Quality Handover Document Cumbria Teaching Primary Care Trust

March 2013 Quality Handover Document

Dr Mike Bewick, Medical director and Director Primary Care; Prof John Ashton, Director of Public Health; Dr Neela Shabde, Director of Children’s Services; Moira Angel, Executive Nurse; Dr Dave Rogers, GP and Deputy medical Director; Dr Andrew Rotheray, GP and Deputy Medical Director

Preface

This document forms part of the Corporate Handover Documents from NHS Cumbria

and constitutes the quality handover element. As such, it should be read in

conjunction with the main Corporate Handover Document

1. Introduction This document forms part of the legacy handover process from NHS Cumbria to the relevant elements of the new NHS architecture established in line with the Health and Social Care Act. It records a specific focus on quality from the perspective of the Medical and Nurse leadership team of the PCT and does so in the context of the broader Corporate Handover Document. The Act has set in train a process of change and development within the NHS designed to sustain improved outcomes through a more clinically-led and responsive NHS service. As part of the process of change, Primary Care Trusts (and Strategic Health Authorities) are being abolished and a new organisational structure is emerging. The NHS is tasked with managing this process of organisational change in a way that keeps a focus on quality and does not inappropriately break the continuity of attention on long running issues and challenges. NHS Cumbria has chosen to support this through an extensive documentation of its strategy for change and the way in which that is reflected in service changes. The documentation is gathered in the Corporate Handover Document, of which this Quality Handover Document forms an integral part. The concept of a Quality Handover Document was introduced by the National Quality Board early in 2012. Each PCT Cluster is required to produce such a document and place it in the public domain through the final board meeting. Context for the handover process In 2011, Primary Care Trusts across the country were grouped together in Clusters. Each PCT retained its statutory form and duties but the grouping was designed to provide stability during the preparatory phases for the reforms and to make the best use of the management resource. Strategic Health Authorities were subsequently similarly grouped. Cumbria PCT had been created in 2006 by the merger of the three PCTs in the north of the county and the Cumbrian part of the former Morecambe Bay PCT. As PCTs were clustered it was decided that the scale and location of the county and the nature of the challenges within it were most appropriately reflected by NHS Cumbria being, in effect, a cluster of one. The PCT and Cluster are therefore coterminous with the County – an important alignment of health and the top tier of local government that had not existed prior to the formation of the PCT. However the nature of the county in terms of both its

history and geography is such that people often identify strongly with their particular part of it. Reflecting this, the PCT had developed a structure of clinically-led, locality decision taking. There are six localities broadly matching the footprint of the district councils. The GP community in Cumbria have valued this locality focus which is able to accommodate the geographic, demographic, social and economic variations but also the interdependencies and shared interest at a county level. They have therefore chosen to shape a Clinical Commissioning Group on a Cumbrian footprint but structured on the basis of the six localities. The result of this is that the current handover process is one in which a PCT Cluster of one PCT is handing over its core commissioning tasks to a single CCG. Similarly there is a transfer of a single set of local public health functions to a single Local Authority and a single set of primary care, specialist commissioning and systems leadership responsibilities to a single NCB Area Team (Cumbria, Northumberland, Tyne and Wear). In the case of the handover from the PCT to the CCG, the CCG is directly building on what has been developed in the Localities as they have increasingly led the commissioning and contracting tasks over recent years within the PCT. The transfer to the County Council is related particularly to the public health functions of the PCT and the core Public Health team within the PCT are being transferred to the Council, with some staff going to Public Health England. Again the handover carries fewer risks of the fracturing of the evidence and experience, because a single PCT is transferring to a single Council and doing so with the movement of a substantially intact team. The County Council will develop the way in which its additional public health responsibilities are discharged and the transferred expertise is deployed and utilised but, at the point of handover, there is an evident degree of continuity of knowledge and action. The transfer to the NCB is essentially to the new Area Team covering Cumbria, Northumberland and Tyne and Wear. It is a new team within a new organisation and it covers a large and complex geographical area. The functions transferring to it relate particularly to the commissioning of primary care and specialist services and to some aspects of systems management. It will be a significant part of the NHS landscape in Cumbria and with functions that impact directly on the quality of the health care of people in the county. The transfer processes are designed to ensure that there is a transfer of sufficient background knowledge to ensure that there can be appropriate continuity and that the Area Team has access to the evidence and intelligence relating to its functions that were within the PCT. The Corporate Handover Document as a whole, and this document within it, contributes to this. Importantly the transfer of these Corporate Handover Documents is being complemented with a series of face to face handover meetings between key “sending” and “receiving” staff at various levels. Addressing Quality in Cumbria The definition of Quality used by Lord Darzi has underpinned Cumbria’s approach to quality. He referred to three domains:

ü Safety ü Effectiveness ü Patient experience

These three clearly have interlocking aspects and are not mutually exclusive but they provide important points of perspective on what has sometimes been seen as a very amorphous and subjective issue. They have been at the heart of the goals of the PCT since 2006. Delivery of safe and effective services that provide a good patient experience is achieved through a broad range of factors and influences. These impact through:

Ø Individual transactions with patients Ø Organisational culture Ø Patient pathways Ø Service configuration Ø Systems management

As a commissioner, NHS Cumbria has discharged its responsibilities through strategic leadership, service redesign and pathway development, utilising the contracting processes to incentivise best practice and penalise poor delivery. It has also sought to ensure that lessons are learned and applied when things have gone wrong in services or in individual care. NHS Cumbria has sought to place clinicians at the heart of these processes and to drive service and quality improvement through the knowledge, experience and relationships of the clinical community. The details of the overall strategic approach, its rationale and what it has delivered are set out elsewhere in the Corporate Handover Document. The formation of the PCT provided the first opportunity for the NHS to take stock of the state of health and health care on a whole system basis across the whole County. In a description used at the time it could be summarised by saying that:

When compared with elsewhere in England, more people become ill than need to do so; of those who do, more people are treated in hospital than need to be and more stay in hospital longer than they need to; more people die younger than they should and more old people have an unhealthy old age. These generalisations about Cumbria conceal variations across localities within Cumbria.

The evidence behind this was set out in the first report by the Director of Public Health in 2007 and has been further developed utilising a life-cycle approach in his subsequent reports. It was also gathered extensively in preparation for the World Class Commissioning process through which PCTs were challenged to demonstrate their understanding of the health needs of their population and their capacity to impact on health outcomes on priority areas. The Strategic Health Needs Assessment was published in 2009 and has recently been refreshed by the NHS and County Council on a joint basis. The PCT inherited a health care system had evolved over the years in largely piecemeal ways. In a general sense it was not evidently the intended “patient led NHS”, working as a whole system. There was some fragmentation between primary care, community health services and hospital services, with an absence of clear clinical pathways and a consistent and seamless approach. This impacted both on the nature of patient experience and on degree of efficiency in the use of resources. In the minds of many it appeared that chronic financial pressures had precluded developments and immobilised the system.

The financial strain in the north of the county had led to the prospect of local, community hospitals being closed in order financially to support the relatively more remote acute hospitals. In the south of the county a hospital-led plan to remove acute services from Kendal echoed something of the same dynamic. It was against this background that the new PCT developed a business plan for a sustainable solution that would be built on clinical pathways reflecting best practice. This approach was about getting the right care, at the right time and in the right place. It involved a rebalancing of hospital and community services and the resolution of the underpinning financial problems, but at its heart it was about good, safe and effective clinical care that offered a sound and sensitive patient experience. The subsequent years have been about the implementation of this approach, in the context of the challenges of local change and the shifting national policy. The vision of Closer to Home was about safe and effective services and a sound patient experience. To achieve it there was a need for a more balanced development of services, with more assertive health promotion and upstream public health interventions and more care being provided in local services through primary and community care - with both resulting in a reduction in hospital admissions/lengths of stay. The consequential reduction in the bed base would contribute to the financial recovery as well as supporting investment in the community services that have a key impact on patient experience. These changes in structure or provision required changes in clinical practice in order to operate in more consistent clinical pathways; the changing clinical practice had implications for staff deployment and for skills and practice at an individual level. The changing clinical practice also had implications for organisational structures and relationships – especially if quality was to be a consistent theme and driver. The PCT set out to place GP leadership at the heart of the commissioning processes. The PCT was also as a direct provider of community services and through the engagement of primary care, it was positioned to push forward to create an increasingly integrated local NHS with an “out of hospital” emphasis. The Corporate Handover Document describes in more detail the development of the strategy; the processes of its implementation and the challenges encountered. In this context the detail is not important but the general theme is, because a key part of the quality agenda during the life of the PCT has been the ongoing reshaping of the service delivery system so that it is fit for purpose and its clinical pathways reflect best practice in terms of effectiveness, safety and patient experience. NHS Cumbria Quality processes Interlinked with addressing quality through this strategic, transformational re-shaping of the clinical pathways and the delivery system that facilitates them, the PCT has also continued to address a wide range of what present as more operational, transactional quality issues. For much of the life of the PCT, the PCT Board had a Quality and Standards Committee which dealt in some detail with quality issues. These particularly related to the provider services of the PCT and following their transfer to CPFT under the Transforming Community Services process, the Committee supported the PCT’s Provider Committee in handing a legacy document to the new provider organisation. Subsequently it was agreed that in the context of the delegated commissioning

arrangements set out in the Accountability Agreement, first with the Clinical Senate and subsequently with the interim Executive of the CCG, quality issues should form part of the main Board agenda rather than being dealt with separately. In 2011/12 and 2012/13 the Board received and approved a number of papers setting out the approach to quality. Serious untoward incidents (SUIs) The Medical and Nurse Directors have increasingly assumed a central role in relation to current quality issues. A core vehicle is the Executive SUI Group, which they lead. It operates a quarterly cycle of systematic quality/risk reviews with each of the provider trusts and oversees quality issues emerging with other providers as they arise. The CCG leadership is now a participant in the SUI group, assuming increasing leadership of it within the agreed framework for transfer of functions, moving towards 31st March. The SUI Group’s role includes:

o Active management/ review of reported cases and incidents o Connectivity with wider programmes of work Overview of regulator and review

reports o Linkage with the Medical and Nursing Director CIP/provider reviews o Briefing the NHS Cumbria Executive Team when necessary

Following a phased transfer of responsibilities for this work from the SHA, its scope now includes all StEIS reportable incidents and Safeguarding Serious Case Reviews, as well as other incidents defined as SUIs through local procedures. There are established escalation routes to the SHA and Regulators. Open StEIS (Strategic Executive information System) cases The National Quality Board expected SHA clusters to performance manage the close down of those open cases on the StEIS system by December 2012. On 1/7/2012 NHS Cumbria were managing 130 open StEIS cases (Cohort 1).

No of StEIS Incidents reported up to July 1st 2012

Cases received before July 2012 212 Cases open at 01/07/2012 130 Closed at 01/07/2012 83 Closed since 01/07/2012 71 Cases still awaiting closure 58

In collaboration with NHS Cumbria, the CCG has in addition commissioned external reviewers with mental health expertise to work on reviewing relevant outstanding cases; the reviewers are required to report back on themes arising from these cases. The themes will be used in the improving outcomes framework which will be the basis for commissioner provider discussions on their duty of quality at future contract and quality forums. All other cases within Cohort 1 have been reviewed by the Clinical Lead responsible. 15 cases remain outstanding for closure pending further assurance. Between 1/7/2012 and 14/01/2013 – 50 New Cases have been reported through StEIS (Cohort 2)

No of StEIS incidents reported since July 2012 Total numbers of Incidents reported since July 2012

50

Open 44 Closed 6 Reports submitted 8 Reports overdue > 45 days Reports outstanding <45 days

15 21

The CCG is revising the arrangements for future case management and is updating policy under the Leadership of the Accountable Officer, CCG Lead for Nursing and Quality and Medical Director for SUIs. The policy revision will be in line with revised national guidance from the Department of Health which confirms accountability arrangements for management of SUIs and safeguarding events within the new organisational forms. A transition and handover plan is in place between Cluster and CCG with timescales in place for transfer of responsibilities. Safeguarding There is direct connection between the SUI Group and the infrastructure to support Safeguarding within the PCT, across the health system and in conjunction with Local Authority partner, with particular reference to the improvements in quality required in the light of the CQC/OFSTED inspection reports. Initially this was given Executive and Clinical leadership from within the PCT and the action and delivery was being driven from within the PCT, this operational leadership has now transferred to the CCG, albeit with continuing transitional support from the PCT. The governance structure has been developed within health to drive the delivery of the necessary quality improvements includes:

Executive Health Steering Group which is providing strategic oversight, intra-organisational alignment and strategic performance management. This group meets on a quarterly basis and consists of all the chief executives of Cumbria health organisations, the Director of Children’s Services and a representative from the SHA. CQC Director Delivery Group which is providing strategic co-ordination and monitoring progress against the 19 recommendations for improvement. This group meets every two weeks. NHS Core Delivery Groups are using a task and finish approach to deliver specific areas of improvement within the CQC action plan. There are six groups:

• CAMHS

• Children with Disability

• Engagement

• Looked After Children

• Safeguarding

• Sexual Assault Clinical Pathway

The Health Safeguarding Network Group has been in place for over 2 years. This is being maintained to ensure all health partners continue to discuss and address wider safeguarding issues. This group reports to both the LSCB and the CASB. Contracting The direct input on quality in the contracting process has been led by a locality GP lead. Initially this was as part of the broad locality commissioning arrangements in the context of the Cumbria Clinical Senate. Latterly, as part of moving towards the NHS

reforms it has been within the Accountability Agreement between the interim CCG Executive and the PCT Board. This agreement established the interim CCG Executive as a committee of the Board. More recently, as part of the transitional processes, the interim Executive has increasingly also assumed a preparatory role for the CCG and then become part of the structure of the CCG, leading it through the authorisation process. Because of this evolution from Clinical Senate as part of the management structure of the PCT to Executive of the authorised Clinical Commissioning Group, there has been a continuity of focus on quality issues in the contract agreement and monitoring processes and the basis for a seamless transition of much of the knowledge and experience. The approach is now being designed and led by the CCG; there is direct input into it from staff associated with PCT functions and many of the data flows are those that have operated within the PCT as well as additional ones being shaped by the CCG. Central to this is a Quality Intelligence Group (QIG). The QIG began life within the delegated arrangements of the PCT and is being developed so that it can be a core building block for the CCG going forward. It is supported by a wide range of data and intelligence flows which are being aligned to it on a continuing basis. The purpose of the group is to scan the available hard and soft intelligence and ensure that feeds directly into relevant action through the contact monitoring or other channels as necessary. The QIG is developing early warning systems in order to spot issues ahead of significant impact upon quality. It is also intended to look behind the immediate data flows to identify trends, issues and underlying concerns, again ensuring that the information is highlighted to the relevant points for action. Handover NHS Cumbria devolved its core commissioning activity to its GP leadership and to clinically led locality groups. It is now transferring its responsibility to a single CCG. It has therefore been possible to develop what has, in effect, been a seamless and prolonged handover process. This process has embedded knowledge, experience and relationships in the new organisation and provides a valuable basis for the necessary continuity. Clearly the CCG will develop its own approach and this may necessarily be different from that of the PCT. There is evidence of emerging clinical networks and collaboration across trusts and also of the building of relationships with the medical school and universities; these provide real opportunities within the new arrangements. At the same time, it needs to be noted that the PCT has encountered a degree of institutional inertia in Cumbria. In seeking to challenge practice and address quality issues, It has come up against entrenched ways of doing things – sometimes rooted in historic organisational arrangements where different hospital sites were different organisations have still not integrated into a single organisation with a common purpose.

QUALITY PROFILE A part of the template for a Quality Handover Document is a quality profile of each provider. For Cumbria the quality profile of the current providers needs to be seen in a context of a number of broad, cross cutting underlying themes. They can be summarised as relating to:

o System change o Leadership and culture (clinical and managerial) o Clinical Governance and system intelligence o Drivers to deliver improved outcomes

The drive for re-shaping services and pathways set out in the Corporate Handover Document is about creating the context for high quality care; its sustained delivery is contingent upon the leadership and culture within which staff operate and the governance and intelligence systems which surround them. From the review of data, incidents and events, the following issues can be seen as being indicative of outstanding quality issues which arise in a context in which these cross cutting themes continue to impact: Hospital mortality Both HSMR and SHMI are aggregate comparative ratios and do not measure rates of death. Despite Trusts having higher ratios, all trusts have shown year on year reductions in the crude numbers of deaths. However both Cumbria acute Trusts have lagged behind others in addressing potentially avoidable mortality. At its November 2012 meeting (before the publication of the latest Dr foster data) the NHS Cumbria Board received a report which highlighted the fact that there were four underlying potential reasons which need to be considered and their influence understood or discounted:

1. Coding and Counting Practices Although there are national guidelines regarding how activity is captured, it is recognised that there will always be some degree of local variation in the interpretation and implementation of this guidance. However, these counting practices may not entirely account for the variation seen and further analysis is generally recommended. 2. Level of Service Being Delivered Although the HSMR and SHMI measures try to adjust for the complexity of patients, the data cannot fully reflect areas where hospitals, departments or individual consultants treat patients with specialist and complex conditions. In these cases it could be expected that more experienced or specialist teams would have a higher mortality rate than the national rate as their work involves the treatment of higher risk patients. For example, it is expected that the HSMR for Percutaneous Coronary Intervention (PCI) related diagnosis groups at NCUHT will increase as the service is implemented and developed to take on more complex patients.

3. Clinical Practice & Governance In some cases, HSMR outliers may reflect issues in clinical practice. This may be due to the way in which hospitals deliver care, aspects of direct clinical practice or the governance arrangements around the provision of clinical care. The clinical activity within a hospital reflects the wider clinical pathway across primary, secondary and potentially tertiary care; it should not be considered in isolation and outliers may reflect issues elsewhere in the pathway. 4. General public health In some cases outliers may reflect particular health issues in the local population. There is anecdotal evidence to suggest that some hospitals with previously high HSMR have seen their results improve alongside general improvements in the health of the populations they serve, where investment has been freed-up to enable a greater focus on, for example, stop-smoking and other public health services.

Both trusts have commenced their own analysis and both are participating in the collaborative established by AQUA (Advancing Quality Alliance) to conduct an independent review of their mortality rates. This work is conducted in three phases and UHMBFT finished the first phase in January 2012. NCUHT joined the collaborative later and have still not finished the first phase. The AQuA first phase report for UHMBFT recommended that the Trust:

• Pays greater attention to the recording of diagnoses as this will significantly influence the calculation of expected mortality rates. • Should strengthen its arrangements in relation to mortality including the development of a mortality reduction strategy and action plan. • Should ensure high levels of clinical engagement and ownership. • Should investigate the level of clinical quality and staffing levels in areas with high levels of expected and actual mortality and consider a care bundle approach to tackling these.

In the second phase AQuA is working with UHMBFT to support the development of a mortality reduction strategy. In the third phase AQuA will support the Trust in the implementation of the strategy and action plan that will accompany it. At NCUHT the progress was initially slower. NCUHT is now also to be subject to a review by Dr Bruce Keogh as part of the follow on from the Francis enquiry. Outstanding areas of action that have been identified include a. The implementation of the acute services strategy within NCUHT

b. Development of a streamlined paediatric assessment and admission service in NCUHT c. Enhanced recovery plans at both Trusts. d. Details of rota changes to consultant contract to achieve a consultant led 7 day service at both Trusts

e. Cross site working in acute specialities f. The alignment of services to demonstrate implementation of the vascular review g. The inclusion of data for stillbirths in SUI reporting h. Evidence of a move to integrated assessments for patients presenting with mental health issues in keeping with suicide prevention strategies.

The broad mortality statistics build from particular incidents and we have noted that over a period of time NCUHT has evidenced some slow reporting of incidents. There is some lack of assurance that lessons are learned from all incidents and applied to practise. Peri-natal deaths In 2011 NHS Cumbria commissioned a review to investigate perinatal mortality, and standards of maternity /perinatal care for women in Cumbria. The first phase of this work (‘Pregnancy and Birth in Cumbria: a statistical review’) was conducted by Liverpool John Moores University and looks at the health of the Cumbrian population of reproductive age, and the factors that might affect maternity outcomes. The second phase, a ‘review of Perinatal Mortality in Cumbria’ looks in detail at all identified stillbirths and perinatal deaths1 that occurred between 1 January 2009 and 31 December 2010 to women living in Cumbria and planning to deliver in either NCUHT or UHMBFT. The full reports have been published and are available at www.cumbria.nhs.uk Four key themes emerged from the analysis of both quantitative and qualitative data in the reports, from which more detailed recommendations were developed:

1. Appropriate risk assessment

a. Every booking should be reviewed by a senior healthcare professional b. Regular clinical audits of maternity care providers to ensure

consistency with NICE and RCOG guidance c. Re-evaluation and clear documentation of each woman’s history and

clinical picture 2. Use of clinical guidelines and evidence-based care pathways

a. Intrauterine Growth Restriction screening (Symphyseal fundal height plotted on a customised growth chart in handheld notes) at each visit, and appropriate clinical action taken where necessary

b. Women should be educated in the significance of reduced fetal movements

c. Adoption of standardised best practice and management of fetal heart rate traces

d. Expert perinatal pathologists should perform post mortem and placental histopathology examinations in all perinatal deaths

e. Documented counselling for investigations after stillbirths by a senior and experienced health care professional

1 Perinatal mortality encompasses both stillbirths (a baby delivered without signs of life at or beyond

24 completed weeks of pregnancy’) and early neonatal deaths (the death of a live born baby occurring

before 7 completed days’)

3. Clinical leadership, education and training

a. Review of all education and training programmes for all clinicians involved in maternity and perinatal care

b. Development and implementation of multidisciplinary learning programmes

c. Staff should be encouraged to learn, develop and attain experience from other maternity services

d. Review of clinical leadership structures to ensure effective and transparent delivery of safe and accountable maternity care

e. Clear clinical risk management for all maternity sites f. Review of documentation standards, with regular audits until optimal,

systematic and consistent documentation is obtained

4. Clinical governance and audit

a. Development of a protocol and policy for review of all serious perinatal adverse outcomes, to inform eh development of subsequent action plans

b. A named individual for implementing this policy in each maternity unit c. Commissioners should make use of contracts to ensure adherence to

this policy d. Consider use of maternity dashboard to plan and improve maternity

services A small number of themes were developed into local quality standards to assist current and future commissioners in ensuring high quality maternity services in Cumbria:

• Education and training

• Consistent and rigorous documentation

• Evidence-based maternity care

• Effective multi-disciplinary care Breast screening incident - NCUHT In Cumbria, breast screening is offered via the North Cumbria programme, provided by NCUHT (for North Cumbria) and the North Lancashire and South Cumbria programme provided by UHMBFT (for South Cumbria). The North Cumbria programme covers fewer than half the number of women covered by the North Lancashire and South Cumbria programme and is one of the smallest programmes in the North West.

A serious untoward incident concerning the North Cumbria breast screening programme was declared in June 2010 and breast screening services were suspended on the advice of the national Breast Screening Programme Office.

The subsequent review of breast imaging carried out at NCUHT identified 16 cases of breast cancer. There was evidence that consultant radiologists had failed to follow current best practice which led to the 16 women having a delayed diagnosis. These women are now bringing a group action against NCUHT.

The screening service was suspended for a total of six months and the service recommenced in January 2011 having been re-commissioned with a new provider, Newcastle Hospitals NHS Foundation Trust.

The screening service operated a catch up programme during 2011 and 2012 which was agreed with the National Programme Office and the SHA and by December 2013 the backlog had been cleared. The North Cumbria breast screening women is now screening women 3 yearly in accordance with national screening protocols.

Child Safeguarding Four serious case reviews were undertaken in Cumbria between 2010 and 2012. These Serious Case Reviews highlighted a number of key issues in safeguarding practice including information sharing, communication, recognition of risk, the quality of assessments and the quality of supervision and management oversight. Clear definitions of what high quality and safe care looked like were not apparent with NICE guidance routinely not being implemented. These reviews also highlighted the need for better systems to cascade learning and thus directly evidence impact on practice both within and across health organisations. At the same time performance management information and monitoring systems was underdeveloped with Section 11 audits the main mechanism for reviewing providers’ progress in relation to their safeguarding systems.

The PCT commissioned two external reviews for children and safeguarding both of which recognised reviews that Safeguarding Leadership, Systems and Professionals needed to be strengthened. They highlighted that the PCT’s statutory responsibility to ensure GP practices and staff had robust systems and practices in place to fulfil their role in safeguarding was underdeveloped. The PCT Response was to focus on specific areas across the health system to address

• Intra agency and intra professional working

• Transparent safeguarding leadership at Executive and Board level

• Capacity, support and development of the Named Safeguarding Professionals

The PCT strengthened its safeguarding leadership and monitoring by:

• The appointment of a full Designated Team including County Lead GPs for Children and Adults

• The appointment of a Safeguarding Business Manager offering a single point of contact for the escalation of concerns from across the health economy to the Designated and Executive Leads

• The appointment of Named GPs supported by an externally commissioned development programme

• Development of a Safeguarding Assurance and Monitoring Group by a PCT Non Executive to ensure safeguarding systems within the PCT and primary care were as they should be.

In 2010-11 it was agreed to adopt the NHSNW safeguarding self assessment standards as part of its formal contract arrangements. These submissions are scrutinised by the PCT/CCG Designated Safeguarding Professionals. The LSCB agreed to accept these provider self assessments in lieu of Section 11 submissions. It was also agreed to formally include monitoring action plans from SCR as part of this self assessment process

CQC/Ofsted Report on Safeguarding, and Looked After Children A Joint inspection (by Ofsted & CQC) of safeguarding children, and looked after children in particular, took place in April 2012. It resulted in separate reports, although the recommendations were the same. The inspections were of safeguarding as an outcome, not a function; i.e. the success of commissioning and providing of services to children in keeping them safe; and the target was NHS Cumbria as the commissioning trust. The CQC findings in respect of health services were that:

• The contribution of health to keeping children & young people safe is inadequate

• The contribution of health agencies to improving outcomes for looked after children is inadequate

The full QQC report is available at www.cqc.oorg.uk The Ofsted Report led to the County Council being served with an Improvement Notice by the Secretary of State. A Joint Improvement Board with an independent chair was established. The PCT and CCG are represented on the Board, and an officer of the Department of Education is an observer. The Board will be in place for the lifetime of the improvement period. The purpose of the Board is to ensure effective, cross-partnership challenge and oversight of the Improvement Programme, enabling it to deliver the requirements outlined in the Improvement Notice, the Ofsted report and the CQC report. The Improvement Board will provide a mechanism to align recommendations and areas for improvement made in both the Ofsted and CQC reports. Successfully addressing the CQC requirements is led by the Health Executive Steering Group which sees the Chief Executives and Medical Directors of Health organisations come together every two months jointly to address the recommendations made by the CQC. A Director Delivery Group meets on a fortnightly basis with the responsibility of maintaining a strategic overview of the progress that is being made. Work is progressing at three key levels – the development of a strengthening partnership with Children’s Services, the move towards a more integrated approach across the health economy and the work of individual health Trusts in response to the CQC reports and in line with CQC registration. Significant progress is being made across all elements of work. However, this is a major programme of work and must continue with added pace to ensure that services improve for the children and families of Cumbria. The key strategies for achieving the recommendations made by the inspectors are:

• Deliver high quality, effective and timely health services using a coherent, joint up approach with an appropriately resourced and skilled workforce to ensure that every child and young person in Cumbria receives equitable access to services that result in improved health service delivery.

• Engagement of children, young people, parents and practitioners so that they actively contribute to the development of new services; the redesign of existing services and the evaluation and monitoring of service delivery.

• Implementation of a system of accountability across all health organisations in Cumbria so that each organisation is held to account in order to deliver improved health outcomes for children and young people in Cumbria.

• Strong multi-agency working including effective partnership working with Cumbria County council and other providers of children, young people services in the county by working together to ensure that every child and young person in Cumbria reaches their true potential.

Each of the Provider Trust now has a variety of projects in place to address the safeguarding shortfalls identified whether as part of wider improvement programmes (UHMBFT and CPFT), as part of acquisition processes (NCUHT) and/or in direct response to SCR findings (eg CPFT following Child F) Adult safeguarding A recent peer review across Cumbria Safeguarding services has highlighted several areas of outstanding risk:

• Clarity of current functions of the PCT hub.

• Clarity of the role of the Health Safeguarding Network Group

• Ensuring that lessons learned from serious case reviews are disseminated across organisations.

• The need for the children’s triage system to be extended to adults.

• The level of joint working between adults and children’s safeguarding boards.

• The arrangements for the out of hours safeguarding systems.

• Level of understanding of the outcomes of safeguarding.

• Level of communication around care homes.

• Data quality

• The need for a review of training processes The CQC identified issues with restraint at Carton Clinic in 2011 on Eden Wood unit this was managed as an untoward incident and an action plan is in place. There is a current ongoing incident management group meeting regarding one nursing home in Allerdale locality and one other nursing home is closed to admissions. As the numbers of frail elderly increase the Care Home sector will come under increased pressure and there is a need to ensure that concerns are addressed. There is a need to develop clear and simple communication channels to enable GPs to discharge their safeguarding duties along side a busy workload. Systems need to be developed to gather data and soft intelligence to ensure

providers are practicing safely to reduce safeguarding incidents. People at risk of suicide on A&E pathways There have been 4 Serious Untoward incidents regarding people at risk of suicide on a pathway of care through A&E and assessment wards.

In Patient Falls Both Acute Trusts have reported an increased number of falls in 2012/13, arising from introduction of harm free care and prevention strategies in hospital settings. Deputy Directors of Nursing are currently leading harm free care and Safety Thermometer work within the acute Trust settings. North Cumbria has introduced the role of the Quality Matron, a Falls Group review of all completed Root Cause Analysis and action plans, updated training and information has been provided to staff regarding slips, trips and falls and what to do after an incident has occurred. The Trust has improved equipment availability, standardisation of documentation, policy changes regarding times of transfer and audit of clinical indicators, however falls continue to occur. A review by NHS Cumbria Head of Clinical Governance and Quality identified the main themes as:

• All RCAs undertaken for slips, trips and falls found fault with documentation

• On many occasions staff did not apply the systems and processes as outline in their organisations falls policies

• None of the patients were being assisted by staff at the time of the fall, half of the patients involved in falls incidents were not confused, but all had significant mobility problems. Patients with capacity were therefore making decisions which endangered themselves by trying to mobilise and their rationale for doing so needs to be further assessed.

• Staffing levels was only identified in one out of 29 reports reviewed as a contributory factor

• For those patients with cognitive impairment, technology was not being used to the best advantage to safeguard care.

UHMBFT major incident In 2011, a section 43 letter was issued to UHMBFT by the South Cumbria Coroner following an inquest into a paediatric death at Furness General Hospital (FGH) and the police announced an investigation in response. In July 2011 the Regulator (CQC) and the Nursing and Midwifery Council jointly undertook on site, compliance visits the Trust’s Maternity Services. The CQC was critical of the Trust with particular regard to the quality and safety of its Maternity Services and the CQC issued a warning notice to the Trust. Following a Risk Summit and the decision of Monitor to declare the Trust as being in significant breach of its terms of authorisation, in October, the SHA declared a NHS Major Incident in respect of the issues at the Trust, delegating to NHS Cumbria the responsibility for establishing a Gold Command and for managing the response to the incident in conjunction with NHS Lancashire, the Trust and SHA, with the involvement of Monitor and CQC. The specific reasons for the declaration of the major incident were:

1. Concern about patient safety following the letter from Monitor to the Trust, regarding their breach of the terms of their authorisation.

2. To provide a vehicle by which the resources of the whole NHS can be mobilized to work co-operatively to support the Trust and provide the public with reassurance and confidence that any concerns they may have are being addressed.

3. To ensure foundations were put in for recovery and the longer term, sustained resolution of the problems.

The task of a Gold Command was to respond to the current situation and to prepare for the future.

Its meetings were designed to ensure that Gold was:

• Informed of, and able to consider the need for any action relating to, any further incidents or events relating to the Trust and its services or any material developments in the wider context.

• Briefed on developments or events within Maternity, Neonatal and Paediatric services and on action taken by the sub group, confirming any decisions as necessary

• Briefed on developments in relation to outpatient follow up appointments confirming any decisions as necessary

• Able to review the need for any proactive intervention with regard to other service areas or governance

• Updated on any further action proposed by the Regulators and other external agencies

• Able to co-ordinate communications messages to the public in order both to support transparency and aid the recovery of public confidence.

It was apparent that the events that triggered the major incident were both of specific concern in themselves and also indicators of a wider failing of governance and process within the Trust. The culture was one in which there was a continuing high risk to quality. The action taken during the period of the major incident by the regulators and the trust itself, along with the wider system did much to create the foundations for safer and sounder clinical care. Gold was able to monitor mitigating actions with an immediate impact on specific risks. In addition to its routine meetings, Gold Command held stock take meetings in November, February and April, in order to review progress to date, to ensure the relevance of Gold’s activity and to consider the circumstances for de-escalation. Following the stock take meeting in April, the recommendation was made to de-escalate the incident and to put in place a co-ordination mechanism for the recovery phase. Following the Standing down of Gold in May 2012, an Incident Co-ordination group was formed to monitor the situation during the recovery within the trust and the return to the use of normal channels for dealing with issues and concerns. The intention was for the Group to have a light touch but to be available to respond quickly in the event of there being evidence of concern or should circumstances warrant it. The emphasis for performance and quality management and for assurance about delivery of the Trust’s recovery plan lay back with the emerging CCGs and the routine processes, including those of the regulators. In February 2013 staffing issues in the maternity unit at Furness General Hospital in led the Board to announce a decision transfer the unit temporally to Lancaster. This decision was then revoked following the engagement of commissioners and the wider NHS system with the calling of a further major incident. It is envisaged that when this incident is de-escalated, a Co-ordination group will be put in place to provide additional assurance across the system as the capacity for matters to be dealt with through ordinary channels is re-built.

Review of Child and Adolescent Mental Health Services [CAMHS] In early 2012 the CCG and CPFT collectively agreed to commission a review of CAMHS in Cumbria. The intention was to determine whether the services currently being provided were suitable, adequately resourced, available to the whole of Cumbria’s population, resulted in appropriate outcomes, and were configured in such a way as to facilitate partnership working with other agencies such as education and local authorities. The resulting report highlights a number of issues relating to:

1. Commissioning and Resourcing

• Cumbria CAMHS has less identified and ring fenced resource, and consequently

fewer staff, than it should. It has 63% of the staff it would have if resourced to the

level of the national average; a shortfall of some 31 staff against this benchmark.

It is recognised that the economic context and changes in clinical practice makes

full realisation of these numbers subject to modification.

• Commissioning specifications are imprecise, inadequate and insufficiently

monitored.

• The lack of outcome data has not triggered effective action.

• The Provider Trust has clearly not been successful in providing consistent

management.

2. Clinical practice

• In noting the significant shortfall in staffing as judged by any benchmark and the

current functioning of the teams, at this stage the Review Team could not give an

assurance to the CCG and CPFT that services are appropriate and responsive to

the needs of children and young people.

• Quantitative recording of data regarding clinical activity presents as inadequate.

• With regard to the skill mix in teams generally there appears to be a marked

deficit in staff who are experienced and skilled in working with patients with major

mental health difficulties such eating disorder, psychosis, OCD, depression etc.

Nursing staff with such skills and experience appear to be in short supply. The

service presents as being unduly oriented, in its staffing and outlook, towards a

psychosocial orientation in general and specialist therapies of a broadly dynamic

orientation in particular. The influence of a medical model presents, on the other

hand, as being very limited in comparison with other CAMHS.

• Three small teams working largely independently of each other and with a

significant element of geographical isolation has resulted in a problematic model

of practice and is a challenge to good governance and quality assurance. The

likelihood is that this factor has contributed substantially to the Service’s current

difficulty.

• Clinicians appear to have been reluctant to take on leadership roles and some

appear to have gone their own way with regard to the services they provide.

3. The wider system

• The current functioning of Cumbria CAMHS is clearly very poorly perceived at

present amongst individuals working in the service, by general practitioners who

refer to the service and amongst individuals in external services with which the

service interfaces.

• 24 hour cover should be an early priority as most CAMHS now provide this and it

is clearly in patients’ interests that they are seen by CAMHS staff from the onset

of their difficulty. The provision of 24 hour cover presents as impractical within the

current resource level. However access to CAMHS at key times could be

improved within the resources currently available.

• The link between tier 3 CAMHS and tiers 1 and 2 merits urgent attention.

Strategic direction and clinical supervision across the three tiers should be

provided from the specialist tier 3 team. However the risk is that if the boundaries

across the 3 teams are not clear then the specialist tier 3 service is likely to

become inundated with referrals which do not require specialist attention.

• The current arrangements for the transition of patients from CAMHS to Adult

Mental Health and other services are considered unsatisfactory. The CCG needs

to clarify that patients who require continuing treatment beyond 18 years and 3

months of age should exit CAMHS after an assessment by adult Mental Health

services. The CCG should ensure that such services are commissioned and the

CPFT need to ensure that such care is provided.

• A local tier 4 unit should not be considered at the present time as it would be a

very high risk diversion to the major task of restructuring the service. The

development of other enhanced services however is likely to attract high quality

applicants as the recruitment is undertaken and should therefore be given serious

consideration. In the absence of a local tier 4 unit children placed outside of the

county in such facilities should be the focus of ongoing clinical review and plans

made for their return to their home community as early as it is deemed safe to do

so. At present children and their families have to travel unreasonable distances

to access Tier 4 care; and the circumstances which necessitate this level of care

are inevitably distressing and this distress will only be made worse by the family

having to travel long distances. A strong clinical case exists therefore for more

local Tier 4 care as a longer term goal.

• In spite of the obvious difficulty a strong case does exist for the development of a

pan Cumbria CAMHS. Whatever team structure is adopted the separate teams

must meet regularly. It could include specific clinical pathways which are

delivered on an across Cumbria basis by combining sessional inputs of skilled

staff from across the teams.

The recommendations from the report set a challenging agenda for practitioners, the

Trust and the CCG if safe, effective services with a sound patient experience are to

form an integral part of the wider children’s service in Cumbria in the future.

Staff satisfaction Overall indicators of staff engagement (with their work, their team and their trust) are below average for trusts of a similar type. The scores for NCUHT and UHMBFT are in the lowest (worst) 20%. For staff working in NCUHT the bottom five ranking scores are for:

• Percentage of staff reporting good communication between senior management and staff, at 8% (compared to an average for acute trusts of 27%)

• Percentage of staff receiving job-relevant training or development in the last twelve months, at 71% (81% average)

• Fairness and effectiveness of incident reporting procedures, at 3.17 out of 5 (3.50 average)

• Staff recommendation of the trust as a place to work or receive treatment, at 2.90 out of 5 (3.57 average)

• Staff job satisfaction, at 3.33 out of 5 (3.58 average) For staff working in UHMBFT the bottom five ranking scores are for;

• Percentage of staff agreeing that their role makes a difference to patients, at 85% (compared to an average for acute trusts of 89%)

• Staff motivation at work, at 3.67 out of 5 (3.84 average)

• Percentage of staff feeling satisfied with the quality of work and patient care they are able to deliver, at 70% (78% average)

• Percentage of staff reporting good communication between senior management and staff, at 19% (27% average)

• Effective team working, at 3.59 out of 5 (3.72 average) Cumbria Partnership Foundation trust staff’s bottom five ranked scores were;

• Support from immediate managers, at 3.58 out of 5 (compared to an average of 3.77 out of 5 for mental health/learning disability trusts)

• Percentage of staff reporting good communication between senior management and staff, at 22% (30% average)

• Work pressure felt by staff, at 3.22 out of 5 (3.02 average, the lower the better)

• Percentage of staff having well-structured appraisals, at 33% (41% average)

• Percentage of staff working extra hours, at 76% (70% average, the lower the better)

The Trust achieved worse than average findings in 17 of the 28 key findings, and 8 of these 17 showed scores in the worst 20% of mental health/learning disability trusts. Workforce Education and Training The capacity and capability of the workforce delivering NHS care is a critical element of quality, in terms of the effectiveness and safety of the care and the nature of the patient experience. It has been noted that Cumbria has particular challenges with regard to recruitment and retention due to its distance from major centres and it being seen as an area for retirement. A recent CQC inspection at NCUHT stated concern related mainly to mandatory training and appraisals. The learning from the major incident in UHMBFT has highlighted areas for staff development. CPFT have a good record of providing staff training but the recent safeguarding inspection has shown that this does not always translate to changing behaviour on the front line. More generally concerns have been raised about the fitness for future purpose of the skills and competencies of the pool of NHS Staff in hospital and community settings.

The PCT has been aware of the need for a more proactive workforce strategy to be developed, notwithstanding the impediments created by the organisational structures and internal focus of provider organisations. As part of developing this and as part of managing the risk of transition, a scoping event was held in October in order to review the existing activity related to Education and Training in Cumbria. A consultant from Skills for Health has been commissioned to provide a report to clarify the receivers for the functions and areas of work identified and this will also feed into the emergent strategy under Education for England, Local Education and Training Boards (LETB’s). Elderly Care A recent review of Quality Care for Older People in Hospital by the Cumbria Health Overview & Scrutiny Committee made a number of recommendations to NHS Cumbria designed to improved outcomes through a coherent Commissioning Strategy. These include the need for Health providers:

• to demonstrate how patient stories are informing practice • to use their Governors as promoters and evaluators of the quality of care • Improved assessments • To see Voluntary organisations as a legitimate voice on quality issues affecting patients

• To improve their monitoring of the patient experience, especially post-discharge

• To improve their handling of key patient information • To reflect the major life choices of older people in their discharge planning • To improve training in dementia awareness, and develop skills in understanding and handling challenging behaviour.

• To review local overnight discharge practices from hospital The Cumbria Chief Nursing and Midwifery Advisory & Development Group were asked to provide oversight to the necessary changes. The Group is to ensure an action plan is developed.

Key Service Risk areas Against the background set out above, in this section we review from a clinical and commissioning perspective the particular quality risk areas in Public Health, Primary Care and the Provider Trusts., noting the management of the risks in transition to the receivers.

1. Public Health

As described above, the central strategy for NHS Cumbria was that of developing health and health care around individuals and their communities, helping more people to stay well and/or to have their health needs met locally, whilst having access to hospital services able to provide the right level of care in the right place at the right time. The strategy involved the redesign of hospital services but this was to be interdependent with a building of capacity in community and primary care and a more focussed approach to promoting health and well being. In terms of the core functions of the PCT and its strategic vision, the evidence of health inequalities and the impact of health promotion is fully part of the picture of NHS quality for the people who live in Cumbria. That evidence gathered by the PCT and the understanding developed about the issues behind it is part of our legacy to be handed over to the receiving organisations. Whilst this may particularly refer to the County Council and Public Health England as they takes on new Public Health responsibilities, one of the key aspirations of NHS Cumbria has been to ensure that public health perspectives are inextricably interwoven with the general health service commissioning and delivery across primary, community and secondary services. There is therefore an evident relevance to the CCG and the Area Team. The CCG will have continuing direct input of a core public health service from colleagues who have moved into the County Council. The Area Team will have its own public health resource. In this context therefore this document can simply record some general themes and lessons from the PCT’s experience.

In Cumbria the commitment to develop whole systems working between health services, local authorities and many significant others was present from the establishment of Cumbria Primary Care Trust in 2006. We recognised then that by working together at a strategic level towards a common purpose, and by devolving leadership and authority to neighbourhood and community level we had the opportunity to craft a public health system fit for modern times. The new organisation started to build strong partnership links at county and district level and began the process of integrating its work with other agencies and local people. Vital to this process was a public health understanding of health and its determinants. The public health directorate was created to address these wider determinants of health in conjunction with local authority and other partners. A multidisciplinary team split between different districts across the county worked from locality bases in Barrow, Carlisle, Kendal and Workington. The team brought together all the functions of public health – health improvement, health protection, commissioning and population-based prevention programmes together with good intelligence, communications and evidence-based supportive materials.

Key to the success of the new team would be its integration into new local and county strategic partnerships. Close working with GPs in each of the six localities was also the basis of developing health improvement strategies to meet local needs. Improving life expectancy for men in Barrow was one of the most significant challenges – needing priority focus on the most deprived wards where life expectancy was several years below the national average. The plan for Barrow involved a wide range of partners – such as Job Centre Plus, Sure Start and the neighbourhood management team as well as council, police, probation and the many community based programmes. Helping people to stop smoking was and remains a major priority; but helping people to get back into work has also been a vital part of the health improvement plan. Strong partnership working, particularly with Barrow Borough Council and voluntary groups, brought about a number of health improvement initiatives such as the Barrow Heart Town Initiative, breastfeeding support programme, child obesity interventions and promotion of physical activity. Carlisle achieved the World Health Organisation’s healthy city status in 2010. Eden and South Lakeland developed strong local strategic partnerships covering large rural areas with widely dispersed populations. They face similar challenges in meeting the needs of their ageing populations, improving the availability of affordable housing, sustaining viable communities and preserving local jobs and educational opportunities. The different communities of West Cumbria created a sustainable community strategy to address their health and environmental challenges. Copeland and Allerdale localities focussed on programmes to help people to stop smoking, reduce alcohol use and promote healthier weight. Partly as a result of the industrial history there are large numbers of people either leaving the workforce or who have never worked. Because the beneficial effects of working are well documented, we have collaborated with local GPs and community organisations to help people overcome health problems so they can stay in or get back into work. From the experience of NHS Cumbria over the last six years, it is clear that there are powerful countervailing pressures that have inhibited the NHS maintaining its desired focus on health and well being and therefore on tackling the raw health inequalities. These risks will need explicitly to be addressed or mitigated by the new organisations if further, sustained health improvement is to be achieved.

2. Primary Care

The risks around primary care are with workforce numbers and variation in practice. There is also a risk related to communication between organisations 1. Workforce Currently some of the primary care providers are running with vacancies and over the Christmas period we had 3 practices where they had no partner or salaried doctor cover at times due to a combination of vacancies suspension and illness. There is also a risk around the age profile of GPs in Cumbria where 44% of GP’s can retire within the next 9 years or earlier.

The CCG is doing a piece of work along with CHOC and the Partnership trust to look at how we can recruit sufficient numbers of Doctors into Cumbria to negate this. 2. Variation in practice Variation in practice is seen within all doctor groups and GPs are no exception to this. We do see variation in prescribing and referring patterns between practices and within practices. Some of this variation is seen in cancer referrals. The localities do monitor this and the practices have referral support staff and medicine managers to help them review this and look at how they can improve. The evidence this approach works is particularly seen in the prescribing budget where Cumbria is continuing to improve and is ranked number 1 in the North West for effective prescribing. There have also been occasions were they variation has been so significant that the primary care governance team have been involved. Benzodiazepine prescribing is an example of this. Variability is dependent both on the population demographics and the cultural attitudes towards prescribing benzodiazepines among GP’s. The variability is significant and inappropriate prescribing produces dependency. High benzodiazepine prescribers have been identified and there needs to be ongoing supportive work to identify the causes and introduce procedures to ensure that best practice is consistent through the County. 3. Communication issues Communication issues are a regular problem between primary care and other providers. Our patients not infrequently report that when they arrive for a hospital appointment, the referral letter is missing, or part of the referral such as the patient history is missing. Patient attending follow-up appointments also find similar issues. This underlines the need to get the primary care patient record accessible by those with responsibility for care of the patient wherever the patient may be. Performance and Practise Management The following paragraphs provide more detail on the way in which in primary care quality issues have been addressed in NHS Cumbria and the handover of them. The Primary Care Directorate has responsibility for monitoring the performance of all independent contractors in Cumbria, to ensure the delivery of high quality, safe patient care in line with contractual requirements. Independent contractors include Primary Medical (GPs), Primary Dental, Optometry and Pharmacy, and the number of contractors in Cumbria are shown in the table below:

The handover plan ensures appropriate transfer to the Area Team of the practice profile data relating to the practices in the CCG along with current and relevant past intelligence relating to performance issues of individuals/practices where there or have been reason for concerns; investigation or action.

Provider Category Contract Type & No

Contract Type & No

Contract Type & No

Total

Primary Medical Contracts – GPs

GMS - 72 PMS - 9 APMS - 1 82

Primary Dental GDS - 104 PDS - 12 116

Optometry 74

Pharmacy 107

Maintaining quality through contract monitoring and performance

Primary Medical Contracts (GP Practices) The performance of Independent contractors is monitored at practice level within the Localities (now within the CCG) and at PCT level, by means of practice profiles and practice reviews. The CCG structures and processes provide a mechanism for continuing upward pressure on practice performance and standards. This will sit alongside the contracting processes which will transfer to the Local Area Team.

Primary Dental Dental Contracts are monitored under the General Dental Services (GDS) Regulations with formal mid-year and end of year reviews. At mid-year, contractors who are reported by the Dental Practice Board (DPB) as having achieved below 35% of contracted activity are formally reviewed and measures to reduce the risk of claw back at year end are negotiated. This may involve a non-recurrent or recurrent in-year adjustment. At year end, all contracts are formally reviewed against activity as reported by the DPB. Face to face meetings are offered to all contract holders, however contracts showing less than 96% achievement are prioritised. Financial penalties are implemented on all contracts who achieve less than 96% on conclusion of the review. The amount recovered is the shortfall up to 100%, i.e. if a contract delivers 94% of contracted activity 6% of the overall contract value is recovered. The timescale for the recovery varies from a single lump sum payment to monthly instalments by the end of the financial year. A breach notice is issued to all contracts who achieve less than 96% of contracted activity and the review includes negotiation in relation to the forthcoming financial year. If the contract holder is unable to satisfy the Dental Commissioning Manager that measures have been put in place to achieve beyond 96% of the contract, a contract reduction is negotiated and agreed as part of the review. Contractors who achieve over 100% of contracted activity on conclusion of the review are able to carry up to 4% into the next financial year. No additional payments are made for contractors who exceed 100% of contracted activity. PASS Group & Performers’ List Committee The remit of the Performers’ List Committee (PLC) is to fulfil the responsibilities of Cumbria Primary Care Trust for monitoring and regulating General Medical, General Dental and Optometric practitioners, under the National Health Services (Performers’ List) Regulations 2004 [“the Regulations”], as amended. The PLC will decide on whether it is appropriate to suspend, remove, contingently remove or conditionally include a practitioner on NHS Cumbria’s Performers’ Lists, and determine any other appropriate action. The Committee meets on a regular basis to discuss and review on-going cases. As and when required, the Committee meets as a Performers’ List Panel for the purposes of conducting oral hearings. Figures indicate that up to 5% of te PCT’s registered performers could, at any one stage, be involved in either the PASS scheme or be subject to the Performers List Committee processes.

ACTION UNDER PERFORMER LIST REGULATIONS NUMBER OF CURRENT

CASES (AS AT 18.1.13)

Suspension 2

Contingent removal 0

Removal 0

Conditional inclusion 16

Voluntary undertakings 0

Performance and Support Scheme (PASS) Groups

The Performance and Support Scheme (PASS) Groups report to the Performers List Committee. The PASS Groups have delegated responsibility for identifying and managing the performance of those General Medical, General Dental and Optometric practitioners about whom concerns are of a lesser gravity than those falling within the provisions of the Regulations. The PLC receives an update on the cases that are dealt with by the PASS Groups. A Pharmacy PASS Group is also in existence although there is no requirement for community pharmacists to join a Performers List. The aim of the PASS groups is to enable individuals to continue to practise, while providing appropriate support to ensure clinical safety. The groups provide remedial support or source more formal training for individuals as appropriate, supported by local regulatory committees, and clinical tutors. During 2012, the following number of new cases were reported and dealt with by the Groups together with outstanding cases from previous years:

NUMBER OF CASES

GP PASS Group 6

Dental PASS Group 3

Optometric PASS Group 0

Pharmacy PASS Group 1

Of these, two of the GP cases were referred on to the Performers’ List Committee, the remainder have been dealt with within the remit of the PASS groups. Appraisal Medical appraisal has been identified by the Royal College of General Practitioners as a key element of revalidation. The GMC issued all GPs with a Licence to Practise in November 2009. The licence does not have an expiry date, but in order to retain their licence all doctors will be required to fulfil the criteria for revalidation. From 2013, revalidation of licensed doctors will be required every five years. Under revalidation, the Responsible Officer (or their deputy) will review a range of data, including a portfolio of specified supporting evidence submitted by the GP, evidence of regular clinical general practice, other clinical governance data and evidence of annual appraisal. From this

information, the Responsible Officer will then decide whether the GP is considered up to date and fit to practise, and if so, will recommend the doctor for re-licensing.

Leadership and Management Structure The GP Appraisal Process is led by the GP Appraisal Lead and Steering Group and the administration is undertaken by the GP Appraisal Co-ordinator. Dr Andrew Rotheray, Deputy Medical Director with responsibility for Revalidation and Appraisal and Anne Steer, Primary Care Business Manager with line management responsibility for the GP Appraisal Co-ordinator, provide a clearly defined link between GP Appraisal and Clinical Governance.

Quality Assurance To ensure that the Appraisal and Clinical Governance processes are in place to support Revalidation, the Strategic Health Authority requires NHS Cumbria to complete the ORSA (Organisational Readiness Self Assessment) tool. This self-assessment exercise is designed to help designated bodies in England, as defined in The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty’s Stationery Office, 2010), develop their systems and processes in preparation for the implementation of revalidation. The results of the self-assessment inform the Secretary of State’s decision regarding commencement of revalidation. The self-assessment process will also enable NHS Cumbria to provide assurance to the level two responsible officer (the responsible officer at the strategic health authority or the cluster of strategic health authorities), regulators, patients, the public, the profession and other interested bodies, that they are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer’s recommendations.

Development Needs The educational needs of appraisers as identified from their evaluation forms are used to inform the programme for the annual Study Day. In addition, in readiness for revalidation, appraisers must undertake top-up training. 71% of appraisers in Cumbria have completed this additional training at March 2012. Dental Appraisal An appraisal system for dental practitioners has also been developed, supported by the Deanery and Dental Practice Advisors. Quality and Outcomes Framework (QOF) Assessment Process All practices participating in the QOF process are required to complete a QOF Self-Assessment and Declaration Document indicating which of the organisational domain indicators they will achieve at year end. Clinical indicators are assessed via the QMAS system which extracts clinical reports on a monthly basis and a final report at the end of the financial year. Whilst practices are not asked to submit any written evidence with their Self-Assessment Declaration to support their achievement of the organisational indicators, they are advised to keep the evidence available within the practice as they may be requested to provide it during a practice visit or a counter fraud probity visit. When the QMAS system provides the end of year final report for each practice, the Primary Care Locality Managers verify the practice achievement via the QMAS system against the Self Assessment Declaration Document submitted by each practice, before signing off the QMAS report as authorised for payment. Where there is disparity between the QMAS report and the practice Self-Assessment, further discussion would take place between the Primary Care Locality

Manager and the practice to seek agreement on achievement. There is a dispute process in place where agreement cannot be reached. From 1 April 2013 onwards QMAS will be replaced by Calculating Quality and Reporting Service (CQRS). CQRS is being developed to support the organisational structures and commissioning arrangements, which is being implemented as a result of the Health and Social Care Act and will be in place to calculate payments for GP practices across England for the 2013/14 financial year. It will be the new system for calculating and reporting on quality services delivered by GP practices, including the QOF, nationally-commissioned enhanced services and services commissioned locally. Exception Reporting Practices may on occasion exclude specific patients from data collected to calculate QOF achievement scores. For example, patients can be excluded from the denominators of individual QOF indicators in accordance with valid exception criteria as detailed in the annual QOF guidance documentation and BMA Exception Reporting Guidance. This may include patients who have been recorded as refusing to attend review, patients for whom it is not appropriate to review their chronic disease, for example where they have a terminal illness, and patients for whom prescribing a medication is not clinically appropriate. In order to analyse the levels of exception reporting, each clinical area is assessed against national and PCT averages showing on QMAS. Any areas that showing a higher average exception rate than the national or PCT average are further investigated and practices are asked to demonstrate the reasons for these exceptions. Assurance and oversight is provided by the Primary Care Governance Group, membership as follows: Medical Director, Deputy Medical Directors, Associate Director of Primary Care, Primary Contracts Manager, Primary Care Lead, Primary Care Business Manager. The objectives of the Governance Group are:

o To facilitate and promote a system of integrated governance throughout primary care

o To raise standards in primary care quality and performance o To provide leadership and direction to the primary care directorate o To provide an overview of the primary care training and education strategy. o To use data to support an “early warning” system around practice and

individual performance The remit of the group covers all aspects of primary care governance, including individual and practice performance issues, contract management, SUI reporting, safeguarding, appraisal, training and dissemination of information as appropriate to support reflective learning. During the current financial year, as we move through transition to become part of the NHS National Commissioning Board, the Governance Group is essential in ensuring that systems are place to maintain appropriate levels of scrutiny and ensure that our organisational memory is protected. We are working with the CCG through the Quality Intelligence Group to develop a database in which all primary care data can be stored, providing an accessible repository in which not only quantitative information but also soft intelligence can be held. There is still work to be done in the development of a common accessible information source and we do not underestimate the complexity

of the task. However experience over the last three years has shown that access to robust data enables us to detect early warning signs of deteriorating performance in primary care and to take early remedial action to support individuals and practices. We also recognise that patient feedback provides a powerful source of information which we currently do not use to its full potential. Again, in conjunction with the CCG we anticipate that a real-time patient feedback system can be put in place in primary care, as well as with secondary care providers. Workforce Development Mapping The current and anticipated impact of changing and increasing demands on health care services together with expected changes in clinical workforce profiles, due to a changing demographic e.g. ageing workforce and retirement forecasts, and an increase in part-time working in balance with work-life preferences, has been a catalyst to further analysis and to inform short and medium-term evaluation and planning.

General Practice Mapping of current clinical resources in relation to local population demographics in two out of six localities (Furness & Allerdale) has highlighted common issues of insufficient numbers of GPs and nurses to effectively manage current and future demand. The purpose of mapping supply and demand was to help to estimate the number of GPs required in the future, to meet the increasing demand resulting from population changes, and from changes to the current workforce, e.g. due to retirement. Many of the challenges faced by Furness and Workington populations include lack of employment, a high percentage of children living in income deprived households, unhealthy lifestyles and poor life expectancy, and difficulties in retaining young people through lack of employment opportunities that combine to create a greater demand on services.

GP Practice Nursing Workforce and Strategy development The engagement of general practice nurses through stakeholder groups and audit to identify skills and training needs has been developed in recent months. A task and finish group of the Cumbria Chief Nursing and Midwifery Advisory and Development group undertook to develop a strategy for all nurses, including non-registered healthcare staff to support and develop nursing staff. A proposal is being made to the Cumbria Clinical Commissioning Group Executive for consideration and agreement in principle of the recommendations within the strategic report and outline business proposal. Safeguarding Several initiatives have been undertaken to raise awareness of safeguarding issues and the importance of appropriate safeguarding policies and procedures in general practice. In September 2010, an audit was undertaken of safeguarding procedures across all general practices. This included the following information:

• The current safeguarding lead within the practice and how they report to the primary care team regarding any concerns that arise.

• Confirmation that the safeguarding lead had undertaken the required level of training for this role.

• Whether practices kept an ‘at risk’ register and annotated electronic notes.

• Held regular primary healthcare meetings to discuss vulnerable children and families

• Whether there were escalation policies in place to inform other agencies of concerns.

• Whether new patient assessment criteria included a risk assessment of vulnerable children and their parents/family.

• Whether there were any risk assessment tools in place

• Whether the practice had completed the RCGP self assessment tool. This information was collated to provide a county-wide picture and to enable resources to be appropriately targeted and awareness raised most effectively. The Quality and Outcomes Framework (QOF) requires that general practitioners and their staff undertake regular safeguarding training. Practices are also asked to submit the names of the GP Safeguarding Lead and their Deputy within their QOF Self Assessment Declaration document. In 2011/12, the delivery of safeguarding training has been extensively reviewed and a new educational package developed. Cumbria-wide Safeguarding Leads for Children and Adults have been appointed. Locality GP Safeguarding Leads have also been appointed and are undergoing training which will enable them to train nominated GP Safeguarding Leads within each of the practices in their Localities. The practice Safeguarding Leads will in turn train all practice staff within their individual practices using the new educational package. The Primary Care Development Team provides regular updates through Practice Manager Forum meetings and its monthly Practice Manager Newsbrief. Specific safeguarding issues are addressed through face to face meetings with practices. To support practices to meet their legal obligations as employers in relation to Criminal Records Bureau (CRB) checks, the PCT agreed to act as an Umbrella organisation, processing checks on behalf of individual practices. The on-going responsibility for ensuring that safeguarding and assurance systems for both children and adults is embedded in general practice rests with the Primary Care Governance Group. Any issues highlighted to this group will be brought to attention of the Safeguarding Project Oversight Group. Care Quality Commission - GP registration GPs and other primary medical services will need to be registered with the Care Quality Commission (CQC) by April 2013. The application process began in July 2012. The essential standards of quality and safety are central to the CQC work in regulating health and adult social care. Each of the standards has an associated outcome that the CQC expect all people who use services to experience as a result of the care they receive. Outcome 8 is Cleanliness and infection control. Infection Prevention Providers need to comply with the requirements with the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. The Code of Practice sets out the 10 criteria against which the Care Quality Commission (CQC) judge a registered provider on how it complies with the cleanliness and infection control requirement, which is set out in regulations. Not all

criteria will apply to primary medical care but to ensure that consistently high levels of infection prevention and control are developed and maintained, it is essential that the Code is read and consideration given to the whole document and not just selective parts. The Infection Prevention Team have been working with primary medical care in auditing practices. Some practices have completed a self-audit whilst others have had visits on site by the team. These audits have highlighted areas that require action to meet the required standard of infection prevention, particularly in areas where treatments and or misnor surgery is undertaken.

Antibiotic prescribing The use of antibiotics can lead inevitably to antibiotic resistance. Inappropriate prescribing leads to development and spread of resistance and therefore efforts should be made to encourage rational antibiotic prescribing. The use of broad spectrum antibiotics should be minimised wherever possible. The Medicines management team continues to raise awareness among prescribers of high volume antibiotic prescribing in Cumbria. In 2008/9 Cumbria was the third highest prescriber of antibiotics (by volume) in the North West with few practices comparing favorably against the national and North of England averages. The latest North West Antibacterial report for Oct 2011-March12 highlighted that Cumbrian antibacterial prescribing has improved over the last 2-3 years. Cumbria is now 8th highest within the North West SHA and below the North West and England averages and has the second lowest cost for antimicrobials in the North West.

Care homes and care agencies

The Infection Prevention Team is involved in the PCT Nursing Home Early Warning Quarterly Reviews. Intelligence from infection prevention audits feeds in to these reviews. The Team continues to take part in training organised by both Care Sector Alliance Cumbria and Cumbria Care.

Peer reviews Cumbria Chief Nursing & Midwifery Advisory & Development Group (CN&M&AD) is establishing a multi stakeholder partnership to champion quality care and ensure alignment in the quality of care throughout Cumbria inclusive of both NHS & non-NHS care organisations.

In 2008 the PCT endorsed an annual programme of unannounced visits to PCT in-patient areas to gain assurance that the PCT was compliant with the criterion set out in the Code of Practice for the Prevention and Control of Healthcare Associated Infections (Department of Health 2009). In doing so issues that were found that would result in a failure to comply was subject to immediate improvement and the areas revisited to check those improvements had been made. The results and resulting actions were reported at Trust Board meetings. Each in-patient area was visited by a Trust Board member – Director or Non-Executive Director, accompanied by either an Associate Director or a member of the Infection Prevention and Control Team. The Infection Prevention Team is currently working with the Chief Nursing and Midwifery Advisory and Development Group in developing a multi-stakeholder peer review process using the process above as a framework. The intention is to use this process in both NHS and non-NHS organisations.

3 The Provider Trusts

University Hospitals of Morecambe Bay Foundation Trust

UHMBFT has been the subject of significant regulatory action over the last year and continues to be regarded by Monitor as being in breech of its authorisation. A major incident was declared in 2011 because of an increasing range of issues and concerns but particularly in the light of safety and quality issues within the Trusts maternity services. The Gold Command established to manage the incident also addressed failings within the outpatient systems which had resulted in large numbers of patients not being followed up within the intended timeframe; shortcomings within the emergency care pathway and wider weaknesses in governance. Action was taken within the Trust to mitigate or address all the identified concerns and to rebuild the confidence of patients, staff, regulators and the commissioners but this recovery process is inevitably still ongoing. In the meanwhile, a subsequent major event was called following the Trust board’s decision that it was not able to provide a safely staffed Special Care Baby Unit in Furness General Hospital and therefore that unit would be temporally transferred to the Royal Lancaster Infirmary, with impact on the wider maternity service at FGH. That decision was revoked following support from the wider system and the Gold command has actively monitored the situation. It is likely that the major incident will be de-escalated in late march and an ongoing Recovery Co-ordinating Group established in order to maintain an ongoing process on the issues from the two major incidents and the regulatory action, and recognising that the police investigation is continuing. Performance indicators show a number of ongoing quality related issues within the trust, notably in relation to Ambulance Turnaround times A&E targets and referral to treatment times. In addition there have been recent reviews highlighting weaknesses in particular pathways including stroke and cancer care. Staffing levels (and the use of bank/agency) have been a concern in some areas. These have been proactively addressed in maternity and elsewhere, mitigating some of the risk, but the solutions are not necessarily financially sustainable. Sickness absence and staff morale have perhaps inevitably, been significant issues over the recent past and continue to present challenges – as referenced above in the staff survey. The different cultures and competing pressures between the three sites, can be seen to continue to present a considerable challenge in building a common identity and a coherent clinical approach across the geographical and social scope of Morecambe Bay. Again, this is being actively addressed by the new management of the Trust but challenges remain. A process of major service review and the development of a clinical strategy has begun in partnership with Lancashire North and Cumbria CCG. It is anticipated that this will lead to material cost reduction by 2014/15 but the scale and scope of the undertaking and the political and public context make this a challenging objective. The CCG is already working directly through its contracting/contracting monitoring processes in order to challenge and incentivise the trust to address immediate quality

performance indicators. This includes the monitoring of the quality schedules and the CQUIN programme. In addition the CCG is working with the Trust in the development of a clinical strategy that will provide a coherent context for a review of pathways and services in order to ensure a sustainable set of services models that can reflect best practice in terms of quality. Recognising the reality that the trust serves two principle CCG populations, Cumbria CCG is collaborating closely with Lancashire North CCG in its operational/contracting activity and in the strategy development. In terms of handover from the PCT to the CCG this is substantially achieved and the active involvement of the leaders of the latter mean that intelligence and memory are substantially transferred. The two Area Teams are also actively engaged in the issues with the support of NHS North. The immediate future for the trust is one of a prolonged period of practice and service change and of financial pressure. It must represent a period of continued heightened risk in terms of safety/quality; staff morale and public confidence.

North Cumbria University Hospitals Trust The PCT consulted on a commissioning strategy (Closer to Home) with specific changes required in the hospital services provided by NCUHT. The strategy was for there to be greater coherence between the two sites and for the development of effective and efficient patient care pathways in line with best practice. Despite apparent support for that Strategy, confirmed through the clinical strategy review process in 2011/12, the Trust has not yet been able fully to deliver the change programme and to secure the essential safety and quality improvements to services and working practices. That lack of progress has resulted in the continuation of the quality (and service and financial) issues that the strategy was put in place to address. Continuing poor performance against key targets such as A&E and RTT as well as the poor SHMI data (see above) can all be seen to be indicative of this underlying delay in delivering the planned service changes to bring practice and performance in line with best practice. At the same time there have been specific service and pathway concerns that indicate specific service weaknesses and imply a more general systemic weakness in governance. The Breast Screening failure led to the declaration of an incident in 2010 and has been the subject of a root cause analysis report published in 2012 . Peer review reports have indicated weakness in cancer pathways. The due diligence process undertaken by Northumbria pointed to issues around risk identification, management and mitigation; the connectivity of the Board to the quality and operational issues within the trust; the maintenance of a quality improvement cycle/culture and the strategic focus and direction of the organisation. More generally there are a range of current indicators which individually and collectively can be seen indicate the risk of quality being compromised. These are all issues which have featured in the quality and contracting process and the SUI Group meetings with the provider and include: :

• Apparent low levels of incident reporting have not been fully understood, • A recent history of concerns being raised by staff and staff organisations regarding staffing levels and structures, and the management response to

incidents and service level concerns. This has been articulated by LINk and through the OSC.

• Whilst bed numbers have reduced, the workforce appears not yet to have been fully realigned to match, and the grade/skill mix is not seen as ideal.

• Performance target breaches remain - particularly referral to treatment times and A and E (again regular level 3 reports)

• The data shows specific clinical pathways with serious quality issues which have yet to be resolved - palliative care has been raised through LINk and elsewhere.

• Whilst some issues raised by the published mortality rates are being addressed, the SHMI Data suggests that data and/or service quality issues remain.

• The trust continues to face major financial challenges in the short and longer term.

• The trust has yet to overcome historical divisions/fragmentation between its sites and to create a coherent service that can be seen to respond appropriately across its patch

• The trust has to deal with a build up of workforce change issues which will have to be addressed and for which there is no longer scope for an incremental process over a longer period.

Staffing levels and skill mix have been a concern in some areas. These are being addressed but link with wider issues of service design and sustainability. The staff survey highlights very substantial and profound issues of confidence and morale. The different cultures and competing pressures between the two sites, can be seen to continue to present some challenge in establishing a coherent clinical approach between the Carlisle and Whitehaven hospitals. Whilst this is being actively addressed by the new management of the Trust but challenges remain. The trust continues to be reliant on additional support/transitional funding. Its core issues have not been addressed in such a way that it can live within its income. A challenging set of Cost Improvement Programme (CIP) targets confront the trust in the immediate future and its history of delivery of these is not strong. The financial challenges have led the trust towards merger and acquisition but this solution been seen as being a potentially powerful way of enabling turnaround and recovery in terms addressing the above quality issues. As Northumbria assumes the management lead and moves towards formal acquisition, action plans are being developed – though they are likely to take some time fully and sustainably to bear fruit. It is likely that as this work continues additional issues and concerns will emerge. It is also inevitable that the Trust will face a period of sustained clinical and service change. In terms of handover from the PCT to the CCG this is substantially achieved and the active involvement of the leaders of the latter mean that intelligence and memory are substantially transferred. The Area Team is also actively engaged in the issues with the support of NHS North.

Cumbria Partnership Foundation Trust Many of the reported performance indicators for the Trust are positive in relation to its mental health and community services. However, there continue to be concerns about aspects of safety, effectiveness and patient experience, particularly but not exclusively relating to the mental health services. The staff and patient survey data when compared against other mental health trusts in the North West shows CPFT being ranked the worst on the patient survey safe, high quality care domain and on the proportional measure of staff in agreement that effective action has been taken by the Trust following errors. . In addition, Mental Health commissioners have expressed particular concerns in relation to contract quality issues and serious untoward incidents. The concerns relate to both to particular events, circumstances or trends and to the adequacy and effectiveness of the trusts response and action plans. Recent Serious Case Reviews, the CQC report on safeguarding, and the external review of CAMHS indicate real issues of concern about quality and/or delivery, including the engagement with patients in their own care. They also bring limited confidence that CPFT learn from SUI themes and take appropriate action that is evident in practice. PCT and CCG staff who work with the Trust have experienced it as having some reluctance to invite and accept different perspectives from both inside and outside the organisation. This requires more exploration in order to identify the reasons for it and its significance in terms of quality. The current change of leadership may well have a material affect. There is continuing dialogue with the Trust on these issues in the SUI Group and also via the main contracting group and the quality sub group. In addition there is currently work to triangulate the ‘information and intelligence’ to agree robust ways to ensure systems and care delivery is safe. In terms of handover from the PCT to the CCG this is substantially achieved and the active involvement of the leaders of the latter mean that intelligence and memory are substantially transferred. The Area Team is also actively engaged in the issues relating to quality, with the support of NHS North.

Other Providers – Nursing Homes A significant number of people receive care in nursing and care homes that is funded by the NHS or jointly funded with Adult Social Care. There have been two serious untoward incidents in Nursing Homes in Cumbria in the last two years. Both these incidents involved poor standards of nursing care particularly in the areas of tissue viability and record keeping. Poor staffing levels and a lack of training were also identified as issues. Both homes required high levels of input from continuing care staff and staff from CPFT to resolve the issues. One home is still the subject of regular incident management meeting as progress has been slow. The incidents highlighted the absence of systematic intelligence about nursing homes. This has led to a situation in which the PCT has been responsive only as

situations have arisen. In the light of this a pilot process has been established (in conjunction with the CCG) within one locality in order to develop more effective and consistent monitoring. This will enable a high level quality profile for the sector to be developed and used, with the potential for early warning signs being identified. Recent safeguarding issues have increased awareness of the reduced focus on some aspects of joint commissioning of residential provision for adults. As part of the transitional process (in conjunction with the CCG) work is being undertaken with Adult Social Care to refresh, strengthen and systematise the joint arrangements which have become somewhat fragmented and ad hoc. This will help facilitate the use of an overall quality profile. Residential services provided outwith the NHS are a key part of the overall care system experienced by people in Cumbria. Further quality surveillance /quality development work in relation to care commissioned from residential and nursing homes is an important issue for the CCG and its partners going forward.

PCT’s quality related functions and responsibilities Recipient bodies

Quality information requirements

Commissioning and contracting with organisations for the provision of secondary care and community services

CCG Contracts (including schedules and CQUINs) and related performance data

Commissioning and contracting with persons and bodies for the provision of primary care (general medical, general dental, ophthalmic and pharmaceutical) services

NHS CB Contracts (e.g. GMS, PMS, GDS etc)

Commissioning and contracting with organisations for the provision of some public health services

CCC& PHE NHS CB

Contracts; Section 75 agreements

Commissioning and contracting with organisations for the provision of Offender Health Services

NHS CB Contracts and related performance data

Determining local health needs and what services are to be provided to meet those, having regard to the resources available

CCG CCC & PHE

JSNA

Make arrangements to secure continuous improvement in the quality of care, having regard to standards published by the Secretary of State

CCG Operating Framework – related performance data

Make arrangements to receive appropriate advice from persons with professional expertise relating to health

CCG, CCC NHS CB

PH and CCGs Agreement

Prepare health improvement plans CCC & PHE CCG

NHS CB

JSNA; Joint Health & Wellbeing Strategy

Develop strategic commissioning plans to meet Operating Framework targets and reflect individual strategies and NSFs including for Carers, Dementia, Cancer services, CHD, Mental Health, Diabetes, Renal Services, Long Term conditions, Young People, Maternity Services, and the National Cancer Plan, and Valuing People

CCG CCC

NHS CB

Commissioning strategies Commissioning plans

Develop Quality, Innovation, Productivity and Prevention (QIPP) plans CCG QIPP plans

Undertake strategic planning and service redesign at a health economy level to include undertaking demand modelling, forecasting and capacity planning.

NHS CB CCG

Capacity plans / Commissioning plans Performance reports

Develop disinvestment as well as investment plans based on agreed criteria including quality, local needs, evidence of effectiveness.

CCG Commissioning strategies / Commissioning plans / QIPP plans

Facilitate links with clinicians (acute, primary care and mental health) to redesign services across whole patient pathways, including specialised services.

CCG NHS CB

Performance reports Commissioning plans

Work in partnership with Local Authorities (LAs) to undertake regular needs assessments. Using the identified current health needs, and identifying future trends, ensure that all commissioned services meet the needs of the population, especially those whose needs are the greatest.

CCG CCC

NHS CB

JSNA

Taking account of available resources, secure healthcare services, ensuring high quality care, improvement in health outcomes, and value for money across all settings and for all patients.

CCG Commissioning plans/intentions JSNA; Joint Health & Wellbeing Strategy

Working with Local Authorities, determine local health improvement targets e.g. in relation to stop smoking, obesity, teenage pregnancy and health promotion, substance misuse, and exercise. Lead and coordinate health improvement activities to address these.

CCC & PHE CCG

NHS CB

JSNA; Joint Health & Wellbeing Strategy

PCT’s quality related functions and responsibilities Recipient bodies

Quality information requirements

Develop collaborative commissioning arrangements through Specialised Commissioning Groups, (SCGs), with other PCT/CTPs, and other commissioners such as NHS prison services, schools etc.

NHS CB SCG activity and commissioning plans

Horizon scanning – in relation to policy development across all sectors CCG NHS CB

Joint Health & Wellbeing Strategy Operating Framework; JSNA; Joint Health & Wellbeing Strategy

Local delivery of national public health policies. CCC JSNA; Joint Health & Wellbeing Strategy

Prepare joint strategic needs assessments for health & social care, with local authorities and other PCTs

CCG CCC

JSNA

Consider requests from local authorities for assistance in the planning of services for carers CCG Carer’s charter and surveys

Ensure there are effective systems in place for effective adult protection – including policies, procedures and relationships with key partners.

CCG CCC

Adult safeguarding policies and procedures; Local Safeguarding Adults Board reports

Working with LAs, jointly commission (plan, agree, monitor and evaluate) services e.g. through joint commissioning arrangements, section 75 agreements and shared posts

CCG CCC

Contracts; Section 75 agreements; PH and CCG Agreement

Participate in Children’s Trusts to ensure the health and wellbeing of children including undertaking responsibilities for Safeguarding (membership of the Local Safeguarding Board, ensuring roles of Designated Dr and Nurse are fulfilled)

CCG CCC

Child safeguarding policies and procedures; Local Safeguarding Children Board reports Section 11 audits

Provide effective support for carers. CCG CCC

Carer’s charter

Effectively involve patients, the public, their carers, and other stakeholders in the planning and delivery of services.

CCG CCC

LiNks / HealthWatch reports; Patient / service user / carer surveys and interest groups

Engage with Local Involvement Networks (LINks)/HealthWatch CCG LINks reports

Respond effectively to patient complaints CCG NHS CB

Patient Complaints Report

Ensure application of mandatory NICE guidance across providers. CCG NHS CB

NICE guidance, evidence to support provider quality and compliance reports

Develop “section 75 “arrangements to manage jointly commissioned services – most commonly in mental health, learning disability and children’s services. Such arrangements have clear governance and specific accountability arrangements for LAs and NHS organisations.

CCG CCC

Contracts; Section 75 agreements; Agreement between PH and CCG Partnership Agreement

Duty to maintain and publish Performers Lists

NHS CB Performers lists – all disciplines

Continuously monitor performance of contracts (and grants) with all providers (NHS, LA, independent or third sector. Specifically, regularly review: - Financial performance

CCG NHS CB

Provider quality, finance and performance reports

PCT’s quality related functions and responsibilities Recipient bodies

Quality information requirements

- Activity levels - Quality standards and outcomes including patient experience - Clinical standards.

Provide pre intervention support to providers where there is a concern over performance. CCG NHS CB

Provider quality, finance and performance reports

Put in place: - Contract variations if required - Exception reports - Actions to address under performance including agreement and implementation and of

recovery plans.

CCG NHS CB

Contracts Provider quality, finance and performance reports

“Relationship management” with range of providers (informal and formal). CCG NHS CB

‘Soft’ intelligence via face to face meetings Contract governance structures

Comment on and agree quality accounts CCG Provider Quality Accounts 11-12 Provider quality, finance and performance reports

Undertake surveys, analyse and use the data to improve services e.g. patient choice surveys.

CCG CCC

NHS CB

Patient surveys Patient engagement activity reports

Working with clinicians, patients and others, continually review effectiveness and improve pathways.

CCG CCC

NHS CB

Service development group reports QIPP plans

Continually review PCT performance and outcomes against similar populations. NHS CB Benchmarking data; CQC risk profiles

Measure and understand the efficiency and effectiveness of PCT spend in all commissioned services, benchmarking against identified best practice.

CCG Contracts (including schedules and CQUINs) and related performance data

Mental Capacity Act 2005; A PCT has a duty to act as a Supervisory Body in relation to Deprivation of Liberty Safeguards.

CCG CCC

MCA / DoLS reports including benchmarking data

Medicines management – provision of prescribing advice to all primary care contractors, supervising and managing controlled drugs. - Communicating and managing drugs and medical devices alerts. - Provide prescribing advice to care homes. - Manage prescribing incentive schemes for practices. - Accountable officer across the system (including independent sector) - Maintaining drugs – e.g. cold chain vaccines

CCG NHS CB

CCC & PHE

Medicines management reports QIPP reports Newsletters

Manage decision-making process for use of high cost drugs and new interventions CCG NHS CB

IFR policies and panel reports

Assurance and risk management – review all risks and issues e.g. internal risks, SUIs, provider risks, risks associated with partners such as Safeguarding Boards.

CCG NHS CB

Risk registers CQC provider Risk Profiles

PCT’s quality related functions and responsibilities Recipient bodies

Quality information requirements

Respond appropriately to all SIs, independent enquiries and incidents, child death reviews, death in custody reviews, homicide inquiries.

CCG CCC

NHS CB

Agreed SI management and reporting policies. Provider action plans SCR reports; Section 11 audits

Undertake serious case reviews and health overview reports CCG CCC

Serious case review reports and associated action plans

Ensure links with CQC and meet requirements and requests. CCG CQC reports and associated action plans

Meet infection prevention and control responsibilities.(including auditing and monitoring implementation of recovery plans)

CCC & PHE CCG

NHS CB

HCAI performance reports Recovery plans

Clinical governance responsibilities CCG NHS CB

Data on PCT/CTPs serious incident, independent contractor poor performance/ GP appraisal data/clinical audit activity/research activity.

Duty to co-operate with local authorities and others to improve well-being of children CCG CCC

NHS CB

Safeguarding policies and procedures

Duty to make arrangements to ensure that PCT functions are discharged having regard to the need to safeguard and promote the welfare of children

CCG CCC

NHS CB

Safeguarding policies and procedures Section 11 audits

Duty to work with local authority in connection with the authority’s arrangements for improving well-being etc of young children

CCG CCC

NHS CB

Children’s Trust reports

Commissioning services for looked after children. CCG CCC

Local Safeguarding Children Board reports Section 11 audits Commissioning intentions/plans

Managing transition between adult and older people’s services, and between children’s and adult services. Specifically patients and users face issues in transition in Mental health, learning disability and services provided for children with complex health care needs.

CCG NHS CB

Provider quality and performance reports

Commissioning for vulnerable groups: ensure services are commissioned specifically, for seldom heard and vulnerable groups such as travellers, asylum seekers

CCG NHS CB

Commissioning plans, provider quality and performance reports

Allegations management (subset of safeguarding but also as employer) CCG CCC

NHS CB

Safeguarding policies Local HR policies

Data sourceSender

Holder/ Lead

Operational

leadNature of the documentation

Highest

security /

confidentlty

level *

Working locations of

documentationTransfer locations Receiver Holder/lead

Key area index, summaries and vignettes;

- Maternity (UHMBT)

- Child safeguarding (CPFT)

- CAMHs (CPFT)

- Adult safeguarding (mixed)

- Cancer services (NCUHT)

- Hospital mortality (NCUHT)

- Primary Care

Evidence document repository - all key areas

Providers on a page reports

Performance summary charts

Board reports ( including archived provider

board reports)

I Drive folders

P Drive - CCG, Performance

CCG - Strategic Planning &

Performance lead (P Rooney)

Operational performance reports relating to

CCG priorities

I Drive folders

P Drive - CCG, Performance

CCG - Strategic Planning &

Performance lead (P Rooney)

Operational performance reports relating to Area

Team priorities

P Drive - NHSCB AT,

Performance

NHS CB Area Team - Director of

Operations & Delivery (A Slater)

Operational performance reports relating to

Public health commissioning priorities P Drive - CCC, Performance

CCC Public Health team - Deputy

Director of Public health (R

Wagstaff)

I Drive folders I Drive folders

Sequel server Sequel server

SUI database PI CITRIX applicationCITRIX application, access

to be provided

Individual SUI folders 2008-mid 2012, including

all individual correspondence, performance

reports, clinical lead case notes, SUI meeting

minutes, correspondence with trusts

PI Sharepoint folderSharepoint folder, access to

be provided

Individual SUI folders mid 2012 - current,

including all individual correspondence,

performance reports, clinical lead case notes,

SUI meeting minutes, correspondence with

trusts

PI S-drive, 'Incident' folder P Drive - CCG,Governance

Incidents and complaints data PI ULYSES systemULYSES system, access to

be provided

Full gold command documentation P2 S Drive folder P Drive - CCG, Governance CCG - Lead Nurse (L Carr)

Summary information, vignette and related

reportsP2

see Key Quality Risk Areas

index above

Key Quality Risk Areas (identified

for Risk Handover April 2013)

Performance data on the

priorities set out in the Operating

Framework relevant to quality

(e.g. waiting times, infection rates

etc.)

Eileen

Osborne (EO)

Mike Bewick

(MB)

CCG - Lead Nurse (L Carr)

Access to be arranged for NHS CB

for primary care related incidents

Major incident, UHMBFT

Holly Marshall

(HM)

Ros Fallon

(RFa)

S drive folders, I drive

folders

P Drive - CCG, Governance

Claire

Cuthbertson

(CC)

Moira Angel

(MA)S drive folderPI CCG - Lead Nurse (L Carr)

PD

EO

CCG - Strategic Planning &

Performance lead (P Rooney)

Information systems to support performance

management PD

Quality Handover Document Control

CC‘Never Events’ and serious

incident data including StEIS,

Key Risk Areas (prepared for Risk Handover April 2013)

National and local standard reports (hard data)

PD - Public Domain

P2 - Confidential/restricted (Part 2)

PI - Patient or personally identifiable

Data sourceSender

Holder/ Lead

Operational

leadNature of the documentation

Highest

security /

confidentlty

level *

Working locations of

documentationTransfer locations Receiver Holder/lead

Charles

Welbourn Various hard copy reports P2 CW filing CW filing

CCG - Director of finance (C

Welbourn)

Pam Kelsall

(PK)Corespondence & reports P2

Chief Executive's S Drive

folderP Drive - CCG, Finance CCG - Chief Officer (N Maguire)

CCG RAF spreadsheet PD S drive folder P Drive - CCG, GovernanceCCG - Strategic Planning &

Performance lead (P Rooney)

PD S drive folder P Drive - CCG, Governance

PDincluded in Audit Committee

papers

Specific Cluster related risk areas ( e.g. H&S) PI ULYSES systemULYSES system, access to

be provided

Hospital mortalityMedical

directorsEO

Summary information, vignette and related

reports

see Key Quality Risk Area

index above

NHS patient surveys PDPublic website

http://www.nhssurveys.org/

Public website

http://www.nhssurveys.org/CCG - Engagement Lead (L Ryan)

Listening to Cumbria exercise;

final report, analysis report, response, response

letters submitted by UHMBFT, NCUHT and CPFT

Public website

www.cumbria.nhs.uk/ccg/List

ening-to-Cumbria.aspx

Public website

www.cumbria.nhs.uk/ccg/List

ening-to-Cumbria.aspx

CCG - Engagement lead ( L Ryan)

Staff survey results MG MGNHS staff survey 2012 full & summary reports

for all trustsPD

Public website

http://nhsstaffsurveys.com/c

ms/

Public website

http://nhsstaffsurveys.com/c

ms/

CCG - Lead Nurse (L Carr)

Individual case files (informal, formal,

redirected, joint protocol/multi-agency)PI

Policy & procedures PD

Data, reports PD

Database - cases, transactions, data for

performance management PI ULYSES system

ULYSES system, access to

be provided

Emails re individual cases

PI

Outlook account Outlook account - continuity

of operational lead

Paper files - livePI

Secure filingSecure filing - continuity of

operational lead

Paper files - archived ( 10 yr limit) PI Secure filing FASTNESS repository

All files have registered receivers

for billing, access rights &

timescales

Subject Access requests ND NDRecord of individual requests for case notes etc

(mostly relating to Continuing Health Care)PI S drive folder P Drive - CCG, Governance CCG Lead Nurse (LC)

Claims management spreadsheet

Individual case files - live, potential, closed

Registered claims ULYSES systemULYSES system, access to

be provided

Paper files - live Secure filing Secure filingCCG - Strategic Planning &

Performance lead (PR)

Paper files - archived (according to limits) Secure filing FASTNESS repository

FASTNESS repository - all have

registered receivers for billing,

access rights & timescales

CCLegal Claims ND

P Drive - CCG, Governance S drive folder

Patient survey results

CCG - Lead nurse (L Carr)

Access to be provided to NHS CB

when responsibilities resolved re

primary care complaints

management

P Drive - CCG, Governance

Charles

WelbournNCUHT acquisition

Risk Assessment Frameworks

Complaints dataNicola Duers

(ND)ND

CCG - Director of Finance ( C

Welbourn)

NHS CB AT - Director of Finance (

R Cornall)

Graham Shipp Mark Graham

(MG)

S Drive folder

CCG - Strategic Planning &

Performance lead (P Rooney)

Cluster RAF spreadsheetEOCC

PI

Data sourceSender

Holder/ Lead

Operational

leadNature of the documentation

Highest

security /

confidentlty

level *

Working locations of

documentationTransfer locations Receiver Holder/lead

CQC inspection reports PD Public CQC website Public CQC website

CQC inspection report intelligence P2S drive folder

Sharepoint folderP Drive - CCG, Governance

CQC inspection notices etc re UHMBT major

incidentPD

see Major incident

UHMBFT above

Nicola

Jackson (NJ)

CQC/OFSTED Improvement Programme - Child

Safeguarding & Children Looked After (includes

inspection reports, programme governance,

meeting notes, action plans and reports)

PD S Drive folder P Drive - CCG, Governance

Katherine

Eliott (KE) Quality accounts from Trusts PD

National NHS Choices

website

http://www.nhs.uk/aboutNHS

Choices/professionals/healt

handcareprofessionals/qualit

y-accounts/Pages/quality-

accounts-2011-2012.aspx

National NHS Choices

website

http://www.nhs.uk/aboutNHS

Choices/professionals/health

andcareprofessionals/quality-

accounts/Pages/quality-

accounts-2011-2012.aspx

KE PCT comments on quality accounts PD Y drive folder

P Drive - CCG, Governance

P Drive - NHSCB,

Governance

Meeting notes

Individual incident records

External & provider action plans

Training records

Serious Case Reviews

Safeguarding Audits

Board papers re adult safeguarding see Board papers

Meeting notes

Individual incident records

External & provider action plans

Training records

Serious Case Reviews

Safeguarding Audits

Board papers re adult safeguarding see Board papers

MA NJ

CQC/OFSTED Improvement Programme - Child

Safeguarding & Children Looked After (includes

inspection reports, programme governance,

meeting notes, action plans and reports)

PD see CQC inspections above

P Drive - CCG, Governance

P Drive - NHSCB AT,

Governance

Quality Accounts

Louise Mason-

Lodge

Neela

Shabde (NS)

Child safeguarding

S Drive folder PI

P Drive - CCG, Governance

P Drive - NHSCB AT,

Governance

CCG - Safeguarding Business

Manager (A Cooke)

Access to be provided to NHSCB

AT Patient Safety team (S

Rushforth)

MA

S Drive folder

EO

CCG - Lead nurse (LC)

NHS CB LAT - Dir of Nursing &

Quality (M Angel)

Anne Cooke

(AC)MAAdult safeguarding

CCG - Safeguarding Business

Manager (A Cooke)

Access to be provided to NHSCB

AT Patient Safety team (S

Rushforth)

CQC inspections - registration

details, warning notices and

related CQC notifications

MA

PI

CCG Lead Nurse (LC)

Data sourceSender

Holder/ Lead

Operational

leadNature of the documentation

Highest

security /

confidentlty

level *

Working locations of

documentationTransfer locations Receiver Holder/lead

Quality schedules within national and local

contracts

P Drive - CCG, Contract

management

CQUIN - schemes and performance reports for

local providers ( & others by exception)

Quality monitoring reports

NCUHT -

Brenda Bragg

CPT - Debbie

Archer

UHMBFT - Nth

Lancs CCG,

Gary O'Neil

KE Policy documents PD S Drive folder P Drive - CCG, Governance

NS Gold Maternity UMBT documentation PDsee Major incident

UHMBFT above

Homicides/unlawful killings,

Domestic Homicide Reviews,

Homicide Independent Reviews,

Deaths in Custody – historic

John Ashton

(JA)CC

Historic review documentation only - paper files

(Live cases are managed by Safer Cumbria

Partnership but also appear within SUI and

Serious case review files )

PI Secure filing FASTNESS Storage

IFR databasePI Citrix application

CITRIX application, access

to be provided

Reports, correspondence, panel meetings PI S Drive folder

P Drive folder - NECS,

Service Planning & Reform

LCAG meeting notes

LCAG assurance documentation

Risk register

Submissions

Directory of service

List of newspapersList of broadcasters

Archive of press releases

Photo library

Comms plans PD

Various contact databases P2

Twitter account

Facebook

U tube

Survey Monkey

Communications resources MG

Sharon Kelly

Standards & Quality meetings with trusts - notes Already held within CCG

arrangements PD

CCG - Head of Contracting (S

Kelly)

Contract and quality performance

monitoring (inc CQINN)

PD

Nigel Maguire

S drive folder

Karen Morley-

Chesworth

(KMC)P2

KMC S Drive folder

CCG - Comms lead (M McAdam)

KMC OnlinePDMG

NHS 111 LCAG governance Helen Ledger EH

MGlocal Newsflash online

database

CCG - Comms lead ( M McAdam)

CCG - Head of Contracting (S

Kelly)

CCC PH - Deputy Director of

Public Health (R Wagstaff) - for

elements relating to PH

commissioning

PD

local Newsflash online

database - access though

continuity of staff

P Drive - CCG, Stakeholder

relationships

Online - access though

continuity of staff

CCG - Senior Commissioning

Managers

CCG - Clinical lead (D Rogers)

S Drive folder

For elements relating to PH

commissioning;

P Drive - CCC, Performance

Already held within CCG

arrangements

CCG - Strategic Planning &

Performance lead (P Rooney) ,

service to be provided through

NECS

CCG - Lead Nurse (L Carr)

Maternity Services, Local

Supervisory Midwifery Authority

reports and audits

Media – Newspapers, Journals

Social Media – Professional and

patient websites

P Drive - CCG, Governance

MA

Exceptional Case Panel /

Individual Funding RequestsMB

Angela

Robinson

Other intelligence (soft data)

Data sourceSender

Holder/ Lead

Operational

leadNature of the documentation

Highest

security /

confidentlty

level *

Working locations of

documentationTransfer locations Receiver Holder/lead

Shirley Forrest

(SF) Stakeholder database PD CCG - Engagement lead (L Ryan)

Christine

Harrison (CH)

Agreement with 3rd sector consortia re Equality

& Diversity involvementPD CCG - E&D Lead (CH)

SF / CHReal Accountability' annual summaries of

engagement activity PD

CCG - Engagement/E&D leads ( L

Ryan & C Harrison)

CCG - Engagement lead (L Ryan)

Local Healthwatch - D Blacklock

Closer to Home consultation - paper

consultation documents PD Filing Filing

Closer to Home consultation - consultation

documents, meetings, correspondence etcPD S Drive folder

P Drive - CCG, Stakeholder

relationships

Mental Health consultation - paper consultation

documents PD Filing Filing

Mental Health consultation - consultation

documents, meetings, correspondence etcPD S Drive folder

P Drive - CCG, Stakeholder

relationships

South Cumbria Acute Services Review

consultation - paper consultation documents PDFiling Filing

South Cumbria Acite Services Review

consultation - consultation documents, meetings,

correspondence etc

PD S Drive folderP Drive - CCG, Stakeholder

relationships

Overview and Scrutiny

CommitteePC SF OSC Quarterly reports (to Jan 13) PD S Drive folder

P Drive - CCG, Stakeholder

relationships

CCG - Strategic Planning &

Performance lead (PR)

Ed Hutton (EH) Contact details for County's 6 MPs PD

EH MP correspondence PI

EH Annual reporting of MP interaction PD

Individual FOIs, letters & responses

FOI tracker/log

SF Board Papers Part 1 PD

SF Board Papers Part 2 P2

SF Committee papers PD

Public website Public website

S Drive folder P Drive - CCG, Governance

Sharepoint (Governance

folders)

Sharepoint access to be

provided

SLHistorical policies - including document

development & registersPD

Sharepoint (Governance

folders)

Sharepoint access to be

provided

Sec of State formally

CCG - CCG General Manager (J

Lawson)

Suzanne

Lofthouse (SL)

Peter Clarke

(PC)Local user groups

Sharepoint site - access to

be provided

PCBoard Governance

SF

SF

Major Consultations PC

CCG - Comms lead (M McAdam)

NHSCB - Director of Operations &

Delivery (A Slater)

CCG - Comms lead ( M McAdam)Sharepoint site PD

Local MPs

Freedom of Information requests CC KMC

Sue Page/

MG

SF

Sharepoint site

SF

S Drive folderP Drive - CCG, Stakeholder

relationships

P Drive - CCG, Stakeholder

relationshipsPD S Drive folderPatients Voice Group legacy document

PDExtant policies

Sec of State formally

CCG - CCG General Manager (J

Lawson)

Sharepoint site - through

continuity of lead

Public website

S Drive folder

Sharepoint (old papers only)

Public website

P Drive - CCG, Governance

Sharepoint - access to be

Sec of State formally

CCG - CCG General Manager (J

Lawson)

CCG - Strategic Planning &

Performance lead (P Rooney)

CCG - Strategic Planning &

Performance lead (P Rooney)

CCG - Strategic Planning &

Performance lead (P Rooney)

Data sourceSender

Holder/ Lead

Operational

leadNature of the documentation

Highest

security /

confidentlty

level *

Working locations of

documentationTransfer locations Receiver Holder/lead

NMC general policy documents and information S drive folder

Individual cases, correspondence - electronic Inbox emails

individual cases correspondence - paper copies Secure filing Secure filing

GMC individual live case files - paper copies Secure filing Secure filing

GMC individual non-live case files secure filing FASTNESS storage

GMC individual case files G Drive folder P Drive - NHSCB AT, Primary

Care

Individual live investigations - paper copies Secure filing Secure filing

Individual non-live investigations - paper copies Secure filing FASTNESS storage

Individual investigations G Drive folder P Drive - NHSCB AT, Primary

Care

Individual live performance issue reports - paper

copiesSecure filing Secure filing

Individual non-live performance issue reports -

paper copiesSecure filing FASTNESS storage

Individual performance issue reports G Drive folder P Drive - NHSCB AT, Primary

Care

Individual live performance issue reports - paper

copiesSecure filing Secure filing

Individual non-live performance issue reports -

paper copiesSecure filing FASTNESS storage

Individual performance issue reports G Drive folder P Drive - NHSCB AT, Primary

Care

RCN routes - general info S Drive folder

RCN routes - individual cases, correspondence Emails

KD Dossier for Risk Handover PIsee Key Quality Risk Area

index above

Individual live cases - paper copies Secure filing Secure filing

Individual non-live cases - paper copies Secure filing FASTNESS storage

Individual cases G Drive folder P Drive - NHSCB AT, Primary

Care

for NMC - MA

KE

MA/MBWhistleblowing - reports re trusts

PI

NHS CB LAT - Dir of Nursing &

Quality (M Angel) (Continuity of

staff)

P Drive - NHSCB

GovernanceKE

PI

Royal Colleges MB KW

Deanery reports MB KW

Whistleblowing – primary care

providersMB KW PI

for GMC -

MB

Kay Wilson

(KW) PI

Professional regulators

Practitioner performance MB KW PI

PI

P Drive - NHSCB,

Governance

NHSCB AT - Director of Nursing &

Quality ( M Angel) (Continuity of

staff)

NHSCB AT - Durham, Darlington &

Tees. (Continuity of staff)

NHSCB AT - Durham, Darlington &

Tees. (Continuity of staff)

NHSCB AT - Durham, Darlington &

Tees. (Continuity of staff)

NHSCB AT - Durham, Darlington &

Tees. (Continuity of staff)

NHSCB AT - Durham, Darlington &

Tees. Continuity of staff

PI

Function Sender and Receiver Lead Officers for Functions (as at 1st March 2013)

NB Functions are shown as transferring to CCG regardless as to whether they are commissioning NECS to provide support. FUNCTION TASK AREAS SENDER LEAD RECEIVER RECEIVER LEAD COMMENTS

Health needs

Intelligence John Ashton CCC Rebecca Wagstaff

JSNA John Ashton HWBB Rebecca Wagstaff

Public Health

Promotion John Aston CCC Rebecca Wagstaff

Protection John Ashton PHE Nigel Calvert

Commissioning John Ashton CCC Rebecca Wagstaff

Marcomms Mark Graham CCC Mark Graham

Primary care

Contract management Mike Bewick LAT Christine Keen

Performance

management

Mike Bewick LAT

CCG

Christine keen

Hugh Reeve

“FHS” Mike Bewick LAT Christine Keen

Regulatory bodies Mike Bewick LAT Mike Prentice

Commissioning

Secondary and

community services

Nigel Maguire CCG Network

Directors

Joint Nigel Maguire CCG Peter Rooney

Spec/collaborative Ros Berry LAT Christine Keen

Continuing HC Rachel Fleming CCG Ellie Roddick

Offender HC Elaine Church LAT Christine Keen

Veterans Elaine Church CCG Peter Rooney

Exceptional cases Ros Berry CCG Laura Carr

Winter planning Moira Angel CCG Peter Rooney

QIPP Charles

Welbourn

CCG

LAT

Charles Welbourn

Robert Cornell

Contract management

monitoring

NCUHT/ UHMBFT/

CPFT

Nigel Maguire CCG Charles Welbourn

Other Nigel Maguire CCG Charles Welbourn

Specialist Nigel Maguire LAT Christine Keen

Performance

Delivery on operating

framework and

performance targets

Ros Fallon CCG

CCC

LAT

Director of

performance

Rebecca Wagstaff

Alison Slater

Delivery on QIPP Ros Fallon CCG

LAT

Director of ops and

performance

Alison Slater

Delivery on Quality Moira Angel CCG

LAT

CCC

Laura Carr

Moira Angel

Rebecca Wagstaff

Governance

Safeguarding children Moira Angel CCG Laura Carr LAT also has

responsibility

Safeguarding adults Moira Angel CCG Laura Carr LAT also has

responsibility

Quality standards Moira Angel CCG Laura Carr LAT also has

responsibility

SUI/StEIS John Ashton CCG Laura Carr LAT also has

responsibility

Litigation Moira Angel CCG/NH

SCB

Peter Rooney

TBC

Complaints Peter Clarke CCG

LAT

Laura Carr

Medicines management

Drugs Budget Andrea Loudon CCG Andrea Loudon

Community

pharmacy

Mike Bewick LAT Alison Slater

AO for Controlled

drugs

Andrea Loudon LAT Mike Prentice

Emergency

preparedness

Resilience planning John Ashton CCG Peter Rooney

LRF John Ashton LAT John Lawlor

LHRP Sue Page LAT

/CCG/

DPH

John Lawlor / Nigel

Maguire/ Rebecca

Wagstaff

Cat 1 response John Ashton LAT John Lawlor CCCG support

Systems management

N Cumbria Sue Page/Mike

Bewick

CCG Nigel Maguire LAT also has

responsibility

S Cumbria Sue Page/Mike

Bewick

CCG Nigel Maguire LAT also has

responsibility

Transitional support

funding

Sue Page /

Charles

Welbourn

CCG

LAT

Nigel Maguire

John Lawlor

Finance

2012/3

Management

Accounting

Financial Accounting

Charles

Welbourn

CCG Charles Welbourn

Year end Charles

Welbourn

LAT John Lawlor /Charles

Welbourn

Final accounts Charles

Welbourn

LAT John Lawlor /Charles

Welbourn

IM&T

Infrastructure Ross Forbes CCG John Roebuck

Software Ross Forbes CCG

CCC

LAT

John Roebuck

Primary care systems Mike Bewick CCG (/

LAT)

William Lumb

Information

Governance

Ross Forbes CCG John Roebuck LAT also has

responsibilities

Caldecott Guardian John Ashton CCG

LAT

Nigel Maguire

Mike Prentice

Estates &facilities

Property management Laura Grierson NHS

property

Services

Ros Berry

Capital programme Charles

Welbourn

CCG Charles Welbourn

LIFT Jeanette Morris NHSPS Ros Berry

Soft FM Laura Grierson NHSPS Laura Grierson

CPFT Stephen Prince

Communications

External Mark Graham CCG Peter Rooney LAT

Communication

functions TBC

Internal Mark Graham CCG Peter Rooney

Marketing Mark Graham CCG Peter Rooney

FoI/MP Mark Graham CCG Peter Rooney

Stakeholder

relationships

MPs Sue Page CCG Nigel Maguire LAT also has

responsibility

CCC

Districts

Sue Page

John Ashton

CCG Nigel Maguire

Network directors

LAT also has

responsibility

OSC Peter Clarke CCG Peter Rooney

Engagement

Patient experience

Peter Clarke CCG

CCG

LAT

Peter Rooney

Laura Carr

Moira Angel

LAT also has

responsibility

Third sector Peter Clarke CCG Peter Rooney

Regulators Mike

Bewick/Moira

Angel

CCG

LAT

Nigel Maguire

Mike Prentice/Moira

Angel

Unions CCG Peter Rooney

HR

Staff relations and

transfer

Sue Page CCG

Caroline Rea One NE providing

HR support to PCT

as sender

Contact with those named above should initially be via: Lonsdale Unit Penrith Hospital Bridge Lane Penrith CA11 8HX Tel: 01768 245317