting. In the main, conditions raised by WCCG have been met and the Trust took the decision to return to national reporting in January 2019. January data was received by Commissioners for analysis and performance reporting in March 2019. The Committee NOTED the update

Document Title Summarised Minutes of the Integrated Governance and Quality Committee


Julie Hesketh, Director of Quality and Governance

Author (Name and Role)

Muna Ahmed, Governance Officer

Agenda Item No. 7.1 Attachment No. 10 B

Purpose (Tick as required)

Approve Discuss Note

Executive Summary: This report summarises the key items discussed at the meetings of the (Merton and Wandsworth) Integrated Governance & Quality Committee held on 19.02.18 and 19.03.19. Note: this summary is not intended to replace the formal minutes of this meeting. Those minutes are available upon request.


Recommendation: The Governing Body is asked to note the contents of the summarised minutes.

Merton Clinical Commissioning Group Governing Body Meeting Part 1

in Public

Date Wednesday 1 May 2019

√

Corporate Objectives This paper will impact on the following:

NA

Risk This paper links to the following CCG risks:

NA

Financial Implications As contained within the summarised minutes

Has an Equality Impact Assessment been completed

NA

Are there any known implications for equalities

NA.

Patient and Public Engagement and communication

NA

Committees previously considered at

The Integrated Governance & Quality Committee has approved the full minutes of this meeting.

Supporting Documents None

SUMMARY OF MINUTES

Integrated Governance & Quality Committee

Meeting date: 19.02.18

Members Present: Sam Page (SP), Natasha Curran (NaC), Stephen Hickey (SH), Andrew Leigh (AL), Karen Worthington (KW), Mike Lane (ML), Clare Gummett (CG), Julie Hesketh (JH), Carol Varlaam (CV), Waqaar Shah (WS), James Blythe (JB)

Main Items Discussed:

Integrated Governance Report

The Committee discussed the following exception reports:

1. St Georges Hospital (SGH) CQC Action Plan - SGH has reported a deteriorating position

with their CQC action plan. Wandsworth CCG is working with SGH to ensure processes

are in place for the actions to continue to be reviewed, implemented and monitored.

2. The Nelson ECG reports - Merton CCG has received Make a Difference (MAD) quality

alerts regarding delays in the Nelson Centre sending ECG reports to GPs. Work is

currently being undertaken to enable reports to be sent electronically.

3. SGH Clinical Harm Group – the group had oversight of all the patients who had come to

harm, as a result of the referral to treatment (RTT) reporting issues. A root cause

analysis was carried out for each patient identified and each patient was informed. This

group will be disbanded and there will be an end of exercise report. The Deputy Director

of elective care will continue to provide a monthly update report on any RTT issues which

will go to the CQRG.

Risk Report

Risk register is up to date. The finance risks were reviewed recently and 4 finance risks were

closed and one new risk opened.

Focussed Risk Review – Commissioning Risks

The Committee reviewed the commissioning risks.

The Committee NOTED the Integrated Governance Report.

Performance report for Merton and Wandsworth

IAPT – Merton is 436 people below target accessing the service. This service has been re-

procured in Merton and additional providers will provide capability to meet target for people

accessing the service. Wandsworth has met its Q3 wait time target.

Cancer – Merton has met 7 out of 9 targets. Wandsworth has met 7 out of 8 targets. The

performance team is reviewing the two targets not met.

A&E - (Merton and Wandsworth) – in December, SGH achieved 85.6% in the 4 hour target, a

slight improvement from November. SGH has a 15 point plan which is still being implemented. A

command and control process is in place to improve patient flow.

Elective care – (Merton and Wandsworth) - SGH is returning to reporting and will report January

data in March.

The Committee NOTED the performance reports for Merton and Wandsworth CCGs.

SGH Community and Children (Wandsworth) Directly Commissioned Services

Wandsworth CCG monitors the quality of Adult and Children’s community services commissioned

from SGH, via the Directly Commissioned Services Clinical Quality Review Group (CQRG), which

is held monthly with an alternate split between children and adults focus every other month.

There are concerns regarding the transition of adult services which SGH will cease to provide from April 2019. WCCG has enhanced monitoring of these services.

The Committee discussed staff vacancies in Children’s services, rehabilitation and therapies

services for children and adults and the looked after children service.

The Committee NOTED the update on SGH Community and Children (Wandsworth) Directly

Commissioned Services.

SUMMARY OF MINUTES

Integrated Governance & Quality Committee

Meeting date: 19.03.19

Members Present: Nicola Jones (NJ), Sam Page (SP), Natasha Curran (NaC), Stephen Hickey (SH), Andrew Leigh (AL), Karen Worthington (KW), Mike Lane (ML), Clare Gummett (CG), Julie Hesketh (JH), Carol Varlaam (CV), James Blythe (JB), Nick Cuff (NiC), Tim Hodgson (TH), John Atherton (JA)

Main Items Discussed: Integrated Governance Report

The committee discussed the following exceptions reports:

1. Primary Care Quality Review Group membership and chairmanship - the Primary Care Quality Review Group (PCQRG) across Merton and Wandsworth CCGs has been in place since September 2017 and its focus is to review and monitor the quality of services. The group is chaired by a contracted GP and it could be perceived as a conflict. An options paper will be brought to the next meeting.

Risk

A new risk on exiting the EU has been added to the register

Focused Risk Review - Quality Risks

The Committee reviewed the quality risks.

The Committee NOTED the integrated governance report.

Performance

1. SGH Queen Mary’s Hospital return to reporting proposal – JA has received the SGH plan

for QMH return to reporting.

2. Moorfields – has developed an action plan to improve its referral to treatment (RTT)

target. They are currently at 88% and aiming to reach 92% by September.

3. Performance trajectories at SGH – Wandsworth CCG is reviewing the deliverability of the

trajectories for the 18 week RTT target and A&E plan.

The Committee NOTED the performance reports for Merton and Wandsworth CCGs. Southwest London St Georges Hospital Mental Health Trust

In 2018, the host commissioner role for South West London and St George’s Mental Health NHS

Trust (SWLStG) transferred from Merton CCG to Kingston CCG. Merton & Wandsworth LDU

continue to monitor the quality of these services as associate commissioner via a Clinical Quality

Review Group (CQRG). Merton and Wandsworth CCGs are working with Kingston CCG on the

frequency of meetings and the content to ensure serious incidents are reviewed and monitored at

the appropriate place.

The Committee NOTED the Southwest London St Georges Hospital Mental Health Trust Update.

Looked After Children Service Update

Performance - projection is to improve performance for initial health assessments in quarter 4.

This will be achieved by working closely with the SGH and Wandsworth CCG. New Standard

Operating Procedures (SOPs) have been developed and are supporting the service to improve.

Staffing - still needs to be addressed. There is a medical staffing interim plan. Nursing - named

nurse has been appointed and will join the team in the next 3 months. Band 7 nurse – due to

shortlist.

Future plan – SGH is working with the community paediatric team to review integrating LAC

service into the Developmental Service.

A recommendations papers on the LAC service will be brought back to the IGQC.

The Committee NOTED the Looked After Children Update.

South West London (SWL) Collaborative Decision Making Committee in Common

(Meeting in public) Tuesday 26 February 2019, 4.00pm – 5.00pm

Meeting rooms 3.1 and 3.2, 120 The Broadway, Wimbledon, London SW19 1RH

MINUTES Members in attendance

Name Designation Organisation David Smith Convenor Merton CCG

Roger Eastwood Lay Member CCG Committee Chair Croydon CCG

Dr Michael Simmonds Clinical Member Croydon CCG

Andrew Eyres Managerial Member Chief Officer, Croydon CCG

Croydon CCG

Dr Naz Jivani Clinical Member CCG Committee Chair

Kingston CCG

Jim Smyllie Lay Member Kingston CCG Tonia Michaelides Managerial Member

Managing Director, Kingston and Richmond Local Delivery Unit

Kingston CCG

Dr Andrew Murray Clinical Member CCG Committee Chair

Merton CCG

Clare Gummett Lay Member Merton CCG Sarah Blow Managerial Member

Accountable Officer, SWL Alliance Merton CCG

Dr Graham Lewis Clinical Member CCG Committee Chair

Richmond CCG

Bob Armitage Lay Member Richmond CCG James Murray Managerial Member

Chief Finance Officer, SWL Alliance Richmond CCG

Dr Jeff Croucher Clinical Member CCG Committee Chair

Sutton CCG

Pippa Barber Lay Member Sutton CCG Michelle Rahman Managerial Member

Acting Managing Director, Sutton CCG Sutton CCG

Dr Nicola Jones Clinical Member CCG Committee Chair Wandsworth CCG

Carol Varlaam Lay Member Wandsworth CCG

James Blythe Managerial Member Managing Director, Merton and

Wandsworth Local Delivery Unit Wandsworth CCG

Committee contact: [email protected]

Start well, live well, age well

Page 2 of 8

In Attendance:

Name Designation Organisation Jamie Gillespie Observer Healthwatch Wandsworth Dr Tony Brzezicki Clinical Lead, ECI SWL HCP Dr Nicola Williams Clinical Lead, ECI SWL HCP Jonathan Bates Director of Commissioning Operations SWL Alliance Zoli Zambo ECI and Digital Programme Lead SWL HCP Gurvinder Chana Governance Lead SWL HCP Lizzie Whetnall Head of CCG Communications SWL HCP Emma Whitaker Business Manager (Note taker) SWL Alliance

Item Title Action

1. Welcome, Introductions and Apologies for Absence - Convenor 1.1. The convenor welcomed all to the meeting. There were no apologies

received for this meeting. The meeting was quorate. The convenor explained that the meeting was being filmed for uploading onto CCG websites. There was no objection from members of the Committee to the filming. No members of the public were present at this meeting.

2. Declarations of Interest - All 2.1. All members and attendees may have interests relating to their roles.

These interests are declared on the register of interests. While these general interests do not need to be individually declared at meetings, interests over and above these, where they are relevant to the topic under discussion, should be declared.

No other declarations of interest were received from the Committee.

3. South West London Effective Commissioning Initiative Policy, Version 3.0 – Jonathan Bates

For Approval

3.1. Jonathan Bates introduced a presentation regarding the latest version (3.0) of the South West London (SWL) Effective Commissioning Initiative (ECI) Policy. The key points were as below: • The ECI policy is focussed on elective care and does not include

emergency, cancer or maternity care services • ECI is about clinical effectiveness. Having a robust policy in place

protects patients from procedures that are ineffective or of limited value. It also assists with identifying patients who would benefit most from, and/or would get the best quality of life following, these procedures

• SWL are in the lead in this area of work, both regionally and nationally. A lot of the ECI work across London (‘Choosing Wisely’) builds on the SWL work and SWL are a national exemplar site

mailto:[email protected]



Page 3 of 8

Item Title Action • Slide six shows what has been updated since the previous version of

the ECI policy; to reflect national policy changes, regional policy changes and fresh clinical evidence

• The SWL ECI team spent a good deal of time talking to local clinicians across a range of organisations to ensure that the policy is as robust as can be

• The red highlighted words on slide nine show where there has been a new addition or significant amendment to the policy

• The NHS England (NHSE) national programme on Evidence Based Interventions (EBIs) was discussed as SWL was drafting its policy. SWL have fed into the NHSE work and have made sure that the current version of the SWL policy takes into account the work that is being done nationally and meets these requirements

• The London ‘Choosing Wisely’ programme developed a policy to align ECI policies across London. SWL had significant representation on the programme’s working groups including sitting on the steering group. SWL already had policies for all the procedures covered in ‘Choosing Wisely’ except one (shoulder decompression) which is now included

• Seven new clinical thresholds have been included in the policy – o Botox for axillary hyperhidrosis – the SWL IFR service asked

the ECI team to consider this for inclusion, in order to reduce IFR applications for this procedure

o Chalazia removal and intervention for snoring– these are a requirement of the NHSE EBI programme

o Complementary therapies – this was previously a stand-alone statement but is now an ECI policy

o Photodynamic therapy – this has been included to ensure equity across SWL, as there is currently huge variability

o Scrotal surgery – this has been included as it was found that some patients that were undergoing procedures were unaware that there is a 10% chance of lifelong untreatable scrotal pain post-surgery; inclusion in the ECI policy will ensure that GP referrals are in line with best-practice and evidence

o Shoulder Decompression - included to be in line with national requirements and ‘Choosing Wisely’

• An Equalities Impact Assessment (EIA) has been undertaken to ensure that no patient, or group of patients, with a protected characteristic is unfairly impacted by this policy. The Equality and Diversity Leads have signed off the EIA and there are action plans in place where necessary.

Next steps If the policy is approved by this Committee, it will be included in the contract to Providers and gives Providers the required one month’s notice to implement the policy from ‘go live’ date (1 April 2019). Through March, the team will liaise with those that this will impact, such as Primary Care and Provider colleagues. There will also be an implementation workshop for Trust Leads held on 12 March 2019.




Page 4 of 8

Item Title Action 3.2. Questions and comments

Committee members thanked the ECI team for all of their hard work in getting version 3.0 of the policy to this stage. Richmond CCG noted that Dr. Phil Moore is not a member of staff at Richmond CCG and there are some Richmond CCG clinicians missed off that were involved in the process. How are SWL going to work with individual clinicians with different clinical practices, rather than Trust wide? In creating this version of the policy, the ECI team have sought input from relevant persons in the sector, including Public Health colleagues. Any unresolved issues and questions not resolved in this version will be picked up in the next iteration of the policy; they are being researched by Public Health colleagues. There will also be some focused pieces of work, including a clinical audit, across SWL to ensure that the policy is being complied with, that there is equity across the system and to ensure the guidance is fit for purpose, in case some clinicians want to continue their procedures in a way that is contrary to the guidance. Has there been an increase in Individual Funding Requests (IFRs) since the ECI Policy version 2.0 has been implemented in SWL? There has been a reduction in IFRs since ECI policy version 2.0 was implemented. This is seen to be due to there now being more clarity around what procedures will and will not get funded. Clinicians are communicating this to patients and it is likely patients will instead go down the correct patient pathway in a timely way, rather than through the IFR route. These programmes can be worrying for the public. It was suggested that the policy should include reassurance that there has been appropriate and adequate consultation with patients and the public, for members of the public who may be concerned about lack of consultation. It was agreed that this should be made clear in the document to show that the patient voice was listened to and informed decision making. It was discussed that a significant part of updating version 3.0 was to bring it in line with the pan-London work initiated by the NHSE London Medical Director; this work included large amounts of engagement, including patient groups, and getting in touch with all relevant medical and non-medical groups in London; which has been at a level that would be almost impossible to achieve at local level. SWL had adequate representation on the steering groups for the pan-London work. Of the remaining procedures that have been changed or added, SWL clinicians have had highly technical discussions. It was added that a public information leaflet, available to all patients, not just those who are looking to have a procedure covered in the ECI policy, would be helpful. An Easy Read version was also felt to be




Page 5 of 8

Item Title Action helpful. It was clarified that the intention is to reinforce and repeat the communication routes put into patient information for version 2.0 of the policy. Has a Quality Impact Assessment (QIA) been completed for the policy version 3.0? It was confirmed that a QIA has been completed by the SWL Local Directors of Quality, and will be made available from each of the CCGs via their Local Director of Quality.

3.3. The convenor asked the Committee members if they approve the South West London Effective Commissioning Initiative Policy, Version 3.0. Each Committee was asked to vote in turn: Croydon – approve Kingston – approve Merton – approve Richmond – approve Sutton – approve Wandsworth – approve The Committee unanimously approved the South West London Effective Commissioning Initiative Policy, Version 3.0.

4. Progress update on delivering the 2019-2020 planning round – Jonathan Bates

For Information

4.1. Jonathan Bates introduced a presentation regarding delivering the 2019-2020 planning round. The key points were as below: • A lot of this work takes place on a local level and CCG staff will be

aware of the local processes in place • Key deliverables (slide four) – there are a significant number of new

items in Mental Health. Lots more is also expected in Cancer and in UEC redesign e.g. ambulatory care. There are challenges SWL has as a system on waiting times and the penalties associated with non-delivery for patients

• Commissioning intentions were issued to Provider organisations in September 2018, in order to consolidate a local and SWL-wide approach to planning and contracting in 2019/20

• SWL Commissioning staff spent a number of months working out activity and financial modelling. They are now in the phase associated with finalising and negotiating contracts and reporting back to NHS England and other relevant regulators

• A new joint planning forum has been established between Providers and Commissioners

• Slide eight contains a ‘spot diagram’ which shows the process at this point in time in terms of negotiating agreed contract positions and progress with Providers. This is used by the SWL Contracting and Delivery Group (CDG) to monitor progress and ensure the right




Page 6 of 8

Item Title Action things go into contracts in a timely way. SWL Commissioners are currently half-way through this process.

James Murray presented the 2019/20 Financial Plans slides: • The SWL Finance Committees in Common (FCiC) have agreed to

have a single slide of the high-level points on finances go to each of the CCGs’ Governing Body meetings

• There have been a number of changes to expectations which SWL are currently working through with Provider colleagues to review what the impact will be for the system

• There is a clear steer to get the NHS back into a financially sustainable position and to get all agencies across the NHS to work together towards this goal

• NHS England are looking to reduce some of the sustainability funds and introduce a Financial Recovery Fund (FRF), which is targeted to help organisations to get to financial balance. Three Trusts within SWL have been offered FRF

• Slide ten shows the SWL five-year allocations – two years are certain and three are indicative. There is also some money being held back for the later years to support transformation and delivery of the ten-year plan

• As part of the planning guidance, SWL need to do a five-year plan over the summer and further guidance should be coming out later in the year. The Governing Bodies will be updated as and when there is further clarity

• SWL are expected to fund the Mental Health Investment Standard at growth plus 0.7%

• Changes to the Market Forces Factor - a supplement to help areas where cost of living is higher to deliver services – will reduce the level of resource given to London. These changes are being tapered in over a five-year period. It affects the capitation position for SWL but does not directly affect CCGs. As a system SWL needs to work with Provider colleagues to ensure that these changes do not destabilise provider services

• The headline cash flow / system total is 5.68% across SWL • The Provider Sustainability Fund has been reduced and is now

included in the non-elective tariff; this is about 1.3% of the system total

• The tariff inflation includes last years' pay inflation • Trust efficiency requirements have been reduced down to 1.1% • Trusts in deficit have to save an extra 0.5% • CCG running costs are expected to be reduced by 20% by 1 April

2021. SWL are currently working through the implications of this • The guidance says there is a facility to move control totals across

organisations but the system total remains the same. This would be a major culture change across the system. Discussions around this have started as part of the planning round




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Item Title Action • CCG Governing Bodies will receive regular updates in order for them

to look at their individual positions as well as the whole system position

• Slide 11 shows a bridge analysis. The red numbers show where SWL currently have financial commitments; the green numbers show where things are to the benefit of the CCGs; the blue numbers set the SWL position. Overall this means a £87m QIPP target as a system

• The biggest risks are QIPP risks at Richmond and Sutton CCGs which will be worked through at CCG level

• Work in progress updates will come to the CCGs’ Governing Body meetings for information.

4.2. Questions and comments

Bob Armitage, the Chair of the SWL FCiC, commented that there had been a thorough and rigorous discussion at the FCiC and the group are happy with the approach as outlined in the presentation. Tonia Michaelides, as SWL Senior Responsible Officer (SRO) for Mental Health, commented that she is very pleased to see an increased number of targets and commitments for Mental Health in the operating and long term plans, although recognising that these come with extra scrutiny. SWL are achieving the Mental Health Investment Standard but this will not be the only question asked. The Commissioning Mental Health teams across the system have been working with South West London and St. George’s Mental Health NHS Trust as a stand-alone provider and as part of the South London Mental Health partnership; and have been discussing with South East London what the two systems can do together to meet the priorities, challenges and increased scrutiny of the new Mental Health expectations. How much is being held back for allocations in later years, and is this separate from the FRF? This is not known at the moment but the funds will most probably be allocated to support what the regulators think are the main strands of the ten-year plan. It is assumed that a system not moving into balance will have these funds pushed more into the FRF.

4.3. The Committee noted the progress of the SWL planning round.

5. Public Questions 5.1. At this point in the meeting, any members of the public present are

invited to ask questions of the Committee relating to the business being conducted, with priority given to written questions that were received in advance of the meeting. At this meeting, there were no members of the public present and no questions were received in advance of the meeting.




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Item Title Action 6. Any Other Business 6.1. There was no other business discussed at this meeting.

7. Close of meeting The convenor thanked the membership of the Committee for their

attendance. The meeting closed at 4.54pm.

Minutes agreed by: David Smith Role: Convenor Date: 14th March 2019
