nhs croydon clinical commissioning group governing … · presentation 6 2.20 mental health - new...

NHS CROYDON CLINICAL COMMISSIONING GROUP GOVERNING BODY

Meeting in Public

Tuesday 6 November 2018 2.00 – 4.00pm

Markee Room, Croydon Conference Centre,

Surrey Street, Croydon CR0 1RG

Croydon Clinical Commissioning Group Governing Body Meeting in Public

Agenda

Meeting: 6 November 2018, 2.00 – 4.00 pm Location: Markee Room Croydon Conference Centre, Surrey Street, Croydon

Members of the public are welcome to attend this meeting of Croydon CCG’s Governing Body meeting. There will be the opportunity to ask questions during the Open Space. Questions will be limited to one question, plus one supplementary question, per person.

Item Time Lead Enclosure

1 2.00 Apologies for absence Chair Verbal

2 Declaration of Interests

Chair Verbal

3 Minutes of the meeting held on 4 September 2018

Chair Enclosure 1

4 Matters Arising ▪ Action Log

Chair Enclosure 2

Standing Items

5 2.10 Joint Chair/Chief Officer Report For information

Agnelo Fernandes/

Andrew Eyres

Enclosure 3

Presentation

6 2.20 Mental Health - New Models of Care and Talking Therapies (IAPT) update

Stephen Warren

Presentation

Strategy

7

2.35

Croydon Partnership Early Help Strategy 2018 – 2020 For approval

Stephen Warren

Enclosure 4

8 2.45

Strategy and Business Planning Update For noting

Stephen Warren

Enclosure 5

Delivery

9 2.50 Operating Plan Progress report Quarter 2 2018/19 For noting

Stephen Warren

Enclosure 6

10 3.00 Integrated Performance & Quality Report Month 5 2018/19 For noting

Elaine Clancy

Enclosure 7

Governance

11 3.10 Report from Integrated Governance & Audit Committee For noting

Roger Eastwood

Enclosure 8

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3.15 ▪ Report from Finance Committee including expenditure decisions taken at Finance Committee

▪ 2018/19 Finance Period 6 (September 2018) ▪ 2018/19 QIPP Programme Period 5 (August 2018) ▪ Contracting Portfolio Report (TBC) For noting

Philip Hogan/

Mike Sexton Mike

Sexton/ Stephen Warren

Enclosure 9 Enclosure 9a Enclosure 9b Enclosure 9c

13

3.25 Report from Quality Committee For noting

Amy Page/ Elaine Clancy

Enclosure 10

14 3.30 Update from Primary Care Commissioning Committee (no report as Committee has not met since previous September meeting update to last Governing Body) For information

Philip Hogan / Martin

Ellis

Verbal

15

3.35 Report from the Committee for Collaborative Decision Making (Meeting as South West London Committees in Common) on 9th October 2018 For noting

Philip Hogan

Enclosure 11

16 3.40 Arrangements for signing of the Better Care Fund Section 75 Agreement for 2018/19 with London Borough of Croydon For approval

Martin Ellis Enclosure 12

Policy

17 18

3.45

3.50

Management of Conflict of Interest Policy ▪ Gifts & Hospitality ▪ Working with the Pharmaceutical Industry.

For approval

Revised Procurement Framework For approval

Elaine Clancy

Stephen Warren

Enclosure 13 Enclosure 14

For Ratification

19 Chair’s Actions ▪ Replacement of the current N3 network by the

new HSCN (Health and Social Care Network) sponsored by NHS Digital

▪ Transferring of Commissioning Responsibility for Wheelchair Provision to London Borough of Croydon under s75 Agreement

▪ Direct Award for the procurement of Telemedicine service for Care Homes

For ratification

Martin Ellis

Martin Ellis

Martin Ellis

Enclosure 15a Enclosure 15b Enclosure 15c

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For Information

20 Minutes of the Quality Committee For information

Amy Page Enclosure 16

21 Minutes of the Clinical Leaders Group For information

Agnelo Fernandes

Enclosure 17

22 Minutes of the Finance Committee For information

Philip Hogan

Enclosure 18

23 Minutes of the Primary Care Commissioning Committee For information

Philip Hogan

Enclosure 19

24 Minutes of the Integrated Governance and Audit Committee For information

Roger Eastwood

Enclosure 20

25 Register of Interests and Register of Gifts & Hospitality For Information

Elaine Clancy

Enclosure 21

Open Space for Public Questions

26 3.55

Any Other Business

27 4.00. Any other business

Chair

Date of next Meetings in Public of

8 January 2018: 14.00 until 16.00 Markee Room, Croydon Conference Centre

PART 2 Meeting to follow 16.00 – 17.00

A glossary of terms/abbreviations can be found at the back of the pack of papers Copies of the papers can be found at www.croydonccg.nhs.uk

To then resolve to exclude the public from the remainder of the meeting on the grounds that publicity would be

prejudicial to the public interest by reason of the confidential nature of the business

PART 2 – GOVERNING BODY MEETING IN PRIVATE

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Croydon Clinical Commissioning Group Governing Body Meeting in Public

DRAFT MINUTES

Date: Tuesday 04 September 2018 Time: 2:00pm – 4.00 p.m. Location: Markee Room, Croydon Conference Centre, Croydon

Present: In Attendance:

Governing Body Members ▪ Agnelo Fernandes (AF), Chair ▪ Andrew Eyres (AE), Accountable Officer ▪ Tom Chan (TC), Medical Director and

GP Governing Body Member ▪ Emily Symington (ES), GP Governing

Body Member ▪ Vaishali Shetty (VS), GP Governing

Body Member ▪ Mike Simmonds (MSi), GP Governing

Body Member ▪ Roger Eastwood (RE), Lay Member

Governance and Conflict of Interest Guardian

▪ Philip Hogan (PH), Lay Member – Finance

▪ Jon Norman (JN) Secondary Care Consultant

▪ Mike Sexton (MSe) Chief Finance Officer

▪ Elaine Clancy (EC) Director of Quality and Governance

▪ Martin Ellis (MC) Director of Primary and Out of Hospital Care

▪ Stephen Warren (SW) Director of Commissioning

▪ Rachel Flowers (RF) Director of Public Health, Local Authority

▪ Gordon Kay (GK), Healthwatch Manager ▪ Ben Smith (BS), Board Secretary

Apologies ▪ Amy Page (AP) Registered Nurse, Lay

Member

Apologies ▪ Guy Van Dichele (GvD), Interim Director

of Social Care and 0-65 Disability, Local Authority

Ref: 2018/09/01

1 Introduction and Apologies Action

1.1 1.2 1.3

Dr Agnelo Fernandes opened the meeting. There were no apologies for absence Dr Fernandes explained that Helen Pernelet, former Lay Member

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with the CCG had asked to observe and video record the meeting as part of doctoral research. There were no objections and members of the public in attendance were advised how to request withdrawal of footage in which they might appear.

Ref: 2018/09/02

2 Declaration Of Interests

2.1 There were no other specific declarations of interest other than the generic interest of practicing GPs.

Ref: 2018/09/03

3 Minutes of the last meeting

3.1 The minutes of the meeting held on 3 July 2018 were agreed as a true record.

▪

Ref: 2018/09/04

4 Matters Arising

4.1 4.2 4.3 4.4

The Action Log was reviewed Action 2018/07/06 was held open since Guy Van Dichele was not in attendance to provide an update around health visitor recruitment. For Action 2018/07/08, Elaine Clancy provided an update on the expected time of completion (November 2018) and planned opening of the new A&E at CHS but added that clarity would continue to be sought. Action 2018/07/10 was closed with the Care Home presentation on the agenda providing the update requested.

Ref: 2018/09/05

5 Joint Chair/Accountable Officer Report

5.1

5.2

5.3

5.4

5.5

Dr Agnelo Fernandes and Andrew Eyres presented the report.

Andrew Eyres announced the release of the latest Improvement

Assessment Framework (IAF) results from NHS England. Croydon

had seen its rating increased from Inadequate to Requires

Improvement.

Andrew Eyres explained that the CCG could not have achieved a

higher overall result due to the CCG’s financial position and being in

special measures in year. As the CCG plans to deliver a surplus

from this year onwards Andrew Eyres says he hopes to report

further improvement in the next results. Andrew Eyres said the

CCG is RAG ranked green for leadership with Governing Body and

positive assurance outturn. Highlighted Clinical areas included

areas Cancer (rated Outstanding) and Maternity (good).

Cheryl Coppell OBE was announced as independent Chair for

South West London STP partnership board.

Andrew Eyres reminded those in attendance that the Croydon CCG

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5.6

5.7 5.8

5.9

5.10 5.11

AGM is scheduled for 25th September 2018 and the public are

welcome in joining the governing body in celebrating achievements

over the last 12 months.

Agnelo Fernandes said he had attended a recent Health

Engagement event describing it to be very interactive and

additionally helpful to have SLAM Governors there ahead of

meeting together with Councillor Avis later in the month. The

meeting had generated ideas and indicated the issues that can be

prevented by improved joint working. Gordon Kay was thanked on

behalf of Healthwatch for organising this.

Agnelo Fernandes described the NHS 70 birthday celebrations that

had taken place both nationally and locally.

Agnelo Fernandes announced that Brian Dickens, previously

reported as having won a London Champion award for his work

around Social Prescribing had attended the national awards.

Jon Norman asked for context to be added in communicating the

reported standards due to the risk of scores being interpreted

negatively in respect of the CCG’s efforts in previous years.

Andrew Eyres explained that while parts of the standards are data

driven e.g. in the 360 survey, the CCG’s leadership past and

present were acknowledged to have made significant contribution to

the CCG’s improvement.

Paulette Lewis highlighted the work of the CCG’s engagement team

in making the Meet the Changemakers event a success

Croydon CCG’s work towards a staff volunteering policy was

praised by Emily Symington. Elaine Clancy described the work of

the Staff forum that also includes staff health and wellbeing

arrangements.

Ref: 2018/09/06

6 Presentation – New Models of Nursing Home Care

6.1 6.2

Martin Ellis introduced Kieran Houser, Head of Out of Hospital Care and Dr Rachel Tunbridge, GP Clinical Lead who gave a presentation on the business case work to include the transformational models of care within Care Homes as part of the One Croydon Alliance Out of Hospital programme. Dr Rachel Tunbridge and Kieran Houser spoke about the work underway to transform the care given to around 3,000 people across 131 care homes in Croydon. There is a strong case for change, Croydon care home residents currently experience 2,000 emergency admissions to hospital and 16,000 days spent in hospital each year. Kieran Houser informed members that the workforce skill mix in care homes can be very variable and staff turnover is generally high.

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6.3 6.4 6.5 6.6 6.7 6.8 6.9 6.10

The presenters said that Croydon needs a different way of thinking about supporting care home residents; hospital is rarely the best place for residents and around 200 care home residents die in hospital every year which often would not have been the resident’s choice. Kieran Houser advised that plans are underway to work with the Council to commission beds based on outcomes, linking to training, and targeting resources to where it is most needed. The CCG is exploring the introduction of telemedicine to reduce hospital admissions. A model was described to link care homes with a clinical triage hub over video phone to support care home staff. The scheme was reported to have been successful elsewhere in the country in improving care, easing demand on GPs and reducing admissions. Paulette Lewis asked about how residents, the public and the staff have been involved and presenters replied that while there is significant data analysis and engagement still to be done, there are a number of forums which include care home managers and staff to create change with them. Kieran Houser said it is recognised that staff development can be key in reducing staff turnover, as well as helping skill mix in care homes. Kieran Houser said the CCG and partners are also keen to develop a recognised and eventually accredited training course for care home staff. Martin Ellis added that one of the other benefits of telemedicine is that it can also provide some continuity for residents and staff. Kieran Houser replied to a challenge that training staff may increase the likelihood of leaving roles for higher paid employment saying that the CCG is working with the council to offer more money to care homes as payments for beds if they can demonstrate a certain level of skill, while uncertain if that will directly translate into higher pay for staff. Tom Chan asked what feedback about care home experience is gathered and how. Kieran Houser described Local Authority information gathering and added that the CCG is also looking at how to involve residents more, firstly by looking at the data and then perhaps developing a bespoke feedback survey for residents. Emily Symington welcomed the work and encouraged work to standardise good lines of communication of care plans. Rachel Tunbridge supported this and noted that some care homes do not currently access they Coordinate My Care system. Agnelo Fernandes referred to other aspects of transformation in the presentation including better integration across health and care services, in particular the award winning ‘red bag’ scheme, used in Sutton, that ensures key information accompanies a care home

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6.11

resident in ambulances and hospital. Agnelo Fernandes added that particular attention will need to be given to coordinating with all services including 111 ensuring patients receive care in the appropriate setting. Agnelo Fernandes also said that the same benefits need be introduced to all care homes suggesting potential nuances for Learning Disability homes and homes with BME residents that may need to be looked at in a different way. Contributors were thanked for the presentation.

Ref: 2018/09/07

7 Commissioning Intentions 2019/20

7.1 7.2 7.3 7.4 7.5 7.6 7.7

Stephen Warren introduced the latest draft of the 2019/20 Commissioning Intentions. The final draft will be sent by the end of September to the CCG’s providers. Stephen drew attention to discussions with GP networks and the One Croydon Alliance Transformation Plan. Stephen Warren described many of the intentions align with South West London CCGs having similar intentions and explained that the final version will include a chapter around the South West London STP. Common enablers will also be added to the final version. Agnelo Fernandes welcomed the evident progress, building on improvements since the CCG was established. Jon Norman sought clarification around reference to Maternity priorities around Choice. Members commented that choice is not always synonymous with less intervention and midwifery setting. There was a question around the recent publications concerning NICE standard around supporting non-emergency Caesarean section. Paulette Lewis asked how the ambition to meet national standards (with continuity of carer) around 50% of deliveries on pathway within around 6 months is to be delivered within existing resource. Agnelo Fernandes suggested this be considered as Governing Body seminar topic for more in-depth discussion. Stephen Warren agreed with Rachel Flowers’ suggestion that the section on joint commissioning is strengthened with reference to maternity linkages. The Governing Body: APPROVED the content of draft Commissioning Intentions and the approach taken towards approval and publication in September 2018

Ref: 2018/09/08

8 Integrated Performance Quality & Performance Report

8.1

Elaine Clancy presented the most recent Integrated Performance and Quality report based on validated month 2 2018/19 data.

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8.2 8.3 8.4 8.5 8.6 8.7 8.8 8.9 8.10

Elaine Clancy advised that sleep studies equipment issues had continued to cause the diagnostic standard to be narrowly missed in month but these were announced to have been resolved. 52 week waits continue to be a challenge, in particular with Kings College Hospital rather than Croydon’s local hospital, having a remedial action plan that the CCG continues to work on supporting commissioners and NHS Improvement (including close monitoring of Croydon patients). Performance at Croydon Health Services NHS Trust against the Emergency Standards were reported to remain extremely challenged though Elaine Clancy said the new A&E facility due to open later in the year has given optimism. Cancer standards were said to continue to show strong performance, and Croydon’s Improving Access to Psychological Therapies (IAPT) access compliance and access to treatment was reported to remain a challenge. Elaine Clancy reported that there had been additional investment and close monitoring of performance has continued. Elaine Clancy said that eleven serious incidents had been reported by CHS and said that each would have an investigation and root cause analysis (RCA). No never events were reported. A ‘deep dive’ investigation in respect of medication incidents at CHS had been completed and the Trust had also begun an aggregated review of mental health patients spending extended periods in the Emergency department. SLAM reported no serious incidents involving Croydon patients but had instigated some multi-agency discharge analysis events. Elaine drew members’ attention to recent visits by the Care Quality Commission to both CHS (unannounced) and to South London and Maudsley NHS Foundation Trust (announced) as well as to local GP practices. The outcomes of inspections of general practices had been reported through the earlier Primary Care Commissioning Committee. Rachel Flowers noted the Croydon work around childhood obesity being identified nationally as an example of excellence. Elaine Clancy described work taking place around a national alert concerning the DocMan system and confirmed the CCG is engaged in ensuring with the nationally directed actions Gordon Kay mentioned some of the communication considerations around IAPT access identified through the ‘meet the change makers even’ and discussed the knowledge barriers and issues with self referral and some other perceived barriers to accessing talking therapies. Agnelo Fernandes said that exploration of these issues and any misconceptions must continue to deliver this priority. Jon Norman welcomed the emergence of a clear plan around Kings

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College London for identifying and following up 12 month wait patients noting that this had been a recurrent concern from the Quality Committee.

Reports from Committees – Integrated Governance & Audit Committee (IGAC) No meeting since last update – Next meeting scheduled for 24 September 2018.

Ref: 2018/09/09

9 Operating Plan 2018/19 Quarter 1 Performance Report

9.1 9.2 9.3 9.4

Stephen Warren presented the report. Stephen Warren explained that the report represents an initial attempt to illustrate the CCG’s performance against the in year operating plan The 360⁰ approach was described to summarise progress against the CCG operating plan by priority programmes of work, each of which reflect: Quality outcomes, activity outcomes, finance (QIPP and non QIPP), performance against national standards and key programme deliverables. Philip Hogan noted that planned care and mental health QIPP delivery have significant implications to the CCG’s financial performance. Stephen Warren said that both teams have recovery plans that are being reported through the CCG’s management and committees. Andrew Eyres encouraged feedback on the format of the report. Members welcomed the report and were advised that the format of the report will continue to be developed with oversight from the Integrated Governance and Audit Committee.

Ref: 2018/09/10

10 Reports from Committees – Finance Committee

10.1 10.2 10.3

Philip Hogan, Lay Member – Finance provided the report from the meetings of the Finance Committee which included the QIPP report, finance report and Contract portfolio reports included in the meeting pack. Philip Hogan described proposals for the scope of activity for the SWL Finance Committees meeting in common scheduled to take place in October 2018 arising from discussion of a control total (of £7.5m surplus) for South West London CCGs. Philip Hogan advised that the Finance Committee had last met on The committee has met twice since the last Governing Body meeting (23 July 2018 and 20 August 2018). Chairs of the Finance Committees of the 6 SWL CCGs met on 21 August 2018. Philip Hogan summarised the key business discussed at these meetings noting the latest finance reports describe an unchanged position of forecasting a £1.2m surplus and a favourable run rate around £0.5m QIPP delivery, particularly in planned care, was recognised by the Committee as the key risk area as discussed in the Operating Plan performance report item.

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10.4 10.5

Mike Sexton reported another emerging risk around the pricing of generic drugs (category M) adding that in the past these price settings have been favourable but a cost pressure is anticipated.

Jon Norman queried the indication in the report around GP Referral Patterns that M3 referrals were 14.2% over and it was questioned whether this was driven by consultant to consultant referrals or other. Stephen Warren said that analysis was taking place to understand this and an update could be provided. Andrew Eyres said there is a national pattern around increase referrals and acknowledged this can impact on waiting times hence the importance of variation team work to ensure best pathways are used. The Governing Body: NOTED a year-to-date surplus of £0.5m (£0.1m Favourable variance) and a forecast in-year surplus of £1.2m (Nil variance). This reflects the 2018-19 plans submitted to NHS England. This includes the Croydon Health Services Contact performing to a plan which includes £10m QIPP NOTED the performance on meeting the Public Sector Payment Policy (95% within 30 days) and cash management. NOTED QIPP Month 4 YTD performance is reported as £6.11m, behind plan (£6.24m) by £130k NOTED A full year forecast outturn of £27.6m against a target of £27.6m; NOTED The significant delivering on the out of hospital programme and continuing health care programme. NOTED The overall risk to the QIPP programme is 10% - 20% (£2.7m - £5.4m) NOTED The underspend against the CHC budget as mitigation

Ref: 2018/09/11

11 Reports from Committees – Quality Committee

11.1 11.2 11.3 11.4

In the absence of Amy Page, Registered Nurse Governing Body Member and Quality Committee Chair, Elaine Clancy summarised the July meeting of the Quality Committee. Elaine Clancy said the Month 1 Performance report was discussed together with available Month 2 data, with particular focus on RTT and Emergency Department issues. Integrated Safeguarding team proposals had been discussed. Further assurances had been sought around the action plan and impact assessments for Learning Disability Health Checks and the work being done to promote the need for assessments within Primary Care.. The Patient and Public Involvement Q1 report had also been presented to the committee Elaine Clancy presented the 2017/18 Annual Safeguarding Report

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11.5 11.6 11.7 11.8 11.9 11.10

to the Governing Body explaining that this had been reviewed in depth at the Quality Committee. Elaine Clancy said the report highlights team changes and the benefits being felt through closer working between safeguarding teams. The report described workshops and training undertaken with colleagues across the healthcare system, and described the safeguarding team’s involvement in partnership working. Following the OFSTED findings in the previous year, the Local Childrens’ Safeguarding Board arrangements had been strengthened and Elaine Clancy said the report describes how the CCG safeguarding team has responded to these changes. Andrew Eyres noted the year had seen the beginning of primary care commissioning. Elaine Clancy said that the relationship with the Primary Care team is developing and that the team already have a very good supportive relationship with GP practices including historic peer review support. In response to a question concerning partners safeguarding arrangements from Agnelo Fernandes, Elaine Clancy said that risks around CCG’s providers safeguarding arrangements that are recorded and update on the risk register and monitored closely by the Quality Committee. Elaine Clancy referred to Working together 2018 and commented that the Improvement board had enabled for closer working with the police and local authority in terms of tighter governance and enhanced ability to challenge. Dr Vaishali Shetty asked whether faster feedback from MASH referrals could be explored. Elaine Clancy replied that the safeguarding board is aware of the issue looking at early intervention support work and around aligning partners around MASH work. Dr Tom Chan asked about safeguarding in care homes and Elaine Clancy replied that significant work is taking place with adult safeguarding and quality assurance being supported as a system. Dr Agnelo Fernandes said recurring comments at practices’ safeguarding training suggested there appeared to have been limited progress in improving the communication back to GPs around safeguarding referrals. Elaine Clancy will report the concern back to the Safeguarding Executive Board meeting with strategic partners. The Governing Body: ▪ NOTED the update from the Quality Committee ▪ APPROVED the Safeguarding Report 2017-18

EC

Ref: 2018/09/12

12 Reports from Committees – Primary Care Commissioning Committee

12.1 Philip Hogan, Lay Member reported on the earlier meeting of the

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12.2 12.3 12.4 12.5 12.7 12.8 12.9

Primary Care Commissioning Committee (4th September 2018). Philip Hogan described meetings taking place as part 2 meetings in May, July and August 2018) from which the public were excluded and which had considered a number of matters discussion.

▪ Risks carried around the GP Estate and GP retirement ▪ Closure of a GP practice part of Parchmore Group was

approved and put in process arrangements for the closure of Coulsdon Medical Centre relating to the CQC report followed by the retirement of the GP Contractor.

▪ A financial support package request from a practice was considered and declined and led to further discussions around the process for accessing working at scale funding.

Updates were received around the process developed around the bidding of for use of the £1m Working at Scale funding for general practice Philip Hogan said London Operation Model was discussed and accepted by the Committee. The Committee also receive any CQC reports relevant to the contractors. Martin Ellis explained an issue posed by the committee’s stated quoracy and that this had been discussed at the earlier meeting in respect of the Terms of Reference for Primary Care Commissioning Committee. Arranging a quorate meeting (one third) from all Governing Body members, healthwatch and health & wellbeing board representatives, emergency meetings on contract matters had otherwise proved extremely difficult to schedule in the required timescale. Martin Ellis said it had been proposed to interpret the Primary Care Commissioning Committee’s quoracy as requiring one third of voting members to be present. Philip Hogan stressed that the intent is to be inclusive. Members agreed with the proposal of the committee that, so long as close review takes place to ensure broad discussion and attendance. The Governing Body: ▪ NOTED the Primary Care Commissioning Committee Chair’s

report

▪ AGREED the point of clarification on Terms of Reference such that: Quorum is one third of all voting members;

Ref: 2018/09/13-16

13 Minutes of the Quality Committee

13.1

The minutes were presented for information and there was no discussion.

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13.2

The CCG Governing Body noted the Minutes.

14 Minutes of the Clinical Leaders Group

14.1

The minutes were presented for information and there was no discussion. The CCG Governing Body noted the Minutes.

15 Minutes of the Finance Committee

15.1 The minutes were presented for information and there was no discussion. The CCG Governing Body noted the Minutes.

16 Register of Interests and Hospitality

16.1 The register of interests and hospitality were presented.

The CCG Governing Body noted the Registers of Interest and Hospitality.

17. Open Space for Public Questions

17.1

17.2 17.3

A question was asked in light of updated NICE guidance in respect of womens’ preferences in giving birth. The member of public asked about the whether Croydon University Hospital (CUH)’s position had changed around the offering of caesarean sections and whether the CCG or CUH had been in contact with NICE about the guidance.

Jon Norman noted a news story suggesting there is a spectrum of responses by Trusts about offering this choice and that a discussion needed to be had with CHS on their position. Agnelo Fernandes confirmed that a Governing Body seminar would be held to understand Croydon’s position and consider relevant data.

A member of the public welcomed care home presentation but asked the CCG to consider the potential impact of increased expectations from Local Authority that add to care home providers’ costs are typically passed on to private paying residents of the home. While the Governing Body noted that this is part of a current national issue and debate. Andrew Eyres added that the CCG commits to ensuring a fair approach with patients in all residential settings working closely with local government colleagues.

18 Any Other Business

18.1

There were no additional items of business.

19 Date of Next Meeting

Tuesday 6 November 2018 14:00 until 16:00, Croydon Conference Centre, Croydon for Meeting on Tuesday 6 December

Signed…………………………………………………….. Dated………………………………………………………

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Enclosure 2

CCG GOVERNING BODY MEETING - ACTION LOGOn target to meet resolution date

Up to 1 week behind target resolution date

Last updated: 31.10.18More than 1 week behind target resolution date

Ref No CCG Date Owner (responsible)Action RAG Status

Due

DateNotes (progress to date, problems encountered, etc.)

2018/07/06 03-Jul-18 Guy Van Dichele Agnelo Fernandes asked Guy VanDichele to investigate concerns around health

visitor recruitment New Action 3 July 2018

2018/07/08 03-Jul-18 Elaine Clancy To clarify the expected time of completion and planned opening of the new A&E at

CHS with the Trust. 06-Nov-18

New Action 3 July 2018

To report further updates (September meeting)

2018/07/10 03-Jul-18 Martin Ellis To provide an update on the CCG’s strategy around care homes CLOSED 04-Sep-18 Closed - Presentation taken to 4 September 2018

Key to RAG Status:

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING IN PUBLIC

6 November 2018

Title of Paper: JOINT CLINICAL CHAIR AND ACCOUNTABLE OFFICER REPORT

Lead Director Dr Agnelo Fernandes Clinical Chair Andrew Eyres Accountable Officer

Report Author Dr Agnelo Fernandes Clinical Chair Andrew Eyres Accountable Officer

Committees which have previously discussed/agreed the report

N/A

Committees that will be required to receive/approve the report

N/A

Purpose of Report For information and noting

Recommendation:

The CCG Governing Body is asked to receive the report for information.

Background:

This is the regular joint report of the Clinical Chair and Accountable Officer to update CCG Governing Body members on developments in the local health and care system and on wider policy issues and developments as appropriate. The report follows the regular format followed by the CCG, however, we always welcome your feedback on the format and content of the report in order to inform future reports.

Joint Clinical Chair and Accountable Officer Report

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1. Overview of Key Business Activities

The following summary highlights key meetings and events since the last Governing Body

(September 2018):

• Croydon Health and Wellbeing Board

• Local Strategic Partnership Board

• Croydon Transformation Board

• Croydon Alliance Board and Delivery Group

• Croydon Professional Cabinet

• South West London Clinical Chairs

• South West London Health and Care Partnership Programme Board

• Board to Board with Croydon Healthcare Services

• Chief Executive and Chairs meeting with Croydon GP Collaborative

• South West London Urgent & Emergency Care Transformation & Delivery Board

• Croydon A&E Delivery Board

2. Annual General Meeting

We held our 2018 Annual General Meeting on Tuesday 25 September at the Braithwaite Hall in the Town Hall. We opened with a marketplace showcasing work from our health and social care and community partners. The meeting itself was opened by our chair, Agnelo Fernandes, who remembered Bosco Saldanha, one of our of most dedicated volunteers, who sadly passed away this year. We were also treated to a performance from the Tudor Academy Choir who sang “With a little help from my friends” by the Beatles and “This is me” from the film The Greatest Showman. The school’s Prime Minister and Deputy Prime Minister spoke about how the school has been learning about the different parts of the NHS and how to use the right service at the right time.

Andrew Eyres, Accountable Officer, spoke about the CCG’s performance over the year, including the improvement of our NHS England rating from Inadequate to Requires Improvement. Highlights included, the development of the joint carers’ strategy with Croydon Council, the ongoing development of multidisciplinary huddles in GP practices and the first GP conference. Mike Sexton, Chief Financial Officer presented a summary on the CCG’s financial outturn and spoke about how we are planning to meet nationally set financial targets in the future.

Lastly we heard special presentations from two colleagues. Rachel Carse spoke about her work in making Croydon a Dementia Friendly community. With an ageing population, the number of people with dementia is set to rise. The CCG has committed to training all its staff in dementia awareness, to develop a dementia roadmap with other members of the Croydon Dementia Action Alliance for local carers and health and care professionals and to work with care homes to review approach to falls with dementia care in mind. Rachel spoke about how

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simple changes to the environment or to processes can support those with dementia and those who care for them.

Brian Dickens, winner of the Regional NHS70 Parliamentary award for Excellence in Primary Care, presented his work in social prescribing. The network of GPs actively involved in social prescribing has gone from one practice in July 2017 to 42 (out of 52) GP practices over the course of a year.

The CCG would like to thank the Tudor Academy Choir, our guests presenters Rachel and Brian and to all our market stall holders for making our 2018 AGM such a great success.

3. Annual report summary

We presented our Annual Report summary at our AGM. This is a public facing version of our Annual Report, which we are required to produce by NHS England. It is aimed specifically at engaging with the public and presenting our performance over the year, as well as our successes and challenges in a summarised and accessible format. We were pleased to hear that those who attended our AGM and filled out a feedback form commented on the attractive look and accessible nature of the booklet. You can read the Annual Report summary, as well as the full Annual Report here:

https://www.croydonccg.nhs.uk/news-publications/publications/Pages/Publications.aspx

4. Staff awards

We also presented our first annual Staff awards. Ros Spink, Engagement Lead and Edward Odoi, Chief Management Accountant, were nominated by their peers and were recognised as regularly living out our organisation’s values of:

• Patient-focussed

• Professional at all times

• Outcomes-focussed

• Ambitious

5. Croydon Transformation Board update

The Croydon Transformation Board is made up of senior representatives from the six organisations in the One Croydon Alliance partnership:

• Age UK Croydon

• Croydon Clinical Commissioning Group

• Croydon Council

• Croydon GP Collaborative

• Croydon Health Services NHS Trust

• South London and the Maudsley NHS Foundation Trust This month the Board discussed the development of the Croydon Transformation Plan which sets out how we will transform health and care on over the next five years in Croydon. We are planning an engagement event to engage on the plan for later this autumn, ahead of publishing the plan in March 2019. This event will complement the engagement work all our partner organisations have done to date. We want to use the event to test our thinking, what we have heard so far from partners and communities and seek advice from front line staff, local people and stakeholders on our priorities within it.

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Other items on the agenda included the Out of Hospital business case for Phase 2 which builds on the success of various projects including the Discharge to Assess process, which speeds up hospital discharges. In the next phase work will concentrate on developing telehealth in care homes, putting doctors and nurses in touch with care home staff to avoid unnecessary hospital admissions and end of life care, including proactive planning in care homes and expanding end of life community engagement. The South West London interoperability plan was discussed, which aims to join up records across Croydon Health Services acute and community systems with GP systems.

6. King’s fund report

In mid-October, the King’s Fund, a health charity that shapes health and social care policy and practice, published a report on the progress in the five sustainability and transformation partnerships (STPs) in London. The report was the second commissioned by the Mayor of London on the progress of London’ STPs. The work of South West London Health and Care Partnership was positively featured throughout the report - in particular, our efforts to bring borough organisations together to deliver better care for local people. Our work to ensure local residents’ views and experiences are at the heart of our plans is also referenced as an example of best practice.

Croydon was singled out for our initiative to integrate care. The One Croydon Alliance, a partnership between local NHS providers, Croydon Council and Age UK Croydon, is delivering co-ordinated support for older people through 18 personal independence co-ordinators. The report highlights the positive impact that partnership has had “by shifting expenditure from delivering acute care towards prevention work and support in the community, initial successes have included fewer patients needing care packages for longer than six weeks after leaving hospital”.

The Fund acknowledges that there a number of challenges are faced by STPs with rapid demographic growth and workforce shortages. It goes on to describe that STPs in London have spent much of their time overcoming the “challenging process by with they were introduced” and that local leaders have focused on building relationships and addressing

gaps in staff and public engagement.

7. Croydon Health and Care Event

We are holding a large scale health and care engagement event for the borough on Tuesday 20 November 2018 in central Croydon. Health and care organisations in Croydon are working more closely together to make services better connected and more joined up. Croydon Council, the NHS, Age UK, the voluntary sector and Healthwatch are developing plans for how we might achieve this and this event will help us test our plans to date and focus on how to address some key challenges. We are inviting health and care frontline staff, local people and representatives from lots of different community organisations from across the borough. Unfortunately, we can’t have everyone in Croydon at the event, so we’ve tried to make sure we have a mix of voices. At the event, we’ll share information about the services that are currently available, evidence we have about the population of Croydon and our work to date. We will use the outcomes of the event to help perfect our Croydon Health and Care Plan which will be published in March 2019. This will complement the refreshed Croydon Health and Wellbeing Strategy for 2019 to 2024. We will then continue to work together with local people and community organisations to put these plans into action.

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8. Welcome to Matthew and farewell to John Goulston

Matthew Kershaw has been appointed as the interim Chief Executive of Croydon Health Services, to lead the Trust as it continues to make improvements in caring for people across the borough. He started on 1 October 2018 as the current Chief Executive John Goulston retires after more than six successful years at the Trust.

Matthew will be responsible for ensuring that CHS further enhances its quality of care and performance – including maintaining some of the lowest hospital waiting times in London – whilst continuing to revive the Trust’s financial health.

The CCG welcomes Matthew and looks forward to working with him in the future. We’d also like to thank John Goulston for his years of service at the Trust and wish him well in his future endeavours.

9. GP Collaborative The CCG would like to welcome the new chair of the Croydon GP Collaborative, Dr Yusuf Rajbee.

We would also like to thank the outgoing chair, Dr John Chan for his years of service. Dr Chan represented the Collaborative in working with local partners to establish the One Croydon Alliance, and signed a 9-year extension to widen its remit. We wish him all the best for the future.

10. Red bag scheme rolled out

We are pleased to announce that the “Red bag” scheme is being rolled out across care homes in Croydon and in Croydon Health Services. Developed by NHS and care home staff, the Red Bag has already been adopted across 11 London boroughs. Started three years ago, Sutton Vanguard’s Hospital Transfer Pathway Red Bag ensures key info such as existing medical conditions and other clinical information is communicated and helps ensure residents return to their care home as promptly as possible once hospital treatment is completed. On average 2.4 bed days are saved per Red Bag used.

Under the new scheme, when a patient is taken into hospital in an emergency they have a Red Bag to take with them. The bag contains:

• General health information, including on any existing medical conditions

• Medication information so ambulance and hospital staff know immediately what medication they are taking

• Personal belongings (such as clothes for day of discharge, glasses, hearing aid, dentures or other items)

The Red Bag also clearly identifies a patient as being a care home resident and provides hospital staff with the information they need to speed up clinical decisions.

Since its introduction, the Red Bag, which has been used with care home residents 2,000 times in south London since April 2017, has also stopped patients losing personal items such as dentures, glasses and hearing aids worth £290,000 in a year. The potential for the innovation is significant with a predicted two million more people aged over 75 in ten years’ time.

11. Integrated Musculoskeletal service launching in Croydon

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Connect Health Ltd have been chosen as the preferred provider to deliver the integrated MSK service in Croydon, after a clinically led procurement process in line with the statutory requirements.

NHS Croydon CCG has worked with patient representatives, secondary care consultants, GPs and physiotherapists to develop a new model of care to make sure all the well-being needs of patients are taken into account, not just treating their health condition.

The new service, which has been procured following a trial in five Croydon practices, will mean that patients will have access to:

• shorter waiting times for an appointment with a physiotherapist with an average of 18 days from referral to first appointment at a choice of over 16 locations across the borough

• telephone assessments, advice and guidance within two days of all referrals

• online advice from a physiotherapist to work best with Croydon residents' busy lives

The new service will promote well-being and self-care so local people can better manage their own conditions. Connect has a strong track record of excellent patient experience and outcomes, developed over 24 years delivering over 30 similar services all over the country, in areas such as Merton and Hammersmith and Fulham.

12. Group consultations in the press

Governing Body member and local GP, Dr Emily Symington, shared the outcomes of and response to successful trials of a new type of appointment at the Royal College of General Practitioners Annual Conference in Glasgow.

Designed to encourage better self-care and embed shared decision making between clinician and patient, group consultations gather around 10-15 patients who have a similar condition or set of clinical problems. All patients have been briefed about the format of the session, what to expect from it and have signed a statement of confidentiality, meaning they are bound to not reveal anything they have heard about any of their fellow participants outside of the session. Independent evaluation showed that 80% of patients reported being more able to cope and keep themselves healthy and 85% would recommend group consultations to friends and family.

Group consultations are an opportunity to combine seeing a clinician, and also elements of peer support, mentoring, learning. Other benefits include more patient involvement in their care leading to better self-care, external support networks and decreasing demand on appointments. Feedback from patients has centred around getting more insight into their condition and what they can do to help themselves. They also reported that they feel less alone and there has been some healthy competition to see who can improve their stats the most! GPs also benefit from professional development and more efficient use of their time.

13. Croydon Health Services CQC report

On Friday 28 September 2018 the CQC published a report on medical care and community services provided by Croydon Health Services. Both were given both overall ratings of “requires improvement” and the Trust remains at “requires improvement” overall.

However, all services were rated as “good” on caring. Both medical care and community health services for adults were also judged “good” on being effective. When combined with the previous inspection last year, the latest report also means seven out of the nine of the core services inspected at Croydon University Hospital are now rated as “good”.

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The CCG remains committed to working with CHS in developing and supporting an action plan based on the CQC’s recommendations and this will be reviewed through the Quality Committee

14. South London and Maudsley NHS Foundation Trust rated Good by CQC The SLAM CQC Inspection report was published in October. The Trust has been rated as Good overall, with a rating of Requires Improvement for the safety domain. The acute wards for adults of working age and psychiatric intensive care units were given an overall rating of inadequate. The CQC issued a warning notice to SLAM regarding good governance and the Trust discussed its response to this at its public board meeting in September and is developing an action following the report publication. The Trust’s progress will be monitored by commissioners at the SLAM Clinical Quality Review Group.

15. LIFE CQC report

The CQC has given a “good” rating to part of the One Croydon Alliance that helps older people regain their independence after hospital stays. The Living Independently For Everyone (LIFE) service was launched in September 2017 to reduce the need for hospital stays among mainly over-65s with long-term conditions. The LIFE team includes professionals from social work, community nursing, therapists, care providers and charity volunteers. Their work covers A&E care assessments, supporting discharge for hospital and supporting people at home, as well as professionals’ confidential discussions of joint care plans for residents.

This assessment included “good” ratings for all aspects of the service, including its safety, responsiveness and how well it was led. The report summary said the service, which operates a specialist rehabilitation service to people who have just left hospital, provided joined-up and safe care which met residents’ needs well, had good communication between professionals and included appropriate staffing levels.

Feedback to CQC inspectors during the visit included comments from a service user’s relative, who said: “The service is very good, I’d rate it outstanding. They’d call and make sure I was happy with everything and that my relative was too. It gave them back the confidence they’d lost.”

In its first year, results from the alliance’s LIFE service include:

• 847 possible hospital admissions avoided

• 15% fewer emergency admissions

• 18% fewer non-elective admissions for residents over 65

• 16% fewer non-elective admissions for residents under 65

In the LIFE service’s first six months, 62% fewer patients needed care packages six weeks after hospital discharge and around 450 residents spent less time in hospital, or none at all.

16. Over the counter medicines

All six south west London CCGs have agreed to work together on self-limiting and minor health conditions for which over the counter items should not routinely be prescribed in primary care. This position statement is in line with NHSE’s guidance which was published in March 2018*. The national guidance covers minor health conditions which were identified in last year’s engagement exercise, but with a number of additional items, plus probiotics and some vitamins and minerals.

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The guidance means that patients can instead go to their community pharmacist who can offer help, advice and over the counter medicines to manage minor health conditions, and if the symptoms suggest it’s more serious i.e. are ‘red flags’, then the pharmacist will direct the patient to the GP. This approach will help to encourage patient self-care and reduce pressure on general practices. For GPs, we recognise that they will be mindful of their contractual obligations to consider, where appropriate, the offer of a NHS prescription for medication deemed to be necessary for treatment of the presenting condition, and to use NHS resources wisely by supporting patients to self-care in line with NHSE guidance on the use of over the counter medicines.

Communication materials for GPs, pharmacists, trusts, councils, schools and patient materials are being developed (based on the national materials) and will be launched this autumn. They are currently being reviewed by CCG Chairs, chief pharmacists, and other GP and pharmacy teams across CCGs in south west London. The launch coincides with winter messages on patients going to the pharmacy at the first sign of illness and keeping a stocked medicine cabinet home, which we are supporting.

*NHS England ‘Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs’ (March 2018) https://www.england.nhs.uk/publication/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed-in-primary-care-guidance-for-ccgs

17. Parchmore Practice Health Service Journal Award and General Practice Award nominations

We are delighted to say that the Parchmore Practice in Thornton Heath has been shortlisted for a Health Service Journal (HSJ) award and two General Practice Awards. The HSJ Awards is the largest annual benchmarking and recognition programme for the health sector. The finalists and winners represent the best in healthcare excellence. The General Practice Awards are the most prestigious awards for primary care professionals

• HSJ Awards 2018 – Parchmore Medical Centre shortlisted for “Primary Care Innovation Award” for “Transformation to Reduce Emergency Admissions and Hospital Outpatient referrals, and rapid Social Prescribing implementation”

• General Practice Awards 2018 – Parchmore Medical Centre have been shortlisted for the “Managing Workload & Improving Access Award” (NHS England)

• General Practice Awards 2018 - Teresa Chapman has been shortlisted for the “Practice Manager of the Year Award”

The HSJ Awards are Wednesday 21 November and the General Practice Awards take place on Friday 30 November. We’d like to congratulate Parchmore for their success and we’ll keep our fingers crossed on the night!

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18. Civic Events Awards

Andrew Eyres attended the 2018 Mayor of Croydon Civic Awards, which celebrates community heroes who live and work across Croydon. Among the range of award winners Patricia Goonetilleke won “Volunteer of the Year” award, having dedicated the last 21 years to volunteer at Croydon University Hospital, tirelessly helping thousands of people in any way she can. Her commitment to the hospital, staff and patients is unwavering as she supports patients who need help, comfort and company – often those who are seriously ill with no visiting family. She makes a genuine, positive different to the lives of people at a time when they are most vulnerable. The CCG warmly congratulates Patricia, a fabulously kind and modest person.

19. The CCG’s Strategic Risks Update The CCG’s Board Assurance Framework, detailing high level strategic risks is provided for the Governing Body. All risks on the full Risk Register are reviewed individually by risk owners, and high-level risks are scrutinised by the Integrated Audit and Governance Committee. Each risk is also regularly reviewed by the relevant Committee of the Governing Body with assigned responsibility for overseeing its mitigation. While an IT disruption meant that the full BAF and risk register could not be taken to the most recent Integrated Governance and Audit Committee in September 2018,a workshop has been proposed to ensure the framework continues to fit for purpose, informed by assurance mapping and analysis received by the CCG’s internal auditors. There are a total of 16 strategic risks on the Governing Body Assurance Framework which have been mapped against the strategic objectives as follows:

Objective Total Risks

15+ 5 - 12

1.

To commission high quality health care services that are

accessible, provide good treatment and achieve good patient

outcomes

9 2 7

2.

To reduce the amount of time people spend avoidably in hospital

through better and more integrated care in the community, outside

of hospital for physical and mental health

1 1

3. To achieve a breakeven position in year 2018/2019 and

sustainable financial balance by 2020/2021 3 3

4.

To support local people and stakeholders to have a greater

influence on service we commission and support individuals to

manage their care

1 1

5.

To have all Croydon GP practices actively involved in

commissioning services and develop a responsive and learning

commissioning organisation

2 2

16 5 11

Following improved engagement with the General Practice together with the success of

working at scale events and securing associated funding, the risk around General practice

failing to transform at the required pace (CCCG084) has since been reduced from a score of

16 to 8.

With Clinical quality review meetings and monitoring reporting to the Quality Committee

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and informing the Primary Care Commissioning Committee, the General Practice quality risk CCCG083) has since been reduced from a score of 16 to 12. The Quality Committee recommended the closure of the risk associated with focus on Patient Experience (CCCG010) following the appointment of a Lay Member with this as their sole portfolio and strong assessment scores received from NHS England (overall Good with features of outstanding)

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP GOVERNING BODY

6 November 2018

Title of Paper: Croydon Partnership Early Help Strategy 2018-2020

Lead Director Stephen Warren Director of Commissioning

Report Author Carolann James Interim Head of Early Help, LBC [email protected]

Committees which have previously discussed/agreed the report.

Croydon Safeguarding Children Board approved 25th September 2018 LBC Cabinet endorsed 24th September 2018


Partner Agency governing bodies during November – December 2018 Health & Wellbeing Board Children’s Improvement Board

Purpose of Report For Information and Endorsement

Recommendation:

The Governing Body is asked to:

1.1 Note the progress made in development of Croydon’s Partnership Early Help Strategy and

plan for implementation.

1.2 Endorse the Partnership Early Help Strategy which was considered for finalisation was

agreed at the Croydon Safeguarding Children Board in September 2018.

Background:

2 EXECUTIVE SUMMARY

2.1 This report is provided to CCG Governing Body to inform on the progress made in

relation to development of the Croydon Partnership Early Help Strategy. This follows Ofsted’s Single Inspection Framework (SIF) in the summer of 2017 where

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LBC received an inadequate grading. 2.2 In relation to Early Help Ofsted’s SIF found that:

• The range and coordination of early help provision for children and families are not fully established. Individual partner agencies are unclear about the early help offer and have not been involved in developing a shared approach to delivering services. ( p.3)

• The range and coordination of early help provision for children and families are underdeveloped. However, partner agencies are at the early stages of working together to develop a new, shared approach to delivering services. (p.10 summary)

• The range and coordination of early help provision for children and families are underdeveloped. Partner agencies remain unclear about the purpose of the early help offer. However, they are at the early stages of working together to develop a new approach, building on the Best Start Programme, which is helping to further develop a shared approach to delivering services. The early help hub facilitates access to services and supports professionals in completing early help assessments. However, there is an insufficient range of evidence-based interventions to support families. The evaluation of work is not taking place, which means that it is difficult to measure impact or demonstrate that the work is sustainable (p10 section 26)

• The early help screening and assessment process builds delay in decision-making processes and operates separately from children’s social care systems. Non social work staff can hold cases for several days without the early help screening team making a decision. For example, some cases wait too long before being allocated for a social work assessment. (p10 section 27)

• The early help strategy is insufficiently coordinated and implemented and the board has not

ensured that pathways to early help services are well understood and applied. Ineffective action to address this fundamental deficit means that the board cannot be assured that children are receiving the right level of help at the right time. (p33 summary)

Ofsted recommended that we: • Strengthen the provision of early help support for children and families and ensure that

partner agencies have a shared understanding of the early help strategy and associated

thresholds.

(Recommendation11 p. 8)

2.3 Croydon’s ambition for children is that all children and young people in Croydon will be safe, healthy and happy, and will aspire to be the best they can be. The future is theirs.

2.4 In Croydon we believe that every child should have the opportunity to reach their full

potential. We believe that children should grow and achieve within their own families when it is in their best interests and it is safe for them to do so. By working together, we will develop flexible services which are responsive to children and families’ needs.

2.5 Croydon is establishing a vision for the future that will provide for:

• A system wide approach, with joint pooled resources and pathways operating across

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organisational boundaries

• An outcome focussed approach delivering long term sustainable solutions for individuals and families to secure resilience and independence

• A shift from acute provision to an increase in prevention and early help activity

• Evidence based services that are built around customer need

• Locality based delivery where appropriate

2.6 Early help is everyone’s responsibility; we want children, families, communities and agencies to work together so that families are assisted to help themselves and are supported as soon as a need arises, thereby improving the wellbeing and life chances for Croydon’s children and young people.

2.7 We will together:

• Understand those families where children may be at risk of not reaching their full potential and share concerns

• Build a relationship with the family as early as possible, and work with them to create a family environment that provides children with the best life chances and prevent problems from arising or escalating

• Reduce the number of children and their families requiring support from specialist services.

2.8 Problems may emerge at any point from conception, through childhood and adolescence to adulthood. Effective Early Help, “Right help, Right time” is provided to prevent or reduce the need for statutory or specialist interventions, wherever possible and safe to do so, resolve the problem and prevent it becoming entrenched and build resilience in children and their families.

2.9 Croydon’s Partnership Early Help Strategy (Appendix A) and delivery plan has been

developed across the partnership, and will align with Croydon’s vision for the new operating model enabling us to provide a joined up, effective early help offer for children aged 0 to 18 years and their families; which is delivered on a locality, multi-agency evidence based model through a shared partnership approach to delivering universal and early help services. The Strategy will be implemented, now agreed by Croydon Safeguarding Children Board, in a phased approach.

2.10 The Partnership Early Help delivery model is shaped around three Early Help

locality hubs, working initially within the three localities established through the Best Start early help provision, in the north, central and south areas of the Borough. These three hubs provide a locality base for bringing together a range of practitioners supporting close collaboration and alignment of services including our realigned Council early help family key work teams, ‘Best Start Family Solutions’, who will work with partners across the locality to collectively delivering an integrated approach to our early help offer.

2.11 In the north of the Borough Early Help Services will form part of the new Gateway

Hub in Thornton Heath which will have its focus on children, young people and families.

2.12 The role of the Early Help hubs is to bring different services and agencies to work

collectively to address local need and to provide a more coordinated and collaborative response to supporting children and families across Croydon. Professionals across the locality areas will be effectively identifying children and

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their families with problems, working out with the family what help is needed and bringing together and aligning different services to support the child and their family in a coordinated way.

2.13 Within the localities the practitioners collectively delivering early help across all

partner agencies will have regular locality meetings and locality network events as part of the collaborative approach to delivering early help to provide help and support for practitioners and agencies working with children, young people and their families, in addition to providing opportunities to share good practice; develop understanding and shape the future of the early help offer to support families across the locality. The localities’ delivery networks help to facilitate a much stronger approach and collaboration and integration across universal and targeted services including schools, GPs and other health services, the police, voluntary and community sector agencies and a wide range of Council services such as children centres, youth services, housing and community support services and children’s social care.

2.14 Croydon’s Partnership Early Help Strategy is a shared partnership approach to collective delivery of the universal and early help offer and partners will be expected to contribute to funding the offer going forward.

Key Issues:

See above

Governance:

Corporate Objective To commission high quality health care services that are accessible, provide good treatment and achieve good patient outcomes To reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital for physical and mental health To support local people and stakeholders to have a greater influence on services we commission and support individuals to manage their care

Risks

a) we do not achieve this change programme at sufficient pace, b) all partners do not engage in the collective delivery of early help services, and c) this strategy doesn’t sufficiently align and embed to the Council and wider partnership future operating model, which is in development

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Financial Implications

It is anticipated that this change programme will be delivered from within existing service budgets. If there are additional costs arising from service transformation then funding from the transformation fund bids can be made. The implementation of this Early Help Strategy will enable the delivery of both service and financial efficiencies. These efficiencies will arise as a result of effective services being delivered in a timely manner and therefore reducing demand for acute high cost services at a later stage. Croydon’s Early Help Strategy is a shared partnership approach to delivering universal and early help services and partners will be expected to contribute to funding the offer going forward. Enabling, through established governance

mechanisms, pooled resources to develop a

broader joint commissioning framework

across partner agencies to direct the

commissioning intentions for early help whole

family approaches and maximise best value.

Conflicts of Interest

None

Clinical Leadership Comments As above

Implications for Other CCGs

Where appropriate and beneficial collaboration with South West London partnership transformation programme is undertaken.

Equality Analysis

Equalities and diversity considerations are key elements of universal, early help and statutory service practice. It is imperative that all supports and services for children, young people and their families are sensitive and responsive to age, disability, ethnicity, faith or belief, gender, identity, language, race and sexual orientation. Croydon has a diverse population of children and young people. Children and young people from minority ethnic groups in Croydon account for 57%, compared with 30% in the country as a whole. The

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proportion of children and young people with English as an additional language across primary schools is 44% (the national average is 18%) The Croydon Partnership Early Help Strategy is aimed at children aged 0 to 18 years whereas the current offer is significantly weighted towards children aged 0 to 5 years.

Patient and Public Involvement

The independent consultants undertaking the review of our early help offer consulted with partner agencies including the voluntary sector, stakeholders within the Council and with services users including young people and their parents. When reviewing the Croydon Partnership Early Help Strategy after twelve months of delivery we will include stakeholders, including children and families in this review.

Communication Plan All partner agencies were represented in the soft launch of the Partnership Early Help Strategy and engagement sessions with practitioners and managers across the partnership are planned between November 2018 and April 2019 as we implement the strategy.

Information Governance Issues

Under working together 2018 Information Sharing (IS) is addressed and we currently have effective IS arrangements in place. A key priority for the 2018-20 period of implementation of this strategy is to:

• Ensure we have in place clear

information sharing arrangements

• Ensure we are making the best use of

IT systems and portals across

agencies and departments

Reputational Issues

No adverse reputational issues – ensuring we have the right help at the right time will enhance our reputation with service users, communities, partners and external agencies such as Ofsted and CQC.

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Croydon Partnership Early Help Strategy 2018 – 2020

Our ambition is that all children and young people in Croydon will be safe, healthy and happy, and will aspire to be the best they can be.

The future is theirs.

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2

Partnership Early Help Strategy V8 final approved September 2018

CONTENTS

Subject Page Number

Foreword 3

1. Preface 5

2. Introduction 6

3. Vision 8

4. Guiding Principles 10

5. Our Priorities 12

6. Our Early Help Approach 15

7. Making a Difference – Performance Early Help Outcomes Framework 18

8. Early Help Delivery Model – Priorities 2018 – 2020 19

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Foreword

This Strategy sets out how Croydon’s strategic partners and wider stakeholders will collectively deliver early help in partnership with

children, young people and their families in order to improve the life chances of our vulnerable and disadvantaged families. There are

many excellent examples of early help already working in Croydon and this strategy seeks to harness the work already in place and create

an effective support system for children and their families which builds on existing good practice and partnership working. Families are

best placed to understand, care for and nurture their children, however, nationally it is estimated that around 30% of children and young

people will, at some stage, experiences difficulties which if addressed early enough, can be prevented from escalating into costly statutory

services. If early help is not offered this can, in worst cases, result in children’s social, emotional, health and educational development to

be impaired and can lead to family breakdown. If effective, early help empowers families to regain control of their circumstances and help

transform the lives of vulnerable children.

Public services are operating within a climate of unprecedented challenge as demand for specialist services increases against an

environment of austerity and reduced resources. An effective Partnership Early Help Strategy requires the full commitment of an

integrated multi-agency approach, appropriate and consistent application of ‘thresholds’ and an alignment of agencies resources. As

described in Working Together Guidance, delivery of effective early help in order to keep children safe is not a single agency responsibility

and requires a whole family approach, owned by all stakeholders, and working in partnership with children and their families. This includes

schools, health, police, probation, children’s social care, services for adults, voluntary, faith and community organisations, private

organisations and the wider public.

In Croydon we have made a commitment to providing effective support to our children and families working in partnership with our

partners. This autumn 2018 we plan to refresh our Children and Young People’s Partnership Board (CYPP Board) to oversee governance

of the Partnership Early Help Strategy and this will support greater partnership working in order to improve outcomes for our children and

their families.

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In the meantime the Chair of our Croydon Safeguarding Children’s Board will sign off this strategy on behalf of partners across Croydon,

with agreement that each agency will secure the necessary approvals from their own governance arrangements and adopt the strategy

within their organisations.

Councillor Alisa Fleming Di Smith

Cabinet Member for Children and Families Independent Chair,

Croydon Council Croydon Safeguarding Children Board

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1. Preface

In July 2018, the Government published revised statutory guidance Working Together to Safeguard Children: a guidance to

inter-agency working to safeguard and promote the welfare of children.

Working Together sets out the legal requirements that health professionals, social workers, police, education professionals

and others working with children must follow. The guidance emphasises that effective support and safeguarding for children

and young people is the responsibility of all professionals working with children and young people and provides advice in support to sections

10 and 11 of the Children Act 2014 where the primary duties for all agencies are set out.

Working Together reminds us that “Nothing is more important than children’s welfare. Children who need help and protection deserve high

quality and effective support as soon as a need is identified. We want a system that responds to the needs and interests of children and

families not the other way around. In such a system, practitioners (individuals who work with children and their families in any capacity) will be

clear about what is required of them individually, and how they need to work together in partnership with others. “

Working Together is defined as statutory guidance and therefore all professionals working with children, young people and families should

make time to read the document. Local arrangements to implement the requirements should be prioritised by leaders and senior managers in

every agency with responsibilities for children, young people, families and carers to enable them to safeguard children and to act in their best

interests.

Effective Support ‘Right Help, Right time’ Guidance for Practitioners provides the practitioner guide to effective

support in Croydon which explains the criteria for providing help to children, young people, families and carers and

could be developed as the local ‘threshold document’ required by Working Together 2018 and should be read in

parallel with the Working Together guidance.

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2 Introduction

Croydon is one of the largest London boroughs with a population of nearly 100,000 children under 18 years with the largest population

(38,000) of young people aged 10 to 17 years of all the London Borough’s. Approximately 23% of children in the Borough are living in low

income families. Children from minority ethnic groups account for 58% of all children living in the area, compared to 21% in the country as a

whole.

We believe that children should grow and achieve within their own families when it is in their best interests and is safe for them to do so. The

majority of children and families are strong and resilient and have good networks and resources to meet their needs. However, some families

will experience difficulties from time to time. Early help means taking action to support a child, young person or their family early in the life of a

problem, as soon as it emerges. It can be required at any stage in a child’s life from pre-birth through to adulthood and applies to any problem

or need that the family cannot deal with or meet on their own.

Recent influential studies and reports 1 show that providing early and effective support to families can prevent complex problems emerging

and enable children and adults to reach their full potential.

Key messages include:

Families benefit more from preventative, rather than reactive services. This approach adds value and is cost effective for all concerned.

Current austere times with financial constraints and welfare changes make it even more important that we use our resources effectively to

improve life chances for those children who are at the most disadvantage.

High performing early help services are joined up and coordinated at both strategic and operational levels.

Robust effective early help services prevent needs escalating.

Services provided during pregnancy and when children are young (under 5) have greater impact on outcomes. Early childhood is one of

the most critical phases of human development. It begins before birth, when a baby’s body and brain are being formed, continues through

1 Early Intervention: the next steps and Early Intervention: Smart Investment, Massive Savings (Graham Allen MP (2011), Foundation Years: Independent Review on Poverty (Frank Field MP Dec 2010, Munro Review of Child Protection, Final Report (Professor Eileen Munro, 2011), The Early Years: Foundations for life, health and learning (Dame Clare Tickell, 2010), Fair Society, Healthy Lives (Sir Michael Marmot, 2010)

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early infancy when key relationships are established, and developmental milestones reached, and includes the preschool years and the

transition into school. Children learn to move, communicate, and interact with the world, and develop a sense of personal and cultural

identity. Early childhood offers the greatest opportunities for positive human development but is also the period when children are most at

risk. Negative influences or Adverse Child Experiences (ACEs) on a child’s development during early childhood can be irreversible without

effective support and interventions.

More recent research indicates, that in the teenage years, young people have an increased level of plasticity in the brain which may make

young people more susceptible to risk taking and potentially negative influences. Having effective evidence based early help services in

place provides an opportunity to reverse the impact of previous negative experiences, even if experienced in their early years by

redefining neural pathways.

We know from what children and their families tell us that it can be daunting asking for help and they would like to be supported by the first

person they approach – this is often someone already known to them. This strategy helps us to make every contact count.

This strategy describes who can benefit from early help, how it is accessed and who delivers it. It enables families, communities and all

professionals to:

Respond quickly and effectively to the need for early help

Intervene and provide support to stop an issue escalating

Ensure there is consensual and partnership approach to working with all children and their families

The strategy supports the ‘Effective Support providing the Right Help, Right Time’ framework being adopted across Croydon ensuring a

cohesive early help offer collectively delivered by all partners with a commitment to:

Working better together in an open, honest partnership approach with consent of the child and their family

Identifying strengths and needs and working together to find practical and achievable solutions

Providing the right information and advice to enable children and their families to make positive changes themselves with support tailored

to their need

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Help children and their families to build protective factors and family resilience to prevent situations recurring

3. Vision

Our ambition for children is that all children and young people in Croydon will be safe, healthy and happy, and will aspire to be the

best they can be. The future is theirs.

In Croydon we believe that every child should have the opportunity to reach their full potential. We believe that children should grow and

achieve within their own families when it is in their best interests and it is safe for them to do so. By working together, we will develop flexible

services which are responsive to children and families’ needs.

Croydon is establishing a vision for the future that will provide for:

A system wide approach, with joint pooled resources and pathways operating across organisational boundaries

An outcome focussed approach delivering long term sustainable solutions for individuals and families to secure resilience and

independence

A shift from acute provision to an increase in prevention and early help activity

Evidence based services that are built around customer need

Locality based delivery where appropriate

Early help is everyone’s responsibility; we want children, families, communities, including faith groups, and agencies to work together so that

families are assisted to help themselves and are supported as soon as a need arises, thereby improving the wellbeing and life chances for

Croydon’s children and young people.

We will as partners together:

Understand those families where children may be at risk of not reaching their full potential and share concerns

Build a relationship with the family as early as possible, and work with them to create a family environment that provides children with the

best life chances and prevent problems from arising or escalating

Reduce the number of children and their families requiring support from specialist services.

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Croydon’s Partnership Early Help strategy and delivery plan has been developed across the partnership, and will align with Croydon’s vision for

the new ‘operating model’ enabling us to provide a joined up, effective early help offer for children aged 0 to 18 years and their families; delivered

on a locality, evidence based model through a shared partnership approach to collectively delivering universal and early help services.

The strategy will be implemented, now agreed by Croydon Safeguarding Children Board, in a phased approach.

The Partnership Early Help delivery model is shaped around three early help locality hubs, working initially within the three localities established

through the ‘Best Start’ early help provision, in the north, central and south areas of the Borough. These three hubs provide a locality base for a

range of practitioners supporting close collaboration and alignment of services, including the realigned Council intensive early help family key

work teams, ‘Best Start Family Solutions’ service, who will work with partners delivering an integrated approach to our early help offer

in the locality.

The role of the Partnership Early Help hubs is to bring different services and agencies to work collectively to address local need and to provide a

more coordinated and collaborative response to supporting children and families across Croydon. Professionals across the locality areas will be

effectively identifying children and their families with problems, working out with the family what help is needed and bringing together and aligning

different services to support the child and their family in a coordinated way, without the need for families being repeatedly assessed and needing

to keep “telling their stories “.

Within the localities the practitioners, collectively across all partner agencies, will have regular locality meetings and locality network events. The

new collaborative approach to delivering early help will offer opportunities to share good practice, develop understanding and shape the future of

the early help offer to support families across the locality. The localities delivery networks will help to facilitate a much stronger approach,

collaboration and integration across universal and targeted services including schools, GPs, and other health services, police, voluntary, faith

and community sector agencies and a wide range of Council services such as children centres, youth services, housing and community support

services and children’s social care.

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4. Guiding Principles

Problems may emerge at any point through childhood and adolescence. Early help is provided to

prevent or reduce the need for statutory or specialist interventions, wherever possible and safe to do

so. Early help seeks to meet the need, resolve the problem and prevent it becoming entrenched.

Within this context our early help approach is based on a set of shared principles:

Early help is everyone’s responsibility. All children and young people should have the opportunity to reach their full potential.

Parents have the primary responsibility to meet the needs of their children and ensure the wellbeing and prosperity of their family.

We recognise that parenting can be challenging and asking for help should be seen as a sign of responsibility rather than a

parenting ‘failure’. It is essential that when support is required, we all act to provide the right help, at the right time, in the right

way to improve children’s life chances.

Wherever possible all children and families’ needs will be met by universal services. Universal services working with children

and adults have a role to ensure families are achieving positive outcomes, to be aware of potential difficulties and act early to

prevent needs escalating. Universal services must remain involved even if a child is receiving additional, intensive or specialist

support to ensure there is a joined up, whole system response to meeting needs.

Listen to children and families and treat them as partners. In most cases it should be the

decision of the parents when to ask for help or advice, although there are occasions when

practitioners may need to engage parents actively and with their consent help them to prevent

problems becoming more serious. All services must keep the child at the centre of the solution,

encourage families to harness their own resourcefulness and build supportive community

networks, thereby enabling families to develop resilience.

Our priority and focus is always the child – understanding their needs and ensuring

their welfare. All services for children and families will safeguard and promote the wellbeing of children and young people.

Operating within the ‘Effective Support – Right Help, Right Time’ framework, skilled practitioners will work in an open, honest and

transparent way with families and with each other, with the confidence to intervene and challenge when appropriate. We will

ensure that children and their families are not subject of repeated assessments.

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All services that work with children and adults must work together to deliver early help. All services will work together with

children and families to promote family strengths, build resilience, independence and support the transition from childhood to

adulthood. This includes effective information sharing and joint working between professionals in children’s and adults services in

order to reduce the impact that adults problems have on children’s experiences and enable the opportunities greater integration can

bring to the whole family.

Early help resources will be deployed through a locality model based on an understanding of the needs of children, young

people and their families. Services for children and families will be commissioned and delivered through a joined up, integrated

locality model to ensure we can best understand the needs of children and families within their communities and maximise our

multi-agency resources using evidence based approaches, learning from feedback and the voice of the child and family, with robust

performance management in effect to

deliver positive sustainable impact

and best value.

Ensure clear pathways to support.

We want all families to have easy

access to support when needed.

Pathways will be clear and we will set

out clearly what support is available

and make it easy for families to

contact services themselves. We will

deliver timely, high quality, effective,

joined up support across the age

range.

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5. Our Priorities

Croydon’s ambition is to move towards a new operating model focussing on prevention and early help. Over recent years Croydon has

reviewed and adapted its early help and prevention strategy but the impact of these revised strategies has not been as far reaching as would

have been hoped for and has not reduced demand on statutory and specialist services. Our children’s improvement plan commits to delivering

an effective all age Partnership Early Help Offer, ensuring consistent application of ‘thresholds’ across the continuum of need and a more

effective whole family, systemic locality based partnership approach to Early Help.

Analysis undertaken through a number of different forums and reviews completed over recent times along with the contributions of partners

participating in the development of our Partnership Early Help Strategy identifies key factors that can increase vulnerability and lead to poor

outcomes for children and families in Croydon.

Our early help priorities in the first two years to support the reduction in demand and impact on statutory services will be to

prevent escalation, where safe to do so, to statutory and specialist services and to enable step down from statutory and specialist

services to early help with a focus on working with families where the following predominant issues are present:

Domestic Abuse

Parental mental ill health

Parental substance misuse

Violence in the community affecting children and young people

Emotional and mental health issues with children and young people

Children at risk of exclusion from school or excluded from school

Child neglect and abuse

Housing and welfare supports for families

Social isolation

Children on the edge of care

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We asked parents what they wanted from early help services:

‘I want my child to be able to get help when he needs

it without us having to keep proving ourselves to new

people – there are too many hoops to jump through –

It is confusing’

Parent of a child on an EHC plan

‘Help when I’m struggling with

my mental health and a way

to get me back on track’

Young single Mother

Having someone who can help

me and my family access other

services

Croydon Parent

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Resilient families will be achieved by a partnership response to a whole system re-design of support to children, young people and families,

across the continuum of need, from pre-birth through to 18 years, using a consistent evidenced based approach to effectively build family and

community resilience in Croydon, focusing on early help and maximising the life chances for children and young people. This approach will

shift the balance of service delivery towards earlier help and prevention, therefore improving outcomes and life chances for families, reducing

demand on high cost statutory services and maximising the effective use of all available partnership resources.

6. Our Early Help Approach

Effective support through the ‘Right Help, Right Time’ framework describes the relationship between four levels of need;

universal, additional, intensive and specialist need.

Effective understanding and application of these levels will ensure children and their families receive help early in

the life of the problem. Practitioners should take an open and honest approach to supporting children and families. Professionals

should always seek a family’s consent to share information to enable them to access the right support, unless to do so a child

would be at risk of significant harm.

Universal – Most children and families will never come into contact with statutory or specialist services. The basic needs of all

children can usually be met by their family, community and faith networks and universal services such as maternity services, health visitors,

school nurses, GP practices, health care, early years, school and education settings, housing and youth services. Universal services are

provided as a right to all children including our most vulnerable children and those with additional, intensive or specialist needs. These

services are also well placed to recognise and respond when extra support may be necessary so that support is addressing family

vulnerabilities early. This may be because of the child’s changing developmental, health and wellbeing needs or because of parental or family

circumstances.

Children with Additional needs – Some children and young people are likely to need extra help to be healthy, safe and achieve their

full potential due to their own needs or their family circumstance. These children’s needs are best supported by those who already work

with them such as health professionals, children’s centres, school settings, organising additional support with local partners as needed. These

services are also well placed to recognise and respond when extra support may be necessary so that support is addressing family

vulnerabilities early.

For some children, young people and families with Intensive needs a co-ordinated multi-disciplinary approach providing an intensive or

package of support where the concerns can be managed without the need for statutory social work intervention or other specialist

interventions. These needs are usually best led by a professional already known to the family. The lead professional will engage the family

and other professionals to co-ordinate support through one outcome based plan. Where the support needed is more than a lead

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professional can organise effectively, referral to the Council’s realigned ‘intensive’ early help family case work locality teams – renamed

‘Best Start Family Solutions’ service can work with the child and family in a more intensive way.

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For some children and young people their needs are so significant that immediate statutory social work or highly specialist intervention is

required to keep them safe, protect them from harm or serious risk to their health or welfare. These needs may emerge after a series of, or

even despite targeted early help interventions, or be sudden and/or so serious as to require an immediate request for services. There will be

concern that the child is likely to, or is suffering significant harm or developmental delay. Examples of specialist services include children’s

social care, child and adolescent mental health services (CAMHS) tier 3 or 4 or the youth offending service.

Everyone working with children and families would need to utilise the four key steps to providing early help:

SEE – identify that there is a possible issue, problem or need and find out more – from the child, young person, their parents, carers and

other professionals and agencies who know the child, as necessary

PLAN – assess the need and plan with the child, young person and their family, alongside other professionals as necessary, how best to

meet that need

DO – agree who will lead the plan, implement the plan together, commission or provide the service

REVIEW – review progress, change the plan, change services or withdraw because the help is no longer needed

The Effective Support Right Help, Right Time framework Guidance for practitioners describes more details about the four levels of need and

application of need and aims to achieve consistency in understanding and practice, when responding to children young people and their families

who need extra support.

Families, communities, universal, targeted and specialist support services must all work together effectively and efficiently to meet

children’s needs at the earliest point to prevent their needs escalating. Fundamental to this is placing the child at the centre of all we do

and recognising that each child and family is individual and each family is unique.

Reaching decisions about levels of need and the best intervention requires discussion, reflection and professional judgement. All

professionals should work together to provide support to families at the lowest level possible according to their needs, but also be ready

to respond if there is an escalation in the child’s needs.

Universal services must remain involved even when more targeted or specialist services are working with the family. An effective early

help offer along the continuum of need, involving a robust range of interventions to support families to meet additional or intensive need

will ensure need is appropriately met and reduce the need for costly reactive services.

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In Croydon we will continue to develop and embed a locality based whole family approach across all children and adult services. This approach

recognises how problems that adults and children experience, for example, mental ill health,

substance misuse and domestic abuse, can impact on the whole family and highlights the

contribution that all agencies can make in ensuring services are provided to support sustainable

improved outcomes and life chances. It means creating a different approach to engaging with

families, working with families not ‘to’ them and fundamentally changing how organisations work

together. This includes greater integration of local services, pooled resources, better systems for

sharing information and recording, taking a whole family approach, and using a range of universal

and targeted services to meet need.

We will, with our partners, develop our prevention and support services/interventions within the

universal and early help offer, such as parenting, mentoring and domestic abuse programmes,

taking into account those predominant key characteristics/issues evident in statutory and

specialist services to enable us to intervene earlier, preventing escalation to specialist services.

Additionally, we will further develop our universal and early help support services to take into

account locality based needs as well as Borough wide needs. We will continue to monitor the impact of these supports and services to ensure we

have the right supports/services available at the right time that make a difference.

We will also ensure that we share across the Council and with partners, communities and families in Croydon examples of good practice in

addition to sharing knowledge of early help and prevention supports available .We will ensure that our ambition for all children is supported by a

confident workforce with a common core of knowledge and understanding about children’s needs and a consistent approach to practice.

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7. Making a Difference – Partnership Early Help Outcomes Framework

A Partnership Early Help Outcomes Framework will be developed with performance indicators to measure outcomes for children, young people

and their families, and enable us to measure the effectiveness and impact of the Partnership Early Help Strategy. It is anticipated that our

Partnership Early Help Outcomes Framework will evolve over time as we implement our strategy. This framework will enable us to be confident

of the effectiveness of our strategy and the impact this makes on supporting improvement of children’s services and improving life chances for

children and their families by preventing issues becoming problems, ‘Right Help, Right Time’ thus reducing the levels of need for children and

their families in specialist and statutory services.

Regular reporting on performance to strategic groups such as the Croydon Safeguarding Children’s Board, Children’s Improvement Board and

within partners governing body groups will occur to enable monitoring of progress and impact of the Partnership Early Help Strategy.

The Partnership Early Help Outcomes Framework will include measuring the impact that the Partnership Early Help strategy enables:

A Good Childhood, for the Best Start in Life – parents have the confidence to raise their children to have a good childhood and reach their

potential

Early help reduces the need for statutory and specialist interventions

Fewer children and young people are victims of crime including sexual exploitation

Fewer young people are involved in crime and anti -social behaviour including gangs

More children’s parents/carers are in employment, education and employment

Fewer families experience homelessness or living in unsustainable accommodation

Fewer children and young people are subject to neglect or abuse

Fewer children are affected by parental domestic abuse, mental ill health or substance misuse

A Great Education to give the best chance in Life – all children are eager to learn and confident in achieving their potential

More children attend early years provision

More children are ‘school ready’ and achieve a good level of development at the end of the foundation stage

More vulnerable children achieve good levels at each key stage

More children have regular attendance at school

Fewer children are at risk of exclusion or excluded from school

More vulnerable children are engaged in education, training and employment

The Best Health outcomes – all children achieve good health

More babies and children survive infancy

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More babies are breastfed

Fewer young people conceive or become parents

More children and young people maintain a healthy weight

More children and young people are fully immunised

More children, young people and adults in their family sustain good emotional health and well being

Fewer young people and adults in their family misuse substances

More young people have good sexual health

Measuring the effectiveness of early help system – early help is an effective and proactive system in Croydon

The Partnership Early Help Strategy is universally and consistently implemented across Croydon

Partnership working is at the centre of all opportunities to support children and their families

More evidence based and effective systemic practice interventions are used to effect sustainable change

The workforce is skilled, competent and have taken up workforce development opportunities ensuring continuous learning

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8. Early Help Delivery Model – priorities for 2018-2020

The Early Intervention Foundation in March 2014 developed an Early Help Maturity Matrix 2 .A mature level of early help is defined as “all

children and their families from groups that are a priority in a local area can access the support they need, when they need it.

Outcomes for children, particularly those in ‘target groups’ who might otherwise not have done so well, are excellent and continuing

to get better”. (Early Intervention Foundations Maturity Matrix).

To ensure we have a mature early help system we need to transform the way professionals work with each other and with families, and to

develop the right culture, systems and behaviours that support the delivery of the model across the partnership. The work of the Croydon

Safeguarding Children Board and the Partnership Early Help Steering Group (formerly known as the Task and Finish Group) has developed the

Partnership Early Help Strategy, and articulated a strong commitment by partners to transform and develop the right culture, systems and

behaviours needed to have a mature early help system in place in Croydon.

We will through the Partnership Early Help Steering group evaluate the impact of the Partnership Early Help Strategy to ensure we are making a

difference and are developing a mature early help system utilising the Early Intervention Foundation Maturity matrix.

The priorities for development during 2018-2020 are:

1. Establish Effective Leadership, Partnership Working and Governance

There are many positive examples of multi-agency working across Croydon to deliver good outcomes for children and their families and

we will continue to expand on this to focus on developing more effective streamlined and joined processes. With partner commitment we

will reenergise the Children and Young People’s Partnership Board (CYPP Board) – providing a multi-agency strategic leadership forum

for Croydon’s children and their families. Delivery and accountability for this Partnership Early Help Strategy and the Partnership Early

Help Outcomes Framework will move from the Croydon Safeguarding Children Board (CSCB) to this group once the CYPP Board has

been fully re-established. The CYPP Board will also have oversight of:

Each partner agency’s response to implementation of this Strategy and its contribution towards other borough wide strategies such

as the Croydon Safeguarding Children Board’s Neglect Strategy and Child Sexual Exploitation Strategy.

Developing an effective outcome based performance management and quality assurance framework to measure impact.

2 Early Intervention Foundation Maturity Matrix

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2. Establish easy to use Early Help online information and advice

In order to help children and their families and practitioners across the partnership to understand the wide range of information and

services available we will build on the Croydon local offer website as a central portal to bring information together. This local offer

website already provides information, advice and guidance to the public on a range of family issues, including support from partner

agencies. Other online websites, advice centres, telephone helplines or supports and services not linked will be connected to this

for the ease of families and practitioners.

3. Develop a suite of tools for early help practitioners to use – ensuring a whole family strength based consistent approach to

working with children and families

The Partnership Early Help steering group will develop an early help family wellbeing assessment and outcome based plan

which will replace all other existing assessment and plans for early help and will become the single multi-agency family

wellbeing assessment and outcome based plan for early help. It will align to the practice approach adopted already within

Croydon of ‘strengthening families’ which will assist children, families and practitioners across all agencies by having a common

approach to practice.

To accompany the assessment and outcome based plan the Partnership Early Help steering group will develop a suite of early

help tools to assist practitioners to understand the child and family journey, consistently monitor and review children’s progress,

evaluate the impact of support and interventions offered to improve outcomes and how to measure a family’s engagement and

their satisfaction level.

4. Develop effective and timely processes for sharing information between agencies

To enable early help to be more effective and ensuring the right help, at the right time, we will work with partners to remove barriers to

effective working and ensure that families don’t need to have a series of assessments or repeatedly ‘tell their stories’ before receiving

the support they need

Ensure we have in place clear information sharing arrangements

Ensure we are making the best use of IT systems and portals across agencies and departments

5. Refresh structures and pathways that support the access to early help

The Partnership Early Help approach is embedded in the Effective Support Right Help, Right Time, Guidance for practitioners and will

be available to all practitioners through the Croydon Safeguarding Children Board website.

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The Council’s existing early help services in place, Best Start, Early Help Hub, Family Resilience Service (FRS), Parenting Hub

and Family Functioning Team (FFT), will be realigned and renamed as ‘Best Start Family Solutions’ service’. Creating a locality

based, systemic, family key worker (casework) service to work with children and families deemed as intensive need under the

continuum of need, including children deemed on the edge of escalation to statutory services and those stepped down from

statutory services. FFT will provide borough wide edge of care interventions for children and their families. Parenting

programmes will continue to be provided for practitioners working with children and families open to both statutory and early

help services.

Locality based Partnership early help hubs will continue to develop greater integration and alignment with communities and

partner agencies, exploring co-location and/or coordination of processes with early years provisions, health visitors, schools,

children and adult substance misuse services and emotional and mental health services

We will work with commissioners and providers to ensure that the early help supports and interventions required in each locality

and across the borough are developed in accordance with need and ensuring impact.

The Partnership Early Help Steering group will develop and agree clear pathways to support access to early help and ensure

children, families and practitioners have clear information on how to access early help.

6. Develop a skilled and competent workforce across the partnership

Delivery of early help requires effective working between professionals and between services including an understanding of each

other’s role, responsibility, organisational culture and values. The Partnership Early Help Steering group governed at this time by the

Croydon Safeguarding Children Board will develop a programme of multi-agency learning and development to strengthen and enhance

the Partnership Early Help offer, to build on the delivery of evidence based practice. This includes:

Awareness raising to ensure that the ‘thresholds relating to risk across the continuum of need’ are clearly understood and

communicated between professionals so that families can move between early help and specialist statutory services at the right

time and when required.

Information sharing and conversations between professionals to identify families who would benefit from early help

Implementing whole family approaches whilst keeping the child at the centre and undertaking strength based assessments of

families including effective engagement and conversations with children and their families

Holding and managing risk

Working with difficult to engage families

Embedding evidence based approaches and interventions across the partnership – including sharing good practice and

developing online resources for practitioners

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7. Develop a joint commissioning framework for early help

Develop an approach that will encourage the development of services within our universal and early help offer across the

partnership, through service redesign, reshaping specifications and identifying opportunities to recommission differently on a

shared basis, or decommission/not recommission services that are not delivering to our identified needs. Ensuring a clear

rationale for what services are required and how they should be delivered. A mixed economy model and trusted partners

approach will be explored.

Commissioning principles will ensure provisions are evidence based, outcome focussed and supported by robust data and

analysis, focus on the needs of children and families, focus on prevention and early help, provide best value, sustainability and

affordability for the future, collaborative with partners, commission across the life course of children and young people and offer

opportunities for learning and innovation.

Enabling, through established governance mechanisms, pooled resources to develop a broader joint commissioning framework

across partner agencies to direct the commissioning intentions for early help whole family approaches and maximise best

value.

Develop an intelligence led approach to commissioning that draws together key public funding streams to develop a broader

joint commissioning framework across partner agencies to direct the commissioning intentions for prevention and early help

Ensure all stakeholders, including children and families, have a voice at every stage of the commissioning cycle and provide

feedback to measure and review impact and enable redesigned services that better meet the needs of our children and

families.

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6 November 2018

Title of Paper: Strategy and Operating Plan Update

Lead Director Stephen Warren Director of Commissioning Mike Sexton Director of Finance

Report Author Fouzia Harrington Associate Director: Strategy, Planning and Estates


None


None

Purpose of Report For Noting

Recommendation:

The Governing Body is asked to: ▪ Note the draft health and care transformation plan on a page ▪ Note the national and local approach to planning for 2019/20

Background:

The Governing Body will be aware of the development of the health and care transformation plan. This report provides an update to its development as well as an outline to national and local approach for planning for 2019/20.

Key Issues:

Health and Care Transformation Plan Update (A five year plan) Croydon is on a journey to sustainably transform health and care services in Croydon. We

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are taking stock of the significant progress made over the past years to transform services and our focus is to reset the momentum and the scale of transformational change and improvement. We are making good progress, however there is still much to do and One Croydon, a partnership of health, social care, voluntary sector and HealthWatch, is taking the opportunity to develop system wide health and care transformation plan. It builds on the exciting opportunity brought by the extension of the Alliance Agreement scope to whole population (from over 65s). It supports the newly developed health and wellbeing strategy and will become a delivery plan for the strategy.

Attached as appendix 1 is a draft plan on a page which sets out the approach for delivering a proactive model of health and care. It demonstrates our golden thread from vision to strategic initiatives. It includes the draft programmes, which are in development, to deliver the vision and goals. The draft plan is currently being widely tested and there is a recognition there is still much work to do including: ▪ Showing alignment with the Health and Well Being Board Strategy ▪ Being explicit about long term condition plans ▪ Show interdependencies between programmes Work continues to refine initiatives and to prioritise the expected outcomes to measure delivery. Work is also underway to develop the system wide financial plan The plan will help identify a roadmap of initiatives to be delivered formally through the Alliance arrangement. The development of the plan is led by the Croydon Transformation Board. Its co-production is through system wide programme boards and informed by a programme of continuous engagement. In addition a large scale health and care engagement event for the borough is planned on 20 November 2018, which will include the public, staff and stakeholders. The purpose is to test the plans to date and to focus on how to take forward some key challenges. The plan is expected to be published by March 2018. Operating Plan 2019/20 Update The emerging health and care transformation plan informed our commissioning intentions for 2019/20 and as it develops will further inform our plans including our QIPP plans for 2019/20. NHS Improvement and NHS England have set out the planning approach for next year in a letter to all CCGs and Trusts. In summary: ▪ the Government has announced a five year budget settlement for the NHS from

2019/20 – 2023/24 – an annual real term growth over 5 years of 3.4%. This allows for enough certainty to develop local credible five year plans, which will support the delivery of the NHS Long Term Plan (to be published by early December).

▪ To support the development of these plans there will be an overhaul of the policy framework, including a clinical review of national standards, the development of new

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financial architecture and a more effective approach to workforce and physical capacity planning.

▪ For 2019/20 individual originations need to submit a one year operational plan which will then be aggregated by STPs and supported by a local system operational narrative. This will create the year 1 baseline for the system strategic five year plan.

▪ The revised financial framework will be set out in the NHS Long Term Plan. 2019/20 will be a transitional year towards the implementation of commissioner provider control totals.

▪ Last year saw improved alignment between provider and commissioner plans in terms of finance and activity. This is expected to improve further.

In Croydon the CCG and Croydon Health Services NHS Trust are already working together to ensure joint planning and therefore greater alignment of plans. A joint planning group has been established and an initial, accelerated local time table developed. The intention is to produce a first draft of a joint CCG and CHS plan by mid-December ahead of the national mid-January submission. This will reflect joint understanding and agreement of demand and capacity, growth rates and CIP and QIPP Plans. In addition, there is agreement to plan for: ▪ A joint control total for 2019/20 ▪ A block contract The outline national and initial local planning timetable is set out below.

Outline national and initial local timetable Date

NHS Long Term Plan published Late Nov / Early Dec 2018

Publication of 2019/20 operational planning guidance

including revised financial framework

Early December 2018

Operational Planning 2019/20

Initial local joint plan (activity and finance) Mid December 2018

Initial plan submission (activity and finance) 14 January 2019

Draft organisation operating plan submission 12 February 2019

Aggregate system plan and operational plan narrative 19 February 2019

NHS Standard contract published 22 February 2019

Contract / plan alignment submission 5 March 2019

National tariff published 11 March 2019

Signed contracts 21 March 2019

Board/governing body approval of budgets 29 March 2019

Final aggregate system operating plan submission and

system operating plan narrative

11 April 2019

Strategic Planning

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Capital funding announcement Spending Review 2019

Systems to submit 5 year plans Summer 2019

Italics = local timetable

Governance:

Corporate Objective To commission integrated, safe, high quality service in the right place at the right time. To have collaborative relationships to ensure integrated approach To achieve financial balance

Risks

Effective planning will support mitigating a range of risks. Croydon has ambitious plans and a key risk is the organisational capacity and capability to develop and implement these at pace.

Financial Implications The Strategic Review sets out the reason for system wide deficits with recommendations for how financial sustainability can be addressed across Croydon partners.

Conflicts of Interest None as part of this report, however there is potential conflicts of interest through the design and implementation of any system change. The OBC principles for working together will form the basis for taking this work forward.

Clinical Leadership Comments Clinical Leadership comments have been sought throughout the planning process and are implicit in our plans. This will continue as we develop our plans further.

Implications for Other CCGs The commissioning intentions reflect the South West London STP being taken forward across SWL CCG’s.

Equality Analysis None as part of this report, however equality impact assessments will be conducted as part of an development of transformational plans.

Patient and Public Involvement None as part of this report, however there has been extensive engagement activities such as the ‘Big Ideas’ events that continue to inform the development of plans going

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forward. There potential will be a focus on ‘issue’ specific engagement to further enhance plans.

Communication Plan The Croydon Communications and Engagement Steering Group will also develop a Strategy for engaging on a wider population programme and with other stakeholders.

Information Governance Issues None as part of this report, there will be information governance issues arising from potential sharing of data. The OBC Information Governance Framework will be built upon.

Reputational Issues

The Strategic report shows the key drivers for system wide deficits. Supporting the next steps demonstrate system wide appetite for significant transformation change to address the challenges.

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STRATEGIC GOALS AND OUTCOMES

Reduce Inequalities

▪ Inequalities of life expectancy

between areas is closing

A sustainable health and care

system

▪ Affordable models of care

delivering improved outcomes

Improve healthy life expectancy

▪ People are living longer and

healthier lives

OUR VISION

Working together to help you lead your life

Croydon’s health and care transformation plan on a page DRAFT v11

Reduce Inequalities




system





healthier lives

STRATEGIC GOALS AND OUTCOMES

Reduce Inequalities




system





healthier lives

Peoples aspirations

▪ I am in control of my own health

and well being

▪ I am able to stay healthy, active

and independent as long as

possible

▪ I live in an active and supportive

community

▪ I can access the support my family

and I need

▪ I can access quality services that

are created with me and my family

in mind

STRATEGIC PRIORITIES

Enable a better

start in life

Improve

quality of life

Improve wider

determinants of

health and well being

Integrate health and

social care

STRATEGIC APPROACH

Stay Well

Greatest Need

Manage Well

Kee

pin

g p

eo

ple

we

ll

Wh

ole

po

pu

lati

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man

ag

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en

t

Inte

gra

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hea

lth

an

d

ca

re

Lo

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bas

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En

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STRATEGIC INITIATIVES

▪ Healthy Weight

▪ Healthy Mind

▪ Immunisation in the

Community

▪ Health, well being and care in all policy

▪ Housing support for mental health

▪ Working with schools

▪ Integrated Care System

▪ Population health management

▪ Active and Supportive Communities

▪ Locality based out of hospital care

▪ Integrated, multi skilled workforce, IT and estates

▪ Adult and social care transformation

▪ Shared decision

making, strength based

care and patient

activation

▪ Active and supportive

communities

▪ Prevention, early

intervention, early

detection

▪ Long term conditions

and disabilities focus▪ Healthy weight

▪ Diabetes

▪ Coronary Vascular Disease

▪ Children with disabilities

▪ Mental health

▪ Information and sign

posting

▪ People have the

support and access in

the right place at the

right time

▪ People are able to

manage well

▪ People are able to stay

well

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Stay Well Manage Well Greatest Need

KEY

▪ Years 1 - 2 implementation


Improve Quality of Life Enable a better start in life Improve wider determinants of health and well being Integrate health and social care

Alignment with Strategic Priorities

Active and Supportive

Communities ▪ Shared decision making, strength based care and patient activation across the whole population

▪ Development of Local Voluntary Partnership, including social prescribing , community development and engagement

▪ Supporting Carers

▪ Maximising volunteering opportunities

▪ Strengths based approaches across disciplines

▪ Use digital technology intelligently to signpost, re-direct, offer support in order to promote behaviour change

▪ Involve opticians, dentists, pharmacists, GPs and allied health care professionals in shared decision making

▪ Skills mix staffing

▪ Strengths based care

▪ “Nudge theory” employed for prescribing & self-

care and self-management to guide behaviour

and activities

▪ Improve health screening▪ Expand group consultation at scale within

primary, secondary and community care in

xxx.

▪ Develop the health champion role

▪ Implement expert patients programme

▪ Roll out group consultation for all conditions

▪ Develop use and coverage of Health Help Now App , service directory, e-market place, signs of

susceptibility

▪ Develop social prescribing at scale across the borough

▪ Review opportunities presented by general practice working at scale

▪ Developing locality based out of hospital care, including social care, housing, welfare and universal support

▪ Implementing Primary Care Working at Scale and development of existing Integrated Community Networks

▪ Network of places to access interventions centred around locality need

▪ Telecare and Telemedicine

▪ Review ambulatory emergency care

▪ Redesign of roving GP

▪ Increase offering of 111

▪ Introduction of GP Extended Access Hubs in New Addington / Selsdon Network

▪ Improve integration between primary and secondary services, including social care and housing

▪ Pathway redesign and process redesign

▪ Establish s single point of telephone access

▪ LIFE at Scale

▪ Supporting Carers

▪ Care homes transformation & telemedicine and

Assistive Technology

▪ Falls & Frailty transformation

▪ End of Life care improvements

Locality Development

PROGRAMMES TO DELIVER OUR INIAITIVES

Health and care transformation plan programmes DRAFT

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KEY



Improve Quality of Life Enable a better start in life

Improve wider determinants of health and well being

Integrate health and social care


Transforming community mental health provision for people with Serious Mental Illness to include: ▪ Enhanced Primary Care – seamless service between primary & secondary care; improved support &

rapid telephone advice for GPs; new primary care mental health support workers; address stigma of mental health.

▪ Community mental health hubs – common access to primary & secondary care; provision of wide range of services (clinical & social including benefits/housing/employment); link to ICNS.

▪ Improved Integrated housing - develop wide range of housing support options (e.g. The Shared Lives Scheme)

▪ Connecting communities – information, Local Voluntary Partnerships, including social prescribing directory of services galvanise communities, PIC support.

Mental health

▪ Improved crisis care pathway for people in mental health crisis.

▪ Improving services for women with mental health issues during the perinatal period through enhanced community multi-disciplinary teams.

▪ Reduce physical ill-health amongst SMI population.

▪ Improved training & employment opportunities for people with SMI.

Better Start in Life

▪ Paediatric pathway redesign

▪ Expand pathway for A&E Frequent

attenders

▪ Promote GP telephone advice line and

asthma nursing service

▪ Healthy Weight - healthy weight prevention and early intervention services

▪ Healthy Mind – develop and implement a screening tool

▪ Bringing Immunisation into the community

▪ Community therapies strategy developed

▪ Children and young peoples mental health

transformation plan

▪ Redesign Children's community ASD

diagnosis and care pathway


▪ Personalised care and choice of place of birth – personalised care plans, increasing midwifery led care

▪ Continuity of care – named lead midwife and buddy throughout a women's maternity journey

▪ Safe care – Multi disciplinary team training on Saving Babies Life's Care Bundle

▪ Multi disciplinary working and working across boundaries

▪ A fairer payment system

▪ Postnatal care – proactive triage phone calls

▪ Perinatal mental health care - increasing

opportunities for identification of those at

risk

Maternity


▪ Talking Therapies – improving access to psychological therapies for people with common mental health problems.

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KEY





All Age Disability and Adult Social Care Transformation (ADAPT)

▪ Workforce reform – staff into localities (older people first), charging, front door from Adult Social Care to Gateway

▪ Digital pathways – E-market place, inc. directory of services, resource allocation, information and advice, Ask Sara (guided advice for daily living)

▪ Children with disabilities – disability registration process, practice developments, transition process improvements

▪ 25-65 disabilities – direct payments, complex care team, placements and brokerage, transitions for over 65s, employment, family group conferences

▪ Active lives – Autism service engagement, day opps and respite market review, needs assessment, community opportunities and co-production

▪ Mental health – CCG/LA funding approach, employment, increase step down provision, placement function

▪ Homes for people with complex health and social care needs – investment and dev, Integrated Framework Agreement refresh, community assets,

Dynamic Purchasing System, placement function

▪ Supporting local integrated of services through repatriation

▪ Strength based care

▪ Improving housing options

▪ Neuro rehab development

▪ Personalised Health Budget and Direct Payment development people with disabilities

All Disabilities


Wider determinants of

health and well being

▪ Transforming acute provision including community facing services

▪ Clinically sustainable hospital

▪ Optimising acute pathways and improving integration

▪ Supporting local integrated services through repatriation

▪ A&E transformation

Modern Acute Hospital


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KEY





Workforce

• Understanding changing workforce requirements• Develop and implement a workforce plan• Whole system training solution• Deliver culture change

IT and Digital

▪ Interoperability Phase 1 and Phase 2 implementation – primary & secondary care, community and acute and mental health & social care

▪ IT infrastructure development

▪ Development of effective System IT Transformation Board and work programme

Estates

▪ Capturing estates requirements across the system and developing whole system estates solution▪ Supporting locality based development including New Addington Health Centre, East Croydon Growth Zone, Coulsdon Health Centre

▪ One Public Estate

▪ GP estate improvement

Communications and Engagement

• Communicate and engage with stakeholders both internally and externally that supports the system transformation• Facilitate public consultations where necessary• “One Croydon” approach

Finance▪ Developing whole system financial approaches

Contracting▪ Designing contracts to incentivise/support models of care

ENABLERS

Others

▪ Development of an integrated care system design options

▪ Joint NHS control total and system financial risk share agreement

▪ Business cases for transformation and contracting developments, including shift to outcomes

▪ Total resource sharing and matrix working

▪ Organisational development

ENABLERS

Integrated Care System

▪ Development and implementation of population health management strategy

▪ Development and implementation of population health management function

▪ Shared Business Intelligence – ‘one version of the truth’

ENABLERS

Population Health

Management



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Tuesday 6 November 2018

Title of Paper: Operating Plan Progress Report Q2 2018/19

Lead Director Stephen Warren, Director of Commissioning Martin Ellis, Director of Out of Hospital Care and Primary Care

Report Author Bobby Miles, Strategy and Planning Manager Fouzia Harrington, Associate Director of Strategy, Planning and Estates


QIPP Operational Board – 22 October 2018 and 29 October 2018 Senior Management Team – 23 October 2018


Governing Body

Purpose of Report For noting

Recommendations:

The Governing Body is asked to: ▪ Note the Operating Plan Progress Report Q2 and the issues arising ▪ Note the Integrated Governance and Audit Committee (IGAC) is overseeing the

development of the report, however due to sequencing of meetings this report is presented to the Governing Body ahead of the next IGAC.

Background:

The Operating Plan progress report for quarter 2 (2018/19) provides a high level

summary of the progress being made against the CCG operating plan by priority

programmes of work, each of which reflect:

1. Quality outcomes 2. Activity outcomes 3. Finance (QIPP and non QIPP where appropriate) 4. Performance against national standards 5. Key programme milestones – which align with QIPP schemes where relevant.

The Operating Plan Progress provides an overview of programme performance and

programme remedial action. Individual performance issues within programmes will be

reflect in the following reports:

▪ QIPP Report (monthly)

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Contains narrative on the progress of the QIPP programmes and their underlying

projects; activity and performance outcomes, programme risks and QIPP financial

performance.

▪ Integrated Performance & Quality Report (monthly)

Contains an operating plan indicators scorecard; an exceptions report for indicators

that are red rated (year to date), which describes the indicator, the issue, causes and

remedial actions being taken; Improvement & Assessment framework (IAF) indicators

dashboard, produced quarterly by NHSE; IAF clinical priority areas; Quality Premium

and quality assurance updates.

▪ South West London CCGs Contracting, Finance and Activity report - operating plan

section only (monthly)

In addition to the South West London CCGs view, this also contains a Croydon CCG

specific information (year to date) on key activity, including GP referrals, elective and

non-elective admissions, and A&E attendances.

Key Issues:

Programme Performance Issues

There are a number of programmes which appear to be on target to deliver

milestones; however, activity and finance outcomes are off target. This is most evident

in the Planned Care programme.

For Planned Care there has been an increase in referrals which has impacted on

outpatient activity plans. In addition, the repatriation of activity back into Croydon has

been slow. Implementation of service redesign initiative across digestive diseases has

been challenging thus resulting in slow progress. Remedial action includes:

▪ Planned Care recovery plan which is focusing on GP variation visits and

understanding referral behaviour across providers to address demand and

inappropriate activity.

▪ Work is also underway to revisit care pathways such as cardiology to rebase the

transformation programme and seek clinical leadership and ownership across the

system.

▪ Soft relaunch of digestive diseases pathway is underway and impact being revised

on a fortnightly basis.

▪ New models of care are being developed for a range of specialities focusing in

integrating care pathways to ensure seamless care for patients, improved

outcomes and efficiencies. These are intended to be implemented / mobilised in

2019-20.

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In addition the mental health programme faces a number of risks to delivery, in the

main due to high demand of mental health beds. Remedial action includes:

▪ A recovery plan to ensure targets are met by end of March 2019.

▪ A CQC action plan also published which includes actions around patient flow

▪ A Mental Health Transformation business case is under development

Reporting Challenges

There are a number of challenges inherent in the current Progress Plan report. To

overcome these issues arising:

▪ The QIPP Operational Board (QOB), which meets weekly, will programme in

performance reviews of each of the programmes. The QOBs first focus was on the

Planned Care programme.

▪ It is expected that the performance report will be used with the Programme Boards to

focus delivery discussions.

Key reporting challenges

▪ The status reporting comes from individuals or teams (e.g. quality outcomes,

milestones) Objectivity will be provided through the QOB performance review

process.

▪ The data is not uniformly timely across or within the programmes and so the report

presents data from different time periods. This can make triangulating outcomes

across different domains difficult. The QOB performance review process will enable

a holistic intelligence to inform the report.

▪ The quality outcomes are not all easily measurable. The quality team will be better

involved in the planning for 2019/20 Operating Plan.

Governance:

Corporate Objective To commission integrated, safe, high quality

service in the right place at the right time.

To achieve financial balance.

Risks Risks are individual to each programme. Recovery

plans are expected to mitigate against identified risks.

Financial Implications The financial position is reflected for each

programme where possible. Detail of implications

is reflected in the finance report.

Conflicts of Interest None identified.

Clinical Leadership Comments None.

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Implications for Other CCGs None.

Equalities Analysis Equalities impact assessment is developed as part of

the individual programmes identified.

Patient and Public Involvement There is no patient and public engagement as part of

his report, but programmes will have been developed

as part of their development.

Communication Plan The progress report will be used with programme

boards to further develop delivery improvement.

Information Governance Issues None identified.

Reputational Issues Having robust progress monitoring arrangements in

place enhances the reputation of the CCG.

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Operating PlanQuarterly Progress Report

Quarter 2 - 2018/19Version 5

1

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2

ContentsAbout this report 3 – 4

Croydon CCG Highlights Q2 - 2018/19 5

Strategic Transformation Operating Plan Highlights Q2 - 2018/19 6

Key issues and actions being taken 7-9

Programmes on a page: • Planned Care; Cancer; Diabetes; Obesity• Out of Hospital; Urgent & Emergency care• Mental Health• Medicines Optimisation• Continuing Healthcare; Children & Young People; Learning Disabilities • Together for Health• Primary Care• Maternity

10 - 23

Changes to performance standards reporting 24

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About this reportPurpose of this reportThis report aims to provide a high level summary of the progress being made against the CCG operating plan by priority programmes of work, each of which reflect:1. Quality outcomes2. Activity outcomes3. Finance (QIPP and non QIPP4. Performance against national standards5. Key programme deliverables – which align with QIPP schemes where relevant

Unless otherwise stated, the data for this report covers Q2. Where it covers a different period, this is clearly shown (e.g., M5, Q1).

This report provides a simple overview of programmes in their entirety as per the Operating Plan; detail of performance is provided by the currently existing performance reports as set out below:

QIPP Report (monthly) Contains narrative on the progress of the QIPP programmes and their underlying projects; activity and performance outcomes, programme risks and QIPP financial performance.

Integrated Performance & Quality Report (monthly) Contains an operating plan indicators scorecard; an exceptions report for indicators that are red rated (year to date), which describes the indicator, the issue, causes and remedial actions beingtaken; Improvement & Assessment framework (IAF) indicators dashboard, produced quarterly by NHSE; IAF clinical priority areas; Quality Premium and quality assurance updates.

South West London CCGs Contracting, Finance and Activity report - operating plan section only (monthly) In addition to the South West London CCGs view, this also contains a Croydon CCG specific information (year to date) on key activity, including GP referrals, Elective and non elective admissions, and A&E attendances.

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About this reportInformation sources of key aspects of this report1. Quality outcomes: Quality & Governance provide the summary; the programme leads provide the programme level status2. Activity outcomes: The activity summary table and the programme level data are provided by the CSU3. Finance: QIPP finance is provided by the PMO; other finance is provide by the Finance team4. National Performance standards: the performance standards data and RAG rating are provided by the CSU. Many of the

performance standards do not have targets; in some cases there is no data available5. Milestones: QIPP project milestones updates are provided by the PMO; non QIPP project milestones updates are provided

by programme leads

Changes made since the Q1 reportSubstantial changes to this report in terms of indicators, are set out in the final three slides of this report

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Croydon CCG Highlights Q2 - 2018/19Quality (M4)CQC Visit UpdatesCHSIn July 2018, the CQC made an unannounced visit to CHS NHS Trust Medical Services and Community Services (Adults and Children and Young People). The full report was published on 28th September 2018. The rating for the trust remained as Requires Improvement, the same as the previous inspection in 2017

SLAMFollowing the CQC inspection at SLaM in July 2018 of forensic services, crisis pathway, community services for older adults and adult eating disorder services, initial feedback from the Trust is that the inspection went well and continued improvements across the services had been recognised by the CQC, including a complete turnaround and completion of all of the actions within the adult eating disorder unit.

PRIMARY CARETwo practices within Croydon borough, Edridge Road Community Health Centre and Coulsdon Medical Centre, have been rated at “Inadequate” overall by the CQC. In addition, two practices, Shirley Medical Centre and Brigstock and South Norwood Partnership have been rated as ‘Requires Improvement’ overall.

The remaining Practices within Croydon borough, which have been inspected by the CQC, are currently rated as ‘Good’ overall.

Performance (M4)A&E – CHS recorded a performance of 85.0% (all type) against the 4 hour standard in July.Key action: Workforce issues are being addressed through remodelling of capacity against demand and continued engagement with temporary workforce to reduce turnover, as well recruitment and retention.

Cancer waits - Croydon CCG did not meet the 62 day standard with an outcome of 78.3% due to 15 breaches out of 69 pathways.Key Action: The Q1 thematic analysis actions are being agreed at the SWL System Leadership Forum

IAPT Recovery rate - The Recovery Rate was below the national standard of 50.0% in July, with 45.6%.Key action: SLaM is continuing to recruit to substantive roles

RTT - The CCG had 21 patients waiting over 52 weeks for treatment in July.Key action: An Improvement trajectory has been agreed based on activity and performance assumptions for RTT (Kings College Hospital)

5

Activity (M5)Operating Plan varianceagainst plan

Key drivers

ReferralsE.M.7 - Total Referrals: 10.5% E.M.7a - GP Referrals: 12.2% E.M.7b - Other Referrals: 7.6%

CHS identified an error in the M1-3 MAR reporting which included non-consultant-led activity, therefore the M1-3 position is higher than it should be. CHS have requested a resubmission, however it is likely that a refresh to the published data would not be seen for some time.

OPE.M.8 - First Outpatients: 1.4%E.M.9 - Follow Up Outpatients: 2.5%

Approx 2% of the OP first over-performance attributed to CDU activity in M1-4 following the temporary closure of ED Obs.

Elective AdmissionsE.M.10 – Total: 4.1%E.M.10a - Day Cases: 3.7%E.M.10b - Elective Admissions: 6.6%

Year on year increase in daycases include increase in Colorectal Surgery and Pain Management.

Non-Elective Admissions (NEL)E.M.11 – Total NEL: -15.5%E.M.11a - NEL 0 LOS: -23.8%E.M.11b - NEL >=1 los: -12.5%

18% of the 0 LOS under-performance attributed to the temporary closure of ED Obs ward, activity recorded as OP during this period.

A&E Attendances (all types)E.M.12 - A&E Attendances: 11.2%

14% of over-performance in CHS type 3 CUCA activity due to an increase in activity during 2017/18 as the service embedded.3% due to SASH duplicate SUS submission

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Strategic Transformation Operating Plan Highlights Q2 - 2018/19

6

QIPP RAG

>=90%>30% AND <90%<=30%

Programme name Director Quality Outcomes

Den

omin

ator

Activity outcomes

Den

omin

ator

Performance Standards

Den

omin

ator

Milestones

Den

omin

ator Full year

planned savings

Full year forecast savings

Full year variance

YTD planned

QIPP

YTD actual QIPP

YTD QIPP variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Planned Care

Cancer On target 2 On target 1 At risk 14 On target 4

Diabetes At risk 3 On target 4 Off target 2 At risk 7

Obesity At risk 2 At risk 3 None 0 At risk 6

Planned Care At risk 4 Off target 13 Off target 8 Off target 7 4.22 2.80 -1.42 1.27 0.45 -0.82 103.78 106.97 -3.19

Out of Hospital Martin Ell is

Out of Hospital Martin Ellis At risk 3 At risk 3 At risk 10 At risk 11 7.57 6.59 -0.98 3.27 2.52 -0.75 82.80 79.50 3.30

Urgent & Emergency Care Stephen Warren At risk 3 At risk 9 At risk 12 At risk 4 0.53 0.03 -0.50 0.20 -0.30 -0.50 23.00 23.20 -0.20

Mental Health Stephen Warren At risk 7 Off target 3 At risk 13 Off target 6 4.55 4.55 0.00 1.93 1.90 -0.03 53.10 53.10 0.00

Medicines Optimisation Martin Ell is At risk 4 On target 1 At risk 3 Off target 4 3.66 2.59 -1.07 1.71 1.67 -0.04 51.10 52.40 -1.40

Named Patients Elaine Clancy / Stephen Warren

Continuing Healthcare Elaine Clancy At risk 4 Delivered 1 At risk 5 At risk 5 3.00 4.39 1.39 1.50 2.19 0.69 28.60 27.30 1.30

CYP: Children's Health Stephen Warren On target 2 At risk 2 On target 3 On target 4 0.20 0.20 0.00 0.00 0.00 0.00

Learning Disabilities Stephen Warren At risk 5 On target 1 On target 4 On target 4 0.90 1.07 0.17 0.43 0.48 0.05 3.70 2.80 0.80

Personal Health Budgets Elaine Clancy 0.31 0.20 -0.11 0.11 0.11 0.00

Together for Health Stephen Warren At risk 7 None 0 None 0 At risk 6

Primary Care Martin Ell is At risk 9 On target 1 No data 4 At risk 6 59.00 58.60 0.40

Maternity Stephen Warren On target 2 At risk 3 No data 4 At risk 5 30.40 28.70 1.70

Other Mike Sexton 2.58 2.44 -0.14 0.20 0.53 0.33

Croydon CCG TOTALS At risk 57 At risk 45 Off target 82 At risk 79 27.61 24.86 -2.66 10.62 9.55 -1.07

Stephen Warren

18/19 Finance at M6 £mProgrammesMilestones % on

target + in delivery + Not due

18/19 QIPP Finance (NET) at M6 (£m)Outcomes % on target or delivered

Outcomes RAGDelivered: all outcomes deliveredOn target: Reds + Ambers = 0At risk: Red + Ambers > 0Off target: Reds + Ambers>= 50% of total

No performance indicator / target

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Programme Strategic Transformation Operating Plan Q2 – Programme Performance Summary and Programme Remedial Action (1 of 3)

Planned Care: Cancer, Diabetes, Obesity (Weight management)SLIDES 10 – 13

Programme Performance: Milestones are delivered or on target; activity and performance standards are off target; quality outcomes are at risk.

Programme progress: The Planned Care programme is delivering transformation across a range specialities/services. Areas that are progressing successfully include: MSK, Dermatology, Gynaecology and ENT; we are also in the process of finalising contractualarrangements for new models of care (e.g., MSK, Dermatology). New MSK service will commence on 1 December 2018; however, it is noted that there has been some delay in implementation. New Model of care for diabetes agreed across local clinical network.

Issues: There has also been an increase in referrals which has impacted on outpatient activity plans. In addition, the repatriation of activity back into Croydon has been slow. Implementation of service redesign initiative across Digestive diseases has been challenging thus resulting in slow progress.

Remedial actions: Planned Care recovery plan which is focusing on GP variation visits and understanding referral behaviour across providers to

address demand and inappropriate activity. Work is also underway to revisit care pathways such Cardiology to rebase the transformation programme and seek clinical

leadership and ownership across the system. Soft relaunch of digestive diseases pathway is underway and impact being revised on a fortnightly basis. New models of care are being developed for a range of specialities focusing in integrating care pathways to ensure seamless care

for patients, improved outcomes and efficiencies. These are intended to be implemented / mobilised in 2019-20.

Out of Hospital SLIDE 14

Programme Performance: Quality, activity and milestones are at risk of deliveryReason:• Phase 2 Business case sign-off process (with Alliance partners) has experienced three months of delay; however, we have now

agreed the sign off process, and the implementation has commenced• Non elective admissions are down 13% YOY for Q1Programme Remedial Action: Detailed project planning for care homes, Falls and End of Life is underway with plans to implement the first cohort of 20 care homes , including the implementation of telemeds by 31 December 2018

Urgent & Emergency CareSLIDE 15

Programme Performance: Performance standards and finances are off targetReason:• CCG has short term capacity issues, which may impact on the level of support it is able to provide to CHSProgramme Remedial Action: • Implementation of a revised Urgent & Emergency care Improvement Plan has started to yield results, including improved 4 hour

performance, and improved rates of assessment of mental health patients within one hour. The plan is owned by the Director of Operations at CHS.

• CCG has short term capacity issues, which may impact on the level of support it is able to provide to CHS; however, the CCG is recruiting to the vacant post, and expect the role to be filled by December 2018

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Mental Health SLIDE 16

Programme Performance: A number of milestones, activity and quality outcomes are at risk. Reason:• Demand remains high for mental health beds; IAPT trajectory is now back on trackProgramme Remedial Action:• MH recovery plan covers the actions required to expedite the correction of ‘At risk’ and ‘Off target’ outcomes. This plan is

managed by the CCG MH team; corrective actions have been developed to ensure targets are met by End of March 2019. • CQC action plan also published which includes actions around patient flow• Mental Health Transformation business case is under development

Medicines OptimisationSLIDE 17

Programme Performance: Quality outcomes and performance standards are at risk. QIPP is on target; overall finances are off targetReason:• Slippage on OTC implementation• Previously unidentified cost pressure from Category M and NCSO drugs• Recruitment of dietician has been slowProgramme Remedial Action:• Dietician appointment is now approved and will be in post by Q4; in the interim SWL lead dietician is providing support (on the

job training), and working alongside and is being supported to review Oral nutritional supplements.• Implementation of recommendations from NHS consultation on OTC medicines will be delivered in Q3

Named Patients: Continuing Healthcare, Children & Young people; Learning disabilitiesSLIDES 18 - 20

Programme Performance: Mainly on track with minor variances Programme Progress update:• The Children’s Transformation team have now met with each of the three pilot practices with frequent A&E attendances and

follow up actions relating to reasons behind attendances is undergoing. Financial modelling is not fully completed and a steering group meeting has been arranged for the 30 October to contribute to the clinical assumptions required. Impact assessments remain outstanding and expect Joint Impact Assessment Panel (JIAP) approval on the 22 November

• Learning Disabilities: 9 out of 10 patients in the QIPP cohort have successfully ben transferred to social care. There remains further negotiation regarding the one remaining patient on the basis that their community package has yet to be agreed. The team has been recruiting for two roles: Complex Care reviewer has been interviewed and offered; Commissioning support officer interviews are on 30 October.

• LD Annual Health checks – continues to show improved uptake compared to the same period last year• LD transforming care programme continues to be on trajectory for discharges, which supports the SWL Transforming Care

partnership to maintain their over performance compared to the wider London

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Together for HealthSLIDE 21

Programme Performance: Milestones at riskProgramme Progress update:• Delivery to date over 500 patients by end of Q2, and anticipate 2000 by end of year; GPFV monies have been identified as an

alternative funding source to allow for further spread of group consultations in East Croydon. Awaiting decision. • CEPN seed funding for EPP secured & this will allow for a very small scale ‘test and learn’ approach; currently 2 x EPP tutors

trained with first EPP community course expected in early Q4• Social Prescribing progressing well across Croydon with 42 Practices now signed up to initiative and 4 out of 6 Networks now with

Social Prescribing Boards established • Health Help Now developments include building a Social Prescribing component within app and website with key discussions

ongoing on how best to promote the initiative as part of the One Croydon Digital Offer. Total downloads of app to date stand at 3,981

Primary CareSLIDE 22

Programme Performance: At riskProgramme Progress update:• GP extended access is in the final stages of implementation.• Network approach in the GP Hubs ‘Go live’ plan is as follows: New Addington went ‘Live’ in September; Purley and East Croydon

are due in November (ahead of schedule)• GP transformation is in progress and is on target. There have been independently facilitated events to develop local working at

scale plans for six networks• Place based care approach has been developed to support the wider health and social care system

MaternitySLIDE 23

Programme Performance: At risk; however, quality outcomes are on targetReason:• Continuing issue in the delivery of Continuity of Carer within the financial envelope and the capacity of Trusts to mobilise full

transformation in line with trajectories. Position statement covering the whole transformation plan (e.g., Continuity of Carer, Choice and Personalisation) is being drafted and will be presented to SMT by end of December 2018.

Programme Remedial Action: • Maternity Action plan is in place to expedite remedial actions – plan managed by CCG senior commissioning maternity manager • Personalised Care plan metrics and definition to be agreed and set by NHSE as part of the transformation programme (Better

Births national review refers)

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Planned Care Responsible Director: Stephen WarrenProgramme lead: Aarti Joshi

Objectives The planned care programme supports the vision of change set out in the NHS Five Year Forward Plan, SWL STP and local priorities including understanding and considering the Croydon population health with the aim to improve health across the entire population, by supporting self-care, developing integrated clinical pathways, supporting secondary care in shifting care into the community and primary care and delivering care according to best practice.

Finance

10

18/19 QIPP Finance (NET) at M6 (£m)

Full year planned savings


Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

4.22 2.80 -1.42 1.27 0.45 -0.82

Quality Outcomes StatusBetter primary and community access to services across the borough. Evidenced by Implementation of 4 x new models of care (ENT, Gynae, Derma, MSK) and care pathways

On target

An enhanced Primary care workforce profile to deliver the transformed services for patients. Evidenced by increase GPwERs (Dermatology), Physiotherapists across practices

On target

Increased support and promotion of patient self-activation, Self-Care and shared decision making. Evidenced through reduction in referrals to secondary care (signposting patients to alternative self care material).

At risk

Increase in quality of patient experience across Dermatology and MSK through embedding new models of care. Evidence through patient feedback in Quarter 4. On target

Milestones Qtr due Status

Planned Care Business Case Sign off 1 Delivered

Market test and procure 2 Off target

Mobilise New models 3 At risk

MSK – Primary Care Based Service (moved from Q3 to Q4) 4 On target

Dermatology – Integrated Community Service (moved from Q3 to Q4) 4 At risk

ENT & Gynae – Development of new model of care 4 Delivered

Dig Diseases – Nurse Specialist Triage 4 At risk

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Planned Care Spend £m £m £m £m £m £mElective 23.29 23.70 -0.41 46.54 47.42 -0.88Outpatient 26.04 27.04 -1.00 52.06 54.18 -2.12Unbundled Diagnostics 2.59 2.68 -0.09 5.17 5.37 -0.20(Over)/Under Performance 51.91 53.42 -1.51 103.78 106.97 -3.19

National Performance standards (M5 unless otherwise stated) Status Freq

DFV Referral to treatment pathways (incomplete pathways On target TBC

DFV Diagnostic test waiting times Off target TBC

DFV Cancelled Operations (CHS) Q1 Off target Q

DFV Number of 52 week referral to treatment pathways Off target M

DFV Total Bed Days (Activity Count from either NHSE Operating Plan return or CFAR) TBA Q

DFV NHS e-Referral Service (e-RS) Utilisation Coverage Off target A

IAF Utilisation of the e-referral service to enable choice at first routine elective referral No 18/19 data Q

IAF Patients waiting 18 weeks or less from referral to hospital treatment (M3) No 18/19 data M

Activity Outcomes Status

Outpatient reduction – 65,612 outpatient activi ty Off target

Elective activi ty reduction - 1,416 of elective activi ty Off target

Non-Elective reduction – 107 At ri sk

A&E Reduction – 71 A&E activi ty At ri sk

Increased activi ty in community and primary care On Target

Number of 52 week referra l to treatment pathways Off target

Tota l Bed Days (Activi ty Count from ei ther NHSE Operating Plan return or CFAR)

TBA

Tota l Referra ls made for a Fi rs t Outpatient Appointment (Genera l & Acute)

Off target

Tota l GP Referra ls made for a Fi rs t Outpatient Appointment (G&A) Off target

Tota l Other Referra ls made for Fi rs t Outpatient Appointment (G&A) Off target

Consul tant Led Fi rs t Outpatient Attendances (Speci fic Acute) At ri sk

Consul tant Led Fol low-Up Outpatient Attendances (Speci fic Acute) Off target

Tota l Elective Spel l s (Speci fic Acute) Off target

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Activity Outcomes (Q1) Status

As diagnosis and screening uptake improves, the expectation is an increase in activity and cost

On target


Implement Pleural and Lung Pathways 1 Off target

Implement shadow monitoring for 28 day Diagnosis 2 Delivered

Develop head and neck pathway 3 On target

FIT bowel cancer screening 4 On target

Cancer Responsible Director: Stephen WarrenProgramme lead: Michael Sutton

Objectives To work with key providers in conjunction with RM Partners Cancer Vanguard to implement the Cancer Delivery Plan locally and across SWL STPs. The vision is to achieve world-class cancer outcomes for the population by 2020/21.

Finance

11

Quality Outcomes Status

Earlier Diagnosis: 4% increase or 60% absolute performance of cancers diagnoses stage 1 and stage 2 At risk

Greater patient satisfaction (cancer patients only) – Annual measure (October 2017) On target

No QIPP FinanceFinance data collected annually at programme budget level


DFV Two week wait for Breast Symptoms On target M

DFV Cancer 31 day wait - first definitive treatment On target M

DFV Cancer 31 day wait for subsequent treatment (surgery) Off target M

DFV Cancer 31 day wait for subsequent treatment (drug regime) Off target M

DFV Cancer 31 day wait for subsequent treatment (radiotherapy) On target M

DFV Cancer 62 day waits (first definitive treatment) Urgent GP referral Off target M

DFV Cancer 62 day waits (first definitive treatment) Screening Off target M

DFV Cancer 62 day waits (first definitive treatment) Consultant Upgrade On target M

IAF Cancers diagnosed at early stage No 18/19 data A

IAF People with urgent GP referral having first definitive treatment for cancer within 62 days of referral No 18/19 data Q

IAF One-year survival from all cancers No 18/19 data A

IAF Cancer patient experience No 18/19 data A

IAF One-year survival from all cancers No 18/19 data A

DFV Cancer two week waits On target M

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Reduction in length of stay for people with diabetes (irrespective of speciality) On target

Reduction in non-elective / emergency activity On target

Reduction of outpatient activity On target

Increased delivery of care in primary/community care settings, following the procurement of new diabetic service On target


Specialist inpatient nurse and specialist podiatrist in post 1 Delivered

Agree scope of business case / procurement 1 Delivered

South London education booking hub go live 3 On target

Business case sign off (moved from Q2 to Q3) 3 At risk

Agree commissioning approach for the new integrated model of care 3 On target

Mobilisation of integrated service 4 On target

Development of measurable outcomes/ KPIs 1 Delivered

Diabetes Responsible Director: Stephen WarrenProgramme lead: Deborah Causer

Objectives To deliver an integrated care system approach to diabetes.

Finance

12


Number of people with diabetes who attend a diabetes structured education programme within 12 months of diagnosis On Target

Increase in the percentage of people with diabetes receiving all eight care processes; Care processes and treatment targets as set out in the National Diabetes Audit.Targets are currently based on 16/17 and are for each of the eight care processes.

At risk

Increase in the percentage of people with diabetes meeting all three treatment targets, as set out in the National Diabetes Audit. Targets are currently based on 16/17 .

At risk

No QIPP FinanceFinance data collected annually at programme budget level


IAF Diabetes patients that have achieved all the NICE recommended treatment targets: Three (HbA1c, cholesterol and blood pressure) for adults and one (HbA1c) for children No 18/19 data A

IAF People with diabetes diagnosed less than a year who attend a structured education course (data obtained locally for Q2) Off target A

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Reduction in medication usage (TBC Q3) At risk

Reduction in need for Tier 4 (bariatric) surgery (TBC Q3) At risk

Reduction in frequency of other health appointments (TBC Q3) At risk

National Performance Standards StatusNONE

Milestones Qtrdue Status

Mapping adult weight management services 1 Delivered

Publish and disseminate adult weight management pathway 3 On target

Diabetes / weigh management procurement approach agreed 1 On target

Diabetes business case sign off 2 At risk

Procurement of agreed approach through diabetes business case 3 On target

Transition and mobilisation of integrated diabetes service 4 On target

Obesity: Weight Management Responsible Director: Stephen WarrenProgramme lead: Deborah Causer

Objectives To commission an integrated weight management service which provides NICE compliant tier 3 and tier 4 bariatric surgery to patients who meet ECI criteria.To ensure the tier 3 and 4 pathways are integrated with tier 1 and 2 services.

Finance

13


[Beyond 18/19] Patient satisfaction with service (not defined) At risk

[Beyond 18/19] Improving outcomes for bariatric surgery (Tier 4 services) (not defined) At risk

No QIPP FinanceFinance data collected not collected at this level

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A&E reduction: 2817 - Performance data is due in Aug At risk

Non Elective reduction (spells): 2913 (242 per month). Up to M2, 238 spells avoided per month At Risk

Excess bed days: 4243 At risk

Out of Hospital Responsible Director: Martin EllisProgramme lead: Kieran Houser

Objectives To increase preventative and proactive care through better delivery of integrated care across health (acute and community services), social care, mental health and voluntary sector services.


Begin roll-out of huddles 1 Delivered

Implementation and development of LIFE team 1 Delivered

Begin implementation new /expanded falls service (moved from Q2 to Q4) 4 On target

Roll-out of discharge to assess for complex patients 2 Delivered

Completion of Integrated Care Network (ICN) implementation 2 Delivered

Implement enhanced end of life care services (moved from Q3 to Q4) 4 On target

Airedale model implemented in care homes 3 At risk

New GP cover model in place 3 At risk

Digitalisation of care planning for care homes 4 At risk

Implementation of Continence Service transformation (not until 2019/20) 2 Off target

Begin implementation of Community IV antibiotics 4 On target

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Integrated networks and care coordination with improved access to support with improved primary care delivery, evidenced by the number of huddles convened. On target

Developing ‘My Life Plan’ supporting person-led preventative care planning in the community, ensuring that quality of care plans meet the quality criteria set . At Risk

Improved integration of pathways: MDT huddles (multi agency) rolled out to all practices (meeting fortnightly at a minimum), and LIFE team (health and social care) co-located and integrated.

On target




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

7.57 6.59 -0.98 3.27 2.52 -0.75

Out of Hospital Q2 2018/19

PlanQ2 2018/19

ActualQ2 2018/19

Variance2018/19

Plan2018/19 Forecast

2018/19 Variance

Non-Elective Spend £m £m £m £m £m £mEmergency Non-Elective 37.6 36.3 1.3 75.2 72.8 2.4Non-Elective 3.8 3.6 0.3 7.7 6.8 0.9(Over)/Under Performance 41.4 39.9 1.5 82.8 79.5 3.3


IAF Injuries from falls in people age 65 and over No 18/19 data Q

DFV Percentage of children waiting more than 18 weeks for a wheelchair Q1 Off target NHS

DFV Total Non-Elective admissions On target M

IAF Delayed transfers of care per 100,000 population No 18/19 data M

IAF Population use of hospital beds following emergency admission No 18/19 data M

IAF Inequality in unplanned hospitalisation for chronic ambulatory / urgent care sensitive conditions No 18/19 data M

IAF Inequality in emergency admissions for urgent care sensitive conditions No 18/19 data M

IAF Emergency admissions for urgent care sensitive conditions No 18/19 data Q

QP Non-elective admissions 0 LoS* On target M

QP Non -elective admissions ≥1 LoS* On target M

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Reduced unnecessary admissions; i.e., target of 45% of patients presenting at A&E who are streamed at the front door to UCC or GP hubs On target

Reduced ED Attendances by 10% against 17/18 Type 1 attendances, through a shift in activity to alternative services (CUCA contract refers) Off target

Reduced average length of stay of NEL Admissions as follows: >7 days target = 25%; >21 days target = 10% by December 2018 On target

Increased performance against 4 hour target (i.e., achievement against trajectory for 2018/19) At risk

Assessment of MH patients within 1 hour (Emergency) At risk

100% emergency admissions seen and clinically assessed by a suitable consultant within 14 hours from the time of admission to hospital At risk

Ambulance handover times within 30 mins At risk

Total A&E Attendances Off target


Implement 111 electronic booked appointments for urgent care services 2 Delivered

Implement improvement plan for Type 1 (Emergency Department) 2 On target

Review and re specify admission avoidance and ambulatory care delivered at the Edgecombe Unit 3 At risk

Delivery of core 24 standards and effective implementation of CUH MH clinical support 3 Delivered

Urgent & Emergency Care Responsible Director: Stephen WarrenProgramme lead: Darren Cooper

Objectives To deliver a functionally integrated 24/7 Urgent Care service for Croydon. Providing public access to the right treatment, in the right place, first time. This service will include NHS 111, GP Out of Hours, Urgent Care Centres, community services, ambulance services, social care and emergency departments. To collaborate to deliver high quality, clinical assessment, advice and treatment with all services having access to patient records.

Finance

15

Quality Outcomes StatusA seamless service and high quality care for our patients, evidenced by regular meetings of the integrated assessment & discharge team (including Acute, Social Care, CCG, Voluntary sector) beginning in October 2018.

On target

Increase opening and access points (e.g., extended GP access, availability of NHS 111 online, GP hubs in each clinical network by September 2018) resulting in 100% coverage of the whole Croydon population (measured by GP appointment hours per 1000 of population) and improved care

On target

Reduce the confusion to patients plus improve patient care and access (1,2); patients will use NHS 111 as first port of call. Evidence of this is reduced activity in GP hubs, more calls to NHS 111, increased number of booked GP Hub appointments.

Off target




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

0.53 0.03 -0.50 0.20 -0.30 -0.50

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Urgent & Emergency Care £m £m £m £m £m £mA&E 8.2 8.3 -0.2 16.3 17.2 -0.8UCC 3.4 3.0 0.3 6.7 6.0 0.7(Over)/Under Performance 11.5 11.4 0.1 23.0 23.2 -0.2


DFV A&E waiting times – total time in the A&E department (CHS - 4 hour standard) Off target M

DFV A&E – 12 hour waits for admission via A&E On target NHS

DFV Ambulances - Proportion of calls closed by telephone advice (Leo to share current metrics) TBA TBC

DFV Ambulances - Proportion of incidents managed without need for transport to A&E TBA Q

DFV Urgent operations cancelled for a second time On target TBC

DFV Ambulance handover times within 30 mins Off target M

IAF Inequality in unplanned hospitalisation-chronic ambulatory care sensitive conditions No 18/19 data Q

IAF Inequality in emergency admissions for urgent care sensitive conditions No 18/19 data M

IAF Emergency admissions for urgent care sensitive conditions No 18/19 data Q

IAF Percentage of patients admitted, transferred or discharged from A&E within 4 hrs No 18/19 data M

IAF Delayed transfers of care per 100,000 population No 18/19 data M

IAF Population use of hospital beds following emergency admission No 18/19 data M

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Reduced Occupied Bed Days from Acute Inpatient beds of 4000 to 3000 by the endof the year Off target

Reduced Average Length of Stay from >100 to <=30 At risk

Zero out of areas placements for acute overspill patients Off target


Re-procure IAPT service to meet national targets, superceded by direct award to SLAM 2 Delivered

Implement Enhanced Primary Care Service to GPs manage mental health in Primary Care 3 On target

Mobilise re-procured forensics pathway 3 At risk

Mental health community services review completed 2 Off target

Implement CATCAR and Core 24 for A&E admissions avoidance 2 Delivered

Enhanced Memory Service pathway implemented 3 At risk

Mental Health Responsible Director: Stephen WarrenProgramme lead: Marlon Brown

Objectives To prevent mental health problems and to ensure early intervention for those with mental illness, through improved access to services , and care provided closer to home where appropriate.

Finance

16

Quality Outcomes StatusEffective community and primary care based services (i.e., low vacancy rate, ratio of patients / permanent staff, skills mix, enhanced support to GPs from SLAM, advice line, single point of access)

Off target

Effective community crisis and liaison services to ensure people only receive inpatient care when required (reduced avoidable admissions) At risk

People receive care closer to home and no inappropriate Out of Area Placement (i.e., more opportunity to have care at home, or closer to home, or not out of area) Off target

Integration of MH with primary care social care and other local services (i.e., Alliance based commissioning) On target

Better care for families and patients suffering from dementia (i.e., prevalence of dementia) At risk

Hospital admission avoidance (i.e., reduction in avoidable hospital admissions) On target

Perinatal mental health improved integrated pathway (Children, maternity) under development (Under discussion with SLAM) On target




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

4.55 4.55 0.00 1.93 1.90 -0.03

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Mental Health Spend £m £m £m £m £m £mTotal MH Spend 26.6 26.1 0.5 53.1 53.1 0.0Inpatient OBDs 8.2 8.3 -0.1 16.4 16.6 -0.1Non-NHS placements 1.0 1.7 -0.7 2.0 3.2 -1.2NCA 0.3 0.3 0.0 0.6 0.8 -0.3(Over)/Under Performance 9.5 10.2 -0.8 19.0 20.6 -1.6


DFV IAPT (Access) as a proportion of prevalence (monthly rate) Off target M

DFV IAPT recovery rate On target M

DFV IAPT Waiting Times (6 weeks) Referral to Treatment M3 On target TBC

DFV IAPT Waiting Times (12 weeks) Referral to Treatment M3 On target A

DFV Estimated diagnosis rate for people with dementia On target TBC

IAF Improving Access to Psychological Therapies recovery rate No 18/19 data M

DFV Mental health measure – Care Programme Approach (CPA) - Q1 Off target Q

DFV Psychosis treated with NICE care package within 2wks of referral On target Q

IAF People with first episode of psychosis treated within 2 weeks of referral No 18/19 data TBC

IAF Proportion of crisis resolution and home treatment (CRHT) services able to meet selected core functions. No 18/19 data A

IAF Out of area placements for acute mental health inpatient care No 18/19 data M

IAF Estimated diagnosis rate for people with dementia No 18/19 data M

IAF Dementia care planning and post-diagnostic support No 18/19 data M

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Reduction in the variation of GP prescribing across seven specificconditions, so that all GPs achieve the mandated target by 31 March 2019. Q1 data

On target

Reduction in the number of self care prescriptions against target, as evidenced on the prescQIPP website.Q1 data – Process to be agreed

At risk

Minimum number of ICN pharmacists’ referrals each month; current target is 60 per month On target


Prescribing Incentive Scheme launched and practice targets agreed 2 Delivered

Business case for dietician developed and approved 1 Delivered

Dietician appointed to support nutritional reviews 1 Off target

Implement recommendations from NHS consultation on OTC medicines (moved from Q2 to Q3) 3 Off target

Medicines Optimisation Responsible Director: Martin EllisProgramme lead: Claudette Allerdyce and Louise Coughlan

Objectives To ensure that patients get best quality and value from the investment in medicines made by the CCG and the wider NHS.

Finance

17


Reduced waste (evidenced by the delivery of PIS key milestone) On target

Reduction in the inappropriate or unwarranted variation in GP prescribing,evidenced through the performance of the Antibiotics STAR – PU indicator On target

Greater promotion and support of the self-care agenda to empower people to be more in control of their own health, achieved through reduced self care prescription (i.e., more OTC medicines)

At risk

Delivery of better integrated care between CHS, primary care and local community pharmacists so that patients receive care that is genuinely seamless, evidenced by the number of ICN Pharmacists referrals per month.

On target




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

3.66 2.59 -1.07 1.71 1.67 -0.04

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Medicines Optimisation £m £m £m £m £m £mPrescribing 20.3 20.1 0.2 40.5 41.6 -1.1Acute - Drugs & Devices 5.3 5.6 -0.3 10.6 10.8 -0.3(Over)/Under Performance 25.5 25.7 -0.2 51.1 52.4 -1.4


IAF Anti-microbial resistance: appropriate prescribing of antibiotics in primary care No 18/19 data M

IAF Anti-microbial resistance: Appropriate prescribing of broad spectrum antibiotics in primary care No 18/19 data M

QP Bloodstream Infections (Leo to advise) TBA TBC

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Achievement of 28/7 assessment KPI On target

Achievement of <12/52 KPI On target

Reduction of complaints/appeals At risk

Achievement of local KPI for patient decision letters Delivered


Achievement of Decision Support Tool location KPI Delivered


Review processes for children and adult service users 2 Off target

Develop and integrate tracking and monitoring system to support achievement of KPIs 1 Delivered

Develop and integrate booking system to support achievement of KPIs 3 On target

Improve and sustain enhanced performance in line with the NHSE and local KPIs 3 On target

Begin the review of high cost Packages of Care 2 Delivered

Continuing Healthcare Responsible Director: Elaine ClancyProgramme lead: Rachael Colley

Objectives To develop and sustain a team that provides a quality service. To ensure timely and robust assessments that reflects the needs of our clients and which are in line with the national framework for CHC, whilst also upholding financial integrity and responsibility.

Finance

18




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

3.00 4.39 1.39 1.50 2.19 0.69

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Continuing HealthCare £m £m £m £m £m £mContinuing HealthCare 10.0 10.5 -0.5 19.9 20.4 -0.4Funded Nursing Care 4.3 3.7 0.6 8.6 6.9 1.7(Over)/Under Performance 14.3 14.2 0.1 28.6 27.3 1.3


IAF Personal health budgets No 18/19 data Q

IAF People eligible for standard NHS Continuing Healthcare (Not in 2017/18 IAF tech guidance) No 18/19 data M

DFV Personal Health Budgets Q1 Off target Q

IAF % of NHS continuing healthcare full assessments taking place in an acute hospital setting No 18/19 data Q

QP CHC assessments in Acute hospital (Q1) Off target A

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Improved patient experience through the achievement of reduced waiting times for statutory and other priority pathways, evidenced through FFT survey results. On target

Reduced risk of significant harm to physical and mental health for children with long term conditions. On target


Reduction in A&E attendance (Frequent attenders) At risk

Shift of level 1 Critical Care to CHS At risk


Saving options for children’s community medical service agreed. This is no longer being sought from community medical practices 1 N/A

Agree vision and strategy for children’s health following engagement 2 Delivered

Implement agreed information, advice and guidance initiatives for GPs 3 On target

Develop LAC CAMHS pathway in place (in place 2019/20) 1 On target

Children & Young People Responsible Director: Stephen WarrenProgramme lead: Amanda Tuke

Objectives To improve health outcomes through self-care and prevention.

Finance

19

Finance data not collected




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

0.20 0.20 0.00 0.00 0.00 0.00


IAF Percentage of children aged 10-11 classified as overweight or obese No 18/19 data A

DFV Improve access rate to CYPMH Q1 On target M

DFV Waiting times for Urgent and Routine Referrals to Children and Young People Eating Disorder Services Not Available A

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Provision of awareness training of health needs affecting people with LD, evidenced by number of sessions in 2018/19 On target

Increase in the numbers on GP LD registers, and an increase in the uptake of Annual health checks as measured in the national performance standard indicator On target

Improved quality of life for people with LD, evidenced by the reduced number of avoidable hospital admissions (Mental health inpatient, and acute) At risk

Improved access to wider non specialist healthcare services, evidenced by the number of providers who make ‘reasonable adjustments’ to their services. This is measured bi-annually

At risk

Greater parity of access for people with LD to primary and secondary care At risk

Activity Outcomes (Q2) Status

Discharge remaining individuals in Transforming care cohort to appropriate community placements

On target


Transforming Care, measured by the number of current inpatient discharges being made to the current cohort of patients 3 On target

Annual Health checks (of LD patients) system developed and implemented across all GPs in Croydon 4 On target

Contract review and contract variation completed as appropriate in support of commissioning intentions for 2019/20 1 Delivered

Market development through the stimulation of new LD service providers in Croydon, which will produce the emergence of new LD providers with whom Croydon CCG can contract services.

2 Delivered

Learning Disabilities Responsible Director: Stephen WarrenProgramme lead: Suzanne Culling

Objectives To support people with a learning disability to live in the community, with the right support, and close to home by making health and care services better.

Finance

20




Full year variance

YTD planned QIPP

YTD actual QIPP

YTD QIPP variance

0.90 1.07 0.17 0.43 0.48 0.05

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Learning Disabilities £m £m £m £m £m £mLD Community Block 0.3 0.3 0.0 0.7 0.7 0.0Transforming Care / Complex Community Placements 0.8 0.6 0.1 1.6 1.3 0.3Continuing Health Care - LD 0.7 0.5 0.2 1.4 0.9 0.5(Over)/Under Performance 1.8 1.5 0.3 3.7 2.8 0.8


DFV Reliance on inpatient care for people with a learning disability and/or autism (Q4 17/18) On target Q

DFV Proportion of people with a learning disability on the GP register receiving an annual health check no data Q

IAF Reliance on specialist inpatient care for people with a learning disability and/or autism No 18/19 data Q

DFV Proportion of people with a learning disability on the GP register receiving an annual health check no data Q

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Increase in number of referrals from GP practices into Social prescribing Hubs with focus on Behaviour Change activities such as Lifestyles/fitness classes & exercise/ health management groups

On target

Increase ‘patient activation’ (knowledge, skills & confidence) amongst Croydon residents particularly those living with at least one LTC At risk

% of people with LTCs benefiting from initiatives that fall within prevention, self-care, self-management and Shared Decision Making On target

6 New sign-posting hubs opened to support patients Delivered

15 new Local Health Initiatives now live Delivered

Social prescribing becoming available Delivered

Improvements to health help now app to support patients to get faster, more reliable outcomes On target


Reducing activity in secondary care At risk

increased used in community and voluntary sector On target

Reduced use of A&E for patients with Long Term Conditions such Diabetes At risk

National Performance Standards StatusNONE


Introduce consistent behaviour change evaluation tool such as PAM or Long Term Conditions Questionnaire (LTCQ) 3 At Risk

Further roll out of diabetes Group Consultations 3 At risk

Implement Expert Patient Programme (smaller scale approach) 3 On target

Review and expand the Make Every Contact Count 3 On target

Review and expand Health Help Now App 4 On target Croydon Social prescribing model reflective of the individual network demographic and need, and rolled out to all GP Practices in Borough (moved from Q3 to Q4)

4 On target

Together for Health Responsible Director: Stephen WarrenProgramme lead: Michael Sutton

Objectives To improve patient outcomes and experience as well as creating conditions for a more financially sustainable local healthcare system, through actively promoting and encouraging prevention, self-care, self-management and shared decision making (PSSSD) among the population to increase independence and responsibility around health.

Finance

21

N/A

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Availability of appointments; i.e., practices meeting the 'reasonable needs of patients': 1) practices to provide services at times that are appropriate to meet the needs of patients; 2) ensure arrangements are in place for patients to access services throughout core hours in case of emergency

On target

Improved patient satisfaction, evidenced by the FFT recommended average for the CCG against the England recommended average (M5) Off target

100% of population have access to GP services seven days a week, measured by GP appointment hours per 1000 of population On target

Improve quality, measured by a reduction in the number of practices rated as either red (inadequate) or amber (requires improvement) against the number of red and amber rated practices at the start of the reporting year

On target

Proactive, coordinated, and accessible care, evidenced by MDT regular meetings (Huddles) convened On target

Increased capacity in primary care , evidenced by extended access; namely, number of appointments (30min /1000 of population) On target

Use of technology to increase patient self care over a two year period to 31 March 2020 through the implementation of 16 ICT projects Off target

Reduction in variation in quality of clinical outcomes; the revised LCS and PDDS contracts will be implemented in April 2019 On target

Improved sustainability & resilience of primary care, evidenced by GPs working closer to their core hours On target


Increased activity in community and primary care (including General Practice) On target


Completed GP Extended Access (Milestone moved to Q3 from Q1) 3 On target

Roll out of online consultations 4 On target

Complete the LCS/PDDS review 2 Off target

Edgridge Road re-procurement completed 3 On target

Maturing at scale approach to manage population health 4 On target

GPFV investment to improve sustainability and resilience 4 On target

Primary Care Responsible Director: Martin EllisProgramme lead: Ruth Frost

Objectives To develop General practice to provide a more resilient and sustainable service and to provide a consistent quality service to residents of Croydon. Working to deliver transformed general practice in line with the London Strategic Commissioning Framework, the GP Forward View, the Croydon Out of Hours strategy 2016/17 to 2020/21, and the 10 High Impact Actions.

Finance

22

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Primary Care £m £m £m £m £m £mLIS / PDDS / £3 per head 2.6 2.1 0.5 5.1 4.7 0.4GPFV 1.0 1.1 -0.1 2.0 2.0 0.0Delegated Commissioning 25.8 25.7 0.1 51.8 51.8 0.0(Over)/Under Performance 29.4 28.9 0.5 59.0 58.6 0.4


IAF Patient experience of GP services No 18/19 data A

IAF Primary care (extended) access No 18/19 data TBC

IAF Primary care workforce No 18/19 data M

DFV Extended access at GP services [for 7 days] E.D.14 (See 128c Primary Care Access) No 18/19 data A

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Quality Outcomes (M5) Status

Increased numbers of women booking for services earlier (at 12+6) from 72% to 80% (CHS data against baseline activity from 17/18) On target

Reduction in numbers of women smoking at deliver from 9% to 7% On target

Activity Outcomes (M5) Status

Increase the number of women who have a personalised care plan from 25% to 100% (Technical requirements in Cerner TBC) and national definitions awaited At risk

Increase the number of births in midwife-led settings from 15% to 20% (includes both home births and deliveries in midwifery-led units) Off target

Continuity of Carer access increased from 3% to 20% by March 2019 (subject to sector wide discussion and agreement) At risk

Milestones (Sector wide transformation plan) Qtr due Status

Roll out of ‘My Maternity Journey’ and personalised care plans 2 Delivered

Develop continuity of carer model and pilot 1 On target

Implementation of Saving Babies Lives’ care bundle 1 Delivered

Engage Primary Care services in Maternity Transformation objectives, to increase repatriation of out of area patients 1 Off target

Map existing Perinatal MH services, leading to the initiation of the development of an integrated pathway. 4 At risk

Maternity Responsible Director: Stephen WarrenProgramme lead: Jane McAllister

Objectives To improve safety, access to continuity of carer, choice and personalisation for maternity services, in order to provide improved outcomes, including a reduction in stillbirths and neonatal deaths and improved women’s experiences.

Finance

23

Q2 2018/19 Plan

Q2 2018/19 Actual

Q2 2018/19 Variance

2018/19 Plan

2018/19 Forecast

2018/19 Variance

Maternity £m £m £m £m £m £mMaternity Pathway 15.2 14.4 0.9 30.4 28.7 1.7(Over)/Under Performance 15.2 14.4 0.9 30.4 28.7 1.7


IAF Maternal smoking at delivery No 18/19 data A

IAF Neonatal mortality and stillbirths No 18/19 data Q

IAF Women’s experience of maternity services No 18/19 data Q

IAF Choices in maternity services No 18/19 data Q

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24

Programme area Performance standards discontinued and removed from the report Out of Hospital IAF People with a long-term condition feeling supported to manage their condition(s) (Not in 2017/18 IAF tech guidance)Out of Hospital IAF Management of long term conditions (Not in 2017/18 IAF tech guidance)Out of Hospital DFV Delayed Transfers of care per 100,000 population (attributable to NHS, social care or both) THIS IS A REPEAT OF 127eOut of Hospital DFV Bed Days (Non-Elective Admissions) Planned Care DFV Number of completed admitted RTT pathways (Not required for performance reporting)Planned Care DFV Number of completed non-admitted RTT pathways (Not required for performance reporting)Planned Care DFV Number of new RTT pathways (clock starts) (Not required for performance reporting)Planned Care IAF Quality of life of carers (Not in 2017/18 IAF tech guidance)Planned Care IAF Adoption of new models of care (Not in 2017/18 IAF tech guidance)Urgent & Emergency Care DFV DTOCs (attrib. to NHS, social care or both)Urgent & Emergency Care DFV Bed Days (Non-Elective Admissions)Urgent & Emergency Care IAF Achievement of milestones in the delivery of an integrated urgent care service (Not in 2017/18 IAF tech guidance)Urgent & Emergency Care IAF Ambulance waits (Not in 2017/18 IAF tech guidance)Mental Health DFV Effective on-site 24/7 urgent and emergency liaison mental health serviceMental Health DFV Percentage of local crisis resolution and home treatment teamsLearning Disabilities DFV Inpatients without a review in the last 26 weeks

Programme area Performance standards removed from the report where data is currently not available StatusPlanned Care IAF Achievement of clinical standards in the delivery of 7 day services (2017) Not calculatedPlanned Care IAF Carers with a LTC who feel supported to manage their condition Not calculatedPrimary Care GPFV GP Forward View (not definable) Not calculatedCYP: Children's Health IAF Children and young people’s mental health services transformation Not AvailableCYP: Children's Health DFV Improve access rate to CYPMH No dataCYP: Children's Health DFV Waiting times for Urgent and Routine Referrals to Children and Young People Eating Disorder Services Not AvailableMental Health IAF Proportion of crisis resolution and home treatment (CRHT) services able to meet selected core functions. Not AvailableMental Health IAF Out of area placements for acute mental health inpatient care (M2) Not calculated

Programme area Performance standards moved to the activity outcomes sections

Out of Hospital IAF Injuries from falls in people age 65 and over (2017/18 Q3)Planned Care DFV Number of 52 week referral to treatment pathwaysPlanned Care DFV Total Referrals made for a First Outpatient Appointment (General & Acute)Planned Care DFV Total GP Referrals made for a First Outpatient Appointment (G&A)Planned Care DFV Total Other Referrals made for First Outpatient Appointment (G&A)Planned Care DFV Consultant Led First Outpatient Attendances (Specific Acute)Planned Care DFV Consultant Led Follow-Up Outpatient Attendances (Specific Acute)Planned Care DFV Total Elective Spells (Specific Acute)Urgent & Emergency Care DFV Urgent operations cancelled for a second timeUrgent & Emergency Care DFV Ambulance handover times within 30 mins Urgent & Emergency Care DFV Total A&E Attendances

Changes to performance standards reporting

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REPORT TO CROYDON SENIOR MANAGEMENT TEAM

23 October 2018

Title of Paper: INTEGRATED PERFORMANCE & QUALITY REPORT

Lead Director Elaine Clancy Director of Quality and Governance

Report Author Simon Lee Associate Director of Quality and Governance Leo Whittaker Head of Performance, Assurance & Emergency Planning


None


Governing Body Quality Committee

Purpose of Report For Discussion and Noting

Recommendation:

The Senior Management Team is asked to: ▪ Note and discuss the Integrated Performance & Quality Report, which is reporting

Month 4 –July 2018 data, where available, and the actions being taken to address key concerns at the time of reporting.

Background:

This report forms part of the CCG’s Quality Assurance activities for its main healthcare providers. Content is based largely on validated Month 4 –July 2018 data, however the latest position is included around service quality, patient safety and decisions that have arisen, where available.

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Key Issues:

Performance Diagnostic Waits (6 week wait) In July, the CCG’s performance remained below the 99.0% target with 98.4%. The majority of breaches occurred in echocardiography at CHS. This was due to unavoidable leave of absence of a physiologist for 4 weeks and whilst the physiologist has since returned there remains a backlog. The trust brought in an additional agency physiologist for 6 weeks to help clear the waiting list down. CHS have reported being on track to report a compliant position for September 52 Week Waits Croydon CCG had 21 patients waiting over 52 weeks in July. 14 of these occurred at Kings College Hospital (KCH). The trust has not been compliant at a trust-level or speciality level for RTT since it recommenced national reporting. KCH have recovery trajectory to clear 52 week waiters by the end of December. The provider carries out a clinical review of patients waiting over 40 weeks and RCAs are available to CCGs upon request. The SWL Joint Review Unit has been established to reduce patients waiting over 30 weeks at SGH, supported by Kingston Hospital and CHS. The CCG is in discussion with Kings about implementing a review of c. 140 Croydon patients waiting over 30 weeks to ensure equity. Accident and Emergency CHS’ 4 hour A&E ‘all type’ performance remained below the national standard and local recovery trajectory with 85.0%. Within this, Type 1 attendances achieved performance of 62.5% and type 3 achieved 98.2%. Key issues contributing to type 1 performance is bed availability, escalation areas remain in use creating greater pressure on beds and staff, unplaced mental health patients and shortage of middle grade emergency department medics. Work streams exist for each of these areas within the A&E Delivery Board action plan. Cancer Waits Croydon CCG met 6 out of 8 cancer wait standards for July. Both the standard for treatment within 62 days of GP referral and following a referral from a screening service were below target for the month, with 78.3% (8 breaches from 38 pathways) and 75.0% (2 breaches from 8 pathways) respectively. Actions relating to a review of breach themes will be agreed at the SWL Cancer Leadership Forum. IAPT Access Performance was below the standard in July. August saw an increase and provisional September data indicates that M6 met the monthly target. Q2 was not met as a whole, however, Q3 remains achievable. Promotion of the service continues, with a recent inclusion of IAPT information in the Crystal Palace Football Club (CPFC) home game programme. This will continue to be shown in the CPFC programme for the next few games. Provisional Sept performance was 1.53% giving a provisional quarter 2 positon of 4.13%

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against 4.2% target. IAPT Recovery Monthly monitoring shows the CCG was below the 50% target in July with 45.6%. The service has seen an improvement compared with last year, however, monitoring of individual therapy types is advised as Online CBT and Group Therapies are considerably below the recovery rate. The CCG will agree monitoring and actions with SLaM in October. Provisional Sept performance was 53%

Improvement & Assessment Framework (no new data) A summary of the CCG’s 2017/18 Assurance Rating is provided on p17 of the report. The CCG moved from ‘Inadequate’ to ‘Requires Improvement’ in its overall rating. This is largely due to improvements in the ‘Well Led’ domain demonstrated by the results of the 360○ stakeholder survey and ‘Sustainability’ domain having a break-even financial plan for 2018/19. Two of the six Clinical Priority Areas had ratings published also, Maternity and Cancer. Maternity achieved a ‘Good’ rating and Cancer an ‘Outstanding’ rating. Further detail is given on p17.

Quality Premium Not all QP indicators have data published as of M4. A more detailed breakdown is available on page 23 of the main report. Quality Premium indicators

Indicator Name Weighting Provisional Performance (M2)

Type 1 A&E Attendances

25.0%

At M4, the CCG below plan with a -1.1% YTD variance.

Non-Elective admissions 0 Length of Stay

M4 data shows -31.5%% under performance, YTD. This is likely to be a data quality issue.

Non-Elective admissions +1 Length of Stay

25.0% M4 data showing a -9.97% under performance, YTD.

Early Cancer Diagnosis 8.5% No in-year data

GP Access & Patient Experience 8.5% No in-year data

Continuing Healthcare 8.5% Q1 targets missed. The latest month’s data for August shows targets were also missed.

Children & Young People’s Mental Health Access

8.5% Q1 provisional data indicates that the CCG is on track to achieve the 34% access standard in 2018/19.

Bloodstream Infections 8.5% Data not yet available

IAPT Access 7.5% Q2 target missed. Provisional data for September indicates a near compliant position for M6.

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Gateway Metrics (% deduction if not met)

Gateway Weighting Provisional Performance (M2)

Achieve the approved CCG financial position year-end

100.0% The CCG are forecasting a £1.2m surplus for 2018/19.

Numbers of patients on an incomplete pathway at March 2019 are lower than March 2018.

50.0%

At M4, there CCG had an 8.6% variance against the plan. The CCG has a Planned Care recovery plan which includes reducing unwarranted variation in GP referrals, non-acute services will be promoted; use of Advice & Guidance via electronic referral system will also be promoted.

Achieve the 62 day maximum wait for GP referrals to first definitive treatment for cancer

50.0%

The target was met in Q1. July saw performance drop to 78.3% against the 85.0% target.

Quality Croydon Health Services NHS Trust Croydon Health Services (CHS) NHS Trust reported 9 SIs in M4, none of which were Never Events. The time taken to report serious incidents has halved from 12 days in M3 to 6 days in M4.

Excessive waiting times within Croydon Health Services (CHS) NHS Trust A&E Department for all patients, especially those requiring admission to a mental health bed, continues to be a major quality concern for Croydon CCG. There is a comprehensive A&E recover action plan monitored by the AEDB. Furthermore, daily system telephone calls take place to provide assistance, where possible. South London and the Maudsley NHS Trust (SLaM) SLaM reported one incident in Month 4. SLaM are hosted a Multi-Agency Discharge Event (MADE) on 19 September 2018 for Croydon Borough as part of the SLaM and Commissioner system response to the ongoing and significant demand in the acute and crisis care pathway. A further event is due to be held in November. CQC Visit Updates The CQC made a number of inspections to Croydon Providers, a summary of which is detailed below.

• In July 2018, the CQC made an unannounced visit to CHS NHS Trust Medical Services and Community Services (Adults and Children and Young People). The full report was published on 28th September 2018. The rating for the trust remained as Requires Improvement, the same as the previous inspection in 2017.

• The CQC inspected SLaMs acute care and PICU pathways in July. This resulted in in the issuing of a Warning Notice. Concerns around the variability of quality of care and services across the pathway were noted, with systems and processes not

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operating as well as they should, quality not being assessed safely and consistently and mitigations not being in place or followed. SLaM has been asked to make improvement by 1st April 2019.

The table below shows details of inspections undertaken by the CQC as part of their scheduled programme or return visits and publications of reports.

Docman CAS Alert CAS Alert received from NHS England regarding a national issue identified for Practices using Docman 7 document management system, which may present a risk to patients.

NHS England has been made aware of an issue where some GP Practices have records,

received by NHSMail, which have not been able to be processed and have not transferred

into patients electronic records. This affects GP Practice using Docman version 7 software

with Electronic Document Transfer (EDT) enabled.

GP Practices were asked by NHSE to complete a number of tasks with specific timeframes

The deadline for the cycle of reporting has passed, all practices have reported with the exception of seven where technical issues, including practice system mergers and availability of CSU technical support staff have complicated matters and are still being worked on.

Location Type Date of

CQC visit

Date report

published

Overall

Rating

Change

to last

visit

Edridge Road Community HC

Return visit 02/08/2018 Not published Inadequate Awaiting outcome

Denmark Road Comprehensive 15/08/2018 Not published Not sufficient evidence to rate

Awaiting outcome

East Croydon Medical Centre

Comprehensive w/c 10/09/2018 Not published Good Awaiting outcome

Croydon GP Hubs (provision under Croydon Urgent Care Alliance CUCA)

Comprehensive 3x sites August/Sept

2018

Not published New service Awaiting outcome

Governance:

Corporate Objective To commission high quality health care services that are accessible, provide good treatment and achieve good patient outcomes. To reduce the amount of time people spend avoidably in

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hospital through better and more integrated care in the community, outside of hospital for physical and mental health. To support local people and stakeholders to have a greater influence on services we commission and support individuals to manage their care.

Risks Risks identified in this paper are considered and included in the Corporate Risk Register as appropriate.

Clinical Leaders comments where appropriate

None


Any financial implications of improving quality would be reported separately. Performance breaches in A&E, RTT, Cancer Waits and Ambulance Response times will impact adversely on the CCG’s Quality Premium award.

Conflicts of Interest No conflicts of interest have been identified or declared as relevant to decision making processes relating to this report.

Clinical Leadership Comments Not applicable in influencing the content of this report.

Implications for other CCGs

Where the CCG is the host commissioner, it is required to ensure it manages quality and performance of these providers. There is currently no single host commissioner for South London and Maudsley NHS Foundation Trusts; where significant quality risks are identified in this Trust the information will be shared with relevant CCGs.

Equality Analysis

Any action plans developed for those areas of high risk will take into account the needs of all our communities.

Patient and Public Involvement There are no current projects or recommendations resulting from this report that require PPI.

Communication Plan Outputs of this report are communicated at the Clinical Quality Review Group for the relevant providers, and at CCG Governance meetings.

Information Governance Issues Patient confidentiality is maintained.

Reputational Issues

Failure to achieve performance standards, deliver improvements in IAF Clinical Priority Areas, manage

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quality issues effectively or identification of poor quality could attract adverse attention from patients, the public and NHS England.

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Longer, healthier lives for

all the people in Croydon

Integrated Performance & Quality Report

July (M4) 2018/19

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Contents

Page 2 of 31

Heading Page

1. Croydon CCG Scorecard – Operating Plan Indicators Page 3

2. Operating Plan Exceptions Management Page 4

3. Improvement and Assessment Framework (IAF) Dashboard Page 14

4. Overall CCG Ratings Page 15

5. IAF Clinical Priority Areas Page 16

6. Quality Premium Page 20

7. Quality Highlights Page 21

8. Quality Assurance – Serious Incidents (SI) Page 22

9. Croydon Health Services (CHS) Complaints and Friends & Family Test (FFT) Page 23

10. South London and Maudsley (SLaM) NHS Foundation Trust - Complaints and FFT Page 24

11. Quality Assurance – CQC Visits Page 25

12. Quality Assurance – Care Home Quality Page 28

13. Quality Assurance – Primary Care Quality Page 28

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CCG Scorecard - Operating Plan (OP) Indicators

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2017/18

2018/19

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

Rolling 12 Month

Trend

Recent

Movement2017/18 2016/17 2015/16

Healthcare Acquired Infection

E.A.S.4 MRSA (PIR Assigned) Monthly 0 1 0 0 0 0 2 0 1 1 2 0 1 0 ▼ 6 3 3

E.A.S.5 C Difficile Monthly 5 9 4 2 8 3 4 3 5 6 5 5 4 9 ▲ 62 58 61

Referral To Treatment

E.B.3 RTT 18 weeks (incomplete pathways) Monthly 92.0% 92.2% 92.1% 92..2% 92.8% 92.9% 92.7% 92.7% 92.7% 92.7% 93.1% 92.9% 92.7% 92.9% ▲ 92.3% 91.9% 93.6%

E.B.4 Diagnostic tests waiting time Monthly 99.0% 97.1% 98.4% 99.7% 99.6% 99.2% 99.3% 99.4% 99.5% 98.9% 99.2% 98.9% 98.5% 98.4% ▼ 98.0% 98.0% 94.3%

E.B.S.4 RTT 52 weeks (incomplete pathways) AP Monthly 0 7 4 2 6 3 6 4 7 12 15 13 19 21 ▲ 72 68 27

Urgent Care

E.B.5 A and E waiting times (CHS) AP Monthly 95.0% 88.30% 90.10% 90.90% 94.80% 93.00% 89.40% 86.80% 87.10% 88.10% 87.90% 88.20% 87.70% 85.04% ▼ 89.9% 89.0% 92.3%

E.B.S.5 Trolley waits over 12 hours (CHS) Monthly 0 0 0 0 0 0 0 0 0 0 1 0 0 0 ► 1 1 0

E.B.S.6 Urgent operations cancelled for a second time or more (CHS) Monthly 0 0 1 0 0 0 0 0 0 0 0 0 0 0 ► 1 0 0

E.B.S.7 Ambulance handover within 30 minutes (CHS) AP Monthly 0 120 86 93 53 63 125 186 165 136 180 107 116 165 ▲ 1317 950 458

E.B.S.7 Ambulance handover within 60 minutes (CHS) Monthly 0 7 3 0 0 0 4 15 7 17 17 10 8 26 ▲ 59 46 7

Mixed Sex Accommodation / Cancelled Operations

E.B.S.1 Mixed sex accommodation breaches Monthly 0 0 0 0 1 0 1 5 0 2 0 0 1 1 ► 11 3 0

E.B.S.2 Cancelled Ops (CHS) Quaterly 0 ▲ 2.4% 0.4% 1.5%

Cancer Waiting Times

E.B.6 Cancer two weeks (monthly) Monthly 93.0% 96.5% 95.0% 94.7% 97.4% 96.8% 95.5% 95.9% 97.3% 97.3% 95.3% 97.9% 97.7% 97.2% ▼ 96.3% 96.7% 95.3%

E.B.7 Breast symptoms two weeks (monthly) Monthly 93.0% 99.0% 93.8% 98.2% 99.1% 98.2% 99.0% 98.5% 100.0% 99.3% 93.5% 100.0% 95.0% 96.1% ▲ 98.5% 97.6% 95.3%

E.B.8 Cancer first definitive treatment 31 days (monthly) Monthly 96.0% 99.2% 98.3% 97.5% 98.0% 97.4% 99.2% 96.6% 98.0% 97.2% 100.0% 98.6% 97.9% 98.5% ▲ 97.6% 97.7% 98.0%

E.B.9 Cancer subsequent treatment 31 days, surgery (monthly) Monthly 94.0% 87.0% 93.3% 100.0% 95.0% 100.0% 93.3% 88.2% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ► 95.2% 96.1% 96.1%

E.B.10 Cancer subsequent treatment 31 days, drug (monthly) Monthly 98.0% 100.0% 98.0% 95.9% 100.0% 100.0% 97.6% 100.0% 97.9% 95.1% 97.6% 97.7% 97.7% 100.0% ▲ 98.5% 99.0% 99.8%

E.B.11 Cancer subsequent treatment 31 days, radiotherapy (monthly) Monthly 94.0% 95.0% 91.4% 97.1% 96.3% 94.4% 91.4% 100.0% 100.0% 93.8% 100.0% 97.4% 97.4% 95.1% ▼ 94.5% 96.5% 98.0%

E.B.12 Cancer composite, 62 days first treament plus rare cancers (m) AP Monthly 85.0% 82.6% 84.6% 79.5% 78.7% 90.4% 87.8% 83.7% 83.9% 89.5% 88.7% 94.1% 85.9% 78.3% ▼ 84.7% 84.4% 82.4%

E.B.13 Cancer first treatment 62 days, Screening (monthly) Monthly 90.0% 80.0% 90.0% 92.3% 77.8% 91.7% 100.0% 86.7% 66.7% 100.0% 50.0% 80.0% 91.7% 75.0% ▼ 89.3% 94.9% 92.4%

E.B.14 Cancer first treatment 62 days, Consultant upgrade (monthly) Monthly 85.0% 73.3% 89.5% 76.9% 80.0% 100.0% 90.9% 88.2% 58.3% 93.3% 94.1% 84.2% 93.8% 84.2% ▼ 84.2% 88.4% 87.1%

Mental Health

E.A.S.1 Dementia Diagnosis Rate Monthly 66.7% 66.9% 67.5% 67.0% 67.9% 67.6% 67.7% 67.6% 67.4% 66.7% 67.4% 67.2% 67.5% 67.7% ▲ 66.7% 67.4% 66.5%

E.A.3 IAPT (Access) as a proportion of prevalence (Monthly rate) AP Monthly 1.40% 0.92% 0.91% 0.70% 0.95% 0.80% 0.65% 1.05% 0.94% 1.52% 1.15% 1.09% 1.03% 1.33% ▲ 10.80% 11.04% 10.36%

E.A.3 IAPT (Access) as a proportion of prevalence (Rolling 3 months) Monthly 4.20% 2.69% 2.80% 2.50% 2.55% 2.46% 2.40% 2.50% 2.64% 3.51% 3.61% 3.76% 3.27% 3.46% ▲ 10.80% 11.04% 10.36%

E.A.S.2 IAPT (Recovery) Monthly 50.0% 50.0% 53.0% 43.0% 50.7% 43.3% 51.7% 47.2% 39.1% 50.0% 46.7% 52.7% 49.60% 45.60% ▼ 47.1% 46.5% 46.6%

E.H.1_B1 IAPT 6 week wait - Referral to Treatment Monthly 75.0% 92.00% 93.00% 92.00% 94.00% 91.00% 96.00% 94.00% 95.00% 96.00% 96.00% 96.00% ► 94.30% 95.4% N/A*

E.H.2_B2 IAPT 18 week wait - Referral to Treatment Monthly 95.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ► 99.9% 99.9% N/A*

E.B.S.3 Care Programme Approach (CPA) Quarterly 95.0% ▲ 91.8% 97.8% 97.8%

E.H.4 Early Intervention in Psychosis (Max 2 week wait) Monthly 53.0% 75.0% 75.0% 45.5% 55.6% 81.8% 100.0% 37.5% 37.5% 66.7% 58.3% 100.0% 100.0% 88.8% ▼ 59.1% 65.9% N/A*

E.H.9 Improved access to CYPMHs QP Quarterly 8.5% ▲ 27.2%

E.H.10 4 week wait for routine referral to CYP for Eating Disorders AP Quarterly 95.0% ▼ 80.6%

E.H.11 1 week wait for urgent referral to CYP for Eating Disorders Quarterly 95.0% ▼ 50.0%

E.H.12 Mental Health Out of Area Placements Quarterly - ▲ 3,841

Out of Hospital

E.O.1 Children waiting <18 weeks for a wheelchair AP Quarterly 100.0% ▼ 28.2%

E.N.1 Personal Health Budgets (per 100,000 registered population) AP Quarterly 70.00 ▼ 4.2

Q.P3a Eligibility decisions <28 days QP Quarterly ≥80.0% ▼ 28.2%

Q.P3b CHC assessments in Acute hospital QP Quarterly ≤15.0% ▲ 27.3%

Primary Care

E.K.3 Annual Health checks delivered by GPs for people with LD AP Quarterly 13.6%

E.P.1 e-Referral Service (e-RS) Utilsation AP Monthly 100.0% 36.4% 36.6% 42.1% 41.9% 44.7% 45.4% 46.5% 47.5% 60.9% 66.3% 79.8% 78.0% 91.4% ▲ 60.9%

27.2%

0.0%

77.5% 82.1% 80.6%

20.0%

18.5%

940

92.0%

Data Supressed

Data Supressed

11.3%

14.9%

4.1

39.0%

31.1%

Data Unavailable

40.0% 33.9% 23.8%

4.4 4.2 4.2

26.5% 22.0% 48.1%

37.5% 12.5%

75.0% 75.0% 50.0%

720 215 345

95.7% 82.1%95.5%

Trend Outturn

0.0% 2.4%

2018/19

Indicator

Action

Plan /

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Operating Plan Exceptions Management

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Indicator / Issue Cause Action Timescale / Assurance

E.A.S.5 C.Difficile ▪ Croydon CCG had 9 cases

reported in July.

▪ 6 cases were assigned to community and 3 to trust.

▪ This takes the YTD position to 23.

▪ Root cause analysis is undertaken for all hospital acquired cases to see if there are any lapses in care / lessons to be learnt.

E.B.4 Diagnostic test waiting times ▪ The CCG failed the national

standard with performance of 98.4% in July.

▪ The non-achievement in July was primarily driven by 90 Echocardiography breaches all of which occurred at CHS.

▪ The Trust reported the drop in performance was driven by a loss in capacity due to a Physiologist taking unavoidable leave for 4 weeks.

▪ The Trust undertook a full capacity and demand review for medical cardiology and cardiology/respiratory diagnostics in conjunction with Kingsgate.

▪ The absent Physiologist had returned from leave and an additional agency physiologist was recruited for 6 weeks from the 13th of August.

▪ The Trust planned to reduce the echocardiography backlog during August and through September, with an expectation that performance will be recovered at end of September. As of week ending 09/09/18 the Trust reported being on track to deliver against the recovery trajectory.

E.B.S.4 52 Week Waits ▪ The CCG had 21 patients

waiting over 52 weeks for treatment in July. □ 14 occurred at KCH □ 2 at Epsom & St. Helier □ 1 at Croydon Hospital □ 1 at Barts Health

▪ KCH □ 3 x T&O – The service

continues to suffer capacity issues

□ 6 x General Surgery – Capacity issues (notably within bariatrics)

KCH An Improvement trajectory has been agreed based on activity and performance assumptions for RTT.

▪ KCH has a trajectory to reduce 52 week waiters to zero by the end of December 2018

▪ The Trust plans RTT performance of 91.9%

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□ 1 at Great Ormond street Hospital

□ 1 at Guy’s and St. Thomas □ 1 at Moorfields.

□ 3 x Other – 2 capacity, 1 pt choice

□ 1x Plastic Surgery – Capacity issues within service.

▪ Epsom & St. Helier □ 1 x Gastroenterology–

breach due patient cancellations. Now treated.

□ 1x Dermatology – Delay in IFR. TCI booked Oct

▪ Croydon Hospital □ 1 x Dermatology – Capacity

and Incorrect clock stop

▪ Bart’s Health □ 1 x Plastic Surgery –

Procedure delays resulting from funding approval process.

▪ Great Ormond street Hospital □ 1 x Other – Onward referral

from SGH, received late (week 52). Treated.

▪ Guy’s and St. Thomas □ 1 x Upper GI Surgery –

Capacity. No treated

▪ Moorfields

▪ Additional capacity through in-sourcing commenced in July 2017.

▪ KCH has extended the contract with 18 Weeks Support to provide additional outpatient and day case activity

▪ A new RTT governance structure has been implemented at KCH

▪ The trust generates a 52wk report daily, which is circulated and discussed with Divisional management teams at a daily RTT Huddle meeting.

▪ A clinical review of patients waiting more than 40 weeks is undertaken. This is done either by review of medical notes or, review of the patient in clinic or by telephone.

▪ The Root Cause Analysis process of 52 week waiters is owned by the Divisional Manager and clinical team.

▪ RCAs will be reviewed at monthly RCA meetings chaired by a Corporate Medical Director.

against the 92% standard by March 2019.

▪ The expectation that the number of patients on the waiting list (PTL) will reduce steadily during 2018/19

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□ 1 x Ophthalmology – Administrative breach. Clock stopped.

E.B.5 A&E Waiting Times (CHS) ▪ CHS recorded a performance

of 85.0% (all type) against the 4 hour standard in July.

▪ Type 1 achieved 62.5%. ▪ Type 3 achieved 98.17%. The local trajectory for July was 91.0% Provisional Sept Type 1 achieved 69.97% Type 3 achieved 94.26% All Types achieved 87.09%

▪ CHS’ type 1 performance was largely due to:

▪ Bed availability – Despite utilising escalation capacity, flow has been the main barrier to achieving the T1 target.

▪ Assessment areas (SAU, RAMU & AMU) remained in use as escalation, capacity, severely reducing the assessment function, and compounding the already challenged flow into the inpatient areas.

▪ Unplaced SLaM patients continue to be one of the main drivers for Exit-block in the ED.

▪ Middle grade ED medics remain difficult to source, leading to a continuation of the issues facing the middle-tier rota

▪ Workforce issues are being addressed through remodelling of capacity against demand and continued engagement with temporary workforce to reduce turnover, as well recruitment and retention.

▪ The Integrated Discharge Team proposal has been approved by AEDB and a pilot is expected to go live on 1st October 2018, focusing on a New Way of Working approach as a more robust model. Patient flow is further supported by the continuation of the 21 Day MDTs and wider system engagement in this process to facilitate discharges.

▪ The implementation of daily MH calls with SLaM have facilitated better oversight of MH patients, but the capacity

The latest AEDB plan contains the metrics and thresholds for aspects of the pathway each group is responsible for overseeing. In line with planning guidance all type performance of 90% is targeted in September 2018 and 95% in March 2019.

▪ The Whole System Winter Plan was also presented at the most recent AEDB.

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issues with SLaM remain, with a Multi-agency Discharge Event (MADE) planned for September.

▪ Other areas of focus includes ACPs, CUCA model developments and AEC are all expected to support performance in the medium term.

▪ The new ED is planned to open in Autumn 2018, which would further support improvements

▪ CHS are due to receive a visit from ECIP in September, to help with diagnosing which areas should be the key focus, analysing current plans and strengthening where appropriate.

E.B.S.7 Ambulance handover breaches (30 & 60 minutes) ▪ There were 165 x 30 minute

breaches and 26 x 60 minute breaches at CHS, in July 2018.

▪ CUH continued to have 30 & 60 minute LAS off-load breaches in the month of July. There was no specific trend to them, but lack of ED capacity was the main driver.

▪ Actions for reducing ambulance handover breaches are covered in the latest Croydon A&E Delivery plan, overseen by the A&E Delivery Board.

▪ The A&E delivery plan includes a timescale to implement redesigned governance, to include terms of reference that address changes in scope, clear and concise reporting structures,

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▪ Exactly half of the 60-minute breaches occurred on the 9th, when CHS were on red escalation due to pressure in ED, starting the day with no available bed capacity and a number of unplaced patients from overnight limiting flow.

▪ The current location of the Emergency Department, awaiting completion of the refurbishment presents other issues, which add to delay.

▪ The proposed governance structure includes subgroups looking at demand management, System Flow and out of hospital strategies,

and work plans against each identified theme in June 2018.

E.B.S.1 Mixed Sex Accommodation ▪ 1 x Mixed Sex Accommodation

(MSA) breach was reported in July for Croydon CCG.

▪ The Breach was reported by

Imperial College Healthcare NHS Trust.

▪ The majority of the trusts breaches are occurring in ITU, by patients awaiting step down from critical care to ward areas and whose discharge is delayed

▪ The trust is undertaking a

detailed assessment of the situation in discussion with commissioners to understand root causes. This involves gaining an understanding of how other Trusts interpret the policy to report breaches within the context of critical care.

▪ The resultant actions with

progress will continue to be reported to the Executive Quality Committee.

E.B.S.2 Cancelled Operations (CHS)

▪ Q1 data shows that CHS

cancelled 27 elective operations for non-clinical reasons at the last minute, 5 of those not being treated within 28 days.

▪ Patients were rebooked for

treatment at the first availability.

▪ A review of harm was undertaken.

▪ Compared to the rest of

London, CHS has a low initial cancellation rate, with the 27 being the fifth lowest in the region.

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▪ Of the 5 cancellations not rescheduled within 28 days, 4 were due to bed availability within 28 days, 1 was uploaded in error. All patients have subsequently been treated and no harm was caused by the delay.

E.B.12 Cancer Urgent GP, 62

Day

▪ Croydon CCG did not meet the standard with an outcome of 78.3% due to 15 breaches out of 69 pathways.

▪ 8 shared pathways between CHS and RMH. – 6 of these were referred after day 38 from CHS and 2 were due to fitness/treatment planning.

▪ 2 shared pathways between CHS and SGH

▪ 4 pathways at CHS ▪ 1 pathways at GSTT

▪ All breach reports will be

reviewed. ▪ The SWL Providers group is

presenting on a quarterly basis a thematic analysis to identify areas of improvement.

▪ The 38/24 day performance trajectories are being agreed with all providers.

▪ Breach reports for July are due 19th September 2018.

▪ The Q1 thematic analysis actions are being agreed at the SWL System Leadership Forum.

E.B.13 Cancer First Treatment,

62 Day Screening

Croydon CCG did not meet the standard with an outcome of 75.0% due to 2 breaches out of 8 pathways.

▪ The new Cancer Waiting Times system roll-out went live in April and does not currently include the facility for Cancer Alliances to access data.

▪ The Transforming Cancer Services Team (TSCT) who provide routine Cancer Waiting Times reporting to STPs and other regional bodies, do not currently have access to the new system. As an interim measure, TCST is being sent aggregated data to enable reporting across London, although this meant reporting from April is more limited than previously (details below).

▪ Data sharing agreements for RM Partners and TSCT are being developed and access to data should resume in October 2018. The aim of these agreements is to give the required access to enable detailed reporting of Cancer Waiting Times data.

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E.A.3 IAPT Access Rate ▪ Croydon CCG saw a significant

increase in performance in Q4. However, performance has dropped in April based on weekly access rates.

▪ Provisional M3 performance was 1.03% against a monthly operating target of 1.4% and the rolling 3 month rate was 3.31% against a 4.2% target.

Provisional August Data: ▪ 1.23% (monthly) ▪ 3.59% (rolling quarter)

▪ Following additional investment

in Q4 to increase access rates, SLAM was able to recruit additional therapists. However, demand needs to be increased in the form of referrals (both GP and self-referrals) to improve performance.

▪ The CCG will work with its partners to ensure a continued programme of promotion of the service and raising awareness.

▪ SLaM and the CCG continue to work collaboratively on increasing demand.

▪ The CCG has recently submitted a revised trajectory against the access rate to provide assurance to NHSE that the standard will be recovered in 2018/19.

▪ A number of practices have confirmed the availability of clinic rooms which could be used to provide IAPT closer to the community. A further 10 practices are in discussion with SLaM.

▪ The CCG has made

additional investment in 2018/19 in order to meet this national commitment.

▪ Work begun in 2017/18 will

be continued to ensure performance is sustained and improved.

▪ Q1 was not met. Q2 is

unlikely to be met.

▪ A step change in performance is required in Q4 as the standard changes from 4.2% to 4.75%. Based on the experience of the step change in Q4 2017/18, this work will begin in Q3 (Oct).

E.A.S.2 IAPT Recovery Rate ▪ The Recovery Rate was below

the national standard of 50.0% in July, with 45.6%.

Provisional August Data:

▪ 51% (monthly)

▪ SLaM cite the reason for variation in recovery rates, from month to month is related to use of locums brought in during Q4.

▪ Recently it was highlighted that Online CBT and Group Therapy had low recovery rates.

▪ SLaM is continuing to recruit to substantive rolls.

▪ The service operates best practice in terms of review of recovery rates by modality and by therapist.

▪ The clinical lead for online CBT has recently attended a

▪ Focus has been primarily on increasing access rates by expanding the service and increasing referrals.

▪ The CCG had been assured that SLaM was employing best practice with regard to improving recovery.

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workshop on how to improve patient outcomes.

▪ The clinical lead for group therapies is carrying a review of effectiveness of the modality.

▪ The CCG will work with SLaM to agree further improvement actions around Recovery Rates, during October.

▪ As access improves towards compliance, it is appropriate to begin closer monitoring of recovery rates.

▪ The CCG will agree improved reporting key actions with SLaM in October.

E.B.S.3 Care Programme Approach (CPA) ▪ Croydon were below the 95.0%

standard for CPA reviews in Q4, this has continued in to Q1 with 92.0%.

▪ The cause of non-compliance is related to workforce issues.

▪ A change in agency rate has led to a number of agency staff leaving.

▪ Whilst teams are seeking to ensure CPAs are carried out, there have been delays in updating the electronic system.

▪ The service has prioritised workload of teams

▪ Completion of CPAs and paperwork is being reviewed fortnightly.

▪ The service plan to achieve Q2.

▪ SLaM are working to recover the standard in Q2

E.H.9 Children’s & Young People’s Mental Health (CYPMH) Services Access ▪ Provisional Q1 data indicates

that the CCG is on track to achieve this access target and Quality Premium for 2018/19.

▪ 11.3% against an 8.5% quarterly target.

▪ There are data quality issues with data, nationally.

▪ Providers are not routinely reporting accurately against the definitions for this metric.

▪ Croydon has experienced data quality issues with CYPMH access reporting.

▪ NHS England has introduced a monthly submission for CCGs to improve the data capture for this target.

▪ During September, the CCG submitted Q1 data in this way, showing a marked improvement on last year.

▪ The CCG missed the 2017/18 target and Quality Premium stretch on this access target.

▪ In 2018/19, the target increased to 34.0% - equating to 8.5% each quarter.

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▪ More children and young people that have been diagnosed and require services are accessing those mental health services.

▪ Action plan developed to ensure compliance for the rest of the year.

▪ At present, this remains achievable.

▪ An action plan overseen by the Quality, Innovation, Productivity & Prevention (QIPP) Operational Board.

E.O.1 Children waiting <18 weeks for wheelchair ▪ In Q1 2018/19, 40.0% of

children received a wheelchair within 18 weeks against a local recovery target of 46.2% and a national target of 100%.

▪ The waiting list at the current service provider has not been maintained as required by Croydon CCG. Additional funding had been granted to the service to reduce waiting times in previous years; however, a material improvement was not delivered.

▪ Concerns about waiting times and the data quality of contract monitoring were raised by the CCG.

▪ The incumbent provider advised further funding was needed.

▪ A decision was taken by the CCG to decommission service and seek new model with a new provider.

▪ From 1 Oct 2018 the

Wheelchair service will no longer be commissioned from CHS.

▪ Responsibility for wheelchairs has been transferred to London Borough of Croydon (LBC) under s75, who will provide wheelchair services (through Croydon Equipment Solutions) as part of their integrated equipment service

▪ LBC are sighted on the statutory requirements and will prioritise waiting times for children.

▪ Through a user engagement event, service users have been advised of this change.

▪ The incumbent provider has undertaken a waiting list validation in order to support the handover to CES.

▪ Mobilisation of transfer of

service is progressing well. ▪ Delivery of children’s waiting

time standard to be delivered in Q4 2018/19.

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E.N.1 Personal Health Budgets

▪ There were 4.1 Personal Health Budgets per 100,000 registered population in place for Croydon CCG in Q1 against an indicative target of 70 per 100k pop.

▪ This equates to 17 PHBs against a target of 290.

▪ Croydon CCG postponed

increasing the number of Personal Health Budgets (PHBs) in 2017/18 due to an investigation in to misuse of money paid to a recipient of a PHB.

▪ The CCG have now reviewed systems and processes and are making improvements to begin rolling out this facility to patients.

▪ Due to the increase in PHBs required, the CCG will need to extend beyond the existing Continuing Healthcare cohort.

▪ A new PHB policy and

Operational Guidance has been agreed to strengthen the governance around payments.

▪ A new payment system has been procured and will be implemented from 1st December

▪ The CCG is exploring increasing the scope of offering PHBs for areas such as Wheelchair service, Mental Health, Learning Disabilities and Maternity.

▪ Once numbers of potential

PHB have been modelled for additional cohorts a timescale for compliance will estimated.

▪ The CCG is unlikely to see an increase in 2018/19 to the level needed to comply with the indicative national target or the submitted trajectory supplied to regional NHSE.

E.P.1 e-Referral Service (e-RS) Utilisation ▪ Croydon CCG is below the

100.0% standard for GPs using eRS to refer to first outpatient appointments.

▪ In July, the CCG achieved 91.0% based on provisional data.

▪ Provisional data for August show the CCG also achieved 91.0%

▪ Following Paper Switch OFF (PSO) in October, providers are not required to accept paper referrals and CCGs are not required to fund activity as a result of paper referrals.

▪ The national target of 100% is now the focus for the CCG.

▪ Croydon’s position has been affected by data quality issues and over-reporting in MAR referral data from CHS.

▪ CHS has requested a resubmission of MAR data

▪ Retrospective adjustment can take up to 12 months due NHS Digitals’ policy on data changes.

▪ CHS has resolved MAR issues from M5.

▪ Croydon's progress has been due to additional resource from NEL CSU visiting GP practices to provide e-RS face

▪ The CCG's recovery trajectory was to meet 100% by the end of Q1 2018/19, which was not met.

▪ Croydon CCG/CUH officially achieved Paper Switch Off on 1st July by reaching 80% utilisation in May (in line with national guidance) using provisional data.

▪ Croydon’s performance is lower than the rest of SWL

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Page 14 of 31


–to face training and the use of e-RS being included in GP Contracts.

▪ Increasing use of eRS aligns to the roll out of the Advice and Guidance function as a related QIPP scheme to reduce unnecessary Outpatient attendances.

and SEL. This is thought to be related to data quality issues in referral data at CHS.

▪ The SWL eRS steering group are aware of this.

▪ QOB has oversight of performance of eRS.

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Improvement and Assessment Framework (IAF)

Page 15 of 31

Better Health Period CCG Peers England Trend Better Care Period CCG Peers England Trend

R 102a % 10-11 classified overweight /obese2014/15 to

2016/1738.5% 6/11 180/207 G R 121a High quality care - acute 17-18 Q4 59 7/11 127/207

103a Diabetes patients who achieved NICE targets2016-17 38.6% 10/11 141/207 R R 121b High quality care - primary care17-18 Q4 64 5/11 173/207

103b Attendance of structured education course2016-17 (2015

cohort)2.7% 8/11 150/207 B R 121c High quality care - adult social care17-18 Q4 63 ➔ 4/11 44/207

R 104a Injuries from falls in people 65yrs +17-18 Q3 2,352 10/11 164/207 R 122a Cancers diagnosed at early stage2016 51.5% 10/11 125/207

R 105b Personal health budgets 17-18 Q4 2.95 10/11 196/207 G R 122b Cancer 62 days of referral to treatment17-18 Q4 86.3% 2/11 47/207

R 106a Inequality Chronic - ACS & UCSCs17-18 Q3 2,208 10/11 114/207 G 122c One-year survival from all cancers2015 73.4% 3/11 42/207

R 107a AMR: appropriate prescribing2018 01 0.884 8/11 34/207 G 122d Cancer patient experience 2016 8.9 2/11 38/207

R 107b AMR: Broad spectrum prescribing2018 01 7.2% 3/11 44/207 R R 123a IAPT recovery rate 2018 02 46.4% 9/11 175/207

108a Quality of l ife of carers 2017 0.62 1/11 147/207 G R 123b IAPT Access 2018 02 2.6% 11/11 204/207

Sustainability Period CCG Peers England Trend G R 123c EIP 2 week referral 2018 03 59.1% 10/11 183/207

R 141b In-year financial performance17-18 Q4 Red ➔ #N/A #N/A 123dMH - CYP mental health (not available) #N/A #N/A

R 144a Utilisation of the NHS e-referral service2018 02 47.5% 9/11 154/207 ¢ n/appR 123f MH - OAP 2018 02 102.0 7/11 134/207

Leadership Period CCG Peers England Trend 123e MH - Crisis care and liaison (not available) #N/A #N/A

R 162a Probity and corporate governance17-18 Q4 Fully Compliant #N/A #N/A G R 124a LD - reliance on specialist IP care17-18 Q4 31 2/11 15/207

R 163a Staff engagement index 2017 3.78 8/11 101/207 G 124b LD - annual health check 2016-17 49.5% 2/11 95/207

R 163b Progress against WRES 2017 0.19 11/11 197/207 ¢ n/app124c Completeness of the GP learning disability register2016-17 0.47% 3/11 96/207

R 164a Working relationship effectiveness17-18 69.49 5/11 94/207 R 125d Maternal smoking at delivery 17-18 Q3 6.7% 6/11 43/207

R 166a CCG compliance with standards of public and patient participation2017 Green R R 125a Neonatal mortality and stil lbirths2016 4.3 2/11 90/207

R 165a Quality of CCG leadership 17-18 Q4 Green #N/A ¢ n/app125b Experience of maternity services2017 79.0 9/11 182/207

Key ¢ n/app125c Choices in maternity services 2017 60.9 7/11 101/207

Worst quartile in England R R 126a Dementia diagnosis rate 2018 03 66.7% 8/11 119/207

Best quartile in England G 126b Dementia post diagnostic support2016-17 83.4% 1/11 7/207

Interquartile range G R 127b Emergency admissions for UCS conditions17-18 Q3 2,635 10/11 146/207

G 127c A&E admission, transfer, discharge within 4 hours2018 03 86.9% 1/11 51/207

G R 127e Delayed transfers of care per 100,000 population2018 03 7.0 7/11 55/207

G R 127f Hospital bed use following emerg admission17-18 Q3 519.7 7/11 136/207

* Patients diagnosed in 2015; # Patients diagnosed in 2014 G R 105c % of deaths with 3+ emergency admissions in last three months of l ife2017 5.76% 4/11 119/207

G 128b Patient experience of GP services2017 82.8% 1/11 153/207

B 128c Primary care access 2018 01 100.0% ➔

R 128d Primary care workforce 2017 09 0.94 1/11 135/207

G R 129a 18 week RTT 2018 03 92.7% 1/11 20/207

¢ n/appR 130a 7 DS - achievement of standards2017 2

R R 131a % NHS CHC assesments taking place in acute hospital setting17-18 Q4 14.9% 5/11 119/207

¢ n/appR 132a Sepsis awareness 2017 Amber

Note: There are no data for NHS Manchester CCG (14L) for the fol lowing indictors : 121a, 121b, 121c,

122d, 125b, 125c, 163a, 163b and 164aQuarterly IAF Dashboard produced by NHSE, July 2018. This represents

Q4, however, many indicators have older data due to the range of data

sources.

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IAF Overall and Clinical Priority Area Ratings 2017/18

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2017/18 CCG end of year ratings were published in Q1. Croydon’s overall rating along with those published for Cancer and Maternity Clinical Priority Areas are shown

below. Ratings for other Clinical Priority Areas have not yet been published.

Overall CCG Rating

CCG 2016/17 2017/18

Croydon Inadequate Requires Improvement

Kingston Good Good

Merton Good Good

Richmond Good Good

Sutton Good Requires Improvement

Wandsworth Good Good

Maternity

CCG 2016/17 2017/18

Croydon Good Good

Kingston Outstanding Outstanding

Merton Outstanding Outstanding

Richmond Good Good

Sutton Outstanding Outstanding

Wandsworth Outstanding Outstanding

Cancer

CCG 2016/17 2017/18

Croydon Outstanding Outstanding

Kingston Outstanding Outstanding

Merton Good Good

Richmond Outstanding Outstanding

Sutton Good Good

Wandsworth Good Good

The CCG received its overall rating for 2017/18. This progressed from inadequate to

requires improvement. Whilst detailed information is not provided supporting the

rating, a significant component would have been as a result of the improved 360○

Stakeholder survey, which went from 61.90 in 2016/17 to 69.49% in 2017/18. This

resulted in the CCG moving out of the worst quartile.

Also, the CCG’s financial plan to move out of deficit by 2019/20 will have also led to a

better rating.

The CCG held on to a rating of good around maternity services. The CCG were in the

top quartile for maternal smoking as of Q3 2017/18. Neonatal mortality and Choice in

maternity services both remained in the interquartile range albeit with improvements

in how the CCG benchmark for both compared with the previous year.

Experience of maternity services improved marginally, but remains within the worst

quartile.

The CCG achieved an outstanding rating for cancer. 3 of 4 underpinning indicators

were in the top quartile with the fourth in the interquartile range. Whilst cancers

diagnosed at an early stage moved from the top quartile to interquartile due to a

decrease from 54.7% to 51.5%, cancer patient experience improved, moving in to the

top quartile range, going from 8.7 to 8.9. Incremental improvements were also seen

in one-year survival rates and 62 day referral to first treatment targets.

Ratings for Mental Health, Dementia, Diabetes and Learning Disabilities for 2017/18

have not yet been published.

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Ratings Improvement & Assessment Framework Indicator

Latest Data in IAF scorecard

CCG Rank / Quartile range

Comments 2016/17 2017/18

Can

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122a Cancers diagnosed at early stage 2016 51.5% 125/207 –

Interquartile SWL Cancer Strategic Leadership Forum coordinating improvements across SWL Trusts. More Croydon patients diagnosed with cancer are surviving after a year. The CCG’s one-year survival rate has increased between 2014 and 2015, with 71.1% to 73.4%, respectively.

122b Cancer 62 days of referral to treatment Q4 2017/18 86.3% 47/207 – Best Quartile

122c One-year survival from all cancers 2015 73.4% 42/207 - Best Quartile

122d Cancer patient experience 2016 8.9 38/207 - Best Quartile

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126a Dementia Diagnosis Rate March

2017/18 66.7% 119/207 - Interquartile

Croydon CCG has maintained compliance for the last 12 and maintains a compliant position at M3 2018/19 of 67.5%

126b Dementia Post Diagnostic Support 2016/17 83.4% 7/207 - Best Quartile

The latest scorecard from NHSE shows that Croydon are ranked 7th in the country. Increasing from 79% to 83.4% in 2016/17, meaning more people diagnosed with dementia in the past 12 months had a face to face review of their care plan.

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Comments 2016/17 2017/18

Me

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123a IAPT Recovery Rate February 2017/18

46.4% 175/207 – Worst

Quartile

The CCG’s Recovery Rate has improved year-on-year. The service employ best practice in reviewing recovery rates at therapy and therapist levels. The CCG will be agreeing a recovery improvement plan in October.

123b IAPT Access February 2017/18

2.6% 204/207 - Worst

Quartile

The CCG invested additional money in 2018/19. Capacity is sufficient to meet the national standard. An joint action plan exists to increase referrals (GP and Self). Additional assurance was required from NHSE in September as to the CCG’s improvement actions.

123c Early Intervention for Psychosis March

2017/18 59.1%

183/207 - Worst Quartile

Monthly performance is variable due to small patient numbers. In June 2018, the CCG achieved 100%.

123d Children & Young People MH Access - - No data available

Provisional data now indicates that the CCG did not meet the target of 32.0% access for 2017/18. Due to data quality issues previous reporting was over-stated. Local data indicates that 27.4% was achieved compared to the 2016/17 estimated baseline of 12.0%. Due to national data issues, a new collection is commencing in Sept 2018.

123e MH Crisis Care and Liaison - - No data available

123f MH Out of Area Placements February 2017/18

102 134/207 - Interquartile

A general shortage of MH beds across the 4 boroughs served by SLaM. Formed of CCG, SLaM and the Local Authority will review individual cases to look for systemic changes that will release beds. The CCG has asked that this group review earlier monitoring data to proactively advise on potential long-waiters.

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Comments 2016/17 2017/18

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124a Reliance on specialist Inpatient beds Q4 2017/18 31 15/207 – Best Quartile

There have been improvements in 124a and 124b since the last publication. 124c is a new count. An action plan is being developed to raise awareness of the benefits to individuals with LD from maintaining the LD register and offering health checks in Primary Care. Q1 data for physical health checks shows an increase from 104 in Q1, 2017/18 to 150 in Q1 2018/19.

124b Annual Health checks 2016/17 49.5% 96/207 - Interquartile

124c Completeness of GP LD register 2016/17 0.47% 96/207 - Interquartile

Dia

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103a Diabetes patients who achieve NICE treatment targets

2016/17 38.6% 141/207 - Interquartile

Local data shows that far greater numbers of people accessed structured education. Nationally, this is under reported and is being addressed by the introduction of a new data collection. The CCG is developing a business case for an integrated diabetes service model. This will include improvements to raise compliance with NICE treatment targets and under recording of diabetes patients on the GP register.

103b Attendance of structured education 2016/17 2.7% 150/207 - Interquartile

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Comments 2016/17 2017/18

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125a Neonatal mortality 2016 4.3 90/207 – Interquartile

Actions to improve patient experience across South West London providers include the establishment of a Service User led group; made up of service users, maternity providers and commissioners, concerned with improving women’s maternity experiences. Service users obtain direct feedback of experiences for analysis and reporting to the Maternity Voices Partnership (MVP). Local MVPs are monitored at SWL level. A separate action plan, developed in Croydon, is in place to improve women’s experiences.

125b Experience of maternity services 2017 79.0 183/207 – Worst

Quartile

125c Choice in maternity services 2017 60.9 101/207 –

Interquartile

125d Maternal smoking at delivery Q3 2017/18 6.7% 43/207 - Best Quartile

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Quality Premium

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The 2018/19 Quality Premium framework sees a significant change to 2017/18 with the inclusion of Emergency Demand Management Indicators being introduced

attracting more than 75% of all QP money. Minor changes apply to the Quality Indicators; however, their value is now much less only accounting for 25% of the QP money

available.

Ref Indicator Name Weighting Indicative Value to Croydon CCG

Provisional Performance (M3)

A1 Type 1 A&E Attendances

25.0% £500,000

At M4, the CCG below plan with a -1.1% YTD variance.

A2 Non-Elective admissions 0 Length of Stay M4 data shows -31.5%% under performance, YTD. This is likely to be a data quality issue.

B Non-Elective admissions +1 Length of Stay 25.0% £500,000 M4 data showing a -9.97% under performance, YTD.

QP1 Early Cancer Diagnosis 8.5% £170,000 No in-year data

QP2 GP Access & Patient Experience 8.5% £170,000 No in-year data

QP3 Continuing Healthcare 8.5% £170,000

Q1 targets missed. The latest month’s data for August shows targets were also missed.

QP4 Children & Young People’s Mental Health Access 8.5% £170,000

Q1 provisional data indicates that the CCG is on track to achieve the 34% access standard in 2018/19.

QP5 Bloodstream Infections 8.5% £170,000 Data not yet available

QP6 IAPT Access 7.5% £150,000

Q2 target missed. Provisional data for September indicates a near compliant position for M6.

TOTAL 100.0% £2,000,000

Other changes to the QP framework for 2018/19 include a revision of the gateway indicators. These indicators must be met otherwise a deduction to any money achieved

from the above indicators will be reduced by the percentages given below.

Ref Gateway Weighting Provisional Performance (M3)

GW1 Achieve the approved CCG financial position year-end

100.0% The CCG are forecasting a £1.2m surplus for 2018/19.

GW2 Numbers of patients on an incomplete pathway at March 2019 are lower than March 2018. 50.0%

At M4, there CCG had an 8.6% variance against the plan. The CCG has a Planned Care recovery plan which includes reducing unwarranted variation in GP referrals, non-acute services will be promoted; use of Advice & Guidance via electronic referral system will also be promoted.

GW2 Achieve the 62 day maximum wait for GP referrals to first definitive treatment for cancer

50.0% The target was met in Q1. July saw performance drop to 78.3% against the 85.0% target.

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Quality Assurance - Highlights

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Indicator / Issue

Cause

Action

Timescale / Assurance

Patients waiting excessive times in Croydon Health Services (CHS) Emergency Department whilst waiting for admission under SLAM services.

Ongoing and significant demand in the acute and crisis care pathway.

➢ SI raised by CHS to investigate multiple incidents.

➢ Daily escalation calls with the Surge Hub, CHS, SLaM and CCG Leaderships.

➢ Multi-Agency Discharge Event (MADE) hosted by SLAM.

➢ 60 days to complete investigation which will be reviewed at CCG SIRM.

➢ MADE event taking place on 19 September 2018.

CAS Alert received from NHS England regarding a national issue identified for Practices using Docman 7 document management system which may result in a risk to patients and requires further investigation.

A risk has been identified by NHS England that patient information sent as letters from Hospitals as attachments to NHS mails, to GP practices which use the Docman 7 document management system, may not have been correctly entered into the Practices’ clinical IT systems.

➢ NHS England have laid out a sequence of actions, to a tight timeframe, to be taken by Practices.

➢ Primary Care, Variation and Quality Team working together and supporting Practices to ensure timeframes are achieved.

The CQC issued SLaM with a Warning Notice following their inspection of acute care pathways which focused on wards for working age adults.

Concerns around the variability of quality of care and services across the pathway were noted, with systems and processes not operating as well as they should, quality not being assessed safely and consistently and mitigations not being in place or followed.

➢ An action plan is being developed by the Trust and will be shared the Croydon CCG.

➢ A response to the Warning Notice by the Trust is due on 1st April 2019.

➢ The action plan will be monitored at the monthly Four boroughs CQRG meetings held with SLaM.

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Quality Assurance – Serious Incidents

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0

2

4

6

8

10

12

14

Serious Incidents Reported by Providers

CHS NHS Trust - Count ofSIs Reported

NHS Croydon CCG - Countof SIs Reported

SLaM NHS FT - Count ofSIs Reported

LAS - Count of SIs Reported

CHS NHS Trust - Count ofNo of days to report

NHS Croydon CCG - Countof No of days to report

SLaM NHS FT - Count ofNo of days to report

LAS - Count of No of daysto report

Croydon Health Services (CHS) NHS Trust reported 6 SIs in

M4, none of which were Never Events. Two SIs were

reported under Diagnostic incident including delay meeting

SI criteria. However, no commonalities were noted in these

incidents.

The average length of time taken to report an SI reduced

significantly at CHS in M4. Following two months with an

average length of time to reporting of approximately 12 days,

M4 saw this halve to 6 days.

SLaM reported 1 SIs in M4, This represents a significant

reduction on the previous month. The SI was reported under

the category Apparent/actual/suspected self-inflicted harm

meeting SI criteria.

It should be noted that one of the SIs, whilst reported by

CHS, involved a significant mental health aspect.

Following on from the work done at the SLaM Multi-Agency Discharge Event (MADE) on 19 September 2018, Croydon CCG will take part in a

second MADE event on 28th November 2018. This event will focus on adult mental health beds, as this has been identified as having a

significant impact on both mental health and acute care pathways. The focus of the event will againe be patients who have a length of stay of

50 days or more in adult mental health beds and the primary aim will be to remove all barriers to discharge, giving patients a clear pathway

and agree a discharge date once the patient is clinically fit. This is part of a continuous series of MADE events across all four Boroughs within

SLaM, which are facing the same issues.

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Quality Assurance – CHS Patient Experience

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0%

20%

40%

60%

80%

100%

120%

50

52

54

56

58

60

62

64

66

Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18

CHS Patients Experience - Complaints (CHS)

No. ofcomplaintsreceived

%acknowledged within 3day target

▪ CHS NHS Trust received 62 complaints in Month 4, 100% of which were acknowledged within the 3 day target. This target has been achieved over the past 6 months consecutively.

▪ The top 3 areas under which complaints were received were Integrated Adult Care (36), Integrated Surgery, Cancer and Clinical Support (19) and Integrated Women’s, Children’s and Sexual Health (5).

▪ Cause for concern about clinical care; access and admission; communication and information; and staffing/clinic related incidents remain the major categories of reasons for the complaints in the Trust. In addition to these, diagnosis problems was also a high reported category in M4.

▪ FFT response rates in A&E rose further in M4, reaching 28.9%, the highest number of responses received in 12 months and significantly higher than the national average of 12.8%. This increase may indicate that the electronic text-based system rolled out in A&E is proving to be successful.

▪ CHS NHS Trust’s internal target for Patient Experience FFT is currently set for 90% of patients to recommend the service to a friend or family member. The Trust did met this target in M4, following a slight underperformance in M3.

▪ Inpatient FFT data was not available for CHS in M4. Further investigation is needed to understand why this data was not nationally published.

▪ FFT rates and the action plans developed following the

Patient’s Surveys for Outpatients, Children’s Inpatients and Maternity service continue to be monitored via the Clinical Quality Review meetings.

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Quality Assurance – Serious Incidents

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0%

20%

40%

60%

80%

100%

120%



Inpatients 91% 91% 92% 94% 96%

A&E 93% 90% 91% 90% 87% 90%

Inpatients response rate 12.6% 15.4% 18.9% 14.3% 14.6%

A&E response rate 8.9% 4.6% 10.5% 16.80% 20.2% 28.9%

Patient Experience - FFT Score and Response Rate (In-patient services and A&E )

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Quality Assurance – SLaM Patient Experience

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0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

78%

80%

82%

84%

86%

88%

90%



FFT - Recommend SLAM 82% 88% 83% 87% 84% 85%

FFT - Recommend England 89% 89% 89% 89% 89% 88%

FFT - Response Rate SLAM 2.32% 3.86% 2.54% 1.92% 2.90% 2.40%

FFT - Response Rate England 2.73% 2.07% 2.79% 2.95% 2.99% 3.57%

Patient Experience - FFT Score and Response Rate (SLAM/England )

5

13

10

6

9

5

7

0 0 0 0 01

00 0 0 0 01

2

0

2

4

6

8

10

12

14

Jan Feb Mar Apr May June July

Patient Experience - Complaints Received (SLaM)

Adults Mental Health Child and Adolescent Mental Health Mental Health Older Adults Learning Disabilities

▪ When benchmarked nationally, SLaM continues to remain slightly below the national average recommendation rate of 88% in Month 4, reporting 85% and response rates are below the England average of 3.57%, at 2.40%.

▪ SLaM received 9 complaints in M4 involving Croydon CCG residents, reported under Adult Mental Health (7) and Mental Health Older Adults (2).

▪ All complaints were acknowledged within the 3 day target.

▪ The Q1 Complaints report was presented at the SLaM Four Boroughs CQRG in October. SLaM received 127 complaints in Q1, of which 24 were from Croydon patients.

▪ Care and Treatment and Attitude/behaviour of staff were the two highest reporting subjects overall and for Croydon patients.

▪ Coordination of treatment was the largest reported sub-category with the majority of complaints relating to poor communication.

▪ Clearer guidance has been given to staff to reinforce expected standards of communication.

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Quality Assurance

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CQC Visit Updates The CQC have made a number of visits to Providers within Croydon borough, a summary of these are detailed below. The Quality Team are strengthening working relationships with the CQC and have been invited to join them on spot provider visits where possible and when required.

▪ Croydon Health Services (CHS) NHS Trust In July 2018, the CQC made an unannounced visit to CHS NHS Trust Medical Services and Community Services (Adults and Children and Young People). The full report was published on 28th September 2018. The rating for the trust remained as Requires Improvement, the same as the previous inspection in 2017. CHS rated requires improvement for Safe, Effective, Responsive and Well-led. The trust received a rating of Good for Caring. The CQC identified a number of issues across both Medicine and Community Services, such as; staffing in both inspected services, with vacancy rates high in adult community, insufficient speech and language therapists and reliance of bank and agency in medicine. A number of national targets were not met within community services, both for adults and children. Furthermore, the monitoring of quality and safety within community services was not sufficiently robust. A significant number of medical patients were outlying on other wards. Moreover, the capacity issues within medicine meant that patients were often moved during the night. Additionally, within medicine identified risks were not always reviewed or dealt with in a timely way. A high level discussion about the findings took place at the CQRG on the same day as publication. CHS is developing an action plan in response to the inspection report which will be monitored through CQRG.

▪ SLaM

Following the CQC inspection at SLaM in July 2018 of forensic services, crisis pathway, community services for older adults and adult eating disorder services, initial feedback from the Trust is that the inspection went well and continued improvements across the services had been recognised by the CQC, including a complete turnaround and completion of all of the actions within the adult eating disorder unit. However, as part of this visit, the CQC also inspected SLaMs Acute and PICU pathway which resulted in the CQC issuing the Trust with a Warning Notice on 25th July. The notice related to:

• Systems and processes not operating effectively to ensure compliance with Health and Social Care Act 2008

• Trust was not always assessing quality and safety of services provided

• Where assessment and monitoring took place, necessary steps to mitigate risks to health, safety and welfare of patients not taken

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Quality Assurance

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• Significant variation between wards that was impacting on care and treatment received by patients.

SLaM has been asked to make improvement by the 1st April 2019. A number of action are

already form part of the borough reorganisation and are underway. Changes and new

improvement strategies have been implemented, and a broader improvement plan is

being developed for submission to the CQC. Progress against this plan will be monitored

at the monthly Four Borough CQRG meeting.

▪ Primary Care Two practices within Croydon borough, Edridge Road Community Health Centre and Coulsdon Medical Centre, have been rated at “Inadequate” overall by the CQC. In addition, two practices, Shirley Medical Centre and Brigstock and South Norwood Partnership have been rated as ‘Requires Improvement’ overall. The remaining Practices within Croydon borough, which have been inspected by the CQC, are currently rated as ‘Good’ overall. The table below shows details of inspections undertaken by the CQC as part of their scheduled programme, return visits or where we are awaiting publications of reports since the previous update.

Location Type Date of

CQC

visit

Date

report

published

Overall

Rating

Change

to last

visit

Edridge Road Community HC

Return visit 02/08/2018

Not published

Inadequate

Awaiting outcome

Denmark Road

Comprehensive 15/08/2018

Not published

Not sufficient evidence to rate

Awaiting outcome

East Croydon Medical Centre

Comprehensive w/c 10/09/2018

Not published

Good Awaiting outcome

Croydon GP Hubs (provision under Croydon Urgent Care Alliance CUCA)

Comprehensive 3x sites August/Sept 2018

Not published

New service

Awaiting outcome

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The Coulsdon Medical Practice The lead GP, who has been providing GP services at Coulsdon Practice for more than 34 years, has taken the decision to retire from the Practice. The Practice will therefore permanently close on 26 October 2018 and Croydon CCG Primary Care Team are working with NHS England to support the dispersal of the patient list and assist these patients with registering with a Practice. East Croydon Medical Centre Heathfield Surgery merged with this practice in the last 12 months, and the Heathfield premises closed in early 2018. The CQC rated Heathfield Surgery as requires improvement when it published the inspection report in August 2017. East Croydon Medical Centre was rated as overall good when previously inspected in June 2017. The report from the merged inspection has not been published. Croydon GP Hubs – CUCA Croydon patients can access urgent GP care via the GP hubs, operating on three sites within the borough. The CQC have recently been inspecting the sites and we are awaiting the reports. It is anticipated that the CQC will undertake return visits for the Practices rated as “Requires Improvement” within the next 6-12 months. The CQC are in regular contact with Croydon CCG Primary Care Team, holding regular conference calls with the Head of the Team. Croydon CCG Primary Care, Medicines Optimisation and Variation teams together with colleagues in the SWL Alliance are working actively to support Practices who are not rated as “Good” by the CQC.

Intermediate Services CQRG Meeting The Intermediate Services CQRG, which is chaired by the CCGs Medical Director, met on 3rd September 2018 to review the quality of provider services whose intermediate contracts are managed by the Commissioning Support Unit. Communitas/ENT, GP Collaborative/ Dermatology, BMI/Gynaecology, Bromley Health/ Diabetes COS/Ophthalmology, Parkside Group Practice/Vasectomy and Boots/Anticoagulation.

The following Quality highlights were discussed:

• Bromley Healthcare (Diabetes) – a contract performance notice has been issues due to underperformance against KPI relating to patients seen within four weeks.

• Communitas/ENT – Whether service had specialist audiology room has been queried, due to issues following tests prior to referral to CHS. Contract team to ascertain whether the room conforms to standards

• Dermatology – Pilot was not working as well as expected and was being considered as part of a wider strategy for intermediate contracts to ensure high quality services are procured.

• Six contracts were due to expire at, or before, the end of the financial year. The posed a risk to continuity of services available to Croydon residents.

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Care Homes Quality The designated nurse for adult safeguarding attends the Care Home Strategy and Delivery Board facilitated by the OOH team. There are a few initiatives and work streams introduced by the OOH team to transform and improve the quality of care provided in care homes. These initiatives relates to telemedicine, workforce development, etc.

Exceptions reported in September 2018 are detailed below:-

Staffing update Barbara Carter became the home manager at Cedar View Care Centre in September 2018 CQC inspections CQC inspections conducted at care facilities providing care for patients under 65 years old diagnosed with mental health issues published in September 2018.

CQC rating High View Care Service

Lilias Gillies Retreat Lodge

Overall rating G RI RI

Safe G RI RI

Effective G G G

Caring G G G

Responsiveness G G G

Well-led G RI RI

The CQC continues to conduct checks at Elmwood NH which was deemed inadequate in May

2018. The designated nurse for SGA attended a provider level concern (PLC) meeting led by

the LA on the 2nd October. This care provider remains under the PLC process.

There are 6 care homes subject to the PLC process and these are monitored with the

involvement of commissioners, LA and CQC.

Partnership working The designated nurse for SGA continues to work closely with colleagues in the Local Authority and Out of Hospital team in the CCG. Primary Care Quality GP CQRG The GP CQRG took place on 26 September 2018. The following items formed the majority of discussions:

• NRLS reporting – SWL reported the highest number of incidents, with Croydon GPs reporting three quarters of incidents. 43 Croydon practices reported an incident between January & June 2018. Overall, the reporting of incident in GP practices is significantly lower than acute providers.

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• The GP Quality Dashboard was discussed, a summary of which can be found in the following section.

• GP Survey 2018 – discussions took place around how practices and networks could share learning to improve responses within Croydon GP practices

• Sepsis Awareness – the use of the Sepsis toolkit was discussed. It was agreed that use of the toolkit should be further promoted within Croydon GPs

GP Quality Dashboard Other than updated data sets, further revisions to the dashboard are not currently planned. Improvements in data that will be reflected in the next in the GP CQRG Dashboard include:-

▪ Friends and Family Test data collection within Practices has improved with more practices contributing data, and more patient responses. 10,047 responses have been captured year to date for Apr-Aug 2018, which is 1202 or a 14% increase in numbers of patients contributing feedback compared to the previous year.

▪ An improved number of LD Health Check has been noted in both Q1 and Q2 2018-19 compared to 2017-18. A 30% improvement is noted in total checks completed year to date, with a count of 393, compared to 302 previously

Croydon CCG Quality, Safeguarding and Primary Care Workshop The next Workshop is due to meet on 27 September 2018 and will consider CQRG Planning & Development and Governance and Work Stream Mapping. The Workshop will be led by the Quality and Safeguarding Team and include representation from Primary Care, Variation and Medicine Management Teams. Docman CAS Alert NHS England has been made aware of an issue where some GP Practices have records, received by NHSMail, which have not been able to be processed and have not transferred into patients electronic records. This affects GP Practice using Docman version 7 software with Electronic Document Transfer (EDT) enabled. GP Practices were asked by NHSE to complete a number of tasks with specific timeframes The deadline for the cycle of reporting has passed, all practices have reported with the exception of seven where technical issues, including practice system mergers and availability of CSU technical support staff have complicated matters and are still being worked on. In total around 30,000 records were impacted, with to date eight potential incidents of harm occurring which the practices have dealt with, across five of the practices. Practices now have robust systems in place to ensure the unprocessed folder is routinely

checked. We are awaiting further guidance nationally regarding next steps and actions.

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6 November 2018

Title of Paper: REPORT FROM THE CHAIR OF THE INTEGRATED GOVERNANCE

AND AUDIT COMMITTEE

Lead Director Roger Eastwood, Lay Chair, Integrated Governance and Audit Committee

Report Author Elaine Clancy, Director of Quality & Governance Ben Smith, Board Secretary


N/A


CCG Governing Body

Purpose of Report For approval

Recommendation:

The Governing Body is asked to note the report of the Integrated Governance & Audit Committee:

Executive Summary:

The Integrated Governance Committee is a Committee of the Governing Body but also provides oversight reporting of the handling of Quality Risks and Financial Risks from the Quality Committee and Finance Committee respectively.

The Integrated Governance Committee has met once since the Governing Body in September 2018. Key Papers: The papers on the agenda on 24th November 2018 were:

• Operating Plan Quarterly Report oversight

• Local Counter Fraud Specialist Report

• Internal Audit Update 2018/19

• External Audit - Audit Findings Report 2017/18

• Service Auditor Reporting Updates: NELCSU Mid-Year Service Auditor Report (Phase 2 2017-2018) and Capita

• Report on Losses and Special Payments

• Report on Waiver of Standing Orders and Prime Financial Policies

• Policy Conflict of Interest

The committee met on Monday 24 September 2018, and reviewed these papers.

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Due to an IT issue, the Board Assurance Framework could not be presented to the Committee meeting for discussion. The Committee reviewed the benchmarking analysis of board assurance frameworks provided by the CCG’s internal auditors that identified some common risk areas and differences in approach to presenting risk information. The Committee also reviewed an Assurance Map that suggests generally comprehensive assurance mechanisms but a few areas when the CCG may need to formalise its assurance arrangements, namely around: GP network performance, delivery of HR Strategy and Estates Strategy. The Chair has proposed a workshop to review Croydon’s document content including developments around the Primary Care since delegated commissioning. Operating Framework Performance Report The Operating Framework Performance Report Q1(2018/19) previously discussed at Governing Body was reviewed and feedback was given on the template. There were suggestions to illustrate how risks are reflected and their anticipated financial impact. Auditor suggestions included improved clarity on actions and Committees assigned follow up responsibilities Audit Reports The Committee received updates on internal audits that report significantly strengthened assurance around continuing healthcare after repeated follow up testing. A positive report was received on Medicines Optimisation and discussions noted the team is led by a joint appointment with CHS. External Audit plans and timescales for 2018/19 were presented and discussed. Service Auditor Reporting Service Auditor Reporting provided detailed compliance reports in respect of risk areas managed by the CCG’s contracted support. The NELCSU Service Auditor Report incorporates the mandatory areas highlighted below: • Payroll • Financial Ledger • Accounts Payable • Accounts Receivable • Financial Reporting • Treasury and Cash Management • Financial Ledger / Financial Services: NHS Shared Business Services (SBS) provides the Oracle based Integrated Single Financial Environment (ISFE) ledger system for all CCGs nationwide and financial services • Employment Services (payroll/pension): NHS Shared Business Services (SBS) provides payroll and pension services off the Electronic Staff Record (ESR), the national payroll system operated by NHS Business Services Authority (NHSBSA). • Primary Care Contract Administration: Capita provides the primary care practice list management and payment system nationwide

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These reports inform the CCG’s Head of Internal Audit Opinion and it was noted that no issues in respect of these areas were noted in the Croydon CCG’s Annual Accounts. Conflict of Interest Policy The Committee reviewed and agreed the CCG’s Conflict of Interest Policy and the Policies for Gifts & Hospitality and Working with the Pharmaceutical Industry. The revised draft policy was noted to have reflected the national guidance issued since the last substantial update of the policy in 2016/17.

Governance:

Corporate Objective To commission high quality health care services that are accessible, provide good treatment and achieve good patient outcomes.

Risks No specific risks for the Risk register or BAF were raised.

Financial Implications There are no budgetary provisions made within this paper or in respect of this process, nor are there anticipated to be any budgetary implications.

Conflicts of Interest No conflicts of interest have arisen or been recorded to date.

Clinical Leadership Comments Not applicable

Implications for Other CCGs Not applicable

Equality Analysis Not applicable

Patient and Public Involvement Not applicable

Communication Plan To be made available to Governing Body members


Not applicable

Reputational Issues Failure to manage quality, financial and conflict of interest issues effectively would attract adverse attention from patients, the public and NHS England.

Report Author: Ben Smith

Email address: [email protected]

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6 November 2018

Title of Paper: REPORT FROM THE CHAIR OF THE FINANCE COMMITTEE

Lead Director Philip Hogan, Lay Chair, Finance Committee

Report Author Mike Sexton, Chief Finance Officer Ben Smith, Board Secretary


N/A


CCG Governing Body

Purpose of Report For approval

Recommendation:

The Governing Body is asked to agree: ▪ The terms of reference for the SWL CCG Finance Committees in Common, subject to

the proposed amendment to the quoracy that only 3 out of 6 GP members need to be present at any point in the meeting.

The Governing Body is asked to note: ▪ The committee has met twice since the last Governing Body meeting (24 September

2018 and 29 October 2018).

▪ The inaugural meeting in common of the SWL CCG Finance Committees was held on 23 October 2018:

(i) The contribution from Croydon CCG to the SWL CCG 2018/19 control total (£7.5m surplus) remains at £1.2m surplus. Whilst there are financial challenges in Sutton CCG and Richmond CCG, these can be supported by other SWL CCGs/NHSE.

▪ The Finance Report (Month 6) and QIPP Report (Month 6), including

(i) Unfavourable expenditure variances on planned care, mental health and prescribing are offset by favourable variance on continuing health care, deferring mental health investment, prior year prescribing accruals, and reserves. QIPP delivery is forecast at 90% (£2.7m slippage

(ii) The unfavourable variances are mitigated by (i) recovery plan, (ii) 0.5% mandatory contingency (£2.5m) and (iii) QIPP contingency (£2.7m).

(iii) CCG management team has initiated a director-led peer review to improve performance in 5 key areas (Mental Health, Planned Care, Together for Health, Children, and Primary Care). The review will conclude mid-December.

(iv) The CCG is forecasting to deliver the £1.2m surplus for 2018/19.

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(v) Demand for, and supply of, acute services remains a key risk. The CCG is actively seeking early year end agreements to ensure this risk is managed by all parties in the system.

• The following expenditure and procurement decisions (>£250k) were made by the Finance Committee:

(i) Contractual commitment to fund the implementation of Health and Social Care Network (HSCN) (£0.6m).

(ii) Contract extensions to incumbent providers to support the transition to new MSK services and dermatology services

(iii) Endorsed the Chair’s Action to enter into the contractual commitment for telemedicine (£0.6m).

(iv) Contract extensions (Diabetes – £0.1m, Gynaecology - £0.2m, Ophthalmology - £0.3m) to support the phasing of the implementation of new integrated services/pathways.

▪ The CCG and Croydon Health Services have started a new joint planning process for

the 2019/20 planning and budget setting round with the objective of agreeing a joint plan and joint control total with the regulators (NHSI/NHSE).

Executive Summary:

The Finance Committee is a Committee of the Governing Body and with oversight reporting to the Integrated Governance and Audit Committee (IGAC) (in its position of oversight for CCG internal control and governance). It has been established to ensure a robust financial strategy is in place and to oversee the organisation-wide system of financial management, working with IGAC to ensure viability, effectiveness and financial probity within the CCG.

The finance papers on the Governing Body agenda are:

• Finance Report (Month 6)

• QIPP Report (Month 6)

• Contract Portfolio Report (M5) The committee met on Monday 24 September and on Monday 29 October 2018. The inaugural meeting in common of the SWL CCG Finance Committee was held on 23 October 2018. The Finance Committee Chairs and CFO/DoF of Croydon CCG and Croydon Health Services met on 26 October 2018 to continue oversight of the finance apsects of working closer together. The key business on 24 September 2018 meeting was as follows:

• Review of Month 5 Financial Performance and QIPP delivery

• The key risks to delivering the CCG’s £1.2m share of the SWL control total are:

• Delivering QIPP (emergency care, MH inpatients, planned care, prescribing)

• Repatriation of St George’s/Kings waiting list activity to CHS or other providers

• Possible transfer of 2000 patients to Surrey

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• Inadequate funding of 2018/19 pay awards for outsourced services, primary care and CHC. NHS providers will be funded directly by DHSC on a monthly basis.

• Outcome of responsible commissioner arbitration.

• Anticipated allocations – overseas visitors (£1m) and extended access (£2m).

• Received an update on forthcoming procurements.

The key business on 29 October 2018 was as follows:

• Review of Month 6 Financial Performance and QIPP delivery

• The key risks to delivering the CCG’s £1.2m share of the SWL control total are:

• Delivering QIPP (MH inpatients, planned care, prescribing)

• Repatriation of St George’s/Kings waiting list activity to CHS or other providers

• Possible transfer of 2000 patients to Surrey

• Outcome of responsible commissioner arbitration.

• Prescribing cost pressure on prices for Category M drugs (generic drugs).

• Anticipated allocations – overseas visitors (£1m) and extended access (£0.2m).

• Review of the capital programme

• Considered expenditure commitments > £250k The key business on 23 October 2018 SWL Finance Committees meeting in common was as follows:

• Reviewing the terms of reference for the meetings

• Reviewed the consolidated Month 6 Financial Reporting pack

• Debated and agreed how the delivery of the SWL CCG control total would be managed across the CCGs.

• Reviewed the budget and outcomes expected from the SWL Programme Office

• Considered the Interoperability Phase 2 Business Case and the Business Case for investment in Children and Young People’s (CYP) services.

The key business on 26 October 2018 meeting between CCG and CHS Finance Chairs was as follows:

• Reviewed progress against the action plan.

• Discussed and noted the practical steps being taken to reach an early year end agreement for 2018/19.

• Discussed and noted the practical steps now being taken to plan together for 2019/20.

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Governance:


Risks Failing to make appropriate preparations for such a report would place the CCG at a reputational risk, initially, principally with its auditors and authorising bodies such as NHSE.









Not applicable


Report Author: Mike Sexton


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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP

GOVERNING BODY

6 November 2018

Title of Paper: 2018/19 FINANCE: PERIOD 6 (SEPTEMBER 2018)

Lead Director Mike Sexton Chief Finance Officer

Report Author Edward Odoi Chief Management Accountant


Senior Management Team – 23 October 2018 Finance Committee – 29 October 2018


Clinical Leaders Group – 07 October 2018

Purpose of Report For discussion and noting

Recommendation:

The Governing Body is asked: ▪ To note the CCG is reporting a year-to-date surplus of £0.7m (£0.1m Favourable

variance) and a forecast in-year surplus of £1.2m (Nil variance). This reflects the 2018-19 plans submitted to NHS England. This includes the Croydon Health Services Contact forecast to perform £2.3m under plan.

▪ To note the consistent performance on meeting the Public Sector Payment Policy (95% within 30 days) and cash management.

▪ The narrative year-to-date is significant success in delivering QIPP in emergency care,

prescribing, continuing care and LD, with real concerns on planned care and mental health service redesign. An unexpectedly high increase in volume of planned care is being seen through CHS, with no reduction in private sector volumes, and limited evidence of QIPP impact. The numbers of births is lower than planned at CHS and across all providers.

▪ The CCG is working with CHS to agree an early year-end financial agreement on the acute and non-acute health services contracts between the two organisations such to support both organisations delivering the financial targets.

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Background:

Financial Performance Targets and Duties

▪ NHSE has given the CCG a financial target to deliver an in-year surplus of £1.2m (cumulative deficit of £67.2m) for 2018/19

▪ Under the Health and Social Care Act, the CCG has a general statutory obligation to contain expenditure within its allocated resources;

▪ The above duties are enshrined in the CCG’s constitution.

▪ The CCG has a duty to use resources for the purposes intended and to demonstrate value for money;

▪ The financial position is reported to the Finance Committee and Governing Body on a monthly basis.

Key Issues:

Financial Performance ▪ Based on the six months ended 30th September 2018, NHS Croydon Clinical

Commissioning Group (the ‘CCG’) forecasts a surplus of £1.2m (£67.2m cumulative deficit) against the financial plan of £1.2m surplus (£67.2m cumulative deficit).

▪ The Month 6 reported position is based on 5 months contractual data and 4 months prescribing actual data. To mitigate this position, alternative data sets have been used to identify trends, including reviewing trends from February/ March 2018 to August 2018.

▪ Key risks are:

➢ Delivery of £24.9m QIPP (incl adverse indicators on GP referral trends, CHS emergency escalation beds open during Q1, and Mental Health Bed Occupancy higher than planned). The risk is assessed as between 10% - 20% (£2.7m - £5.4m) of the original plan. This is not unusual for a large scale recovery plan.

➢ Prescribing Prices: Increase of up to £1m in CAT M prices.

➢ Insufficient funding to cover the 3-year staff pay deal.

➢ Unquantified waiting list backlog at St George’s and Kings

➢ Potential impact of transfer of 2000 patients to Surrey may not be cost neutral.

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Governance:

Corporate Objective To achieve financial surplus of £1.2m in 2018/19

Risks • Delivery of £24.9m QIPP (incl adverse indicators on GP referral trends, CHS emergency escalation beds open during Q1, and Mental Health Bed Occupancy higher than planned). 10% -20% risk on delivery

• Insufficient funding to cover the 3- year staff pay deal.

• Unquantified waiting list backlog at St George’s and Kings

• Potential impact of transfer of 2000 patients to Surrey

Financial Implications The CCG is mitigating risks to achieve the £1.2m surplus required.

Conflicts of Interest No specific conflicts of interest.

Clinical Leadership Comments Clinical Leadership Group is supporting the delivery of the QIPP and transformation programme.

Implications for Other CCGs Croydon CCG works closely with the other SWL

CCGs as part of the SWL Health and Care

Partnership.

Equality Analysis All QIPP and expenditure programmes are

required to have an EIA, compliance monitored

by the PMO.

Patient and Public Involvement All service redesign, QIPP projects and

expenditure reductions must meet the requisite

PPI requirements.

Communication Plan The 2018/19 Financial Position and QIPP Programme have been share in the public domain and with stakeholders.


Restrictions on access to patient level activity data limiting the ability of CCG to review provider performance and to monitor some QIPP schemes.

Reputational Issues Delivery of financial plan. After 2 years, the CCG is no longer in (Financial) Special Measures as a result of the improvement in the annual overall assessment.

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Finance Report September 2018 (Month 6)

Mike Sexton - Chief Finance Officer

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Contents

1. Finance Scorecard

2. Key Indicators

3. Summary Financial Position

4. Acute Services

5. Mental Health, Community, and Primary Care Services

6. Prescribing

7. Other Programme Services and Running Costs

8. Risks and Mitigations

9. Statement of Financial Position and Cash Flow

10. Appendices

- Revenue Resource

- Capital Allocation

- Expenditure with Alliance Partners

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1. Finance Scorecard – September 2018

Financial Strategy Financial Performance

• The CCG refreshed its 5-Year Financial Model (2017/18 –

2021/22) and agreed it with Croydon Transformation Board

partners in November 2017.

• Financial recovery and improvement plan agreed in June

2018.

• The QIPP challenge to deliver £1.2m surplus in 2018/19 is

£27.6m

• Joint working through the OneCroydon Alliance is supporting

the delivery of integrated schemes.

• The CCG reports an in-year finance forecast position of

£1.2m surplus (£67.2m cumulative deficit) against the

financial target of £1.2m surplus (£67.2m cumulative deficit)

in line with the original detailed plan submitted to NHSE. This

is predicated on the delivery of £24.9m QIPP ((90%).

• Whilst QIPP slippage may be mitigated in-year, from non –

recurrent mitigations slippage will adversely affect the

underlying financial position going into 2019/20 and therefore

increases the QIPP in 2019/20.

• Year-to-date success in delivering QIPP in emergency care,

prescribing, continuing care and LD, with real concerns on

planned care and mental health service redesign.

Financial Governance Financial Risk

• No longer in (Financial) Special Measures following 2017/18

IAF rating of Requires Improvement

• The Internal Audit programme reviews CCG financial

governance and control: ratings are pending and will be

available next month.

• Improved assurance has been reported on CHC processes,

following the implementation of the transformation plan with

the NEL CSU.

• Finance Committee has been reviewing the CCG against the

NHSE Financial Control and Governance Assessment.

• Forecast contract performance with Croydon Health Services

• The delivery of the £27.6m QIPP

• Adverse indicators on GP referrals and Planned care

Activity levels.

• Not all CHS medical escalation beds were closed over the

summer.

• Mental Health inpatient bed occupancy is higher than

planned, diverting resources away from the community.

• Prescribing prices: Increase CAT M prices of up to £1.0m

• 2000 patients transferring to Surrey may not be cost neutral

and GP at Hand/Babylon

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2a. Key Indicators – September 2018Financial

Performance Target/ Indicator

Measure Target Previous ForecastM05

Current ForecastM06

Revenue

Resource Limit

(RRL)

NHSE Set Target (In Year) £1.2m £1.2m £1.2m

Statutory Duty (In-Year) Breakeven £1.2m £1.2m

Statutory Duty (Cumulative) Breakeven (£67.2m) (£67.2m)

Underlying

Position

Underlying Position £2.1m Breakeven Breakeven

Capital Resource

Limit (CRL)

Stay within CRL £0.3m £0.3m £0.3m

Cash Forecast Stay with Cash Forecast £561.2m £561.2m £561.2m

Better Practice

Payment Policy

Payment of valid invoices within

30 days

95% NHS: 95.01%, Non-

NHS: 97.85%,

Total:97.24%

NHS: 94.74%,

Non-NHS: 97.68%,

Total:97.07%

Cash Balance % of initial drawings in bank

account at end of the month

1.25% 0.18% 0.11%

QIPP Delivery of Identified

Programme Savings

£27.6m £24.9m £24.9m

Running Costs Stay within running cost

envelope.

£8.4m £8.4m £8.4m

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2b. Budget Virements

5

➢ The Revenue Resources Limit

adjustment for M6 was a funding

reduction to cover Flu and

pneumococcal vaccine.

➢ CCG is expecting resources for

overseas visitors (£1m) and

primary care (£0.2m working at

scale). Draft papers from NHSE

indicate these amounts will be

allocated.

➢ Acute activity reserve, QIPP

investment, and QIPP contingency

have been aligned to the acute

commissioning budgets to align

risks with mitigations.

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3a. Month 6 Financial Position Summary – September 2018

➢ The CCG is reporting an in-year

outturn surplus of £1.2m (Nil

variance).

➢ For Month 6, the service lines with

year-to-date, and forecast, favourable

variances are offset by adverse

variances on other lines e.g. acute.

➢ Note the excellent performance

against the Public Sector Payment

Policy (95% within 30 days) and cash

management.

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3b Month 6 QIPP Summary – September 2018

•The CCG is forecasting to deliver the £24.85m against a QIPP target of £27.61m.•Savings of £9.6m YTD reported to NHS England against a cumulative plan of £10.6m (variance of £1m). SUS data for

months 1-5 is available however M6 is an estimate for reporting requirements. Prescribing has a national 2 month time lag.

•Mental Health has slipping irrecoverably although investment slippage mitigates this within the programme. This means that

although the QIPP target will be achieved, funds will not be reinvested to improve quality of services.

•Planned Care has had significant slippage across a number of projects. Some projects have been removed from the

programme entirely. Some mitigation plans are in place however approx. £1.6m is irrecoverable and there may be further

slippage. A recovery plan to address the £1.6m has been approved by QOB and delivery is underway however financial

modelling of the initiatives needs further scrutiny.

•Urgent Care (CUCA) QIPP is failing and is irrecoverable. There is considerable operational improvement required to shift

the balance between urgent care and A&E. Hands on support has been offered and an action plan is being worked up.

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4a. Acute Services

The CCG received Month 5 monitoring

reports from providers for reporting in

Month 6.

Based on the data available, the CCG is

reporting a year to date £1.7m adverse

variance and forecast outturn of £2.7m

adverse variance. The year to date and

forecast adverse variance is mainly driven

by overspend on SGH, GSTT, BMI

contracts and non delivery of the

cardiology and Respiratory QIPP offset by

forecast underspend of £2.3m on the CHS

contract.

The forecast position reflects the agreed

contracts value for the year and a

conservative estimate on over

performance especially where the contract

value has not yet been agreed.

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4b.CHS Escalation Beds

The adjacent graph shows use of

escalation beds continued in

September 2018 and this is primarily

attributed to continued deterioration

of all performances types from end of

August and early September.

CHS have put in place emergency

turnaround action plan that includes

3Cs type operation in place with a

view to continue the approach

leading in to opening of new ED in

Autumn 2018. Integrated Discharge

Team to be rolled out at CUH from

8th October to aid in improvement of

patient flow and support overall

performance.

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4c. GP Referral Patterns – 2015/16 –2018/19

Next Steps

- A recovery plan to address referral variation has been developed

- This plan is being reviewed by QOB fortnightly to ensure actions are completed according agreed timelines.

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- The graphs below provide an illustration of GP referrals across five South London providers (Kings, CHS, Kingston, SGH and ESTH).

- The 2017/18 referral pattern since October 2017 appears to be similar to that of 2016/17.

- In comparison to 2017/18 M5 referrals are 12% higher.

- In comparison to the operating plan, M5 YTD referrals are above by 4.7%.

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4d. e-RS Utilisation

The graph shows Croydon CCG's progress increasing

utilisation of the e-Referral System (e-RS) since

October 2017, compared to SWL CCGs and SEL

CCGs (as an alternative STP benchmark). This uses

provisional monthly data from weekly utilisation

reports published by NHS Digital.

Croydon's progress has been largely due to securing

additional resource from NEL CSU to visit GP

practices to provide e-RS face –to face training and

the use of e-RS being included in GP Contracts. This

programme of work is managed within the Croydon

Primary Care Team. Increasing use of eRS aligns to

the roll out of the Advice and Guidance function as a

related QIPP scheme to reduce unnecessary

Outpatient attendances.

The national target is for all (100%) GP referrals, for a

new Outpatient Attendance, to be sent via e-RS from

April 2018/19. Nationally this is not being achieved

The Croydon's recovery trajectory is to meet 100% by

the end of Q1 2018/19, which is consistent across all

SWL STP members. This was not achieved.

Croydon CCG/CUH officially achieved PSO on 1st

July by reaching 80% utilisation in May.

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5a. Mental Health, Community, and Primary Care

Mental Health (including Learning Disabilities):

The Mental Health Services reflects a year to date

£644k favourable variance and a full year forecast of

£302k favourable variance which are mainly driven by

underspend on Learning Disabilities expenditure.

Community Health Services:

The Community Health Services reflects a year to date

£341k favourable variance mainly driven underspend on

Intermediate Care Services budget lines. The reported

forecast position is £89k favourable mainly driven by

£627k overspend on the Community Contract (MSK

and Wheelchairs Services) offset by expected

underspend of £725k on the Intermediate Care Services

budget lines.

Continuing Health Care:

The Continuing Health Care reflects a forecast

underspend of £1.7m driven mainly by underspend on

the Learning Disabilities and Funded Nursing Care

clients.

Primary Care including Delegated-Commissioning:

The Primary Care £705k year to date underspend

relates mainly to prior year Local Incentives Schemes

accrual not required and £520k forecast overspend

driven by £952k expected pressure on Prescribing

offset by prior year Local Incentives Schemes accrual

not required.

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5b. Adult Mental Health Inpatient Occupied Bed Days

The Adult Mental Health Acute External

Overspill is reporting 236 actual Occupied

Bed Days (OBDs) for August 2018.

The year to date total Adult Mental Health

Acute Occupied Bed Days (OBDs) is above

plan.

The Croydon Mental Health Programme

Board is reviewing actions to strengthen

community services and maintain the

excellent discharge rates achieve in

2017/18.

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6. Prescribing Expenditure Trend and Update

Note: Prescribing data has a two month processing lag. Only 4 months actual data is available for 2018/19. The graph

above reflects the Year to date (July 2018) actual activity and finance. The DHSC has confirmed that Category M

reimbursement prices to community pharmacies will increase across England by £15m a month from August 2018 and

there is a further cost pressure attributable to Category M items that were taken off NCSO at the end of March 2018 but

then entered the drug tariff at an increased price. The expected additional cost pressure for Croydon CCG for both

issues is circa £1.0m.

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7. Other Programme Services and Running Costs

➢ Other Programme Services: OBC,

NHS 111, Service Redesign, NHS

Property Services Ltd recharge,

Safeguarding and Marie Stopes.

This is reflecting a year to date

overspend of £0.5m and £1.1m

forecast underspend mainly driven

by release of the (0.5%)

Contingency offset by £0.3m

overspend on the Non Recurrent

Spend and £1.1m overspend Other

Programme Services budget lines.

➢ The running costs budget is £8.5m

and is forecasting a breakeven

position.

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8. Risks and Mitigations

£m £m

Plan 1.2

Forecast Unfavourable Variance

Acute Overperformance (3.2)

Primary Care

QIPP Slippage (2.7)

Total Forecast Unfavourable Variance (5.9) (5.9)

Forecast Favourable Variance

QIPP Contingency 2.8

0.5% Contingency 2.5

Other 0.2

Primary Care 0.4

Total Forecast Favourable Variance 5.8 5.9

Net Variance to Plan 0.0

Total Reported Position 1.2

Risks (not in forecast)

£m £m

Plan 1.2

Risks

Acute Overperformance (1.5)

Primary Care (1.4)

QIPP Slippage (2.5)

Total Risk (5.4)

Mitigations

QIPP Contingency 1.7

0.5% Contingency 0.0

Review of B/S accruals 2.6

Total Mitigations 4.2

Total Net Risk (1.2)

Total Net Risk Adjusted Position (0.0)

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Month 6 Forecast Position

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9a. Statement of Financial Position

▪ The Statement of Financial Position (as at 30th

September 2018) is summarised in the adjacent

table. The net working capital position (net

£60.3m liability) reflects £64.5m of creditors offset

by debtors and prepayments of £4.2m

▪ The Balance Sheet is showing a negative £1.7m

cash balance. The actual balance in the bank

account was £45k; the difference was due to a

BACS payment at the end of the month that

cleared through the bank accounts the following

day.

▪ Included within prepayments is £2.1m relating to

the Maternity WIP and included within accruals is

£3.4m relating to Partially Completed Spells.

▪ A significant element of the accrued liabilities

relates to prescribing cost and NHS activity which

has yet to be billed. The balance relates to non-

SLA expenditure and contingencies.

▪ The value of the CCG’s net Fixed Assets as at

30th September 2018 is £386k.

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9b. Statement of Cash Flow

▪ The statement reflects the total book cash outflow since March 2018 with the cash balance of negative £1.7m reported in the

Statement of Financial Position.

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9c. Capital Spend Update

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10a. Appendix 1 - Revenue Resource Limit

The Revenue Resource Limit

(RRL) is the statutory expenditure

limit for the CCG on revenue

expenditure.

The updated total revenue

resource limit for 2018/19 is

£495.3m (including Running

Costs).

The cash funding for the CCG

(Maximum Cash Drawdown) of

£561.2m is based on the RRL

(£495.3m), but also includes

funding for historic deficit

adjustment (£68.3m).

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10b.Capital Allocations

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10c. Expenditure with Alliance Partners

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP

GOVERNING BODY 6 November 2018

Title of Paper: 2018/19 QIPP PROGRAMME – MONTH 6 REPORT

Lead Director Mike Sexton, Chief Finance Officer

Report Author Kate Archer, Head of PMO


QIPP Operational Board (QOB) – 22 October 2018 Senior Management Team – 23 October 2018 Finance Committee – 29 October 2018


Clincal Leaders Group – 7 November 2018

Purpose of Report For information and noting

Recommendation:

Governing Body is asked to note:

▪ Month 6 YTD performance is reported as £1m behind plan at £9.6m (against plan of

£10.6m)

▪ Overall, we project to deliver £24.9m QIPP against the plan of £27.6m for 2018/19 (90%)

▪ Planned Care, Medicine Optimisation, Mental Health and Phase 2 of Out of Hospital projects

have slipped with savings irrecoverable meaning that the envisaged quality benefits have also

not been realised

▪ MH slippage can only be mitigated by deferring additional investment into MH services and

underspend against the CHC budget is mitigating the programme.

▪ Performance Improvement Programme that is being implemented, including recovey

plans in place for planned care and mental health

Background:

The QIPP programme is a range of initiatives to deliver quality and outcome benefits to patients, and consequential financial benefits, through Quality improvement of services, Innovation in delivering healthcare, Productivity improvement, and Prevention of disease and illness. The clinically-led QIPP programme is expected to improve care for patients by reducing the need for high-cost hospital care. The 18/19 QIPP programme has been built around six primary programmes that collectively identify a total of £27.6m:

1. Out of Hospital transformation 2. Planned Care transformation 3. Mental Health transformation 4. Named Patients 5. Medicines Management transformation 6. Corporate projects

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Key Issues:

• With significant delivery risks emerging and not improving, the Senior Management Team is

implementing a Performance Improvement Programme. The details have been reviewed by

the Finance Committee

Governance:

Corporate Objective To commission high quality health care services that are accessible, provide good treatment and achieve good patient outcomes. To reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital for physical and mental health. To achieve in year financial balance in 2018/19. To support local people and stakeholders to have a greater influence on services we commission and support individuals to manage their care. To have all Croydon GP practices actively involved in commissioning services and develop a responsible and learning commissioning organisation.

Risks

Failure to deliver cost savings detailed in the paper represents a significant risk to the financial sustainability of the organisation.


Delivery of our QIPP target is a vital contribution to achieving financial balance.


No specific conflicts of interest.

Clinical Leadership Comments The CCG Medical Director chairs the QIPP Operational Board (QOB) alongside the Chief Finance Officer as Business co-chair. The CCG Chair attends most QOBs. Each QIPP scheme has an identified GP Lead.


The CCG is fully engaged with the South West London (SWL) STP process. The PMOs across SWL meet regularly to share ideas and align approaches.

Equality Analysis

All projects are conducting Equality Impact Assessments as they move through the development lifecycle.

Patient and Public Involvement

Patients are included at programme board level, supporting the developments of QIPP schemes both currently and for the future.

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Communication Plan Each project manager develops their own bespoke

Communication and Engagement plan as part of project planning.


Monitoring of some schemes is impaired by the inability to access patient level data.

Reputational Issues

QIPP programme delivery is critical in addressing CCG authorisation conditions and directions.

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QIPP Report

Mike Sexton - Chief Finance Officer

1

September 2018 (Month 6)

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Contents1. QIPP Scorecard

2. Key risks and mitigation

3. Overview of 18/19 portfolio

4. Year to date status

5. Programme Highlight Reports:

Programme 1 – Planned Care highlight report

Programme 2 – Out Of Hospital highlight report

Programme 3 – Mental Health highlight report

Programme 4 – Medicines Optimisation highlight report

Programme 5 – Named Patients highlight report

Programme 6 – Corporate highlight report

6. Developing future QIPP

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1. QIPP ScorecardQIPP Strategy QIPP Reported Performance • The 18/19 QIPP target of £27.6m was fully identified

against specific schemes• The QIPP efficiency challenge has been assessed

for the next 5 years (circa £15m / 2.4% pa) • Service level targets for 2019/20 have been finalised.

Planning is ongoing• Detailed benchmarking of acute service expenditure

has slipped but will be completed by end of October 2018

• Month 6 YTD performance is reported as £1m behind plan at £9.6m (against plan of £10.6m)

• Overall, we project to deliver £24.9m QIPP against the plan of £27.6m for 2018/19

• Planned Care, Medicine Optimisation, Mental Health and Phase 2 of Out of Hospital projects have slipped with savings irrecoverable meaning that the envisaged quality benefits have also not been realised to date

• MH slippage can only be mitigated by deferring additional investment into MH services

QIPP Governance QIPP Delivery Risk• Additional Performance Improvement

Governance is being implemented by SMT (Annex 2)

• QIPP delivery is robustly governed by the QIPP Operational Board (QOB) chaired by Medical Director. Each programme reports monthly

• Deloitte audited ‘QIPP readiness’ for 2018/19 in Dec 2017 as GREEN

• 2018/19 financial plan, including QIPP, has been assured and signed off by NHS England

• Internal audit review has recently been completed –final report pending

• Planned Care Respiratory, Digestive Diseases, VFC, ENT & Gynae slippage is irrecoverable (£821k net)

• Cardiology has been removed as a project (£597k net).• ECIs (£468k net) remains at risk.• Mental Health slippage is likely irrecoverable • Personal Health Budgets, Medicines Optimisation and

Out of Hospital projects have also slipped• Childrens is progressing slowly • Overall programme slippage is partially mitigated by

CHC over-delivery

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2. Key risks & mitigations

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Risk MitigationFailure to deliver the highestQIPP target ever for Croydon

• SMT has agreed and is implementing a Performance Improvement Programme in addition to the Task and Finish Recovery Groups for Planned Care and Mental Health. This includes a rapid review and increased scrutiny of recovery plans (Appendix B) to report mid December 2018.

• £10m (largest amount to date) agreed in provider contracts• Improved use of Aspyre supports robust monitoring• Strengthened substantive PMO team offering hands on support to project managers

Projects may not be sustainable beyond 18/19 & changes implemented may slip back

• Increased focus on creating a strong relationship with CHS to thoroughly embed change

• Increased clinical engagement with GPs to do the same• Encouraging cross team working within the CCG• Planning for 19/20 has commenced to ensure transformation is robustly evidenced

QIPP in childrens progresses too slowly and savings may not be realised this year

• PMO have offered increased hands on support and to assist the team to plot key milestones within timely parameters, to demonstrate that the QIPP project is high priority for the team

Further slippage in delivery planned care programme.

• Recovery project plan now in use with fortnightly reporting to QOB

Further slippage in Mental Health programme

• Investment will slip in parallel to mitigate which assures the financial target but does not provide for reinvestment into services to improve quality of care

• Recovery plan now in use with fortnightly reporting to QOB

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3. Overview of 18/19 QIPP portfolio

5

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12 TotalPlanned full year savings (£m) 1.46 1.51 1.53 1.75 2.20 2.18 2.37 2.37 2.37 3.33 3.34 3.21 27.61Full year forecast outturn (£m) 1.46 1.51 1.26 1.89 1.15 2.29 1.87 1.80 2.19 2.80 2.83 3.81 24.85Slippage 0.00 0.00 (0.27) 0.14 (1.05) 0.11 (0.51) (0.57) (0.17) (0.53) (0.51) 0.59 (2.76)

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ProgrammePlanned cumulative

M6 savings (£m)Actual cumulative M6 savings (£m)

Variance (£m)

Planned full year savings (£m)

Full year forecast outturn (£m)

Variance (£m)

Deliverability RAG

Financial RAG

Planned Care 1.27 0.45 (0.82) 4.22 2.80 (1.42)Out of Hospital -Phase 1 2.94 2.49 (0.44) 5.87 5.69 (0.19)OOH Phase 2 incl urgent care 0.53 (0.27) (0.80) 2.23 0.93 (1.30)Mental Health 1.93 1.90 (0.03) 4.55 4.55 0.00Medicine Optimisation 1.71 1.67 (0.04) 3.66 2.59 (1.07)Named Patients 2.04 2.77 0.74 4.50 5.86 1.36Corporate 0.20 0.53 0.33 2.58 2.44 (0.15)Total 10.61 9.55 (1.06) 27.61 24.85 (2.76)

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• Savings of £9.6m YTD reported to NHS England against a cumulative plan of £10.6m (variance of £1m). SUS data for

months 1-5 is available however M6 is an estimate for reporting requirements. Prescribing has a national 2 month time lag.

• Mental Health has slipping irrecoverably although investment slippage mitigates this within the programme. This means

that although the QIPP target will be achieved, funds will not be reinvested to improve quality of services.

• Planned Care has had significant slippage across a number of projects. Some projects have been removed from the

programme entirely. Some mitigation plans are in place however approx. £1.6m is irrecoverable and there may be further

slippage. A recovery plan to address the £1.6m has been approved by QOB and delivery is underway however financial

modelling of the initiatives needs further scrutiny.

• Urgent Care (CUCA) QIPP is failing and is irrecoverable. There is considerable operational improvement required to shift

the balance between urgent care and A&E. Hands on support has been offered and an action plan is being worked up.

• Three OOH Phase 2 business cases have now been approved however due to delays in approval, slippage of at least

£800k is forecast.

• The Childrens QIPP project is progressing slowly and it is unclear whether any savings will be made this year.

• Additional underspend of the CHC budget on top of their £3m QIPP programme is partially mitigating against the overall

QIPP programme slippage.

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Programme 1 – Planned Care highlight report

Programme 2 – Out Of Hospital highlight report

Programme 3 – Mental Health highlight report

Programme 4 – Medicines Optimisation highlight report

Programme 5 – Named Patients highlight report

Programme 6 – Corporate highlight report

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1 – Planned Care Responsible Director: Stephen WarrenGoverning Body GP Lead: Tom Chan

RAG ratings: Financial savings Quality improvements Programme deliverability PerformancePr

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The planned care programme supports the vision of change set out in the NHS Five Year Forward Plan, SWL STP and local priorities including understanding and considering Croydon’s needs, with the aim to improve health across the entire population. Initiatives include supporting self-care, developing integrated clinical pathways, supporting secondary care to shift care into the community and primary care, and delivering best practice care.

Planned Care have identified underperformance of QIPP of £1.6m to date and have therefore developed a recovery programme which aims to address appropriateness of GP referrals into secondary care by undertaking practice variation visits with Clinical Leaders to share current activity data and best practice. The recovery plan also proposes to undertake a review of elective activity by stabilising RTT, encourage repatriation of activity from private providers back into CHS and continuing with Q4 QIPP delivery in ENT, Gynaecology and Digestive Diseases.

Additional progress this month includes:• The new model of care implementation for MSK, provided by Connect Health, is scheduled to go-live on 3rd December 2018 with some risks to delivery. • The incumbent intermediate provider for Dermatology has objected to the pilot so a roundtable meeting has been scheduled to agree next steps. • The Ophthalmology new model of care business case is still in draft however implementation timelines remain in place for 1st April 2019. • Digestive diseases project has been re-designed. The expectation was that by now all colorectal and gastrointestinal referrals (2ww, Urgent and

Routine) will be triaged using the new telephone and assessment pathway (TAP). Currently the service is in place for 2ww only. A new model of care is the process of being designed for approval.

• Neurology continues to remain on track for delivery against the plan. • Cardiology and Respiratory have been removed from the existing QIPP programme. Significant difficulty scheduling a clinical meeting with the

cardiologists is delaying identification of a new model of care. QIPP for 18/19 has been written off whilst 19/20 plans continue. • ECIs is continuing to overspend due to the prior approval process not being followed. This is jeopardising QIPP savings and is being investigated.• Virtual Fracture Clinical rollout is set to commence 1st January 2019, however various IG issues is putting delivery of 18/19 QIPP at risk. • Diabetes new model of care and business case is ready for sign off on 29th October 2018.

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Activity & performance outcomes• Incomplete RTT pathways performance above target at 92.9%• All cancer 2ww is above target of 93% at 97.9%• Diagnostic test waiting times underperforming at 98.39% against a target of 99% • 52 week waits is underperforming against target with 21 patients waiting >52 weeks against a target of 0• Underperformance of Cancer 62 day waits for definitive first treatment with an actual of 83.9% against target of 85% Fi

nanc

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Ris

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1. There is a risk that delivery of the Planned Care recovery programme will not claw back the £1.6m QIPP for 18/19 within Q4 due to practices

2. There is a risk that if Clinical Engagement remains variable within the team, quality benefits will not be realised. 3. There is a risk that without clear governance arrangements, implementation and QIPP delivery will continue to slip. 4. There is a risk that Gynaecology performance will remain unclear due to the amalgamation of both Acute and

Intermediate data within BMI. Without a clear understanding of current performance the project is unable to accurately plan for recovery, if necessary.

5. Right Care qualitative benefits are at risk within certain conditions (CVD and Diabetes) – these are being investigated

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Clinical Engagement is poor, Cardiologists refusing to meet with Planned Care Team, despite two months of chasing.

Clinical Leaders are not attending Pre-QOB to review their projects with the project managers

Plan 4.22Forecast 2.8Variance -1.42

Plan 1.27Actual 0.45Variance -0.82

Year to date (£m)

Full Year (£m)

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2 – Out of Hospital (incl urgent care)Responsible Director: Martin Ellis / Stephen WarrenGoverning Body GP Lead: Tom Chan

RAG ratings: Financial savings Quality improvements Programme deliverability Performance Pr

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The Out of Hospital programme seeks to transform care for older age adults focussing on patients aged 65 and over. It is in its second year of the two year initiative and the Integrated Community Networks (ICNs) and Living Independently for Everyone (LIFE) schemes are in progress. The Urgent Care team is currently aiming to reduce and prevent the hospital admissions supporting the overall Out of Hospital programme.

Three of the projects in phase two of the programme (End of Life Care, Falls and Care Homes) were presented at CLG, Professional Cabinet and Alliance Delivery Board in September where the model of care was approved. Implementation and planning continues to progress and detailed project plans are being prepared, including the procurement piece for tele-medicine and plans for deployment. Impact assessments for the Joint Impact Assessment Panel (JIAP) are also being prepared with a view to have these signed off by 25 October. Alongside this, a task and finish group has been set up by the team to develop workforce training and development as well as a competency framework for Care Homes and End of Life Care. The team have confirmed that some elements of the projects are not currently requiring investment are already underway namely, Red Bags.

The Greenbrook initiatives continue to be strategized and the Urgent Care team have proposed a number of initiatives to support the QIPP delivery. These include an update to the Health Help Now app, targeted communications and work with NHS 111 amongst others with an aim to gain support from key stakeholders and provide improved information for patients resulting in less hospital admissions. The project lead has met with the communications team to develop a plan to communicate and drive the above initiatives with a view to have this implemented by M8.

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Activity & performance outcomes

Out of Hospital• Out of Hospital activity is still being finalised as part of the detailed design plans for M7.

Urgent Care • Early analysis shows a reduction in activity for Q1 compared to last year. This is likely due to the impact of GP hubs

coming online in September and increasing utilisation on they become fully embedded.• The extended access Hub is now live and impacting on activity. We will begin to formally monitor data from M7.

Fina

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Ris

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• Croydon University Hospital (CHS) have indicated that the implementation of the business case may not lead to a ward closure. Further discussion is required between the Alliance Partners to mitigate against this.

• Out of Hospital and Urgent Care delivery capacity and potential recruitment issues remains a risk. These have both been raised as formal risks by the PMO and mitigating actions are underway

• There remains a risk of poor engagement from clinicians in implementing the required changes to support improvements to the CUCA model, as well as the risk of poor patient education leading to increased pressure on the urgent care system.

• There is a risk that the Greenbrook project may affect patient choice to treatment. Impact assessments are being worked through in detail.

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Year to date (£m)

Full Year (£m)

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3 – Mental Health Responsible Director: Stephen WarrenGoverning Body GP Lead: Vaishali Shetty


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SLaM Occupied Bed Days (OBDs) – the MADE event revealed that many patients fit for discharge are being delayed due to both internal and external factors, which increases the patient’s length of stay and therefore our costs. SLaM has been asked for weekly updates on this cohort and the CCG are supporting linkage with social care and housing to support the moves. Negotiations regarding a new risk share have been tied into 19/20 contract negotiations.

Forensic Scheme involves a re-procurement to enable what was a male only provision to expand/extend its provision to include a wider cohort of patients as well as offer female provision and thus reduce the number of more costly spot purchase arrangements. Phase 1, transfer of male patients from the previous provider to the new provision at Penrose, is complete. Phase 2, involving the transfer of low support and female patients from a second series of properties to Penrose, has commenced but has been delayed due to issues securing appropriate accommodation. This has now been overcome and one of the two houses will be ready to receive for patient transfer by 19th Oct. MH Placements progress has been delayed due to team capacity issues however the outcome of the scoping excercise and an informed initial plan will go to SMT for sign off on the 5th November.

The MH NCA Policy, that will encourage Croydon patients to be treated in the borough, under the block contract arrangements rather than out of area, gained JIAP approval on 11th Oct. The team are now working to disseminate the policy and complete the associated actions.

There are concerns that the Core24 scheme will not deliver the intended financial savings therefore an escalation meeting with SLaM took place on the 9th October whereby follow on actions were agreed to work towards performance recovery including establishment of a steering group.

Unfortunately the forecast QIPP savings are not being delivered from any of the MH projects presently, therefore a recovery plan was requested by SMT. A plan is now in place to support QIPP, including work around recovering costs associated with incorrect responsible commissioner allocations.

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• LoS and OBD remain high, but since the MADE event, SLaM have made positive steps to accelerate processes and patients are being discharged.

• Performance regarding Core24 continues to fail against targets and is not yielding the expected system efficiencies. This is forming part of the recovery plan.

• The Croydon Talking Therapies Service achieved the national targets for access over the last quarter and has maintained this achievement in performance over the last two weeks.

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1. There is a risk that the NCA policy, once published, does little to redirect Croydon patients as planned. A covering letter to appeal to providers is being disseminated along with the policy in an attempt to minimise.

2. SLaM OBDs- there is a risk that the planned savings will not be achieved due to failure to negotiate a revised cash releasing risk share and the current long OBDs. A recovery plan is being worked up and there is refreshed momentum from SLaM to resolve issues following the MADE event.

3. Core24 – there is a risk that financial savings will not be made, a steering group and recovery plans are being worked up to restore performance and therefore some financial savings.

4. There is a risk that lack of capacity within the MH team will impact on the ability to deliver the MH Placements (Westways rehabilitation) project without further significant slippage.

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4 – Medicines Optimisation Responsible Director: Martin EllisGoverning Body GP Lead: Tom Chan


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The Medicines Optimisation QIPP programme is made up of primary care elements and aims to provide the framework to support CCG’s vision to deliver Healthier Lives for all the people in Croydon. The team continue to drive delivery of the ‘Business As Usual’ work programme with now all practices having received an individualised prescribing visit which outlines their baseline performance and supportive actions to undertake to address areas where performance is below the selected target against selected indicator.

Peterborough and Cambridge CCG presented their approach to the Over the Counter (OTC) implementation at the September Clinical Leadership Group (CLG) meeting which gained further support. Targeted communication has been sent to all CCG leads to promote key benefits of the project and best practice approaches to adopt. Despite this however, there have been concerns raised from the Local Medical Council over the content of the communication(s) aimed at GPs. The team is addressing these concerns and a meeting has taken place between the project lead and the Head of Communications and Engagement to ensure the message is satisfactory for all stakeholders involved.

The ONS projects has now recommenced and an agreement has been made over funding with Croydon University Hospital (CUH). Despite the slippage with this project, the practice Support Pharmacists continue to receive ongoing training on the management and review of patients receiving ONS production in the interim of the PSD post coming on board in order to continue to driver project delivery. Contract variation is also currently underway and the team await confirmation of the recruitment by CUH.

Recruitment continues within the team and two Pharmacy Technicians have been recently appointed to help support project delivery. The Medicines Waste Band 8 Pharmacist post is currently at job matching stage and is expected to be advertised imminently.

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The CCG is achieving 2 of the 3 antimicrobial quality premium antimicrobial prescribing targets:• Reduce inappropriate antibiotic prescribing for Urinary tract infections (UTI) in Primary Care- in M3 CCG is

maintaining its target of ≤3,850 (at M3 data 2,294).• Sustained reduction of inappropriate prescribing in Primary Care Items per STAR-PU ≤ the England 2013/14

mean performance value of 1.161 items/STAR-Pus (at M3 data: 0.880) • A 30% reduction (or greater) in the number of Trimethoprim items prescribed to patients aged 70 year or

greater, against June 2015/ May 2016 baseline • Work is required to on the third target to reduce GNBSI across the whole health economy reduction – i.e. E coli

BSI reported at CCG level

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1. Category M reimbursement prices is to increase across England by £15M a month from 1 August 2018, this will result in a cost pressure of £670k against BAU QIPP programme.

2. All key prescribing information is still being hosted on the PCT’s legacy intranet of which maintenance is becoming increasingly unstable. The team are working with the IT team to scope alternative solutions.

3. The CCG has received additional funding to support the roll out of GP extended access, however no additional funding has been allocated to the prescribing budget. There is a risk that demand and overall activity will increase due to increased ease of access, which would lead to unaccounted growth in the prescribing budget and as a result lead to a cost pressure for 18/19. Fo

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5 – Named Patients (incl paediatrics) Respons’ Directors: Elaine Clancy/Stephen WarrenGoverning Body GP Lead: Mike Simmonds (Childrens)


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eThe Named Patients programme is made up of four individual projects that aim to improve the quality and care of complex patients by transformingcurrent services and ensuring patients are receiving appropriate care for their specific needs. These projects are:(i) Continuing Health Care, (ii) Children’s Transformation, (iii) Learning Disabilities and (iv) Personal Health Budgets.

Personal Health Budgets have experienced further delays with the deployment of the IT solution (My Care Banking). The team have successfully completed a robust operating process and the My Care Banking contract is to be signed off on the 16 October. The project has slipped another month therefore the software is now expected to come into place on the 1 December, as a result of some staff turnover. The lead project manager will be resigning from post on the 25 October and an interim replacement has since joined and an extensive handover is undergoing with support from the senior team. The new interim project manager will also manage a follow up training event for patients in early December.

Continuing Health Care (CHC) have now seen revisions in the care packages of 41 clients which has resulted in cost savings for the CCG, which is on track. The Associate Director for CHC is working closely with the finance team to finalise a revised monitoring process. The team have also appointed a new business admin lead to help support QIPP delivery and the new recently appointed QIPP nurse has proved to be an asset within the team and has contributed significantly to the project savings.

Learning Disabilities haven’t seen any further movement from the one remaining client within the cohort however a steering group meeting has been arranged for the 26 October to discuss best options on transferring this last client. The team have also been recruiting for two roles and shortlisting has now been completed with a view to interview and appoint on the 30 October.

The Children’s Transformation team have now met with each of the three pilot practices with frequent A+E attendances and follow up actions relating to reasons behind attendances is undergoing. Financial modelling is still to be fully completed and a steering group meeting has been arranged for the 30 October to contribute to the clinical assumptions required. Impact assessments remain outstanding and the team have been scheduled to attend the Joint Impact Assessment Panel (JIAP) on the 22 November to get these approved.

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Learning Disabilities: • Following a joint assessment process, nine patients have been appropriately transferred off CCG funding from the

original plan of 10.Continuing Health Care: • Following continued assessments and reviews 41 patients have been appropriately transferred off CCG funding.

An action plan has now been created to track progress is being made at achieving relevant Quality Premium Indicators. Fi

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1. PHB: Staff resource. The team are looking at recruiting options and the PMO team are well briefed to avoid any immediate delays to the project. An interim replacement has been appointed to support project delivery.

2. LD: Staff resource. The team will be recruiting for a Band 6 Commissioning Support Officer and a Complex Care Reviewer. Shortlisting has been completed for both roles & interviews are expected to take place on 30 October.

3. CHC: No joint funding policies in place. The team are currently looking at other CCG’s to adopt a ‘best practice’ approach.

4. Childrens: financial modelling is outstanding and savings are due to commence, but have slipped. There is a risk that savings will not be made in 18/19. Fo

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Plan 4.5Forecast 5.86Variance 1.36

Plan 2.04Actual 2.77Variance 0.74

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6 – Corporate Responsible Director: Mike SextonGoverning Body GP Lead: Tom Chan


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date The Corporate programme brings together a number of projects that seek to ensure that our use of funds is as efficient as possible.

Budget and balance sheet reviews are ongoing across the organisation, led by the Deputy CFO.

Both locally and at SWL level, services offered by the CSU are under review to ensure that the service provided is efficient and fit for purpose, and where more appropriate, services are in-housed. The business case regarding in-housing some of the CSU teams has been submitted to NHSE and the finance team have yet to approve as there has been some significant delays. It is now likely that this won’t be approved until January 2019 (Q4). If approved a staff consultation will take place with possible TUPE implications investigated. It is possible that some of the in-housing savings forecast will not be realised in year. This will be re-scoped in M4 to establish the correct plan.

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• There are no performance targets linked to this programme area• These projects are transactional and therefore monitoring is clearly possible via Finance team

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1. The SWL Collaborative rebate may not be forthcoming. CFO escalating with SWL team2. CSU management reduction is being managed by SWL meaning that timelines and decisions, although

influenceable, are not entirely within Croydon’s control. There may be some slippage, some of which may be significant. Investigations are underway

3. The budget and balance sheet review project may identify cost pressures as well as areas for cost savings

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6. Developing 2019/20 QIPP

15

• Scoping document templates have been circulated for new projects to be formally proposed to QOB during 1st week of December

• This month’s CSU ‘deep dives’ report centred on CHS inpatients and outpatients with a view to identifying QIPP opportunities. The PMO will ensure that these are included on our pipeline list

• Benchmarking findings, triangulated with Alliance findings and clinical opinion, will be finalised this month & presented to QOB

• Other pipeline ideas, as identified through working with peers and other avenues, and commissioning intensions will be reviewed to ensure that all possible opportunities are being followed up

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Annex 1 – breakdown of all projects

QIPP Programme breakdown 18/19 as at 18.10.18 18/10/2018

Programme Area Project Gross saving Investment Net saving Gross saving Investment Net saving Variance

Planned Care Advice and Guidance £60,552 -£6,574 £53,978 £60,552 -£6,574 £53,978 £0

Planned Care Cardiology £2,232,332 -£1,635,000 £597,332 0 0 £0 -£597,332

Planned Care Dermatology £425,238 -£188,365 £236,873 £425,238 -£188,365 £236,873 £0

Planned Care Digestive diseases £570,660 -£275,753 £294,907 £170,440 -£82,440 £88,000 -£206,907

Planned Care ECIs £934,572 -£189,000 £745,572 £934,572 -£189,000 £745,572 £0

Planned Care ENT £477,982 -£322,338 £155,644 £239,500 -£161,500 £78,000 -£77,644

Planned Care Gynaecology £643,874 -£248,271 £395,603 £322,000 -£124,000 £198,000 -£197,603

Planned Care Introduction to Avastin £208,397 £0 £208,397 £0 £0 £0 -£208,397

Planned Care IVF £429,000 £0 £429,000 £429,000 £0 £429,000 £0

Planned Care Moorfield Packages £100,000 £0 £100,000 £100,000 £0 £100,000 £0

Planned Care MSK £1,323,000 -£896,467 £426,533 £1,323,000 -£896,467 £426,533 £0

Planned Care Neurology £231,402 -£88,000 £143,402 £231,402 -£88,000 £143,402 £0

Planned Care Opthalmology £300,000 £0 £300,000 £300,000 £0 £300,000 £0

Planned Care Programme Delivery (Change Mngt) £0 -£187,072 -£187,072 £0 -£187,072 -£187,072 £0

Planned Care Respiratory £1,065,864 -£756,000 £309,864 £267,000 -£189,000 £78,000 -£231,864

Planned Care Virtual Fracture Clinic £215,000 £0 £215,000 £107,500 £0 £107,500 -£107,500

Out Of Hospital- Phase1 End of Life £118,612 £0 £118,612 £118,612 £0 £118,612 £0

Out Of Hospital- Phase1 ICNs £3,699,138 -£1,957,000 £1,742,138 £3,699,138 -£1,957,000 £1,742,138 £0

Out Of Hospital- Phase1 Intermediate Care £31,970 -£104,000 -£72,030 £31,970 -£104,000 -£72,030 £0

Out Of Hospital- Phase1 LIFE £3,047,146 -£390,000 £2,657,146 £3,047,146 -£390,000 £2,657,146 £0

Out Of Hospital- Phase1 Mental Health £110,154 £0 £110,154 £110,154 £0 £110,154 £0

Out Of Hospital- Phase1 Drugs & Alcohol £799,000 £0 £799,000 £799,000 £0 £799,000 £0

OOH Phase 2 incl urgent care Care Homes £300,000 £0 £300,000 £150,000 £0 £150,000 -£150,000

OOH Phase 2 incl urgent care Care Homes Airedale £200,000 £0 £200,000 £100,000 £0 £100,000 -£100,000

OOH Phase 2 incl urgent care End of Life coordination centre £300,000 £0 £300,000 £150,000 £0 £150,000 -£150,000

OOH Phase 2 incl urgent care End of Life phase 2 £200,250 £0 £200,250 £100,250 £0 £100,250 -£100,000

OOH Phase 2 incl urgent care Falls phase 2 £200,000 £0 £200,000 £100,000 £0 £100,000 -£100,000

OOH Phase 2 incl urgent care ICS continence £100,000 £0 £100,000 £100,000 £0 £100,000 £0

OOH Phase 2 incl urgent care ICS wheelchairs/contracts £100,000 £0 £100,000 £50,000 £0 £50,000 -£50,000

OOH Phase 2 incl urgent care LIFE expansion into Kings/St Georges £300,000 £0 £300,000 £150,000 £0 £150,000 -£150,000

OOH Phase 2 incl urgent care Greenbrook - GP variation £125,000 £0 £125,000 £125,000 £0 £125,000 £0

OOH Phase 2 incl urgent care Urgent Care Pathways £1,000,000 -£600,000 £400,000 £500,000 -£600,000 -£100,000 -£500,000

Medicines Optimisation 18/19 BAU Workplan Activities £1,102,614 £0 £1,102,614 £1,119,355 £0 £1,119,355 £16,741

Medicines Optimisation SWL MO Workplan £743,603 £0 £743,603 £666,450 £0 £666,450 -£77,153

Medicines Optimisation Category M Drugs £660,000 £0 £660,000 £660,000 £0 £660,000 £0

Medicines Optimisation 17/18 Focused Projects FYE £240,000 £0 £240,000 £85,981 £0 £85,981 -£154,019

Medicines Optimisation Medicine Waste in Care Homes Stretch £200,000 £0 £200,000 £0 £0 £0 -£200,000

Medicines Optimisation Medicine Rebate Scheme £100,000 £0 £100,000 £20,188 £0 £20,188 -£79,812

Medicines Optimisation Pharmoutcomes £100,000 £0 £100,000 £8,250 £0 £8,250 -£91,750

Medicines Optimisation Focused Prescribing Projects-ONS £87,610 -£31,610 £56,000 £14,000 -£31,610 -£17,610 -£73,610

Medicines Optimisation OTC Prescribing £250,000 £0 £250,000 £50,000 £0 £50,000 -£200,000

Mental Health Community Forensic Beds £1,100,000 £0 £1,100,000 £670,000 £0 £670,000 -£430,000

Mental Health Mental Health OBDs £2,333,000 £0 £2,333,000 £0 £0 -£2,333,000

Mental Health Mental Health Placements £500,000 £0 £500,000 £250,000 £0 £250,000 -£250,000

Mental Health NCAs £500,000 £0 £500,000 £319,000 £0 £319,000 -£181,000

Mental Health Voluntary Sector £114,000 £0 £114,000 £114,000 £0 £114,000 £0

Mental Health MH Investment Slippage £0 £0 £0 £3,198,000 £0 £3,198,000 £3,198,000

Mental Health Core 24 - Acute MH Admissions £515,471 £0 £515,471 £330,471 £0 £330,471 -£185,000

Named Patients Continuing Health Care Transformation £3,000,000 £0 £3,000,000 £3,000,000 £0 £3,000,000 £0

Named Patients CHC Stretch £88,000 £0 £88,000 £1,386,000 £0 £1,386,000 £1,298,000

Named Patients Learning Disabilities £861,000 £0 £861,000 £1,020,000 £0 £1,020,000 £159,000

Named Patients Paediatric £200,000 £0 £200,000 £200,000 £0 £200,000 £0

Named Patients LD intensive support house £50,000 £0 £50,000 £50,000 £0 £50,000 £0

Named Patients Personal Health Budgets £381,468 -£74,432 £307,036 £234,518 -£29,741 £204,777 -£102,259

Corporate Local level CSU fee reduction £300,000 £0 £300,000 £300,000 £0 £300,000 £0

Corporate SWL level CSU management fee reduction £100,000 £0 £100,000 £0 £0 £0 -£100,000

Corporate Budget and balance sheet review £1,534,000 £0 £1,534,000 £1,736,000 £0 £1,736,000 £202,000

Corporate CSU mngt fee reduction stretch £250,000 £0 £250,000 £0 £0 £0 -£250,000

Corporate SWL Collaborative rebate £400,000 £0 £400,000 £400,000 £0 £400,000 £0

Grand Total £35,559,909 -£7,949,882 £27,610,027 £30,073,687 -£5,224,769 £24,848,918 -£2,761,109

PLAN FORECAST (as per M6 Non-ISFE)

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP Governing Body

6th November 2018

Title of Paper: CONTRACT PORTFOLIO REPORT MONTH 5

Lead Director Stephen Warren Director of Commissioning

Report Author Aarti Joshi/Michael Sutton (Commissioning) Josie Wright (Contracting)


Finance Committee on 29th October


Senior Management Team Governing Body

Purpose of Report For discussion and noting

Recommendation:

GB is asked to: ▪ Note the Contract Portfolio Report and action plans.

Background:

The Planned and Urgent Care Commissioning Group (PUCCG) reviews monthly contract performance, identifies areas of concern and agrees actions that need to be undertaken. This report provides the committee with an update on contract performance, details the actions to be undertaken, progress on actions to recover performance.

Key Issues:

At month 5 the key issues are as follows: ▪ Mitigated YTD position of £478k over performance for acute portfolio and mitigated FOT is an

over-performance of £2.6m (Section 1)

▪ Over-performance is largely at the following providers: St Georges, Guys and St. Thomas, and

BMI Shirley Oaks (Section 1)

▪ Over-performance is seen in Outpatients and Elective PODs. (Section 1 and 2).

▪ Quarter 1 negotiations are in progress between the CCG and CHS. (Section 4)

▪ The community services block contract is currently reporting an under performance against

plan (Section 4)

▪ Adult Mental health OBDs were over plan in June - August but September has seen a small

reduction but still over plan. This means at months 5 there is over performance on £121k on the

risk share. A recovery plan is in place to bring this back on track.

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Governance:

Corporate Objective To commission integrated, safe, high quality service in the right place at the right time. To have collaborative relationships to ensure integrated approach

Risks

Risks are detailed in the report.


As described in the report.


N/A

Clinical Leadership Comments N/A


Implications as per associate arrangements

Equality Analysis N/A

Patient and Public Involvement N/A

Communication Plan N/A

Information Governance Issues N/A

Reputational Issues

Over performance at the Trusts may impact upon the CCG’s reputation.

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Executive Summary Contract Portfolio Report Month 5

1. Introduction

The purpose of this report is to provide the committee with an update on contract performance across all the CCG contracts. This includes identifying areas of over/under performance and actions being undertaken to investigate and recover performance. This paper references the Contracting Finance and Activity Report (CFAR), which provides detail of all the provider’s contract performances. This report has been reviewed by the Finance committee and is available on request. 1.1 Overall Position Statement 2018/19 The month 5 freeze position for Croydon CCG reported a mitigated YTD position of £478k over-performance across its acute STP and non-STP portfolio a favorable movement of £1.5m on the previous month. The mitigated FOT is an over-performance of £2.6m, which is an improved position on the previous month’s movement of £3m.The main driver for the improved position is at CHS due to £1.5m of Quarter 1 challenges, which have a likelihood of being accepted. The table below shows the year to date and forecast outturn position by POD. POD areas of over performance include, direct access diagnostics, drugs and devices, elective and outpatients.

Outturn by provider is shown overleaf:

To note CHS is underperforming by £1.5m against plan YTD (month 5). The main providers contributing to the current overperformance are BMI, St. George’s and GSTT.

Current SLAM month 5

CCG Ledger month 6

YTD Budget YTD ActualYTD

Variance% Variance FOT Budget FOT Actual

FOT

Variance% Variance

Previous

Month FOT

Variance

Improved/

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% Variance YTD Plan YTD ActualYTD

Variance% Variance

£'000s £'000s £'000s % £'000s £'000s £'000s £'000s £'000s %

A&E £9,590 £9,471 £119 1.2% £23,012 £23,201 (£189) (0.8%) (£819) £630 76.9% 87,571 92,476 (4,905) (5.6%)

CQUIN £2,652 £2,734 (£82) (3.1%) £6,514 £6,580 (£66) (1.0%) (£582) £516 88.7% 2,612 2,612 0 0.0%

Cri tica l Care £4,823 £4,781 £42 0.9% £11,574 £11,533 £42 0.4% £266 (£224) (84.4%) 3,096 3,517 (421) (13.6%)

Direct Access £3,849 £4,076 (£228) (5.9%) £9,236 £9,785 (£549) (5.9%) (£751) £202 26.9% 995,992 1,035,279 (39,287) (3.9%)

Drugs & Devices £4,399 £4,677 (£278) (6.3%) £10,554 £10,832 (£278) (2.6%) (£239) (£39) (16.3%) 60,029 56,363 3,666 6.1%

Elective £19,406 £19,749 (£343) (1.8%) £46,544 £47,424 (£880) (1.9%) (£914) £34 3.8% 15,162 16,287 (1,125) (7.4%)

Emergency £31,334 £30,290 £1,044 3.3% £75,157 £72,779 £2,378 3.2% £2,127 £251 11.8% 14,191 12,626 1,565 11.0%

Maternity Pathway £12,683 £11,962 £721 5.7% £30,432 £28,726 £1,705 5.6% £1,301 £405 31.1% 7,756 6,804 952 12.3%

Non-Elective £3,207 £2,961 £246 7.7% £7,692 £6,767 £924 12.0% £957 (£33) (3.4%) 2,405 2,210 195 8.1%

Other £6,534 £7,336 (£801) (12.3%) £15,646 £18,968 (£3,323) (21.2%) (£2,563) (£760) (29.6%) (21,331) 29,437 (50,768) 238.0%

Out Patient 1st £8,035 £8,375 (£340) (4.2%) £19,276 £20,124 (£849) (4.4%) (£1,360) £511 37.6% 49,184 48,324 860 1.7%

Out Patient Fol low Up £8,892 £8,954 (£63) (0.7%) £21,335 £21,537 (£202) (0.9%) (£1,107) £905 81.7% 102,653 104,083 (1,431) (1.4%)

Out Patient Procedure £4,772 £5,207 (£435) (9.1%) £11,453 £12,518 (£1,064) (9.3%) (£1,174) £110 9.4% 26,255 28,942 (2,687) (10.2%)

PTS £1,579 £1,582 (£3) (0.2%) £3,789 £3,867 (£78) (2.1%) (£26) (£52) (195.4%) 261,664 20,749 240,915 92.1%

Unbundled Diagnostics £2,156 £2,234 (£78) (3.6%) £5,174 £5,371 (£196) (3.8%) (£734) £538 73.2% 22,677 25,018 (2,341) (10.3%)

Total £123,911 £124,390 (£478) (0.4%) £297,387 £300,013 (£2,626) (0.9%) (£5,620) £2,995 53.3% 1,629,917 1,484,728 145,189 8.9%

Mitigated SLAM Month Mitigated Forecast Previous Month Mitigated FOT Activity

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▪ Planned and Urgent Care Commissioning Group (PUCCG)

2.1 Areas of over performance identified in Month 5

▪ Croydon Health Services – Croydon CCG is underperforming at CHS against plan by £1.5m YTD. The significant improvement in month is due to planned and technical adjustments, including £1.5m of challenges from the Q1 reconciliation to be agreed by the Trust.

An area of overperformance at CHS is Outpatient activity, (£319k) against plan. However, (£311k) of this activity has been apportioned through non-elective pathways including the Edgecombe unit and CDU discussed in a previous report.

▪ St. Georges – Month 5 is reporting a £529k variance to plan. Over performance is driven by Outpatients (£223k above plan), which includes £101k of planned challenges. The CCG is investigating, whether this increase is due to increased productivity to support the Trust’s turnaround programme. In addition, there is £216k non-elective over performance largely due to two clinical haematology long stay patients; one of which is uncoded and may be charged to NHSE.

▪ Shirley Oaks BMI – (£1.3m) over plan YTD in elective and outpatient activity, due to the reduced budget set in line with CHS’s repatriation strategy which has not repatriated work from BMI. Discussions are taking place between the Clinical lead and the practice regarding referrals to BMI at the referral variation visits. The CCG is presenting waiting times to GPs to show that BMI referral to treatment waits are almost as long as CHS to encourage referrals back to CHS.

▪ GSTT – Is (£623k) over plan largely due to long stay critical care patient discussed in previous reports.

The above issues will be discussed at the next PUCCG meeting, scheduled for the 25th October 2018.

Current SLAM month 5

CCG Ledger month 6

YTD

BudgetYTD Actual

YTD

Variance

%

Variance

FOT

BudgetFOT Actual

FOT

Variance

%

Variance

Previous

Month FOT

Variance

Improved/

(Deterior-

ated)

% Variance YTD Plan YTD ActualYTD

Variance% Variance

£'000s £'000s £'000s % £'000s £'000s £'000s £'000s £'000s %

STP Trust

Croydon Health Services £71,847 £70,293 £1,554 2.2% £172,432 £170,165 £2,267 1.3% (£97) £2,363 2449.1% 1,147,817 1,193,552 (45,735) (4.0%)

Epsom and St Hel ier Univers i ty Hospita ls £4,147 £3,959 £187 4.5% £9,952 £9,697 £255 2.6% £243 £12 4.8% 22,668 22,139 529 2.3%

South West London Elective Orthopaedic Centre £2,002 £1,974 £28 1.4% £4,805 £4,886 (£81) (1.7%) (£226) £145 64.2% 991 1,007 (16) (1.6%)

Kingston Hospita l £169 £186 (£17) (10.2%) £406 £430 (£24) (5.9%) (£28) £4 15.2% 526 577 (52) (9.8%)

The Royal Marsden £2,056 £1,880 £177 8.6% £4,935 £4,480 £455 9.2% £416 £39 9.5% 5,538 5,481 57 1.0%

St George's Healthcare £10,868 £11,396 (£529) (4.9%) £26,082 £27,297 (£1,215) (4.7%) (£1,059) (£156) (14.7%) 23,957 26,403 (2,446) (10.2%)

St. George's Community Services At Queen Mary's Hospita l£131 £123 £8 6.2% £314 £309 £5 1.5% £3 £2 50.5% 354 390 (36) (10.1%)

Total STP £91,219 £89,811 £1,408 1.5% £218,926 £217,264 £1,662 0.8% (£748) £2,410 322.0% 1,201,851 1,249,549 (47,698) (4.0%)

Non-STP Trusts

Over 5m

King's Col lege Hospita l £9,210 £8,877 £333 3.6% £22,103 £22,050 £53 0.2% (£449) £502 111.9% 40,066 40,186 (120) (0.3%)

Moorfields Eye Hospita l £4,678 £4,864 (£187) (4.0%) £11,226 £11,485 (£259) (2.3%) (£252) (£7) (2.9%) 23,217 24,214 (997) (4.3%)

Guy's and St Thomas ' £3,237 £3,859 (£623) (19.2%) £7,768 £8,632 (£864) (11.1%) (£1,009) £145 14.4% 210,286 17,460 192,826 91.7%

Surrey and Sussex Healthcare £2,558 £2,573 (£16) (0.6%) £6,139 £5,948 £191 3.1% £52 £139 267.4% 7,882 7,344 538 6.8%

London Ambulance £6,297 £6,297 £0 0.0% £15,113 £15,113 £0 0.0% £0 (£0) 0.0% 0 0 0 0.0%

Under 5m

One l ine - a l l consol idated £3,290 £3,400 (£110) (3.3%) £7,896 £7,770 £126 1.6% £245 (£119) (48.5%) 90,886 87,515 3,372 3.7%

non-NHS

One l ine - a l l consol idated £3,424 £4,708 (£1,284) (37.5%) £8,217 £11,751 (£3,535) (43.0%) (£3,459) (£75) (2.2%) 55,728 58,460 (2,732) (4.9%)

Total Croydon CCG acute £123,911 £124,390 (£478) (0.4%) £297,387 £300,013 (£2,626) (0.9%) (£5,620) £2,995 53.3% 1,629,917 1,484,728 145,189 8.9%

Mitigated SLAM Month Mitigated Forecast Previous Month Mitigated FOT Activity

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2.2 Update on Previous Actions

▪ Change in Emergency Pathway at CHS: The CCG is awaiting feedback from a letter sent by the Director of Commissioning regarding the pathway change at CHS. This has resulted in a shift activity from non-elective to outpatients resulting in an overperformance described above.

▪ Repatriation strategy: The CCG has met with CHS and agreed to focus efforts on redirecting GP referrals in T&O from BMI back to CHS. The repatriation group have offered to support CHS in the development of a business case for more marketing support at the Trust.

Plans for CHS were set to include £3.5m of repatriation. However, underperformance has not yet been seen in other trusts. The CCG understands that CHS has improved productivity through its new booking systems reducing cancellations on the day and DNAs.

▪ SASH increased emergency activity: A review of LAS data shows that the increased emergency attendances is due to patient choice, for patients who live closer to SASH than CHS. This reflects some of the underperformance experienced at CHS.

Appendix 1 has details of specific actions and progress/next steps for reference.

3.0 South London and The Maudsley (SLaM)

At Month 5 key areas to note are: ▪ Total number of A&E Psych liaison team waiting time breaches has seen a reduction at M5 but

remains high. A number of focussed actions are in train to address this.

▪ Adult Mental health OBDs were over plan in June - August but September has seen a small

reduction but still over plan. This means at months 5 there is over performance on £121k on the

risk share. A recovery plan is in place to bring this back on track.

▪ Average LOS for September was 50.8 days showing a downward trend since the MADE event and

other actions. The aim is to reduce this to 35 days.

4.0 Contract Updates 4.1 Croydon Healthcare Services (CHS) ▪ Repatriation - CHS has been asked to quantify repatriation figures from both the Joint Referral

Unit (JRU) and its own internal repatriation strategy. CHS activity via the JRU in July and August

accounted for £280k of activity and included CCGs other than Croydon. Referral data provided by

CHS has demonstrated increases in patient choice of the provider compared to 2017/18.

▪ Q1 Reconciliation - Quarter 1 negotiations are in progress between the CCG and CHS.

Challenges of note include; Best Practice, Planned Care QIPP Delivery, ECI retrospective

challenges and CDU counting and coding. The expectation is to agree a Q1 settlement by the end

of October and a year-end agreement by the end of November.

▪ Community Contract -The Month 5 community services contract is reporting significant under

performance on a number of service lines. Further investigation has shown this may be due to

data omission by the Trust (Appendix 2). Significant areas of underperformance can be seen in

the following areas:

Continence Service (59%) Health Visitor for the Elderly (63%) CITMS (30%) Domiciliary Service (44%) Wheelchair Service (69%) Paediatric Asthma Service (32%) Children’s Hospital at Home (34%)

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Paediatric OT (53% Paediatric Physiotherapy (44%) Looked after children (81%)

This has been raised at the DQIP/Tech meeting and will be rectified in Month 6. The CCG will

review this activity once the data is refreshed.

The Trust has now completed their community budget review, which has been shared with the

CCG finance lead as well as the adult and children’s commissioner leads. The next steps are to

review the budgets, service specifications and activity, which will then be applied to the CHS

contract via a further contract variation.

A number of services such as district nursing, community matrons and health visitor for the elderly

will be realigned with LIFE and ICN and as such, service specifications are to be updated to reflect

the changes with potentially new contractual metrics. This work is being reviewed with the

contracts team and Out of Hospital leads. The remaining adult services will be reviewed with the

planned care commissioners and a meeting date is being progressed. Similarly, this work will be

carried out with the Children’s community services lead.

The current community SLAM has not been updated to reflect the latest contract variation (CV) of

£31,790,303. The correct financial value has been applied in the quarter 1 challenge process. A

further CV is being agreed with the addition of the prescribing dietician funding and removal of 4

months of the CIMS (MSK) service, which has now been awarded to an external provider.

4.2 South London and The Maudsley (SLaM) Contract value is being varied to include additional CPNs as part of the OOH Business Case £28k agreed for 2018/19. Parties have agreed to meet bi-monthly to commence 19/20 contract negotiations and cover off any outstanding 18/19 issues inclusive of: ▪ Local CQUIN – Final details of one part of the CQUIN

▪ Mental Health Investment Standard – a report showing current position is being drafted by the

trust and will become a standing item during core contract meetings.

▪ SDIP – will be developed further to address newly highlighted poor performing services

▪ IAP – SLaM to forward plan outlining capacity and current vacancies across all community

services

▪ Revise risk share to be leveraged on average length of stay through the year. Contracted OBDs to

be recalculated

4.3 Acute Contracts awaiting agreement Two Acute Contracts have not yet been agreed. Their status are as follows: ▪ Imperial: Contract value not yet agreed with host; gap analysis in progress. (2017/18 value -

£754k)

▪ SASH: Host has yet to agree the position. (2017/18 value - £5.3m)

4.4 Trusts with contracts agreed exceeding £5m SWL Elective Orthopaedic Centre, Kings, Epsom St Helier, Moorfields, Guys and St Thomas’ and St George’s Hospitals have had contracts signed. The following contract is in the process of being finalised:

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▪ Royal Marsden: Contract value Agreed at £4,935,000. Indicative Activity Plan has been received

and is with CCG finance awaiting signature.

4.5 Independent Providers ▪ BMI: The CCG is now the host for the BMI Shirley Oaks contract. Croydon CCG has now agreed

the financial value and IAP for 2018/19 (£3m). The other associates to this contract (Sutton,

Merton and Wandsworth CCGs) have also agreed contract values.

Regular monthly contract management meetings with BMI have been set up to review and monitor

the contract. At the September contract meeting BMI agreed to carry out an audit on the ECI

procedures undertaken in 2018/19. The ToR have been shared and the CCG is awaiting

agreement. BMI also agreed to review T&O activity seen within a 2-month period, reporting to the

CCG the source of appointments. BMI reported that the majority (88%) of T&O appointments are

directly booked in by GPs and 12% are referred by the current MSK service (CIMS) due to patient

choice. This is being shared with GPs in the variation visit being undertaken by the CCG.

5.0 CUCA Contract ▪ There has been a decrease in Urgent Treatment Centre (UTC) and Out of Hospital (OOH) activity

in M5 attributed to seasonal variance.

▪ Activity at the GP hubs has also seen a decrease. The number of patients at the GP hubs who

received a booked appointment saw a decrease with the exception of the East Croydon hub,

which saw an increase. However, the majority of appointments continue to be walk ins. The CCG

have suspended KPI performance thresholds relating to bookable appointments until a workable

IT solution can be found.

▪ Due to over performance in cap activity and the breaching of KPI thresholds shown in the CFAR

report, CUCA has underperformed against plan by £271k YTD. The activity plan and actuals are

shown in the table below.

▪ The CSU, CCG and CUCA are working to agree a contract variation which addresses the

performance against KPIs and aims to reduce the significant under achievement against the KPIs.

The contract variation (CV) will also address the baseline issues that CUCA has been raising. The

CV is in final draft stage.

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▪ As part of the CV, the CSU, CCG and Provider have now agreed upon a “re-weighting” of KPIs

which place more emphasis on the areas of importance namely streaming. This work includes

removing some incentivised KPIs that are not effective and realigning the incentive monies to

remaining KPIs to higher priority areas in order to achieve CUCAs outcomes.

▪ Although Roving GP activity has marginally increased, it has been acknowledged by the Trust and

the lead Commissioner that the Roving GP service is not cost effective. Instead the resource will

be shifted to support improved functioning of the UTC with a focus on clinical leadership and

streaming and redirection.

▪ Work is ongoing to incorporate the GP Extended Access Service into the CUCA contract as a

variation is underway and in a final draft version. The Parkway Health Centre extended access

hub has already gone live and the other 2 hubs are planned for within the next couple of months.

The draft contract variation is currently with the Provider, there is further discussion to be had

around rent issues.

6.0 Intermediate Contracts Many of the planned care services are coming to the end of their contract term with no further extension clauses. The CCG’s future commissioning arrangements are being considered alongside the transformational work and proposed changes to the CCG’s procurement strategy, which is aimed to facilitate transformation and support local provider development. A separate paper details the CCG’s approach to the implementation of the CCG’s contestability framework and implications across all contracts expiring in the next 6 months. 6.1 Month 5 Summary Reports

The summaries below give a high-level position on contract performance for each of the Intermediate Services for 2018/19. A more detailed position and analysis is available in this month’s CFAR report. ▪ Dermatology – The current contract has been extended until 31st March 2019, ensuring continuity

of care, whilst CCG agree arrangements with CHS and the GP collaborative to pilot a single

provider contract.

▪ ENT - The ENT contract is due to end 31st March 2019 following a contract extension to allow for

transformational work to continue.

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▪ Ophthalmology (COS) -This contract has been extended for a further 11months until 31st March

2019, whilst transformation plans are finalised and implemented.

▪ Gynaecology (BMI, Shirley Oaks) - The contract comes to its end on 31st March 2019.

Transformation programme currently underway which will inform decision on whether or not to

extend this contract further.

▪ Diabetes (Bromley Healthcare Ltd) - The contract has been extended until 31st March 2019. The

business case for the agreed new of model care is due to be presented at the QIPP Operational

Board at the end of October 2018.

▪ Vasectomy - The contract has been extended by a further 12 months, until 31st March 2019.

▪ Anti-Coagulation - The service (Boots) has been extended for 12 months, until the 31st March

2019.

▪ Locally Commissioned Services (LCS) – A full review of the LCS specifications has taken place

aligning the LCS to strategic transformational objectives of the CCG.

The financial summary table below shows the intermediate contract performance at month 5.

▪ SWL Elective Activity Oversight

Appendix 3 provides an overview of the South West London Elective Activity which indicates unexpected growth in referrals. Croydon has seen an increase in referrals against plan however the reported figures are higher due to data quality issues in month 1-3 which will continue to show in the published data. The actual increase in referrals is in the region of 12% and not the 25% as reported in the published MAR data. More details are provided in pages 65-67 of the CFAR report.

▪ Conclusion

Croydon CCG’s acute contract YTD position indicates £478k over-performance with a forecast outturn of £2.6m. Over-performance across range of providers including St. Georges, Guys and St. Thomas and BMI Shirley Oaks. Key areas of concern that are being investigated and taken forward include

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over performance in A&E and outpatients PODs and repatriation of activity from Independent and out of borough trusts. Q1 reconciliation is currently progressing with CHS, with the expectation that this will be agreed by the beginning of November 2018. The Month 5 community services contract is reporting significant under performance on a number of service lines. Further investigation has shown this may be due to data omission by the Trust. This will be refreshed for Month 6 The Planned and Urgent Care Commissioning Group will continue to review and monitor the identified actions and outcomes following the deep dive reviews provided by the contracts team, to ensure that over performance is effectively managed. The SLAM contract has been signed by both parties. Variation documents to be signed off including a revised value for: ▪ OOH CPNs

▪ Local CQUIN

▪ SDIP

▪ IAP

For all contracts that are due to expire by 31st March 2018, the CCG’s future commissioning arrangements are being considered alongside the transformational work and proposed changes to the CCG’s procurement strategy, which is aimed to facilitate transformation and support local provider development.

▪ Recommendations

SMT is asked to: Note the Contract Portfolio Report and action plans.

Appendix 1: PUCCG Action Log Appendix 2: Community Contract update

Appendix 3: Electivity Activity Oversight

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Planned and Urgent Care Commissioning Group Meeting Action Log

# Date RaisedArea

Issue Action Owner Due by RAG Progress

Status

102 30.08.18 Consultant Activity Mapping The CCG identified a need to map consultants activity at BMI against NHS Trust. Essentially we would need to understand which NHS Trust, the BMI consultants are working for.

JW to look into how the CCG can map consultant activity to understand which NHS trusts the consultants are coming from that are undertaking the activity at BMI Shirley Oaks.

Josie Wright 20.09.2018 ClosedJW: The information is available on the NELIE portal, this is a piece of work led by the BI team not contracts but I could sit down with Planned Care and help in terms of familiarising themselves with the portal. This is a BI task. Closed on 27/09/2018

106 30.08.18 Deep Dives: Schedule The group realised the need for a detailed Deep Dive Schedule, to include specific timelines around submission of the DD report (full paper).

AJ and JW to discuss the programme for the Deep Dives, to include timelinesfor submission of papers.

Aarti Joshi 10.09.2018 ClosedFarrah Ashley (Senior Contracts Manager) shared aprovisional schedule with AJ on 27/09/2018. Closed on 2/10/2018

111 27.09.18 Planned Care Recovery Plan AJ presented the RP for Planned Care aimed to recover financial position (1.6 million) and advised that we‘ll focus on Reducing inappropriate referrals in the first instance. At the same time AJ requested the group’s support and would welcome any ideas relevant that would help shape the plan. JW advised that she had not seen the plan before and AJ requestedthat the plan should be shared with JW and her team.

CS to re send today’s agenda – the Plan was atttached. Chrys Spyropoulou Closed

Closed on 02/10/2018

112 27.09.18 Consultant Activity Mapping The CCG identified a need to map consultants activity at BMI against NHS Trust. Essentially we would need to understand which NHS Trust, the BMI consultants are working for.

ACTION: CS to email Angela Wood and query how Planned Care can use the Portal to acquire that type of information.

Chrys Spyropoulou Closed 02/10/2018 Report developed to be shared withPUCCG at next meetingClosed on 02/10/2018

OverdueProgressing within timescaleCompleteClosed

PUCCG Action Log from 16th October 2018 Meeting

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Service YTD

Variance

Adult Community Services -97

-468

508

2241

-954

2884

-1088

-

-

-

Adult Learning Disabilities -1200

-

Adult Therapy Services -44

-308

197

-1750

-

-

-283

-1437

Cardiology One Stop -

Community Respiratory

Services

15

-

-42

Fall Team -702

-

Rehabilitative &

Independent Living Services

-

-

-129

365

-24

129

-2,187

Service YTD

Variance

Children's Specialist Services -704

-2016

4532

-498

-

-2280

-1354

Specialist Community Health

Services

2348

Universal Children's Services -

-1799

-122

-679

-2,571

30,586,160 12,897,389 191,686

Croydon CCG 770,143

31,356,303 12,897,389 191,686 195,479 -4,757

Community SLAM Report

SLA Activity and Finance Targets for CHS Community Contract

Commissioner: Croydon CCG

Data updated to: 19/09/2018

Start date: 01/04/2018

End date: 31/08/2018

Financials Activity

Service Line Team System Proposed

Annual Plan

YTD Plan (£) Annual Plan YTD Plan YTD Actual % YTD

Variance

2324 968 871 -10%A3 BHF Heart failure Cerner 282,380 117,658

3724 1552 1084 -30%A4 CITMS EMIS 207,162 86,318

2900 1208 1716 42%A2 Community Cardiac Nurse Specialists Cerner 375,365 156,402

10530 4388 6628 51%A6 Community Matrons (Enhanced Case EMIS 579,178 241,324

3862 1609 655 -59%A5 Continence Service EMIS 927,518 386,466

216339 90141 93025 3%A1 District Nursing EMIS 6,979,437 2,908,099

4170 1738 650 -63%A7 HV for Elderly EMIS 419,878 174,949

- - 2063 -A33 Rapid Response EMIS - -

- - 36 -A32 Single Point of Access EMIS - -

- - - -A8 TACS team EMIS 4,878,989 2,032,912

11243 4685 3485 -26%A17 Learning Disability EMIS 1,044,786 435,328

- - 0 -A18 Safeguarding Adults team EMIS 158,672 219,269

2588 1078 1034 -4%A12 Adult SALT Cerner 275,390 114,746

44009 18337 18029 -2%A11 CIMS Cerner 2,619,948 1,091,645

1395 581 778 34%A10 Dietetics Cerner 142,591 59,413

9626 4011 2261 -44%A34 Domiciliary Adult Physiotherapy EMIS 417,402 173,918

- - 4242 -A14 Equipment Services Other 992,895 413,706

- - 0 -A16 Long Term Conditions EMIS 56,917 23,715

35035 14598 14315 -2%A9 Podiatry Cerner 1,058,055 440,856

4966 2069 632 -69%A15 Wheelchair Service EMIS 605,972 252,488

- - 0 -A30 Cardiology One Stop 31,265 13,027

3227 1345 1360 1%A26 Community Pulmonary Rehabilitation

Service

Cerner 75,795 31,581

- - 0 -A25 COPD funding 498,384 207,660

511 213 171 -20%A27 Oxygen Assessment Service Cerner 52,619 21,925

7118 2966 2264 -24%A28 Falls and Bone Health (incl Integrated falls Cerner/EMIS 252,494 105,206

- - - -A29 Integrated Falls Service EMIS 102,526 42,719

- - 1769 -A20 A&E Liaison Team Cerner 355,414 148,089

- - 0 -A19 CICS EMIS 720,301 300,125

3798 1583 1454 -8%A21 Community Neurorehabilitation Cerner 717,115 298,798

4082 1701 2066 21%A24 Community Stroke Team Cerner 304,763 126,985

525 219 195 -11%A22 Neuro-Psychology Service Cerner 143,804 59,918

154 64 193 201%A23 Rehab Consultant Cerner 129,828 54,095

160,976

Financials Activity

ADULT SERVICES SUBTOTAL 25,406,843 10,739,340 372,126 155,053

Annual Plan YTD Plan YTD Actual % YTD

Variance

Service Line Team System Proposed

Annual Plan

YTD Plan (£)

7435 3098 2394 -23%C13 Audiology EMIS 286,809 119,504

14059 5858 3842 -34%C6 Children's' Hospital at Home (CHAH) EMIS 941,961 392,484

19376 8073 12605 56%C7 Children's' Medical Services EMIS 1,296,375 540,156

3714 1548 1050 -32%C11 Paediatric Asthma Service EMIS 152,772 63,655

- - 440 -C9 Paediatric Diabetic Children EMIS 55,396 23,082

10257 4274 1994 -53%C8 Paediatric Occupational Therapy EMIS 595,703 248,210

7437 3099 1745 -44%C10 Paediatric Physiotherapy EMIS 470,156 195,898

721 300 2648 781%C1 Rainbow Homeless Health EMIS 272,880 113,700

- - 0 -C4 Health Visitor Liaison EMIS 83,236 34,682

5322 2218 419 -81%C3 Looked After Children (LAC) EMIS 378,702 157,793

3928 1637 1515 -7%C2 Safeguarding Children team EMIS 288,750 120,313

15672 6530 5851 -10%C5 Special Schools Nursing EMIS 356,577 148,574

34,503

COMMUNITY SUBTOTAL 460,047 195,479 -4,757

CHILDREN YOUNG PEOPLE & FAMILIES SERVICES SUBTOTAL 5,179,317 2,158,049 87,921 36,634

COMMUNITY GRAND SUBTOTAL 460,047

CQUIN

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Elective Activity Oversight

October 2018

OctoberAppendix 5

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2

CCG

Total Referrals GP Referrals Other Referrals 1st OPD Attendances

Plan activityActual

activityDiff (#) Diff (%)

YTD growth

over same

period last

year

Plan activityActual


YTD growth

over same

period last

year

Plan activityActual


YTD

growth

over same

period last

year

Plan

activity

Actual


YTD

growth

over

same

period last

year

London 1,463,712 1,468,782 5,070 0.3% 3% 909,040 914,177 5,137 0.6% 2.2% 554,672 554,605 -67 0.0% 4.47% 1,410,537 1,405,922 -4,615 -0.3% 5.1%

NHS Croydon CCG 58,445 64,574 6,129 10.5% 25% 36,053 40,472 4,419 12.3% 25.4% 22,392 24,102 1,710 7.6% 24.67% 54,634 55,169 535 1.0% 10.4%

NHS Kingston CCG 23,860 24,217 357 1.5% 5% 16,610 17,327 717 4.3% 8.8% 7,250 6,890 -360 -5.0% -2.89% 42,001 41,685 -316 -0.8% 4.0%

NHS Richmond CCG 28,970 27,128 -1,842 -6.4% -6% 20,310 18,868 -1,442 -7.1% -7.6% 8,660 8,260 -400 -4.6% -3.63% 33,385 32,297 -1,088 -3.3% -0.9%

NHS Merton CCG 29,461 31,093 1,632 5.5% 8% 22,448 22,721 273 1.2% 3.4% 7,013 8,372 1,359 19.4% 22.49% 32,281 32,071 -210 -0.7% 6.7%

NHS Sutton CCG 22,004 24,573 2,569 11.7% 12% 18,104 19,755 1,651 9.1% 8.3% 3,900 4,818 918 23.5% 26.86% 22,898 24,185 1,287 5.6% 13.8%

NHS Wandsworth CCG 58,532 60,066 1,534 2.6% 2.8% 41,185 40,879 -306 -0.7% -1.1% 17,347 19,187 1,840 10.6% 12.07% 57,866 55,400 -2,466 -4.3% 0.7%

South West London

STP221,272 231,651 10,379 4.7% 9% 154,710 160,022 5,312 3.4% 6.5% 66,562 71,629 5,067 7.6% 14.15% 243,065 240,807 -2,258 -0.9% 5.2%

CCG

Follow Up OPD Attendances Total Elective Admissions Ordinary Day Case

Plan activityActual


YTD growth

over same

period last

year

Plan activityActual


YTD growth

over same

period last

year

Plan activityActual


YTD

growth

over same

period last

year

Plan

activity

Actual


YTD

growth

over same

period last

year

London 2,526,988 2,525,452 -1,536 -0.1% 4.3% 393,341 390,140 -3,201 -0.8% 2.8% 57,551 54,889 -2,662 -4.6% -3.8% 335,791 335,251 -540 -0.2% 4.0%

NHS Croydon CCG 142,601 143,879 1,278 0.9% 8.8% 15,678 16,196 518 3.3% 4.0% 2,319 2,441 122 5.3% -3.0% 13,359 13,755 396 3.0% 5.3%

NHS Kingston CCG 40,872 39,543 -1,329 -3.3% 2.5% 7,290 7,031 -259 -3.6% 1.6% 1,600 1,305 -295 -18.4% -12.5% 5,690 5,726 36 0.6% 5.5%

NHS Richmond CCG 45,232 45,008 -224 -0.5% 5.7% 7,218 7,286 68 0.9% 4.1% 1,277 1,200 -77 -6.0% -3.1% 5,941 6,086 145 2.4% 5.7%

NHS Merton CCG 58,796 57,378 -1,418 -2.4% 5.9% 8,002 7,753 -249 -3.1% 0.8% 1,516 1,283 -233 -15.4% -12.5% 6,486 6,470 -16 -0.2% 3.9%

NHS Sutton CCG 62,831 65,690 2,859 4.6% 8.5% 9,854 10,418 564 5.7% 9.5% 1,563 1,435 -128 -8.2% -4.9% 8,291 8,983 692 8.3% 12.2%

NHS Wandsworth CCG 100,912 97,999 -2,913 -2.9% 5.8% 12,113 12,000 -113 -0.9% 1.4% 2,433 2,100 -333 -13.7% -12.5% 9,680 9,900 220 2.3% 4.9%

South West London

STP451,244 449,497 -1,747 -0.4% 6.8% 60,155 60,684 529 0.9% 3.7% 10,708 9,764 -944 -8.8% -8.1% 49,447 50,920 1,473 3.0% 6.3%

SWL STP – Elective activity variance to Operating Plan by CCG

Month 5 – August 2018/19

Key

XXX – 5% greater or 10% lower than the Operating plan

XXX – 10% greater than the Operating plan

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SWL CCGs - HEADLINE MESSAGES

Referrals• There has been an unexpected growth in referrals numbers across SWL with the greatest growth appearing to be in Croydon and Sutton

CCGs• There was a peak in referral numbers in M2 across all SWL CCGs however a reduction can be seen since then though M5 still shows 5%

higher than planned activity • The main driver for this growth can be seen within ‘Other referrals’. These are referrals from A&E or other urgent and emergency service

into a consultant-led service. • There were a number of ‘data quality’ issues that drove both the increase in GP referrals and Other referrals however the former has been

resolved in the main through validation and GP practice visits.o The latter issue is due to

▪ The incorrect labelling of referrals from A&E/urgent care to a consultant-led service however the providers who have experienced this are confident that they have resolved the issue

▪ The incorrect referral activity submission from Chelsea and Westminster that has impacted predominantly on Richmond CCG figures

o We have requested to be able to re-submit the data correctly for the year to date and are awaiting a response to this request

First and Follow up OPD Attendances• There was a slight increase in activity against the operating plan in the first three to four months of the year as a number of Trusts put extra

activity on to prepare for implementation of Paper Switch Off (PSO) and to try and reduce their backlog waiting lists however this has not dropped back to close to plan following the summer period

Total Elective Admissions• Overall Elective admissions have remained slightly higher than the operating plan

o The number of inpatient (ordinary) elective work is much lower than the operating plan however this can be explained by the ECI (Effective Commissioning Initiative) policies that have been put in place. There have also been some changes in treatment pathways that moves patients from in-patient treatment to day case treatment as per best practice guidelines

o This latter change would explain the reason for the higher than expected day case activity against plan

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SWL CCGs Mar-18 Jun-18 Jul-18 Aug-18Variance to

Mar-18Trend

NHS CROYDON CCG 23,071 24,327 24,688 24,662 1,591

NHS KINGSTON CCG 7,963 9,360 9,317 9,291 1,328

NHS MERTON CCG 7,518 7,857 7,832 7,837 319

NHS RICHMOND CCG 9,911 11,543 11,954 12,171 2,260

NHS SUTTON CCG 12,891 13,291 13,266 13,047 156

NHS WANDSWORTH CCG 10,563 11,092 11,414 11,339 776

SWL Total 71,917 77,470 78,471 78,347 6,430

Jun-18 Jul-18 Aug-1819 21 153 4 44 13 94 2 13 1 36 10 9

39 51 41

NHS MERTON CCGNHS RICHMOND CCGNHS SUTTON CCGNHS WANDSWORTH CCG

SWL Total

SWL CCGsNHS CROYDON CCGNHS KINGSTON CCG

RTT Incomplete Pathways by CCG(waiting list against March-2018)

RTT Incomplete Pathways > 52 weeks by CCG

ProviderNHS CROYDON

CCG

NHS KINGSTON

CCG

NHS MERTON

CCG

NHS RICHMOND

CCG

NHS SUTTON

CCG

NHS

WANDSWORTH

CCG

SW

London

Total

BARTS HEALTH NHS TRUST 1 1

EAST KENT HOSPITALS UNIVERSITY NHS

FOUNDATION TRUST 1 1

EPSOM AND ST HELIER UNIVERSITY

HOSPITALS NHS TRUST 1 2 3

IMPERIAL COLLEGE HEALTHCARE NHS

TRUST 1 1 2

KING'S COLLEGE HOSPITAL NHS

FOUNDATION TRUST 12 2 1 5 20

KINGSTON HOSPITAL NHS FOUNDATION

TRUST 1 1 1 4 7

MOORFIELDS EYE HOSPITAL NHS


OXFORD UNIVERSITY HOSPITALS NHS


CCG Total 15 4 9 1 3 9 41

RTT waiting list against March-18 (providers)

RTT Incomplete Pathways > 52 weeks SW London CCGs by Trust

Provider Mar-18 Jun-18 Jul-18 Aug-18Variance

to Mar-18Trend

KHFT 16,376 19,399 19,352 19,741 3,365

CHS 20,285 22,024 23,029 23,055 2,770

ESTH 28,781 27,828 27,467 27,847 -934

SGH - - - - - -

RMH 1,826 2,614 2,491 2,378 552

Total 67,268 71,865 72,339 73,021 5,753

SWL Provider and CCG- RTT waiting list

Total Waiting List and Long Waiters• The number of patients waiting on the incomplete RTT PTL across SWL has grown by over 6000+ since March 2018. Work is ongoing to validated the entire

PTL.• All CCG’s bar Merton and Richmond have started to see a reduction in the total numbers on the waiting list

• 52Week waits: The number of patients waiting over 52 Weeks on an incomplete pathway has decreased from 51 in July to 41 in August. Out of the 41 breaches 20 were at Kings College Hospital.

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REPORT TO CROYDON CLINICAL COMMISSIONING GROUP GOVERNING BODY IN PUBLIC

6 NOVEMBER 2018

Title of Paper: REPORT FROM THE CHAIR OF THE QUALITY COMMITTEE

Lead Director Amy Page, Governing Body Member Chair, Quality Committee

Report Author Elaine Clancy, Director of Quality & Governance Simon Lee, Associate Director of Quality and Governance


N/A


CCG Governing Body


Recommendation:

The Governing Body is asked to note the update on matters discussed at the Quality Committee.

Executive Summary:

The Quality Committee is a Committee of the Governing Body but also provides oversight reporting to the Integrated Governance and Audit Committee (in its position of oversight for CCG internal control and governance) and has been established to oversee the application of quality in services commissioned.

The Quality Committee has met once since the last Governing Body meeting. The papers on the agenda at the September meeting were:

• Croydon CCG Strategic and Operational Quality And Safety Risks

• Integrated Performance and Quality report M3

• Mortality Review Update

• Learning Disabilities Health Check Update

• Continuing Healthcare Improvement Update

• CQRG Minutes – for information

No QIPP Report (Quality Annex) was presented to the Committee An update was provided on the current quality and safety risks. The committee was informed of new risks that had been identified since the previous meeting. The risks related to provider safeguarding arrangements for Croydon Health Services (CHS) and a potential gap in leadership; a situation with which the CCG has been supporting. A risk related to the Continuing Healthcare Learning Disabilities register and whether yearly review were being completed. Weekly meetings with the LD Continuing Healthcare nurse were taking place to address this. The Quality committee reviewed and discussed the Month3 Integrated Performance and Quality report. Areas of particular focus were CHS A&E performance, IAPT and Quality Premium. A recent deterioration in A&E performance resulted in the CCG meeting with

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NHSE to discuss the situation and recovery. IAPT Access and Recovery performance was still challenged. A detailed action plan is in place which includes significant promotion of the services available. It was noted that progress had been made against a number of Quality Premium Indicators. An updated was provided on the LeDeR programme. 22 reviews had been received for Croydon, with 11 allocated to reviewers and three completed. The support required to ensure completion of reviews was discussed, and it was acknowledged that further support will be needed. The committee discussed Learning Disability Health Checks, compliance of which was improving based on the latest available data. A significant number of the annual health checks are due in Q3 & Q4, with the next cut of data available in November 2018. The progress of the Continuing Healthcare (CHC) service was discussed. Areas of focus identified by a recent audit were discussed. This included contracts with providers not being in place – a tracking tool was now in place to support the team in managing this. Reviews following initial assessment was highlighted as a concern; a tracking tool was now also in place to support this process and ensure that 3 and 12 month reviews take place. Finally, lack of progress of a joint funding policy was discussed. In addition to the above discussion about CHC, the SWL STP FNC Equity and Choice Policy was discussed. The policy focussed on the management of patients where significant care was required to keep the patient in the home, with the safety of the patients being paramount. It is anticipated that the policy will be used minimally and that every effort will be made to resolve any issues locally with the patient and their family.

Governance:


Risks Quality and Safety Risks are considered at each meeting together with matters to be escalated to the Governing Body. Where applicable these are listed within the paper.








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Not applicable


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6 November 2018

Title of Paper: REPORT FROM THE CHAIR OF THE CROYDON CCG COMMITTEE

FOR COLLABORATIVE DECISION MAKING (meeting as SWL Committees in Common)

Lead Director Philip Hogan, Lay Member, deputising as Vice Chair (For Roger Eastwood)

Report Author Ben Smith, Board Secretary


N/A


CCG Governing Body


Recommendation:

The Governing body is invited to note the following decisions taken by the Croydon CCG Committee for Collaborative Decision Making meeting with South West London Committees in Common. Unanimous decisions are understood to be binding on the Croydon CCG Governing Body 1) Health Based place of Safety – Pan London Configuration - Case for Change The Committees unanimously agreed to support the proposals 2) Continuing Healthcare and Funded Nursing Care Choice and Equity Policy The Committees unanimously approved the policy. 3) SW London Commissioning Intentions. The Committees unanimously agreed to ratify the SWL Commissioning Intentions. 4) New diabetes glucose monitoring system (Freestyle Libre) criteria, implementation and impact for SWL. Noted for implementation

Executive Summary:

Under paragraph 3(3) of Schedule 1A of the National Health Service Act 2006 (inserted by the Health and Social Care Act 2012) CCGs’ constitutions may provide for their functions to be exercised by any members or employees of the CCG.

The Croydon CCG Constitution provides a mechanism that allows specified functions to be delegated to a designated committee, which may meet with identical Committees of other CCGs in a CiC arrangement. Where the decisions of the CiC are unanimously made, the decisions are binding on the constituent CCGs.

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The Governing body of each of the CCGs in South West London has resolved to create a “Committee for Collaborative Decision Making” that will participate in a Committees in Common (CiC) arrangement. The participant CCGs for a particular CiC meeting are determined by the nature of issue delegated to the committee.

The Committee met on Tuesday 9th October 2018. Croydon CCG were represented by:

▪ Philip Hogan, Lay Member, (Chair of the Croydon element of the meeting as acting Vice-Chair)

▪ Andrew Eyres, Accountable officer, ▪ Dr Mike Simmonds, GP Governing Body Member (deputising for Dr Agnelo

Fernandes), A video recording of the meeting can be viewed at the following location: https://youtu.be/eL9N2c45qp8 The matters discussed at the Committee are described below. 1) Health Based place of Safety – Pan London Configuration - Case for Change Proposals were received by the committees meeting in common for Health Based Places of Safety for patients detained under the Mental Health Act and the proposed location of sites across London. For Kingston, Merton Sutton, and Wandsworth there will be no change to the existing HBPOS at Springfield Hospital and work will continue to ensure the service meets the pan-London specification. For Croydon the residents will continue to access the Maudsley Hospital HBPOS, which already meets the new specification. The proposal was approved unanimously by all committees meeting in common. 2) Continuing Healthcare and Funded Nursing Care Choice and Equity Policy The policy has been developed due to expensive domiciliary care packages that may significantly exceed nursing home placement fees. SWL CCGs will commission the provision of NHS funded Continuing Healthcare (CHC) in a manner which reflects the choice and preferences of individuals as far as is reasonably possible, ensuring patient safety, quality of care and making best use of resources. Cost has to be balanced against other factors in each case, such as a patient’s desire to live at home. This policy had been considered at Croydon’s Senior Management Team and Quality Committee. In reviewing the policy, Croydon CCG had reiterated that the linchpin of CCG decisions should be around safe and quality of care. Some of the most expensive packages, that this policy addresses, concern patients with an intensity of need or 1:1 constancy of complex care needs that indicates safety issues for carers and loved ones as well as the patient (e.g. advancing dementia). The Croydon SMT and Quality Committee members agreed to accept the policy but asked for an internal process to be implemented in Croydon CCG to support decisions. Andrew Eyres reported to the Committees meeting in Common that Croydon’s associated procedure (for these clinical decisions) was to be led by Dr Tom Chan, Medical Director.

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The Croydon Committee meeting as Committees in Common with SW London CCGs agreed unanimously to Approve the policy. Minor amendments were made in the associated guidance to provide the appropriate contact details for the relevant CCGs and to add clarity that the guidance can be sought from the healthcare professional as the referring clinician (replacing reference to ‘your GP’) 3) South West London Commissioning Intention. The final versions of 2019-20 Commissioning Intentions for SWL CCGs were presented. Each year commissioners in the NHS are required to set out their priorities for the coming year and how they will improve the health of the communities they serve. There is a contractual element with the CCG’s providers (acute, community, GP, voluntary sector) where each CCG is required to give six months’ notice of the intentions The document contains local commissioning intentions, discussed at our 4th September 2018 Governing Body, which had been shared with Croydon CCG’s providers. Croydon CCG’s Committee for Collaborative Decision Making supported the ratification of the SWL Commissioning Intentions. The Committees meeting in common unanimously supported the ratification of the SWL Commissioning Intentions as a framework and direction of travel. Free style Libre (for information) The guidelines for this treatment for diabetes patients were already submitted to Croydon Prescribing Committee where it was approved for use earlier this year. Financial impact for Croydon is estimated to be around £200k per annum.

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Governance:


Risks Failing to make appropriate preparations for such a report would place the CCG at a reputational risk, initially, principally with its auditors and authorising bodies such as NHSE.

Financial Implications There are no new significant budgetary implications represented by matters discussed.



Implications for Other CCGs The arrangements for committees meeting in common applied to all six South West London CCGs.

Equality Analysis Not applicable. Equality analysis was applied to the individual papers considered.


Communication Plan SWL Committees in Common papers are published on the website and video footage of the meetings is available to the public


Not applicable


Report Author: Ben Smith, Board Secretary


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Title of Paper: Arrangements for signing of the Better Care Fund Section 75 Agreement for 2018/19 with London Borough of Croydon

Lead Director Martin Ellis

Report Author Kieran Houser


N/A


SMT

Purpose of Report To update the Governing Body on progress with the section 75 agreement for 2018/19, and to seek approval for delegation of sign-off responsibility.

Recommendation:

The Governing Body is asked to approve the request to delegate sign-off responsibility to the Accountable Officer and Chief Finance Officer for the 2018/19 Better Care Fund section 75 agreement.

Background:

The Better Care Fund (BCF) is a pooled fund between health and social care designed to shift health and care activity into the community, avoid admissions to hospital, and speed up discharge from hospital following admission. The schemes supported by the BCF fund are jointly agreed between Croydon CCG and London Borough of Croydon, and are contractualised in a section 75 agreement.

The mandated CCG contribution to the BCF is £23.3m (£14.3m on health, £8.2m on social care, and £560k on joint projects) – see Appendix 1 for details.

Monitoring of BCF metrics and impact are reported monthly to the Joint Commissioning Executive (JCE) who also have sign-off responsibility for the section 75 agreement each year. The JCE took on this responsibility in 2018/19 when it was merged with the BCF Executive Group.

The CCG Governing Body has responsibility for signing off section 75 agreements.

The section 75 agreement for 2018/19 will essentially be a refresh of the 2017/18 agreement. None of the schemes will have changed, the financial schedule and governance arrangements will be refreshed, but other than that there is general continuity from last year and no major changes to report on.

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Key issues:

In September 2018, the JCE requested that an updated draft of the section 75 agreement be submitted to them for review in October 2018. Ahead of this, the new draft was produced and shared with CCG and Local Authority JCE members for comment.

Unfortunately, the October meeting was cancelled due to key members not being available to join. Therefore the section 75 agreement will be viewed for the first time by the JCE at the November meeting (7/11/18), which takes place after the next CCG Governing Body meeting (6/11/18).

There are likely to be further edits needed after the JCE review in early November, but following this the group will likely want to move towards sign-off as soon as practical after this – most likely at the December 2018 JCE meeting.

This may mean that the CCG Governing Body will not see a version of the section 75 agreement ahead of signing as the next meeting is scheduled for 8th January 2019.

Recommendation:

In light of the sequencing of events required to sign-off the BCF section 75 agreement, it is recommended that the CCG Governing Body delegate sign-off responsibility to the Accountable Officer and Chief Finance Officer, in order to sign as soon as the JCE have reviewed and agreed the final draft. This could then be ratified at the 8th January 2019 CCG Governing Body meeting in public.

Governance:

Corporate Objective

To commission high quality health care services that are accessible, provide good treatment and achieve good patient outcomes. To reduce the amount of time people spend avoidably in hospital through better and more integrated care in the community, outside of hospital for physical and mental health. To achieve sustainable financial balance by 2020/21.

Risks

There is a risk that should the recommendation not be approved, the signing of the section 75 agreement may be delayed until after the next CCG Governing Body meeting in mid-January 2019.

Clinical Leaders comments where appropriate

Not Applicable


None

Conflicts of Interest None

Implications for other CCGs None

Equality Analysis

Equality Impact Assessments were undertaken as part of the design of the service specifications.

Patient and Public Involvement None

Communication Plan None

Information Governance Issues None

Reputational Issues None

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