nel joint commissioning committee meeting part 1 · kpi key performance indicator lap local area...

An alliance of North East London Clinical Commissioning Groups

City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs

NEL Joint Commissioning Committee Meeting Part 1

12.30-2.10pm Wednesday 13 November 2019

Committee rooms, Unex Tower

5 Station Street, Stratford, E15 1DA

NELCA Joint Commissioning Committee - Part 1 Date and time: 12.30-2.10pm Wednesday 13 November 2019

Venue: Committee Rooms, Unex Tower, 5 Station Street, Stratford, E15 1DA

Agenda

No. Time Item Page Action required Owner

1. Welcome

1.1

12.30pm

Welcome, introductions, apologies

Declarations of interestVerbal Chair

1.2 Minutes of the last meeting and matters arising

Action log

18

23

Approve

Monitor Chair

2. Patient and public engagement

2.1 12.35pm Questions from the public Verbal Discussion Chair

3. Commissioning

3.1 12.50pm Homerton University Hospital - update Tabled Note Frances

O’Callaghan

3.2 1.05pm Specialised Commissioning – A Case for Change

24 Discussion Les Borrett

4. Strategy

4.1 1.15pm Whipps Cross redevelopment programme update

31 Note Steve Collins

Alastair Finney

4.2 1.25pm Moorfields Consultation - update 55 Note Les Borrett

5. Performance

5.1 1.35pm Performance report – month 5 85 Note Archna Mathur

6. Finance

6.1 1.45pm Changes to the System Financial Framework: Financial Improvement Trajectories and Indicative Financial Recovery Allocations

92 Note Henry Black

7. Risk Register

7.1 1.55pm Approach to risk management 109 Approve Kash Pandya

8. Forward planning/ AOB

8.1 2.05pm JCC meeting planner 112 Discussion Chair

Date of next meetings: 8 January 2020 11 March 2020

2

NELCA JCC - Acronyms List

ACRONYM MEANING

A&E Accident & Emergency

AI Artificial Intelligence

APMS Alternative Provider Medical Services (a type of Primary care contract)

AQP Any qualified provider

BAF Board Assurance Framework

Bart's / BHT Barts Health NHS Trust

BHRUT Barking, Havering and Redbridge University Hospitals NHS Trust

BMA British Medical Association

CAS Clinical Assessment Service

CCG Clinical Commissioning Group

CCU Critical Care Unit

CEG Clinical Effectiveness group

CEPN Community Education Provider Network

CHP Community Health Partners

CIL Construction Industry Levy

CPD Continuing Professional Development

CQC Care Quality Commission

CQRM Clinical Quality Review Meeting

CQUINs Commissioning for Quality and Innovation (Payment Framework)

CSA Child sexual assault

CSU Commissioning Support Unit

CYP Children and Young People

DES Direct Enhanced Service

DoH/ DH Department of Health

DoPM Department of Psychological Medicine

DToC/ DToCs Delayed Transfers of Care

EBI Evidence Based Interventions

3


ED Emergency Department

ELFT East London Foundation Trust

ELHCP East London Health and Care Partnership

ELHCP ODG East London Health and Care Partnership Operational Delivery Group

EMIS web Egton Medical Information Systems (System that records patient consults)

EPCS Extended Primary Care Service

EPCT Extended Primary Care Team

EPR Electronic Patient Record

ETTF Estates and Technology Transformation Fund

FOI Freedom of Information

GB Governing Body

GIA Gross internal area

GLA Greater London Authority

GMC General Medical Council

GMS General Medical Services (a type of Primary care contract)

GP General Practitioner

HBPoS Health Based Places of Safety

HEE Health Education England

HLP Healthy London Partnership

HMT Her Majesty's Treasury

HUH The Homerton University Hospital NHS Foundation Trust

IAPT Increasing Access to Psychological Therapy

ICP Integrated care partnership

IG Information Governance

IMT Information Management and Technology

INEL Inner north east London

IPS Individual placement and support schemes

ITU Intensive Therapy Unit

IUC Integrated urgent care

JCC Joint Commissioning Committee

JSNA Joint Strategic Needs Assessment

KGH King George Hospital

KPI Key Performance Indicator

LAP Local Area Partnership

LAS London Ambulance Service

LAs Local Authorities

4


LBN London Borough of Newham

LBWF London Borough of Waltham Forest

LCFS Local Counter Fraud Specialist

LD SAF Learning Disability Self-Assessment Framework

LEB London Estates Board

LEDU London Estates Development Unit

LES Local enhanced service

LITA London Improvement and Transformation Architecture

LMC Local Medical Committee

LTP (NHS) Long Term Plan

MoLCV Medicines of limited clinical value

MOU Memorandum of Understanding

MPIG Minimum Practice Income Guarantee

NAFO Newham Alternative Funding Option

NCCG Newham Clinical Commissioning Group

NDPP National diabetes prevention programme

NEL North East London

NELCA North East London Commissioning Alliance

NELCSU North East London Commissioning Support Unit

NELFT North East London Foundation Trust

NHS PS NHS Property Services

NHSE NHS England

NHSI NHS Improvement

NICE National Institute of Health and Care Excellence

NUH Newham University Hospital

ONEL Outer north east London

OOH Out of hours

OPD Outpatient department

OPE One Public Estate

PALS Patient Advice and Liaison Service

PCCC Primary Care Commissioning Committee

PCT Primary Care Trusts

PHE Public Health England

PMS Personal Medical Services (a type of Primary care contract)

PoLCV Procedures of low clinical value

PolCE Procedures of low clinical effectiveness

5


PPE Patient and Public Engagement

PPG Patient and Public Group

PREM Patient Reported Experience Measure

PROM Patient Reported Outcome Measures

PTL Patient Tracking List

QIPP Quality, Innovation, Productivity and Prevention

QOF Quality Outcome Framework (Assessor Validation Reports)

R&D Research & Development

RAG Red, Amber, Green

RAS Referral assessment service

RICS Royal Institute of Chartered Surveyors

RLH Royal London Hospital

ROI Return on Investment

RTT Referral to treatment

SEP Strategic Estates Plan

SMI Severe mental illness

SMW Spending Money Wisely

SPA Single Point of Access

SRO Senior Responsible Officer

STP Sustainability and Transformation Plan or Partnership

6

NHS North East London Commissioning Alliance (City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs)

Voting Members

Name Title Name of organisation and nature of its business

Position Held/Nature of Interest

Type of Interest Date

Declared

Date

Updated Financial Non-financial

Professional

Non-Financial

Personal

Jane Milligan

Accountable Officer –NELCA/NEL STP

NEL Commissioning Support Unit

Partner is employed substantively

X 2014 - Present

22 July 2019

NHS England Partner on secondment to Central London Community Healthcare as Director of Primary Care Development.

X April 2019 - present

Action For Stammering Children

Partner is a Trustee for Action for Stammering

Children

X Oct 2013 – Present

Stonewall Ambassador X Oct 2014 – Present

Peabody Housing Association Board

Non-Executive Director X Jan 2017 – Present

Date November 2019

Edited by Kate McFadden-Lewis, Board Secretary

Joint Commissioning Committee Register of Interests

7


Ken Aswani Chair –Chair Waltham Forest CCG

Allum medical centre

GP partner X 1990 – Present

11 September 2019

NEL RCGP faculty

Board member X 1995 – Present

CQC GP inspector X 2014 – Present

Clinical panel Member X 2015– Present

Member practice Fednet X 2014 – Present

WhippsX University Hospital Education and research fund

Trustee X May 2017 – Present

Muhammad Naqvi

Joint Chair JCC & Chair Newham CCG

Woodgrange Medical practice

GP partner X 2015-present 10 March 2019

Frenford clubs for young people (registered charity/ voluntary organisation)

Trustee X 2012-present

NHC - Newham GP Federation, Woodrange practice is a shareholder

GP partner X 2015-present

Novartis Clinical Mentor X 2018-present

Primary care APMS contract for GP caretaking – Dr Abiola’spractice

X March 2019-present

Anil Mehta Joint Chair JCC & Chair

Fullwell Cross Medical Centre

GP Partner X April 2013 – present

28 Feb 2019

8


Redbridge CCG

Metropolitan Police

Forensic examiner X November 2015 – present

The Cleaning Company

Sister-in-law is the owner

X 2013 – present

NHSE GP appraiser X February 2015 – present

Healthbridge Direct

Shareholder X September 2014 – present

Fouress Enterprises Ltd

Director X 2015 – present

Prescon Ad-hoc screening work X January 2018 – present

London Healthwise Ltd (non trading)

Director X 2009 - present

Sam Everington

Chair THCCG Bromley By Bow Partnership - based at the Bromley by Bow Centre Charity 1999

GP X 1989-present 7 March 2019

Chair of Chairs London CCGs X 2018-present

East London Health Partnership (STP)

Clinical Lead X 2011- present

Tower Hamlets health and wellbeing board

Deputy chair X 2016- present

BMA Council member and Vice President

X 1989- present

Queen Mary University of London.

Fellow and Honorary Professor

X 2014- present

9


Tower Hamlets CCG

Wife Linda Aldous is the practice nurse Board Member

X

Bromley by Bow partnership

Wife Linda Aldous is a Partner

X

MDDUS (insurance for the GP partnership)

As a GP partners member

X 2005- present

Queens Nursing Institute

Vice President X 2017- present

College of medicine

Vice President and Council member

X 2016- present

NHS property board

Board member X 2018- present

NHS resolution Associate Director July 2018- present

Atul Aggarwal

Chair Havering CCG

Maylands Healthcare

GP Partner X April 2013 – present

28 Feb 2019

Maylands Healthcare Ltd

Director and shareholder in

on-site pharmacy

X April 2013 – present

Parkview Dental Practice

Sister is NHS dentist within

Havering

X 1996 – present

Essex Medicare LLP

Part owner which owns

Westland Clinic,

Hornchurch. Space rented

out to Inhealth

(Diagnostic),Nuffield Health

(Brentwood), Communitas

Clinics (Dermatology &

X 2014– present

10


Gynaecology)

Havering Health Ltd.

Shareholder. X September 2014 – present

Barking, Dagenham and Havering LMC

Co-opted member 2013 – present

Westlands Clinic (Langton dental) have an outsourced contract with BHRUT for oral surgery.

Spouse is a dentist. X May 2018-present

Mark Rickets

Joint Chair JCC and Chair C&H CCG

GP Confederation Nightingale Practice is a Member

X

HENCEL I work as a GP appraiser in City and Hackney and Tower Hamlets for HENCEL

X

Homerton University Hospital NHS

Foundation Trust

CCG Representative on Board of Governors – historic

X

Nightingale Practice (CCG Member Practice)

Sessional GP X

Jagan John Chair, B&D CCG

King Edwards Medical Group

GP Partner X June 2010- present

28 Feb 2019

King Edwards Medical Group

Other GPs are family members

X June 2010-present

Proactive Care - Healthy London Partnerships NHS England

Clinical Lead X Mar 2017- present

11


North East London Foundation Trust - Barking & Dagenham Community Cardiology Service

GPWSI in Cardiology X Aug 2018- present

Together First Limited (GP Federation)

Practice is a Shareholder

X May 2014- present

Harley Fitzrovia Health Limited

Director and Shareholder

X Jan 2018- present

Monifieth Limited (Director and Shareholder)

X Mar 2018- present

Health 1000 Director

Prime Ministers Challenge Fund Lead BHR

X Dec 2014- Nov 2018

Kash Pandya

Vice Chair JCC and Lay member B&D CCG

NHS Havering CCG

Lay member, Governance and Audit Chair

X 2013-19 26 June 2018

Redbridge CCG a Lay member governance and audit chair

X

University of Essex

Independent Audit Committee member

X 2013-19

Southend-on-Sea Borough Council


X 2016-18

Brentwood Citizen's Advice Bureau

General Advisor X 2009 – present

Accenture Son is employed as Legal Counsel

X 2015 – present

Historic - Hillcroft College for

Council member & honorary treasurer

X May 2017 – present

12


Women (Surbiton)

Historic - Health & Safety Executive


X May 2017 – present

Richard Coleman

Lay Member Havering CCG

BHR CCGs Brother-in-law is

Independent GP on the Primary Care

Commissioning Committee

X January 2017- present

13 March 2019

Price Waterhouse Cooper

Nephew is a partner X X August 2013 – present

Khalil Ali Lay Member Redbridge CCG

Dr Joseph GP practice, Collier Row

Family Doctor X April 2017 – present

13 March 2019

St Francis Hospice

Spouse is a regular donor


Cancer Research UK

Spouse is a regular donor


Sue Evans Lay Member C&H CCG

Loughton Youth Project (registered charity)

Trustee and Treasurer X October 2017 – Sept 2018

18 March 2019

Worshipful Company of Glass Sellers Charity Fund

Secretary to Trustees, X October 2017 – present

St Aubyn’s School Charitable Trust/Limited Company

Trustee and Director X October 2017 – present

Essex Advisory Committee for Justices of the Peace

Lay Member X October 2017 – July 2018

13


Barts Health Trust/BHRUT

Self and family are patients in the NELCA area.

X October 2017 – present

Caroline White

Lay Member

WFCCG

Red Edge Communications Ltd - Communications/journalism/PR company

Director X 2015 - present

30 July 2019

BMJ P/T employment - Senior Media Relations Executive

X August 2017 - present

Freelance Medical Journalist

X Ongoing

Medical Journalists’ Association - Executive committee post to promote the interests of medical journalists

Co- vice chair X September 2017 - present

Women of Walthamstow

(WoWStow) - Local sexual health campaign group

Member X 2011 - present

Linford Road, Wood Street

PPG member X 2017 - present

Labour Party Associate Member X 2015- present

Noah Curthoys

Lay Member THCCG

Bridgenor Group Ltd

Director & Owner X June 2015 - current

11 July 2019

14


Northshott Consulting Ltd

Director & Owner X March 2011- current

The Democratic Society (Belgian based NGO/charity)

Board member X July 2019 - current

The Democratic Society

Senior Partner X July 2016-June 2019

Phil Horwell Lay Member, Newham CCG

Deloitte Management consultant

X April 2019 - current

15


Non-Voting Members

Name Title Name of organisation and nature of its business

Position Held/Nature of Interest

Type of Interest Date Declared

Date Updated

Financial Non-financial Professional

Non-Financial Personal

Henry Black Financial Representative JCC & NEL STP

BHRUT Wife works as Deputy Director of Income and Planning at BHRUT

X Feb 2018 - Present

4 January 2019

East London Lift Accommodation Services Ltd

Director X Feb 2018 – Present

East London Lift Accommodation Services No2 Ltd

Director X Feb 2018 - Present

East London Lift Holdco No2 Ltd



Director X Feb 2018 – Present



ELLAS No3 Ltd Director X Feb 2018 - Present

ELLAS No4 Ltd Director X Feb 2018 – Present

Infracare East London Ltd


Mark Tyson Barking & Dagenham Local Authority

NIL

Mark Ansell Havering Local Authority

NIL

Adrian Loades

Redbridge Local Authority

Redbridge Living, a company 100%

Director X October 2018 - present

29 April 2019

16


owned by LB Redbridge to develop housing schemes within the Borough.

Ellie Ward City of London Corporation

NIL

Gareth Wall Hackney Local Authority

NIL 21 July 2018

Heather Flinders

Waltham Forest Local Authority

Colin Ansell Newham Local Authority

Health and Care Space Newham

Director X May 2019-present

19 July 2019

Denise Radley

Tower Hamlets Local Authority

CACI Family member (Marc Radley) is a director of CACI (supplier of information and IT systems to public sector)


13 March 2019

Hertfordshire Partnership NHS Foundation Trust

Ordinary member X April 2016 – present

Fiona Smith Chief Nurse, NELCA JCC

Director & co-owner

Honesta Partners Ltd, a LLP Healthcare Consultancy company

X 1 November 2018

Spouse is also a director

Honesta Partners Ltd, a LLP Healthcare Consultancy company

X

Registered Board Nurse

NHS Newham CCG X

Charlotte Harrison

Secondary Care Consultant, NELCA JCC

Consultant Psychiatrist and Deputy Medical Director

South West London and St Georges MH NHS Trust

X May 2005 - present

13 March 2019

17

NIL 30 September 2019

An alliance of North East London Clinical Commissioning Groups City and Hackney, Newham, Tower Hamlets, Waltham Forest, Barking and Dagenham, Havering and Redbridge CCGs

NEL Joint Commissioning Committee – part 1 12.30-2.15pm Wednesday 11 September 2019

Committee Rooms, Unex Tower, 5 Station Street, Stratford, E15 1DA

Minutes

Present:

Khalil Ali Lay Member, NHS Redbridge CCG

Dr Ken Aswani Chair, NHS Waltham Forest CCG

Henry Black Chief Finance Officer, NELCA

Richard Coleman Lay Member, NHS Havering CCG

Noah Curthoys Lay Member, NHS Tower Hamlets CCG

Sue Evans Lay Member, City & Hackney CCG

Phil Horwell Lay Member, Newham CCG

Dr Anil Mehta Chair, NHS Redbridge CCG

Jane Milligan Accountable Officer, NELCA

Dr Muhammad Naqvi (Chair) Chair, NHS Newham CCG

Kash Pandya Lay Member, NHS Barking and Dagenham CCG

Denise Radley Local Authority Representative, Tower Hamlets

Dr Mark Rickets (items 1-3.2) Chair, NHS City & Hackney CCG

Gareth Wall Local Authority Representative, Hackney

Caroline White Lay Member, NHS Waltham Forest CCG

In attendance:

Les Borrett Director of Strategic Commissioning, NELCA

Sarah Garner - for Colin Ansell Associate Director of Collaborative Commissioning, NCCG/ LBN

David Maher Managing Director, NHS City & Hackney CCG

Kate McFadden-Lewis (minutes) Board Secretary, NELCA

Chris Neill Executive Director of Commissioning and Performance and Deputy Managing Director, NELCA

Simon Hall (items 1-3.2) Director of Transformation, ELHCP

Apologies:

Colin Ansell Local Authority Representative, Newham

Linzi Roberts-Egan Local Authority Representative, Waltham Forest

Professor Sir Sam Everington Chair, NHS Tower Hamlets CCG

Charlotte Harrison Secondary Care Consultant, NELCA

Dr Jagan John Chair, NHS Barking and Dagenham CCG

Adrian Loades Local Authority Representative, Redbridge

Archna Mathur Director of Performance & Assurance, NELCA

Fiona Smith Chief Nurse, NELCA

18


No. Item

1.1 Welcome, introductions, apologies Dr Muhammad Naqvi welcomed attendees to the meeting, and apologies for absence were noted as above. There were no declarations of interest.

1.2 Minutes of the last meeting and matters arising The minutes of the last meeting were accepted as an accurate record, and all actions are complete or in progress.

2.1 Questions from the public

Questions from Paul Rosenbloom and Brian Steedman, Waltham Forest Save our NHS: 1. What are the key performance indicators of the success of the STP, and will these indicators becarried forward to measure success of the Long Term Plan?

Answer: There are currently 30 metrics being worked up as part of the long term plan (LTP) across the following eight areas, with improvement trajectories being set over a 5 year period via an STP data collection tool. Trajectories for the below areas will be set during the current LTP planning process:

1. Cancer2. Mental Health3. PHB/Personalisation4. Diabetes5. Stroke6. Maternity7. Primary Care8. Learning Disabilities and Transforming Care Partnerships

Referral to treatment targets, and Cancer and A&E waiting time measures have not been included in the data collection tool at present. There is an ongoing clinical review into these metrics due to report in April 2020. These measures are, however, listed as part of the LTP’s headline metrics and we anticipate that further detail may need to be provided on these metrics post the end of September LTP submission.

Organisations across ELHCP will continue to be rated by the Care Quality Commission. ELHCP has seen significant improvements in ratings across all Trusts. ELFT – outstanding, Homerton and NELFT – Good, BHRUT & Barts have exited special measures. There have also been improvements in primary care, with the proportion of good or Outstanding GP practices improving in all CCGs – with one CCG now having only Good or Outstanding practices.

2. What surgical specialisms would be included if Whipps Cross is developed as a Centre ofExcellence for older people, and conversely, of the surgical specialisms currently provided at Whipps Cross, what surgical specialisms would not be provided?

Answer: We have just published an outline narrative regarding surgical specialties at each of our hospitals at https://www.bartshealth.nhs.uk/news/find-out-about-our-future-plans-for-surgery-6446

We will be working with stakeholders, staff, patients and the public to develop these principles.

Questions from Meenakshi Sharma, BHR: 1. Is a type A&E by definition an A&E for the whole demographic or can it be for a sub-group of thewhole demographic?

19


Answer: Type 1 A&E national definition does not restrict by age or conditions, there is no type 1 A&E which restricts access by age in the UK.

2. What are the options for the future of King George Hospital that are on the table at the currenttime?

Answer: This question is substantially the same as the question asked at the last meeting (JCC - Q 25). The development plans are in early stages, and reassurance was given that there would be thorough engagement with the community as the plans develop.

Question submitted today from Andy Walker, BHR: The type 1 performance for King George and Queens was alarming last winter.

Queens was especially alarming with 9071 attendances and a 4 hour performance of 48%.

So will or has this committee taken steps to seek extra funding for more beds and staff for this coming winter to improve the service?

Answer: A winter plan is developed each year in conjunction with our providers, and incorporates our demand and capacity work. Capacity and demand is discussed regularly at the A&E Delivery Board and there are currently no plans to increase the bed base at BHRUT – this is not currently the major driver of A&E performance, staffing is and we are working with the Trust to try to help them address the staffing issues but recruitment is a significant challenge.

3.1 NEL mental health strategy David Maher presented on the key areas of mental health transformation taking place across north east London aligned with Five Year Forward View for Mental Health and NHS Long Term Plan ambitions. Key discussion points included:

i. the role of Primary Care Networks (PCNs) in supporting the delivery of this programme ofwork

ii. the important role peer support, and sharing learning plays in improving services andoutcomes

iii. the need to modernise inpatient servicesiv. the important role for youth councils in raising awareness in schoolsv. the significant workforce issue, and the plans in place to address this, including linking with

the local NEL universities and training institutionsvi. the need to ensure that the mental health community model includes a focus on older people

and those in nursing homesvii. the need to strengthen involvement and engagement with the voluntary sectorviii. that the majority of the funding is new, predominantly recurrent, with some areas ring-fenced,

including crisis services, social services and PCNs, as well as an allocation of funding fortransformation.

3.2 Long Term Plan draft submission Simon Hall updated on the three components of the NHS Long Term Plan (LTP) draft submission to be completed for the 27 September deadline: finance, performance trajectories and the narrative, which will show how the transformation of services in NEL will happen. Discussion points included:

i. that the plan has been developed with a great deal of input from a wide range ofstakeholders, and oversight from the clinical senate

ii. key focus areas include diagnostics, workforce, housing and social care

20


iii. it is expected that the feedback from NHSE/I will be an iterative process, with meaningfulfeedback linked to the clinical aspirations of the LTP.

The draft submission is available on the ELHCP website for comment until 25 October 2019: https://www.eastlondonhcp.nhs.uk/ourplans/draft-response-to-the-long-term-plan.htm

3.3 WEL surgical strategy and initial engagement Chris Neill presented the proposed narrative on which Barts Health NHS Trust and commissioners would like to engage staff, the public and key stakeholders on the plans to develop centres of sub-specialist expertise (surgical hubs). In discussion, the Committee noted:

i. that ensuring links to the BHRUT strategy, and collaborative working across NEL, as well asLondon, is key.

ii. the need for a stronger research focus, including aspiration around Artificial Intelligence (AI)iii. the need for a more detailed description for a ‘centre of excellence for surgery relevant to the

care of the elderly’iv. the importance of monitoring the impact of this on patient choicev. improved patient experience as the main driver for the programme, and therefore the

proposals which impact this the most should be prioritised.

4.1 Child sexual assault and abuse hub in north east London - update Chris Neill updated on the implementation of the child sexual assault (CSA) and abuse hubs in north east London, and the proposal to move to a one site model of CSA medicals across the seven NEL STP boroughs. The proposal, supported by clinicians, will ensure adequate on site paediatric cover.

In discussion it was noted that transportation policies were not included in the proposals, which will be particularly important for those children who live furthest from the hubs. This will be explored and included. (ACTION: CN/ SG)

The Committee approved the proposals, as set out in the paper, to move to a one site model of CSA medicals.

4.2 Evidence Based Interventions policy – engagement outcome Les Borrett presented the outcome of the six week engagement process on the Evidence Based Interventions policy. The policy will be approved through CCG Governing Bodies, and it is envisioned that providers will be notified in October 2019. The policy will be reviewed yearly. Discussion points included:

i. the vital importance of clear communication of this to patients, the public and clinicians, thatthis is evidence based commissioning of efficient and high quality, safe services

ii. the need to ensure that clinicians are fully informed and able to clearly communicate andexplain the policy to patients.

5.1 Performance report – month 3 Les Borrett presented on the month 3 performance across the STP area, highlighting that A&E performance remains the most challenging area, and the focus on 52 week waits across the patch. Discussion points included:

i. the programme in place sharing good practice and addressing the differences in performanceacross the patch, in particular Continuing Health Care and IAPT, which can impact on A&Eand primary care attendances

ii. the importance of monitoring providers to ensure data is accurately recorded. For example,with a number different providers of IAPT across the patch, there is some disparity in datacapture.

21


6.1 Risk Register Kash Pandya presented the NELCA JCC risk register to the Committee, highlighting the main risks and mitigating actions to deliver the NELCA priorities, and outlining the plans in place to refresh and strengthen the risk management arrangements in preparation for NEL 2021, which will be presented at the next meeting. The Committee agreed the proposals.

7.1 Meeting planner: noted.

8 Any other business: none.

Date of next meeting: 12.30-2.30pm Wednesday 13 November 2019

22

ReferenceMeeting

date Minute

referenceAction Owner

Target completion date

Comment

JCC - 18 12/09/2018 5.1Commissioning Strategy 2018/19 - 2021/22:Include an overview of the unwarranted variation across NEL, how this relates to better care for patients, as well as the implementation plan for the next update to the Committee.

Les Borrett Nov-19The commissioning strategy update will form part of the STP long term plan refresh.

JCC - 24 10/07/2019 4.2

Better Care Fund update to include: • comparative performance across the key BCF indicators and initiatives• sharing of good practice across the patch, such as personal health budgets, continuing healthcare and winter planning.

Les Borrett Jan-20 On the meeting planner.

JCC - 26 10/07/2019 6.1

Risk Register:• Ensure the national pensions issue, and the impact on capacity in primary care and workforceretention, is addressed on the risk register.• Include the progress being made on the BHR recovery plan as a mitigation on the financial risk, S3.

Kash Pandya/ Kate McFadden-

LewisJan-20

JCC - 27 11/09/2019 4.1Child sexual assault and abuse hub in north east London: Ensure that transportation policies are included in the proposals.

Chris Neill Dec-19

NEL JCC action log 13/11/2019

Highlighted items represent a recommendation to remove from register

23

NELCA Joint Commissioning Committee

13 November 2019

Title of report Specialised Commissioning – A Case for Change

Item number 3.2

Author Les Borrett, Director of Strategic Commissioning

Presented by Les Borrett

Contact for further information [email protected]

Executive summary The paper sets out the changing arrangements for specialised commissioning and seeks the JCC’s support for the approach suggested.

Attached is a paper presented by the Regional Director of Specialised Commissioning (London) to London STP and provider leads setting out the need for change in how NHSE and local systems manage specialised commissioning in future.

As STPs move to ICS status it becomes increasingly necessary for the whole spectrum of population health within that ICS to be considered together. Historically NHS England have commissioned approximately 20% (by cost) of the care provided to patients accessing local providers’ services. The separation of CCG from NHSE commissioned services has led to fragmented care pathways, with, for example, investment in community based mental health for children split from investment in inpatient care for the same cohort. It has become very difficult to make ‘upstream’ investment eg in community sickle cell care when the costs of hospital care for those needing emergency admission is met by another organisation, leading to a lack of aligned incentives.

Nationally the cost of specialised services has continued to outstrip allocation growth, being driven by new technologies and better treatments as patient acuity increases. As acuity increases it is possible under Payment By Results to upcode activity, leading to both higher average costs and volume growth. A complicating factor is the use of provider footprints for contracts rather than STP populations, meaning that all activity undertaken by specialised services at Barts Health is funded by the NHSE London region, regardless of source of referral.

In north east London all five providers have some level of contracted income with NHSE specialised commissioning. The main service areas funded in this way are:

Renal, including dialysis and transplant

Cardiac surgery

Cancer, including chemotherapy

24


Neonatal care

Specialised neuro-rehabilitation

Neurosurgery

HIV

Sickle cell and Thalassemia

Inpatient CAMHS

Medium secure psychiatry

Perinatal psychiatry.

NHS England have recognised that the current arrangements need to change and are starting to work with STPs to develop new models of commissioning. Broadly these fall in two categories although these are not mutually exclusive:

Provider-based collaboratives taking on management ofdevolved allocations. This model is being rolled out in mentalhealth where from April 2020 budgets for Tier 4 CAMHS willbe held on long term contracts by a consortium of all themental health trusts in North Central and North East London.A similar approach is being piloted across the south Londoncardiac network.

Delegation of commissioning to STPs – this model will applywhere services are most clearly linked to a pathway involvinga range of partners, such as HIV or neuro-rehabilitation. In thismodel CCGs and Trusts would risk share any gains or lossesfrom redesign of services. In NE London neuro-rehab,involving local CCG investment in longer term care andinvestment in acute care would be a good test case of thisframework.

NEL STP has identified five priorities for piloting new approaches – cardiac, renal, neurorehab, sickle cell and HIV (on the basis that the roll out of the CAMHS model is already national policy).

It is critical that these changes are clinically led and not seen as just transferring commissioner risk across organisations. The five areas chosen were reviewed by Clinical senate and considered to offer clear benfits for patients linked to improving primary and community care (eg renal and cardiac) or addressing known gaps in care (eg neuro-rehab). The STP needs to work with lead clinicians in these areas to define benefits – in some cases there is clear clinical ownership (eg renal) but not in others.

A workshop across London is scheduled for November where these outline plans will be developed further with a view to early pilots starting in 2020/21.

Action required The JCC are asked to support the direction of travel and identify any key opportunities for clinical engagement.

Where else has this paper been discussed?

London Specialised Commissioning Planning Board

NELCA Chairs’ meeting - Oct 2019

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Strategic fit

Commissioningimplications

Local authority/integratedcommissioning implications

Integration of NHSE and CCG commissioning will support the delivery of improved outcomes for patients by aligning strategies and creating new models of delivery.

What does this mean for local people?

Services should be more flexible and designed around local patterns of need.

How does this drive change and reduce health inequalities (unwarranted variation)

Local commissioning of specialised services should support local clinicians plans to redesign models of care and ensure equity of access.

Impact on finance, performance and quality

Detailed financial modelling has yet to be undertaken on proposed changes. Local oversight of performance issues and quality should improve services over time.

Risks The current level of financial risk on these services sits with NHS England. Devolution will lead to additional risks being borne locally if systems are not in place to redesign services and manage demand. There is also a risk that capacity to manage this change is not available locally leading to delay or loss of engagement in the process.

26

Paper to London Planning Board

New approaches for Specialised Commissioning: For discussion

September 2019

Introduction This paper builds on a paper that recently went to London Regional Executive (LRET) and a discussion at London

Leaders meeting this week. The LRET paper was designed to update on the specialised commissioning position,

both immediate and longer terms by describing how precarious the position was if no action was taken given

confirmed notified allocations for the next two years and indicative figures to 2023/24. The paper set out some

immediate actions but also some more medium term actions designed to give ICS development every chance

of success.

This paper will give some back ground on London Specialised Commissioning’s financial position but its

principle aim is to set out some areas for discussion and to start to outline a programme of work designed to

transform how specialist services are currently commissioned to reflect the vision and aspiration that Sir David

Sloman has set out and that will underpin London’s delivery of the long term plan via the London Vision.

Need for change: background The current Specialised Commissioning plan for 2019/20 shows a deficit position of £42m after the delivery of a

stretch QIPP target of £40m above the amount we have already agreed in contracts for the year. This reflects

an underlying deficit of c£90m. In total the QIPP ask for 2019/20 is c158m or 3.5%, which is similar to the %

total required in 2018/19 (outturn deficit £99m).

As part of national and London work in preparing for the current planning round we have undertaken some

financial modelling work for example looking at a projected QIPP ask over the next four years under a base‐

case scenario (national modelling), which varies from 3.1% to 2.23% in 2023/4 with an allocation growth of

c3.5% p.a. If we continue to work in the same way the position worsens to suggest a deficit in 2021 of c.£96m

minimum rising to £166m . Playing these out to 2023/24, the deficit could reach £380m.

Clearly, this is not a sustainable position either for commissioners or for providers. Nationally there is no longer

the flexibility to continue to cover regional hub deficits – central funds are fully committed to existing priorities.

If the current ways of commissioning continue, the pressure will fall on London as a system to resolve this,

which will mean a drain on transformation investment from CCGs and NHS London. LRET has therefore

supported that for London to reach a sustainable financial position, a radically different approach to

commissioning and providing specialised services will be required.

Our budget overall is £4.6bn in 2019/20 and for 2019/20 we have agreed 34 part blocked, fully blocked or low

risk contracts (of 47 total) to a value of c.£2.4bn or 52% of our overall budget. The remainder of our contracts

are more volatile cost and volume PbR contracts. Within these partially blocked contracts some have pass‐

through Drugs and Devices lines but these are considered generally low‐risk. One of the pieces of work

therefore required is for further discussion with Trusts on contracting forms/ approaches to risk management

for 20/21. AT LRET behest, we are looking at discussing activity based contracts or fixed cost total envelopes as

part of ensuring we are part of system control targets. It is recognised how challenging this will be, hence a

need for early discussion on how to agree thoughtful ways to manage risk and concerns about risk transfer to

Trusts as part of this process. LRET has asked for a proposition by the end of September and it is essential that

this is a collective system response not just a Spec Com assessment of what is the most workable and agreed

approach.

27

In previous years, specialised commissioning QIPP has largely been transactional and based on a very strong

programme of medicines optimisation e.g. benefiting from drugs moving to a generic price or the introduction

of biosimilars etc. This will always be part of the work programme and should continue to deliver strongly.

However, the smaller part of the QIPP programme has traditionally been described as transformational and

intended to take costs out of the system as pathways of care were redesigned. For many reasons, including the

current contract system and rising demand, this has not been very successful, low savings delivered year‐on‐

year being suggesting a more systemic issue. In order to move away from this LRET are supporting a need to

review the use of PbR contracts and move to a whole system approach.

To make the system balance there are a range of more restrictive measures available. This includes a menu of

actions which could be instigated to reduce the specialised commissioning risk. Some are already in place

including work to reduce variation as part of a national programme but others will have the impact of shifting

costs around the system which now is viewed as out with how London wants to work and not in line with

current aspirations to find ways to take costs entirely out of the system. Other actions would require national

specialised commissioning agreement such as the delay to rolling out CPAG or new NICE drugs. Generally, when

we have previously reviewed this list nationally it has been deemed too unpalatable and that currently appears

to be the view. So we need an alternative and system wide agreed approach.

Priority programme for 2019/20 It much clear now that in order to deliver a transformation programme Specialised Commissioning will need to

work more closely with providers, especially their clinical leadership who have the ability to deliver those

changes. Given a recognition that a reliance on transactional QIPP was neither sustainable nor likely to be well‐

received in the context of different and more collaborative ways of working, the 19/20 QIPP programme was

more focused on trying to develop transformational schemes. The following ‘big‐ticket’ areas have been

identified:

Neurosurgery

Outpatient redesign

HIV infrastructure service redesign

Super stranded patients, including long term ventilated adults and critical care.

These services were identified either as part of a national work programme such as neurosurgery or because

of other changes, e.g. in HIV where the cost of infrastructure payments to trusts are based on an outdated

model which does not reflect the impact of new drugs or a more outpatient/community‐based service.

However these service plans were developed either internally within London specialised commissioning or as

part of the National Specialised commissioning improving value work programme, and did not involve

providers or the ICS/STPs. Although there is some overlap on the areas identified, e.g. in outpatients where

we are working with STPs to understand their plans and look at opportunities for whole pathway change, it’s

clear that we cannot generate sufficient transformational schemes to bridge the current (19/20) c£40m QIPP

stretch gap, or that can deliver the 3.10% QIPP requirement recurrently for 2020/21.

Having concluded that financially we cannot continue to fund specialised services in the same way and neither

could ICS’s sustain a devolved budget on this basis, LRET think a radically different approach to contracting is

required. This is particularly true in terms of any attempt to devolve services to ICS’s to manage in the run up to

April 2021. If this is to happen, they need to be financially sustainable and fit with the wider planning of those

systems.

Actions to date National and London letters have already gone out to London Trusts setting out the Specialised Commissioning

20/21 financial assumptions to be included in the current STP planning round. Feedback has been limited

28

although several Trusts have noted already that they do not favour a block arrangement for a further year.

Opportunities are being sought to talk to Trusts and STPs about our position and to ensure that all direct

commissioning funding is included as part of system totals. The current incentives in the system need to be

changed in order to facilitate successful devolution and the new approach to contracting as laid out above will

support this. We are in the process of setting up a series of meeting with our larger Provider Trusts (contract

value) and for Specialist Providers such as RBH and GOSH.

Work has started and is quite well developed on delivering Mental Health Provider Collaboratives as previously

has been discussed at this meeting. In discussion with the St Georges Cardiac Services Programme Board we

have identified that the model of Provider Collaboratives and lead Providers within collaboratives is a model

we are planning to pursue in South London. This would be for all specialised services, staring with Cardiac and

ultimately leading to all specialised services in South London potentially being contracted via a lead provider.

We are looking at setting up a Provider Collaborative model in North Central/East London, starting by looking

at renal services as an opportunity to start these discussions. Our first step is to agree to some funding for a

programme manager to work with the Royal Free, and Barts to start to develop a proposition for discussion.

This work is all at a fairly early stage and faces many challenges both in terms of system buy‐in, challenges in

legislation as to who can commission Prescribed Specialised Services, governance, conflicts of interest etc. One

of the biggest challenges is how funding is allocated as it has been agreed that specialised commissioning

allocations will continue to be issued to NHSE Hubs based on hosted Trusts, with the exception of mental

health where funding will become place‐based so will see a small net increase in the London budget.

Although discussions have started with Providers in South London, at the same time there has been a more

concerted effort to engage with STPs to look at other opportunities for more joint working, to both share

commissioning expertise but also to look at opportunities to move some specialised commissioning funding to

STPs to support service redesign. One small example is for neuro–rehabilitation where there are opportunities

to plan a more cohesive service if both STPs and specialised commissioning could jointly review their bed

/service position. This is a small example and probably reflects that other attempted transfers of funding back

to CCGs e.g. for Bariatric surgery have not always been successful.

We have also set up a Devolution steering group, chaired by Mark Turner with representation from the 5

STPs/ICS, as well as the national specialised commissioning team and South East Region. There has been

discussion on principles and some quite high level aspirations but following the creation of a task and finish

group a series of actions are proposed and subject to LRET agreement. An update will be given at this meeting

on how we propose to engage with wider system representation to ensure what is ‘devolved’ has wide spread

support/commitment from STP/ICS.

A workshop has also taken place with the new specialised commissioning team in South East Region. This was

an opportunity to talk to our colleagues on respective finances and actions planned to move to more

sustainable financial position. Clearly, from a London provider’s perspective especially for those in the South

East, it is essential to understand South East Region’s aspirations and if for example they intend to move more

work London providers as a result of their work on service compliance etc. We will be talking to colleagues in

East Of England as well to understand their plans e.g. given the discussions going on between Barts and BHRUT

on some areas of joint service planning e.g. neurological cancers, Mechanical thrombectomy etc.

This is a very brief summary of some of the current thinking within specialised commissioning. It’s essential that

this is reviewed and agreed as part of an overall London system and that the actions proposed are both agreed

and supported, and enhanced so that overall London commissioners and providers are able to move to a more

sustainable long term financial position.

29

Next Steps: In order to move towards new and sustainable contracting arrangements we will need to:

Be clear that we will all need to agree a new form of contract to all London Trusts in 20/21, based on

the envelopes provided and with a clear upper ceiling on values based on our allocations and control

totals and an onward prioritised programme of devolution and transformation.

Work with Providers on how this would work and how risk sharing agreements would work. It is

suggested that we set up a series of exploratory meetings with some nominated Trust leads, RDoF,

contract and finance leads from Specialised Commissioning to inform the approach for next year. It

would be helpful if this could be started prior to the contract notification deadline at the end of

September 2019.

Use the notification process for 2020/21 (contractual notice letters due on 30th September 2019) to set

out the new direction of travel has been endorsed by LRET and therefore the next contracting round

should be expected to comply with these principles.

Accelerate the work that has started on devolving commissioning responsibility either to provider

collaboratives (as with New Models of Care in Mental Health) or to STPs/ICSs, so that increasingly the

specialised commissioning spend is seen as part of the total resource available for the systems within

London

Use the London specialised planning board to own a shared work programme for developing a

sustainable QIPP programme that recognises the joint responsibility for service transformation, the

avoidance of cost shifting and single focus on cost reduction.

Work much more closely with STPs and ICS as they develop their plans to better understand how

pathways of care might be changed, so over time there is an increased focus on prevention and

therefore gradually reduce numbers of patients requiring specialised services in say cardiac and renal

etc.

Work with other Regions, specifically South East England and East of England to understand their

service plans, to recognise that London Hospitals are used to address service changes elsewhere. This is

currently happening with SE paediatric burns work moving not to Brighton Hospital but to Chelsea

Westminster Hospital

Use LRET to influence actions in the national decision making e.g. proposals to change service

specifications, which have additional costs to Regions. The new service specification for adult critical

care is a good example

For Discussion Views are sought on this paper in general and specifically on the list of proposed actions and specifically on

views on how we might work up proposals for contract form/risk shares as part of the preparation for the

20/21 contracting round. We would also welcome thoughts on how we might develop a system QIPP approach

for 20/21 (and beyond) that moves us away from delivering transitional QIPP to a more sustainable programme

of clinical /system changes that take costs out of the system and contribute the London delivery of the Long

Term Plan.

Jo Murfitt

Regional Director of Specialised Commissioning and Health in The Justice

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Joint Commissioning Committee

13 November 2019

Title of report WX Redevelopment Programme Update

Item number 4.1

Author Alastair Finney, WX Redevelopment Programme

Presented by Steve Collins, Executive Director of Finance, WEL CCGs


Executive summary This paper sets out an overview of progress on the Whipps CrossRedevelopment Programme and next steps in light of theGovernment’s recent funding commitment.

This includes an update on: a health and care services strategy forWhipps Cross (including the need for alignment withCommissioner out of hospital strategies), how that is informing thescope of a new hospital, as well as the emerging ‘masterplan’options for where a new hospital might be located on the WhippsCross site. It also provides an update on the programme’s ongoingcommunications and engagement work.

The masterplan options all include dedicated space for otherhealth and care services that might benefit from co-location withthe hospital on the Whipps Cross site. UnderstandingCommissioner views at an early stage for how this space could beutilised to support the delivery of the emerging out of hospitalstrategies will be important.

The next key milestone is to finalise the Strategic Outline Case(SOC), expected to be completed by the end of 2019. The JCCcan expect a further paper seeking support for the SOC early inthe new year.

The Trust is working closely with NHS England / NHSImprovement to understand the impact of the fundingannouncement on the programme plan, with a view to acceleratingand streamlining the current approvals process for the scheme.We will inform the JCC of any changes to the timescale describedabove as a result of this.

Action required To note and discuss:

the progress update on the redevelopment of Whipps CrossHospital and the intention to submit a further paper to the JCC early in the new year to secure support for the Trust’s SOC

the Government’s recent funding announcement and the possibleimpact of this on the approvals process and timescales for theWhipps Cross programme

the importance of continued close working between the Trust andlocal partners to ensure alignment with the emerging out of hospitalstrategies, including the opportunity for other health and care

31


services to be provided on the Whipps Cross site that would benefit from co-location with the hospital.


This paper summarises discussions and paper presented at a number of forums, including the Programme Board and Barts Trust Board

Strategic fit



The Whipps Cross Redevelopment is a strategic priority for the local health system as well as the local authorities, which will be reflected in the commissioner plans and ELHCP’s response to the NHS Long Term plan implementation.


The opportunity for a brand new hospital as part of a wider integrated health and wellbeing setting alongside housing, leisure, culture and other facilities, providing significant benefits for the local community.


The overall plan seeks to provide fit for purpose, long term improvements for north east London.


Significant.

Risks

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NORTH EAST LONDON COMMISSIONING ALLIANCE

REPORT TO THE JOINT COMMISSIONING COMMITTEE: 13 NOVEMBER 2019

WHIPPS CROSS REDEVELOPMENT PROGRAMME

INTRODUCTION

1. This paper provides an overview of progress on the Whipps Cross Redevelopment Programmeand next steps in light of the Government’s recent funding commitment. It includes an update on:a health and care services strategy for Whipps Cross, how that is informing the scope of a newhospital, as well as the emerging ‘masterplan’ options for where a new hospital might be locatedon the Whipps Cross site. It also provides an update on the programme’s ongoingcommunications and engagement work.

THE GOVERNMENT’S HEALTH INFRASTRUCTURE PLAN

2. The Government published its new Health Infrastructure Plan (HIP) on 30 September 2019setting out plans to deliver a long-term, rolling five-year programme of investment in healthinfrastructure, including capital to build new hospitals, modernise primary care estate, invest innew diagnostics and technology, and help eradicate critical safety issues in the NHS estate. Atthe centre of this is a new hospital building programme.

3. As part of this, the Government announced six new large hospital builds that are sufficientlydeveloped in order to get the full go ahead now, subject to business case approvals, with the aimbeing to deliver by 2025. Whipps Cross Hospital was confirmed as one of the six schemes -which will benefit from £2.7bn funding and are known collectively as ‘HIP1’- alongside; Epsomand St. Helier University Hospitals NHS Trust, Leeds Teaching Hospitals NHS Trust, ThePrincess Alexandra Hospital NHS Trust, University Hospitals of Leicester NHS Trust and WestHertfordshire Hospitals NHS Trust.

4. The Secretary of State for Health and Social Care wrote to the Trust on 9 October 2019(Appendix 1) following the Government announcement, confirming that Whipps Cross is one ofthe six schemes that will form the first £2.7 billion phase of the major hospital rebuilds. His letterstates that he is “giving the full go ahead now, subject to business case approvals, for yourWhipps Cross University Hospital Scheme, to deliver a brand new hospital, providing a range ofpatient services including emergency, and maternity”.

THE WHIPPS CROSS REDEVELOPMENT PROGRAMME

5. The current Whipps Cross Hospital buildings are unsuitable to deliver 21st century healthcaretoday, let alone in the future, with projected increases in both the demand and the complexity ofpatients. The vision for the redevelopment programme is to deliver a brand new hospital as partof a wider integrated health and wellbeing setting alongside housing, leisure, culture and otherfacilities, providing significant benefits for the local community.

6. A programme team at Whipps Cross is overseeing the work, supported by staff across BartsHealth as well as local health system and local authority partners. There continues to be verygood engagement from Waltham Forest and Redbridge CCGs and the East London Health andCare Partnership, with senior representation from each on the redevelopment partnership boardchaired by Alwen Williams.

THE HEALTH AND CARE SERVICES STRATEGY

7. The redevelopment of the Whipps Cross site offers an opportunity to do more than just operatewithin a different building. The programme of work and its system-wide focus allows us to

33


redefine models of care and drive improvements in outcomes and patient experience, as well as seeking a sustainable solution to increasing demands on the hospital.

8. Earlier this year clinicians across Whipps Cross, Barts Health and local providers andcommissioners worked together to develop a health and care services strategy for Whipps CrossHospital. This involved close to 200 individuals across 12 clinical working groups. The emergingoutputs from the working groups have been endorsed by the Clinical Senate for North EastLondon.

9. The key conclusions of this work are twofold. First, confirmation that Whipps Cross shouldcontinue to deliver all the core services currently provided - such as Accident and Emergency andconsultant-led maternity services - but the models of care for many of these services should bedelivered differently in the future. Common features of the new models of care envisaged include:faster access to specialist treatment; rapid diagnostics and same-day results; better care co-ordination; and closer working with primary care providers and community services to delivermore care closer to people’s homes.

10. Second, Whipps Cross can become a centre of excellence for the multidisciplinary managementof frail and older people, providing services focused on fragility, mobility, vision, hearing andbalance for the whole population served by Barts Health. This could be cemented by asignificantly enhanced provision of a research, education and training offer to those involved inthe care and treatment of frail and older people. Moreover, the opportunities that the wider sitepresents for the co-location of multi-agency teams supports the vision of integrated care for thepopulation.

11. The strategy is well aligned to the aspirations in the NHS Long Term Plan (LTP) and will form akey part of the East London Health and Care Partnership’s LTP response. This is critical, as thevision for Whipps Cross cannot be delivered without the support of the wider local system,particularly in supporting those people who do not need to be treated in hospital and could becared for closer to or in their homes.

12. The Trust is working closely with commissioner and STP colleagues to ensure that the out ofhospital integrated care strategies being developed in Waltham Forest and Redbridge align withthe assumptions in the Whipps Cross strategy, in order to articulate a single coherent and co-ordinated vision for the health of the local population. Moreover, the Whipps Cross sitemasterplan options all include space for health and care services that would benefit from co-location with the hospital. It will therefore be important to understand at an early stage how thisopportunity could be best utilised to support the delivery of improved out of hospital services.

HOSPITAL SCOPE AND MASTERPLANNING

13. The emerging outputs of the Whipps Cross service strategy determine what facilities – and thescale of them – needed in a new hospital. We looked at the projected population growth for aspecific Whipps Cross catchment population and then applied the new models of care envisioned– alongside key operational policies such as national guidelines on 92% bed occupancy - to helpforecast the future demand of services.

14. This work suggests increased activity at Whipps Cross in the future, but with more patients seenand treated on the same day. This would mean a similar sized hospital to today but:

built to modern standards and with far more space dedicated to clinical activity than today with services consolidated into a new hospital building meaning much better clinical

adjacencies maintaining the flexibility to adapt to the future

15. This requires a smaller hospital footprint, hence the need for a masterplan to consider thepositioning of a new hospital and the opportunities for redeveloping the rest of the site. Following

34


detailed work with local partners and relevant experts, the emerging ‘site masterplan’ options, which particularly focus on the possible locations of a new hospital on the Whipps Cross site, were published on 1st October. This provides the opportunity for members of the local community, staff and wider stakeholders to provide their views and the feedback received will, in part, inform the options appraisal as part of the development of the Strategic Outline Case.

16. In addition, on 14th October we published Building a Brighter Future for Whipps Cross (Appendix2), providing an overview of the programme and next steps, including the wider local healthcarecontext, the anticipated services and scope of a new hospital, and the emerging masterplanoptions for the site.

COMMUNICATIONS AND ENGAGEMENT

17. Effective communication and engagement with staff, patients, the public, their representativesand local community groups is critical to the success of the redevelopment, to ensure people arekept informed, to engage and gather feedback on emerging proposals and to build support andmomentum for the redevelopment.

18. In addition to the publications described above, on 15 October 2019, a public meeting took placeat Leytonstone School. This provided an opportunity both for the Trust and local partners to shareprogress and engage with around 200 members of the public. This builds on the work the Trusthave been doing in meeting with around 50 local groups, comprising approximately 800 localpeople and the work of its Community Engagement Action Group, set up to gather views fromamong local audiences we often find hard to reach.

19. The Trust attended a meeting of the Health Overview and Scrutiny Committee in Waltham Forest(on 31 October 2019) and will be attending a meeting of the Redbridge Health Overview andScrutiny Committee on 7 November 2019. To continue to strengthen engagement going forward,the Trust is establishing a Patient and Public Reference Group to challenge and support the work.

TIMESCALES AND NEXT STEPS

20. The next key programme milestone is to finalise the refreshed Strategic Outline Case (SOC)which is anticipated to be completed by the end of 2019. This would likely mean a paper comingto the JCC early in the new year to confirm support for the SOC on behalf of the commissioner inNorth East London.

21. The expectation had been that subject to approval of the SOC, the Outline Business Case (OBC)Stage would likely commence in around mid-2020. However, in light of the HIP announcement –and in order to meet the ambitious 2025 delivery that envisages - an accelerated approvalsprocess is now expected, with a streamlined approach for the Trust in working across regionaland national structures. The Trust are actively discussing this with senior officials at theDepartment of Health and Social Care and NHS England / NHS Improvement in order to confirmthe precise implications of the Government’s announcement on planning assumptions andtimescales. We will update the JCC if there are any changes to the timescale highlighted aboveas a result of those discussions.

22. To support that process, we are rapidly developing our thinking on the steps needed to swiftlystep up the programme resources and plans to be ready to take advantage of an acceleratedtimescale. In the meantime, the detailed work continues to finalise the SOC. It is important tostress that the onus to demonstrate readiness does not just apply to the Trust but as statedearlier, to commissioners and partners in the local health system in providing assurance ofsystem level alignment of plans, particularly around out of hospital provision.

35


CONCLUSION AND RECOMMENDATION

23. The Government commitment to funding a new hospital at Whipps Cross is enormously welcomeand is a real endorsement of the work undertaken to date to demonstrate the case for changeand develop a shared vision with local partners for the redevelopment of Whipps Cross. We’regrateful for the close and positive working relationship with CCG and STP colleagues in EastLondon that has helped support this.

24. The Joint Commissioning Committee is asked to note and discuss:o the progress update on the redevelopment of Whipps Cross Hospital and the intention to

submit a further paper to the JCC early in the new year to secure support for the Trust’s SOCo the Government’s recent funding announcement and the possible impact of this on the

approvals process and timescales for the Whipps Cross programmeo the importance of continued close working between the Trust and local partners to ensure

alignment with the emerging out of hospital strategies, including the opportunity for otherhealth and care services to be provided on the Whipps Cross site that would benefit from co-location with the hospital.

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Alwen Williams

Group CEO

Barts Health NHS Trust

09 October 2019

Dear Alwen,

New NHS Capital Funding – Barts Health NHS Trust

On Sunday, I announced the next stage in our strategic investment in the NHS, with

the Health Infrastructure Plan to ensure that our health infrastructure is fit-for-

purpose for decades to come. The Prime Minister set out on Wednesday his plan that

“in the next ten years we will build 40 new hospitals in the biggest investment in

hospital infrastructure for a generation.” As a step towards this, we have committed

funding for 6 new hospitals as well as seed funding to support the initial stage of a

further 34 building projects.

I am delighted to inform you that your major scheme is one of the six that will form

the first £2.7 billion phase of the major hospital rebuilds. I am therefore giving the

full go ahead now, subject to business case approvals, for your Whipps Cross

University Hospital Scheme, to deliver a brand new hospital, providing a range of

patient services including emergency, and maternity.

The announcement is alongside a second phase of schemes where a further 21

projects, comprising 34 hospitals, will now be able to commence the next stage of

development of their plans, a further £200m investment to update or replace

diagnostic equipment, and our plans for a new capital system for ensuring funding

reaches the frontline when and where it is needed, with national infrastructure to

support this, and clear accountability for how it is spent. These plans include

proposals for assisting Trusts, including allowing some access to early funding and

streamlining the business case process. Other projects will be able to bid into HIP2

and other future waves too.

As part of our rolling investment programme, I have confirmed that there will be

future phases of HIP, with opportunities for the NHS to put forward further new

hospital projects.

37

All this comes on top of the extra £33.9 billion a year we’re putting into the NHS by

2023-24 to secure its long term future and support the NHS Long Term Plan. In

addition, I announced in the summer a further £2.1 billion increase in NHS capital

including £250m to assist the NHS to become a world leader in artificial intelligence

and health research.

I am delighted to be taking these steps to help ensure that the critical health

infrastructure is fit for the future and enables the NHS to provide better quality of

care for patients.

Yours ever,

MATT HANCOCK

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Building a Brighter Future for Whipps Cross

October 2019

39

CONTENTS

Introduction 3

The story so far 4

The local health and care system 5

The services in a new hospital 6

The scope of a new hospital 8

Selecting a site for a new hospital 10

Next steps 12

Masterplan options 13

Whipps Cross Redevelopment partner concordat 16

Whipps Cross Redevelopment40

INTRODUCTION A hospital holds a special place in thehearts and minds of the community it serves. No-one wants to be ill or injured enough to go there – but everyone wants it to be there for them when they need it. The challenge for the NHS today is to transform the pattern of care that hospitals have traditionally provided, in order to meet the future needs of a population that is growing, getting older, and has increasing expectations from medicine.

Whipps Cross occupies that special place for the people of Waltham Forest and Redbridge The hospital existed long before the NHS was created, and its Victorian buildings and long corridor are distinctive parts of the local landscape It is one of the biggest local employers, and every day almost 1,800 patients pass through its doors – as well as numerous relatives, friends and other visitors

Those patients overwhelmingly say they are happy with the care provided by our staff They commend the compassion, friendliness and emotional support offered by our doctors, nurses and other professionals Yet they are also well aware of the limitations of the ageing, sprawling estate, and their feedback

on facilities is understandably negative These mixed feelings underpin the ground swell of public support for a brand new Whipps Cross hospital Over 3,000 people signed up to Waltham Forest Council’s campaign in 2018 The Government has now committed investment to make this happen between 2020 and 2025 in a first wave of hospital building

The redevelopment of Whipps Cross is a once-in-a-lifetime opportunity to design a new hospital from scratch It is also a unique chance to be at the forefront of national efforts to transform how healthcare is provided for local people, as set out in the NHS Long-Term Plan Our vision is for a new hospital within a wider health and wellbeing setting, alongside new homes, leisure, culture and other community facilities

The Barts Health group and its local partners are sharing some early ideas about the potential site of a new hospital, the services it will provide, and the scope of the building We want to hear what staff, patients, residents, community groups and members of the public think about them Your feedback will help us develop a robust business case for a new hospital to bring our vision to life

Alastair Finney

Whipps Cross Redevelopment Director

41

1 This concordat was renewed in May 2019 It is included on page 16

Whipps Cross Hospital is a cherished part of the local community it serves, and has been for over 100 years. As a result it has some of the oldest hospital buildings still in use in London, spread across a large area. Neither the buildings nor their layout are suitable for delivering the modern services that patients, staff and the public deserve.

Over 40% of the estate pre-dates the NHS, more than double the national average We would need to spend £88million just to maintain the buildings in an acceptable condition (one of the biggest maintenance backlogs in the country) The 18-hectare site is the size of 25 football pitches, and facilities on it have grown piecemeal over the years

A new hospital will bring services together, reducing the area of land needed and releasing a large amount of land for other purposes, providing benefits to the local community That’s why the Barts Health group, Waltham Forest Council and other local partners issued a concordat in 2016 setting out our joint vision for the future1

We agreed to work together for a new state-of-the-art hospital, providing all the Early 20th Century Present day

THE STORY SO FARcore services it does today – such as A&E and maternity – within a wider health and wellbeing setting alongside hundreds of new homes, leisure, cultural facilities and more Developing the whole site is important because a new hospital would not be affordable without making better use of land that is not needed for it This vision underpinned an initial strategic case for a combined development in 2017, and has led to discussions with the NHS about how it could be realised

In 2018 our plans were endorsed by the East London Health and Care Partnership (ELHCP), the strategic NHS body that

brings together local boroughs, trusts and clinical commissioning groups It made the redevelopment of Whipps Cross its top priority for capital investment The NHS nationally gave the go-ahead to continue developing a business case for Treasury approval

A project team based at Whipps Cross has commissioned expert advice, consulted clinicians and other staff, and engaged with interested parties (including community groups) about our plans Now in 2019 the Government has backed the case for investment This is an ideal point to share the progress we have made so far and further engage local people in the next stage of this exciting journey


A theme of the NHS Long-Term Plan is for local areas to work together to provide integrated services spanning hospital and community settings, so patients can receive more joined-up care closer to home. Local organisations are responding to this vision through the ELHCP.

The partners believe the redevelopment of Whipps Cross will be the catalyst for different teams to work together on delivering holistic care to the local population It will enable them to design new clinical pathways in response to patients’ needs, to develop a diverse range of support for patients, carers and families, and deliver all this through innovative workforce models that draw on the strengths of all our organisations

In Waltham Forest itself, clinical commissioners and the local authority are finalising an integrated care strategy that challenges local organisations to work together to enable 275,500 residents to start well, live well, stay well and age well For GP and other primary and community services this means:

• Enabling generally-well people to stayhealthy, understand risks to their health,and obtain prompt clinical support forurgent same-day concerns

THE LOCAL HEALTH AND CARE SYSTEM

• Helping those with long-term conditionsmanage their care, enjoy a full and activelife, and not deteriorate

• Supporting those with the most complexneeds or disability to stay out of hospital;but when that is unavoidable, supportthem to return home as soon as possible

Important common elements are to ensure care is consistent, simple to access, and provided at the appropriate level Work is under way to develop these new models of care in more detail and transform people’s experience of primary and community care in the borough This will translate into specific proposals for developing additional out-of-

hospital capacity, in terms of both buildings and workforce

Our collective aim is that people feel supported by their local NHS and social care providers, and are visited by friendly faces familiar with their needs They will be involved with all decisions made about their care They will have one phone number to call, and be confident that it gets the help they need Their wider health and social needs will be understood and they can easily access community support And they will be assessed by an expert and get a specialist opinion or diagnostic results without having to go to hospital

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THE SERVICES IN A NEW HOSPITAL

Whipps Cross is a busy, popular local hospital with a full range of acute services. The Barts Health group is committed to ensuring that a new hospital will continue to provide emergency and maternity care for the local population.

We took the opportunity of the redevelopment to work with clinicians, GPs and other local health and care partners on a health and care services strategy for the hospital This was a chance to look afresh at how best to provide healthcare in the future, in line with the aspirations of the national NHS Long-Term Plan Working alongside our local health and care partners, we looked at how best to meet the future needs of our population in a way that facilitates care closer to home and reduces unnecessary overnight stays in hospital

We took into account projections that the local population in the area served by Whipps Cross is due to grow by 11% over the next decade Within that overall growth, the number of people aged over 65 is expected to increase by a quarter Our clinicians believe that modern advances in medicine, care and technology mean fewer people need to visit hospital, or spend so long there in future Nevertheless, we also need to plan for a

substantially larger number of older people than today

Our emerging conclusion is that a brand new modern hospital should have the same range of acute services as now, yet provide improvements in the quality of care, with faster and more convenient access for patients A new Whipps Cross hospital will therefore continue to provide all the core services currently offered, including A&E and consultant-led maternity care

However, many of these services could be delivered differently from the ways they are now Our clinicians have agreed to adopt a new model of care as standard across different clinical pathways Implementing that would mean:

• faster access to appropriate and specialisttreatment

• rapid diagnostic tests and same-day results

• better care co-ordination, with more carecloser to home

The idea is that at the point of entry to hospital, a senior clinician would assess patients and direct them towards to the right treatment, with appropriate diagnostics People with particularly complex needs would be identified early and assigned a care co-


ordinator Multi-disciplinary teams within the hospital would work with GPs, mental health practitioners and others in the community to ensure care is joined up And every pathway would adopt digital solutions such as shared care records and virtual appointments

Although the strategy was devised for a new hospital, it equally applies to the old one too Elements of the new way of working are already happening For example, our Forest Assessment Unit identifies older patients with frailty when they attend the Emergency Department and works closely with colleagues in the community to allow an early return home with adequate support

Change will continue to spread through services even before the new hospital opens its doors, and the new buildings and facilities will allow a step change in the quality of care we can provide By working in this way, we believe we can better manage the growing demand for urgent care, reduce the amount of time that people spend in hospital beds, and transform the experience of outpatients

We also propose that Whipps Cross becomes a centre of expertise for the care of frail patients, particularly older people This fits with separate proposals by Barts Health surgeons to develop a specialist centre of

excellence at the hospital in the treatment of fragility fractures In due course the hospital would become the provider of choice for expert services on fragility, mobility, vision, hearing and balance for patients across the Barts Health group

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THE SCOPE OF A NEW HOSPITAL

Our work has uncovered some uncomfortable findings about the current hospital. For example, each original inpatient ward is half the size that experts now recommend to ensure privacy, dignity and infection control for patients. The physical layout of wards means doctors, porters and cleaners have to travel further to do their rounds, causing lower productivity and higher staffing. We estimate such inefficiencies in the estate layout cost the hospital £13 million a year that we would all prefer to spend on patient care.

At the same time, we don’t have enough facilities on the estate For example, the limited physical capacity for diagnostic tests means patients in hospital beds have priority for scans Unfortunately, that sometimes means patients are admitted and kept in hospital unnecessarily, simply so they can access diagnostics quickly

So we asked health planning experts to take the emerging outputs of our strategy, and establish what facilities – and the scale of them – would be needed in a new hospital This exercise involves clinicians and managers from key departments across the hospital, and will take some time to reach a conclusion

Designing a hospital from scratch means we can work out which services need to be located close to each other for clinical

efficiency and effectiveness We can ensure the layout minimises patient journeys, and maximises patient privacy and dignity We can embrace new and emerging technologies, employ novel and creative approaches to the workplace, and build in flexibility to anticipate future change And of course we can ensure a new building meets modern NHS technical standards

So, for example, NHS guidance is that for safety and efficiency, hospitals should operate on the basis of 92% bed occupancy Fire regulations specify the most beds we could have in any ward is 32, and the minimum proportion of single rooms is set down nationally at 50% We expect this work to show that a brand new fully-equipped modern hospital for Whipps Cross with a different physical layout could treat more patients, more quickly, and more conveniently

The starting point in estimating the scope of a new hospital is the likely growth in the population, which is expected to rise over the next ten years This growth is offset by trends in modern healthcare which treat people more quickly With more integrated primary and community services, people won’t have to stay in hospital if they don’t need to A lot of modern surgery doesn’t necessarily require patients to stay overnight Video technology enables doctors to see outpatients remotely, through ‘virtual’ consultations


We think that a new hospital at Whipps Cross could have a similar overall floor area to now but be configured quite differently over several storeys In particular, it would have far more space devoted to clinical activity than today, and be able to undertake more clinical activity We estimate:

• Procedures done in outpatients will increaseby one-third

• Operations done as day cases will increaseby a half

• More people will receive ‘same dayemergency care’ instead of being admittedto a bed

• More people will be treated in thecommunity instead of the hospital

This means:

• We must make more space for day casesurgery, especially for children

• More space will be needed for ‘same dayemergency care’ and diagnostics

• We can allocate more beds to maternity,children’s services and critical care

• We will not need quite as many overnightinpatient beds as before

This represents a significant shift from the traditional model of inpatient care to a more flexible approach that is more convenient for patients Yet it is not a sudden change When

the NHS opened for business in 1948, its hospitals had almost half a million beds Today the NHS has about one fifth of that number – although over the same period the population of the country has risen by one-third

We think that the overall requirement for bed space at Whipps Cross in ten years’ time will remain broadly similar to today, with a mixture of emergency and inpatient beds for overnight stays, plus accommodation for day cases However the balance between these categories will shift, with marginally fewer overnight inpatient beds and substantially more day case facilities (which are often reclining chairs rather than beds as we traditionally think of them)

Building a state-of-the-art hospital for Whipps Cross offers the prospect that our patients will benefit from the best possible medical, nursing and therapy care while also spending less time in the hospital environment New technology means fewer people will need to wait in outpatient clinics as more consultations are provided virtually Modern surgery means they will have routine operations done as day cases Advances in A&E mean those who need urgent care can take advantage of ‘walk-in walk-out’ facilities Projecting healthcare needs and trends 10 years into the future is not an exact science, and so we should incorporate a degree of flexibility for the future as we design the building and the wider site

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SELECTING A SITE FOR A NEW HOSPITAL

The original Whipps Cross hospital was constructed as a series of wards branching off a central spine, which affectionately become known as the longest hospital corridor in the NHS (if not in Europe). Over the years, a motley collection of standalone buildings and in-fill facilities grew up around this central core. The result, looked at from the air, is that the site today consists of about eight distinct blocks, with Hospital Road running through the middle.

In line with our vision to make better and more varied use of all the space available,

we commissioned architects to explore the constraints and opportunities of the whole estate Their brief was to consider where a new hospital could be built with minimum disruption to existing hospital services yet maximum benefit to the local community

We agreed some principles to underpin this ‘masterplanning’ exercise We wanted to keep as much green space as possible, and improve the ecology of the area We asked ourselves whether we should retain the historic buildings Accessibility was also a consideration for creating a new neighbourhood of hospital, community healthcare facilities and homes

This work showed that a brand new hospital, with a full range of acute health services for a growing population, could be built on a fraction of the land now occupied at Whipps Cross In fact, it is surprising to discover that a modest multi-storey building big enough for all our clinical needs – and with an almost identical floorspace to today – could have a ground footprint on no more than one-fifth of the site, releasing the remainder of the estate for development

After taking extensive expert advice we believe there are three practical locations for a new hospital on the existing site:

MAP © GOOGLE EARTH


a) The area where there is existing unusedand derelict buildings, including the formernurses’ accommodation block alongsidePeterborough Road

b) The 1930s extension (beyond junction 9 ofthe Victorian corridor) and adjacent landbetween Margaret Road and James Lane(currently occupied by the Margaret Centre,day units and an ambulance depot)

c) The Margaret Road/James Lane areaconnected by a bridge to the maternity siteacross Hospital Road

All three locations include provision for new A&E and maternity units and some medium- to high-rise construction Each has space for community health facilities next door to the hospital, and a separate multi-storey car park The historic towers of the original Whipps Cross infirmary would be part of the land released for housing And Hospital Road would become the High Street of a new community

Each of these locations has different implications that we need to consider Do they enable clinical services to be transformed to better meet patients’ needs? What are the impacts on affordability, accessibility and environmental concerns? Does this location

affect how we might develop the rest of the estate? How long would it take to develop the location, and how much disruption would construction cause? What do local residents and users think?

Maps and descriptions of these locations are included on pages 13-15, and a more detailed

description of the site masterplan is available at: www bartshealth nhs uk/future-whipps

We are seeking feedback from staff, stakeholders, patients and the public on these emerging ideas while we prepare the next stage of the process towards a full business case

NURSERY

AMBULANCE DEPOT

FORESTSITE

VICTORIANSITE

NURSES SITE OUTPATIENTS

MATERNITY

ENERGY CENTRE

1930sSITE

JAMES LANESITE

Whipps Cross Redevelopment 49

NEXT STEPS

On 30 September 2019 the Department of Health and Social Care published its Health Infrastructure Plan. This listed Whipps Cross among six hospital projects “that are sufficiently developed in order to get the full go-ahead now, subject to business case approvals.” The plan indicated the six would be delivered by 2025.

The preparatory work we have done so far means we are on track to submit a revised Strategic Outline Case (SOC) around the turn of the year The feedback we receive in response to the ideas set out here will help us finalise that document We are keen to get input from all quarters, including our staff as well as members of the public

Government guidelines for business cases require us to set out a number of options in the SOC, including two in which a new hospital is not built These are known as the ‘business as usual’ and ‘do minimum’ scenarios and are required in order to ensure the case for investment is robust and gives value for money Our three prospective locations for a new build will sit alongside them

We are keen to hear your views on the options that are emerging and the issues that are most important to you We have launched a short questionnaire to gain feedback from

individuals, and arranged a public meeting A series of staff conversations and updates with the redevelopment team are taking place across the hospital Our Community Engagement Action Group is gathering views from among local audiences we often find hard to reach We are also setting up a Patients and Public reference group to champion the community voice in the redevelopment programme We want to maintain a dialogue with staff, local residents, our patients and all interested parties

through regular meetings and using all the communications channels of the Barts Health group and its partner organisations

No final decisions have yet been made, either about the shape of the new hospital or how the rest of the site could be used When the SOC is approved, the next phase of detailed work will begin At that stage we will want to continue to hear your views and ideas to support us in developing our proposals further

Thank you for taking the time to read this. You can read more about how we are building a brighter future for Whipps Cross and have your say at www.bartshealth.nhs.uk/future-whipps


Option A: New build hospital on the ‘nurses’ siteA brand new state-of-the-art hospital built on the disused site of the former nurses’ accommodation Significant land would become available for development

WHIPPS CROSS ROAD

JAM

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HALFORD ROAD

FULR

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AMBULANCE DEPOT

H I G H S T R E E T

Existing buildings

New hospital buildings

Residential-led mixed-use development

Health and social care

Open space

High Street

NURSERY

PETERBOROUGH ROAD

Key features• A new, state-of-the-art hospital

on the disused site of the formernurses’ accommodation

• Quickest and least disruptive optionas the site is disused and thebuilding would be built in one phase

• Probably ‘mid-rise’ (6-8 storeys) withsome taller elements

• A new multi-storey car park wouldprobably be needed

• The Forest Site buildings couldbe demolished and new greenspace provided

Option A – New build hospital on Nurses’ site

Please note in these diagrams:• The red line indicates the boundary of the land owned by the hospital• The development blocks, site roads etc are illustrative only

51


built across the existing 1930s siteand James Lane site

• Services would be moved fromphase 1 site before work starts.Once phase 1 is built, servicesincluding A&E, intensive care,theatres and wards would move in;then a temporary bridge to existingoutpatients would be installedwhilst phase 2 is built

• Probably ‘high-rise’ (8-12 storeys)• A new multi-storey car park would

probably be needed• The Forest Site buildings could

be demolished and new greenspace provided

Option B: New build hospital on 1930s and James Lane sitesA brand new state-of-the-art hospital built across the current 1930s site and James Lane site This would need to be built in two phases Significant land would become available for development

H I G H S T R E E T

PHASE 2 PHASE 1

WHIPPS CROSS ROAD

JAM

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HALFORD ROAD

FULR

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PETERBOROUGH ROADOption B – New build hospital on 1930s and James Lane sites

The existing ambulance depot would need to be re-located, subject to discussions with London Ambulance Service

Existing buildings




Open space

High Street


Option C: New build hospital on James Lane and Outpatient/Maternity sitesA brand new state-of-the-art hospital built over the current James Lane and Outpatient and Maternity sites It would need to be built in two phases, with the two buildings permanently linked over a new ‘High Street’ Significant land would become available for development


built as a split site across a new‘High Street’

• Services would be moved fromphase 1 site before work starts.Once phase 1 is built, servicesincluding outpatients and maternitywould move in then a temporarybridge to A&E, intensive care,theatres and wards would beinstalled while phase 2 is built

• Probably ‘high-rise’ (8-12 storeys)with some ‘mid-rise’ (6-8 storeys)

• A new multi-storey car park wouldprobably be needed

• The Forest Site buildings couldbe demolished and new greenspace provided

H I G H S T R E E T

PHASE 2

PHASE 1

WHIPPS CROSS ROAD

JAM

ES L

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HALFORD ROAD

FULR

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PETERBOROUGH ROADOption C – New build hospital on James Lane and Outpatient/ Maternity sites

The existing ambulance depot would need to be relocated, subject to discussions with London Ambulance Service.

Existing buildings




Open space

High Street

Whipps Cross Redevelopment 53

www.bartshealth.nhs.uk/[email protected]

Switchboard: 020 7377 7000©Barts Health NHS Trust

MAY 2019

MAY 2019: PARTNERS REAFFIRM COMMITMENT TO WHIPPS CROSS VISIONThe organisations who are working together on the Whipps Cross Redevelopment Programme have agreed a new ‘concordat’ which reaffirms how they will work together to deliver their shared vision Alwen Williams, Group Chief Executive of Barts Health said: Whipps Cross is such a valued asset for our community, and the agreement we’ve signed shows that we are all committed to delivering a shared plan to make the best use of the site for generations to come

Whipps Cross Redevelopment Programme Partnership Concordat

The redevelopment of Whipps Cross Hospital offers an unprecedented opportunity to regenerate a unique site and create an integrated health, care and wellbeing campus This has the potential to bring together a wide range of services designed around the needs of the local population, including housing, leisure and culture Through the Redevelopment Programme we can develop new clinical pathways and realise operational efficiencies within an integrated care system, whilst also supporting economic regeneration and growth in North East London Achieving such an ambition requires a genuine partnership between local authorities, clinical commissioners, healthcare providers and others in the wider healthcare system

This Concordat sets out our mutual commitment to collaborate for the benefit of the patients and communities we each serve, in accordance with agreed principles We will:

• participate fully in the Programme by sharing ideas andoptions at all stages, and ensuring that all views withineach organisation are gathered and represented;

• identify and agree ways of co-producing developmentwork with staff and local communities, so existing andfuture service users are fully engaged in the process;

• regularly feedback insight from stakeholder involvement,so that proposals set out in the business case come asno surprise to those with an interest in the outcome;

• take an active role in decision making, and proactivelyassess the impact of any proposals either on existingservices or the people most likely to be affected;

• inform each other of any issues or other workprogrammes that might affect the delivery of theRedevelopment Programme at the earliest possible stage;

• act as ambassadors for the Programme, by raising itsprofile, promoting wider understanding of its benefits,and encouraging the sharing of lessons learned

Between us we have agreed areas where each partner is best qualified to lead We will review this Concordat annually

Alwen Williams, Group Chief Executive Barts Health NHS Trust

Jane Milligan East London Health & Care Partnership

Martin Esom London Borough of Waltham Forest

John Brouder North East London NHS FT

Selina Douglas Waltham Forest, Newham and Tower Hamlets CCGs

Ceri Jacob Barking and Dagenham, Havering and Redbridge CCGs

For more information about the redevelopment programme and to suggest ideas for future newsletters, visit www.bartshealth.nhs.uk/future-whipps, email [email protected] or follow #FutureWhipps and @WhippsCrossHosp on Twitter

The original Whipps Cross Redevelopment Concordat was signed in 2016 and renewed in May 2019.

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NELCA Joint Commissioning Committee

13 November 2019

Title of report A report from NHS Camden Clinical Commissioning Group (CCG) in partnership with NHS England Specialised Commissioning on behalf of all commissioners of Moorfields’ services.

Item number 4.2

Author Denise Tyrrell, Programme Director NCL CCGs, Moorfields Consultation

Felicity Bull, Assistant Director - Communications, NEL

Presented by Les Borrett, Director of Strategic Commissioning

Denise Tyrrell, Programme Director NCL CCGs, Moorfields Consultation

Contact for further information [email protected]; [email protected]; [email protected]

Executive summary NHS Camden CCG and NHS England Specialised Commissioning, working in partnership, are leading a public consultation on a proposed new centre for Moorfields Eye Hospital.

The consultation, which ran between Friday 24 May and Monday 16 September 2019, gave patients, residents, staff and other key stakeholders the opportunity to comment on the proposal to create a new centre for eye care, research and education in King’s Cross with project partners UCL and Moorfields Eye Charity.

This report provides an update on the progress on the formal public consultation proposal to relocate Moorfields Eye Hospital from its site in City Road, Islington to St Pancras. The report includes the draft summary of findings from the public consultation on the proposal, highlighting the key themes expressed through the consultation; plans in place to respond to those views; and the next steps for decision-making.

For further information and consultation documentation and the draft consultation outcome report, please refer to the consultation website https://oriel-london.org.uk/consultation-documents/ where you can read or download the consultation document, draft consultation findings and other background information.

Action required The Joint Commissioning Committee is asked to:

NOTE the draft consultation findings report key findings

NOTE the integrated health inequality and equality impactassessment summary

NOTE the progress in the development of the decision-makingbusiness case (DMBC)

In preparation for the Moorfields’ Consultation Committee inCommon decision-making meeting, COMMUNICATE to theprogramme board anything of significance in this report pertinentto proceeding to the next stage.

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Draft Consultation Findings Report: Published and sent to stakeholders on 23 October 2019 for two

weeks to check that the report reflects the input from theconsultation

Sent to the North East London CCGs’ Governing Body membersfor feedback

Strategic fit



Local strategic fit.


This report highlights the extensive engagement undertaken through the Moorfields consultation of the proposed move of Moorfields Eye Hospital from City Road site.


This report was written in accordance with the provisions of the Equality Act 2010.


Resource implications:

These are adequately covered through the programme board and through the 14 CCGs1 and NHSE specialised commissioning.

Risks Where applicable any risks are identified within the report.

Any conflicts of interest are managed robustly and in accordance with the NEL conflicts of interest policy.

1 The 14 CCGs who commission over £2m p.a. of activity from Moorfields.

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1. Introduction

On 24 May 2019, a consultation was launched to seek the views from as many people as possible about the proposal to move services from Moorfields’ City Road site and build a new centre bringing together excellent eye care, ground-breaking research and world-leading education in ophthalmology.

This centre would be a multi-million pound development on land that has become available on the site of St Pancras Hospital, just north of King’s Cross and St Pancras stations.

NHS Camden CCG, on behalf of all clinical commissioning groups with NHS England/Improvement Specialised Commissioning, together with Moorfields Eye Hospital, led the consultation, which will influence and inform the Decision-Making Business Case (DMBC).

The DMBC will be instrumental in gaining Clinical Commissioning Group and NHS England Specialising Commissioning support for the proposed relocation, which must demonstrate that proposals for service change demonstrate evidence to meet four tests before they can proceed. These tests include strong public and patient engagement, patient choice, clinical evidence base and support from clinical commissioners.

The Moorfields’ consultation programme received: 1,511 survey responses to the consultation questions, 212 other forms of responses including emails, telephone and social media and formal responses; feedback through 99 open discussion workshops, and meetings. Responses have been received from as far as Devon and Dundee, which indicates that the consultation approach has reached the national patient/resident population.

In line with scrutiny regulations, the North Central London Joint Health Overview and Scrutiny Committee is leading a joint scrutiny process for the consultation and proposed move.

2. Context

Moorfields provides eye health services to more than 750,000 people each year. Its main site at City Road in Islington has a 24-hour ophthalmic A&E and provides a range of routine elective eye care for London residents and specialised services for patients from all over the UK.

The current facilities at City Road date from the 1890s. There is very little space to expand and develop new services; the lay-out of the buildings affects efficiency and patient access, and the age of the estate creates difficulties for installing new technologies.

3. Consultation

In the consultation document published on 24 May 2019, we described how the proposed new centre would bring together excellent eye care, ground-breaking research and world-leading education in ophthalmology on land that has become available on the site of St Pancras Hospital, just north of King’s Cross and St Pancras stations in central London.

If approved, services would move to the new centre from the current hospital facilities on City Road in Islington, along with Moorfields’ partner in research and education, the UCL Institute of Ophthalmology.

We highlighted the role of NHS Camden Clinical Commissioning Group (CCG), on behalf of all CCGs that plan and buy Moorfields’ services for residents, and in partnership with NHS

57

England Specialised Commissioning, as decision-makers who must decide whether the proposed move is:

in the interests of the health of our populations, locally and nationally in line with our long-term plans to improve health and care an effective use of public money.

To inform its decision, Camden CCG has sought views about the proposed change, including access to the proposed new site, from:

people who use Moorfields’ services, their families and carers including people who may need services in the future other people who live with sight loss local residents and the public community representatives, including in the voluntary sector staff and partners in health and social care relevant local authorities.

We have been working with the Consultation Institute (tCI), an independent advisory body, to ensure that our consultation process, from pre-consultation to evaluation, meets the highest standards. Following the tCI Gateway 5 review on 9 October 2019, we are heading towards achieving best practice attainment.

4. Draft Outcome report – key findings

In order to ensure the findings of the consultation were interpreted and presented in an objective way an independent third-party provider, Participate, was appointed to manage the receipt of responses, analyse findings and produce an independent report of the process and findings of the consultation.

The findings in the draft consultation report from Participate was sent to all Governing Body members of the 14 CCGs on 24 October 2019 requesting feedback on anything of significance in this report pertinent to proceeding to the next stage. The report can be found on the consultation website https://oriel-london.org.uk/consultation-documents/ and summarised here.

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4.1. Overview of consultation responses Between 24 May to 16 September 2019, the consultation programme received 1,511 survey responses to the consultation questions, as well as 212 other forms of response including: emails, telephone, social media and formal responses. Ninety-nine discussion groups were held and themes from those were also recorded.

Who responded?

The survey responses represent a high number of current or former service users at 62% (935). Additionally, a wide range of teams, groups and organisations responded; many of which were health-related, had close links with Moorfields, or were charities related to eyecare (Figure 1).

What do they think of the proposals?

Overall there is strong support for moving to the St Pancras Hospital Site.

From the survey responses 73% (1,098) think a new centre is needed with 8% saying they don’t think a new centre is needed (Figure 2)

62%8%

8%

15%

7%

Figure 1: Respondents to the Moorfields Consultation survey

Current or formerpatients/services users

Carers or familymembers

Members of the public

Moorfields/UCLH staff

Other

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The minority of responses not in favour of the move are concerned with losing ahistoric building, loss of NHS assets and moving away from a facility and route withwhich they are familiar

Some concerns were also voiced about the new site relating to:

o The last half mile of the journey as public transport stops short of the siteentrance

o Accessibility, both in terms of travelling to the new hospital site, and in termsof navigating around it

o A busy and heavily congested area meaning it could present difficulties forvisually impaired, elderly and disabled patients

Staff and patients expressed an interest to be kept informed of the development ofthe project and to have a voice in the design of the new hospital

Stakeholders are generally positive about the move to the St Pancras site withorganisations such as Royal National Institute of Blind People (RNIB) keen to beinvolved in the project

73% agree or strongly agree that it should be at the St Pancras Hospital Site with10% stating they disagree or disagree strongly.

0% 20% 40% 60% 80%

a. I think a new centre isneeded.

b. I don't think a new centre isneeded .

c. I don't have a view onwhether a new centre is

needed.

Not answered

Figure 2: Q4 Please select one of the following statements that most closely matches your view.

NEL

NCL

NWL

SEL

SWL

OL

NA

Total

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Additionally, 81% of staff respondents strongly agreed or agreed with the proposed

location, with just 7% strongly disagreeing/disagreeing that the centre should move to St Pancras

We received feedback on alternative locations. These are being considered as part of the options review process

Stakeholders also provided an extensive list of suggestions relating to the implementation of the new hospital

Some stakeholders expressed a desire for ophthalmology services to be delivered locally where possible, and were keen to seek reassurance around the future of Moorfield’s satellite sites

The relationship between the Oriel programme and Transport for London and Camden Council were highlighted as key to the success of the project, especially around integrated transport and planning permission.

29%

39%

6%

6%

20%

Figure 3: Extent to which respondents agreed or disagreed with the location at St Pancras Hospital site

Strongly agree

Agree

Neither agree/disagree

Disagree

Strongly disaree

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4.2. How we have engaged with people Our approach has been an emphasis on active participation, as well as seeking written responses to the proposals. The programme of consultation activities included open discussion workshops, discussions with key groups and meetings on request.

We understand from listening to people that they are apprehensive about how any change would be managed with minimal disruption, smooth transition and continuity of service. To make sure that we address these concerns we have considered how issues of equality affect service users in the proposed changes.

The Equalities Act 2010 places duties on health and care organisations to reduce health inequalities and ensure that service design and communications should be appropriate and accessible to meet the needs of diverse communities.

To ensure the NHS has paid ‘due regard’ to the matters covered by Public Sector Equality Duty, we have undertaken an integrated health inequality and equality impact assessment (HIEIA) process which is designed to ensure that a project, policy or scheme does not discriminate against any disadvantaged or vulnerable people or groups.

We have worked with organisations that led us to people with a range of protected characteristics, so that we captured their views on the proposal itself and any potential impact on equality. There were 38 meetings and conversations with people with protected characteristics and rare conditions. They included networks of children and young people, older people, people with learning disabilities, mental health problems, physical disabilities, multiple disabilities and sensory impairment. We also met people from LGBTQ+ and BAME groups, including people with these characteristics and with sight loss.

Assessment of the impact of the proposals on these groups, as well as its ability to reduce inequalities between patients, has been undertaken in two phases. Both of these have been led by independent organisations, and represent an objective assessment of the likely impact of the proposals.

We have also engaged with partners in London, Essex, Hertfordshire and Kent, as well as further afield; providing briefings to overview and scrutiny committees, health and wellbeing boards and Healthwatch.

And we have heard from residents in north, south, east and west London, Essex, Hertfordshire, Bedfordshire, Suffolk and Norfolk. Over a quarter of survey responses have come from people who live outside London.

4.3. Main feedback from engagement The main themes of feedback during this engagement have not changed during the consultation, and remain as follows:

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Clinical quality The issue most highlighted as “very important” by people is high quality clinical expertise. Overall, it was stated that clinical quality is more important than any travel issue, which could be overcome. Transport to and from the proposed St Pancras site There were a number of aspects listed that were key concerns for people in regard to travel and transport to and from the St Pancras site. The main themes included:

Travelling the last half mile Engaging with Transport for London Help with travel Difficulties posed by King’s Cross being a busy area.

Accessibility to the proposed site A number of suggestions and solutions were listed to help with accessibility to the proposed new centre. For example having a green line and tactile flooring, moving bus stops, operating a meet and greet facility, better signage. Accessibility around the proposed site Improved accessibility around any potential new centre was identified as important. It was considered crucial that staff, service users, carers and representatives from supporting groups and charities are involved in the design and development of the proposed centre to ensure it meets a wide range of needs. Patient experience Improving patient experience the through:

Good communication Better patient facilities for treating service users and allowing for improved

privacy. There were comments on the benefits and drawbacks of gender specific wards, toilets and non-gender specific areas.

Transition to the proposed new centre Managing the transition to the proposed new centre included communicating progress updates using a multi-channel communication approach. Some groups expressed the need to include people with disabilities and other protected characteristics in the design of the new centre. It was felt that no-one knows better about what is accessible and what doesn’t work than the users themselves. The breadth of involvement during the consultation was commended.

4.4. Key INEL/ONEL highlights Out of a total 1,511 survey responses received, 248 responses were from north east London. 65% of those who responded to survey are those who currently use eye health (ophthalmology) services at Moorfields or have you used them in the past three years. There was a majority agreement with 61% thinking a new centre is needed and 16% of respondents who disagree or strongly disagree.

40 out of the 126 (32%) respondents who said they don’t think a new centre is needed live in the north east London area. This finding could infer there are more concerns from those living in the north east London area about building a new centre with the perceived potential for disruption to services and travel difficulties. In addition, some felt that a facility is missing in the east of London.

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Overall, there were slightly higher levels of disagreement with the proposal of a new centre from those living in north east London. Some stakeholders were keen to help develop services in their locations to reduce patient flow to Moorfields.

In addition to completing the survey, around 300 people were contacted through over 17 focus group meetings and discussions that were held with number of organisations and charities. This included people in protected characteristics groups and seldom heard groups across INEL/ONEL. Below is a list of groups from north east London who were involved in these discussions through the consultation process:

Action on Hearing Loss. Beyond Sight Loss - Tower Hamlets (60 people) City and Hackney Older Person’s Reference Group (OPRG) HIVE (Hackney

Informed Voices Enterprise) City and Hackney PPI Committee Community Commissioning Panel, Tower Hamlets East London Co-production Forum (Older People) Newham CCG patient participation group (20 people Newham Council and CCG Co-production Forum NE London Older People’s Reference Group (70 people) North East London Patient Reference Group Tower Hamlets Older People’s Reference Group Waltham Forest CCG Patient Reference Group (PRG).

Feedback from the majority of the groups was that most are in favour of building a new centre, with similar issues reflected in the meetings as identified from the survey feedback.

Engagement also included an hour long radio interview about Moorfields proposal in Forest Gate whose target audience is north east London residents.

5. Decision Making Business Case (DMBC) overview

The DMBC is being developed in line with the NHS England guidance document “Planning, assuring and delivering service change for patients” (version 3, March 2018), and HM Treasury’s Green Book guidance relating to the capital investment decisions involved in supporting the proposed changes.

It is being drafted on behalf of the 14 CCGs who commission over £2m p.a. of activity from Moorfields, and NHS England Specialised Commissioning who are the largest commissioner of Moorfields activity, to conclude the public consultation on Oriel.

The report will describe the aims, the approach and the methods by which we have listened to people, how we have adjusted our actions as a result of their responses and how we ensured that the outcome of consultation would influence decisions.

The DMBC, subject to the consultation outcome report, is expected to:

Confirm that the key parameters for the project have not changed since the Pre Consultation Business Case (including the case for change, activity modelling and preferred option)

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Detail the consultation process undertaken, as well as the external assurance

obtained which will confirm the robustness and transparency of the process Present the findings and key themes from the consultation, demonstrating how these

are shaping proposals for the project

Present the Health Inequalities and Equality Impact Assessment, which examines the impact of the proposals on groups with characteristics protected by the Equality Act 2010, as well as considering the impact of the proposals on the whole of the population served and identifying and addressing factors which would reduce health inequalities

Demonstrate how the development of the preferred option is compliant with the Secretary of State for Health and Social Care’s four tests of service reconfiguration

Demonstrate that the preferred option is affordable to commissioners and providers, and deliverable.

It will be presented to the Committee in Common and to NHS Specialised Commissioning in December 2019 for final decision-making on the proposals to move Moorfields Eye Hospital from City Road to the St Pancras Hospital site.

6. Integrated health inequality and equality impact assessment (HIEIA)

A HIEIA has been undertaken prior to the consultation and throughout the consultations.

The HIEIA process is designed to ensure that a project, policy or scheme does not discriminate against any disadvantaged or vulnerable people or groups. This ensures the NHS pays ‘due regard’ to the matters covered by Public Sector Equality Duty.

It examined both the potential impact of the proposals on groups with characteristics protected by the Equality Act 2010, as well as considering the impact of the proposals overall of the population served and identifying and addressing factors which would reduce health inequalities.

It found that the nature of care that users access at Moorfields Eye Hospital’s City Road site means that they are more likely than in other healthcare settings to have one or more of the protected characteristics that this assessment is seeking to identify and help mitigate. Also, as a centre of specialist care, users of services at the City Road site often have a long and trusted relationship with the teams located there. These themes were pronounced in the consultation feedback both in the survey and in focus groups.

The HIEIA specifically focused on the impact of the proposed relocation. The analysis showed a number of protected characteristics, health inequalities and health impacts were not negatively impacted by this proposed relocation. A summary of the key impacts are;

Most stakeholder feedback obtained as part of the consultation supported the proposal to relocate, believing that this relocation would support the integration of eye care with research and education. Specifically supporting the opportunity for closer working with organisations such as the Francis Crick Institute, RNIB and UCL.

Respondents to the consultation felt that the new centre would benefit both patients and staff, in that a specialist and highly regarded hospital such as Moorfields needs 21st century purpose-built facilities providing a world class centre of excellence

The analysis did not show disproportionate impact due to relocation on patients currently covered by specialised commissioning

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Elderly patients (due to age and comorbidities) and patients with protected

characteristics are the ones most likely to be negatively impacted by the proposed relocation. This is because changes to their journey, namely concerns about the busy nature of kings cross, can cause stress and anxiety for these groups

The proposed relocation to a new centre has the potential to improve staff morale as a result of modern professional environments.

The commissioners and Moorfields Hospital are developing an action plan to respond to the finding and recommendations of the HIEIA which will be outlined in the DMBC.

7. Clinical case for change

The clinical case for change and the proposals were reviewed by the London Clinical Senate at a panel in November 2018.

Following the Review Panel, the London Clinical Senate submitted a report on its findings to the CCGs in which it confirmed that it found “that there was a clear, clinical evidence base to support the proposed move of the services at City Road to the new site at St Pancras Hospital.”

The panel made recommendations to which commissioners have responded. Its report, and subsequent correspondence, was published by commissioners as part of the formal consultation, which notes that all recommendations have now been addressed. They are available at www.oriel-london.org.uk.

Additionally, a wide range of clinicians has been engaged throughout the process to ensure proposals have patient outcomes central to plans. There has been broad and varied communication with a range of clinical staff.

Clinical leads from the commissioners and Moorfields have been supporting the proposal to relocate, subject to the consultation outcome, in the following ways:

Contributing to shaping the clinical case for change Developing patient pathways and agreeing activity assumptions Presenting the case for the consultation at the Clinical Senate review Supporting the PCBC and DMBC in passing local governance processes Participating in the consultation and encouraging colleagues to do the same Involvement in patient/public engagement – listening, participating, and feeding back

on plans.

8. Ophthalmology activity modelling and financial impact

The assessment of commissioner affordability has been based on activity modelling undertaken by independent advisors, Edge Health. Detailed modelling of demographic growth, additional demand factors and potential for activity reduction through referral management, this exercise has been undertaken.

All commissioners directly involved with the consultation have reviewed the activity growth assumptions for the proposal and have confirmed that the assumptions of Moorfields Eye Hospital align to those of the 14 CCGs listed below and NHS England Specialised Commissioning.

This exercise has assumed an underlying rate of activity growth of 3.1% per annum in outpatient activity across all commissioners (14 CCGs and NHS England Specialised

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Commissioning) in the new proposed facility. Moorfields are not assuming any additional funding from CCGs based on the fact that the location and quality of the premises is changing.

The activity modelling also examined the potential for activity to be re-provisioned (i.e. provided in a different setting). This showed that some outpatient, urgent and emergency activity growth could be delivered in an alternative setting, and the impact of this on annual activity growth rates is shown in the table below. This shows the scale of the opportunity for future changes to the model of care, and commissioners plan to continue to work with system partners to achieve this.

As this is activity provided from a different setting rather than avoided, it is assumed that the cost to commissioners might be reduced but would not be avoided. Moorfields and commissioners will continue to work together to ensure patients are seen by the most appropriate clinician in the most appropriate location, while delivering value for money.

Projected activity growth for the City Road catchment population

Outpatient activity

Surgical activity

Urgent and Emergency activity

Projected annual activity growth across the City Road catchment

3.1% 2.6% 2.9%

Potential annual growth if activity is re-provisioned where possible

2.3% 2.6% 1.9%

Source: Edge Health report (September 2019)

9. Compliance with requirements

9.1. The Secretary of State for Health and Social Care’s four tests NHS England, in its guidance published in December 2013, outlined good practice for commissioners on the development of proposals for major service changes and reconfigurations.

Building on this, the 2014/15 mandate from the Secretary of State for Health and Social Care to NHS England, outlines that proposed service changes should be able to demonstrate evidence to meet four tests:

1. Strong public and patient engagement 2. Consistency with current and prospective need for patient choice 3. A clear clinical evidence base 4. Support for proposals from clinical commissioners.

Reconfiguration proposals must meet the four tests before they can proceed. These tests are designed to demonstrate that there has been a consistent approach to managing change, and therefore build confidence within the service, and with service users and the public.

From 1 April 2017, NHS England introduced a new (fifth) test to evaluate the impact of proposals that include a significant number of bed closures. There are no plans to reduce beds, therefore this test does not apply.

The Secretary of State for Health and Social Care’s four tests were closely considered throughout this process and are considered to have been met.

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9.2. The Mayor of London’s six tests The King’s Fund and Nuffield Trust published a report2 in September 2017 which recommended that greater city-wide leadership is needed to successfully implement the five NHS Sustainability and Transformation Plans (STPs) for London. In response to this, the Mayor of London set six assurances required for him to give his support to the STPs. While not directly required for this public consultation, compliance with these when implementing service change is considered best practice:

Impact on health inequality – The impact of any proposed changes to healthservices in London must not widen health inequalities. Plans must set out how theywill narrow the gap in health equality across the capital.

Hospital capacity – Given that the need for hospital beds is forecast to increase dueto population growth and an ageing population, any proposals to reduce the numberof hospital beds will need to be independently reviewed to ensure all factors havebeen considered. Any plans to close beds must be an absolute last resort, and mustmeet at least one of the NHS’ ‘common sense’ conditions.

Sufficient investment – Proper funding must be identified and available to deliver allaspects of the STP plans.

Impact on social care – Proposals must consider the full financial impact any newmodels of healthcare, including social care, would have on local authority services,particularly in the broader context of the funding challenges councils are alreadyfacing.

Clinical Support – Proposals must demonstrate improved clinical outcomes,widespread clinical engagement and support, including from frontline staff.

Patient and public engagement – Proposals must show credible, widespread andongoing patient and public engagement including with marginalised groups.

The Mayor of London has responded to the consultation confirming that he considered the first four tests (above) and is broadly content with the proposed move for Moorfields Eye Hospital’s City Road services. The final two tests will be considered later in the year, after the commissioners have published the formal consultation report and reached a decision.

10. Scrutiny

The final consultation findings report and consultation process will be presented for scrutiny to the North Central London Joint Health Oversight Scrutiny Committee (NCL JHOSC) on 29 November 2019.

We are working closely with the NCL JHOSC chair and officers in preparing for this meeting.

Due to the complexity of the consultation covering local authorities across England, NCL JHOSC has agreed that representative councillors from other HOSCs and JHOSCs can attend the scrutiny meeting on 29 November 2019.

11. Post-consultation steps and decision-making process

The consultation closed on 16 September 2019 following an extensive 16-week consultation period to the offset any negative impact of running a consultation during the month of

2 Sustainability and transformation plans in London, an independent analysis of the October 2016 STPs (completed in March 2017)

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August. Responses received have been independently analysed and a draft consultation outcome report has been developed for the Consultation Programme Board.

This draft report was published on 23 October 2019 and shared widely as we seek feedback on the outcome and any recommendations.

Following this, representatives from the Consultation Programme Board, CCG Governing Body members and NHS England Specialised Commissioning will consider the report in the context of the Decision Making Business Case as well as other influencing factors, such as the Secretary of State for Health and Social Care’s four tests and Mayor’s six tests to determine whether they will support the proposal.

These will then be summarised in the Decision-Making Business Case to assist CCGs, through the Committee in Common to be held on 19 December 2019, in their decision-making on the proposals. Specialised commissioners will follow NHS England’s governance processes in their decision-making.

The outcomes of the consultation will also be presented to North Central London Joint Health Oversight and Scrutiny Committee on 29 November 2019 for assurance that the consultation process has been completed satisfactorily.

Subject to approval of the Decision-Making Business Case, Moorfields would then proceed to develop its Outline Business Case. Feedback provided during the consultation process will be used to inform the Trust’s proposals in the business case and next steps. Should the Outline Business Case and Full Business Case receive approval from NHS England/Improvement, Moorfields will go on to implement the proposal, taking into consideration themes from the consultation and recommendations from commissioners.

NHS England/Improvement requires Moorfields to submit a Strategic Outline Case, Outline Business Case and Full Business Case for approval for their capital investment proposals.

12. Timeline

16 September Consultation closed

23 October

November

Publish draft consultation outcome report for feedback to make sure the summary is an accurate reflection of views https://oriel-london.org.uk/consultation-documents/

Publish final consultation outcome report

Approval of economic and financial cases

December

Socialisation of draft DMBC

Scrutiny and assurance

Decision-making by Committee in Common and NHS England/Improvement

January 2020 Announcement of decision.

13. Appendix A Ophthalmology System Modelling SummarySeptember 2019

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Ophthalmology system modellingAnalysis of present, projection of future, scenario modelling, and supporting engagement

A report by Edge Health for Specialised Commissioning, CCGs and Moorfields Eye Hospital September 2019

70

Agenda

• Ophthalmology activity in context

• Supporting engagement

• A developing Model of Care

• Modelling approach and summary outputs

• Scenarios and sensitivities

• Looking forward

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Moorfields activity is spread over a number of commissioners

NHS Barnet CCG77,800 appointments

201 per 1,000 population

NHS Camden CCG37,900 appointments


NHS Islington CCG34,300 appointments


NHS Haringey CCG49,600 appointments


NHS Enfield CCG64,300 appointments


34,070 people are currently

living with sight loss in NCL

+50% growth expected in the next

16 years

58% of activity on the City Road site is commissioned by one of the 14 CCGs or Specialised Commissioning

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… and commissioners commission from other keyproviders

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Barnet

Camden

Enfield

Haringey

Islington

City & Hackney

Havering

Newham

Redbridge

Tower Hamlets

Waltham Forest

Ealing

East and North Herts

Herts Valleys

NCL

NE

LN

WL

Her

ts a

ndW

est

Ess

ex

Share of outpatient appointmentsC

om

mis

sio

nin

g C

CG

Moorfields Royal Free North Middlesex Barts Health BHRUT East and North Herts West Herts Other73

Alongside three well attended workshops, we engaged +40 people involved in the work

Workshop 1 (July 10-11)

• Shared objectives, approach towork, and initial analysis

• Group shared initial feedback onpurpose of work

Workshop 2 (August 8)

• Shared population healthmodelling and potential impact ofchanges over the next 10-20 years

• Group provided input to modellingassumptions for key pathways

Workshop 3 (August 28)

• Shared summary modellingoutputs, which included impact ofpotential pathway changes

• Group identified challenges fordelivery

1:1 meetings

• 43 meetings – 1:1s or small groups

• All stakeholders – Spec Comm,CCGs, LOCSU, Moorfields, otherstakeholders

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Through the workshops and 1:1s, a person centred model of care was developed

Self management/support

• Health education• Problem solving skills development• Self detection• Support to live well at home (e.g. with dry

AMD)• Support for blind / partially sighted• Continued use of care plans

Screening • Targeted early detection• Wearables

Primary/community care

• Direct referrals, standardised referrals forms• Development of community assets• Pre/post-op support• Remote access to advice and guidance• Decision aids

Diagnostics and referrals

• Diagnostic hubs• Risk stratification• Triage, including use of AI

Acute care • Improved referrals• When community is no longer appropriate • Rapid access pathways• Patient treated in the right place at the right

time

Doing things differently

• Follow ups:o Virtual clinicso Closer to home where possible and

appropriate

Tertiary care • Highly complex care• Delivered through tertiary providers

Discharge • Shared care protocols• Shared decision making• Care plans and patient ownership of care plan

Emergency • Care in the community where appropriate• 24/7 provision

Support byModel of care

Digital connectivity

• Secure cloud platforms• Primary (optoms, GPs),

secondary

Digital infrastructure

• Servers, networks, andwider infrastructure

Linked data • Linked data over time, providers, and treatment areas – not just eyes

Std. Op. model(s)

• Standard models for working across areas

Flowing feedback

• Feedback provided betweensystem providers to improve and refine performance

Research and development

• Research and development to improve care

• Patient centric approach• Support for organisations

providing innovation

Analytics • Development of AI tosupport improveddiagnostics and triage

Community investment

• Supporting investment innew equipment (e.g. OCTs)

Accredited optometrists

• Accredited providers toensure consistent service provision

Policy • Inform development of policy to support deliver andimprovement

Person centred

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… this sat behind the three part approach to themodelling work

Part 1 –population need

growth

Part 2 –additional

demand growth

Part 3 – pathway changes

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>> Part 1 – population need growth

Royal College of Ophthalmologists: Way

Forward Report

Mathur et at

NEHEM

Reidy and Minassian(2012)

011010101011101011010

011

011

Specialised commissioned activity: 0.2%

Other paediatrics: 0.7%

Cataracts: 2.4%

Glaucoma: 1.8%

Medical Retina: 1.9% + Diabetic retinopathy: 0.3%

Other conditions: 1.3%

Epidemiological modelling

Population growth and change projections

Prevalence to activity conversion

i. Literature and data collection ii. Projection and calculation iii. Summary growth rates

Part 1 –population need

growth


demand growth


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>> Part 2 – additional demand growth

i. Historic trend analysis ii. Insight iii. Summary growth rates

Specialised commissioned activity: 1.3%

Cataracts: 0%

Glaucoma: 1.46%

Medical Retina: 2.36%

Other conditions, incl. paeds: 1.48%

Analysis of historic growth rates

Historic paediatric activity in particular commissioned by Specialised Commissioning has grown substantially above the expected change in need

Over the past 10 years growth in cataract appointments has been relatively flat, and no greater than what would be expected from need

Glaucoma outpatient activity has steadily growth at >3% per year, this is about 40% higher than would be expected from need alone

Due primarily to a rise in injections, medical retina outpatient activity has grown at more than twice the rate that would be expected from need

Growth in “other” activity, including paediatrics, has consistently been larger than would be expected from demographics and needPart 1 –

population need growth


demand growth


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>> Part 3 – pathway changes

i. Collecting modelling assumptions ii. Estimating FA impact iii. Estimating FUp impact

Literature reviews

Empirical modelling

1:1 interviews and workshops

NCL Clinical Design Group

Specialised commissioned activity: 0%

Other paediatrics: 0%

Cataracts: 50%

Glaucoma: 20%

Medical Retina: 30%

Other conditions: 0%

Consolidating and combining

assumptions

Specialised commissioned activity: 25%

Other paediatrics:25 %

Cataracts: 80%

Glaucoma: 25%

Medical Retina:25%

Other conditions: 0%Part 1 –

population need growth


demand growth


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… these build up into summary calculations

3. Referral refinement hasa relatively limited impact as first attendances are small share of total appointments

1. Thedemographic growth has the largest impact on medical retina and glaucoma activity

2. Demand has historicallyoutstripped need – this effect is as large as the demographic change

4. Nearly 30% ofgrowth could mitigated by transferring follow-ups out of hospital

Annual growth in ophthalmology activity, City Road catchment area (2018/19 to 2034/35)

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Summary high level growth calculations

Annual growth OutpatientsInpatient and

day caseUrgent and emergency

Before reprovisioning 3.1% 2.6% 2.9%

With reprovisioning 2.3% 2.6% 1.9%

Average growth in ophthalmology activity, City Road catchment area (2018/19 to 2034/35)

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A range of 2.5%-3.8% has been estimated for OP activity with sensitivity and scenario modelling

Lower bound = 2.5% p.a Upper bound = 3.8% p.a90% of outcomes

Example scenarioPopulation growth - +10%Diabetes - +0.2%Ethnicity - 0%Additional demand - +25%Referrals refinement:Cataract + 70%Medical Retina + 25%Glaucoma + 30%

Assumption Sensitivity range Notes

Population Growth

All +/- 20%Modelling is based on detailed ONS modelling, and supported by review of GLA

estimates. A relatively narrow band is therefore appropriate.

Risk factorsDiabetes 0 to 2% p.a. Similarly, the assumptions in both these areas are based on detailed national

publications. Given the relative levels of uncertainty in the predictions, a wider range is applied than for population growthEthnicity -2 to 2% p.a.

Additional demand

All +/- 66%Although based on historic data, the additional demand modelling relies on the

assumption that historic trends persist. For this reason a much lower level of certainty is applied to these assumptions, and a broader range applied.

Referral refinement

Cataracts 30 to 70% These ranges, as with the central estimates, were informed by the workshops and broader engagement. In general, the upper estimate is roughly the share of patients who could feasible avoid a first attendance, whilst the lower estimate

represents a more conservative estimate of how much of this is achieved.

Glaucoma 15 to 25%

Medical Retina 20 to 50%

Follow-up re-provision

Cataracts 70 to 90%

These estimates follow the same pattern as for referral refinement – central estimates and ranges have been informed and co-developed through the

workshops and engagement.

Glaucoma 20 to 30%

Medical Retina 20 to 30%

Specialised Commissioning: Paediatrics

20 to 30%

Specialised Commissioning: Adult

20 to 30%

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The App allows further disaggregation and testing

Link to app

Headline growth and activity outputs

Ability to break down by geography and condition

Understand key drivers of growth

Select pre-designed scenario…

… or adjust anyinput assumption

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https://edgehealth.shinyapps.io/Ophthalmology_Demand_Activity/

Looking ahead, some key points came out of the work

Pathway development work has focused on improvements to referrals into hospital eye services, but the largest volume of activity is follow-up. There should be investment in new approaches for dealing with this activity.

Eye care across NC London is fragmented. Some CCGs commission services while others do not, so the hospital becomes the last resort. Commissioners should consider greater coordination.

Historic changes in activity go beyond just population need. Largely this is due to new eye-saving developments, but there are other drivers that need better understanding to support planning.

The Model of Care is a starting point. Further work is needed to identify how this can be delivered – not just in NC London, but across a wider area to provide patients with consistent and predictable care.

Shifting activity into primary care and the community requires further assessment – what capacity and capability exists, and what would need to be done to develop and enable this capacity to deliver.

The NHS Long-Term plan committed to reducing face-to-face outpatient appointments by up to a third. Substantial progress can be made towards this in ophthalmology, but system working and investment is required.

Having established system working to support the delivery of this work, which has enabled good progress to be made with aligned stakeholders, it is important to build on this momentum to support other system goals.

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13 November 2019

Title of report Month 4/5 Performance Report

Item number 5.1

Author Archna Mathur, Director of Performance & Assurance, NELCA

Presented by John Flood, NEL CSU

Contact for further information Archna Mathur, Director of Performance & Assurance, NELCA

[email protected]

Executive summary The paper outlines the performance headlines as at M4/5 201920 (or latest position where available). Key points for JCC to note:

NEL STP level risks to delivery against NHS Constitutional standards:

A&E Performance at Barts Health NHS Trust and BHRUT

RTT performance, waiting list size and position on > 52 weekwaits at Barts Health and BHRUT

Diagnostics performance at Barts Health and BHRUT

Cancer performance at BHRUT.

NEL STP level risks to delivery of non-constitutional standard metrics:

30 minute ambulance handovers at BHRUT

SMI (severe mental illness) Physical health checks in all CCGsapart from City and Hackney

Length of stay over 21 days at Barts Health and BHRUT

Offer of Personal Health Budgets in CCGs apart from TowerHamlets and Waltham Forest

CYP (Children and Young People) mental health access inBHR and Newham CCGs.

NEL STP level compliant performance:

Early Intervention psychosis waiting times

Estimated Dementia diagnosis rate

IAPT Access and recovery

Adults with learning disabilities in receipt of inpatient care.

Performance against other key services and metrics:

NHS 111 metrics:

NHS 111 calls answered within 60 seconds (95% standard)

NHS 111 calls abandoned within 30 seconds (< 5% standard)

% ambulance dispatches of calls triaged: 9.3% vs 10.8%London average

% calls closed to self-care 26% vs 33% target.

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Inappropriate out of area placements:

Across NEL STP for July, there were 765 inappropriate out ofarea placement bed days translating to:

15 patients in from Waltham Forest

5 patients each in Barking and Dagenham, Redbridge,Havering and Newham

0 inappropriate placements for city and hackney andTower Hamlets.

Quality information has been provided for information.

Action required The JCC is asked to note this report.


This paper has been discussed at the NELCA SMT meeting on the 22 October 2019.

Strategic fit

Commissioning implications


Commissioning Implications:

Underperformance against constitutional standards creates a case for change in the way in which services are commissioned and how both elective and non elective demand is planned and managed by commissioners and primary care.

Local Authority/integrated commissioning implications:

As above with implications specifically for integrated commissioning around urgent care, reducing lengths of stay, commissioning of care home capacity for example.


Local people will be aware of how services that are commissioned to meet their needs around quality, safety and access perform, and the processes in place to provide assurance


The performance report highlights national standard performance which means that all services across England are measured in the same way for equitable delivery.


The performance report highlights where increases in activity could be driving commissioning costs e.g. A&E attendances or unplanned admissions, with the consequence of under performance against a national standard. If a performance standard is not delivered, this could impact on patient quality e.g. waiting times for outpatient appointments or planned surgery, resulting in the need to ensure processes are in place gain assurance on patient safety and minimising the risk of clinical harm. Equally, if performance standards are met, then the impact on patient outcomes will be seen e.g. delivery of the 62 day cancer standard driving improving early diagnosis and one year survival.

Risks Current risks are insufficient improvement to consistently deliver 18 weeks, reduction in over 52 week waiters, A&E standards, diagnostic access times and consistent delivery of Mental health standards

86

Currently compliant against trajectory/performance standard but performance at risk

AT RISK (2)

Mental Health Dementia Mental Health IAPT Access Mental Health IAPT recoveryTransforming Care

IP reduction Learning Disabilities

16 p 2 - 5 p 2 -

NEL STP performance during Aug-19 was 69.6%, delivering above the 66.7% national standard. 6/7 CCGs met target.

NEL STP’s access rate performance in Aug-19 (provisional) was 5.15%, meeting the target. 3/7 CCGs met target.

NEL STP IAPT recovery rateperformance in Aug-19 (provisional)was 54.3%, above the 50% standard.6/7 CCGs achieved the standard.

NEL STP level position at July 2019/20 showed 40 adults with learning disabilities (LD) in receipt of inpatient care, 14 below the NHSE target of 54.

ELHCP STP Executive Performance update – M5 2019/20 Published Data

Performance On Track against trajectory/ performance standard ON-TRACK (1)

Mental Health EIP waiting time

6 -

NEL STP achieved the waiting times element of EIP across 7 of 7 CCGs in Jul-19 reporting 87.9%, delivering on the operating plan 2019/20 target of 56%.

Not compliant and performance trajectory deteriorating /not improving NOT IMPROVING (4)

Elective Care RTT

A&E 4 Hour Wait LAS Handovers

Mental Health SMI Physical Healthcheck

NHS 111LOS >21

Days

16 - 5 - 5 - 4 - 3-

1 q

NEL STP achieved 84.19% in Jul-19. The NEL PTL position is 4,014pathways over-plan for the month, mainly driven by BHRUT (5,191 pathways over-plan) and HUH (51pathways over-plan).

NEL STP A&E performance in Aug-19 was 84.82%, 4.71% below STP trajectory.

NEL STP performance driven by 1.15% deterioration at Barts Health.

NEL STP performance against the 30 minute handover threshold 89.4% in Aug-19, a 2.6% improvement from the previous month.

In Aug-19, for NEL STP the number of 30 min LAS handover breaches was 1,246, down from 1,372 in Aug-19. BHRUT reported 1,101 of total breaches for Aug-19

During Q12019/20, 40.1%.NEL STP patientson GP SMIregister receivedall six physicalhealthchecks,below the 50%Q1 target.

In Aug-19, NEL reported79.4% of calls answered within 60 seconds; a deterioration compared to 83.2% in Jul-19 and below the 95%standard. NEL’s % calls abandoned within 30 seconds was achieved with a performance of 3.1%.

In Aug-19, NEL reported390 patients waiting >21 days against a trajectory of 371.

Performance improving but not yet on track IMPROVING (3)

Cancer Personal Health

Budgets

U&ECDTOC Minors Breaches

Diagnostics

1 - 1 p2

- 4 - 3 -

62 day cancer performance compliant at STP level 86.3% in August; however BHRUT remain non-compliant in 4 cancer standards (incl 62 day).

STP level performance during Q1 19/20 was 1157, above target, due to exceptionally strong performance at TH. 2/7 CCGs met target.

NEL STP average bed days lost to DTOCs was 106 in Jul-19; exceeding the revised NEL STP target of (69).

NEL STP achieved 98.9% in Aug-19 – a deterioration on the 99.2% reported the previous month.

NEL STP reported 261 breaches in Aug-19, 50 more breaches than the 211 reported in Jul-19 with a decrease in attendances (circa 5,000 attends).

NEL STP improved but remained non-compliant in Jul-19 against the diagnostics DM01 standard at 2.88%, above the national standard of 1%.

July’s position was driven by improvements in DM01 performance at Barts.

Issu

es

/ A

ctio

n /

Mit

igat

ion

Diagnostics Elective Care RTT Mental Health

NEL STP deterioration in July’s performance was driven by BHRUT (2.41% driven predominantly by MRI) against the 1% Standard. BHRUT DMO1 trajectory forecasts delivery in Sept-19. BHRUT have worked up recovery actions for the challenged modalities and also provide weekly DM01 reporting which is discussed at the bi-weekly planned care meeting, BHR CCG’s Performance & Quality meetings.

At Barts Health, all sites continue to remain compliant with the Diagnostics standard, MRI is the key driver for sustained underperformance.

Barts is currently recalibrating the MRI recovery action plan and forecasts return to compliance in Sep-19 (slippage from Aug-19). Progress will be monitored at TSG to understand key risks to recovery of the standard as planned. All sites continue to remain compliant with the Diagnostics standard, MRI is the key driver for sustained underperformance.

NEL STP performance remains challenged across Barts Health and BHRUT in Jul-19. Barts Health met the long wait trajectory with 16 52ww. The PTL was 88,172, remaining below plan for a further month. Aug-19 pprovisional data indicates the Trust will not achieve the long wait trajectory with 18 patients >52ww vs a plan of 15; however the PTL continues to remain below plan. The Trust is piloting an average weeks wait in lieu of the 92% reporting standard. Average weeks wait in Jul-19 is 10.12; and 10.76 into Aug-19.

BHRUT achieved 78.86% in Jul-19, missing the trajectory of 83.37% for the month by (-4.51%). At month end, the PTL was 42,206 up from 42,551 in Jul-19 and 5,191 above the plan of 37,360 for M4 of 19/20. Significant risk identified in the number of patients waiting over 52+ ww position albeit improved to 16 this month and unvalidated data indicates Aug-19 is circa 22.

IAPT access and recovery rates continue to showsustained delivery at STP level, although remains morechallenged at BHR. BHR recovery plans are in place,with oversight through STP MH Assurance Group.CYP Access Rate: CYP overall STP level performance at August 2019 is marginally below cumulative indicative plan. CCG level recovery plans are in place to support delivery during 2019/20.

URGENT AND EMERGENCY CARE

ELELCTIVECARE

CANCER/DIAGNOSTICS

PRIMARYCARE

MENTAL HEALTH TRANSFORMING CARE

Key: Number of consecutive months that performance is in assigned category.

Arrows denote movement between categories.qp , no change -

87

Quality: HCAI

What are our key issues impacting delivery?

Theme Issue description and root cause Mitigation Owner/ lead Resolution date

1 SRO with performance and contracting support to identify issues and mitigations to programme delivery

How are we performing?

KPI ELHCP Site/ Providers

MRSA

National

Target –

zero

tolerance

In Aug-19, NEL STP

providers reported 1 MRSA

case (from 0 cases in the

previous month).

• In Aug-19, there was 1 MRSA case

at Bart’s, up from 0 in the previous

month.

• Both BHRUT and Homerton reported

zero cases.

• Bart's = 1

• BHRUT =0

• Homerton =0

• MRSA Provider assessment is based

on Hospital onset cases, therefore

Community onset cases have been

excluded.

C.diff

11 =

Cumulative

threshold

for NEL

STP

Providers

In Aug-19, there were 10

cases of C.diff attributed to

NEL STP providers, 3 more

than reported in the

previous month.

NEL STP remains

compliant with the

threshold.

• In Aug-19, Bart's reported 10 cases

of C-diff from 7 in the previous month

against a threshold of 8.

• BHRUT reported 0 cases of C.diff in

Aug-19, same as the previous month

against a threshold of 2.

• Homerton reported 0 cases of C.diff

in Aug-19, the same as in the

previous month against a threshold of

1.

88

Quality: Mixed Sex Accommodation (MSA)


Providers Issue description and root cause

1. Barts Breaches are occurring at Newham and Whipps Cross, though Whipps Cross has seen a general reduction over the last few months. All breaches remain

related to discharge from critical care areas at the time of step down to level 1.

2. BHRUT MSA breaches reported is higher than expected due to issues with step down from critical care.

How are we performing?

KPI ELHCP Site/ Provider Tables and graphs

The MSA breach

rate target is zero.

In Aug-19, NEL STP

providers reported a

total of 19 MSA

breaches (a reduction

of 3 cases from the

previous month).

NEL STP providers

cumulative 2019/20

YTD position is 100

MSA breaches.

• BHRUT reported 2 MSA

breaches in Aug-19, 4

fewer than the previous

month. Cumulative

2019/20 YTD position is

24.

• Bart's reported 17 MSA

breaches in Aug-19, 1

up from 16 in the

previous month.

Cumulative 2019/20

YTD position is 76.

• Homerton reported 0

MSA breaches in Aug-

19, the same as in the

previous month.

Cumulative 2019/20

YTD position is 0.

89

Never Events

Serious Incidents

• BHRUT – Reported (9) serious incidents in September with 42 out of the reported 74

currently remaining open from April to date. No performance issues identified. Main

themes – Diagnostic Delays, falls resulting in harm, treatment delays and maternity.

• Barts Health – Reported (13) serious incidents in Sept-19.

• HUH- Reported (19) serious incidents between 1 April to 30 September 2019, themes

are falls, pressure ulcers and lack of risk assessment and documentation, no concerns

on numbers or themes

• NELFT: Reported (6) serious incidents for WEL in Sept-19 with key themes identified

as pressure ulcers, attempted/ actual suicide and deterioration. NELFT also reported

(9) serious incidents for BHR in Sept-19 and main themes attributed to pressure ulcer,

self-inflicted harm and sub-optimal care of the deteriorating patient.

• ELFT: Reported (5) serious incidents in Sept-19 with key themes identified as

attempted/ actual suicide, violence and aggression.

NEL Acute Providers have reported a total of 13 Never Events for 2019/20 YTD

• BHRUT – The Trust has reported (4) Never Events for 2019/20 YTD and all attributed to retained foreign object post procedure. External

thematic review currently underway looking at common root causes, especially human factors.

• Barts Health – The Trust has reported (7) Never Events for 2019/20 YTD and three of these were at Wx, two at NUH and the remaining

two at RLH. The site level reasons detailed are:- Wx - Wrong block The nerve block was administered to the wrong site, Mis-selection of

high strength midazolam during conscious sedation. NUH - Wrong implant/prosthesis, Wrong site surgery. RLH - Wrong teeth removed,

Unintentional connection of a patient requiring oxygen to an air flowmeter.

• HUH: The Trust reported (2) Never Events at HUH for 2019/20 YTD with both occurring in the month of May - wrong implant (IUD) and

wrong site surgery (wrong mole removed).

• NELFT: Reported zero (0).

M6 key updates– (Serious Events and Never Events)

90

Safety: CQC Updates


Provider Rating

1 ELFT Outstanding

2. NELFT BHR: significant concerns, remedial action plan in place. Now Requires Improvement.

Regulation 28 issued for patient suicide

HEE significant concerns

WEL: Recent inspection requires Improvement (key issue: crisis care)

3. Barts Requires Improvement (NUH – RI; WX – RI; RLH – Good; SBH – Good) – key issues: NUH maternity; NUH Diagnostics

4. WEL Care

Homes

Quality issues highlighted

Newham (6 homes) : 2 Inadequate, 2 Requires Improvement , 2 Good

WF (3 homes) : 2 good, 1 Requires Improvement

THCCG (2 homes) : Both Require Improvement

5. BHRUT CQC are currently on site and in the process of a comprehensive style inspection.

HEE significant concerns – remedial actions in place monitored by HEE.

6 Homerton CQC are visiting Homerton and inspecting acute, community and Mary Seacole Nursing Home. CQC meeting with HUH mid-December

and they will then inspect HUH sometime in a 12 week period after that. HUH well led review is expected during this period as well.

91


13 November 2019

Title of report Changes to the System Financial Framework:

Financial Improvement Trajectories and Indicative Financial Recovery Allocations

Item number 6.1

Author Dion Davies & Thomas Rollason

Presented by Henry Black

Contact for further information Dion Davies

Executive summary A paper to present the changes to the system financial framework for a 4-year period from 2020/21, with particular focus on the introduction of Financial Improvement Trajectories.

Action required For information.


N/A

Strategic fit



Effects the level of financial co-ordination and integration required between commissioner and provider partners.


No direct effect. Indirectly, it should encourage a closer financial relationship between system partners.


No direct effect.


Changes imposed on to the system for sustainability funding for providers. Further changes to the allocation of ‘bonus’ PSF payments to providers in relation to their control totals.

Risks Financial improvement targets are assigned to providers and commissioners, risk on system financial stability if these cannot be delivered.

92


Changes to the System Financial Framework:

Financial Improvement Trajectories and Indicative Financial Recovery Allocations

On 4 October 2019 Sir David Sloman the NHS Regional Director wrote to NEL STP to outline developments in the NHS financial regime.

The letter sets the scene by revisiting the objective to return the NHS to balance and the three interrelated objectives:

1. Continuing to balance the NHS’s books nationally across providers and commissioners;2. Reducing the aggregate provider deficit each year and returning the provider sector to balance in

2020/21; and

3. Reducing year-on-year the number of trusts and CCGs individually in deficit, so that all NHSorganisations are in balance by 2023/24.

The letter then reiterates a number of elements that have changed in the financial framework from 2019/20 intended to improve system working, including:

Building to removal of financial control totals in 2020/21; Transferring £1bn from PSF in to the national prices; Reducing CQUIN to 1.25% Replacement of existing support funds PSF and CSF with FRF (Financial Recovery Fund)

available to both providers and commissioners.

A number of the actions that have taken place to support long term planning:

Published 5 years of CCG & Primary Care allocations; LTP Transformation funds published; Provided indicative specialist commissioning allocations to providers.

The main points of the letter cover the following:

1. Sharing of Financial Trajectories and indicative FRF allocation; and2. Efficiency expectation of 1.1% across all organisations and an extra 0.5% for those not in surplus

The letter includes deficit reduction trajectories for both deficit providers (Barts and BHRUT), surplus targets for the current surplus providers (ELFT and Homerton) and a surplus expectation for BHR CCGs.

93


Table 1. System Trajectories and Indicative FRF –by organisation

Under the new reporting regime, the ELHCP system (including FRF) would move into surplus by 23/24.

To note – the draft LTP financial plan submitted did not achieve the system wide trajectory despite higher efficiencies in all organisations except C&H:

Table 2. Efficiencies % by organisation September Draft LTP

Projection =====>2020/21 2021/22 2022/23 2023/24

ICS CCG Code % % % %BHR Barking an07L ‐2.7% ‐2.5% ‐2.2% ‐2.2%

BHR Havering 08F ‐2.8% ‐3.4% ‐2.7% ‐2.4%

BHR Redbridge08N ‐2.2% ‐2.0% ‐1.8% ‐1.7%

C&H City & Hac07T ‐1.1% ‐1.1% ‐1.1% ‐1.1%

WEL Tower Ham08F ‐1.6% ‐1.5% ‐1.5% ‐1.5%

WEL Waltham F08W ‐1.7% ‐1.6% ‐1.6% ‐1.5%

WEL Newham 08M ‐1.5% ‐1.4% ‐1.4% ‐1.4%

Financial Improvement Trajectory

Indicative FRF

Financial Improvement Trajectory

Indicative FRF Financial Improvement Trajectory

Indicative FRF Financial Improvement Trajectory

Indicative FRF

excl. FRF excl. FRF excl. FRF excl. FRF£M £M £M £M £M £M £M £M

B&D 3.17 1.73 0.14 0.13

C&H

Havering 4.11 4.29 4.26 0.18

Newham

Redbridge 3.98 0.25 0.17 0.15

WF

TH

BHRUT ‐46.25 39.843 ‐42.91 39.843 ‐39.83 39.843 ‐37.1 37.1

Barts ‐85.39 39.843 ‐80.54 39.843 ‐76.44 76.44 ‐72.69 72.69

ELFT 2.25 2.33 2.41 2.49

HUH 1.68 1.74 1.79 1.85

NELFT

Total ‐116.45 79.686 ‐113.11 79.686 ‐107.5 116.283 ‐104.99 109.79

Target inc FRF ‐36.764 ‐33.424 8.783 4.8

2020/21 2021/22 2022/23 2023/24

94


The letter identifies a number of areas where changes are going to take place and we can expect further notification:

1. The new FRF regime is seen to enable a move away from nationally mandated surplus control totals,on the basis that surplus organisations should determine level of surplus appropriate to theircircumstances and commensurate with their own investment and transformation plans,

2. Expect discussions with the sector level regulators on supporting regulatory architecture and inparticular the capital and loan funding regime

3. Over next couple of months development of a regulatory regime to recognise position oforganisations in balance, in receipt of FRF and those off plan.

4. FRF allocations will be earnt by receiving organisations achieving their target, however, a materialproportion of the FRF will be linked to achieving the system financial improvement trajectories, inorder to encourage system working.

o National guidance will be issued alongside operational planning guidance for 2020/21explaining how this will work in more detail

5. There is an expectation that the system trajectory target is reflected in the final ELHCP plan andmust include any costs associated with financing deficits not covered by FRF.

6. Net neutral changes to organisational trajectories are acceptable7. All the trajectories and FRF may be subject to change8. There is a plan to introduce a scheme for providers that deliver their breakeven and surplus

trajectories, comprising 2 elements;o One year transitional arrangement reward payment of 0.5% of relevant income for existing

providers in surplus (break even? Not clear) before sustainability funding that deliver surplus(trajectory target? Again not clear) in 2020/21

o Reward payment for deficit organisations reaching breakeven during the planning period(20/21 – 23/24?). Which will deliver 0.5% reward at end of year breakeven achieved andagain at end of subsequent year if breakeven maintained.

o Expect further information alongside 2020/21 planning guidance

To note: the desire to let organisations determine their surplus/Break even position in light of their circumstances may be sensible; however, a system trajectory target that requires these organisations to be in surplus to a specified level at first glance seems contradictory,

There is a great deal of additional guidance to be expected, which will no doubt provideclarity on these issues,

Allowing surplus provider organisations within a system to determine their own target locallycould undermine delivery of a system target derived nationally,

Some clarity as to whether CCG surplus targets are also open to local determination would bedesirable.

Projection =====>ICS Provider 2020/21 2021/22 2022/23 2023/24

% % % %WEL ELFT ‐2.3% ‐2.2% ‐2.3% ‐2.3%

WEL Barts ‐3.0% ‐2.9% ‐2.5% ‐2.5%

BHR NELFT ‐3.3% ‐1.6% ‐1.3% ‐1.4%

BHR BHRUT ‐4.5% ‐3.1% ‐2.9% ‐2.3%

C&H Homerton ‐3.2% ‐3.2% ‐2.9% ‐2.8%

95


Final area covered related to recently published Health Infrastructure Plan (HIP) and highlighted proposals for improvement to allocation approval and governance of capital regime:

Moves towards giving systems multiyear certainty to prioritise capital needs and funding at locallevel;

Flagged that there is a need for capital allocations to take into account accumulated cashreserves/revenue surpluses so there is a benefit of being in balance

To note: no comment on improving the ‘emergency’ loan sign off process and none of this wold appear to help our organisations with the biggest capital investment requirements.

96


Summary of Financial Changes

Known Changes

Historical Systems Changes in 2019/20

Change in Funding

Commissioner Sustainability Fund

Merged into a Financial Recovery Fund to be predominantly provided (exclusively in NEL) to Providers.

Provider Sustainability Fund

£1bn Part Moved into national prices

CQIN @ 2.5% CQIN @ 1.25%

Increased Publication

Shorter term allocations Publication of 5 year CCG Allocations

Publication of indicative Spec Comm Allocations

Publication of Long Term Plan Transformation Funds

Future Changes

Historical Systems Changes for 2020/21


In‐year control total targets

Published Financial Improvement Trajectories (FIT)

Linked to indicative FRF allocations

Change in Funding

CCGs must move towards 1% cumulative Surplus

CCGs not currently at 1% cumulative surplus must deliver an additional 0.5% efficiency

Cash flow loans to Trusts from DHSC

FRF allocations expected to minimise any such loans

Relationship Change

Nationally mandated control totals for all

Reduced interventions in in‐balance and surplus organisations.

Change in Funding

System Control totals monitored but no direct link to PSF allocation

System Financial Improvement Trajectories

Linked to part of FRF allocation


Organisational FIT can be changed as long as net‐neutral across system

Change in Funding

Greater surplus than planned providers receive 'bonus' PSF

1 Year Non‐Recurrent Bonus (0.5% of relevant income) ‐ NB these payments must better the provider’s bottom lines i.e. they can't be spent

Deficit provider reaching breakeven in‐year

2 Years Non‐Recurrent Bonus (0.5% of relevant income) ‐ NB these payments must better the provider’s bottom lines i.e. they can't be spent

NHSE Led Capital Programme

Health Infrastructure Plan ‐ Government announced hospital (re)building programme

NHSE Led Capital Programme

Multi‐Year capital plans to be developed

97

Sir David Sloman Regional Director Wellington House

133-155 Waterloo Road London

SE1 8UG

4 October 2019

Jane Milligan

North East London

1st Floor, Vicarage Lane Health Centre

10 Vicarage Lane

London

E15 4ES

Dear Jane,

Financial improvement trajectories and indicative Financial Recovery Fund allocations

Thank you for your continued leadership of the strategic planning process for your system. As

set out alongside the NHS Long Term Plan (LTP), we want financially sustainable services to be

the norm; for quality, efficiency and effectiveness to continue to improve; and for health

inequalities and unwarranted variation to be addressed.

As you know, putting the NHS back onto a sustainable financial path is a key priority in the LTP

and is essential to delivering the service improvements it contains as well as meeting the

government’s tests. This includes returning the NHS to financial balance by achieving three

interrelated objectives:

- continuing to balance the NHS’s books nationally across providers and commissioners;

- reducing the aggregate provider deficit each year and returning the provider sector to

balance in 2020/21; and

- reducing year-on-year the number of trusts and CCGs individually in deficit, so that all

NHS organisations are in balance by 2023/24.

For 2019/20 we made a number of changes to the financial framework for NHS organisations.

The measures we introduced were designed to encourage system working and build towards

the removal of financial control totals from 2020/21. They included transferring £1 billion from

the Provider Sustainability Fund into national prices, reducing the value of CQUIN to 1.25% and

creating the FRF.

98

At the same time, we also sought to set a realistic national efficiency requirement for all

organisations and to give local systems certainty about the future resources available to them

and the financial ‘ask’ over the LTP period. We published five years of core CCG and primary

care allocations, gave local systems greater certainty over future funding for LTP commitments,

and greater control over how those funds are deployed. Indicative specialised commissioning

allocations have also been supplied at provider level.

We recognise that, to date, you have been developing your strategic plans to deliver stretching

but achievable levels of financial performance, but without bespoke trajectories specific to each

organisation. We are now in a position to be able to share, for the organisations in your system,

the financial improvement trajectories and indicative Financial Recovery Fund (FRF) allocations

for the purposes of strategic planning. You should consider these as you continue to develop

your strategic plans and they should be reflected in the final plans due to be submitted in mid-

November.

At the heart of the approach is a more realistic national efficiency requirement for all

organisations, with the default annual national tariff efficiency factor being set at 1.1%, and

providers in deficit and CCGs yet to achieve a cumulative surplus of 1% are expected to reduce

their deficit by delivering additional efficiency of at least 0.5%, until they are back in balance.

Organisations with the largest deficits will be expected to deliver against the more stretching

trajectories and return to balance at the fastest pace. All organisations will be held more robustly

to account for delivering financial improvement over the period at these stretching but

achievable levels.

As previously signalled, to continue the process of reform, from 2020/21 we are proposing to

simplify the funding arrangements and recognise the reality that, whether financed through

distressed finance loans, PSF or FRF, deficits impose a cost on the rest of the NHS. We need

to materially reduce the size of deficits over the next four years by placing a greater requirement

on organisations with the biggest deficits to reduce waste and improve efficiency. We are in

discussions with the Department for Health and Social Care (DHSC) about the balance of cash

and loan funding in the future financial framework. To aid planning we are though now giving

indicative figures for cash financing through the FRF. The FRF has been allocated to minimise

the number of organisations which would require loan financing if they hit their deficit recovery

trajectories, whilst at the same time ensuring that organisations requiring loan financing also

receive an appropriate share of the funding available.

As indicated in previous guidance, from 2020/21 what remains of the Provider Sustainability

Fund (PSF) will be transferred into the FRF, as will the Commissioner Sustainability Fund

(CSF). The FRF will therefore be available to both providers and CCGs in deficit (although the

vast majority of sustainability funding is expected to continue to flow to providers). Crucially, this

will allow us to begin to move away from nationally-mandated surplus control totals, and, as a

result, reset our regulatory relationship with organisations which are at least in balance. We

believe that such organisations should have the freedom to determine the levels of surplus

appropriate to their circumstances and commensurate with their own investment and

transformation plans. We will continue discussions with the sector on the supporting architecture

and, in particular, the operation of the capital and loan funding regimes. Critically, over the next

couple of months we will further develop the regulatory regime to recognise the position of

organisations in balance, in receipt of FRF and those of which are off-plan.

99

Although the main requirement for organisations to earn their FRF allocations will be the

delivery of their own financial improvement trajectories, a material proportion of FRF allocations

will be linked to the achievement of system financial improvement trajectories (calculated by

summing the financial improvement trajectories of the organisations within systems) in order to

encourage system working. Separate national guidance will be issued alongside operational

planning guidance for 2020/21 setting out in more detail how this will work.

The financial trajectories and indicative FRF allocations for the organisations in your system are

set out in Appendix 2. The financial improvement trajectory figures represent the financial

performance (after payment of MRET, where relevant) we expect the organisations in your

system to be able to achieve before any FRF. As well as the efficiency requirements outlined

above, the trajectories reflect the approaches to financial risk management taken by my regional

team. These figures are also being communicated individually to organisations. The trajectories

and FRF allocations are based on the strategic planning assumptions and may be subject to

change including, for example, the distributional impacts of certain changes to the national tariff.

You should ensure that the final version of your strategic plan is consistent with these

trajectories and includes any costs associated with financing deficits not covered by the FRF

(which should be separately identifiable).

There is an expectation that systems work together to shape plans and agree any changes to

organisational trajectories to reflect local circumstances. Changes need to be net-neutral within

a system for each year.

Tables summarising the derivation of the financial improvement trajectories for the organisations

in your system are contained in Appendix 1. Please contact [email protected] if you would

like to discuss in more detail how the trajectories have been derived.

We are also planning on introducing a scheme for providers that deliver their breakeven and

surplus financial improvement trajectories, who will no longer receive PSF and will not be

allocated FRF. This will comprise two elements; firstly, a one-year transitional reward payment

worth 0.5% of relevant income for providers currently in surplus (before sustainability funding)

that deliver a surplus again in 2020/21, and secondly, reward payments for deficit providers

reaching breakeven during the planning period. The latter scheme will provide a 0.5% reward

payment at the end of the year in which breakeven is achieved and at the end of the

subsequent year, provided financial performance is maintained. Reward payments will be

expected to improve providers’ bottom lines. We will also need to consider links to system

performance. Further information will be provided alongside operational planning guidance.

Finally, I wanted to draw your attention to the Health Infrastructure Plan (HIP), published by the

DHSC on Monday. The HIP confirms the new large hospital building programme announced by

the Government over the weekend. Those trusts that have been announced as receiving

funding in the first phases of the HIP should be receiving confirmation letters from DHSC

shortly. We will also shortly write to those concerned to confirm details of the necessary

business case approvals process. Trusts that are not currently part of HIP1 and 2 should

continue developing their plans and priorities for local NHS infrastructure, and where

exceptionally strong schemes come to light, we and DHSC will consider these in the context of

available funding. We are also working with the Government on securing much needed mental

health and primary care capital investment. The HIP document also sets out some proposals for

improvements to the allocation, approval and governance of the capital regime. While there is

100

mailto:[email protected]

further work to do to develop these, it includes positive moves towards giving systems multi-

year certainty to prioritise their capital needs and funding at a local level, although we have also

been clear that we need to ensure that any capital allocations take into account accumulated

cash reserves and revenue surpluses to ensure there continues to be a benefit for those

systems that have delivered and maintained overall financial balance in line with their financial

recovery trajectories.

I look forward to receiving your final strategic plans in November.

Your sincerely,

Sir David Sloman

Regional Director

101

Appendix 1

Summary of derivation of financial improvement trajectories

NHS Barking and Dagenham CCG - £m 2020/21 2021/22 2022/23 2023/24

Financial improvement trajectory (pre FRF) 3.170 1.730 0.140 0.130

Indicative FRF - - - -

Indicative financial improvement trajectory (including FRF) 3.170 1.730 0.140 0.130

Note 1: Baseline is the prior year trajectory excluding the prior year’s CSF (for 19/20) and assumed FRF

Note 2: Adjustments include inflation/volume pressures, MFF impact and ambulance funding pressure

Note 3: CCGs with historic cumulative deficits are expected to move towards delivering an in-year 1% surplus until 1%

cumulative surplus is achieved. Positive values represent additional efficiencies required over the 1.1% in tariff. Where

the trajectory is better than what the allocations growth/known financial impacts would suggest, the table will not cast.

NHS City and Hackney CCG - £m 2020/21 2021/22 2022/23 2023/24

Financial improvement trajectory (pre FRF) - - - -


Indicative financial improvement trajectory (including FRF) - - - -






NHS Havering CCG - £m 2020/21 2021/22 2022/23 2023/24









NHS Newham CCG - £m 2020/21 2021/22 2022/23 2023/24




102






NHS Redbridge CCG - £m 2020/21 2021/22 2022/23 2023/24









NHS Tower Hamlets CCG - £m 2020/21 2021/22 2022/23 2023/24









NHS Waltham Forest CCG - £m 2020/21 2021/22 2022/23 2023/24









Barking, Havering and Redbridge University Hospitals NHS Trust -

£m 2020/21 2021/22 2022/23 2023/24

Baseline (excluding FRF, PSF and MRET) (see note 1) (55.084) (50.551) (47.211) (44.131)

MRET funding 4.301 4.301 4.301 4.301

103

Adjustment for financial impacts (see note 2) (1.132) (1.869) (1.719) (1.698)

Additional performance improvement requirement (see note 3) 5.665 5.209 4.799 4.428

Financial improvement trajectory (pre FRF) (46.250) (42.910) (39.830) (37.100)

Indicative FRF 39.843 39.843 39.830 37.100

Indicative financial improvement trajectory (including FRF) (6.407) (3.067) - -

Note 1: Baseline is the prior year trajectory excluding the prior year’s PSF (for 19/20), non-recurrent MRET and assumed

FRF. Trajectories have been adjusted for any asset disposals in the baseline.

Note 2: Adjustments include impacts due to MFF and AfC changes, activity growth and national tariff cost uplift and

efficiency factors.

Note 3: Positive values represent additional efficiencies required over the 1.1% in tariff. Where the trajectory is better

than what the MRET/known financial impacts would suggest, the table will not cast.

Barts Health NHS Trust - £m 2020/21 2021/22 2022/23 2023/24

Baseline (excluding FRF, PSF and MRET) (see note 1) (118.653) (94.750) (89.900) (85.800)

MRET funding 9.360 9.360 9.360 9.360


Additional performance improvement requirement (see note 3) 29.222 10.120 9.495 9.225

Financial improvement trajectory (pre FRF) (85.390) (80.540) (76.440) (72.690)

Indicative FRF 39.843 39.843 76.440 72.690

Indicative financial improvement trajectory (including FRF) (45.547) (40.697) - -




efficiency factors.



East London NHS Foundation Trust - £m 2020/21 2021/22 2022/23 2023/24

Baseline (excluding FRF, PSF and MRET) (see note 1) 2.364 2.250 2.330 2.410

104

MRET funding - - - -

Adjustment for financial impacts (see note 2) (0.300) (0.278) 0.230 0.212

Additional performance improvement requirement (see note 3) 0.186 0.358 - -







efficiency factors.



Homerton University Hospital NHS Foundation Trust - £m 2020/21 2021/22 2022/23 2023/24

Baseline (excluding FRF, PSF and MRET) (see note 1) 0.377 (0.607) (0.547) (0.497)

MRET funding 2.287 2.287 2.287 2.287


Additional performance improvement requirement (see note 3) - 0.580 0.479 0.531







efficiency factors.



105

Baseline (excluding FRF, PSF and MRET) (see note 1) - - - -

MRET funding - - - -

Adjustment for financial impacts (see note 2) 0.404 (0.207) 0.230 0.210

Additional performance improvement requirement (see note 3) - 0.207 - -







efficiency factors.



106

North East London NHS Foundation Trust - £m

2020/21 2021/22 2022/23 2023/24

Appendix 2

System financial improvement trajectories and indicative financial recovery fund allocation

North East London

£m 2020/21 2021/22 2022/23 2023/24

% In

System

Financial

Improvement

Trajectory

(excl FRF)

Indicative

FRF

Allocation

Financial

Improvement

Trajectory

(excl FRF)

Indicative

FRF

Allocation

Financial

Improvement

Trajectory

(excl FRF)

Indicative

FRF

Allocation

Financial

Improvement

Trajectory

(excl FRF)

Indicative

FRF

Allocation

NHS Barking and

Dagenham CCG 100% 3.170 - 1.730 - 0.140 - 0.130 -

NHS City and

Hackney CCG 100% - - - - - - - -

NHS Havering CCG 100% 4.110 - 4.290 - 4.260 - 0.180 -

NHS Newham CCG 100% - - - - - - - -

NHS Redbridge CCG 100% 3.980 - 0.250 - 0.170 - 0.150 -

NHS Tower Hamlets

CCG 100% - - - - - - - -

NHS Waltham Forest

CCG 100% - - - - - - - -

Barking, Havering and

Redbridge University

Hospitals NHS Trust

100% (46.250) 39.843 (42.910) 39.843 (39.830) 39.830 (37.100) 37.100

Barts Health NHS

Trust 100% (85.390) 39.843 (80.540) 39.843 (76.440) 76.440 (72.690) 72.690

East London NHS

Foundation Trust 100% 2.250 - 2.330 - 2.410 - 2.490 -

Homerton University

Hospital NHS

Foundation Trust

100% 1.680 - 1.740 - 1.790 - 1.850 -

107

North East London

NHS Foundation

Trust

100% - - - - - - - -

Total (116.450) 79.687 (113.110) 79.687 (107.500) 116.270 (104.990) 109.790

108

Joint Commissioning Committee 13 November 2019

Title of report NEL approach to risk management

Item number 7.1

Author Kate McFadden-Lewis, Board Secretary, NELCA

Presented by Kash Pandya


Executive summary Good governance requires each committee to hold a risk register for its responsibilities. The NELCA JCC risk register is based on the JCC objectives and covers:

S1 Robust demand and capacity planning across NEL

S2 Improving self care and demand management and increasing care closer to home

S3 Securing the future of NEL health and social care providers and commissioners

S4 Improving the commissioning of specialised care

S5 Securing local council leadership for key NEL programmes

S6 Delivery of primary care at scale

E1-3 Enabling programmes of workforce, digital and estates

AD1 Streamlined and robust assurance on system transformation and improvement plans

AD2 Integrating CSU services into CCGs where required.

To reflect the move towards a NEL ICS from 2021, the current NELCA JCC risk register is under review, and the proposed changes detailed in this report.

Action required The Committee is asked to agree the proposed changes to arrangements for risk management, including holding a Board Development session on the NEL JCC approach to risk management.


JCC risk group 28 October 2019.

Strategic fit:



The risk register notes the main risks and mitigating actions to deliver the NELCA priorities. The risks should be considered and integrated into local CCG Board/Joint Committee Assurance Frameworks where required.


The risk register sets out the key actions being implemented to address any finance, performance or quality risks.


Highlighting the risks to deliver the NELCA priorities within the Scheme of Delegation, and the actions taken to minimise the impact of those risks, is part of making sure the work of the JCC is transparent and accountable to local people.

Risks Inadequate governance arrangements, and/or failure to operate an effective approach to risk management would expose NELCA to the risk that appropriate mitigations are not able to be identified and put in place, and therefore the JCC’s stated objectives are not able to be achieved.

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Current NELCA JCC Risk Register, purpose and background

1. The Joint Commissioning Committee has a responsibility to maintain sound risk managementprocesses and ensure that internal control systems are appropriate and effective and where necessary to take remedial action. It is a key part of good governance.

2. The purpose of the Joint Commissioning Committee risk register is to set out the key risks to theNorth East London Commissioning Alliance (NELCA) in achieving its objectives and priorities andthe actions in place to manage those risks.

3. The risk register is organised around the NELCA corporate objectives. The JCC has set out itsforward plan that includes updates on its key strategies and programmes. The risk register will beupdated each time to reflect the progress being made, as well as identifying any new risks from theconsideration of its business.

Risk register review – preparing for NEL 2021 commissioning arrangements

4. The current NELCA JCC risk register is under review to reflect the move towards a NEL ICS from2021, section below refers. In the interim, individual NEL CCGs continue to manage risks through their own board/joint committee assurance framework (AF) arrangements. The NELCA JCC risk register only considers the responsibilities delegated by the CCGs to the JCC and the progress being made to mitigate any resultant risks.

5. Following discussions with Audit Chairs and JCC Members, it has been agreed to keep the riskmanagement and the risk register under review to ensure the risk arrangements are robust andembedded firmly within the ELHCP, Alliance and its member CCGs. Further work is underway,aligned to the review of NEL risk management arrangements, to improve the approach. Many ofthe risks identified in the register are ones that apply equally to the ELHCP as much as to NELCA.Given this, it is intended to explore how we can move potentially to a common NEL risk register,while recognising the formal accountability back to respective organisations.

6. The JCC is currently only delegated some risks by the CCGs, with the bulk of the risk managementbeing managed through the CCG AFs and the robust processes behind them. With the ambition tobecome a NEL ICS by 2021, the current JCC risk register is being reviewed and revised to ensure itreflects the key risks to the overall system, including, where appropriate, those related to the 2021programme which sets out how we will get there (noting that the programme will have its own riskregister covering all risks within the programme workstreams).

7. It is envisioned that the risks to delivery of the NEL strategic delivery plan will become the basis ofthe NEL ICS risk register. Once the NEL Long Term Plan priorities have been agreed, and timelinefor their delivery, this will inform the NEL risks and their management.

8. The proposed new format of the risk register, which will show one risk per page, and includeprogress of the risk score against a trajectory, as well as clearly outlining how and where the risk ismanaged, was agreed in principle at the July 2019 JCC meeting.

9. A ‘task and finish’ risk group which includes two audit chairs, the JCC nurse and governance staff isin place, meeting regularly and overseeing this work. The group have agreed a number of principlesand actions, including:

the NEL SMT team will own the risk register and be responsible for ensuring that the risksare regularly reviewed in detail

each risk will be assigned an SRO/ SMT lead and relevant committee (once they areestablished)

each risk will include evidence for the mitigations, and show volume indicators to show themovement of the risk score over time

the group agreed that it would be helpful if timescales were not restricted to one year where appropriate risks from the 2021 programme, as managed by the NEL 2021

programme board via the NEL 2021 risk register will be escalated to the JCC forconsideration (in line with the risk rating methodology)

110


CCG risk registers will be reviewed and compared, and a decision made on any risks thatneed to be escalated to the JCC register

a common template for risk management/ AFs across NEL will be established in the lead upto NEL 2021

the JCC risk register is a ‘living document’ and always evolving.

10. the risk management group strongly recommends that, in order to make further progress on thereview of the risk register, an executive officer is assigned to be accountable for the delivery of therevised approach to risk management.

Process for escalating and deescalating risks

11. As the JCC is a collaborative committee of all CCGs, each Governing Body must own the risk andassociated mitigating action through its risk management arrangements. For risks that are red-rated (scored 15 or greater), CCGs should ensure that these are covered in their own risk registers and Board Assurance Frameworks.

12. CCG risk registers will be regularly reviewed, risks that are common across the seven CCGs will bereviewed for potential inclusion on the JCC risk register.

13. The risk group has recommended that a JCC OD session is dedicated to the approach to riskmanagement, including a review of current risks, how new risks are identified, and a robustdiscussion around risk tolerance and appetite.

Risk appetite and tolerance

14. In order for the JCC to achieve its objectives, and improve healthcare for the population of NEL, it isrecognised that a degree of risk must be taken, with a range of appetites for different risks. It is to be expected that risk appetite will change over time, and will be dependent on current performance. For example, good performance will allow greater risk to be taken with pilots and innovations aimed to result in better performance.

15. The risk review uses the standard NHS methodology that considers the likelihood of the riskalongside its severity. Both measures are scored out of 5 (with 5 being the most likely and worstimpact). The risk score takes account of the mitigating action proposed. This then gives a risk scoreand categorisation of:

16. It is proposed that the JCC have a robust discussion around the level of risk that will be toleratedagainst the categories of risk we face across all business areas. We will ensure that robust plansare put into place to lower the level of risk for any rated severe (scored 15 or above on the riskmatrix), as well as any of the different types of risk at a rating greater than those agreed for thevarious business areas.

Next steps, to be agreed: 1. dedicate an hour of the 11 December JCC OD session to a discussion on the approach to risk

management in preparation for NEL 2021, including a robust discussion and review of current risks and mitigations as well as general agreement on risk appetite and tolerance

2. agree an executive officer who is accountable for the delivery of robust risk management acrossNELCA

3. following this session, bring the revised risk register to JCC meetings.

Risk rating Risk Score Low 1 – 3 Medium 4 – 6 High 8 – 12 Severe 15 - 25

111


Joint Commissioning Committee and Clinical Senate meeting plan – 2019/20

Regular items:

Minutes / Action log/ Questions from the public Performance report – tailored to the agenda items and include friends and family test Future of commissioning – 2021 vision Risk register Meeting plan

Clinical Senate Joint Commissioning Committee

Month Subject / Topic Month Items

10 April

Stroke Network – developing collaborative,system wide clinical approaches across NEL

East London Prevention Program (ELoPE) –Promoting the coordination of CVD preventionacross NEL

10 April Moorfields Hospital proposals - Pre Consultation Business

Case – part II

8 May

Neurosurgery provision/reconfiguration acrossNEL

Integrated Care System & ELHCP governanceupdate

8 May

STP refresh update

Cancer Diagnostic Hub: update on patient engagement

North East London Spending Money Wisely Programme update

12 June

Stroke – Presentation of a proposed uniformstroke care pathway for NEL – Senate tocontribute support via input, feedback and nextsteps.

Neuro-Rehab – INEL STB overview ofprogramme

Spending Money Wisely – Update paper onlycirculated (no presentation)

12 June OD session – future of commissioning

Item 8.1

112


10 July Mental Health – LTP developments; senate to

input and feedback 10 July

ELFT update

Better Care Fund – update

ELHCP Transformation Programme

Update on development of LTP

o to include NELCA progress on the LTP vision

14 August LTP and London vision 14 August OD session - cancelled

11 September

Primary Care Networks – Consideration ofuniform PCN structures and governance acrossNEL that promote collaboration and integration.

NEL LTP Enabler Workstream programmeupdate: Digital Transformation.

11 September

Long Term Plan draft submission

Barts Health surgical strategy

Aligning Commissioning Policies – engagement outcome

Update on progress on the NEL child sexual abuse hubs

Mental Health Strategy- including crises intervention, suicideand veterans and Early Intervention in Psychosis

Update on LITA/HLP/CSU – part II

9 October Stroke – Strategic programme updates

Whipps Cross redevelopment progress update9 October OD session – Progress on digitalisation

13 November NEL Enabler Workstream programme update:

Workforce 13 November

HUHT update

Update on specialised commissioning

Progress on redeveloping Whipps Cross

Moorfields Consultation - update

Neurosurgery (part 2)

NHS Long Term Plan sign off (part 2)

11 December Medicines Optimisation - Strategic Programmeupdates

11 December

Pathology (part 2)

OD session:

Workforce strategy Approach to identifying and managing risk

8 January NEL LTP Enabler Workstream programme

update: Infrastructure (Estates)8 January

NELFT update

Future of commissioning – update

Medicines Optimisation strategy

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Estates Strategy update

Neuro-Rehab Level 2b business case

Better Care Fund update

12 February

Urgent & Emergency Care - StrategicProgramme updates

0 – 25 (Children’s & Young Persons) StrategicProgramme updates

Personalisation Strategic Programme updates

12 February OD session - Primary care at scale

11 March

ELHCP Clinical Senate review:

o Terms of Reference

o Membership

o Lessons Learnt/ Future Senatedevelopments for 20/21

11 March

BHRUT update

Operating Plan 2020/21

Transforming Care

Cancer

JCC Review:

o Terms of Reference

o 2020/21 programme

JCC to be scheduled: Vascular Acute paediatrics Health-based places of safety ICS system updates (WEL/ BHR/ C&H/ INEL) Demand management – update from demand and capacity group OD session on Health and Wellbeing Board plans.

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