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Lewisham Clinical Commissioning Group Governing Body

Members of the public are invited to ask questions of the Board at the designated time on the agenda, in relation to matters on the agenda and at the discretion of the Chair.

Date: 5 September 2013 Time: 13:00 – 15:30 Venue: Room 1, Civic Suite, Lewisham Town Hall Chair: Dr Marc Rowland AGENDA

Time Item Papers Presented by

1. 13:05 Welcome and introductions Chair

2. 13:10 Case Study Presentation

3. 13:25 Apologies for absence

4. Declarations of Interest Members should discuss any potential conflicts of interest with the Chair prior to the meeting

Enc 1 Chair

5. 13:30 To agree minutes of previous meeting and review the action log

Enc 2

Chair

6. 13:35 Matters arising

7. 13:40 Risk Management and Board Assurance Framework

Enc 3 Graham Hewett

8. 13:50 Chair’s Report Enc 4 Dr Marc Rowland

9. 14:00 Chief Officer’s Report Enc 5 Martin Wilkinson

10.

14:10 Reports from Governing Body Subcommittee Chairs

Audit Committee – meeting held on 9 July 2013 Strategy and Development – meeting held on 1 August 2013

Delivery – meeting held on August 2013

- Integrated Performance Report Including

Finance and QIPP, Performance and Quality

Enc 6 Enc 7 Enc 8 Enc 9

Ray Warburton Dr David Abraham Dr Marc Rowland Tony Read

Chair: Marc Rowland Chief Officer: Martin Wilkinson

1

11. 14:35 Draft Strategic Plan and Engagement Plan Enc 10 Charles Malcolm-

Smith ITEMS FOR DECISION

12. 14:45 Commissioning Intentions – to agree the

process, timetable and financial parameters Enc 11 Susanna Masters

13. 14:55 Review of Governance Arrangements for the Governing Body meetings

Enc 12 Susanna Masters

14. 15:05 Information Governance Policies Enc 13 Tony Read

ITEMS FOR DISCUSSION

15. 15:20 Questions from members of the public Chair

16. 15:25 Potential Audit and Risk Management Issues Chair

ITEMS FOR INFORMATION These items are for information only and will therefore not be discussed

17. Approved Committee minutes for information

• Delivery Committee (18 July 2013) • Strategy and Development Committee (6 June

2013) • Audit Committee (18 March 2013)

Enc 14 Enc 15 Enc 16

18. Any other business

19. 15:30 Date of next meeting – 3 October 2013; 13:00 – 15:30, Civic Suite, Lewisham Town Hall

The Committee to agree that the public should be excluded from the meeting while the remaining business is under consideration, as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted.

Chair: Marc Rowland Chief Officer: Martin Wilkinson

2

GLOSSARY OF TERMS AAS Admission Avoidance Service ACRA Advisory Committee on Resource Allocation ADASS Association of Directors of Adult Social Services A&E Accident and Emergency AfC Agenda for Change AHC Annual Health Check (by the Health Commission) AHP Allied Health Professional AHSC Academic Health Science Centre AHSN Academic Health Science Network APMS Alternative Provider Medical Services AQP Any Qualified Provider ASTRO-PU Age, Sex, Temporary Resident Originated Prescribing Unit AWP Allocation Working Paper

BDA British Dental Association BMA British Medical Association BME Black and Minority Ethnic BNF British National Formulary BPPC Better Payment Practice Code

CAMHS Child and Adolescent Mental Health Services CAS Central Alert System

C&B Choose & Book CBT Cognitive Behavioural Therapy CCG Clinical Commissioning Group CCNT Children’s Community Nursing Team CEMACH Confidential Enquiry into Maternal and Child Health CIO Chief Information Officer CIP Cost Improvement Programme CNST Clinical Negligence Scheme for Trusts COPD Chronic Obstructive Pulmonary Disease CRL Capital Resource Limit CPA Care Programme Approach CPD Continuing Professional Development CPN Community Psychiatric Nurse CPR Child Protection Register CQC Care Quality Commission CQUIN Commissioning for Quality and Innovation CRB Criminal Records Bureau CSU Commissioning Support Unit CSP Chartered Society of Physiotherapy CSP Commissioning Strategy Plan CSR Comprehensive Spending Review CSS Commissioning Support Service CYPPB Children and Young people Partnership Board

DAT Drug Action Team

DGH District General Hospital DH or DoH Department of Health

E&D Equality and Diversity EDS (NHS) Equality Delivery System EI Early Intervention EIA Equality Impact Assessment EIP Early Intervention in Psychosis EMIS Practice Information System ENT Ear, Nose and Throat ERMA Emergency Response Management Arrangements EPP Expert Patient Programme EPR Electronic Patient Record EPS Electronic Prescription Service ESR Electronic Staff Record) EWTD European Working-Time Directive FCE Finished Consultant Episode FHS Family Health Services FIMS Financial Information Management System FNP Family Nurse Partnership FOI Freedom of Information FOT Forecast Outturn FT Foundation Trust

GAD Government Actuary’s Department

GDC General Dental Council GDS General Dental Services GMC General Medical Council GMS General Medical Services GOS General Ophthalmic Services GP General Practitioner GPI General Practitioner Interactive GPS Government Procurement Services GPSI or GPwSI General Practitioner with a special interest GPSoC General Practitioner Systems of Choice GSTT Guy’s & St. Thomas’s NHS Foundation Trust

HCA Health Care Assistant HCAI Healthcare-Associated Infection HCAIs Healthcare Acquired Infections HCAS High Cost Area Supplement HEMS Helicopter Emergency Medical Service HIA Health Impact Assessment HIEC Health Innovation and Education Cluster HMO Health Maintenance Organisation (USA) HoNOS Health of the Nation Outcome Scales HRG Healthcare Resource Group HRG4 Healthcare Resource Group version 4 HSC Health and Social Care (Northern Ireland)

HSJ Health Service Journal HTA Health Technology Assessment HV Health Visitors HWB Health and Wellbeing Board

IAPT Improving Access to Psychological Therapies (programme) IC Information Commissioner ICAS Independent Complaints Advocacy Service ICD International Classification of Diseases ICE Integrated Communication and Engagement ICO Integrated Care Organisation ICP Integrated Care Pathway ICT Information and Communication Technology ICU Intensive Care Unit I&E Income and Expenditure IFRS International Finance Reporting Standards IG Information Governance IMCA Independent Mental Capacity Advocate IM&T Information Management and Technology IP Information Prescriptions IP Inpatient IPR Individual Performance Review IRP Independent Reconfiguration Panel IST Intensive Support Team

JCP Jobcentre Plus JHWS Joint Health and Wellbeing Strategy JIP Joint Investment Plan JNC Joint Negotiating Committee JSNA Joint Strategic Needs Assessment KPI key Performance Indicator KSF (NHS) Knowledge and Skills Framework

LA Local Authority LCFS Local Counter Fraud Specialist LDC Local Dental Committee LES Local Enhanced Services LETBs Local Education and Training Boards LGA Local Government Association LHNT Lewisham Healthcare NHS Trust LIFT Local Improvement Finance Trust LINks Local Involvement Networks LMC Local Medical Committee LOC Local Optical Committee LPC Local Pharmaceutical Committee LSP Local Strategic Partnership LSL Lambeth, Southwark & Lewisham LTC Long-Term Conditions

MCATS Musculoskeletal Community Assessment and Treatment Service

MADEL Medical and Dental Education Levy Resignation Scheme MECS Minor Eye Condition Scheme MFF Market Forces Factor MHRA Medicines and Healthcare Products Regulatory Agency MMR Measles, Mumps, Rubella (vaccination) MPET Multi-Professional Education and Training MPIG Minimum Practice Income Guarantee MRI Magnetic Resonance Imaging MRSA Methicillin-Resistant Staphylococcus Aureus MSK Musculoskeletal

NCAS National Clinical Assessment Service Programme NCB National commissioning Board NCEPOD National Confidential Enquiry into Patient Outcome and Death NCVO National Council for Voluntary NTDA National Trust Development Authority NHS National Health Service NHS SBS NHS Shared Business Services NHS CB NHS Commissioning Board NHSLA NHS Litigation Authority

OD Organisational Development OGC Office of Government Commerce OJEU Official Journal of

the European Union ONS Office for National Statistics OOH Out of Hours OP Outpatient Assessment OSC (local authority) Overview and Scrutiny Committee PACS Picture Archiving and Communications System PALS Patient Advice and Liaison Service PASA Purchasing and Supplies Agency PBMA Programme Budgeting and Marginal Analysis PbR Payment by Results PDP Personal Development Plan PHE Public Health England PHO Public Health Observatory PI Performance Indicator PMS Personal Medical Services PNA Pharmaceutical Needs Assessment POD Point of Access PPA Prescription Pricing Authority PPE Patient and Public Engagement PPG Patient Participation Group PPI Patient and Public Involvement PRCC Principles and Rules for Cooperation and Competition PROM Patient-Reported Outcome Measure

QA Quality Assurance QALY Quality-Adjusted Life Year QIPP Quality Innovation Productivity and Prevention

QMAS Quality Management and Analysis System QOF Quality and Outcomes Framework

RIO System Provider Serviced RO Responsible Officer RRL Revenue Resource Limited RTT Referral to Treatment

SBS (NHS) Shared Business Services SCG Specialised Commissioning Group SFI Standing Financial Instructions SLA Service Level Agreement SLaM South London and Maudsley Mental Health Foundation Trust SMR Standardised Mortality Ratio SNOMED Systematised Nomenclature of Medicine SO Standing Order SOPHID Survey of Prevalent HIV Infections that are Diagnosed SSBU Shared Service Business Unit SUS Secondary User Services

TIA Trans Ischaemic Attack- Stroke Indicator TDA – Trust Development Authority TSA – Trust Special Administrator TUPE Transfer of Undertakings (Protection of Employment) Regulations 1981 UCC Urgent Care Centre

UDA Units of Dental Activity

VCS Voluntary and Community Sector VFM Value for Money VPR Virtual Patient Record VSM Very Senior Managers VTE Venous Thromboembolism

WHO World Health Organization WIC Walk in Centre WTD Working-Time Directive WTR Working Time Regulations

NHS Lewisham Clinical Commissioning Group Governing Body ENCLOSURE 1 Declarations of Interest – 2013/14

Name and role in organisation

Company/ Organisation

Position/ Shareholding/ remuneration

Directorships and or other significant interests

Any connection with a voluntary or other organisation contracting for the NHS

Research funding / grants that may be received by the individual or any organisation they have a role in

Other specific interests / Any other specific relationship which the public could perceive would impair or otherwise influence the individuals judgement or actions in their role within the CCG

Personal interest or that of a family member or close friend

Dr Marc Rowland Chair

Partner in Jenner GP Practice

South East London Doctors Cooperative (SELDOC)

None None Small sum for GP research received by the Practice Approx £5000 to Practice

Professional Advisor to the Institute of Medical Education at the London Southbank University

Dr Arun Gupta Clinical Director

Partner Half time – South Lewisham Group Practice

Partner South East London Doctors Cooperative (SELDOC)

None Attend BHF Board for IKIC

None Clinical Advisor to Public Health

Dr Hilary Entwistle Clinical Director

Senior Partner Woolstone Medical Centre Member of SELDOC

Senior Partner South East London Doctors Cooperative (SELDOC)

None None None None

Dr David Abraham Senior Clinical Director

Morden Hill Medical Practice

GP South East London Doctors Cooperative (SELDOC

Member of IFR panel and is remunerated for one session a month.

Dr Faruk Majid Senior Clinical Director

GP South East London Doctors Cooperative (SELDOC)

None None None None

Dr Marc Rowland Clinical Director

Partner in Jenner GP Practice

South East London Doctors Cooperative (SELDOC)

None None Small sum for GP research received by the Practice Approx £5000 to Practice

Professional Advisor to the Institute of Medical Education at the London Southbank University

Martin Wilkinson Managing Director

Lewisham CCG Managing Director Lewisham CCG

None None None None

Tony Read Chief Finance Officer

Lewisham CCG Chief Finance Officer Lewisham CCG

None None None None

Aileen Buckton Director of Adult Social Care

Non-voting member Lewisham CCG

None None Director of Adult Social Care Lead Commissioner for Joint commissioned services (Adult)

None None

Ray Warburton Lay Vice Chair

Lewisham CCG None Director of Ray Warburton’s Perspectives Limited

None Co-opted Executive Committee member of Lewisham LINk

Diana Robbins Lay Member

Lewisham CCG None None Co-opted Executive Committee member of Lewisham LINk

Dr Judy Chen Clinical Director

Partner Rushey Green Group Practice – practice provides cover to UCC for one day a week

None None My practice supports Rushey Green Time Bank I am named GP for safeguarding

One of my salaried GPs is the Drug and Alcohol lead for Lewisham and the practice provides an in-house service for

I am a carer in Lewisham for a young adult with learning difficulties. My daughter and I as her carer use the

community detox for alcohol. Grant Thornton UK LLP is Rushey Green Group Practice accountant.

services provided by the Children’s Transition Team and Adults with Learning Disabilities Team

Prof. Ami David MBE Board Member Nurse

Lewisham CCG Director AD Community Nursing Consultant a subsidiary of Prasand International Limited specialising in risk management and offering consultancy/project management to health care organisations (private and NHS) and Royal Colleges. Visiting Professor of Nursing Leadership and Expert Practice London South Bank University. Non-Executive Director of Medway Community Healthcare CIC Fellow Queens Nursing Institute Nurse Member Lambeth and Southwark CCGs Governing Body Nurse Member

Governing Body meeting

Minutes of the meeting of the Lewisham Clinical Commissioning Group (LCCG)

Governing Body held on Thursday, 4 July 2013 at 13.00 at Cantilever House, Eltham Road, London SE12 8RN

Present Dr Helen Tattersfield Clinical Chair, LCCG Dr David Abraham Senior Clinical Director, LCCG Dr Judy Chen Clinical Director, LCCG Prof. Ami David MBE Nurse Member, LCCG Dr Hilary Entwistle Clinical Director, LCCG Dr Arun Gupta Clinical Director, LCCG Dr Simon Parton LMC Chair Mr Tony Read Finance Director, LCCG Ms Diana Robbins Lay Member, LCCG Dr Marc Rowland Clinical Director, LCCG Mr Ray Warburton OBE Lay Vice Chair, LCCG Mr Martin Wilkinson Chief Officer, LCCG

In Attendance Ms Lesley Aitken Corporate Services Manager, LCCG (minutes) Mr David Basfield-Birch Lewisham Bereavement Mr Bill Bishop Lewisham Bereavement Ms Alison Browne Nurse Director, LCCG Mr Graham Carter Member of Public Mr Easonibare QVT Ms Nina Gray-Lyons Lewisham Pensioner’s Forum Mr Graham Hewett Head of Integrated Governance, LCCG Mr Desmond Hodgson Healthwatch Lewisham Ms Keri Lewis Communications Officer, SLCSU Mr Charles Malcolm-Smith Head of Strategy and Organisational Development, LCCG Ms Susanna Masters Corporate Director LCCG Ms Katrina McCormick Deputy Director Public Health, LB Lewisham Mr Andrew McKenzie South London and Maudsley Ms Victoria Medhurst Commissioning Programme Manager, LCCG Mr Alistair Munro Janssen Pharmaceuticals Mr Tony Nickson Chief Executive, Healthwatch Lewisham Mr Ashley O’Shaughnessy Service Redesign Programme Lead, LCCG Mr John O’Sullivan QVT Ms Kelly Scanlon Communications Lead, SLCSU Ms Samantha Young Teva Pharmaceuticals

Apologies Ms Aileen Buckton Executive Director Community Services, LB Lewisham Dr Faruk Majid Senior Clinical Director Dr Danny Ruta Public Health Director, LB Lewisham

ENCLOSURE 2

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LEW13/74 Welcome and Announcements Dr Tattersfield welcomed members of the public to the Governing Body meeting of NHS Lewisham Clinical Commissioning Group. She especially welcomed Mr Nickson, the Healthwatch Governing Body representative, to his first meeting and asked for thanks to be passed on to Ms Gillard who had represented Lewisham LINk at the meeting. LEW13/75 Declarations of Interest There were no new declarations of interest given at this stage of the meeting.

LEW13/76 Previous Minutes The minutes of the previous meeting were taken as a true record

. LEW13/77 Action Log and Matters Arising All actions had been addressed. LEW 13/78 Chief Officer’s Report . Mr Wilkinson asked for any comments on his report. In response to a question raised Mr Wilkinson confirmed that Ms Karen Bates, Adult Safeguarding Designated Nurse, along with a relevant Clinical Director as required would represent the CCG at the Safer Lewisham Partnership meetings. Regarding the two Cancer Commissioning teams, Mr Wilkinson explained that although hosted by NW London CSU and the other by North Central and East London CSU the two cancer commissioning teams would cover the whole of London. A meeting had been arranged between representatives from the Cancer Commissioning team and Mr Wilkinson and Dr Majid to discuss any relevant issues. Professor David welcomed the approach taken by the Health Visitors Expansion Programme which would be locally managed. The CCG, working with Lewisham Council Joint Commissioners would have flexibility for the service, though there were national specifications. The Governing Body NOTED the report LEW13/79 Chair of Governing Body Report Dr Helen Tattersfield gave the report. Her report highlighted the difference between PCTs and CCGs which was primarily now the degree of clinical involvement in decision making. She acknowledged that there may be a need to assert ourselves to ensure new ways of working succeeded. Work was being undertaken with practices to bring forward changes including work on reducing the increasing pressure on practices and improve access issues for patients. A membership event was being held on 18 July which would look at these matters in more detail. The Governing Body NOTED the report LEW13/80 Chair of Strategy and Development Committee Report Dr Abraham gave the report which reflected the detail of the Strategy and Development Committee meeting which was held on 6 June 2013. Dr Abraham clarified that the Strategy and Development Committee looked at the direction of travel and Delivery Committee looked at how we got there.

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Ms Robbins added that the Public Engagement Group would now feed into the Strategy and Development Committee. The Governing Body NOTED the report LEW13/81 Chair of Delivery Committee Report Dr Tattersfield reported that the Delivery Committee covered a wide range of matters with a high focus on quality. She highlighted that the smoking cessation target for 2012/13 had been met with three quitters achieved over target. The Committee NOTED the report LEW 13/82 Integrated Performance Report Mr Read gave the report. 82.1 Finance and QIPP Report The finance report reported on month 2, to 31 May 2013. Mr Read explained that it was too early in the year for hard indicators. A start budget of £365m had been confirmed which equated to the Revenue Resource Limits. This was based on known commitments on acute contract activity. The CCG was presently assuming that it was in line with plan in both its programme costs and its £25 per head running costs. At Month 2 the CCG was reporting an overall underspend against the budget of £950k. This was £44k better than the planned surplus target. There was an early indication that some areas of performance in acute services were higher than planned. This would be looked in fuller detail at the Delivery Committee. The first meeting of the Finance and Risk Group would be held on 22 July where the key risks including the transfer of responsibility for specialist services from PCTs to NHS England, would be discussed. This action had resulted in a £10.4m budgetary adjustment taken from the start position, though this should be cost neutral for CCGs. It was agreed that the situation would be closely monitored with a report back with the Month 6 data at the end of October 2013.

ACTION: Tony Read

The CCG had identified QIPP schemes of £16m which had been risk assessed to a still challenging £12.1m. Ms Robbins said that it would be good to know what were new QIPP projects and what were ongoing. Mr Read would circulate an analysis to the Governing Body to include an explanation of what the QIPP headings meant. Ms Robbins requested that the term physical disabled be amended to physically disabled people. There should be no cut to services but schemes would be developed on a lower level of activity. Mr Read explained that there were exception reports for three performance standards which were significantly off target:

1. Improving Access to Psychological Therapies (IAPT) – the service was seeing more patients with severe needs where recovery was more challenging. It was noted that Lambeth and Southwark had higher recovery rates though they shared the same provider with Lewisham. South London and Maudsley NHS Foundation Trust (SLaM) would bring an action plan to address this to the next contract meeting.

2. A&E 4 hour standard – since May Lewisham Healthcare NHS Trust (LHNT) had met the standard. The quarter to date was 95.24% with an updated figure was 95.4%. There would be

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further work on a Recovery and Improvement Plan with the SEL Urgent Care network retained as the Urgent Care Board until an Urgent Care Board can be developed for the new Lewisham and Greenwich NHS Trust.

3. Mixed Sex Accommodation – there were reported breaches at King’s and Queen Elizabeth sites.

The exception report would be refreshed at the beginning of Quarter 2. King’s were the provider for critical care and would be undergoing capital works this year which would address the situation.

Mr Warburton pointed out that there was a ‘not applicable’ comment in the Health Inequality Duty and the Public Sector Equality Duty box on the coversheet for this report though mixed sex accommodation and mental health (IAPT) were both good examples for this section. There needed to be a follow through on these issues with the Governing Body being assured that the duties were being considered.

Mr Read accepted the point and would complete any future coversheet accordingly.

Mr Wilkinson wanted to thank LHNT, along with the Council and the CCG on their effort to rise above the 95% target for A&E 4 hour standard.

82.2 Quality

Mr Hewett presented the report. This was the first Quality Report for the Governing Body and was a summary of the full report which went to the FLAG (For Learning and Action Group) and the Delivery Committee. An exception report was included for any Red rated quality concerns, these were: • Safeguarding Mandatory training. • GP Patient Survey • Same Sex Accommodation breaches • Maternity Services Professor David raised the issue of pressure ulcers and would like the grades of the ulcers and where they were acquired to be included in the next report. Mr Hewett said that FLAG had been looking at pressure ulcers matters. Mr Warburton added that as this was a continuing issue should it not be escalated to a Red? Ms Robbins explained that some of the ulcers were acquired before the patient arrived at LHNT.

Ms Browne said that they were looking at a wide scale project on Pressure Ulcers across Greenwich, Bexley and Lewisham especially for recovery times. There would be a report back in October.

ACTION: Alison Browne

Ms Robbins raised concerns over the patient experience element of the quality dashboard where further development was needed. It would be helpful to triangulate patient experience in line with Healthwatch and find appropriate measures.

ACTION: Graham Hewett

The Governing Body reviewed and NOTED the Integrated Performance Report and exception reports.

LEW 13/83 Strategic Plan Mr Malcolm-Smith led the presentation on the Strategic Plan 2013-2018. The Governing Body had participated in a series of workshops to develop a new strategy for the organisation for the next five years. By October 2013 there would be a finalised strategy in place.

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Mr Malcolm-Smith circulated the slide pack for the presentation, a full copy of which can be found at: http://www.lewishamccg.nhs.uk/about/ourboard/Board%20papers/Commissioning%20Strategy%202013-18%20presentation.pdf The key issues of the presentation were:

The Case for Change; context and challenges Health Outcomes: There was improvement in the health outcomes for the local population but not compared to the average in England. Cancer was worse in 2011-12 but there was now a downwards trend. Demographic Change: There were population increase pressures on Lewisham with an increased number of people with long term conditions. Inequalities: The nine most deprived wards ranked consistently in the worst five for key health outcome indicators. Provider Challenges; local providers were under pressure with high demands. Financial; the spend on maternity in Lewisham was higher than England and cluster average. The Vision; Dr Entwistle provided a a case study for Long Term Conditions (LTCs). She gave the case on how two patients, an older married couple, both with LTCs accessed services in 2013 and how their experience would be improved with the CCG’s vision for integrated care for patients with LTCs in 2019. Mr Warburton said that reference to a carer’s assessment would have been good with a need to flag the appropriate information for the patient and for the carer. Dr Entwistle replied that this would get picked up in the care plan for both patient and carer. The Vision and Strategic Outcomes; Ms Susanna Masters presented this section. The Key Outcomes proposed to measure the CCG’s success in improving the quality of services and health in Lewisham were:

• Potential years of life lost from causes considered to be amenable to healthcare • Life expectancy • Under 75 Mortality rates for the three biggest causes of death in Lewisham; cancer,

cardiovascular diseases and respiratory. • Neonatal mortality and stillbirths (within 28 days) • Patient experience • End of Life Care

The financial challenge based on estimates of the financial position for the next 5 years showed an accumulated reduction of 10% in the CCGs commissioning budget. The CCG proposed to work to transform local services through; Ensuring solid foundations and specific CCG focus on; primary care, unplanned care, frail older people, maternity ‘team around the mother’ and Long Term Conditions through integrated care. Ms Robbins suggested that the Vision should be based on the ‘FREDA’ principles, linked to the Human Rights Act (Fairness, Respect, Equality, Dignity, Autonomy).

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http://www.lewishamccg.nhs.uk/about/ourboard/Board%20papers/Commissioning%20Strategy%202013-18%20presentation.pdf

http://www.lewishamccg.nhs.uk/about/ourboard/Board%20papers/Commissioning%20Strategy%202013-18%20presentation.pdf

Mr Warburton added that with regard to self-management this can only be placed with patients if they wanted it. Mr Read suggested adding a measure around quality of life. A quality of life indicator would be added to slide 14.

The suggested approach to communicating and engaging CCG member practices, the public, stakeholders and partners was by a summary of the strategy and accompanying questions;

• Do you support the vision? • Do you agree with the strategic priorities? • Would you like to be more involved in co-designing the proposed changes to local health and

social care?

The questions would be reviewed with the Patient Engagement Group (PEG) at their meeting on 19 July. Dr Parton asked if the CCG had to save money by spending less where was that money going to. That appeared to be a cut rather than saving. This needed a further conversation. On slide 25 regarding Primary Care improvement, sustainability of local practices should be the first bullet point. Regarding spending power Mr Read said that the Government had confirmed an increase in NHS funding. Lewisham had 6.9% more income than the DoH suggested which may require a down adjustment. There was an increase in the demand for high care services which would require further savings to support. Mr Nickson said that with regard to stakeholder engagement, there was the Lewisham Compact which was a set of principles which defined how public bodies engaged with the voluntary sector in Lewisham. It was suggested that the Governing Body should sign up to the Compact. This would be reviewed at Public Engagement Group (PEG).

ACTION: Diana Braithwaite Dr Chen added that Under 5’s which was linked with maternity, working with acute trusts and the Local Authority, should be included. Mr Warburton requested that more was mentioned about family and other carers, regarding what support given and what support they needed. The Governing Body; APPROVED the draft case for change analysis AGREED the draft overarching strategic vision for better health, best care and best value AGREED the draft models of delivery for the strategic priority areas AGREED the approach for communication and engagement on the draft strategy with the CCG membership, patients and the public, and stakeholders LEW 13/84 Corporate Objectives Mr Wilkinson gave the report. The Governing Body would track the progress on the delivery of the Corporate Objectives through the Delivery Committee and exception reporting to the Governing Body. The Delivery Committee would receive bimonthly reports on the progress of the delivery of the agreed Corporate Objectives. Mr Warburton asked for immunisations of Under 5’s to be added to the Plan on a Page.

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Ms Robbins asked for the Frail and Vulnerable strategic theme to be made more robust. She would discuss how to achieve this with Ms Masters outside of the meeting. The Governing Body APPROVED the CCG’s detailed Corporate Objectives for 2013 -14 The Governing Body NOTED the planned process by which the detailed Corporate Objectives would be monitored by the Delivery Committee LEW 13/85 Risk Management Report and Board Assurance Framework Mr Hewett presented the report which was to advise the Governing Body of the high and very high risks to achieving its corporate objectives. There were seven papers included in the report:

1. Risk Management Report 2. Board Assurance Framework (BAF) 3. The Risk Register 4. Information Governance Exception Report 5. Claims for NHS Funded Continuing Healthcare Exception Report 6. Adult Safeguarding Exception Report 7. The transfer of Specialist Commissioning Exception Report

Mr Warburton said that the BAF was a good piece of work though the description of risks required further work and needed to be more SMART. Mr Warburton would discuss the assurance source in the BAF with Mr Hewett outside of the meeting. The BAF and Risk Register would be discussed at the Finance and Risk Group. With regard to the Information Governance (IG) risk Mr Read explained that it had gone from green to red because of the demise of the PCT and formation of CCGs, the toolkit was based on PCT information which was no longer admissible. There were three key areas to bring the risk down:

1. The Adoption of the two policies; Information Security and Information Governance, which would be approved at the Delivery Committee.

2. To undertake an IG toolkit assessment with an initial submission mid year and the final submission at year end.

3. To solve the Primary Care accessing confidential patient information issue.

In house IG training was being given to CCG staff on 10th and 24th August.

Ms Robbins asked why ‘failure to have the highest standards to protect Children from harm’ only had a target score of moderate. Mr Hewett responded that the Governing Body could set the target for any risk. This would be looked at in the Finance and Risk Group.

ACTION: Graham Hewett The Governing Body NOTED the Risk Management Report, APPROVED the Board Assurance Framework and NOTED the exception reports for the risks scored ‘very high’

LEW 13/86 2013/14 Start Revenue Budget

Mr Read gave the report which detailed the final start revenue budget as agreed with the CCGs Directors for 2013/14.

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The CCG had received a total revenue allocation of £365m of which £357.85m related to Programme expenditure with £7.16m related to running costs. This included the £10.4m reduction which related to the London wide funding gap for specialist expenditure. There were £25 per head running costs. There were NHS England assumptions that the CCG would have a 1% surplus, 2% non-recurrent investment reserve and 0.5% as a general contingency included within its expenditure. Section 6 of the report showed a breakdown of budgets. The main changes were in acute where the budget had been reduced to reflect the £10.4m Specialist adjustment. Mr Wilkinson thanked Mr Read for negotiating down the at risk amount stated by NHS England from £3.5m to £297K. The Governing Body NOTED the update to determine start budgets for 2013/14 NOTED the agreement to delegated budgets by relevant Directors NOTED the key budgetary risks and the potential areas of mitigation AGREED the start revenue budget for 2013/14 for NHS Lewisham CCG, following agreement by relevant Directors.

LEW 13/87 Proposed Use of 2% Non Recurrent Budget

Mr Read gave the report which set out the proposed use of the 2% Non Recurrent Budget for 2013/14. The CCG’s operating plan allocated the 2% (£7284k) non recurrent monies as follows:

• 1% - £3641k community based care strategy • 0.5% - £1821k pump priming other QIPP • 0.5% - £1821k managing in year risk in accordance with the SEL CCG collaborative risk

management framework.

Appendix A of the report detailed the proposed three year Non Recurrent spend by the CCG on the SEL CCGs’ Community Based Care Programme. Any 2013/14 proposed service changes would be scrutinised and considered by the Delivery Committee. The Governing Body AUTHORISED the investment of the 2% Non Recurrent budget for 2013/14 as set out in the proposal. APPROVED the collaborative approach to investment of 1% Non Recurrent budget in the CBC strategy over three years. NOTED that the 2014/15 and 2015/16 budget decisions would be formally taken as part of the budget setting process for these years. LEW 13/88 Revised Governance Arrangement for the Governing Body Ms Masters gave the report on the proposed changes on the CCG governance arrangements. It was recommended that the Governing Body met in public bi-monthly interspersed by Governing Body workshops in order to consider key strategy and operational issues. The Audit Committee would continue to meet on a quarterly basis. Lewisham CCG Patient and Public Involvement & Inequalities Group (PPI&I) resolved at its last meeting to form a joint Patient Engagement Group to support the work of the Health and Wellbeing Board (HWBB). This joint group would bring together key stakeholders from across Lewisham’s public, voluntary and community sectors.

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It was agreed that the LCCG PPI&I Group would be renamed Public Engagement Group (PEG) and would continue to meet on a bi-monthly basis. The Delivery Committee would continue to meet on a monthly basis but to ensure more in depth challenge it was recommended that the agendas be organised over a two month cycle. Following the March 2013 Audit Committee, where there was a request for a forum where financial and risk matters could be discussed more fully, it was recommended that a Finance and Risk Group be created as a sub group of the Delivery Committee. Following an independent review of the current structure of the Health and Wellbeing Board, to ensure they were fit for purpose, new governance arrangements were proposed with the following supporting groups:

• Joint Public Engagement Group • Health and Wellbeing Delivery Group • Adult Joint Strategic Commissioning Group • Children’s and Young People’s Commissioning Group

There would continue to be a Health and Wellbeing Agenda Planning Group. The report cover sheet had been revised with the following changes:

• CCG’s objectives - to indicate how the report linked with CCG strategic objectives • Stakeholder involvement – now changed to Public Engagement • Public Sector Equality Duty – had been expanded to take into account the Health Inequalities

Duty and Public Sector Duty.

Mr Warburton explained that the second bullet point on the areas of focus on the Remuneration Committee terms of reference referred to all staff not employed under agenda for change. Ms Robbins said that the reduction of the number of in-public Governing Body meetings by definition meant that fewer topics would be discussed in public she suggested a review in December of the new arrangements. This was agreed.

ACTION: Susanna Masters/Lesley Aitken The Governing Body APPROVED;

• The formal Governing Body meetings would be held bi-monthly in public • The Governing Body would hold bi-monthly Governing Body workshops • The Remuneration Committee Terms of Reference • The Strategy and Development Terms of Reference • The Delivery Committee Terms of Reference

LEW 13/89 Virtual Patient Record (VPR)Outline Business Case Mr Read gave the report. This Outline Business Case for VPR which covered the implementation of a VPR in Lewisham acute, community and primary care and the Queen Elizabeth Hospital had been considered by the Strategy and Development Committee having previously been approved by the LHNT Board. The Committee had asked for the additional costs to be looked into. There had been a strong commitment from LHNT that this would be a starting point but could include other health and social care services in the future. There had been no decision yet on whether there would be capital support for the first two years.

Page 9 of 14

A full Business Case would come back to the Governing Body in either September or October.

ACTION: Mr Read Ms Robbins confirmed that this had been discussed at the Strategy and Development Committee and that there was a strong case for patient engagement on what was proposed. Dr Gupta added that there was definitely support for patient access and a patient portal. Patient input would be required on how that portal should be developed. Mr Wilkinson said that the VPR was for sharing information between providers and should be incorporated into the patient engagement agenda throughout the summer. Dr Abraham said that patients were more concerned that GPs did not have access to patient information; there was a need to discuss VPR with patients as an enabler. Mr Warburton added that the system would be based on consent and that the risks and benefits should be shared equally across all involved. The Governing Body APPROVED the outline Business Case, subject to conclusion of risk management agreements between the CCG and LHNT. They CONFIRMED the Revenue Funding arrangements through cash releasing benefits and APPROVED delegated responsibility to the Chief Officer to determine satisfactory risk management agreement. LEW 13/90 Working in Partnership with the Pharmaceutical Industry Policy Dr Gupta gave the report. The policy was developed because of changing relationships and aimed to take a neutral stance on the principle of whether the CCG should or should not work in partnership with the pharmaceutical industry and set out a process for making this decision on a case by case basis depending on the merits of individual proposals. The policy had been discussed by the Management Group and Delivery Committee where comments had been raised and the policy amended accordingly. It was confirmed that the register of all joint working projects would be kept on the public website. Following discussion it was agreed that the policy required further clarity of scope into member practices The revised policy incorporating comments made would be taken to the LMC. Mr Read requested a review of the business case and finances ahead of any decision as part of the policy flow diagram. The Governing Body did not approve the policy at this stage but AGREED that Chair’s action could be taken for approval if required because of timeliness. LEW 13/91 Healthwatch Lewisham – Draft Workplan 2013/14 Mr Nickson gave the report. He explained that this was a work in progress which had been requested by the Local Authority. From 1 April 2013 the delivery body for Lewisham Healthwatch was Voluntary Action Lewisham (VAL). The contract was for two years. VAL had convened a governing sub group and was in the process of developing a reference group which would be a public facing group. The report included a draft performance framework which would be used to monitor the effectiveness of the services provided by Healthwatch Lewisham.

Page 10 of 14

They employed a Development Officer and two Engagement Community Officers Mr Wilkinson said that the CCG looked forward to working with Lewisham Healthwatch. The Governing Body NOTED the report LEW13/92 Any Other Business There was no other business reported. LEW 13/93 Reports taken for information only The approved minutes of the Delivery Committee held on 16 May 2013 and the Strategy and Development Committee held on 4 April 2013 were taken for information. LEW 13/94 Questions from members of the public Dr Tattersfield invited questions from members of the public present at the meeting. Q – Is the 2% contingency used for preventative initiatives? Mr Read – there was a national expectation from the Department of Health (DH) that the 2% non recurrent contingency would be used flexibly, there was no prescriptive instruction from the DH on how it could be spent. Q – Are there any funds for preventative initiatives? Mr Read – most preventative services were transferred to the Local Authority through the transfer of Public Health. It was possible to ascertain what funds for preventative work were available. Risk stratification actively seeks patients who were at risk of needing interventions at some stage. Dr Tattersfield added that this conversation should be raised at the Health and Wellbeing Board who now lead on local health and wellbeing and is part of the council governance since April 2013. Q – Is funding available for community groups and voluntary sector? Mr Wilkinson – there is a timetable for agreeing funds with most funding being committed to acute services. There were some opportunities for smaller schemes which could work with the voluntary sector although they would need to show value for money and link to CCG priorities. Not all schemes had to be tendered for. Further discussions would be held with VAL. LEW 13/95 Potential Audit issues The Board Assurance Framework would go to the Audit Committee and they would also monitor the governance arrangements presented to today’s Governing Body. LEW13/96 Date of Next Meeting The next meeting for the Governing Body would be held between 13:00 – 15:30 on Thursday 4 September 2013, at Civic Suite, Lewisham Town Hall.

Page 11 of 14

Minute Reference

Action Responsible Person

Timescale Status/Comments

July 2013

13/82.1 Report on the transfer of specialist services to NHSE and the budgetary adjustment at the end of October 2013.

Tony Read December Governing Body

13/82.2 There would be a report back in September on the wide scale project being undertaken on Pressure Ulcers across Greenwich, Bexley and Lewisham especially for recovery times. . To triangulate patient experience in line with Healthwatch to find an appropriate measure for the quality dashboard.

Alison Browne

Graham Hewett

October meeting

October meeting

13/83 The Lewisham Compact would be reviewed at the PEG meeting.

Diana Braithwaite To be confirmed Public Engagement Group is scheduled for 20.09.13. The Lewisham Compact is an agreement between the council and local voluntary and community groups.

13/85 To look at the level of risk on ‘protect children from harm’ at the Finance and Risk Group

Graham Hewett July Finance and Risk Group

The Risk has more controls to manage the process including a review of the Looked After Children. A presentation of this review will be going to the Delivery Committee.

13/88 To review holding Governing Body meetings

in public bi-monthly to be reviewed in six months.

Susanna Masters/Lesley

Aitken

Timetabled for February 2014

meeting

This has been added to the forward planner

Page 13 of 14

13/89 A Full Business Case for VPR would come back to the Governing Body.

Tony Read September/October

Page 14 of 14

A meeting of the Governing Body 5th September 2013

ENCLOSURE 3 Risk Management Report and Board Assurance Framework

CLINICAL LEAD: Marc Rowland MANAGERIAL LEAD: Susanna Masters

Post Chair Post Corporate Director

AUTHOR: Graham Hewett Post Head of Integrated Governance

RECOMMENDATIONS: The Governing Body is asked to:

1. Note the Risk Management Report 2. Approve the Board Assurance Framework as evidence that:

a. the CCG is aware of the full range of risks presenting to the corporate objectives

b. that the CCG has adequate controls to mitigate those risks c. where existing controls have not reduced the residual risk score to the target

there are credible action plans 3. Note the exception reports for the risks scored “very high.”

SUMMARY: The purpose of this report is to advise the Governing Body of the high and very high risks to achieve its corporate objectives. Also the report identifies the controls and assurances that have been put in place to mitigate the risks and highlights where there are gaps and the actions being taken to close them. Exception reports provide greater detail of the four “very high” risks; Information Governance, Claims for NHS Funded Continuing Health Care, Adult Safeguarding and the transfer of Specialist Commissioning. The following papers are attached:

1. Risk Management Report 2. Board Assurance Framework 3. Exception Reports for

• Information Governance • Claims for NHS Funded Continuing Health Care • Adult Safeguarding • The transfer of Specialist Commissioning

KEY ISSUES: There are four very high risks impacting the corporate objectives. Exception reports are attached for risks affecting:

• Information Governance • Claims for NHS Funded Continuing Health Care • Adult safeguarding • The transfer of specialist commissioning

Since the last Governing Body meeting on 4th July 2013, representatives from the Audit Committee met with the Head of Integrated Governance and Governance Officer to discuss their assurance requirements as part of the Lewisham CCG Risk Management process. As an outcome of this meeting it was agreed:

• Only the BAF would come to the Governing Body and would be the first item on the agenda to assign more time for discussion.

• The BAF would identify for each of the risks the responsible Committees. • The Management Team would ensure that the BAF was fully completed including the

risks definition being more specific, ensuring that the Controls do not repeat the risk and that the Assurance Source and Assurance Gaps fields are populated.

• Ongoing work within the CCG to ensure that the Risk Management Process is part of normal business.

CORPORATE AND STRATEGIC OBJECTIVES The report impacts on all corporate objectives.

CONSULTATION HISTORY: • Risk Management Group July 27th 2013

PUBLIC ENGAGEMENT

• There has been no public engagement and none is planned other than presentation of the report at the Governing Body held in public.

HEALTH INEQUALITY DUTY How does this report take into account the duty to:

• Reduce inequalities between patients with respect to their ability to access health services.

• Reduce inequalities between patients with respect to the outcomes achieved for them

by the provision of health services. PUBLIC SECTOR EQUALITY DUTY How does this report take into account the duty to:

• Eliminate discrimination, harassment and victimisation and any other conduct that is prohibited under the Equality Act 2010

• Advance equality of opportunity between people who share a relevant protected characteristic and people who do not share it

• Foster good relations between people who share a relevant protected characteristic and those who do not share it

The report will help identify where there are risks that the CCG will not meet its Health Inequality and Public Sector Equality duties and the controls and actions taken to mitigate these risks. RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Susanna Masters E-Mail: [email protected] 020 3049 3237

AUTHOR CONTACT: Name: Graham Hewett E-Mail: [email protected] 020 3049 3237

mailto:[email protected]


Risk Management Report Governing Body 5th September 2013 Summary

1. The August 2013 Board Assurance Framework is attached.

2. The CCG is currently managing a significant number of high and very high risks. Part of the reason for the skewed distribution towards high and very high risks is a result of organisational change; new organisations and relationships have not yet had sufficient lifespan to produce assurance reports. The Governing Body should see a gradual drift from very high to lower rated risks as routine reporting generates assurances at monthly and quarterly intervals.

3. Since the last Board Assurance Framework (July 2013) there has been two changes in the assessments of risk:

• “The Introduction of NHS 111 will destabilise the Unplanned Care System” (Risk 587) has increased from a Residual likelihood of “Unlikely” to “Possible” increasing the score to 12 due to NHS Direct withdrawal from the market.

• “The failure to oversee the implementation of effective arrangements to safeguard children” (Risk 573) was reduced from a Residual of “Catastrophic” to “Major” taking score down to 8 due to the controls around LAC which are now in place.

4. Exception Reports for all “Very High” rated risks are also attached for:

• Information Governance • Claims for NHS Funded Continuing Health Care • Adult Safeguarding • The transfer of Specialist Commissioning

5. The Board Assurance Framework continues to be monitored closely by the Finance and Risk Group who meet on a monthly basis for in-depth scrutiny of the financial reports and the risk management processes, the Risk Register and the Board Assurance Framework. Also, the Risk Management Group meets on a monthly basis to review the Risk Register, Actions and Assurance processes.

Heat Map

6. The heat map (below) illustrates the distribution of risks by residual risk score. a. 4 risks are rated very high b. 24 risks are rated high c. 4 risks are rated moderate

Date: 29/08/2013. Version: 1.0. Author: Lorraine Smedmor. Status: Final. Approvals: None Page: 1 of 2

Risk Reference by Risk Score

Low 1-3

Moderate 4-6

High8-12

Very High15-25

582 578 589

597 579 592

598 580 594

600 581 574

588601603604606649573576584595620577583585587590599607616617

Date: 27/06/2013. Version: 1.0. Author: Lorraine Smedmor Status: Final. Approvals:.None Page: 2 of 2

Risk Matrix Impact

LiklihoodNegligible

1Minor

2Moderate

3Major

4Catastrophic

5

Rare1

Unlikely2

4 10

Possible3

4 10 1

Likely 4

3

Almost certain

5

Board Assurance Framework - August 2013

Objective: 01. Five Year Strategic Plan

Inherent Controls Current Assurance Source Assurance

Gaps

Actions Target

Ref Description C L Total C L Total C L Total

Risk

580 4 3 High (12) Strategy Plan Monitoring at Strategy and Development Committee of health outcomes.

Strategic Planning Process

Strategic Monitoring Framework not yet established.

4 3 High (12) 4 2 High (8)Commissioning Intentions Completed

Susanna Masters

30/09/13

Strategic Plan Monitoring Framework Completed

Charles

Malcolm-Smith

03/10/13

Strategic Plan Sign-off

Charles

Malcolm-Smith

03/10/13

CCG strategy does not plan sufficient transformational change to improve health outcomes or financial balance or both

Causes:Limited leadership capacityLack of a Strategic planLack of detailed Commissioning Intentions

Effects:Continued and new unmet health needsorFailure to achieve financial balanceor both

Committee:Strategy & Development Committee

Susanna Masters

1




Gaps

Actions Target


Risk

606 4 3 High (12) Each strategic priority has a lead clinician.

Timetable and processes for 2013/4 including responsible committees, agreed through paper to Delivery Committee (20th June) and Audit Committee (9th July)

QIPP projects jointly managed by Clinical Directors and reported to Delivery Committee

Clinical Leadership Refresh of OD planCommissioning Cycle workshop arranged for 1st AugustPotential change in clinical directors through election of new Clinical Directors by October 2013.Clinical Directors portfolios to be updated.

4 3 High (12) 4 2 High (8)Clinical Director elections

Charles

Malcolm-Smith

01/10/13

Clinical Director portfolios aligned to corporate objectives 2013/14

Martin Wilkinson

12/07/13

Refresh of OD Plan

Charles

Malcolm-Smith

31/07/13

Failure of the CCG to implement effective clinically led decisions

Cause:Insufficient capacity.Insufficient capability.

Effect:Failure to deliver major change to services.Failure to deliver strategic plans.

Committee:Delivery CommitteeStrategy and Development Committee

Martin Wilkinson

2




Gaps

Actions Target


Risk

649 4 4 Very High (16) Business Cases for new NHS Organisations

SEL CBC Steering Group.

Reports to Delivery Committee.

Community Based Care Strategy

Service change not yet completed

Reports from TSA governance structures.

SEL / NHS E Transition Board.

TSA and NHS E Business Case and funding approval

TSA arrangements Reports from governance structure not yet received.

Lewisham business plan not yet agreed.

Outcome of the Department of Health appeal.

4 3 High (12) 3 2 Moderate (6)CCG Strategy to be completed

Charles

Malcolm-Smith

31/07/13

Commissioning Intentions

Susanna Masters

30/09/13

Service specifications for maternity and unplanned care

Diana Braithwaite

30/09/13

Strategic Monitoring

Charles

Malcolm-Smith

31/10/13

TSA arrangements

Susanna Masters

31/07/13

Negative impact of the implementation of TSA recommendations on the provision of services for the Lewisham population, particularly on maternity and unplanned services

Cause:The underpinning assumptions are incorrectProposed or future mitigation not implemented

Effect:Insufficient capacity in the right placesAccess to services and inequalities worsenedImplementation plans for the new service are poorly coordinated and have unintended negative impact on other inter related servicesThe TSA agenda distracts the CCG from focusing its resources on the delivery of its key CCG authorisation responsibilities and on its strategy to transform the commissioning commissioning of local services


Susanna Masters

3




Gaps

Actions Target


Risk

583 4 4 Very High (16) NHS England Planning Guidance.TSA Governance Arrangements.NHS England London Region Assurance team.

Planning Assumptions No NHS England Planning Guidance available.LHNT Long Term Financial Strategy not received.

4 2 High (8) 4 2 High (8)Design and Agree Governance Arrangements for Integration Transformation Fund

Tony Read

31/03/14

Planning Assumptions

Tony Read

03/01/14

Risk of medium to longer term income and expenditure assumptions being inaccurate

Causes:Unpredictable changes to allocations and price.

Effects:Unsustainable strategic plan.

Committee:Finance and Risk Group

Tony Read

599 4 3 High (12) Strategy and Development Committee and Strategy workshop reviewed and challenged plans.

Strategy workshop agreed the strategic case for change on 6th June 2013.

Governing Body agreed Draft Strategic plan - 4th July 2013

Strategic Commissioning Groups

Governing Body to agree final Strategic Plan - 3rd October 2013.

Engagement exercise with Members, Public and Stakeholders

4 2 High (8) 4 1 Moderate (4)Agreeing the Strategic Plan on 3rd October

Charles

Malcolm-Smith

03/10/13

Engagement exercise to be undertaken during August - October 2013

Charles

Malcolm-Smith

30/10/13

The Strategic Framework is insufficiently robust

Cause:Strategic Plan is not sufficiently informed by evidence, research. horizon scanning. knowledge of best practice and bench marks.

EffectStrategic Plan's impact on outcomes, quality and costs is insufficiently ambitious.


Susanna Masters

4




Gaps

Actions Target


Risk

607 4 3 High (12) Health and Well Being Board Minutes

Outcomes of the NHS England Assurance Process quarterly meetings and annual review

Collaborative Working NHS England Assurance process is new and their are not yet any agreed outcomes

The Health and Well Being Board is new and not yet providing valid assurance.

4 2 High (8) 4 1 Moderate (4)Prepare reporting arrangements for NHS England Assurance Process

Mike Hellier

30/07/13

Failure to achieve the full potential of the new commissioning arrangements working with NHS England, Lewisham Council, SE London CCGs and CSU

Causes:Failure to establish working arrangements with new partners eg. Local Authority, CSU, other CCGs, NHSE.Fragmentation of Commissioning Arrangements.Ineffective use of staff capacity.

Effect:Ineffective use of capacity across the whole system for the health benefits of Lewisham people.

Committee:Strategy and Development Committee

Susanna Masters

Objective: 02. Commissioning Intentions


Gaps

Actions Target


Risk

5


Objective: 02. Commissioning Intentions


Gaps

Actions Target


Risk

599 4 3 High (12) Strategy and Development Committee and Strategy workshop reviewed and challenged plans.

Strategy workshop agreed the strategic case for change on 6th June 2013.

Governing Body agreed Draft Strategic plan - 4th July 2013

Strategic Commissioning Groups

Governing Body to agree final Strategic Plan - 3rd October 2013.

Engagement exercise with Members, Public and Stakeholders

4 2 High (8) 4 1 Moderate (4)Agreeing the Strategic Plan on 3rd October

Charles

Malcolm-Smith

03/10/13

Engagement exercise to be undertaken during August - October 2013

Charles

Malcolm-Smith

30/10/13

The Strategic Framework is insufficiently robust

Cause:Strategic Plan is not sufficiently informed by evidence, research. horizon scanning. knowledge of best practice and bench marks.

EffectStrategic Plan's impact on outcomes, quality and costs is insufficiently ambitious.


Susanna Masters

Objective: 03. Health and Wellbeing Board Strategy


Gaps

Actions Target


Risk

6




Gaps

Actions Target


Risk

579 4 3 High (12) Performance Reports for in year delivery at Delivery Committee.Performance updates to Health and Well-being Board.

Draft Health & Wellbeing Strategy

The final Health and Wellbeing Strategy has not yet been agreed

Health and Well Being Board Minutes.

Joint Strategic Needs Assessment (JSNA)

Delivery Plan for Health and Wellbeing Board Strategy not yet agreed.

4 3 High (12) 4 2 High (8)Alcohol and Smoking Targets

Susanna Masters

30/09/13

Draft Strategic Plan is aligned with the Health and Wellbeing Delivery Plan

Charles

Malcolm-Smith

31/07/13

Health and Wellbeing Strategy to be agreed on 19th September

Susanna Masters

30/09/13

Strategic Plan - Sign Off on 5th October

Charles

Malcolm-Smith

03/10/13

CCG Strategy fails to contribute to the delivery of the 9 Strategic Priorities of the Health and Wellbeing Strategy

Cause:Lack of clear CCG's strategic plan and outcome targetsCCG's Strategic Plan is not aligned with the Health and Wellbeing strategyFailure to implement CCG's strategic plan

Effects:Insufficient progress delivering outcome measuresInsufficient improvement in health and well being

Committee:Health & Wellbeing Board

Susanna Masters

7




Gaps

Actions Target


Risk





Susanna Masters

30/09/13


Charles

Malcolm-Smith

03/10/13


Charles

Malcolm-Smith

03/10/13


Causes:Limited leadership capacityLack of a Strategic planLack of detailed Commissioning Intentions

Effects:Continued and new unmet health needsorFailure to achieve financial balanceor both


Susanna Masters

Objective: 04. Maternity and Under 5’s (Community Based Care)


Gaps

Actions Target


Risk

8


Objective: 04. Maternity and Under 5’s (Community Based Care)


Gaps

Actions Target


Risk













Charles

Malcolm-Smith

31/07/13


Susanna Masters

30/09/13


Diana Braithwaite

30/09/13


Charles

Malcolm-Smith

31/10/13

TSA arrangements

Susanna Masters

31/07/13





Susanna Masters

Objective: 05. Older People (Community Based Care)


Gaps

Actions Target


Risk

9


Objective: 05. Older People (Community Based Care)


Gaps

Actions Target


Risk

595 3 4 High (12) Reports of impact of AQP going to Delivery Committee on a quarterly basis.

Contract Management

Spot contracts with Terms and Conditions.

Use of Spot Purchase in Exceptional Cases

3 3 High (9) 2 3 Moderate (6)Engagement of Nursing Homes to join the Framework

Michael Ogunlokun

01/10/13

Recovery Action Plan on managing Financial Risk and QIPP Targets

Michael Ogunlokun

16/09/13

Risk of Insufficient Capacity in Continuing Care Provision

Cause:Too few providers have signed up to the AQP Contract Framework.

EffectsPatient choice is limited to 24 homes across SE London geographical areal.Impact on Reputation.CCG will need to purchase beds outside AQP Framework which will impact on cost assumptions.

Committee:Delivery Committee

Dee Carlin

600 3 3 High (9) Project Initiation Documents signed off at:Diabetes Steering BoardRisk Stratification Board

Project Management

Report to Strategy and Development Committee.Strategic Commissioning Plan.

Strategic Framework Strategic vision not defined.

3 2 Moderate (6) 2 2 Moderate (4)Implementation of Risk Profiling and Development of Care Plans

Victoria Medhurst

31/07/13

Failure to deliver the Integrated Case Management Programme

Cause:Rushed implementation.Unclear strategic vision.

Effect:Fragmented services.Poor patient experience.

Committee:Programme Management MeetingDelivery Committee

Diana Braithwaite

10


Objective: 06. Primary and Community Care (Community Based Care)


Gaps

Actions Target


Risk

601 4 3 High (12) Strategy and Development Committee.CBC Transformation Board.

CBC Strategy Implementation of the workstreams; Integrated Care SystemsPrimary and Community CarePlanned CareEnabling workstreams

CBC Transfomation BoardSEL Directors of CommissioningSEL London Clinical Stratetgy CommitteeProgramme Executive Group

CCG participation and engagement in all relevant CBC workshops

4 3 High (12) 3 2 Moderate (6)Failure to deliver the Community Based Care Strategy within Lewisham in line with agreements with other CCGs in SE London

Cause:Unrealistic timescales.Unclear objectives.

Effect:No improvement to quality of primary and community services.Poor patient experience related to access to services.

Committee:Programme Management CommitteeDelivery Committee

Diana Braithwaite

Objective: 07. LTC Care Planning and Risk Stratification (Community Based Care)


Gaps

Actions Target


Risk

11


Objective: 07. LTC Care Planning and Risk Stratification (Community Based Care)


Gaps

Actions Target


Risk

600 3 3 High (9) Project Initiation Documents signed off at:Diabetes Steering BoardRisk Stratification Board

Project Management

Report to Strategy and Development Committee.Strategic Commissioning Plan.

Strategic Framework Strategic vision not defined.

3 2 Moderate (6) 2 2 Moderate (4)Implementation of Risk Profiling and Development of Care Plans

Victoria Medhurst

31/07/13

Failure to deliver the Integrated Case Management Programme

Cause:Rushed implementation.Unclear strategic vision.

Effect:Fragmented services.Poor patient experience.


Diana Braithwaite

Objective: 08. Unplanned Care (Community Based Care)


Gaps

Actions Target


Risk

12




Gaps

Actions Target


Risk

587 4 3 High (12) Sitreps and quality reports.

NHS 111 Clinical Governance

The SEL NHS 111 Programme Board

Viable Contracted NHS 111 Service

Decision to be taken by SEL Clinical Strategy Committee on 28th August and subsequently by Governing Body based on Options paper to CSC.

Working with LAS Decision on Options Paper outstanding.

4 3 High (12) 3 2 Moderate (6)Monitor National Review of 111

Chris Gadney

31/07/13

The introduction of NHS 111 will destabilise the Unplanned Care System

Cause:Failure of NHS 111 to direct patients to the appropriate care setting in a timely manner

Effects:Patients attend inappropriate servicesPoor patient experience / experience delaysPotential or actual harm to patients


Diana Braithwaite

13




Gaps

Actions Target


Risk

601 4 3 High (12) Strategy and Development Committee.CBC Transformation Board.

CBC Strategy Implementation of the workstreams; Integrated Care SystemsPrimary and Community CarePlanned CareEnabling workstreams

CBC Transfomation BoardSEL Directors of CommissioningSEL London Clinical Stratetgy CommitteeProgramme Executive Group

CCG participation and engagement in all relevant CBC workshops

4 3 High (12) 3 2 Moderate (6)Failure to deliver the Community Based Care Strategy within Lewisham in line with agreements with other CCGs in SE London

Cause:Unrealistic timescales.Unclear objectives.

Effect:No improvement to quality of primary and community services.Poor patient experience related to access to services.

Committee:Programme Management CommitteeDelivery Committee

Diana Braithwaite

14




Gaps

Actions Target


Risk













Charles

Malcolm-Smith

31/07/13


Susanna Masters

30/09/13


Diana Braithwaite

30/09/13


Charles

Malcolm-Smith

31/10/13

TSA arrangements

Susanna Masters

31/07/13





Susanna Masters

Objective: 09. Mental Health


Gaps

Actions Target


Risk

15


Objective: 09. Mental Health


Gaps

Actions Target


Risk

603 4 3 High (12) Revised QIPP Plans which will be reported to the Strategy and Development meeting.

Contract Management QIPP Plans not yet agreed.

4 3 High (12) 3 3 High (9)Clarification of Business Rules and Financial Risk

Dee Carlin

03/10/13

Community Mental Health Services Review

Dee Carlin

02/09/13

Contract Management

Dee Carlin

31/12/13

Quality Agenda sign off needed for 2013/14 Contract

Dee Carlin

03/10/13

Failure to fully deliver 2013/14 Mental Health QIPP target savings

Cause:The failure to agree with main provider on the level of in-year savings possible as a result of reviewing the Community Mental Health model.

Effect:Failure to realise potential savingsFailure to implement a new Community Mental Health model this year.


Dee Carlin

Objective: 10. Contracts 2014/15


Gaps

Actions Target


Risk

604 4 3 High (12) Strategy and Development Committee minutes.PEG.


Commissioning Intentions still under development.

CSU performance monitoring meetings with LCCG

Contracting Team

4 3 High (12) 3 2 Moderate (6)Commissioning Intentions to be comepleted - October 2013

Susanna Masters

30/09/13

Failure to agree 2014/15 Acute Contracts that deliver our Commissioning Intentions

Cause:Impact of TSA.

Effect:Loss of financial control.Poor provider performance.

Diana Braithwaite

16


Objective: 11. Integrated Governance Reporting


Gaps

Actions Target


Risk

578 4 4 Very High (16) SI Reports from all providers at FLAG and GB.Complaints Reports from all providers at CQRGs and by exception to FLAG and Delivery Committee.

Policies and Procedures

Insufficient capture of reporting of quality indicators.Absence of integrated governance reporting including quality indicators to Delivery Committee and GB.

Quality Reports for LHNT and SLAM.Care Home Quality monitored by Local Authority.Quality indicators to be reported have been agreed by FLAG.Access to My Health London Primary Care Data.

Quality Assurance Framework

First report not expected until June.Inability to access some Primary Care outcomes data.

4 3 High (12) 4 1 Moderate (4)Develop CGRG process for SLaM

Alison Browne

01/10/13

Francis Recommendations

Alison Browne

31/10/13

Non-NHS Providers Assurance Process

Alison Browne

01/09/13

Patient Engagement

Diana Braithwaite

31/10/13

To ensure that we continue to receive good Quality Reports from CQRG

Alison Browne

01/10/13

Failure to recognise warning signs of poor performance and quality across Lewisham

Causes:Effects of TSA and changes to provider landscape.Inability to capture sufficient quality indicators to provide assurance to FLAG, Delivery Committee and Governing Body.Inability to monitor Primary Care Outcome data.

Effects:Harm to patients.Damage to reputation.Possible financial loss.

Committee:For Learning and Action Group (FLAG)CQRGDelivery Committee

Alison Browne

Objective: 12. Quality Assurance


Gaps

Actions Target


Risk

17




Gaps

Actions Target


Risk

574 5 4 Very High (20) Job description.Employment records.mandatory training reports to the CCG Safeguarding Group.

Expertise and Staffing Further control would be achieved by appointing a Named Adult Safeguarding GP.

LCCG Health Safeguarding Group.


Significant numbers of pressure ulcers acquired in all care settings.

Updates on Pressure Ulcer Action Plan taken to FLAG

Pressure Ulcer Action Plan Monitoring

5 3 Very High (15) 5 2 High (10)Compliance of Liberty Safeguards across Health Providers

Karen Bates

31/10/13

Compliance with Mental Capacity Act Training

Karen Bates

31/10/13

Implementation of Pressure Ulcer Action Plan

Karen Bates

01/01/14

Review resources for effective monitoring of Adult Safeguarding in Lewisham CCG

Alison Browne

30/12/13

Safeguarding Supervision

Karen Bates

31/10/13

Staff and Expertise

Karen Bates

30/08/13

Failure to oversee the implementation of effective arrangements to safeguard Adults at risk

Cause:A failure to follow policies and guidelines.

Effects:A serious safeguarding incident or failure to recognise institutional abuse or neglect in commissioned services.

Committee:NHS Lewisham CCG Health Safeguarding Group

Alison Browne

18




Gaps

Actions Target


Risk

578 4 4 Very High (16) SI Reports from all providers at FLAG and GB.Complaints Reports from all providers at CQRGs and by exception to FLAG and Delivery Committee.


Insufficient capture of reporting of quality indicators.Absence of integrated governance reporting including quality indicators to Delivery Committee and GB.

Quality Reports for LHNT and SLAM.Care Home Quality monitored by Local Authority.Quality indicators to be reported have been agreed by FLAG.Access to My Health London Primary Care Data.


First report not expected until June.Inability to access some Primary Care outcomes data.

4 3 High (12) 4 1 Moderate (4)Develop CGRG process for SLaM

Alison Browne

01/10/13

Francis Recommendations

Alison Browne

31/10/13

Non-NHS Providers Assurance Process

Alison Browne

01/09/13

Patient Engagement

Diana Braithwaite

31/10/13

To ensure that we continue to receive good Quality Reports from CQRG

Alison Browne

01/10/13

Failure to recognise warning signs of poor performance and quality across Lewisham

Causes:Effects of TSA and changes to provider landscape.Inability to capture sufficient quality indicators to provide assurance to FLAG, Delivery Committee and Governing Body.Inability to monitor Primary Care Outcome data.

Effects:Harm to patients.Damage to reputation.Possible financial loss.

Committee:For Learning and Action Group (FLAG)CQRGDelivery Committee

Alison Browne

19




Gaps

Actions Target


Risk

587 4 3 High (12) Sitreps and quality reports.

NHS 111 Clinical Governance

The SEL NHS 111 Programme Board

Viable Contracted NHS 111 Service

Decision to be taken by SEL Clinical Strategy Committee on 28th August and subsequently by Governing Body based on Options paper to CSC.

Working with LAS Decision on Options Paper outstanding.

4 3 High (12) 3 2 Moderate (6)Monitor National Review of 111

Chris Gadney

31/07/13

The introduction of NHS 111 will destabilise the Unplanned Care System

Cause:Failure of NHS 111 to direct patients to the appropriate care setting in a timely manner

Effects:Patients attend inappropriate servicesPoor patient experience / experience delaysPotential or actual harm to patients


Diana Braithwaite

20




Gaps

Actions Target


Risk













Charles

Malcolm-Smith

31/07/13


Susanna Masters

30/09/13


Diana Braithwaite

30/09/13


Charles

Malcolm-Smith

31/10/13

TSA arrangements

Susanna Masters

31/07/13





Susanna Masters

21




Gaps

Actions Target


Risk

576 3 3 High (9) Performance reports to Delivery Committee.CSU have reported 2 for end of June 2013.

King's have assured the CSU that the backlog will be cleared by the end of September 2013.

Performance Meetings with King's

The CCG is not the Commissioner for specialist services and so therefore has no direct control on capacity.

3 3 High (9) 3 2 Moderate (6)Monitor implementation of King's plan to increase capacity

Mike Hellier

30/09/13

Failure to achieve the recovery plan for the 52 week standard for Lewisham patients

Cause:Insufficient capacity at King's during 2012/13 requiring over 52 week waiters to be treated in Q1 2013/14.

Effect:Poor patient experience.


Tony Read

595 3 4 High (12) Reports of impact of AQP going to Delivery Committee on a quarterly basis.

Contract Management

Spot contracts with Terms and Conditions.

Use of Spot Purchase in Exceptional Cases

3 3 High (9) 2 3 Moderate (6)Engagement of Nursing Homes to join the Framework

Michael Ogunlokun

01/10/13

Recovery Action Plan on managing Financial Risk and QIPP Targets

Michael Ogunlokun

16/09/13

Risk of Insufficient Capacity in Continuing Care Provision

Cause:Too few providers have signed up to the AQP Contract Framework.

EffectsPatient choice is limited to 24 homes across SE London geographical areal.Impact on Reputation.CCG will need to purchase beds outside AQP Framework which will impact on cost assumptions.


Dee Carlin

22




Gaps

Actions Target


Risk

573 5 4 Very High (20) Lewisham CCG Safeguarding Group receives reports form all Lewisham Safeguarding Children's Board is the lead for across borough and receives reports form all agencies LHT safeguarding board reports to CQRG

Child Safeguarding Policies and Procedures

Report to NHS Lewisham CCG health safeguarding group

Mandatory Training Reports have been received but provide negative assurance

Employment Records.Job Descriptions.SLAs with LHNT.Mandatory training records presented to CCG Safeguarding Group.

Staffing and Expertise Mandatory training reports not yet prepared.Further control could be gained from the appointment of a designated nurse LAC.

4 2 High (8) 3 1 Low (3)Designated Nurse LAC

Alison Browne

01/01/14

Mandatory Training LHNT

Alison Browne

29/11/13

The Failure to oversee the implementation of effective arrangements to safeguard children

Causes:Failure to follow policies and guidelines

Effects:Serious child protection incidents or failure to recognise abuse or neglect.

Committee:NHS Lewisham CCG Health Safeguarding Group

Alison Browne

23




Gaps

Actions Target


Risk

616 4 3 High (12) Reports of action plan to Delivery Committee.

Francis Report The Francis Group have yet to complete their review and development of their action plan.

Serious Incident Reports reviewed at FLAG and GB.GP Quality Alerts reviewed at FLAG and CQRG LHNT.


4 2 High (8) 4 1 Moderate (4)Francis Review and Action Plan

Alison Browne

31/12/13

Failure to learn from and respond to other events i.e. to become an "Organisation that Learns."

Caused by:Lack of processes and resources to review and respond effectively to outside events.

Effect:LCCG repeats failures that might have been prevented.Potential or actual harm to patients.


Susanna Masters

Objective: 13. Grip on day to day business


Gaps

Actions Target


Risk

24




Gaps

Actions Target


Risk

589 4 4 Very High (16) Face to face IG Training undertaken on 10th and 24th July. Effectiveness and understanding of training and policies needs to be undertaken by end of January 2014.

Patient Consent Inadequate process for monitoring that appropriate consent is sought.

IG Steering Group.Internal Audit due February / March 2014 to sign off all IG Policies and to ensure all evidence in place.


IG Policy and Data Security Policy not yet approved by GB.IG Toolkit Self Assessment will not be completed until at least December.Information Asset owners not identified and information assets not mapped.

Job descriptionEmployment record

Staffing and Expertise A mandatory training report is required.

4 4 Very High (16) 4 2 High (8)Policies

Mike Hellier

05/09/13

Preparation for IG Toolkit audit

Mike Hellier

31/12/13

Failure to achieve adequate Information Governance Standards

Causes:Lack of capacity and competency.

Effects:Unlawful access to PID.Insecure handling of PID.Reputational Damage.Financial Penalty.

Committee:Information Governance Steering Group

Tony Read

592 4 4 Very High (16) Budgetary provision Confirmation from National Legacy Team has not been receivedAdequacy of the value of the provision is uncertain

Finance report to Delivery Committee

Claims assessment and processing

Procedure for payments authorisation to be agreed with Chief Financial Officer

4 4 Very High (16) 4 2 High (8)Exception reporting

Michael Ogunlokun

27/08/13

Claims for NHS Funded Continuing Care affect Financial Plans

Cause:Successful claims for NHS funded Continuing Care.

EffectUnbudgeted expenditure.Failure to meet financial targets.


Dee Carlin 25




Gaps

Actions Target


Risk

JDsPerformance Reports to Michael Ogunlokun.

Recruitment of Band 7 Nurses

594 5 4 Very High (20) Acute contract monitoing reports

Activity Monitoring Indications are that the actual value of transfer for Lewisham CCG is circa £3.5m compared to the £10.4m allocation adjustment

Signed contractsContract management

SLaM Heads of Terms (signed August 2013)

Contract Reopener Clause

Technical Group output.Data Triangulation Technical Group not completed review.

4 4 Very High (16) 4 2 High (8)Technical Group

Tony Read

22/11/13

Transfer of Specialist Commissioning will not be cost neutral to CCG

Causes:Transfer and contracting arrangements.

Effects:Financial deficit.


Tony Read

26




Gaps

Actions Target


Risk





Susanna Masters

30/09/13


Charles

Malcolm-Smith

03/10/13


Charles

Malcolm-Smith

03/10/13


Causes:Limited leadership capacityLack of a Strategic planLack of detailed Commissioning Intentions Effects:Continued and new unmet health needsorFailure to achieve financial balanceor both


Susanna Masters

27




Gaps

Actions Target


Risk

581 4 4 Very High (16) Finance and Activity reports to Delivery Committee and Governing Body.Internal Audit reviews of Acute Contracting processes and Claims Management.

Acute Budget Reserves and Risk Management

Adequacy of reserves not certain.

QIPP Reporting through PMO arrangements.Contractual guarantee of financial savings.Integrated Reports to Delivery Committee.

QIPP Programmes Acute Activity is being reported by CSU to the CCG and requires further development.

Acute Activity and Finance monthly reports reviewed by the Delivery Committee and Governing Body.

Signed Contracts

4 3 High (12) 4 2 High (8)Deliver the QIPP Programme

Diana Braithwaite

31/03/14

Review reasons for overperformance

Neil Stevenson

30/10/13

Work with CSU to optimise activity reporting

Diana Braithwaite

30/10/13

Acute Contract over-performance will lead to loss of financial control

Causes:Failure to halt the year on year rise in acute activity and expenditure over and above planned levels.Contract over-performance of a value greater than contingency budgets.

Effects:Failure to meet financial targets.Failure to deliver within operating plan.

Committee:Finance & Risk Group

Diana Braithwaite

588 4 3 High (12) Policies to be authorised by Chief Officer.Policies have been reviewed by Audit Committee and comments incorporated.


Counter Fraud Policy drafted but not yet agreed.Anti-bribery policy drafted but not yet agreed.

Session held in April 2013 at Cantilever House.A further session to be held on 22nd May for Joint Commissioning team in Catford.Counter Fraud reports to Audit Committee.Counter Fraud plan approved at Audit Committee on 9th July 2013.

Promoting Awareness Mandatory Training Report required.

4 3 High (12) 4 1 Moderate (4)Approve Draft Policy

Tony Read

02/09/13

Inadequate Counter Fraud and Anti-bribery Arrangements

Causes:Inadequate Counter Fraud Plans, training and awareness.

Effects:Financial loss.Reputational Damage.


Tony Read

28




Gaps

Actions Target


Risk

584 3 4 High (12) KPI Reporting by CSU.

Action Log of meetings.

Customer Feedback survey.

Contract Monitoring of the CSU Contract

Service specifications are not clear.

3 3 High (9) 3 3 High (9)CSU Service Specifications to be reviewed with appropriate KPIs

Susanna Masters

30/09/13

Failure of CSU to deliver service as required by CCGs

Causes:Unclear service specifications.Poor performance by CSU indicated by not meeting KPIs.CSU services not properly used by CCGs.

Effects:Breach of statutory duties.

Committee:Core Contract Meetings

Susanna Masters

620 3 3 High (9) Minutes of Contract Meetings

Contract Meetings

South London CSU Reporting.Exception Reports where performance dips.Agreed recovery plan for Lewisham Healthcare and Whole System pursued via contractrual meetings.Lewisham healthcare have now achieved quarter one to date at the standard

Monitoring No Urgent Care dashboard.

3 3 High (9) 3 2 Moderate (6)Demand and Capacity Planning

Mike Hellier

20/09/13

Develop Winter Plan

Mike Hellier

30/09/13

Emergency Department Performance against 4 Hour Target will not be achieved

Causes:Emergency Department Performance has not been achieved in Q3 and Q4 2012/13.

Effects:A constitutional commitment is not met.


Tony Read

29




Gaps

Actions Target


Risk

577 4 3 High (12) Employment records.Job descriptions.HR report on Objective setting and PDP

Competent Staff No known assurance gaps

Functions and responsibilities map agreed at SMT A+

Functions and Responsibilities

No known assurance gaps

Approved at Authorisation.

Integrated Governance Framework

No known assurance gaps

Accountability meeting 9th May A+Accountability meeting 4th August A+

NHS England Assurance Process

National Assurance Process not yet fully defined.

4 2 High (8) 4 1 Moderate (4)Complete the National Assurance Process

Charles

Malcolm-Smith

31/03/14

Failure to comply with non financial statutory requirements

Cause:Insufficient management resource.Insufficient competencies.Insufficient assurance mechanisms.Lack of clarity of statutory requirements of the CCG.

Effects:Breach of statutory duties.


Susanna Masters

583 4 4 Very High (16) NHS England Planning Guidance.TSA Governance Arrangements.NHS England London Region Assurance team.

Planning Assumptions No NHS England Planning Guidance available.LHNT Long Term Financial Strategy not received.

4 2 High (8) 4 2 High (8)Design and Agree Governance Arrangements for Integration Transformation Fund

Tony Read

31/03/14

Planning Assumptions

Tony Read

03/01/14

Risk of medium to longer term income and expenditure assumptions being inaccurate

Causes:Unpredictable changes to allocations and price.

Effects:Unsustainable strategic plan.


Tony Read

30




Gaps

Actions Target


Risk

585 4 3 High (12) Agreed CSU Business Continuity Plan.Exercise testing.

Business Continuity Plans

Currently the CSU only has a draft BCP - concerns escalated to Richard Bates - 28th August 2013.

Internal AuditInternal Audit Internal Audit plan for CSU not yet agreed.No internal audit field work or reports undertaken for CSU.

4 2 High (8) 3 1 Low (3)CSU Business Continuity Plans requested and Demonstration of Exercise

Susanna Masters

30/09/13

Failure of business critical systems at CSU

Causes:CSU failing to manage business critical systems.

Effects:Loss of financial control.Loss of information to monitor contracts including and Serious IncidentsInadequate of support services including HR, communications and engagement

Committee:Core Contract Meeting

Susanna Masters

590 4 3 High (12) Minutes of all key meetings where COI are recorded.

Policy and Procedures The COI policy is due for review and updatingThe CCG is required to develop "case law" in the management of COIs in liaison with other CCGs

Register of Interest.Publication in Annual Governance Statement.

Register of Interests Register of interests does not include all staff.

4 2 High (8) 4 1 Moderate (4)Register of Interest

Graham Hewett

30/08/13

Poor management of Conflicts of Interest

Cause:Lack of awareness of rules and policiesLack of internal challenge

Effect:External challenge to decisions Delay to implementing strategic plansreputational damage


Susanna Masters

31




Gaps

Actions Target


Risk






Alison Browne

31/12/13





Susanna Masters

32




Gaps

Actions Target


Risk

617 4 3 High (12) Minutes of Finance and Risk Group

Finance and Risk Group

Financial reporting.Internal Audit.External Audit.

Financial Control and Governance

4 2 High (8) 4 1 Moderate (4)Establish Balance Sheet Opening Entries

Tony Read

30/08/13

Failure to comply with financial statutory requirements and NHS England expectations

Cause:Unplanned expenditure.Unplanned income reduction.

Effect:Failure to manage within revenue resource limit.Failure to manage within capital resource limit.Failure to manage within combined resource limit.Failure to manage within cash limit.Failure to manage within running cost allowance.Failure to deliver a 1% revenue surplus.


Tony Read

33




Gaps

Actions Target


Risk

597 3 3 High (9) Strategy reviewed and monitored at Patient Engagement Group.

Engagement Strategy Strategy not yet complete.

Job descriptions.Recruitment Process

Management Resource

3 2 Moderate (6) 3 1 Low (3)Public Engagement Delivery

Diana Braithwaite

29/11/13

Ineffective Public and Patient Engagement

Cause:Lack of comprehensive strategyLack of management capacity

EffectLoss of credibility with patients and publicLoss of support for major change

Committee:Patient Engagement Group

Diana Braithwaite

598 4 3 High (12) Business Continuity Plans approved at SMT.Exercise Andy Murray completed and identified new actions. IA+

Business Continuity Plans

Further updates required to Business Continuity Plan following Exercise Andy MurrayAwaiting formal assurance from NHS England

3 2 Moderate (6) 2 2 Moderate (4)BCP Exercise Plan

Graham Hewett

31/10/13

Risk of CCG staff being unable to undertake their duties in event of an emergency

Causes:Cantilever House being shut due to fire / flood or other disaster.Inability to travel due to sever weather.Telecommunications failure.

Effects:Failure to deliver statutory functions.Failure to effectively commission the local health system

Committee:Senior Management Team

Susanna Masters

34


Objective: 14. Organisational Development


Gaps

Actions Target


Risk

606 4 3 High (12) Each strategic priority has a lead clinician.

Timetable and processes for 2013/4 including responsible committees, agreed through paper to Delivery Committee (20th June) and Audit Committee (9th July)

QIPP projects jointly managed by Clinical Directors and reported to Delivery Committee

Clinical Leadership Refresh of OD planCommissioning Cycle workshop arranged for 1st AugustPotential change in clinical directors through election of new Clinical Directors by October 2013.Clinical Directors portfolios to be updated.

4 3 High (12) 4 2 High (8)Clinical Director elections

Charles

Malcolm-Smith

01/10/13

Clinical Director portfolios aligned to corporate objectives 2013/14

Martin Wilkinson

12/07/13

Refresh of OD Plan

Charles

Malcolm-Smith

31/07/13

Failure of the CCG to implement effective clinically led decisions

Cause:Insufficient capacity.Insufficient capability.

Effect:Failure to deliver major change to services.Failure to deliver strategic plans.


Martin Wilkinson






Alison Browne

31/12/13





Susanna Masters 35


Objective: 14. Organisational Development


Gaps

Actions Target


Risk

582 3 3 High (9) Minutes of March LCCC.Policies and Procedures

Regular performance report against ED Objectives.

3 2 Moderate (6) 3 1 Low (3)EDS Performance Report

Charles

Malcolm-Smith

28/06/13

Failure to Deliver Equality and Diversity Objectives

Cause:Focus on competing priorities.

Effects:Worsening or static health inequalities.


Susanna Masters

36

EXCEPTION REPORT

Failure to achieve Information Governance Standards

NHS Lewisham CCG Very High Risk 20

Raised by: Tony Read

0208 049 3833

Date Raised: 27/06/2013

Exception Report Ref.

Description of the Issue: The CCG is required to meet a range of Information Governance Standards, set out in the Information Governance Toolkit, and which are audited each year. The next audit is scheduled for January / February 2014. The risk is rated very high at the present time because the new CCG does not have current formal IG assurance against the requirements of the IG Toolkit. The Information Commissioner has wide ranging powers including legal actions and imposition of fines. IG breaches therefore can lead to loss of reputational and finances. It is anticipated that the CCG will meet the requirements of the IG toolkit at Level 2 by the year end. Root Cause Analysis: New organisational structures, systems and new IG rules that have not yet been tested. There have been changes to the ability for CCGs and CSUs to lawfully access and use Patient Identifiable Data (PID) for which solutions are not yet fully implemented. Anticipated / actual data and RAG position Metrics Q4 Q1 Q2 Q3 Q4 Actual Actual Anticipated Anticipated Compliance with IG Toolkit at Level 2 Green

(PCT) Red Red Red Green

Date: 29/08//2013. Version: 1.1 Author: Tony Read . Status: Final . Approvals: None Page: 1 of 3

Risk 589 There is a risk that failure to achieve adequate Information Governance Standards caused by changes required as a result of the NHS reforms will lead to unlawful access to or insecure handling of PID, reputational damage and financial penalty.


Recovery Plan:

No Action (A) / Milestone (MS) A / MS Owner End Date Resources Contingency /Dependency

1 To draft and agree new Policies - IG policy - Information security policy

A Head of System Intelligence

30/08/13 CSU Information Governance Officer

Sign off by IG Steering Group and Governing Body

2 Implementation of IG Controls preparation for the Jan / Feb Audit.


31/12/13

3 Undertake an information flow mapping exercise, assign Information Asset owners



4 Achieve 100% coverage of IG training and testing of understanding by CCG staff


31/12/13 CSU Information Governance Officer and online training access

Two workshops have been held in 2013 to date.

5 Identify PID stored by CCG and assess lawful basis of access. Store “beyond use” all records without a lawful use



6 Establish new systems to access PID through Data Services for Commissioner Regional Offices (DSCRO) AHSICs and Accredited Safe Havens (ASH)

A CSU 31/10/13

Reporting Reported to and monitored at Information Governance Steering Group and Delivery Committee Lessons Learnt: None yet Additional Comments: The CCG is supported by the SEL CSU for IG.


EXCEPTION REPORT

Claims for NHS Funded Continuing Care Affect Financial Plans


Raised by: Dee Carlin

Date Raised: 27/06/2013 Updated 16/8/2013


Description of the Issue: Provision was made in the 2012/13 PCT Accounts to meet potential retrospective claims for NHS Funded Continuing Healthcare (CHC) and claims arising from “periods of unaccessed care”. . The “periods of unaccessed period of care claims” represent a special one off financial risk to the CCG arsing from the CCG’s CHC responsibilities. The total value of the CCG’s provision to manage this risk is £2.76m. However, the CCG has not yet received confirmation from the National Legacy Team that the provision will be returned to the CCG and the adequacy of the value of the provision is uncertain. Status of current Lewisham unaccessed period of care claims No of cases Current status Impact on financial risk to CCG 29 Closed Reduces overall risk to CCG. 40 Open/awaiting detailed processing. To be estimated 69 The numbers are subject to constant changes i.e. arising from transfers in to Lewisham for other CCGs or decisions by patients to withdraw their claim before CCG completes necessary processing of a claim. Period of unaccessed care claims bear some resemblance to retrospective claims which are processed each year by the PCT and will now be continued by the CCG. The total value of this CCG’s provision in respect of retrospective claims for CHC is about £445,000k. This is constant financial risk arising from the discharging of the CCG’s statutory duties to assess and provide NHS Funded continuing healthcare to Lewisham patients. A simplified flow chart describing the pathway for processing of claims and the link to CCG financial risk is shown below. Similar outcomes applicable to CHC retrospective reviews.Date: 27/06/2013. Version: 1.0 . Author: Michael Ogunlokun Status: Final . Approvals: None Page: 1 of 7

Flow chart showing pathway for processing of claims and links to 4 potential outcomes

Final pool of all CHC Claims/retrospective review for LCCG patients Total financial risk £3.21m

Outcome 1: valid claim or successful retro claim CCG makes financial payout £

Outcome 2: patient wins local CHC CCG appeal process. CCG makes financial payout £

Outcome 3 patient wins NHS England appeal process. CCG makes financial payout £

Outcome 4: patient wins NHS Ombudsman CCG appeal process. CCG makes financial payout £

Claims made to CCG Joint Comiss Team (Risk of £2.765m)

CCG Internal processing (GP registration, legal authorisation checks etc) and triage of all claims

claims requiring minor or detailed clinical assessments by LCCG staff (inc 2 x 1 WTE Band 7 nurses)

Lewisham patient claims sent in by other CCGs

Annual in year risk of retrospective reviews Risk of £445K

Date: 27/06/2013. Version: 1.0 . Author: Michael Ogunlokun Status: Final . Approvals: None Page: 2 of 7

Root Cause Analysis: Financial risks arising from CHC claims is linked to 4 potential claim outcomes, but the level of uncertainty of this risk increases as the claim progress from outcome 1 to outcome 4. 1. Outcome 1- A successful ‘period of unaccessed care claim or CHC retrospective claim requiring Lewisham CCG to make financial payout to patients, families or their legal representatives. The CCG joint commissioning team will on the basis of finding from minor or detailed clinical assessments determine eligibility and recommend appropriate level of financial payment (with interest) to patients within this category. There are currently 40 cases in the system at the moment, awaiting minor or detailed clinical assessments and there is no scientific way of predicting how may of these claims will fall into this Category or any other category shown in the flow chart. The current financial/likely impact is Best case financial risk is £332k (5% of current claims are successful) Likely financial risk is £1.99m (30% of current claims are successful) Worst case scenario financial risk is £6.64m (i.e. 100% of current claims are successful) 2. Outcome 2- In the event that the CCG team rejects a patient’s claim (period of unaccessed care), patient have a right to use local CCG appeal processes to seek redress. This appeal might be managed by local CCG complaints process or the setting up of an independent multi-disciplinary team to review each individual case. A successful appeal could potentially lead to a financial payout by Lewisham CCG. There are no pending CCG appeals in the system at the moment, are processes are in place to avoid blocks to this part of the system. There are no reliable methods of estimating how many local appeals may result from the current 40 cases and their potential outcomes (success or failure). This means the size of financial risk attributable to this cohort of cases cannot be quantified. Best case- 95% in favour of CCG, or 2 claims against Lewisham CCG at cost of £104, 936 per claim i.e. worst individual case estimate of paying over 2 years at weekly rate of £1009/wk. Likely-90% in favour of CCG, 4 claims against Lewisham CCG or £419,744 Worst case - 80% Or 8 claims against Lewisham or £839,488 Date: 27/06/2013. Version: 1.0 . Author: Michael Ogunlokun Status: Final . Approvals: None Page: 3 of 7

3. Outcome 3- these cohorts of patients are those choosing to seek redress using NHS England CHC appeal processes. This replaces the previous NHS London wide CHC appeal. Here again a successful appeal will lead to financial payout by Lewisham CCG, the size and magnitude of these payouts cannot be predicted. NHS Lewisham has never had any of its previous CHC decisions overturned by NHS London. This is a direct result of rigorous CHC processes currently in place in Lewisham. Across London CCGs, 2 out of every 10 appeals are overturned by NHS London. The financial risk to CCG as same as in 2, because of the same level of uncertainty around predicting potential outcome around how many appeals and their likely outcomes. 4. Outcome 4- These cohort of patients are those who having been through stages listed in outcomes 1 to 3 above, go on to seek re dress through NHS Ombudsman. The average length of time from progressing a case from outcome 1 to 4 is between 12 and 18 months. Again as in all outcome listed above, a successful appeal (in the patient’s favour) will lead to a financial payout by Lewisham CCG. As in previous outcomes, the size of the financial risk can not be quantified or predicted but is estimated to same as in 2 above.

Describe the possible causes of the issue as this will help identify possible potential solutions and inform where effort should be targeted The value of successful claims is not known. Anticipated / actual data and RAG position Metrics Q1 Q2 Q3 Q4 Actual Actual Anticipated Anticipated Amber Amber Green Green No of closed cases 78 29 No of open cases 44 40 Total 122 69


Risk 592 There is a risk that claims for NHS Funded Continuing Care affect Financial Plans caused by successful claims for NHS funded continuing care leading to unbudgeted expensiture and failure to meet financial targets.


Recovery Plan:


Contract for Part time Continuing healthcare manager extended to complete screen all claims and sign post/manage claims through all stages of NHS appeal process.

A Michael Ogunlokun

June 2013.

£98k set aside for staff cost

Appointment of 2 WTE band 7 nurses (across Lewisham, Lambeth and Southwark) to increase staffing capacity to manage clinical aspects of all Lewisham actual Continuing Care claims

A M Ogunlokun July 2013. £18k for half year cost in 2013/14.

Collaborative work with Lambeth and Southwark CCGs

Regular report to CCG risk Management Body to include information on 2013/14 estimated financial risk.

MS M Ogunlokun Once every two months

None

Provision made in CCG accounts for potential liabilities arising from claims (£2.765m).

A Tony Read/Neil Lall

April 2013. £2.765m

Robust Continuing Care Policies/processes in place.

A M Ogunlokun March 2013.

None

Reporting CCG Risk Management group on a monthly basis Date: 27/06/2013. Version: 1.0 . Author: Michael Ogunlokun Status: Final . Approvals: None Page: 6 of 7

Lessons Learnt: None yet Additional Comments: None


EXCEPTION REPORT

Failure to oversee the implementation of effective arrangements to safeguard adults at risk


Raised by: Alison Browne

020 3049 2639



Description of the Issue: There is an ongoing risk of a serious safeguarding incident as a result of the failure to follow policies and guidelines across the local health economy. The LCCG Adult Safe Guarding Lead is undertaking a training needs analysis with provider organisations and is ensuring that there are sufficient arrangements for clinical supervision in this area. Root Cause Analysis: Lack of training and understanding of safeguarding policies in Provider organisations. Anticipated / actual data and RAG position Metrics Q1 Q2 Q3 Q4 Actual Actual Anticipated Anticipated Providers implementing Serious Safeguarding Incidents Policies

Red Red Amber Amber

Date: 28/08/2013. Version: 1.0. Author: Alison Browne. Status: Final . Approvals: None Page: 1 of 3

Risk 574 There is a risk that the failure to oversee the implementation of effective arrangements to safeguard Adults caused by failure to follow polices and guidelines will result in a serious safeguarding incident or failure to recognise institutional abuse or neglect in commissioned series.

Date: 28/08/2013. Version: 1.0. Author: Alison Browne. Status: Final . Approvals: None Page: 2 of 3

Recovery Plan:


Compliance of Liberty Safeguards across Health Providers

A Designate Nurse – Safeguarding Adults

31/10/13 A review of training strategies and current trends

Training around delivering care to patients who lack capacity to consent


31/10/13 Visiting all Health Providers to review training needs analysis and current training records

Implementation of Pressure Ulcer action plan


01/01/14 Pressure ulcer action plan

Review resources for effective monitoring of Adult Safeguarding in Lewisham CCG

A Nurse Director 30/12/13 JD for adult safeguarding GP

Safeguarding adult safeguarding Supervision to Health Providers


31/10/13

Review compliance against mandatory safeguarding training in Lewisham CCG


30/08/13 Update requested from HR to indicate current training completion by staff within the CCG

Reporting Exception Reporting is done at the Delivery Committee on a monthly basis Lessons Learnt: Safeguarding is now a standard agenda item on the CQRM for LHT and will be for SLaM. Date: 28/08/2013. Version: 1.0. Author: Alison Browne. Status: Final . Approvals: None Page: 3 of 3

EXCEPTION REPORT

Transfer of Specialist Commissioning will not be cost neutral to the CCG


Raised by: Tony Read

0208 049 3833



Description of the Issue: Financial modelling indicates that the cost of specialist services transferred from PCTs to NHS England is less than the sum of commissioning budgets transferred from PCTs to NHS England and subsequent deductions to the CCG’s allocation made by NHS England. This causes a potential cost pressure for the CCG in 2013/14 that could cause the failure to achieve financial targets. The picture is repeated across the NHS in London. A Technical Group has been formed to assess the size of the challenge and to propose a means of resolution. Root Cause Analysis: Uncertainty regarding the correct value of the specialist service transfer from PCTs to NHS England Anticipated / actual data and RAG position Metrics Q1 Q2 Q3 Q4 Actual Actual Anticipated Anticipated PCT and CCG allocation transfer equals cost of transferred services (i.e. cost neutral to CCG)

Red Red Unknown Unknown

Date: 29/08/2013. Version: 1.1 Author: Tony Read . Status: Final . Approvals: None Page: 1 of 3

Risk 594 There is a risk that the transfer of Specialist Commissioning will not be cost neutral to the CCG caused by the transfer of PCT and CCG allocations in excess of cost leading to failure to meet financial targets in 2013/14.


Recovery Plan:


1 Agree contract with providers that correctly apply the specialised service Identification Rules

A Director of Commissioning

31/5/2013 CSU MDT Joint commissioning unit CCG baseline allocation workings Trust 12/13 activity and cost analysis

2 To monitor work of Technical Group and ensure recommendations from Technical Group are implemented London-wide.

A Chief Financial Officer

22/11/2013

3 To deliver cost neutral outcome A Finance Director – NHS England London region

22/11/2013

Reporting London Chief Financial Officers group monthly Delivery Committee monthly. Finance and Risk Working Group Lessons Learnt: None yet Additional Comments:


Governing Board Chair’s Report September 2013 Governing Body meeting

Message from Dr Helen Tattersfield Outgoing Clinical Chair – Lewisham CCG In his judgement Mr Justice Silber made specific reference to the fact that local GP commissioners did not support the recommendations of the TSA and this was one of the deciding factors in his ruling that those recommendations be quashed.

As Lewisham Commissioners we have consistently said that we have been tasked with representing the needs of our local population and the views of our membership and agreed with the then secretary of state Andrew Lansley that as GPs we were best placed to know the needs and ensure appropriate services for our patients.

We also said that we are responsible commissioners aware of the financial constraints and need for improved quality standards and that we would, working with our partners in health and social care find a working solution that would meet the needs of our population in both a safe and affordable manner.

The challenge now is to do this. The government have said they will appeal the JR decision but we should not wait for the outcome of this to get on with building the healthcare system locally that will make this vision a reality. Already we are working with our neighbouring CCG colleagues to ensure that the local changes in hospital provision result in safe, quality and affordable services for our population. This has involved difficult negotiations and will continue to require the collective strength of the six CCGs to ensure that the providers do produce the cost efficiencies and quality improvements required.

The opportunities to build something effective are already in place.

Our working relationship with the Local Authority is of trusted partnership and our influence with our local trust considerable.

The establishment of local neighbourhood teams including not just health and social care but voluntary sector and, in time, patient groups and education bring the promise of truly joined up working.

Benefits of this to both patients and us as GPs are real and have the potential of completely transforming working in the community not only ensuring the best possible health and social care interventions but using the network of self-help and

ENCLOSURE 4

voluntary support agencies to enable the population to better care for itself and its vulnerable members.

It will take not just good commissioning to make this work, each member of the new partnerships must fulfil their role and we as GPs will be pivotal to this opening our doors to new colleagues and our minds to new ways of working.

As commissioners we will need to facilitate this supporting the time needed to establish and maintain the new relationships and enabling practices (along with our colleagues in NHS England) to adapt ways of working both internally and together with neighbouring practices to not only improve access and quality of services but reduce stress and improve practice working conditions to bring back the satisfaction of doing a job well.

We must support training of all practice and community staff, facilitate peer to peer review and encourage the spread of good practice and learning between practices. We must provide practices with the tools to understand what they are doing well and where they could do even better and make whatever data collection is essential an easy and not time consuming task that improves outcomes rather than distracts from day to day patient care.

We already have good examples of this working well, the fantastic improvement in children’s immunisation, reductions in unnecessary prescribing spend and the fall in COPD admissions being just three of our early achievements.

The threat to Lewisham Hospital and to local commissioning is not over but if we prove responsible commissioners, continue to improve outcomes, manage within budget and engage with our population in a real and formative way our ability to rebuff future threats will be much greater.

The role of each and every GP and indeed every participant in health care provision is key.

Every improvement in healthcare however small contributes to our collective success. Every £ we save in responsible prescribing and appropriate referring supports us in achieving required financial balance. Every GP alert that highlights a quality issue enables us to act fast to ensure patient safety. Every partnership conversation and every patient participation group enables us to engage with our colleagues and our community and each step gets us closer to achieving a sustainable, enjoyable and safe health service.

The future is full of challenges but the collective opportunities are there to forge something to be really proud of.

Message from Dr Marc Rowland Incoming Clinical Chair – Lewisham CCG Following Helen will not be easy. You will understand that after reading her last report above. I will not go through it in detail but I would be happy to discuss any of the points she makes. We have been very privileged to have her take us through this difficult time for the NHS and Lewisham. She has left us in a good place to move forward using the template she has helped us create developing the collective opportunities she points out we have. We hope very much we can keep her working with us in some capacity. Lewisham has a unique position in the centre of South East London geographically and, recently, medico-politically. We have boundaries with three of the CCGs, nearly four, as we are only the length of Crystal Palace Parade away from Lambeth and Bexley is only three miles away. The recent developments in South East London have radically altered our plans over the last year but now, whatever the outcome of the JR and working with other CCGs, providers and Lewisham Borough we will use this opportunity to innovate and provide the best health care we can for our residents.

ENCLOSURE 5

Chief Officer’s Report

Report for September 2013 meeting

1. Elections

The CCG membership completed its first elections since authorisation. This was for all its representatives on the Governing Body: the CCG Chair, two Senior Clinical Directors and four Clinical Directors. The election was carried out according to the CCG’s Constitution and administered by an independent organisation, Electoral Reform Services.

The outcome was that Dr Marc Rowland was elected Chair, Drs David Abraham and Faruk Majid as Senior Clinical Directors, and Drs Arun Gupta, Judy Chen and Hilary Entwistle as Clinical Directors. There is a vacancy for a Clinical Director which will be re-advertised.

The next stage of elections will be for Neighbourhood Representatives and Chairs. This will be held during September.

2. Trust Special Administrator update

In July Justice Silber ruled that the Trust Special Administrator and the Secretary of State acted outside their lawful powers in recommending and deciding on changes to health services at Lewisham hospital. The Department of Health has submitted an appeal to this judgement.

The decision relates only to service changes that had been proposed at Lewisham Hospital as a result of the TSA report. It is anticipated that the dissolution of South London Healthcare Trust will happen as planned. The work being led by the NHS Trust Development Authority for the acquisition of Queen Elizabeth Hospital by Lewisham Healthcare NHS Trust continues to progress.

While we await the outcome of the legal proceedings we are continuing with our strategic plans to improve local health services and make sure that Lewisham people have access to high quality services that remain affordable.

3. Integrated Pioneer Project

It’s excellent news that Lewisham is one of the CCGs that have been shortlisted as a potential ‘pioneer’ in Norman Lamb’s programme to support and develop integration between health and social care. If successful we would be offered a tailored package of support to move forward our plans for greater integration.

More information about the National Collaboration for Integrated Care and Support can be found at: http://www.england.nhs.uk/2013/05/14/c-care/

4. South East London Community Based Care (CBC) Strategy

The CBC Transformation Board, chaired by clinical lead Dr Marc Rowland (Lewisham CCG), have met to review progress of the programme. The board’s view was that the programme is broadly on track – with the major workstreams (Community and Primary Care, Integrated Care and Planned Care), and enabler workstreams having made expected progress since April. Each of these has a CCG Chief Officer as sponsor, an identified clinical lead and a PMO project manager. Other

Chair: Dr Marc Rowland Chief Officer: Martin Wilkinson

members of the workstreams represent stakeholders from across south east London, including GPs, Local Authority partners, CCG staff, patients and the voluntary sector. Workstream updates 4.1 Community and Primary Care It was recognised that this workstream should be understood as a ‘Super-Enabler’ as its success in enabling the treatment of many more patients in community settings will underpin delivery of the CBC in all areas. Work is currently focused on: establishing and sharing models of best practice; establishing common standards for urgent care; and interfacing with the development of 111. Workshops are planned to take forward all of these areas over the summer. Vital to the success of this work will be premises and infrastructure and it was acknowledged that this workstream will need to focus on specific estates requirements relating to CBC development. CPD funding for primary care and commissioning organisations has been agreed by the HE South London Board, with letters being sent soon to confirm allocations. HESL are keen to find a mechanism to make the most effective use of the primary care allocation and have asked their primary care forum to develop an approach to managing it. The CBC Transformation Board agreed to help shape a way forward to ensure the aims of the programme are supported and ensure that the south east London monies will be allocated through the CCG capitation formula. 4.2 Planned Care A desktop review has been undertaken looking at synergies across planned care across the CCGs to identify shared opportunities for improvement. Five main areas have been identified: operational efficiencies (referral management / protocols); diagnostics and pathology; gynaecology; self-management; and estates-readiness for increased provision of planned care in community buildings. These themes were explored at a workshop held on 10 July. In addition, a SPOT (Spending and Outcome Tool) analysis is underway to review value for money by comparing spend against positive outcomes for patients. 4.3 Integrated Care A workshop was held on 5 July which explored: what was committed to in the Trust Special Administrator (TSA) report; the national picture – including the DH ‘Shared Commitment’ statement on integrated care and development of the Pioneers programme, sponsored by Norman Lamb; what work is being undertaken in the boroughs; and how learning can be shared. 4.4 Enablers The enabling workstreams are intended to support the three main workstreams, above. Preparatory work is underway within these workstreams to enable a focused response to the specific needs of the main programmes. 4.5 Finance A commitment to the funding of the programme was agreed, including investment and pump priming for projects within workstreams. Each CCG proposed how the 1% non-recurrent monies will be committed. The Transformation Board welcomed this and supported the allocation. 4.6 Measuring the progress and impact of the programme Measures and metrics to enable tracking of the programme have been reviewed and will include clinical outcomes, key NHS and social care performance indicators, quality of care and patient


experience metrics. The programme board will maintain oversight of these metrics, review exception reports and work with CCGs to ensure that the work stays on track and benefits are being achieved.

4.7 Engagement Dr Marc Rowland presented the programme to the Stakeholder Reference Group in May to both update stakeholders on the overall programme and ask for their feedback on the priorities for the communications and engagement plan.

An engagement event to launch the CBC programme with stakeholders and providers is to be planned for the autumn. This will enable leaders from across the health and social care system in south east London to understand the ambition of the programme, share early successes and build confidence that such a transformation of care can be achieved.

Martin Wilkinson Chief Officer – Lewisham CCG 28 August 2013


Report from the Chair of the Audit Committee

Meeting held on Monday 9 July 2013

Thanks Dr Das, the CCG’s former Secondary Care Doctor was thanked for her contribution to the work of the Audit Committee. Mr Wilkinson and Mr Read were thanked for the independent coaching session for the Audit Committee, which they had made possible. Any further sessions will be rolled into the development programme for the Governing Body. Internal Audit Plan 2013/14 Mr Read introduced the Internal Audit Plan and related timetable, and progress since the last meeting of the Audit Committee. Mr Wilkinson confirmed that the Plan captured the risks the CCG faced and addressed management needs. The SLCSU Audit Plan would be viewed alongside the CCG Plan for assurance. KPMG, Head of Internal Audit, reported that final reports for the audits of Children and Adult Safeguarding, Data Protection/Sharing Protocols, and Budgetary Control/Scheme of Delegation would come to the October 2013 meeting. The Quarter 2 data required for the Acute Contracting review would not be available until October 2013; but in order to make progress KPMG was asked to consider undertaking some preliminary controls work checks based on Quarter 2 data. The Committee confirmed its previous request that when the terms of reference are set for the individual reviews, they will be aligned with issues on safety, quality, cost effectiveness and CCG reputation. KPMG assured the Committee they would use a wide range of indicators when looking at the CCG’s response to the Francis report, and Mr Wilkinson confirmed that the CCG would develop an early warning system. External Audit It was confirmed that Grant Thornton had been appointed as the CCG’s External Auditor on a four year appointment. Since the last Audit Committee, Grant Thornton had completed the audit of the PCT and given their unqualified opinion, unqualified opinion on regularity, unqualified opinion on value for money. It was noted that the audit planning and interim audit procedures would commence in November 2013. The External Audit Plan would come to the January or March 2014 Audit Committee, and the final Annual Audit Letter to the June 2014 meeting for approval.

ENCLOSURE 6

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Security Management Mr Read gave a progress report on the work of the CCG’s Local Security Management Specialist (LSMS) for Quarter 1 of 2013/14. The priority areas were: tackling violence against staff, protecting NHS property and assets and the security of drugs, prescription forms and hazardous materials. No incidents had been reported for the first quarter. It was acknowledged that the CCG had not received security training, it was agreed that this training would be combined with a Counter Fraud awareness presentation. Counter Fraud Plan for 2013/14, and Counter Fraud and Anti-Bribery Policies Mr Read introduced the 2013/14 Counter Fraud Work Plan and informed the Committee of the progress made by the Counter Fraud team since 1 April 2013. The Counter Fraud Plan had been drafted by Ms Johal (London Audit Consortium) and Mr Read. It was confirmed that the counter-fraud and anti-bribery policies would be signed off by Mr Wilkinson under delegated powers in the Constitution. So that staff members are able to raise concerns about suspected fraud and bribery, the CCG will provide a supportive message that staff would be able to go to named senior officers in confidence. An information leaflet attached to payslips detailing how to raise concerns would be sent out to all staff in August 2013. It was noted that the Counter Fraud team regularly sends out information to staff and will have a page on the CCG intranet on how to report any concerns and details of the confidential hotline. It was agreed that Ms Robbins would liaise with Ms Johal (London Audit Consortium and Head of the Counter Fraud team) to produce a form of words for a desktop message regarding reporting concerns. Staff will be encouraged to attend the Counter Fraud training sessions. An attendance record would be kept. Governing Body members would also be invited to the next session. Training would be arranged for Joint Commissioning to be held at Laurence House. The Whistle Blowing policy would be reviewed with an emphasis that staff would be listened to when making an allegation. The key messages on duties and policies in section four of the Anti-Bribery Policy, would be pulled out for a statement to staff. The Audit Committee approved the Counter Fraud Plan. Overview of CCG committees and meetings to identify where risks are identified and handled, and assurance is sought and given Mr Hewett talked to a report setting out the CCG’s risk categories and the groups and committees which has an overview and assurance role of each. Mr Hewett pointed out that the report showed the risk categories, the number of risks in each category, where they were reported to by exception, and from which committee assurance was given. There

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were 14 corporate objectives which were reviewed monthly by the risk owners. Exception reports, matched to their corporate objective, would go to the Governing Body. The Audit Committee thanked Mr Hewett, Mr Wilkinson and Mr Read for their responsiveness to the Committee’s queries. It was confirmed that the Risk Management Framework is being refreshed and is being taken to the September 2013 Governing Body meeting. The Board Assurance Framework, risk register and risk scoring tool Various concerns of the Audit Committee regarding the BAF were discussed. A prime concern was that the BAF did not have enough time devoted to it at Governing Body meeting and should have a more prominent position on the agenda. It was agreed that agenda flows, time allocation and the front sheet would be reviewed. It was agreed that further detailed issues would be picked up outside the meeting. It was also agreed that training on supporting staff in completing risk registers would be given as part of the Organisational Development Plan. KPMG said that the Governance and Risk Management audit would look at the BAF, and they would share good examples of an exception report if requested. Clinical leadership in commissioning Mr Wilkinson spoke to a report which responded to concerns raised in writing by the Audit Committee, and clarified where the main responsibility for commissioning cycle activities sat. It was highlighted that clinicians and management worked in partnership through the commissioning cycle adding value and delivering outcomes. He acknowledged that there was still work to do and that the development of the commissioning intentions was a risk on the BAF. The report had been to the Delivery Committee and would be used, with case studies, for the workshop on 1 August 2013. Sarah Cottingham would lead a workshop in September 2013 on Acute Contracting. Clinical audit system review Mr Hewett gave the verbal report. There were two aspects to the system: national clinical audits and local clinical audits. Nationally there were a suite of NICE audits which were agreed across the country. Diabetes and Heart Disease were key audits for Lewisham. Clinical Quality Review Groups were monitored along with other groups. Any exceptions would be reported at the For Action and Learning Group (FLaG). National clinical audits were reported in the trust’s Quality Accounts. It was acknowledged that it would be a stronger process if providers and CCG met at the beginning of the year to develop local a clinical audit programme. Internal audit arrangements for CSU It was noted that the draft Internal Audit Plan, produced by KPMG, for the CSU had been signed off at their Executive Management Team. Two tranches of work had been identified: tier 1 reviews where the CSU operates on behalf of the CCG, and tier 2 reviews to cover CSU internal governance arrangements.

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The CSU had requested from NHS England to have shadow arrangements for an Audit Committee and Board.

Deloittes would undertake an external audit of the CSU and would produce an Annual Report on behalf of NHS England.

A web based training tool

It was noted that the Healthcare Financial Management Association (HFMA) has developed a web-based training tool to support the learning of Audit Committee members. This e-learning package can be subscribed to with a range of modules; each taking around 2-3 hours to complete. Ms Robbins agreed to trial a module and report back to the Audit Committee.

Audit Committee – objectives and timetable for 2013/14

The Audit Committee Cycle, from July 2013 to July 2014, was discussed under the headings including: governance; finance; Internal Audit; External Audit; Clinical Audit; Counter Fraud; and CSU Internal Audit arrangements. The meeting agreed what topics will be discussed at what point during the cycle.

Date of next meeting

The next meeting of the Audit takes place on 8 October 2013.

Note: the minutes of the 9 July 2013 meeting will be presented to the Governing Body once they have been confirmed at the next meeting of the Audit Committee in October 2013.

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Report from the Chair of the Strategy & Development Committee

Meeting held on Thursday 1st August 2013 1. South London Academic Health Science Network Dr Chris Streather (Managing Director) and Zoe Lelliott (Director of Strategy and Performance) from the South London Academic Health Science Network (AHSN) presented background information on the organisation. Key areas covered:-

- AHSN will promote effective spread and adoption of good practices. - The AHSN prospectus highlights diabetes, dementia, alcohol and MSK; aim is for

consistent standards - Every workstream will have patient and/or carer and/or third sector involvement. The

board of the AHSN has representatives from Healthwatch and the third sector - Meetings of the London Clinical Senate and London Health Board will ensure there is no

duplication between the work of the AHSN and London Strategic Clinical Networks - Underlying principles support efficiency and affordability considerations: ensuring patients

are looked after better, earlier and reducing secondary care spend. 2. Commissioning Intentions 2014-15 Presented by Susanna Masters (Corporate Director) and Tony Read (Chief Financial Officer). Projected Quality Innovation Prevention and Productivity (QIPP) programme requirement is £24m for 2014-15 and 2015-16. CCG is expected to achieve a 2% surplus from 2014-15. Main QIPP focus will be primary care improvement and long-term conditions. Strategic commissioning groups were proposed to take forward development of commissioning intentions in line with financial parameters. The committee agreed the financial parameters for the commissioning intentions. The approach and timetable were agreed subject to some adjustments. 3. Public Engagement Strategy The strategy was approved, subject to some changes to the Terms of Reference for the Public Engagement Group (PEG), the development of a pictorial version, that its charter clarifies patient involvement in decisions about their care, and more information on how patient data is used.

ENCLOSURE 7

4. GP New Referral Strategy

Presented by Ashley O’Shaughnessy (Commissioning Programme Lead).

The committee approved the strategy which contains plans for new GP outpatient referrals.

5. Immunisation Strategy

Presented by Dr Donal O’Sullivan (Consultant in Public Health Medicine, Lewisham Public Health).

The committee noted the following: • Childhood immunisation has been increasing though there are still challenges for MMR2

and pre-school booster rates. • The programme to support the 2013-14 seasonal influenza vaccination• Work on an automated call and re-call system• The annual workplan

6. Proposed Programme Review of Public Health Budget 2013-15

Update provided by Dr Danny Ruta (Director of Public Health). Bids submitted for funding would be assessed against their expected public health impact and whether the investment/disinvestment would allow the council to mitigate the impact of its cuts to services.

Discussion highlighted the importance of a communications strategy to support improvement plans.

It was agreed Dr Arun Gupta (Clinical Director) would sit on the prioritisation panel on behalf of the CCG.

7. Organisational Development Plan Update

Presented by Charles Malcolm-Smith (Head of Strategy & Organisational Development). The current workplan covers the period to December 2013. This would be reviewed by the management team and Clinical Directors. A revised OD plan would take account of the capability element of the CCG annual assurance process which is under development.

8. Equality & Diversity Update

The committee received a written report provided by Valerie Richards (Equality & Diversity Lead, South London Commissioning Support Unit). The report contained the progress and timeline for revision and publication of equality objectives by 13th October 2013.

9. Any Other Business

Items on the London Strategic Clinical Networks and hospital communication were noted.

Delivery Committee

Thursday 15th August 2013

Integrated Performance Report

Finance (Month 4)

At month 4 the CCG is forecasting to deliver its £3.699m planned surplus. The main expenditure pressure relates to the acute contract position. The main risk relates to the specialised services transfer. The SLaM contract is over performing compared to previous months.

The main areas of acute overspend are within the Lewisham (4% overspend) and Kings (10% overspend) contracts. There are indications of higher demand at Kings and Guys. Whilst this is not indicated at Lewisham, the Trust is still running at winter capacity in terms of beds.

The LHT Business Meeting in September will explore any changes to admission thresholds to speed through the system. A number of pieces of work are being undertaken that will assist with managing the acute over performance:

- Finnamore has been commissioned to undertake a demand and capacity review of urgent care systems across South East London.

- A report will be produced following the visit of the Emergency Care Intensive Support Team to LHT and QE

It was agreed to seek regular Board to Board conversations re: contract performance.

QIPP

Areas not performing to plan include GP 1st Outpatients, COPD & Other Respiratory Conditions, reduction in emergency admissions and client group placements.

An exception report for GP Outpatient 1st Attendances was received. A recovery plan has been developed and an interim project manager has been secured to support the delivery of the programme. A proposal has been submitted to LHT requesting support to provide data at practice level. A programme will need to be developed to re-engage practices in reviewing the outpatient referrals/attendances. Contract leavers will be utilised and a short-term LIS developed to support practice review of referrals.

Performance The following items were highlighted as improved outcomes:

- Lewisham CCG delivered the stop smoking plan in 2012/13 with 1803 smoking quits against a target of 1800

- For long term conditions the emergency admissions figures for chronic ambulatory care and unplanned admissions are both reducing

- The latest GP patient survey for July 2012 to March 2013 shows a significant improvement year on year (58.9% in 11/12 to 61.8% in 12/13) in the indicator for patients with long term conditions feeling supported by services

ENCLOSURE 8

- Infection control plans were met for 12/13 and are within plan for 2013/14. There have been no MRSA infections in the 1st quarter and 7 C. Difficile infections, which is within plan.

The following items were highlighted as issues:

- Under 19 emergency admission rates for asthma, diabetes and epilepsy are higher and are flat against a national decline

- Under 19 lower respiratory tract infections are rising, as are London and national figures - The exception report for psychological therapy service recovery rates will be reviewed following

the contract meeting with SLaM in September - The capital works at Kings have started and the mixed sex accommodation breaches are forecast

to reduce to zero by October 2013 - Kings have stated that incomplete pathways over 52 weeks will be cleared by the end of

September 2013. - Cancer waiting times are a concern but waiting on the first quarter data.

The Friends and Family Test scores for A&E and inpatients have been published for all providers. LHT is in the top decile of providers for A&E scores but in the bottom decile of providers for inpatient scores. The Clinical Quality Review Group for LHT will review these scores in September 2013. Quality The following issues were considered at the FLAG meeting on 8th August

- It was agreed that there should be a report of the range of services provided to Lewisham residents at the Queen Elisabeth Hospital, Woolwich.

- SM is advising on contractual approaches with regards to discharge letters / communication between GPs and the hospital.

- Looked After Children targets for initial health screening and annual reviews are not being met. AB is working on and an action plan for improving performance, which will be brought to the next Delivery Committee meeting.

- Karen Bates is preparing a summary paper detailing the actions being taken to reduce the number of pressure ulcers. This will be reviewed by FLAG in September and presented to the Delivery Committee in November along with an update against the actions agreed.

- Concern was raised that LHT failed its clinical supervision audit by the Local Supervision Agency. AB and FM visited the Maternity Department and saw no indication of quality failures however it was recognised that walkabouts alone do not ensure quality.

- Assurance was received regarding INR calibration - Concern was raised about the management of patients with mental health conditions in A&E.

Sophie Gayle has been asked to follow up and report back to FLAG. - It was noted that GP raised Quality Alerts regarding the district nursing have reduced significantly

following work to improve the quality of the service. CCG Assurance NHS England has signed off Lewisham CCG’s QIPP and financial plan. NHS England has assessed Lewisham CCG’s Serious Incident arrangements as having adequate capability and capacity to undertake this responsibility. Urgent Care Centre (UCC): Assess, Redirect/Treat Pilot The evaluation of the UCC Assess Redirect/Treat Pilot highlighted:

- The GP model was an expensive resource in the delivery of the pilot in comparison to the ENP model

- There was no overall cost saving due to the number of patients redirected being less than plan

- Positive outcomes – impact on 4 hour performance target, improved patient flows, reduced duplication in the patient pathway and positive patient satisfaction, popular with UCC/ED staff

The Delivery Committee approved the implementation of assess, redirect/treat for patients attending the UCC/ED with non-urgent low level health care needs through the utilisation of the existing workforce.

Primary Care Rebate on Medicine Leuprorelin (Prostap)

The proposed rebate scheme for Leuprorelin issued by Takeda UK Ltd was approved for a 12 month period.

111 Update

The Delivery Committee acknowledge the current position of NHS 111

Mental Health Business Case Update

There are currently outstanding risks and financial implications that need to be resolved before the CCG can complete its review. Two main issues were highlighted:

- The business case assumes a change in practice and available capacity within primary care so people do not need to go into hospital. However there is no plan in place for this.

- The model is based on a reduction in the number of in-patient beds. A suggested process for agreeing up front how bed and ward closures will be decided in order to avoid future disagreements or unintended consequences has been requested.

Update on implementation of NHS personal Health Budgets (adults) in Lewisham

The plan is to go live on 14th October 2013. Patients will be given the choice of using CCG commissioning service or to access cash payments to make their own arrangements or to have an agent who will manage their care/finances on their behalf. The NHS patient pathways, for fast track and non-fast track in Lewisham were explained.

The Delivery Committee will receive an update every 6 months. Evaluation is required before rolling out to new client groups. This should be picked up through the strategy and commissioning intentions for 2015/16.


ENCLOSURE 9

Integrated Performance Report – Month 4 2013/14

CLINICAL LEADs: Dr. Faruk Majid, Clinical Director , Dr Helen Tattersfield , Chair MANAGERIAL LEADS: Tony Read, Chief Financial Officer

Diana Braithwaite, Commissioning Director Alison Browne, Nurse Director

AUTHOR/S: Commissioning Directorate & Joint Commissioners

Graham Hewett, Integrated Governance Manager

Mike Hellier, Head of System Intelligence

RECOMMENDATIONS:

The Delivery Committee is requested to • note the integrated performance report• note the progress on the QIPP Programmes for 2013/14• receive the report as assurance that FLAG has implemented systems and processes to

identify and address quality issues as they arise within our service providers.

SUMMARY:

The Quality, Innovation, Productivity and Prevention programme is a national Department of Health strategy involving all NHS staff, patients, clinicians and the voluntary sector. It aims to improve the quality and delivery of NHS care while reducing costs to make £20bn efficiency

savings by 2014/15. These savings will be reinvested to support the front line.

KEY ISSUES: Finance (Annex 1)

This report covers the four month period to 31st July 2013 for NHS Lewisham Clinical Commissioning Group (CCG). At Month 4 the CCG is reporting break even against its issued budgets and is therefore achieving its required 1% surplus. The full year forecast is to deliver the £3.699m planned (1%) surplus in full.

At Month 4 the CCG is reporting a financial surplus in line with plan of £1,812k year to date position. It is expecting to deliver the 1% planned surplus at the year end.

1 | P a g e D e l i v e r y C o m m i t t e e : Q I P P 2 0 1 3 / 1 4 : M o n t h 4

The acute position represents the most significant area of expenditure pressure and the CCG has been required to use its contingency reserve to cover the cumulative and full year forecast overspends within the acute position. The CCG’s QIPP schemes are forecasting to deliver £10.77m (89%) of its £12.098m target. The main area of under-delivery is the schemes to reduce GP New Outpatient Referrals and those within Continuing Healthcare. Further information on these is outlined within the QIPP report

Quality, Innovation, Productivity and Prevention (QIPP) 2013/14: Monitoring Report M4 (Annex 2)

1. Lewisham CCG has a collective QIPP target for 2013/14 of 12m. 2. A proportion of our acute QIPPs are guaranteed (3.5m). 3. The monitoring report provides an overview of the key milestones for each work stream and any

key developments in-month. 4. Reporting at Month 4 projections, are that the CCG will miss its QIPP target by 1.3m. 5. Work is underway on all affected QIPP areas to develop and implement recovery plans. 6. The core QIPP areas are; GP 1st Outpatients (reduction in outpatient attendances), COPD &

Other Respiratory Conditions and Heart Failure (reduction in emergency admissions). 7. Of primary concern (and as reported last month) the GP Outpatient 1st Attendances is projected to

deliver no QIPP savings in 2013/14, which includes MSK. Initial review of activity suggests underperformance against the target in a number of key areas, which relates both to GP 1st Outpatient Attendances and Follow-ups but specifically; MSK, Gastroenterology, Pain Management, Paediatrics, Clinical Haematology, Anti-coagulation and Gynaecology.

8. Consequently, an Exception Report has been submitted (See Annex 2). In addition, resources (3 months interim) have been secured to lead on the implementation of the recovery plan and delivery of the outpatient strategy as approved by the Strategy & Development Committee on 1st August 2013.

9. The report does not contain the level of activity data as submitted throughout 2012/13. The format, type and timeliness of the data provided by the CSU are still being developed and this in part relates to national regulations as of 1st April 2013.

10. Not all the work of the various directorates is reflected in this overview as invariably it is those that are monitored and performance managed financially (efficiency savings) and reflects the ‘productivity’ (P) in QIPP that are represented.

Performance A detailed outcomes and constitutional commitments report is at Annex 3 with the detail on Constitutional commitments status is at Annex 4. Exception status is as follows: • Psychological Therapies (revised exception report relating to recovery rates for service users to

be reported to Delivery Committee and onto Governing Body in October 2013) • Accident and Emergency – 4 hour standard is being met. A report will be provided to Delivery

Committee – including preparations for winter 2013/14 • Mixed Sex Accommodation breaches are due to be reduced to zero by October 2013 following

capital works at Kings. • 18 weeks – the number of patients waiting over 52 weeks. Kings has stated that it plans to reduce

this number to zero by the end of September 2013. 2 | P a g e D e l i v e r y C o m m i t t e e : Q I P P 2 0 1 3 / 1 4 : M o n t h 4

Friends and Family Test results for Lewisham Healthcare will be discussed at the Clinical Quality Review Group with the Trust in September 2013 and any exception report will be reported in future. Quality (Annex 5) This is the August Quality Report for the Delivery Committee. The report has been reviewed and updated following the For Learning and Action Group (FLAG) held on 8th August 2013. The Quality report is divided into eight sections.

1. Quality Dashboard (safety, effectiveness and experience) The Quality Dashboard will be updated quarterly. The dashboard reported here is unchanged from that reported to Delivery Committee in June.

2. CQC Interventions The CCG is currently monitoring the implementation of action plans following unannounced inspections and an outlier alert at Lewisham Health Care NHS Trust (LHNT). Assurance has been received at the CQRG. LHNT and the CCG are waiting for CQC feedback following an unannounced visit to the maternity department on the 1st August 2013.

3. Quality Issues and Actions by provider FLAG is monitoring quality issues at LHNT that have been escalated from the CQRG or via other routes including: information flows from the hospital to GPs, safeguarding training compliance, the prevalence of pressure ulcers, district nursing services and has completed a deep dive into Looked After Children’s services. FLAG is working to improve its quality assurance frameworks for mental health services, for continuing health care and for the quality improvement aspects of primary care.

4. Patient Experience Themes and Actions FLAG is monitoring an escalated issue concerning how LHNT supports patients with communication needs.

5. Public Engagement Themes and Actions FLAG has noted the progress made to develop a Public Engagement Strategy which will help inform the CCG’s understanding of the quality of local services. FLAG identified that the delayed official launch of Health Watch Lewisham had left a temporary gap in the CCG’s information streams.

6. GP Raised Quality Alerts FLAG noted the marked decline in the number of quality alerts related to district nursing services.

7. Serious Incidents Requiring Investigation (SIRIs) The Quarter 1 SIRI Report showed that there were 23 SIRIs at LHNT during the period. Sixteen of these were pressure ulcers acquired at the Trust. There was one Never Event (surgical error) reported by LHNT.

8. Coroner’s Rulings (Rule 43) There were no new Coroner’s Rulings report to FLAG in August.

CORPORATE AND STRATEGIC OBJECTIVES Grip on day to day business

CONSULTATION HISTORY:


The Quality Part of this Report has been reviewed by FLAG

PUBLIC ENGAGEMENT:

Patient engagement and involvement although fundamental and intrinsic to a number of work streams (E.g. Mental Health, End of Life, COPD and Diabetes, ART pilot and UCC) has not been a factor in producing this overview report.


• Reduce inequalities between patients with respect to their ability to access health services. • Reduce inequalities between patients with respect to the outcomes achieved for them by the

provision of health services. PUBLIC SECTOR EQUALITY DUTY How does this report take into account the duty to:




•

RESPONSIBLE MANAGERIAL LEAD CONTACT:

Name: Diana Braithwaite E-Mail: [email protected]

Name: Tony Read E-Mail: [email protected]

Name: Alison Browne E-Mail: [email protected]

AUTHOR CONTACT/S:

Name: Ashley O’Shaughnessy, Commissioning Programme Lead

E-Mail: [email protected]

Name: Chris Gadney, Commissioning Programme Lead


Name: Victoria Medhurst, QIPP Programme Lead


Name: Corrine Moocarme

E-Mail:






Name: Susan Grose

E-Mail:

Name: Graham Hewett E-Mail: [email protected] Telephone: 0207 3049 3237

Name: Mike Hellier

E-Mail: [email protected] Telephone 0207 3049 3322



Finance report to the Lewisham CCG Delivery Committee Annex 1 Month 4, period to 31st July 2013, and full year forecast. Introduction 1. Introduction

1.1. The purpose of this report is to set out the 2013/14 financial position for Lewisham CCG as at Month

4, as well as providing an assessment of the likely year-end financial position. This reflects the latest information available and the high-level assessment of financial risks outlined previously.

2. Revenue Resource Limit and Start Budget 2.1. The CCG’s Revenue Resource Limit totals £364,552k plus £7,160k for its £25 per head running cost

allowance (RCA). The CCG must manage within both resource limits.

2.2. The CCG’s Revenue Resource Limit has been reduced by £460k relating to a baseline transfer to NHS England for Acute Dental Services. This aligns allocation to commissioning responsibility and is in line with the CCG’s expectation.

Table 1: Revenue Resource Limits

Programme Running Costs Total £000s £000s £000s Baseline Allocation 364,146 7,160 371,306 Anticipated (6,754) 0 (6,754) Total Allocation 357,392 7,160 364,552

2.3. Within the anticipated allocation the CCG has assumed,

• £426k will be transferred from NHS Southwark CCG to NHS Lewisham CCG relating to Community Dental Funding which due to historical arrangements presently sits within Southwark CCG’s allocation

• £424k will be transferred from NHS Lambeth CCG to NHS Lewisham CCG relating to the transfer of Manley Court from Lambeth to Lewisham

Whilst these allocation adjustments have been agreed with the relevant CCGs, the adjustments have yet to be actioned by NHS England and confirmed in Lewisham CCG’s advised allocation. This is not considered as a material risk to the CCG’s income at this stage and no adjustment has therefore been made in the reported month 4 financial position.

2.4. As a PCT, Lewisham received £3.492m funding for Joint Working with the Local Authority. The

treatment of this allocation within the new NHS structure is yet to be confirmed and isn’t reflected within the above Revenue Resource Limit. It is possible that NHS England will pay the money directly to Lewisham Council from 2013/14.

3. Headline Financial Performance

3.1. As at Month 4 the CCG is reporting an overall underspend of £1,812k. This is in line with the plannedsurplus. The CCG is forecasting to deliver its planned surplus of £3,699k.

3.2. The CCG is required to separately report budget and expenditure for Programme (healthcare) and Running costs. Programme budgets are under-spent by £1,739k and Running cost budgets are under-spent by £73k.

3.3. The Month 4 Acute position, based on the Month 3 Service Level Agreement monitoring (SLAM) reports position, indicates a continuation of the pressures within the Lewisham Healthcare (LHNT) and Kings positions. The Forecast Outturn of £3.994m is based on a risk assessment of the present position undertaken by the South London Commissioning Support Unit’s Acute Multi Disciplinary Team.

3.4. The Month 4 Adult Joint Commissioning position reflects under-delivery of QIPP savings in client group services and budget pressures associated with mental health contracts.

3.5. The CCG is meeting this pressure through the under-spend within the community budget and through the use of its contingency reserves.

Table 2: Headline Financial Performance

Year to Date Annual Overall CCG Budget Budget Actual Variance Budget Actual Variance

£000s £000s £000s £000s £000s £000s Acute Contracts 63,253 64,552 (1,299) 191,496 195,490 (3,994) Community Services 9,943 9,637 306 29,830 29,239 591 Joint Commissioning Adults 25,065 25,443 (378) 75,195 76,169 (974) Joint Commissioning Children 720 778 (58) 2,159 2,334 (175) Primary Care Budgets 12,453 12,403 50 37,359 37,209 150 Corporate Budgets 2,672 2,514 158 8,018 7,607 411 Reserves 5,598 4,378 1,220 16,795 12,803 3,992 Planned Surplus 1,812 1,812 3,699 3,699 Total CCG Budget 121,517 119,705 1,812 364,552 360,853 3,699

Programme/ Running Cost Split Programme Budgets 119,131 117,392 1,739 357,392 353,860 3,532 Running Cost Budget 2,387 2,313 73 7,160 6,993 167 Total CCG Budget 121,517 119,705 1,812 364,552 360,853 3,699

4. Acute 4.1. The Year to Date (YTD) and forecast year end position for the CCG’s acute budgets is set out below, Table 3: Acute Financial Performance Year to Date Annual Budget Actual Variance Budget Actual Variance Local Acute Service Agreements £000s £000s £000s £000s £000s £000s Guy's and St Thomas' NHS Foundation Trust 10,911 10,741 170 32,583 33,302 (719) King's College Hospital NHS Foundation Trust 8,697 9,475 (778) 26,090 28,962 (2,872) Lewisham Healthcare NHS Trust (LHNT) 37,928 39,076 (1,149) 114,096 118,648 (4,552) LHNT planned under-performance - CCG led QIPPS (313) 0 (313) (1,250) 0 (1,250) South London Healthcare NHS Trust 1,780 1,816 (36) 5,339 5,447 (108) Total Local Acute Service Agreements 5,510 5,909 (399) 16,529 17,267 (738) External Service Agreements 1,411 1,312 98 4,382 4,382 0 Non Contracted (2,669) (3,777) 1,107 (6,272) (12,517) 6,245 Other Acute 5,510 5,909 (399) 16,529 17,267 (738) Total MDT Acute Contracts 63,253 64,552 (1,299) 191,496 195,490 (3,994) 4.2. The YTD position is based on the Month 3 flex information which shows a year to date over-

performance of 3.9% for contracted activity.

4.3. The key drivers to this are at Lewisham (£1.15m), due to pressures around emergency admissions, outpatients, direct access and drugs & devices and Kings (£0.78m) which is over-performing within emergency, non-elective admissions and critical care.

4.4. The year-end forecast has been based on an adjusted straight-line forecast that considers the impact

of working days, seasonality trends and the impact of underlying growth applied at a CCG and POD level.

5. Joint Commissioning Adults

The Joint Commissioning budgets are presently showing a £378k overspend with a forecast of £974k at the year end. This is based on increasing activity within the variable element of the mental health contracts (£622k FOT) and an assessment of the current commitments across continuing care and client group services.

6. Community

The community position continues to underspend, £306k to date, with a forecast year end position of £591k. This position reflects under-spends within the local Urgent Care Centre budget, and on the Admission Avoidance service within the LHNT contract, which partially offsets the over-performance in LHNT emergency position.

7. Specialised Services Risk

Following the disaggregation of acute expenditure between CCGs and NHSE (for Specialist Services) a £288m funding gap has been identified across London in relation to acute hospital specialised services. NHS England has deducted the £288m from London CCGs’ opening revenue resource limits pro rata to the opening RRL. The Lewisham impact of this is £10.4m. Acute and mental health contracts have been set based on specialized services adjustments advised by the providers.

As part of the disaggregation of specialist budgets there was a further £10.5m adjustment to the CCG initial baseline for Specialist Mental Health Services.

A reconciliation based on reported activity at month 6 is planned which is expected to resolve these issues risk at a pan-London level, achieving financial neutrality across the system, however at an individual CCG level this may not be the case. There is consequently a difference in the available budget and the contracted position, creating a potential material financial risk to the CCG. The CCG has been able to identify £7.1m of these adjustments leaving a potential £3.4m risk to the CCG budgets. It is anticipated that NHS England will deliver a cost neutral outcome for the specialized services transfer for London. This will be known only after the report from the London Technical working Group in November. On this basis the CCG is assuming that cost neutrality will be achieved and consequently is reporting a cost neutral position in both the month 4 cumulative and year end forecast positions.

8. QIPP Position 8.1. The CCG has identified QIPP schemes of £16m, which have been risk assessed to £12.1m. The CCG is

presently forecasting to deliver £10.77m of its plan.

8.2. The main areas of underperformance are within GP New Outpatient Referrals and continuing healthcare, further information on these is provided within the QIPP report. Whilst there are further shortfalls across a number of the other acute QIPPs the Month 3 SLAM data appears to indicate improvement within the position, these will be closely monitored over coming months.

Table 4: Risk Assessed QIPP Forecast Year End Year to Date Year End Variance Plan Actual Plan Actual Actual % £000s £000s £000s £000s £000s GP New Outpatient Referrals Outpatient Reductions 402 - 131 - (402) (100%) Total GP New Outpatient Referrals 402 - 131 - (402) (100%)

Long Term Conditions COPD & Other Respiratory 317 62 135 21 (255) (81%) Diabetes 197 219 85 73 21 11% Heart Failure 166 38 81 13 (128) (77%) MSK Integrated Pathway 255 151 99 50 (104) (41%) Total Long Term Conditions 935 469 399 156 (466) (50%)

Other Acute Acute KPIs 2,021 2,021 674 674 0 0% Outpatient Reductions 308 157 79 52 (151) (49%) Excess Bed Day Reductions 205 349 70 116 144 70% Other 2,787 2,698 855 899 (89) (3%) Total Other Acute 5,321 5,225 1,677 1,742 (96) (2%)

Urgent Care A&E Reductions 280 262 144 87 (18) (6%) Total Urgent Care 280 262 144 87 (18) (6%)

Medicine Management LHNT Pharmacy Schemes 397 395 132 132 (2) (0%) Prescribing Efficiency 1,500 1,683 561 561 183 12% Total Medicine Management 1,897 2,078 693 693 181 10%

Mental Health Mental Health 500 500 167 167 0 0% Total Mental Health 500 500 167 167 0 0% Continuing Care NHS Fully Funded Continuing Healthcare 600 - 200 - (600) (100%) Total End of Life 600 - 200 - (600) (100%)

Other Client Group Activity Management 2,033 2,033 678 678 0 0% Estates 130 200 67 67 70 54% Total Other 2,163 2,233 744 744 70 3%

Total 12,098 10,767 4,155 3,589 (1,331) (11%)

9. Other issues

9.1 The Department of Health legacy arrangements for PCTs are expected to wind up at the end of

August. The arrangements for outstanding PCT debtors, creditors and 2012/13 year end accruals and provisions are not yet confirmed.

9.2 Opening balances for the CCG’s balance sheet will not be known until after the wind up of the above legacy arrangements. This presents some risk, most notably to the matching of expenditure on retrospective continuing healthcare claims to the PCT’s provision.

9.3 The CCG has not been notified of its cash limit for 2013/14

10. Summary and planned action

10.1 The CCG is delivering its planned surplus at Month 4, and is forecasting that it will meet its planned year-end surplus of £3.699m.

10.2 A more detailed assessment of financial risk and establishment of the opening balance sheet will be presented to the Finance and Risk Working Group.

1 | P a g e QIPP Report Month 4 Lewisham Clinical Commissioning Group: Exception Report - Outpatients

Appendix 2: QIPP M4 Monitoring – Exception Report

EXCEPTION REPORT

PROGRAMME: QIPP 2013/14 Project: GP New First Outpatient Referrals

SRO: Clinical Director:

Diana Braithwaite, Commissioning Director Dr Faruk Majid

Project Lead: Ashley O’Shaughnessy, Programme Lead

Date Raised/QIPP Ref.: 09.08.13/BC;OP01 Project Value (QIPP Target): £402K

De

scri

pti

on

CCG is at M4 is project to under deliver against its 12m target for 2013/14 by 1.3m.

RC

A

Analysis has demonstrated that one of the major contributing factors to this under delivery relates specifically to the GP New First Outpatient Referrals. This work stream leads on development and implementation of the Outpatient Strategy. The available activity data from SLAM to date shows a significant over performance of activity for consultant lead activity; outpatient attendances and follow-ups, which if this trajectory continues could result in the 402K not being delivered. There are a number of core areas that do need to be further explored; however a great deal of this is dependent on the availability of data to the CCG. Included in the under delivery is the MSK service, where the financial modelling has failed to produce estimated or projected savings.

RECOVERY PLAN Objective Outcome Lead/s Due Date

1. Increase Project Management Resource

This work stream is has been delivered by the Programme Lead and does not have a dedicated Project Manager as with other programmes. An interim resource has been secured for 3 months to support with the delivery of the programme.

Diana Aug

2. Review of outpatient activity by GP Practice

LCCG no longer has access to data at practice level. Essentially, data was in the past provided to practices on referral/attendance activity via GPI and in some instances this was proactively sent directly to practices by Clinical Commissioning Facilitators. A proposal has been submitted to Lewisham Healthcare NHS Trust to request support in providing this data. LHNT have agreed in principle to provide the data subject to jointly agreeing some governance arrangements.

Diana Aug/Sept

3. Develop practice engagement programme to review referrals:

A programme will need to be developed to re-engage practices in reviewing the outpatient referrals/attendances; a) Neighbourhood Leads (11.09.13) b) Membership Forum (11.09.13)

Diana/ Ashley

Sept

2 | P a g e QIPP Report Month 4 Lewisham Clinical Commissioning Group: Exception Report - Outpatients

c) Neighbourhood Meetingsd) CCF practice visitse) GPI pushf) Realign P2P posts (existing leads E.g. ENT) to support specialities which are over

performing

Sept/Oct Sept Oct

4. Utilising contract leavers andClinician 2 Clinician

(a) Contracting: Via the CSU discussions with LHNT with regard to OPFU (Follow-ups) (b) Clinician to Clinician discussions with LHNT (c) MSK Summit with LHNT, CSU Contracting and CCG Clinical Directors (d) Consider/review access to clinical advice prior to referral E.g. telephone, email and/or Choose & Book

Neil/ Diana Neil/ Diana

Sept/Oct

5. Development short-term (01.10.13to 31.03.14) of LIS to supportpractice review of referrals

The purpose of the LIS (Lewisham Incentive Scheme) is to enable practices to prospectively review referrals before they are made. The funding will support backfill in practices.

Ashley Oct

6. Evaluation of a ‘formalised’ approachto referrals for implementation in2014/15

This will underpin the Outpatient Strategy. The aim is not to be prescriptive on what model/s would be appropriate for Lewisham but that a formalised approach is required in order to reduce referrals and ensure the sustainability of any reductions into 2014/15.

Ashley Mar

CCG Risk Register

Risk Ref. Risk Title Inherent Risk Priority

581 Acute Contract over-performance will lead to loss of financial control Very High (16)

Corporate Objectives

Ref. Corporate Objectives RAG

10. Grip on day-to-day business: Ensure that the CCG delivers its statutory commissioning responsibilities and NHS England’s requirements. Outcome: Appropriate financial controls and assurance frameworks are in place to achieve financial balance – Monthly.

Monitoring

Project Management Meeting – Weekly

QIPP Programme Board – Monthly

Delivery Committee – October

Performance Update for Governing Body Annex 3.

Outcomes and Constitutional Commitments

The Constitutional Commitments report is attached at Annex 3. This

The improved outcomes and performance highlights are:

• Lewisham CCG delivered the stop smoking plan in 2012/13 with 1803 smoking quits against a plan of 1800. Before this was achieved, the CCG set the same plan for 2013/14, and, with a renewed focus on practice data and CCG tools to ease the reporting process, it should be possible to achieve this level.

• For long term conditions the emergency admissions figures for chronic ambulatory care and unplanned admissions are both reducing. In addition the latest GP patient survey for July 12 to March 13 shows a significant improvement year on year in the indicator for patients with long term conditions feeling supported by services. This rise was from 58.9%in 11/12 to 61.8% in 12/13. This puts the CCG very close to its plan for 13/14 of 62.3%.

• All of the preventing people dying indicators are moving in the right direction in the most recent data.

• The CCG has delivered its infection control plans for 12/13 and is within plan for 2013/14 year to date at June 13. There have been no MRSA infections so far and 7 CDifficile infections, which is within the plan set for the CCG.

• The CCG has been Green rated for Constitutional Commitments by NHS England for Quarter 1 2013/14.

The outcomes and performance issues are as follows:

• Emergency admissions for under 19s for asthma, diabetes and epilepsy as adirectly standardised rate per 100000 population are higher and are flatagainst a national decline.

• Emergency admissions for under 19s with a lower respiratory tract infectionare rising, but so are London and national figures. Again these arestandardised for the population.

0.0

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Emergency Admission of Children (U19) WITH LRTI

Lewisham

London

England

• The Exception report for psychological therapy service recovery rates will bereviewed following the contract meeting with South London and MaudsleyNHS Foundation Trust in September. This will be reported to OctoberDelivery Committee.

• The Exception Report for mixed sex accommodation was presented at theJuly Delivery Committee and following the capital work at Kings is forecast toreduce to zero by October 13. This will be known for the November DeliveryCommittee.

• Incomplete pathways over 52 weeks are largely at Kings. The Trust hasstated that it will clear its incomplete pathways over 52 week waiters by theend of September 2013. This will be known for the November DeliveryCommittee.

The Friends and Family Test scores for A&E and inpatients have been published for all providers for Q1 13/14. In June 2013, Lewisham Healthcare is in the top decile of providers for A&E scores (and the response rate meets the standard unlike many providers), but in the bottom decile of providers for inpatient scores. The Clnical Quality Review Group for Lewisham Healthcare will review these scores in September 13 and any relevant exception report will be reported to Delivery Committee.

Cancer waiting times have been achieved in Quarter 1 2013/14 except for two amber rated indicators. The two week standard for breast symptoms is at 91.5% against a 93% standard which is four breaches beyond the standard. The 62 day standard from GP referral to treatment is at 84% against a standard of 85% or two beaches beyond the standard. Both indicators were delivered in Quarter 4 12/13. The CCG will be seeking both understanding and any required recovery action to put these indicators back on track and will report these to Delivery Committee.

Lewisham CCG Consitutional Commitment Indicators Performance Scorecard 2013-14 Annex 4

Q4 12/13 Standard Target

NHS CONSTITUTION

Year End

Actual Forecast Last YearFeb Mar Quarter 1 Quarter 2 Quarter 3 Quarter 4Aug Sep Oct Nov Dec JanJul

Year to DateApr May Jun

Monthly Indicators Exce

ptio

n Re

port

Ref

CB_B1: RTT 18 week compliance, admitted patients 92.1% 90.0% 90.4% G 92.6% G 93.4% G 90.0% 91.3% GCB_B2: RTT 18 week compliance, non admitted patients 97.8% 95.0% 97.9% G 98.0% G 97.5% G 95.0% 98.5% GCB_B3: RTT 18 week compliance, incomplete pathways 93.8% 92.0% 93.6% G 93.8% G 94.1% G 92.0% 92.9% GCB_B4: Diagnostic test waiting times 98.97% 99.00% 99.31% G 98.68% A 98.95% A 99.00%CB_B5: A and E 4 hour waiting time compliance (LHNT only) 91.70% R 95.6% 95.0% 95.6% G 95.0%CB_B6: All cancer two week waits 96.4% G 95.1% 93.0% 93.9% G 96.8% G 95.1% G 93.0% 94.7% GCB_B7: Breast symptoms (cancer not initially suspected) 95.10% G 91.5% 93.0% 93.2% G 89.7% A 91.5% A 93.0% 95.1% GCB_B8: Cancer first definitive treatment in 31 days 97.60% G 99.1% 96.0% 100.0% G 100.0% G 99.1% G 96.0% 98.2% GCB_B9: Cancer subsequent treatment 31 days, surgery 98.10% G 100.0% 94.0% 100.0% G 100.0% G 100.0% G 94.0% 97.1% GCB_B10: Cancer subsequent treatment 31 days, drug 97.6% A 100.0% 98.0% 100.0% G 100.0% G 100.0% G 98.0% 99.3% GCB_B11: Cancer subsequent treatment 31 days, radiotherapy 92.6% A 96.3% 94.0% 93.50% A 94.6% G 96.3% G 94.0% 98.1% GCB_B12: Cancer first treatment 62 days, GP referral 86.0% G 84.0% 85.0% 78.30% R 93.8% G 84.0% A 85.0% 88.4% GCB_B13: Cancer first treatment 62 days, screening referral 100.00% G 94.1% 90.0% 100.0% G 100.0% G 94.1% G 90.0% 95.5% GCB_B14: Cancer first treatment 62 days, consultant upgrade 90.00% 100.0% 100.0% 100.0% 90.0%CB B15 : Ambulance Category A Red 1 Time for Response 77.7% 75.0% 77.6% G 77.9% G 77.4% GCB B15 : Ambulance Category A Red 2 Time for Response 76.5% 75.0% 75.8% G 77.7% G 75.9% GCB_B16: Ambulance category A 19 minute transportation time 98.2% 95.0% 98.0% G 98.5% G 98.2% GCB B17 : Mental Health CPA within 7 days following inpatient 95.70% G 99.0% 95.0% 99.0% GCB_B18: Mixed sex accommodation breach count 5 A 7 0 Perf 03 3 A 3 A 1 A 0

SUPPORTING MEASURESMonthly Indicators

CB_S6: RTTs in excess of 52 weeks: Admitted patients 3 R 0 4 R 5 R 1 R 0CB_S6: RTTs in excess of 52 weeks: Non admitted patients 1 R 0 1 R 1 R 0 G 0CB_S6: RTTs in excess of 52 weeks: Incomplete Pathways 3 A 0 3 A 4 A 2 A 0CB_S9: A and E trolley waits over 12 hours 0 0 0 0 0

Notes:Cancer waiting times will be considered on a quarterly basis to decide on exception reporting.Perf 03 was considered at the July Delivery Committee.

Governing Body Quality Report

LCCG Quality Report Annex 5 August 2013

Contents

Section Page

LCCG Quality Dashboard 2

CQC Interventions 5

Quarterly Quality Issues and Actions LHNT (Acute) LHNT (Community) SLAM Continuing Nursing Care Primary Care

7 8 9 10 11

Patient Experience Themes and Actions

12

Public Engagement Issues and Actions 15

GP Raised Quality Alerts 16

Serious Incidents 18

Coroner’s Rulings (Rule 43) 21

Date: 08/08/2013. Version: 1.0. Author: Graham Hewett. Status: Final. Approvals: FLAG 08/08/2013. Page: 1 of 21

Section 2: Quality Dashboard


Section Three: CQC Interventions

Name of Provider CQC Regulation Intervention Action Reported Date of CQC Intervention Description of Agreed Improvement Plan / Trajectory Description of CCG Assurance Process

(Note: Responsible Clinician & Officer)

Lewisham Health Care NHS Trust

Following an unannounced visit which included medical and care of the elderly wards the following areas were identified as requiring improvement: Outcome 1 Respecting and involving people who use the service- Outcome 4 Care and welfare of people who use the service

08/02/2013 Unannounced visit 11/02/2013 Formal feedback from CQC

What follows is a summary of the key actions that the Trust is taking in response to improve outcomes 1 and 4 • Patient experience monthly score cards • dignity and respect training sessions for all staff • monthly quality ward rounds performed by

matrons on each ward • ward dignity champions • Executive director walk about and the

development of an OD plan for the new organisation.

• Improvement will be measured through existing systems of patient feedback with additional metrics from the quality reviews. These will be reported back to all wards and to directorate governance meetings.

• The patients forum also undertake walkabouts within the trust

• Documentation was identified as an issue and

there are now monthly audits of nursing documentation and completion of care plans to ensure compliance and evidence care planning.

• All wards have been issued with a planner to ensure the timely completion of audits and a poster campaign of no decision about me without me has been launched.

• Improvement will be measured as above and the action plans will remain on the quality agenda

Actions monitored at CQRG An action plan has been prepared by the Trust (see highlights in previous column) and this will be reviewed at the CQRG in August 2013 Faruk Majid Alison Browne


Section Three: CQC Interventions Lewisham Health Care NHS Trust Maternity Department

Care Quality Commission maternity outlier alert for emergency caesarean section rates at Lewisham Healthcare NHS Trust

analysis of maternity indicators undertaken by the Care Quality Commission has indicated significantly high rates of emergency caesarean section rates

Letter received by the Trust on 02/05/2013

The CQC have asked the Trust to respond with further analysis. The Trust have responded to the letter. The response was seen at the July FLAG meeting and the July CQRG.

Monitored at CQRG and FLAG A report to the July CQRG showed that the current status was 28% which is the same as the London average. An action plan is in place to reduce this further. The action plan will be reviewed again at the CQRG.

Lewisham Health Care NHS Trust Maternity Department

The Trust are waiting for feedback from CQC following the visit.

Unannounced visit to the maternity department

Waiting for feedback Waiting for feedback


Section Four: Quarterly Quality Issues

Lewisham Healthcare NHS Trust (Acute)

RAG

Quality Issue Identified Commissioner Actions Taken and Planned CCG Group

with Oversight

Discharge letters often lack important information and are not always sent in a timely manner Letters to GPs sent to wrong Practices

Faruk Majid to meet with Trust consultant leads to discuss. FLAG recommended in July that the template communications should be presented to Patient Participation Groups and the Neighborhood Forums

The Trust are establishing a “data issues” email address and will advise GPs that all incorrectly addressed correspondence should be returned and alerted through this email This is linked to the item above

Monitor via GP Alerts monthly

CQRG FLAG

Safeguarding Training compliance not meeting targets. On trajectory to recover by September 2013.

Compliance is good for levels 1 and 4 but not for levels 2 and 3 FLAG reviewed a report from the LCCG Health Safeguarding Group which showed that the plan was on trajectory.

CQRG FLAG

High numbers of pressure ulcers are acquired by patients at the Trust – including community services

A joint project has been started to review the outcomes of pressure ulcers and to make recommendations and changes to practice. Karen Bates has developed an action plan for review at FLAG in September and the next CQRG and the next safeguarding group.

CQRG FLAG

The CCG needs assurance that the Trust is developing a new quality reporting format for the new merged Trust across Lewisham and Greenwich

A series of workshops have been agreed, facilitated by The Good Governance Institute, to include all the CCG members of CQRGs for Lewisham, Bexley and Bromley. The workshops will focus on the structure, process and assurance roles of a single CQRG for the new merged Trust.



Lewisham Healthcare NHS Trust (Community)

RAG


with Oversight

District Nursing services do not consistently meet expected quality standards

The Trust has appointed a new lead for the District Nursing service and an organization wide service review is underway An action plan has been in place since January and there has since been a reduction in the number of GP raised Quality alerts concerning the DN service. CQRG will receive a report in August FLAG will receive a report in September

CQRG FLAG

Concerns were raised that Looked After Children Assessments were not performed consistently

A deep dive review of health safeguarding issues related to Looked After Children (LAC) to improve service delivery was undertaken. Recommendations were made about improving assessment uptake, care pathway and roles of designated staff going forward. April 2012 OFSTED Report for LAC reported the service was Excellent and Good Action plan and report received by FLAG in August 2013. To be monitored by FLAG in September.

CQRG FLAG



South London and Maudsley NHS Foundation Trust

RAG


with Oversight

LCCG does not have an effective CQRG with SLAM LCCG are working with SLAM and the other main CCG contractors to organise a single CQRG Sue, Alison, Sam and Graham met and have mapped out the quality assurance process for SLAM and mental health. This is in draft form and will be distributed when complete.

FLAG

There are three distinct and separate processes and organisational structures for monitoring and signing off Serious Incident reporting and investigations at SLAM

LCCG is working with SLAM and the other key CCGs to introduce a single SI monitoring process and sign off meeting. Lambeth and Southwark CCGs have now stepped back from this proposal. A new proposal has been agreed for a quarterly SI review meeting with all four Boroughs. This leaves a gap for LCCG as we don’t currently have a viable process for signing off that actions have been completed. GH to progress linked to above.

FLAG

There appears to be a national issue relating to the availability of CAMHS beds. We are not clear of the position in Lewisham or what might be causing capacity

GS, AB, SM, GH to discuss at meeting re Quality Assurance at SLAM. See above. Monitor by exception at FLAG.

FLAG

SLAM are not reporting any Pressure Ulcers as SIs. The CCG requires assurance that this is a true reflection and not as a result of poor reporting.

KB will include SLAM in her action plan for addressing PUs across SEL. MH to produce a benchmarking report of SIs and incident reporting for August FLAG



Continuing Health Care


with Oversight

Lewisham residents are being admitted to LHNT with pressure ulcers acquired at home:

Nursing homes are not reporting pressure ulcers for CNC funded patients through the NHS Serious Incident processes FLAG is not in sight of quality indicators for CNC patients

The LCCG adult safeguarding nurse has started a project to review the reporting processes and support for nursing homes to improve the reporting of quality. KB will include nursing homes in the action plan for improving the management and prevention of pressure ulcers. The action plan will be monitored by FLAG KB has also visited some nursing homes to help implement the NHS Patient Safety Thermometer

FLAG



Primary Care (including OOH, NHS 111)

RAG


with Oversight

NHS 111 Capacity and service quality issues Implementation of NHS 111 across LSL has been halted until the capacity and service issues can be resolved. NHS 111 have reported greatly improved performance across Bromley, Bexley and Greenwich since the Easter bank holidays

NHS 111 Clinical Governance Group

Following a concern regarding the variance between an individual’s INR as measured by the capillary and venous system, below sets out the plan to gather the required information to

1) Gain assurance that the current system for analysis of INR within the Community Service is within accepted limits of accuracy

2) Inform any review regarding whether a change in the point of care equipment and system is required

Katherine Howes presented a paper to FLAG in August which gave assurance that services were safe and which identified lessons to be learned for dissemination to GPs and pharmacists. This issue is now resolved.

FLAG


Section Five: Patient Experience Themes and Actions


Provider Summary of Patient Experience Themes Actions agreed with provider Group

Responsible for Oversight

RAG

LHNT LHNT produce a quarterly report of complaints including quantitative and qualitative data regarding complaints performance and the themes.

The Trust will report the next complaints report in September

CQRG

LHNT

Where a patient has expressed a communication need (either themselves or via GP referral letter) – low vision/sight difficulties for example - then larger font (16/18 rather than 12) or Braille letters should be produced rather than the standard format. As part of equalities duties, we and our providers should be making reasonable adjustments to accommodate these needs.

The issue was raised at the July CQRG The Trust already has provision for meeting communication needs eg braille, large font, and language support and can meet patients’ needs if this is indicated within the referral letter. AG will raise with EMIS to amend EMIS referral templates. Information to GPs will be disseminated via GPI once the referral templates have been implemented. The Trust is going to review its internal policy and report back to the August CQRG

CQRG

LHNT

Friends and Family Test Data has been published nationally for the first time in July 2013. LHNT has performed well in terms of required response rates. The score for A&E was particularly good. The score for inpatient settings was the lowest for South East London.






Inpatient Total

ResponsesTotal

EligibleResponse

Rate

Friends and Family Test Score

AREALondon Area Team 14,958 49,047 30.5% 63

TRUSTRN7 DARTFORD AND GRAVESHAM NHS TRUS 400 1,351 29.6% 69RJ1 GUY'S AND ST THOMAS' NHS FOUNDAT 1,022 3,069 33.3% 77RJZ KING'S COLLEGE HOSPITAL NHS FOUND 714 1,838 38.8% 60RJ2 LEWISHAM HEALTHCARE NHS TRUST 370 1,209 30.6% 54RYQ SOUTH LONDON HEALTHCARE NHS TRU 499 3,054 16.3% 65

SLHT SITES SLHT Princess Royal University Hospital - RY 303 1,573 19.3% 66SLHT Queen Elizabeth Hospital Woolwich - R 144 1,347 10.7% 55SLHT Queen Mary's Hospital Sidcup - RYQ10 52 134 38.8% 90

A&E Total

ResponsesTotal

EligibleResponse

Rate

Friends and Family Test

Score

AREALondon Area Team 15,420 136,068 11.3% 47

TRUSTRN7 DARTFORD AND GRAVESHAM NHS TRUS 243 3,776 6.4% 74RJ1 GUY'S AND ST THOMAS' NHS FOUNDAT 505 7,585 6.7% 49RJZ KING'S COLLEGE HOSPITAL NHS FOUND 809 10,163 8.0% 37RJ2 LEWISHAM HEALTHCARE NHS TRUST 1,035 5,662 18.3% 75RYQ SOUTH LONDON HEALTHCARE NHS TRU 629 6,055 10.4% 16

SLHT SITESSLHT Princess Royal University Hospital - RYQ 25 2,884 0.9% 79SLHT Queen Elizabeth Hospital Woolwich - RY 604 3,171 19.0% 14






Lewisham CCG Commissioner

During Q1 2013/14, a total of 7 Complaints were received, 2 of which were legacy complaints. 29% of all complaints were forwarded to NHS England or other organisations. There are currently no common themes amongst the complaints received in the first quarter. A total of 28 PALs requests were received by the CSU which mainly related to GP services.

None required. FLAG


Section Six: Public Engagement Themes and Actions

RAG

Public Engagement Themes Actions Identified

Public Engagement Strategy The Public Engagement Strategy has been approved by the Strategy and Development Committee. A Head of Patient Engagement has been appointed and will start work on the 1st September FLAG heard at its August meeting that Health Watch had delayed its official launch until November 2013. The slow start up of Health Watch means that the CCG is not receiving the valuable input expected from patients

A first priority for this role will be to develop more detailed action plans arising from the strategy MW / AB / GH to write to Health Watch with priorities for 2013/14


Section Seven: GP Raised Quality Alerts

1. QUALITY ALERTS SUBMITTED DURING JULY 2013

• Total of 75 QAs submitted during July • 98 QAs raised issues about service providers • 5 QAs raised issues not connected with service providers • 1 complimentary QA was submitted: for Lewisham Hospital Pathology-Microbiology Dept

(Narrative 4.5 p.10)

2. MAIN THEMES FROM JULY 2013 DATA

2.1 Lewisham Healthcare NHS Trust

74 LHNT QAs (UHL + LCS) 10 District Nursing QAs

This represents 10% of the total number of QAs submitted (the same as June)

1 Lewisham Hospital NHS Trust (LHNT) data in this table has been separated into hospital and community: University Hospital Lewisham (UHL) and Lewisham Community Services (LCS). Other abbreviations: GSTT (Guy’s & St Thomas’, KCH (King’s College Hospital), SLaM (South London & Maudsley), SLHT (South London Health Care Trust, e.g. Queen Elizabeth Hospital, Woolwich; Princess Royal University Hospital).

NUMBER OF QUALITY ALERTS PER PROVIDER SUBMITTED OVER THE LAST 12 MONTHS

Provider1 Aug

2012 Sep

2012 Oct

2012 Nov 2012

Dec 2012

Jan 2013

Feb 2013

Mar 2013

Apr 2013

May 2013

Jun 2013

Jul 2013

UHL 42 58 58 73 40 31 60 94 48 36 45 64 LCS 14 10 20 20 25 18 25 24 14 12 7 10 GSTT 6 5 9 8 6 7 7 12 7 5 2 11 KCH 4 9 7 7 8 7 8 16 14 11 3 8 SLaM 8 3 5 2 4 6 5 8 4 4 3 2 SLHT 2 0 2 3 1 2 3 3 2 3 3 1 Other 4 5 6 11 9 4 16 29 4 4 8 7 Total 80 90 107 124 93 75 124 186 93 75 71 103


Section Seven: GP Raised Quality Alerts

District Nursing

0

2

4

6

8

10

12

14

Appt delayCancellationWaiting time

Clinical care -effectiveness

Clinical care -safety

Communicationwith patient or

staffcommunication

Communicationwith practice

Main issues of concern raised about District Nursing Mar-Jul 2013

Mar-13

Apr-13

May-13

Jun-13

Jul-13


Section Eight: Serious Incidents Requiring Investigation (SIRI) SUMMARY: Lewisham Healthcare Trust There has been 1 incident reported to date in Q2 by Lewisham Healthcare Trust 1 Pressure Ulcer Grade 3 (1 acquired under Trust Services) There were 29 incidents reported during Q1 2013/14 by Lewisham Healthcare Trust; 6 have been de-escalated as the Pressure Ulcers was acquired outside Trust services. The other 23 incidents are: 1 Never Event – Surgical Error 21 Pressure Ulcer Grade 3 (16 acquired under Trust services, 5 de-escalated) 2 Grade 4 Pressure Ulcers (1 acquired under Trust Services and 1 under de-escalation request) 1 Unexpected Neonatal Death 1 Unexpected admission to NICU 1 MRSA Incident 1 Radiology/Scanning incident 1 Slips / Trips/ Falls The table below compares the number and types of incidents reported in Q1 2012/13 and Q1 2013/14. The bar chart shows that there has been an increase in the number of Acute acquired Pressure Ulcers and a reduction in the number acquired in Nursing Homes. “Other PU’s” are when Pressure Ulcers have been acquired in other Borough’s or patients home and not under Lewisham Healthcare services.


Section Eight: Serious Incidents Requiring Investigation (SIRI)

There are no outstanding Final Reports waiting to be received from Lewisham Healthcare Trust but Pressure Ulcer Incidents are still being reported outside the 48 hour window, during Q1 2013/14 a total of 22 incidents were reported for Q4 12/13. SLaM There has been 1 incident reported in Q1 2013/14 May 2013 (suspected suicide). During Q1 2012/13, 2 incidents were reported (suicide and assault). 8 Final Reports have been received from SLaM which are currently being reviewed by colleagues at the CSU. Three outstanding final reports are due in the next month following agreed extension requests.

0

2

4

6

8

10

12

14

12/13

13/14


Section Eight: Serious Incidents Requiring Investigation (SIRI) Incidents involving Lewisham Residents reported by other Trusts King’s There are currently 2 ongoing incidents involving Lewisham Residents reported by King’s. One of the King’s incidents is a Never Event and Lewisham CCG Senior Management Team have been informed of this incase of media interest. The other relates to an unexpected Neonatal Death. GSTT There is 1 incident involving a Lewisham Resident reported by GSTT (Surgical – Trauma and Orthopedics) and the final report is now due. GSTT forwarded 4 copies of STEIS alerts to Lewisham CCG all for Lewisham Residents who had acquired Pressure Ulcer Grade 3’s outside their services. Lorraine Smedmor has passed these onto Peter Chatfield at Lewisham Healthcare Trust who will review these and report on STEIS if the ulcers were acquired within their services and GSTT will be able to de-escalate from their organisation. Other Blackheath BMI – an incident reporting form was submitted from Lewisham Healthcare Trust to Lewisham CCG to alert them to an incident involving a patient who was clinically unescorted from Blackheath BMI to UHL. Alison Browne was informed of this incident and Blackheath BMI was contacted and a copy of the investigation report has been requested once complete.


Section Eight: Coroner’s Rulings (Rule 43)

The Current Status of recent Coroner’s Rulings is shown below.

There has been no new Coroner’s Reports

Ref No. IDCoroner's case

NumberDate of Coroners

reportServices affected Brief description CCG Response Lead

Date Response Sent

Status

01/2013 JB 20.10.19371579-12 07/01/2013 SEL CCGs / Care Homes Poor management of DNR

Led by Lambeth CCGCorrine Moocarme

18/04/2013 Closed

02/2013 DF 02.08.1961 1612-11 11/04/2013 General Practice Drug transcription error Alison Browne 31/05/2013 Closed

03/2013 IM 26.01.19693135 - 10 13/05/2013 LHNT A&E and SLAM

Max wating time at A&E for for a mental health assessment

Dee Carlin 08/07/2013 Closed

Coroner's Reports Tracker - Lewisham CCG



ENCLOSURE 10 DRAFT STRATEGIC PLAN

CLINICAL LEAD: Dr David Abraham MANAGERIAL LEAD: Susanna Masters

Post Senior Clinical Director Post Corporate Director

AUTHOR: Charles Malcolm-Smith Post Head of Strategy & Organisational Development


• Note the progress on development of strategy • Note and comment on the draft strategy summary • Note and comment on the plans for engagement and draft engagement pack

SUMMARY: This report provides an updated summary of the draft commissioning strategy. It covers the vision and outcomes, ‘case for change’, strategic priorities, and engagement plans. A draft engagement pack is included separately.

KEY ISSUES: The Governing Body have participated in a series of workshops to develop a new strategy for the organisation and received a presentation at its meeting on 4th July which covered the main content areas. The outline vision or ambition for the strategy uses the ‘better health, best care, best value’ framework. The draft strategic themes and priority areas in the table below have been mapped against challenges identified in the ‘case for change’:

Strategic Themes Strategic Priorities

Healthy Lifestyles and Choice

1. Health and wellbeing – smoking cessation, alcohol abuse, obesity and cancer

2. Maternity and acute children Frail and Vulnerable People 3. Frail older people (including end of

life care) Long Term Conditions

4. Long Term Conditions – eg COPD, diabetes, CVD, dementia

5. Mental Health

Deliver Services Differently

6. Primary care development and planned care

7. Urgent Care 8. Greater integration of health and

social care commissioning These proposed strategic priorities have also informed the work to date on the 2014/15 draft Commissioning Intentions. The key outcomes proposed to measure our success in the next 5 years will include mortality rates for the main causes of death and neo-natal mortality, patient experience of support for long-term conditions, and if possible an appropriate measure to encompass quality of life. Appendix 1 contains those trajectories agreed by the shadow Governing Body in November 2012 for life expectancy at birth and mortality rates for cancer, cardiovascular disease, and respiratory disease. Proposed trajectories are being developed for the remaining health outcomes. The key outcomes and trajectories will form the basis for a monitoring framework for the strategy which will be developed. The initial plans for engagement on the draft strategy were discussed at the CCG’s Public Engagement Group (PEG) in July. However the engagement has not progressed as quickly as planned because feedback from the PEG meant that revisions were required to the suggested approach and areas for engagement with the public, links to the Health and Wellbeing Strategy were strengthened, and also in July NHS England launched its ‘Call to Action’ national consultation programme to be integrated into our engagement activity. The engagement plan was therefore revised to take account of all of these factors and is contained in Appendix 2. The proposed engagement material is contained in the draft engagement pack which accompanies this report. The engagement plan includes a schedule for an on-line survey and social media, and meetings with local groups, the CCG membership, GP Practice Patient Groups (PPGs), and key stakeholders. A final draft strategic plan will be presented to the Governing Body for approval in October which will take into account the outcomes of the engagement process and equalities analysis.

CORPORATE AND STRATEGIC OBJECTIVES The strategy will provide five year strategic objectives and inform corporate objectives from 2014. The refresh of the strategy is one of the corporate objectives for 2013-14.

CONSULTATION HISTORY: • Members of the Governing Body, and representatives from Lewisham Public Health

and providers have participated in workshops to develop the draft strategy content. • In July 2013 the Health and Wellbeing Board received an update on the development

of the strategy and confirmed that it is aligned with the Health and Wellbeing Strategy. PUBLIC ENGAGEMENT

• The next phase of the development of the strategy will encompass public engagement. Plans are contained in Appendix 2 of the draft strategy summary.



• Reduce inequalities between patients with respect to the outcomes achieved for them by the provision of health services.

The population health needs analysis has identified population health inequalities which will form part of the on-going monitoring of the strategy. PUBLIC SECTOR EQUALITY DUTY How does this report take into account the duty to:




An equality analysis assessment is being carried out which will inform the final draft strategy during the next phase of development. RESPONSIBLE MANAGERIAL LEAD CONTACT:

Name: Susanna Masters E-Mail: [email protected] Telephone: 020 3049 3216

AUTHOR CONTACT: Name: Charles Malcolm-Smith E-Mail: [email protected] Telephone: 020 7206 3246

NHS LEWISHAM CLINICAL COMMISSIONING GROUP

SUMMARY OF OUR COMMISSIONING STRATEGY 2013-18

CONTENTS

Introduction Page 2 Who We Are 3 Our Vision – Better Health, Best Care, Best Value 4 Commissioning Differently – ‘The Case for Change’ 7 Transforming Local Services – Strategic Priorities 12 Appendix 1 - Better Health – Key Health Outcomes 18 Appendix 2: Engagement Plan

19

1

INTRODUCTION

NHS Lewisham Clinical Commissioning Group was established on 1 April 2013 and is responsible for commissioning (planning, buying and monitoring) the majority of health services in Lewisham. We are a membership organisation made up of all the GP practices in Lewisham.

This is our five year commissioning strategy for 2014/15 to 2018/19. It is a framework for how we will work over the next five years and has been developed in the context of national requirements to improve health outcomes, significant service and financial challenges facing the NHS and the rising expectations of patients and the public. As a new organisation, clinically led and formed from the membership of all our GP practices it sets out our commitment to the people of Lewisham. The strategy sets out our purpose, vision, our understanding of the health needs of Lewisham residents and our ambitious plans to improve their health and wellbeing. It explains how we will use our available resources to ensure they receive high quality, safe health services which are good value for money. The strategy will shape our priorities and service improvement plans; help us develop our commissioning intentions and annual operating plans our over the next five years. It is informed by the experiences and views of our patients and the public, the Lewisham Joint Strategic Needs Assessment and the Lewisham Health and Wellbeing Strategy.

We have a good record of partnership working and the strong relationships with the local authority, health care providers, Health watch Lewisham, and voluntary and community organisations will continue to be critical to our success as we deliver these plans.

We will focus on local transformational plans to enable us to develop a sustainable local health service which meets local health needs and which will help us deliver our vision for the best health and best care for Lewisham residents

Dr Marc Rowland Martin Wilkinson

CCG Chair (Elect) Chief Officer

2

1. WHO WE ARE

Lewisham CCG took over full responsibility for planning and buying most of the healthcare services for Lewisham residents on 1st April 2013. These services include:

• Hospital care • Rehabilitation care • Urgent and emergency care • Most community health services • Mental health and learning disability services

Primary care services such as GPs, pharmacists, dentists and opticians and some other specialist services are commissioned by NHS England1.

Our aim is to secure the best possible health and care services for Lewisham residents in order to reduce health inequalities and improve health outcomes. We will do this by using findings about the health needs of our population2 to identify priorities and to make plans for how healthcare can be provided. We have contracts with a range of health service providers that includes NHS and private hospitals and voluntary sector organisations. We monitor how well the services are being delivered to ensure that they are meeting the needs of our patients, that they are safe and of high quality, and that they are providing value for money.

We are overseen by NHS England which makes sure that we have the capacity and capability to commission services successfully and to meet our financial responsibilities.

As a membership organisation, our GP member practices work closely in local or neighbourhood groupings, to discuss common problems that are arising, and to see how local services can be improved and co-ordinated better

The GPs in Lewisham have elected seven representatives, including the CCG Chair Dr Marc Rowland, to lead clinical commissioning in Lewisham. As well as spending time on commissioning, these GPs are still practising clinicians and they work closely with other doctors to share information about the services that people need.

They are members of the CCG’s Governing Body, along with two lay members, a nurse and a hospital doctor as well as two senior managers (the CCG’s Chief Officer and Finance Director). The Governing Body has responsibility for agreeing commissioning plans, ensuring public funds are spent correctly and for monitoring the quality and safety of services.

1 Visit www.england.nhs.uk for more information 2 JSNA http://www.lewishamjsna.org.uk/

3

http://www.england.nhs.uk/

http://www.lewishamjsna.org.uk/

2. OUR VISION – BETTER HEALTH, BEST CARE, BEST VALUE

This section describes the difference we aim to make through commissioning to meet the challenges we describe in section 3.

Our mission is visually represented as:

Working together with Lewisham people is at the centre of everything we do.

To improve the health outcomes for our local population by commissioning a wide range of support to help Lewisham people to keep fit and healthy and reduce preventable ill health

To ensure that all services commissioned are of high quality – in terms of being safe, positive patient experience and based on evidence and good practice

To commission services more efficiently, providing both good quality and value for money, by improving the way services are delivered, streamlining care pathways, integrating services

4

Our Ambition

We will determine our success in improving the health of Lewisham people through measures of life expectancy, rates of premature mortality from the three biggest causes of death in Lewisham (cancer, respiratory diseases and cardiovascular disease), infant mortality, patient experience and end of life care. See Appendix 1 for more detail.

We will determine our success by commissioning services differently, in partnership with other commissioners, to deliver high quality support and care which is:

• Proactive and planned, with a focus on early detection, diagnosis and intervention

• Patient centred, personalised to the individual’s preferences and choices and considers the whole person rather than specific health conditions

• Empowering to the individual to be confident in their management and decision making about their own care, as far as they want and are able to

• Developing local neighbourhoods and communities to help people and communities to manage their health and wellbeing by finding local solutions.

We will measure our success by operating within our commissioning budget and demonstrating that we have used the budget effectively, delivering value for money.

Better Health - the Five Year Vision

To reduce the gap in key health outcomes between Lewisham and England by 10% over the five year period

Best Care – the Commissioning Vision

High quality care for everyone

Best Value – the Financial Vision

To commissioning more effectively with the most efficient use of resources

5

The Quality, Innovation, Productivity and Prevention (QIPP) programme is the national initiative that aims to make the NHS work more efficiently so that there are more funds available for treating patients. Delivering a successful QIPP programme in Lewisham will be crucial to ensuring we are using our resources in the most efficient way to enable us to meet our vision for better health and best care.

6

3. COMMISSIONING DIFFERENTLY – ‘THE CASE FOR CHANGE’

This section explains why we need to work differently with you: the public, other commissioners and providers of care. The challenges outlined provide the ‘case for change’: why we need a new strategic vision to improve the way we commission services. No change will not deliver our vision for better health, best care and best value.

The Health Needs of Lewisham’s Population

In order to obtain information on the health and wellbeing of the people of Lewisham, we have referred to Lewisham’s Joint Strategic Needs Assessment (JSNA) (http://www.lewishamjsna.org.uk/) The JSNA brings together in one place a wealth of information on the health and social care needs of Lewisham’s citizens, complemented by information on the social, environmental and population trends that are likely to impact on people’s health and well-being. The JSNA also includes the community and patient view on local health and social care services.

Our six particular challenges are:

• Inequalities

While there are improvements in population health, there are still differences between different part of the borough, for instance life expectancy at birth is rising (now on average 76.6 years for men and 81.3 years for women) but for men in Lewisham Central and for women in Telegraph Hill it is significantly lower than the average. The same is true for all cause mortality rates which have been falling in Lewisham but in Lewisham Central is significantly higher than the Lewisham average.

• Population

The Lewisham population is projected to grow across all age groups over the next five years. For this period the largest percentage growth rate is in the 20-64 year old age group, and for the period 2013-28 the largest growth will be in the 65-90+ age group.

The increasing number of births expected to plateau towards the end of the decade.

• Cause of Death

Cancer is now the main cause of death (33% of deaths), followed by circulatory disease (26%), respiratory disease (13%) and dementia (10%).

7

http://www.lewishamjsna.org.uk/

• Health Promotion

More people smoke than the national average and reducing the number of people in Lewisham who smoke would make a major impact on the key causes of premature death.

• Long-Term Conditions

There will be increasing numbers of people who have long-term conditions and this will further increase with the ageing population, particularly the likelihood of having more than two conditions.

Lewisham’s black and minority ethnic communities are also at greater risk from health conditions such as diabetes, hypertension and stroke.

Dementia - with the increasing age of the population the number of dementia cases will rise; prevalence increases particularly in the population older than 65.

• Mental health

Prevalence of mental illness is high in Lewisham and there are inequalities within the borough: southern wards which are also deprived (such as Downham, Bellingham and Whitefoot) have higher needs for services than some other areas.

• Birth weight

The percentage of low birthweight babies falling but is still a significantly higher rate than the England average, though it is now comparable to London as a whole.

Health outcomes

Our aim is to improve health outcomes for all of the Lewisham population. Over the last 10 years health outcomes have got better for Lewisham people however compared to other similar London boroughs we have further room to improve. (NHS Commissioning Board Outcomes Benchmarking Support Packs: CCG Level 2012 and Lewisham Health Profile 2012 English Public Health Observatories).

A ‘long term condition’ is a health problem that cannot be cured but can be controlled by medicines or other treatments. Examples include diabetes, heart disease, chronic obstructive pulmonary disease (COPD), dementia, depression, and there are many more.

8

Public feedback

We have collected patient and public feedback from a number of sources, including questionnaires, the PALS service and complaints, and outreach events. A summary of the main messages is:

• The birthing unit at Lewisham is highly praised

• It is important to include patients and carers in care plans

• Older people can feel disengaged as they are seldom involved in decisions

• Access to primary care varies

• There are positive views of community pharmacy services

• Patients value A&E Service

• People would like to see care joined up

Provider landscape

All our health service providers, public, voluntary and privately owned organisations, are facing challenges to secure sustainable primary, community and acute services.

Health service providers face increasing demand because:

Health demand overall is increasing – rising rate of people with one or more long-term conditions and an ageing population

Public expectations - patients using services 24/7 and seeking treatment for minor conditions rather than healthy living and self management

Medical advances are helping people to live longer but, in line with this, more people can expect to live for some time with a care and support need. The NHS can now treat conditions that previously went undiagnosed or were simply untreatable.

Health services providers face increasing difficulty in providing/supplying services:

Increasing costs - the cost of providing care is getting more expensive. The NHS now provides a much more extensive and sophisticated range of treatments and procedures

Greater scrutiny and higher expectations of quality and governance standards. For example workforce standards - the impact of the European

9

Working Time Directive (EWTD) on the hours doctors work and staffing levels.

Limited financial resources to buy health services - the broad consensus is that for the next decade, the NHS can expect its budget to remain flat in real terms, or to increase with overall GDP growth at best. This represents a dramatic slow-down in spending growth for the NHS.

Locally primary care, community care and hospital providers are considering how they can work together differently to make their services more sustainable.

The outcomes of the Trust Special Administrator (TSA) review of the South London Healthcare NHS Trust will have a further impact on the organisation of local NHS organisations with the planned merger of Lewisham Hospital and the Queen Elizabeth Hospital in Greenwich. We are committed to working together with all local health providers, other commissioners and you, to identify and implement the best configuration of local hospital services which will deliver our strategic aims of ‘better health, best care and best value’ for Lewisham people.

Financial Context

We currently receive (2013/14) around £365m to commission most of the healthcare services in Lewisham which we allocate as follows:

If Lewisham CCG continues to commission in the same way as today it will result in the CCG facing a funding gap between projected spending requirements and resources available of around £34 million between 2014/15 and 2018/19 (approximately 9% of projected costs in 2018/19). This estimate is taking into account current expected

54%

17%

10%

3% 11%

5%

Acute services

Mental Health services

Community services

Continuing Care services

Primary Care services

Other

10

productivity improvements and assumes that the health budget will remain protected in real terms.

• CCG Expected Case

Based on the above assumptions, the expected financial position for the CCG would be an accumulative financial gap of £34m over 5 years. We will be doing further work during autumn 2013 to test and update our current financial assumptions, so that we can be more certain about our future financial position.

340

350

360

370

380

390

400

410

£ million

No change expenditure

Baseline Allocation

Accumulative gap £34million over 5 years

Conclusion – the case for change

The changing health needs of the Lewisham population will increase demand on services

We need to improve our health outcomes

We need to improve quality and accessibility of local services to all

The current configuration of health services is not likely to be sustainable

There will be gap in finances, between resources available and expenditure

More of the same will not address this challenge

This means working with our partners to do things differently

11

4. TRANSFORMING LOCAL SERVICES

This section describes the changes we plan to make to our commissioning to achieve our vision.

Our commissioning strategy does not sit alone, and we will be working in partnership with other South East London clinical commissioning groups and in particular as members of the Lewisham Health & Wellbeing Board to meet the health needs identified in the JSNA.

Priorities

We have identified eight strategic priorities that we will focus on to transform services:

Strategic Themes Strategic Priorities Healthy Lifestyles and Choice

1. Health and wellbeing – smoking cessation, alcohol abuse, obesity and cancer

2. Maternity and acute children Frail and Vulnerable People

3. Frail older people (including end of life care)

Long Term Conditions

4. Long Term Conditions – eg COPD, diabetes, CVD, dementia

5. Mental Health Deliver Services Differently

6. Primary care development and planned care

7. Urgent Care 8. Greater integration of health

and social care commissioning

Over the past eighteen months we have asked Lewisham people “what’s important about your health services”, and we have listened to what you told us. Your feedback helped us to set the priorities that will help us to meet our challenges that we have described in our case for change. We call this linkage our ‘golden thread’.

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Strategic Priorities Case for Change Summary Health promotion – smoking cessation, alcohol abuse, obesity and cancer

This provides long-term benefits in helping to address our health needs challenges such as the main causes of death (cancer, circulatory diseases, respiratory disease) and inequalities between different areas of Lewisham.

Maternity and acute children

We want to build on the positive public feedback about the maternity unit at Lewisham Hospital and to support the long-term sustainability of our local maternity providers. We also need to address the rates of low birthweight babies.

Frail older people (including end of life care)

Our health needs analysis has highlighted the increasing numbers of frail elderly people, while public feedback has identified that older people feel disengaged in their care.

Long Term Conditions – eg COPD, diabetes, CVD, dementia

Long term conditions and dementia rates are increasing and we need to ensure that our local services are able to manage this demand efficiently while providing high quality care which is inclusive of patients and carers in care planning

Mental Health There is a high prevalence of mental health need in Lewisham, and in this area too we have heard feedback about how important it is to include patients and carers in plans

Primary care development and planned care

The demands on these sectors are increasing with the increasing prevalence of long term conditions and dementia. Public feedback has highlighted that access to primary care varies and with a positive view of the contribution of pharmacies.

Urgent Care Patients value A&E services but providers need to work more effectively to manage demand and the pressures on their services.

Greater integration of health and social care commissioning

People would like to see care joined up. This will also be essential as our population develops more complex health needs and there is increasing pressure on our services.

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Strategic Aims

For each of our priorities we have identified the changes we will aim to implement.

1. Health and Wellbeing

Working with Health & Wellbeing Board partners to deliver the nine priorities of its strategy, with a particular focus on reducing smoking, alcohol abuse, obesity, and increase awareness, screening and early diagnosis of cancer.

2. Maternity and Acute Children

For maternity, our focus is to improve quality standards including caesarean rates, late booking of first antenatal assessment and low birth weight babies and to develop the team round the mother’ to enhance continuity of care, choice, and autonomy, to normalise the experience of childbirth. Also we will work to improve communication and partnership working between users and community service providers at a neighbourhood level and we will co-ordinate capacity planning for maternity services to manage demand effectively working collaboratively with SEL CCG’s, in the wider context of the planned merger of Lewisham Hospital and Queen Elizabeth Hospital in Greenwich.

For the under 5’s we will improve commissioning working with the Children's and Young People's Partnership Board to implement the Children and Young People’s Plan (see http://www.lewisham.gov.uk/myservices/socialcare/children/Documents/CYPP%202012-15FinalAug13.pdf).

3. Frail Older People (Including End of Life Care)

We will work with individuals, carers and local providers, including care homes to put in place improvements to identify frail older people so that we can make sure they are getting the care they need, to develop processes for joint care planning, and improve fall prevention by identifying those people at risk.

Specifically for care homes, we will ensure medical support and care provision to all nursing and residential care, and extra support for staff training.

4. Long-Term Conditions

Building on COPD, Heart Failure and Diabetes service redesign work, to develop further integrated care pathways and the provision of personalised care, using risk stratification tools to systematically identify people earlier with health issues, improving the patient’s and carer’s experience by changing the culture and behaviours so the patient is at the centre and is supported to take greater responsibilities, with the opportunity for a healthcare personalised budget we will develop and evaluate Intermediate Care

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http://www.lewisham.gov.uk/myservices/socialcare/children/Documents/CYPP%202012-15FinalAug13.pdf

http://www.lewisham.gov.uk/myservices/socialcare/children/Documents/CYPP%202012-15FinalAug13.pdf

facilities to reduce emergency admissions, ensuring effective discharge planning, and implement the local dementia strategy.

5. Mental Health

With Lewisham people, we will support mental wellbeing as part of holistic approach to supporting and caring for individuals. We will improve the early identification and access to appropriate interventions e.g. Improving Access to Psychological Therapies (IAPT) services. Strategically we will continue to move to community based case, so reducing the requirement for secondary care outpatients and inpatient admissions for both adults and older adults with mental health problems.

6. Primary Care Development and Planned Care

Working with primary care we will ensure high quality of care for all by levelling up standards and reducing variations between practices and care for specific communities, focused on access, prevention and early detection, use of technology in self-management, effective medicines management, and supporting the sustainability of local practices.

7. Urgent Care

Our overarching ambition is to ensure that the right care is delivered in the right place, at the right time to reduce the requirement for unplanned care, working with providers of urgent care. We will do this by developing clearer sign posting and information to help users to choose the right service and to support self management. Also we will review, with stakeholders, the current different ways Lewisham people access urgent care to develop and implement the most appropriate model(s) and configuration of A&E, Urgent Care Centre and Walk In Centre which will deliver accessible, quality and affordable urgent and emergency care in Lewisham within the context of the planned merger of Lewisham Hospital and Queen Elizabeth Hospital in Greenwich.

8. Greater Integration of Health and Social Care Commissioning

All of the above strategic priorities will be supported by an integrated delivery model for Lewisham that is based on the best available evidence on how we can transform the way health and social care services are delivered to have a positive impact on an individual’s experience, achieving better outcomes, including reducing inequalities and providing best value. It will use the following principles:

• It centres on the person as a whole

• It is a population-based whole system approach to commissioning

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• It facilitates the empowerment of patients and local communities

Our delivery model has been developed in partnership with the Health and Wellbeing Board and is based on four different levels of advice, support and care an individual may receive, recognising that each person’s health is unique and dynamic, so will need different levels of advice, support and care from a variety of services during their life time:

• Healthy, Independent Living for All – empowering and supporting individuals, families and communities to take action to make healthy lifestyle choices

• Early Intervention - identifying at an early stage when more support is required and providing fast and convenient access to high quality support and advice

• Targeted Intervention – identifying those specific high risk individuals who

would benefit from active intervention to avoid a potential crisis such as an inappropriate admission and re-admissions to hospital.

• Complex Care – coordinating and managing a complex health and social care package in a single care plan which is tailored around the needs of the individual, carer and the family with them at the heart and still in control - ‘nothing about me, without me’.

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Complex care

Targeted Intervention

Early Intervention

Healthy, Independent Living For All

Integration of health and social care commissioning

Social Care Primary &

Community Care

Hospital Care Urgent Care

Long Term Care:

- Long-term conditions (COPD, diabetes, CVD)

- Mental health

- Frail older people

CCG PRIORITIES

Healthy Choices:

- Maternity - Health promotion

DELIVERY MODEL

Provision

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Appendix 1 - Better Health – Key Health Outcomes

We will measure our success in improving the quality of services and health in Lewisham through the following outcomes:

Outcomes Measures Target 2018 Life Expectancy

Potential years of life lost from causes amenable to healthcare

To be confirmed

Life expectancy at birth Females 83.8 Males 79.8

Disability free life expectancy To be confirmed Causes of death

Under 75 mortality rate from cancer 104 deaths per 100,000

Under 75 mortality rate from cardiovascular disease

54 deaths per 100,000

Under 75 mortality rate from respiratory disease (bronchitis, emphysema and other COPD)

31.5 deaths per 100,000

Infant mortality Neonatal mortality and stillbirths (within 28 days)

To be confirmed

Patient experience People feeling supported to manage their condition

To be confirmed

End of life care Preferred place of death To be confirmed

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Appendix 2: Engagement Plan

Are we up for the challenge? Developing a local strategy for Lewisham 2013/14

Engaging on our priorities

2012 Our outreach programme in 2012 utilised the ‘Have Your Say’ patient survey – presenting outcomes across the borough; asking patients about what they do and don’t value in their health service. We attended a series of local meetings and engaged with GP Practice Patient Groups.

January 2013 Shaping Your Health Services On the 31st January 2013 over 50 Lewisham patients, members of the public, carers and local councillors filled the Lewisham Town Hall Civic Suite. The engagement event was to enable discussions on the Lewisham Clinical Commissioning Groups (LCCG) Strategic Priorities to improve services and patients health. • Complete the engagement cycle by ensuring that the CCG

feedback to patients: ‘You Said We Did’ • Confirmed that patients were happy with the priorities • Considering good practice, expectations and barriers what

patients thought of our plans

Developing a local strategy for Lewisham

July Lewisham Peoples Day Launch

Our strategy was launched at Lewisham Peoples Day on Saturday 13th July. Local people where encouraged to comment on the strategy and priorities using questionnaires. LCCG engaged with 120 residents and 73 completed the questionnaires.

September /October

In the September the CCG will be widening its engagement on the strategy. Our programme will be launched via our website. It will incorporate the NHS England ‘A call to action’ national programme launched on 11th July 2013.

• On-line survey/s and social media: Residents will be able to follow and be involved in the debate using Twitter and in addition to completing an on-line survey.

• CCG membership: Engaging with our members at the Membership Forum (11.09.13) and Neighbourhood meetings (13.09.13, 19.09.13, 26.09.13 and 02.10.13)

• Working with local groups: We will be taking our strategy out to a number of local groups including the Pensioners Day Event (18.09.13) and Artful Dodgers (08.10.13).

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• GP Practice Patient Groups (PPGs): We will be developing an outreach programme with partners to engage with our PPGs ensuring that patient views and experiences are captured.

• Talking to our stakeholders: Healthier Communities Select Committee (LCCG Public Engagement Group (20.09.13), Health & Well Being Board (19.09.13) and Local Medical Council (18.09.13).

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Are we up for the challenge?

Developing a local strategy for Lewisham

1

DRAFT

1. Our Vision 2. The case for change 3. Our priorities 4. Our ‘Call to Action’ in Lewisham Slide 1

Better Health: Improving health outcomes for Lewisham people

Although things have been getting better in Lewisham, there still needs to be improvements. These are some of the challenges we have to meet:

Inequalities While there are improvements in Lewisham’s health, there are still differences between different parts of the borough. Many people live alone, have low incomes and live in poor housing.

Cause of Death The main causes of death are cancer circulatory disease, and respiratory disease; rates have been falling in Lewisham but they are still worse than the national average.

Long term conditions More people are living with long term conditions and this will increase with an ageing population, particularly the likelihood of having more than two conditions. As people get older they are more likely to have complex health problems.

Mental Health Rates of mental illness are high with some areas of Lewisham having a higher need for services than others. Cases of dementia will rise due to the ageing population, especially in those over 65.

Slide 3

We asked local people about the care they receive from Lewisham health services and what could be improved.

Best Care – What are our challenges?

Getting the basics right Make sure that everyone has the same good access to primary care services.

Integration More care needs to be joined up.

Involved in their care Patients and carers need to be involved in care plans, particularly older people who are seldom involved in making decisions about their care.

Affordability There is praise for the Lewisham Hospital birthing unit and A&E services. We will need to do things differently to make local services affordable.

Slide 4

Best Value – Our Financial Challenge Demand for health services are rising. People are living longer and there are new and expensive treatments being developed. We need to make sure that we get the best value for the money we have available to spend on local health services. This means that we have to make some tough decisions about the way in which we spend money.

Slide 5

340

350

360

370

380

390

400

410

£ million

No change expenditure

Baseline Allocation

Accumulative gap £34million over 5 years

Best Value – How far does our money go?

£1000 will buy us…. 31 appointments with a GP Between 3 and 14 A&E attendances 3.5 first outpatient appointment - diabetes 4.5 first outpatient appointment - cardiology Slide 6

Why is change necessary?

Why do we need to do things differently? To improve health for Lewisham people: reducing reduce reduce inequalities, so everyone can live healthier, happier lives To ensure high quality and safe care, accessible to all Financial pressures – we need to spend every pound wisely.

We call this our ‘case for change’

Slide 7

Our Strategic Priorities Over the past eighteen months we have asked Lewisham people “what’s important about your health services?”, and we have listened to what you told us. Your feedback helped us to set these priorities that will help us to meet our challenges. There is more information on how we plan to deliver these priorities in our strategy.

Strategic Themes Strategic Priorities Healthy Lifestyles and Choice

Health and wellbeing – smoking cessation, alcohol abuse, obesity and cancer

Maternity and acute children Frail and Vulnerable People Frail older people (including end of life care)

Long Term Conditions

Long Term Conditions – eg COPD, diabetes, CVD, dementia

Mental Health

Deliver Services Differently

Primary care development and planned care

Urgent Care Greater integration of health and social care commissioning

Slide 8

Are you up for the challenge? We are. Our strategy sets out ideas for doing things differently because we believe that to make sure NHS services for Lewisham people provide best care, better health, best value we need to think and work differently together. The NHS ‘Call to Action’ sets out how the NHS needs to change to meet the challenges ahead. The more people who share their views and ideas on the future of the NHS, the better the service will become. We need your help to make sure we have our plans right. So our question is “are you up for the challenge of helping us to do things differently?” Slide 9

What needs to change? We believe there are three areas we need to work together with you, the Lewisham Health & Wellbeing Board and our healthcare providers to transform: •Getting the basics right every time •Supporting you to manage your health •Ensuring health and social care services work together as one

Slide 10

ONE: Getting the basics right every time Big ideas do not mean anything if we are not getting the basics right. We want to hear from you to make sure you are treated well, given clear advice and feel involved in your care. Our basics are: Patients should receive the best care. Our services must be high quality, safe and based on evidence of best practice Focus on prevention and early detection of ill health Information about health services needs to be clear and easily available Primary care and community services must be excellent and accessible. We would like to hear your experiences of using local health services. Our Questions Do we need to include anything else? Are we getting the basics right at the moment? Slide 11

Why is no one telling me what is

happening? I have been waiting a long

time.

I need to see a doctor today, but

can’t get an appointment at my

practice

What are you doing to stop

hospital infections like MRSA?

How long should I wait to be referred to the specialist?

Slide 12

Getting the basics right

TWO: Supporting you to stay well We believe the NHS is a health service, not just an ‘illness’ service, and to make this work we need to do things differently so we better support you to stay well and care for your loved ones. Patients should work together with care providers to help them stay well: ‘No decision about me without me’ People are more likely to stay well when they are supported by friends, family or their local community. Isolated people are more at risk of ill health We want people to feel able and supported to make healthier lifestyle choices and to look after their care. Our Questions How can we support you to stay well? What makes it difficult to stay well, and what can we do differently?

“Please recognise that you can make a significant contribution to your own, and your family’s, good health and wellbeing, and take personal responsibility for it”. NHS Constitution

Slide 13

How can I help my husband to stop

smoking?

I’d like to know more about support

for losing weight

I feel unwell but could my

pharmacist help me rather than

going to my GP?

Where can I get advice about living

well with diabetes?

Slide 14

Supporting you to stay well

THREE: Ensuring health and social care services work together as one As a partner on the Lewisham Health & Wellbeing Board, we are committed to making more local services ‘joined up’. We plan to do this in the following ways: Our Questions How can health and social care services work better together? What do we need to do differently so that people receive joined up care? Slide 15

• Services need to work together to meet the needs of every individual •Each patient will get the best possible care for them. Integrated Care

•Making sure the health needs of each patient are considered altogether when planning care rather than treating their individual conditions.

Whole Person Care

•People who are frail or have complex health needs have a named key worker who makes sure they have clear care plans and co-ordinates their care between different providers

Key workers

I’m sure someone should be visiting

Dad today, but how can I check?

Why do I have so many different

appointments at the hospital?

Why doesn’t my social worker

know how often the district nurse

visits?

Which number do I call to find out when my next blood test is?

Slide 16

Joined up care


ENCLOSURE 11

Lewisham CCG’s Commissioning Intentions 2014/15 and 2015/16

CLINICAL LEAD: Dr David Abraham MANAGERIAL LEAD: Susanna Masters

Post: Senior Clinical Director Post: Corporate Director

AUTHOR: Susanna Masters Post Corporate Director


• Agree the process and timetable for the completion of the CCG’sCommissioning Intentions;

• Note the indicative financial parameters which are being assumed for QualityInnovation, Productivity and Prevention (QIPP) schemes for 2014/15 and2015/16.

SUMMARY: This report summarises:

• Purpose of Commissioning Intentions• Proposed process for developing Lewisham’s Commissioning Intentions;• Financial context for the CCG’s Commissioning Intentions and the assumptions for

QIPP schemes for 2014/15 and 2015/16;• Draft timetable to complete the Commissioning Intentions and agree contracts.

KEY ISSUES:

1. Purpose of the CCG’s Commissioning Intentions

Commissioning Intentions are developed and published on an annual basis by commissioners to set out their intended plans for the forthcoming year(s). The Commissioning Intentions are a formal statement about the proposed Operating Plan’s priorities and proposals to improve and change the commissioning of local services, to achieve the CCG’s strategic objectives, which Members, the public and stakeholders can discuss and develop further before the next year’s contracts are agreed by 31st March 2014.

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Also the Commissioning Intentions process includes giving formal six months notice to individual providers of significant contractual changes for the following financial year – as required by the Terms and Conditions of the National Contract. Appendix 1 provides a summary of the standard content of an organisation’s Commissioning Intentions, as an example.

2. Proposed process for Lewisham CCG’s Commissioning Intentions

The proposed stages to develop the Commissioning Intentions and take forward contract negotiations are summarised in the table below with a detailed timetable given at Appendix 2:

Table 1 - Key Stages

Lewisham CCG’s Commissioning Intentions and Contract Agreement – Key Stages

Stage 1 – develop wider commissioning context for Commissioning Intentions – July – September 2013;

Stage 2 - develop draft high level Commissioning Intentions – by September;

Stage 3 - refine and finalise Commissioning Intentions informed by the Members, Public and other key stakeholders – by beginning of October 2013;

Stage 4 - develop high level Quality, Innovation, Productivity and Preventative (QIPP) Implementation Plans – by end November 2013;

Stage 5 – agree Contract Negotiation Strategy agreed for each Provider – by December 2013;

Stage 6 – agree financial envelopes agreed for each Provider – including QIPP and impact of contract levers – December 2013

Stage 7 – undertake Contract Negotiation – during January - March 2014;

Stage 8 – final agreement of 2014/15 contract – by 31st March 2014.

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Stage 1 – Develop wider commissioning context for Commissioning Intentions

The Commissioning Intentions are set within the wider commissioning context of: • The NHS Mandate for 2013/14 and 2014/15, which is expected to be updated in the

Autumn 2013; • The Health and Wellbeing Strategy and the draft Delivery Plan to achieve the nine

strategic priorities, which has been developed by the Health and Wellbeing Board partners. This has been informed by the Joint Strategic Needs assessment (JSNA);

• The CCG’s draft Strategic Plan’s strategic objectives and priorities which has been developed to reflect the CCG’s specific commissioning responsibilities and incorporated feedback from Members and the public;

• The South East London’s Community Based Care strategy developed in collaboration with the other five CCGs in south east London;

• The conclusions of the Trust Special Administrator’s(TSA) recommendations as they relate to the South London Healthcare Trust and the implications for local services with the planned merger of Lewisham Healthcare Trust with Queen Elizabeth Hospital, Greenwich;

• Intelligence from local clinicians and in year contract monitoring and our Clinical Quality Review Groups (CQRGs).

• Feedback from Public identifying what matters most to Lewisham people and how the CCG plans to change the commissioning of services in response.

Stage 2 - Develop draft high level Commissioning Intentions

The high level CCG’s Commissioning Intentions are being developed focusing on the following eight strategic priorities to transform local services:

Table 2 - Strategic Commissioning Priorities

Strategic Commissioning Priorities

1. Health Promotion - to contribute to the achievement of the Health and Wellbeing Board’s strategic priorities.

2. Maternity and acute children - to improve clinical standards and health outcomes and to pilot the ’team around the mother’.

3. Frail older people – to improve care provided specifically end of life care, falls prevention and in local care homes.

4. Long Term Conditions - to develop integrated care pathways

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including for Diabetes, COPD, CVD, Stroke and dementia.

5. Mental Health – to support mental wellbeing and shift more care to be provided in the community.

6. Primary care development and planned care – to improve the quality and planned accessibility for all.

7. Urgent Care - to ensure that the right care is delivered in the right place, at the right time by commissioning the best network of urgent care providers.

8. Greater integration of health and social care commissioning – to support the delivery of all the above strategic priorities by providing different levels of advice, support and care from a variety of health and social care services to support independence and healthy choices for all.

The draft high level Commissioning Intentions will be presented to the Governing Body’s seminar on 5th September highlighting the CCG’s key actions being proposed and the associated potential benefits and risks. Further details of the draft high level Commissioning Intentions can be found at Appendix 3.

Stage 3 - Refine and finalise Commissioning Intentions informed by the Members, the Public and other key stakeholders – by beginning of October

During September the CGG will review further its high level Commissioning Intentions to prioritise those objectives and actions which are planned to have the most significant impact on delivering the CCG’s strategic objectives – Better Health, Best Care, Best Value. At this stage it will be important that the CCG maximises the potential opportunities of the collaborative commissioning arrangements with other CCGs in South East London as part of the Community Based Care Strategy, with Lewisham Council and the wider Integration of health and social care and with NHS England in developing Primary Care and specialised services.

This work will be informed by the wider engagement exercise being undertaken during September and October, which incorporates the NHS England ‘A call to action’ national programme launched on 11th July 2013. The CCG’s engagement exercise will use a number of different ways to encourage the CCG’s Members, public and stakeholders to engage including:

• On-line survey/s and social media: Residents will be able to follow and be involved in the debate using Twitter and in addition to completing an on-line survey.

• Members – We will arrange for a dedicated agenda item at the forthcoming meetings to discuss 4

the draft Strategy and draft Commissioning Intentions - Membership Forum (11.09.13) and Neighbourhood meetings (13.09.13, 19.09.13, 26.09.13 and 02.10.13);

• Working with local groups: We will be taking our strategy out to a number of local groups including the Pensioners Day Event (18.09.13) and Artful Dodgers (08.10.13).

• GP Practice Patient Groups (PPGs): We will be developing an outreach programme with partners to engage with our PPGs ensuring that patient views and experiences are captured.

• Talking to our stakeholders: Healthier Communities Select Committee (LCCG Public Engagement Group (20.09.13), Health & Well Being Board (19.09.13) and Local Medical Council (18.09.13).

This stage will result in final agreed commissioning intentions being signed off by the CCG’s Governing Body.

Stage 4 - Develop high level QIPP Implementation Plans – by end November 2013

It is proposed that the high level QIPP implementation plans are based on the following financial planning assumptions for 2014/15 and 2015/16, as summarised in the following two tables below:

Table 3 – Financial Assumptions

Assumption 201415 201516

Allocation Uplift 2% 2%

Tariff Deflator (1.2%) (1.2%)

Demographic Growth 0.8% 1.5%

Non Demographic Growth

2% 2%

Prescribing Uplift 4% 4%

Planned Surplus 2% 2%

Integration Transformation Fund

(0.3%) (3.1%)

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Table 4 - Forecast Financial Position 2014/15 – 2015/16

201415 201516

Pre QIPP Expenditure 380,232 369,875

Total Allocation 366,554 359,547

QIPP Requirement (13,678) (10,328)

So in conclusion, the above forecast position for 2014/15 – 2015/16 identifies that a QIPP target of about £24 million will be required over the two years period. At this stage this is an estimate for planning purposes, but it assumes that:

• specialist transfers are cost neutral; • 2013/14 QIPP of £12.1m is delivered in full; • There is no contract over performance; • Excludes the impact of the Integration Transformation Fund in 2015/2016.

Consequently, the final QIPP requirement will change. Based on bench marking information and financial modelling, the following indicative QIPP targets are proposed for two year Commissioning Intentions by strategic priority area:

Table 5 - Draft QIPP Net Requirements

Strategic Priority Draft QIPP Net Requirements2014/15-2015/16

1. Health and wellbeing 2. Maternity and acute children £0.8m (working within the NHS tariff) 3. Frail older people (including

end of life care)

4. Long Term Conditions £4.0m - £5.0m (reducing emergency admissions)

5. Mental Health /client groups £2.0m 6. Primary care development– £5.0m - £6.0m (reducing out patients

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planned care work) £2.0m – £4.0m (reducing expenditure on prescribing)

7. Urgent Care £0.6m (reducing A&E attendances) 8. Greater integration of health

and social care £4.0m - £7.5m (more effective whole system working)

TOTAL

£18.4m - £25.9m

Stages 5 - Contract Negotiation Strategy agreed for each provider The Delivery Committee will be responsible for developing and agreeing the contract negotiation strategy for each provider working with joint Commissioners, other CCG’s, specifically Greenwich CCG, South London CSU and NHS England for primary care commissioning. The high level contract negotiation strategy will be signed off by the Governing Body on 5th December in Part II of its meeting. Stage 6 - Financial envelopes agreed for each provider Financial envelopes will be agreed for each Provider by the Delivery Committee (through the Finance and Risk Group) to including QIPP requirements and impact of contract levers (eg CQUINs) Stage 7 - Contract Negotiation – during January, February and March 2014; The responsibility for contract negotiation of individual contract will be lead by small contracting teams and overseen by the Delivery Committee who will receive regular monthly reports on progress during January, February and March. Stage 8 - 2014/15 Contract Agreement with the signing of the contact 2014/15 contracts should be agreed and signed by 31st March 2014.

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Appendices Appendix 1 - An example of the contents of an organisations Commissioning Intention’s Appendix 2 - Commissioning Cycle 2014-15 – key dates Appendix 3 - Draft High Level Commissioning Intentions by Strategic Priority

CORPORATE AND STRATEGIC OBJECTIVES Corporate Objective number 2 - Commissioning Intentions - To develop and consult on 2014/15 Commissioning Intentions

CONSULTATION HISTORY: Members of the Governing Body, Public Health and providers have participated in workshops to develop the draft strategic plans and shape the proposed models of care, upon which the Commissioning Intentions are based. Strategy and Development Committee (1st August ) - agreed the financial parameters for the Commissioning Intentions and the approach and timetable for the completion of the CCG’s Commissioning Intentions. Commissioning Cycle workshop (1st August) - included discussion of greater involvement of Governing Body in setting direction and priorities so an additional Governing Body workshop has been arranged for the 5th September 2013.

PUBLIC ENGAGEMENT The CCG’s Commissioning Intentions is the translating of the CCG’s Draft Strategic Plan’s ambitions, priorities and financial challenges into a commissioning Operating Plan for the first two years. A public engagement exercise is currently underway of the CCG’s Draft Strategic Plan during August - October 2013.




PUBLIC SECTOR EQUALITY DUTY How does this report take into account the duty to:

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• Eliminate discrimination, harassment and victimisation and any other conduct that is

prohibited under the Equality Act 2010 • Advance equality of opportunity between people who share a relevant protected

characteristic and people who do not share it • Foster good relations between people who share a relevant protected characteristic

and those who do not share it

An Equalities Impact Assessment is being undertaken of the draft Strategic Plan.

Each Strategic Commissioning Group will be asked to assess the impact of its proposed investment and disinvestment plans on reducing inequalities and promoting equal opportunity between people who share a relevant protected characteristic and people who do not share it

RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Susanna Masters E-Mail: [email protected] Telephone: 020 3049 3216

AUTHOR CONTACT: Name: Susanna Masters E-Mail: [email protected] Telephone: 020 3049 3216

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APPENDIX 1

An example of the contents of an organisations Commissioning Intention’s The Commissioning Intentions usually includes the following sections: The overall strategic context – objectives, ambition (desired outcomes) and priorities - based on the Draft Strategic Plan;

NHS Mandate requirements – with local responses to the national requirements supported by local delivery plans;

Quality standards – including national and specific local quality requirements. For example implementation of the local action plan responding to the Francis report and recommendations;

Intelligence from local clinicians on areas identified to require improvement;

Feedback from Public identifying what matters most to Lewisham people and how the CCG plans to change the commissioning of services in response;

Notification of new/revised Service Specifications - for key service areas which includes models of care, integrated care pathways, locally developed clinical protocols, key quality and performance standards. For example for maternity and unplanned care services;

Planned service improvement and changes - including high level proposals to invest and disinvest to achieve improvements in Quality, Innovation, Productivity and Prevention (QIPP Plans) These QIPP plans will require the approval of a business case, at a later stage of the commissioning cycle, before the investment proposals are approved.

Procurement Approach – determining the most appropriate procurement approach to achieve the commissioning objectives as there are many different procurement tools available to CCG. For example:

• Formal Tendering/opportunities for new /existing providers; • Any Qualified Provider (AQP) approach; • Decommission/termination of contracts; • Service Developments; • Piloting of schemes; • Enhancing current service contracts.

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Contractual Implications for Individual providers – identifying contractual changes to specific providers. For Example

• Changes in Contract Terms – eg requirement for information sharing; • Changes in contract arrangements – eg risk sharing arrangements; • Changes in contract levers – ie incentives and disincentives; • Changes in contract volumes – informed by TSA as required; • Changes in quality and/or performance standards; • Changes in monitoring arrangements.

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APPENDIX 2

Commissioning Cycle 2014-15 – key dates

Commissioning Cycle Activity Responsible Governing Group

Specific Meeting in 2013/14

PLANNING Previous years contracting round - to review overall outcomes, residual risks and lessons learnt to inform 2014/15 Contracting Round

Delivery Committee – to review outcome of 2013/14 contract negotiation

20th June

Contract Monitoring – integrated contract monitoring undertaken quality, finance, activity and performance- bi-monthly

Delivery Committee – to oversee contract monitoring with exception reporting to the Governing Body.

May, July, Sept, Nov, Jan, March

Update Strategic Plan - with refreshed outcomes framework ,revised population assessment, updated financial assumptions; modelling; provider landscape changes; sensitivity analysis - during April – June

Strategy and Development Committee - to oversee the preparation of the Strategic Plan

Governing Body Workshop 6th June and 27th June

Finalise Draft Strategic Plan Governing Body – to sign off draft Strategic plan

4th July

Preparing Commissioning Intentions – including contractual levers framework, assumptions by Providers –during June – August

Strategy and Development Committee - to agree the process to prepare the Commissioning Intentions

workshop and Committee meeting 1st August;

Stakeholder Engagement Exercise - testing the strategic plan and its priorities with all key stakeholders through a series of events and meetings – during July and August

Public Engagement implementation of the engagement plan working with partners

September

Stakeholder Engagement Exercise Feedback – to receive feedback on key themes and proposed changes to Strategic Plan and Commissioning Intentions taken as result

Governing Body – to endorse a summary of agreed to changes to Draft Strategic Plan and Commissioning Intentions to formally sign

5th September

Commissioning Intentions – letter sent to each Provider

Strategy and Development Committee - to oversee the sending out of the Commissioning Intentions

30th September

Finalise Strategic Plan and Commissioning Intentions

Governing Body – to sign off 3rd October

AGREEING QIPP Implementation Plans – detailed activity and financial assumptions including overall contractual levers framework signed off for each key provider, during October –

Strategy and Development Committee - to oversee the completion of high level QIPP plans for 2014/15; Governing Body – to sign off

7th November 5th December

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November high level QIPP Plans Contract Negotiation Strategy - agreed for each Provider

Delivery Committee /Governing Body– to sign off high level contract negotiation strategy in Part 2 on 5th December

5th December (GB) 19th December (Delivery)

Financial envelopes agreed for each Provider – including QIPP and impact of contract levers

Delivery Committee (through the Finance and Risk Group) – to sign off financial envelopes within the parameters of agreed QIPP plans.

16th January

Contract Negotiation –on progress on signing contract

Delivery Committee – to monitor contract negotiation escalation to Governing Body if outside the Contract Strategy parameters supported by regular lead clinician/manager meetings/telephone conference calls with CSU

16th January 20th February 20th March

2014/15 Contract Agreement Chief Officer signs the agreed contract

31st March 2014

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APPENDIX 3 Draft High Level Commissioning Intentions by Strategic Priority

1. Health Promotion - to contribute to the delivery of the Health and Wellbeing Board’s nine priorities with a particular focus on reducing smoking, alcohol abuse, obesity and increase cancer awareness, screening and early diagnosis.

2. Maternity and Acute Children –to improve clinical standards and health outcomes across all local maternity units, working with other SEL commissioners The key draft commissioning plans include: • Integrate community maternity services at a neighbourhood level with a named

midwife to support women to navigate the choice of care they require; • Pilot the “team around the mother’ for ante-natal, birth and post-natal care, to evaluate

the operational feasibility of model eg clinical governance, workforce issues, payment and the value for money ;

• Co-ordinate capacity planning for maternity services to manage demand effectively working collaboratively with SEL CCG’s, in the wider context of the TSA;

• Improve quality standards including caesarean rates, late booking of first antenatal assessment; low birth weight babies;

• Acute Children’s services - review provision for unplanned care and care pathways for specific issues such as sickle cell, working with NHS England.

3. Frail Older People (Including End of Life Care) - our aim is to support frail older people in Lewisham to live a longer and fulfilled life, with care and support that is delivered with courtesy, compassion and respect for their autonomy, privacy, sense of self-worth and dignity. This will involve working with individuals, carers and local providers, including care homes, to put in place: • A way to identify frail older people so that we can make sure they are getting the care

they need. • Develop joint care plans with involvement of patient and/or family following an

assessment of their health and social care needs with specialist advice from geriatrician and medicines management, where appropriate. The care plan would set out plans to reduce potential risks, such as falls, pressure ulcers etc and reviews medications

• Implement a plan to prevent falls by identifying those people at risk. • Ensure that all care homes receive appropriate medical support

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• Provide support to residential and nursing homes to ensure staff are trained to meet the special needs of frail and vulnerable older people (safeguarding, medicines management, infection control, falls, pressure ulcers, UTI, continuing care, end of life care etc.) Early identification and assessment of those residential placed patients who care needs are changing and will require more intensive nursing care;

• Refresh implementation plan for the End of Life Care commissioning strategy, in light of national guidance on the Liverpool care pathway; to deliver transformational care across the whole care pathway.

• Implement the Carers’ commissioning strategy

4. Long-Term Conditions - to develop further integrated care pathways and the provision of personalised care, building on the successful COPD service redesign model by: • Systematically identifying people earlier with health issues (risk stratification) and

proactively supporting them with appropriate care planning and /or case management;

• Promote healthy life styles to reduce an individual’s’ risk profile;

• Changing the culture and behaviours to create a different relationship with the patient where the patient is at the centre and is supported to take greater responsibilities in improving their own health and making decisions which reflect their own preferences, so improving the patient’s and carer’s experience;

• Developing and evaluating Intermediate Care facilities – admission avoidance; rapid response team; rapid assessment unit (step up), and ‘step down’ care – reducing emergency admissions , particularly ‘ambulatory sensitive care conditions’;

• Ensuring effective discharge planning - reducing emergency readmissions; • Implementing the local dementia strategy.

5. Mental Health :

• Support mental wellbeing as part of holistic approach for adults and childrens

individuals; • Increase early identification and speedy access to appropriate interventions e.g.

Improving Access to Psychological Therapies (IAPT) services; • Shift to community based case and so reduce the requirement for secondary care

outpatients and inpatient admissions for both adults and older adults with mental health problem;

• Improve admissions route to and discharge planning and after care support.

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6. Primary Care improvement and planned care – to develop plans to support primary care to improve: • Access to planned care and urgent advice and support the development of different

ways of working to manage demand and improve access e.g. Proactive Primary Care; • Quality of care for all by reducing variation between practices and care for specific

communities; • Shift to appropriate level of planned care - implementing the outpatient strategy,

reviewing how diagnostic services can be more effectively used, including GP Direct Access reducing hospital based care ;

• Prevention and early identification - supported by Public Health; • Self-management - facilitated by the utilisation of new technologies eg Telehealth; • Infrastructure for primary care – by supporting new systems; workforce capacity and

capability development, for example the roles and responsibilities of practice nurses. • Sustainability of local practices by exploring with primary care providers different

business models. • Medicines Management- improving community pharmacy access , specifically to

widen access to minor conditions; • Medicine optimisation – develop pharmaceutical care plans using a medicine

optimisation team.

This will require close working with NHS England, Public Health England, London Borough of Lewisham Public Health and other South East London CCGs.

7. Urgent Care – our overarching ambition is to ensure that the right care is delivered in the right place, at the right time to reduce the requirement for unplanned care, working with providers of urgent care to ensure: • Simple, equitable access to advice, support and care 24/7 by developing a managed,

integrated network of providers; • Clear sign posting and information to help users to choose the right service and to

support self-help and reduce unplanned care; • High quality of care by ensuring consistent quality of care and by sharing of

information and shared records; • Effective utilisation of different models of unplanned care - review roles of A&E, UCC

and New Cross Walk In Centre; • Alternative care pathways for emergency cases working with LAS.

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8. Greater Integration of health (primary, community and secondary care) and adultsocial care commissioning - by implementing the Lewisham’s integrated delivery modelwhich is based on providing advice, support and care to an individual, recognising thateach person’s health is unique and dynamic, so will need different levels of advice,support and care from a variety of services during their life time . The delivery of thispriority is represented by a pyramid with four levels of advice, support and care - seeAppendix 2• Healthy, Independent Living for All – empowering and supporting individuals,

families and communities to take action to make healthy lifestyle choices and toengage in activities that maintain and improve their physical and mental well-beingand to maintain their independence, by providing relevant advice and assistance onissues such as not smoking, eating healthily, drinking less alcohol and exercisingmore;

• Early Intervention - identifying at an early stage when more support is required andproviding fast and convenient access to high quality support and advice. For example,when an individual or family is finding it less easy to manage alone without additionalassistance, such that a little bit of help now will prevent more work later;

• Targeted Intervention – identifying those specific high risk individuals who wouldbenefit from active intervention and management of their care to avoid a potentialcrisis such as an inappropriate admission and re-admissions to hospital. The aim is tomitigate risk through proactive intervention;

• Complex Care – coordinating and managing a complex health and social carepackage in a single care plan which is tailored around the needs of the individual,carer and the family with them at the heart and still in control - ‘nothing about me,without me’. For example, the care package to support a person choosing to die athome. Often it is these complex cases that fall through the cracks of a non-integratedcare system.

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A meeting of the Governing Body 5 September 2013

ENCLOSURE 12 Arrangements for Governing Body Part I and Part II meetings

CLINICAL LEAD: Dr Marc Rowland MANAGERIAL LEAD: Susanna Masters

Chair Corporate Director

AUTHOR: Lesley Aitken Corporate Services Manager

RECOMMENDATIONS: The Governing Body is requested to consider and endorse the recommendations that:

• The vast majority of business conducted by NHS Lewisham Clinical CommissioningGroup Governing Body continues to be undertaken in public in Part I of the GoverningBody meeting with only business that is deemed confidential in Part II, as defined byDepartment of Health legislation;

• Only voting Governing Body members attend Part II of the Governing Body meetingwith non-voting members and officers invited when requested.

SUMMARY: 1. Background

The Corporate Governance Directorate was asked to clarify the arrangements andattendance for the Governing Body’s Part II meeting, as part of the wider review ofgovernance arrangements, to ensure that the CCG continues to reflect the principles ofgood governance.

This report provides a summary of the CCG’s Constitutional requirements and nationalguidance on public meetings and considers different potential options for the attendanceat the Governing Body’s Part II meetings.

KEY ISSUES:

1. Lewisham CCG’s ConstitutionNHS Lewisham Clinical Commissioning Group‘s constitution sets out that the following posts are voting members of the Governing Body:

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• Chair • Senior Clinical Directors x 2 • Clinical Directors x 4 • Lay Member with the lead for Audit – Vice Chair • Lay Member with the lead for Patient and Public Participation • Registered Nurse • Secondary Care Doctor • Chief Officer • Chief Finance Officer

NHS Lewisham Clinical Commissioning Group‘s constitution states that in addition to the voting members the following appointments on an advisory (non-voting) capacity will be invited to join the Governing Body meetings:

• Local Medical Committee • Public Health • Local Authority • Healthwatch

NHS Lewisham Clinical Commissioning Group‘s constitution states that : ‘Meetings of the Governing Body shall be in public unless the CCG considers that it is not within the public interest to permit members of the public to attend a meeting or part of a meeting (for example to prevent disruption, to discuss a confidential matter or where publicity would be prejudicial to the public interest), in which case the Chair of the meeting shall request that the public be excluded for the relevant part of the meeting and members of the meeting shall be required not to disclose confidential contents of papers or minutes.’ 2. National Guidance on Public and Private meetings To date there has been no written directive on who from the Governing Body membership should attend Part II of the Governing Body meetings. The Nolan principles on openness state that ‘holders of public office should be as open as possible about all the decisions and action that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands’. – Appendix 1 Department of Health legislation on admission of the public to meetings of public organisations http://www.legislation.gov.uk/ukpga/Eliz2/8-9/67/section/1 states: 1.1.1. The public and representatives of the press may attend all public meetings of the

Board and are invited to ask questions of the Board at the designated time on the agenda, in relation to matters on the agenda and at the discretion of the

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http://www.legislation.gov.uk/ukpga/Eliz2/8-9/67/section/1

Chair. The public shall be required to withdraw upon the Board resolving as follows: 'that representatives of the press, and other members of the public, be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest', (Section 1 (2), Public Bodies (Admission to Meetings) Act 1960).

1.1.2. Information and discussion of a confidential nature includes: (a) information relating to a patient, unless it can be anonymised; (b) information relating to an employee or office holder, former employee or applicant for any post or office; (c) the terms of, or expenditure under, a tender or contract for the purchase or supply of goods or services or the acquisition or disposal of property; (d) negotiations or consultation concerning labour relations between the group and its employees; (d) any issue relating to legal proceedings which are being contemplated or instituted by or against the group; (e) action being taken to prevent or detect crime or to prosecute offenders; (f) the source of information given to the group in confidence; or (g) any other matter which, in the opinion of the Chair, is confidential or the public disclosure of which would prejudice the effective discharge of the group’s functions.

3. Potential Options for Part II Meetings The potential options for attendance at the Governing Body’s Part II meeting are either:

a. All voting and non- voting Governing Body members to attend Part II of the Governing Body meeting;

or b. Only voting Governing Body members to attend Part II of the meeting with non-voting

members and officers invited when requested Given the general principles of good governance, as summarised in the Nolan Principles (see Appendix 1), it is recommended that the vast majority of business conducted by NHS Lewisham Clinical Commissioning Group Governing Body continues to be conducted in public in Part I of the Governing Body meeting, with only business that was deemed confidential and met the criteria at 1.1.2 , as shown above, to be taken to Part II. As members of the public will be excluded from the Part II of the Governing Body meeting it is recommended that the Governing Body adopt option (b) that only voting members of the Governing Body attend Part II of the meeting with officers invited when requested. The meeting will be serviced by the Corporate Services Manager.

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Appendix 1 – Nolan Principles

CORPORATE AND STRATEGIC OBJECTIVES Corporate objective – Grip on day to day business; to ensure effective corporate governance arrangements are maintained to ensure that the CCG discharge its statutory functions in accordance with the agreed CCG’s Constitution.

CONSULTATION HISTORY: The Revised Governance Arrangements for Governing Body report was taken to Delivery Committee on 6 June for discussion and comments and approved at the Governing Body meeting on 4 July 2013. The Arrangements for the Governing Body Part I and Part II meetings report was taken for comment to the Management Team meeting on 20 August 2013.

PUBLIC ENGAGEMENT The public may attend all meetings of the Governing Body held in public and are invited to ask questions of the Board at the designated time on the agenda, in relation to matters on the agenda and at the discretion of the Chair. The papers and minutes of the Governing Body meetings held in public are to be found on the CCG website at: www.lewishamccg.nhs.uk




PUBLIC SECTOR EQUALITY DUTY How does this report take into account the duty to:




4

The recommendation of this paper is that the vast majority of the CCG’s business is conducted in public. This will further ensure that the CCG is publicly held to account to deliver its Public Sector Equality Duty. RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Susanna Masters E-Mail: [email protected] Telephone: 020 7206 3345

AUTHOR CONTACT: Name: Lesley Aitken E-Mail: [email protected] Telephone: 020 7206 3360

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APPENDIX 1 Nolan Principles

The ‘Nolan Principles’ set out the ways in which holders of public office should behave in discharging their duties. The seven principles are:

a) Selflessness – Holders of public office should act solely in terms of the public interest.They should not do so in order to gain financial or other benefits for themselves, their family or their friends.

b) Integrity – Holders of public office should not place themselves under any financial orother obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties.

c) Objectivity – In carrying out public business, including making public appointments,awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.

d) Accountability – Holders of public office are accountable for their decisions and actions tothe public and must submit themselves to whatever scrutiny is appropriate to their office.

e) Openness – Holders of public office should be as open as possible about all the decisionsand actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.

f) Honesty – Holders of public office have a duty to declare any private interests relating totheir public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.

g) Leadership – Holders of public office should promote and support these principles byleadership and example.

Source: The First Report of the Committee on Standards in Public Life (1995)65

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ENCLOSURE 13 INFORMATION GOVERNANCE POLICIES

CLINICAL LEAD: Alison Browne MANAGERIAL LEAD: Tony Read

Director of Nursing, Caldicott Guardian Chief Financial Officer Senior Information Responsible Officer

AUTHOR: Mike Hellier Head of System Intelligence

RECOMMENDATIONS: The Governing Body is asked to approve for adoption the interim Information Governance and Information Security policies

SUMMARY: Lewisham CCG is required to adopt policies for Information Governance in its statutory role. The work programme for Information Governance is:

Q1 and Q2 Adopt IG policies. Define controls.

Q3 Operate controls: ensure IG mandatory training and other controls in place.

Q4 Audit of controls and second submission of IG Toolkit.

This is overseen by the Information Steering Group on behalf of the Delivery Committee.. This is Chaired by the Senior Information responsible Officer. The Caldicott Guardian and Clinical lead for Information are members.

KEY ISSUES: The Information Governance policy is a framework to manage information appropriately. For personal information, it ensures confidentiality and security as well as that processes are in place to ensure appropriate standards of quality and ethical use. It outlines responsibilities. There is more work to do to identify CCG member responsibilities in their role as commissioners (rather than as providers). One of the critical issues currently is that, outside of defined exceptions (e.g. safeguarding), the holding of personal information is limited as a CCG. PCT’s operated safe haven arrangements for the management of data with personal confidential data. Nationally, arrangements are being made for new Accredited Safe Havens (ASH) and Data Services for Commissioners Regional Offices (DSCRO) which will enable the secure and lawful handling of Patient Identifiable Data (PID). It will be necessary to

update the CCG’s IG policies as a result. Meanwhile it is important for the CCG to adopt interim policies.

The Information Security policy defines the information security management and assurance arrangements. It outlines the systems that ensure current information security obligations are met, how changes, performance and incidents are managed. For example Lewisham CCG has raised its first information security incident relating to Outlook roaming profiles with access to NHS Net accounts.

The Delivery Committee requested that the final policies incorporate • Clear arrangements for communicating to the public and staff what information is

being collected and how it is used. • Better clarity on what is meant by confidential and how confidential data is accessed

by operational teams (e.g. the HR department) • More focus on information that is held on portable devices and responsibilities of the

device user • clearer information on escalation of issues

These will be incorporated into the final versions of the policies and brought back to the Governing Body for adoption to replace these interim policies.

CORPORATE AND STRATEGIC OBJECTIVES Objective – Grip on Day to Day Business

Risk: Failure to Achieve Adequate Information Governance Standards leading to unlawful access of Personal Confidential Data or Patient Identifiable Data and/or insecure handling of this data. The effect may also be reputational damage and financial penalties. Current risk status 16.

CONSULTATION HISTORY: These interim policies have been agreed by the Information Governance Steering Group. They have been reviewed by the Senior Management Team and Delivery Committee. The South London CSU support on Information Governance has gone through an internal CSU review process for providing common policies for CCGs.

PUBLIC ENGAGEMENT No public engagement has taken place.

HEALTH INEQUALITY DUTY Restricting access to PID to lawful purposes protects the health inequality duty

PUBLIC SECTOR EQUALITY DUTY Restricting access to PID to lawful purposes protects the duty to




RESPONSIBLE MANAGERIAL LEAD CONTACT: Name: Tony Read

AUTHOR CONTACT: Mike Hellier E-Mail: [email protected] Telephone: 0207 206 3322


Policy – Information Governance

Document Title: Policy Information Governance Issue Date: Jun-2013 Document Status: Interim Approved Review Date: Jun-2014

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Document control

Document Information

Document Name: Policy – Information Governance

Ownership: Senior Information Risk Owner

Consultation: Information Governance Steering Group, May 2013

Approved by: Lewisham Clinical Commissioning Group, IG Steering Group

Date: Jun-13

Supersedes: N/A

Description: Interim policy to cover Information Governance

Audience: All staff

Contact details: [email protected]

Change History

Version Date Author Approver Reason 0.1 Jan-12 IG Manager,

T Francis IG Steering Group 1st Draft

0.2 Jun-13 IG Manager, H Thomas

IG Steering Group Delivery Committee

Updated draft for interim approval

1.0 Jul-13 IG Manager, H Thomas

IG Steering Group

Governance and Lewisham Clinical Commissioning Group

Lewisham Clinical Commissioning Group has prepared this information governance framework document with the assistance of the steering group, sub committees and other relevant bodies, for the purpose of supporting Information governance within the organisation and for all staff working in or on behalf of the organisation.

The information governance framework provides a solid basis upon which information governance and all its component parts will be implemented throughout the Lewisham Clinical Commissioning Group. The Framework outlines the roles and responsibilities of those who are tasked with overseeing that IG is appropriately supported and that all necessary guidance and advice is available in an effective and efficient manner as well as the responsibilities of all staff.

The Framework is based upon the legal requirements of the Data Protection Act, Common law duty of Confidentiality and Human Rights Act, and the DH, CfH assurance model the Information Governance Toolkit (IGT).

Details of the Equality & Equity Impact Assessment Checklist can be found in Annexe A


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Table of Contents

1.0 Introduction ....................................................................................................................................... 4

1.1. Policy statement and aim....................................................................................................... 4

1.2. Objectives ............................................................................................................................... 4 2.0 Scope of the Policy ............................................................................................................................. 5 3.0 Governance ........................................................................................................................................ 6

3.1. Roles and Responsibilities ...................................................................................................... 6 4.0 The Use of Information ...................................................................................................................... 6

4.1. Use of Personal Data .............................................................................................................. 7

4.2 Use of Information to improve performance ........................................................................ 7 5.0 Data Quality ....................................................................................................................................... 7 6.0 Transferring of information ............................................................................................................... 8

6.1. Safe Havens ............................................................................................................................ 8 7.0 Disclosure and Sharing information .................................................................................................. 8

7.1. Public rights of disclosure ...................................................................................................... 9

7.2. Active disclosure of information in line with the Freedom of Information Act 2000 ......... 10 8.0 Information Security ........................................................................................................................ 10 9.0 Audit and monitoring criteria .......................................................................................................... 11

9.1. Monitoring of compliance .................................................................................................... 11

Monitoring of compliance ............................................................................................................... 11

9.2. Non Compliance ................................................................................................................... 11 10.0 Review .............................................................................................................................................. 12

10.1. Next formal review............................................................................................................... 12

10.2. Latest Version ....................................................................................................................... 12 11.0 Statement of evidence/references .................................................................................................. 12 12.0 Implementation and dissemination of document ........................................................................... 12 13.0 Annexes ............................................................................................................................................ 13 Annexe A - Equality & Equity Impact Assessment Checklist ....................................................................... 13


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1.0 Introduction 1.1. Policy statement and aim

Information Governance is a framework to manage information appropriately. For personal information it ensures confidentiality and security as well as that processes are in place to ensure appropriate standards of quality and ethical use. Corporate information and records must also be managed appropriately and where possible provided to the public to ensure transparency and accountability. Lewisham Clinical Commissioning Group uses information to understand local population needs and plan services accordingly, procure resources, evaluate service quality and outcomes and for benchmarking its activity against similar organisations. In addition to these functions are the statutory duties of Commissioning Care Groups.. The NHS and the administration of the NHS is dependent upon the appropriate use of Personal Data and management of the secondary use of this data. Information is transferred to other organisations and the suppliers of services to support these functions and disclosed in accordance with statutory, regulatory or organisational requirements. Information forms a key component of the current Government’s Information Revolution for the NHS. This restates the NHS’s intention to ensure effective decision making, inform and empower patients through the provision of accurate, accessible and coherent information. Lewisham Clinical Commissioning Group must discharge its statutory and organisational responsibilities with care and consideration and all staff and those working on behalf of the organisation are responsible and contribute towards the effective and responsible governance of information in line with the organisation’s aims and objectives. This policy provides an overview of how information will be governed and used, including how the organisation will discharge it duties. This requires a systematic approach based on procedures owned, understood and supported by all those working on its behalf.

1.2. Objectives The Board is committed to ensuring that all information that is the responsibility of its organisation and its service providers which relates to patients, clients and staff is processed, protected and disclosed appropriately to provide improved healthcare and decisions for patients.

The right information, to the right people, at the right time. This policy sets out the aims for the management of information and associated risk. This includes: Effective and efficient management of information for the care of service users and the

management of the care service


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Actively advance the management of information to improve the provision of services,

information and care of patients Engage with partner organisations and where appropriate and lawful, share information to

support care and the public interest Discharge its obligations to disclose information in response to lawful requests with due

regard to its duties of confidence by following clear and systematic processes Ensure that systems and processes are effective to ensure the confidentiality and security of

personal and other sensitive information. Ensure that all information and data processed, held and managed is of the highest quality in

terms of completeness, accuracy, relevance, accessibility and timeliness. Ensure that all information and data is held in a consistent and systematic manner that

ensures its accessibility, accuracy and integrity throughout its lifecycle To actively provide information in line with the Freedom of Information Act 2000 and other

regulatory or organisation requirements Ensure those working on behalf of the organisation and its patients are informed, trained and

active in the appropriate management of information, and To ensure that change is undertaken in a structured and systematic manner that ensures

information governance issues are dealt with a timely, proportionate and appropriate.

In Summary Our objective is the effective and appropriate governance of information by the organisation and those working on its behalf in accordance with best practice, statute and regulatory requirements.

This policy supports these aims and objectives.

2.0 Scope of the Policy

This policy is applicable to: All information and data held and processed by the organisation.. All information must be

managed and held within a controlled environment, including personal data of patients and staff, as well as corporate information. It applies to information, regardless of format and includes legacy data held by the organisation

All permanent, contract or temporary personnel and all third parties who have access to organisation premises, systems or information. Any reference to staff within this document also refers to those working on behalf of the organisation on a temporary, contractual or voluntary basis

Information systems, data sets, computer systems, networks, software and information created, held or processed on these systems, together with printed output from these systems, and

All means of communicating information, both within and outside the organisation and both paper and electronic, including data and voice transmissions, emails, post, fax, voice and video images i.e. recorded CCTV or live conferencing.

This document refers to information as a term which encompasses all data forms. The term information is defined in this setting as details that can be understood independently, for


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example an email or data(information) that requires the context of a system in order to be understood, for example SUS data.

3.0 Governance

3.1. Roles and Responsibilities A full list of responsibilities and current post holders is available in the Information Governance Framework. The Chief Officer is accountable for information within the organisation, and delegates’ responsibility for the management of information risk to the Senior Information Risk Owner and Information Asset Owners who have specific responsibilities. The Information Governance Manager is responsible for ensuring that a framework for proper governance and assurance is in place All staff are responsible for abiding by this policy and in discharging their duties in accordance with law, ensuring that the confidentiality and security of information in all formats is maintained and that any disclosure is appropriate and provided to the correct contact point. In this they are supported by the procedures, best practice guidance and the Information Governance Manifesto of the organisation. Details on other relevant policies, protocols and guidelines are available in the Information Governance Framework.

4.0 The Use of Information

Information is used, or processed, or created by the organisation for the pursuit of its legitimate business interests and discharge of its statutory functions. All use of information within the organisation and by those working on its behalf must be in accordance with these objectives and obligations. All information must be used, created and managed in a professional and businesslike manner. It must be accessible to the organisation on a long term basis and must be stored in a systematic and consistent manner. Access to information systems, such as the email, the internet or network, and records of the organisation are provided to staff for business purposes. All access and use must be appropriate and in line with the discharge of their duties. Where staff creates information they are doing so on behalf of the organisation, for example when sending emails, and are accountable for the information they create, for its appropriateness and accessibility.


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4.1. Use of Personal Data

Personal data relates to information about individuals, service users or members of staff and can include anything that makes them identifiable. It does not have to include particular demographic information, such as name and address, and can consist of a combination of factors that would make it possible to identify the individual. Information provided to the NHS, is done so on the expectation of confidentiality and often in a healthcare setting. It is important for staff and working practice to account for this and to ensure that any secondary use of personal data, for non-care purposes, in done in accordance with the legal and organisational requirements. The Organisation will provide and maintain a privacy notice or fair processing notice which details what personal data is held and processed, for what purpose it is processed and who it is shared with and what governs that process. Each directorate or team within the Organisation must aim to provide a clear statement for their area of its responsibility.

4.2 Use of Information to improve performance

The Organisation will actively seek opportunities to improve the performance of the NHS and its commissioning bodies with whosoever it supports by the better use of information and data. This includes: Use of anonymised or de-identified patient data to inform better health care decisions for

individuals and the community To review processes and functions within the organisation to ensure efficient and effective

data processing To engage with partner organisations to scope appropriate information sharing which

ensures that the patient and public can exercise choice and are kept informed Any change processes with the Organisation are required to be managed and to account for the requirements to ensure the appropriate and effective information management. All staff managing change must ensure that they scope potential information governance issues before commencing the change process.

5.0 Data Quality

In order to support effective commissioning and to support efficiency, all systems and standard working practice involved in the processing of information must ensure the accuracy and quality of information.

Data Quality encompasses: Accessibility – information can be accessed quickly and efficiently through the use of

systematic and constituent filing Accuracy – information is accurate, with systems that support this work through guidance Completeness – the relevant information required is identified and working practice ensures

it is routinely captured


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Relevance – information is kept relevant to the issues rather than for convenience with

appropriate management and structure Timeliness – information is recorded as close as possible to the time of being gathered and

can be accessed quickly and efficiently

6.0 Transferring of information

All transfers of information within and outside the organisation must be managed and comply with the information security requirements and follow a clear process. All Directorates and teams should have a clear statement of their inward and outward flows of personal data. This process must identify The appropriate method, and inherent risks, of the transfer The contact point and details to which the information is routinely transferred. All contact

points should identify a team and position, rather than an individual to which the information is being transferred

How the transfer is confirmed and completed In addition where the transfer of information involves personal or identifiable data: The purpose and justification for transferring the information Ensure that the security standards of the method of transfer are appropriate It is expected that most transfers of information will be routine and follow an identified process. The transfers of information within the organisation and between this organisation and external bodies must be managed in an appropriate manner and by secure methods, or with sufficient mitigation in place.

6.1. Safe Havens

In order to support the appropriate transferring of information, the organisation will identify appropriate Safe Haven locations. Safe Havens answer the requirements of the Data Protection Act 1998, Principle 7, The NHS Code of Practice: Confidentiality and the NHS Care Record Guarantee. Safe Havens have arrangements and procedures in place to ensure person identifiable or sensitive information can be held, received and communicated securely.

Where Safe Haven locations are not available to staff the relevant Safe Haven procedure for the method of transmission should be applied.

7.0 Disclosure and Sharing information

As a public body an organisation can only share information if their statutory powers expressly allow it or there is implied permission in order to pursue legitimate interests, which can be demonstrated. As the NHS works with Health information that is provided in confidence there are greater restrictions to sharing or disclosing information. This includes:

The common law duty of confidence, which extends after death


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Health Information is sensitive information and requires justification under schedule 2 and

schedule 3 of the Data Protection Act which requires additional safeguards for its use

Any basis of disclosure and sharing needs to be understood and clearly stated before it is undertaken. This decision must demonstrate that the disclosure or sharing: Is reasonable and done in good faith for a defined purpose Is lawful and relevant to the purpose intended or is based upon public interest needs

Data sharing in the NHS is also governed by the Caldicott Principles which supports the legal framework.

Disclosure or sharing of personal data requires one of the following conditions to be met: The Informed and valid consent of the individual, balanced against any duty of care and

consideration of capability to provide that consent Disclosure is in the public interest, which must demonstrate consideration of the balance of

public interest against the individual and provision of a confidential service Disclosure is in accordance with the law

All routine sharing of information must be supported by a clear statement that can be made available to the public or patients. This fair processing or privacy notice should detail what information is being shared, who is it is being shared with and to what purpose and benefit. In addition, all routine information sharing must be accompanied by a current Information Sharing Agreement or Framework that sets out the all relevant issues.

7.1. Public rights of disclosure

All staff are reminded that there are several pieces of legislation that require information to be released to the public (the Freedom of Information Act 2000 or Environmental Information Regulations 2004), or the subject of that data (Data Protection Act 1998) or those with a claim to the estate of the deceased or lawful right (Access to Health Records 1990). Access to information legislation applies to information in all formats, this includes emails, voice recordings and images. In order to meet this responsibility, all staff are responsible for ensuring that records in part or in the whole are: Accessible – ensuring that they can be found within a systematic and consistent filing

structure Appropriate and relevant – this includes a professional and appropriate tone Have Integrity or completeness – so that they can be used in an ongoing basis Confidential – appropriately safeguarded to ensure confidentiality with a clear statement of

who was provided access to the information. Identified – systems and staff should ensure that person identifiable, sensitive, confidential

and corporate information is clearly stored and marked as such.


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7.2. Active disclosure of information in line with the Freedom of Information Act 2000

Details of the organisation’s policy on active disclosure and compliance with the Freedom of Information Act, is outlined in the organisation’s Freedom of Information Policy and associated protocols and procedures. Also the organisation discloses information of this nature through its publication scheme routinely.

8.0 Information Security

The purpose of information security is to ensure business continuity, to minimise the impact of security related incidents and to ensure the integrity of the information and data held by the Organisation. Information security enables information to be processed and shared with appropriate safeguards in place. It ensures the protection of information and assets as well as identifying and acting on threats to that security.

Information security is both the technical and physical. It ranges from the security of networks, to the use of appropriate passwords by staff and storage of confidential information in secure environments and storage. All staff are contributory to information security and have key responsibilities in its maintenance.

All staff are contributory towards the security of information and all Information Asset Owners are required to have a clear statement on the information security and risks in place for the assets within their remit.

Information Security has three basic components: Confidentiality: assuring that sensitive information or data is accessible to only authorised

individuals, and is not disclosed to unauthorised individuals or the public.

Integrity: safeguarding the accuracy and completeness of information and software, and protecting it from improper modification.

Availability: ensuring that information, systems, networks and applications as well as paper records are available when required to departments, groups or users that have a valid reason and authority to access them.

This subject is fully addressed in the Organisation’s Information Security Policy.


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9.0 Audit and monitoring criteria

9.1. Monitoring of compliance This policy and adherence to it will be audited regularly and will be monitored. Compliance with this policy, framework and procedures are undertaken through the Information Governance Toolkit annual self assessment and an audit undertaken on the level of assurance provided by the submitted evidence. Table 1 below sets out how we will monitor implementation and utilisation of this Policy. Table 1 Document Audit and Monitoring Table

Monitoring requirements “What in this document do we have to monitor”

We will ensure that staff are aware of the Policy, the constituent aspects of the information governance framework, and abide by legal, technical and mandatory IG requirements Performance in the Information Governance Toolkit and the completion of a Data Flow Mapping exercise

Monitoring Method Information Governance Toolkit annual assessment

Monitoring prepared by IG Lead and IG Support (SL CSU)

Monitoring presented to Information Governance Steering Group

Frequency of presentation Annual independent audit, submissions in line with Department of Health Guidance

Monitoring of compliance Compliance with all aspects of Information Governance will be undertaken as part of the Information Governance workplan or at the direction of The Organisation’s Audit Committee, Senior Information Risk Owner or Caldicott Guardian

9.2. Non Compliance Failure to comply with the standards and appropriate governance of information as detailed in this policy, supporting protocols and procedures can result in disciplinary action. All staff are reminded that this policy covers several aspects of legal compliance that as individuals they are responsible for. Failure to maintain these standards can result in criminal proceedings against the individual. These include but are not limited to: Data Protection Act 1998 Freedom of Information Act 2000 Computer Misuse Act 1990 Common law duty of confidentiality Human Rights Act 1998


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For a full list of relevant legislation and guidance see the Information Governance Framework.

10.0 Review

10.1. Next formal review Review will take place of the 1st anniversary of adoption and subsequently every three years until rescinded or superseded.

10.2. Latest Version The audience of this document should be aware that a physical copy may not be the latest version. The latest version, which supersedes all previous versions, is available at the location indicated in the document control section of this document. Those to whom this protocol applies are responsible for familiarising themselves periodically with the latest version and for complying with protocol requirements at all times.

11.0 Statement of evidence/references

A full list of guidelines, evidence and references will be provided and maintained in the Information Governance Framework.

12.0 Implementation and dissemination of document

The updated Policy, once approved by the Organisation’s Audit Committee or delegated group, will be shared with all staff through the all staff email, updated on the intranet, and shared with the Organisation Management Board. A team briefing will be provided to support this dissemination.

Awareness of the policy will be checked through a staff survey and spot checks on at least an annual basis.


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13.0 Annexes

Annexe A - Equality & Equity Impact Assessment Checklist

Annexe A - Equality & Equity Impact Assessment Checklist This is a checklist to ensure relevant equality and equity aspects of policies, protocols or guidance have been addressed either in the main body of the document or in a separate equality & equity impact assessment (EEIA)/ equality analysis. It is not a substitute for EEIA/ equality analysis which is normally required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to see whether the EEIA has covered the ground and to give assurance that the proposals will not only be legal but also fair and equitable and lead to reduced health inequality.

Challenge questions Yes/No DK/NA

Comments

1. Does the document set out the health care needs of the groups intended to benefit from the proposal, including any differences in need in terms of the legally protected or other characteristics (such as socioeconomic position)

2. Does the document set out any known existing inequality in access, quality, experience and outcome of care for populations relevant to the proposal (ie as defined in 1. and in relation to the existing health or care service)?

3. Are there any particular public concerns about equality about the policy area than need to be addressed?

4. Has the policy described any gaps in knowledge about 1 -3, and any action taken to fill gaps (or recommendations for action)

5. Does the document set out risks to equity of access, quality, experience and outcomes including risk of direct or indirect discrimination, and risk to good relations between people of different groups?

6. Does the document describe any specific opportunities to promote equality and human rights, good relations between people of different groups, to enhance participation, etc?

7. Does the document describe how the proposal, policy etc will address the identified inequalities, and

8. Does the document make recommendations to mitigate risks and enhance the opportunities to promote equality and equity?

9. Does the document describe how monitoring and reporting will take place to assure equality and equity in the future including to stakeholders. [audit and monitoring table may be used]

* Race/ ethnicity, gender (including gender reassignment) age, religion or belief, disability, sexual orientation, marriage or civil partnership, pregnancy and maternity. This will include groups such as refugees and asylum seekers, new migrants, Gypsy and Traveller communities; and people with long term conditions, hearing or visual impairments, mental health problems or learning disability


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Policy and Strategy – Information Security

Document Title: Policy/Strategy – Information Security Issue date: Jun-2013 Document Status: Interim Approved Review date: Jun-2014

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Document control

Document Information

Document Name: Interim Policy and Strategy - Information Security

Ownership: Senior Information Risk Owner

Consultation: Information Governance Steering Group, May 2013

Approved by: Lewisham Clinical Commissioning Group, IG Steering Group

Date: Jun-13

Supersedes: N/A

Description: Interim policy to cover Information Security principles and processes

Audience: All staff

Contact details: [email protected]

Change History

Version Date Author Approver Reason 0.1 26/02/2013 IG Manager,T Francis IG Steering Group 1st Draft 0.2 10/06/2013 IG Manager,

H Thomas IG Steering Group Delivery Committee

Updated draft for interim approval

1.0 17/06/2013 IG Manager, H Thomas

IG Steering Group Delivery Committee

Approved by IG Steering Group

Governance and Lewisham Clinical Commissioning Group

Details of the Equality & Equity Impact Assessment Checklist can be found in Annexe A

Lewisham Clinical Commissioning Group has prepared this information governance framework document with the assistance of the Lewisham Clinical Commissioning Group steering group, sub committees and other relevant bodies, for the purpose of supporting Information governance within the organisation and for all staff working in or on behalf of the organisation.

The information governance framework provides a solid basis upon which information governance and all its component parts will be implemented throughout the Lewisham Clinical Commissioning Group. The Framework outlines the roles and responsibilities of those who are tasked with overseeing that IG is appropriately supported and that all necessary guidance and advice is available in an effective and efficient manner as well as the responsibilities of all staff.

The Framework is based upon the legal requirements of the Data Protection Act, Common law duty of Confidentiality and Human Rights Act, and the DH, CfH assurance model the Information Governance Toolkit (IGT).

Document Title: Policy and Strategy – Information Security Issue date: Jun-2013 Document Status: Interim Approved Review date: Jun-2014

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Table of Contents

Policy and Strategy – Information Security ................................................................................................... 1 1.0 Introduction ....................................................................................................................................... 5

1.1. Policy and Strategy statement and aim ................................................................................. 5

1.2. Objectives ............................................................................................................................... 5 2.0 Scope of Policy and Strategy .............................................................................................................. 5 3.0 Governance ........................................................................................................................................ 6

3.1. Roles and Responsibilities ...................................................................................................... 6

3.2. Senior Information Risk Owner .............................................................................................. 6

3.3. Nominated Information Security Officer (each Network) ..................................................... 6

3.4. All Staff ................................................................................................................................... 7 4.0 Information Security Assurance Plan ................................................................................................. 7

4.1. Overview ................................................................................................................................ 7

4.2. ICT Risk Register (by Network) ............................................................................................... 7

4.3. System Level Security Policies ................................................................................................ 7

4.4. Information Security Incidents ............................................................................................... 9

4.5. Performance ........................................................................................................................... 9

4.6. Change Management ............................................................................................................. 9

4.7. Mandatory Controls ............................................................................................................... 9

4.8. Information Asset Owner Review .......................................................................................... 9 5.0 Information Security Incidents and Events ...................................................................................... 10

5.1. Identifying Information Security Incidents .......................................................................... 10

5.2. Examples of Information Security Incidents ........................................................................ 10

5.3. Escalation of Information Security Incidents or Event ........................................................ 10

5.4. Response and Resolution ..................................................................................................... 10

5.5. Recording and Reporting of Information Security Incidents or Event ................................. 11

5.6. Service Provision to other organisation’s ............................................................................ 11

5.7. Management of CRS Smartcard Incidents ........................................................................... 11 6.0 External Information Security Incidents and Events ....................................................................... 12

6.1. Provision of service by third parties. ................................................................................... 12

6.2. Nominated Contact Point or Security Manager................................................................... 12

6.3. Data Protection Act 1998 – Data Processing ....................................................................... 12 7.0 Performance .................................................................................................................................... 12

7.1. Measures of ICT Performance .............................................................................................. 12

7.2. Informatics Performance Measures .................................................................................... 13

7.3. Other Security Performance Measures ............................................................................... 13 8.0 Change Management ....................................................................................................................... 13

8.1. Change Management that requires SIRO sign off ............................................................... 13

8.2. Change Management that requires Caldicott Guardian sign off ......................................... 14 Document Title: Policy and Strategy – Information Security Issue date: Jun-2013 Document Status: Interim Approved Review date: Jun-2014

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8.3. Sign off where these criteria do not apply ........................................................................... 14 9.0 Mandatory Controls and improvements ......................................................................................... 15

9.1. Mandated Safeguards .......................................................................................................... 15

9.2. Risk Mitigated Safeguards Include ....................................................................................... 16

9.3. Access Control ...................................................................................................................... 16 10.0 Information Asset Owner’s Review ................................................................................................. 16

10.1. Asset Management .............................................................................................................. 16

10.2. Annual Information Asset Owner Assurance ....................................................................... 17 11.0 Audit and monitoring criteria .......................................................................................................... 17

11.1. Monitoring of compliance .................................................................................................... 17

11.2. Non Compliance ................................................................................................................... 18

11.3. Disciplinary measures .......................................................................................................... 18 12.0 Review .............................................................................................................................................. 18

12.1. Next formal review............................................................................................................... 18

12.2. Latest Version ....................................................................................................................... 18 13.0 Statement of evidence/references .................................................................................................. 19

13.1. Legislative and Regulatory Environment ............................................................................. 19

13.2. Other References ................................................................................................................. 19 14.0 Implementation and dissemination of document ........................................................................... 19 15.0 Annexes ............................................................................................................................................ 19 Annexe A - Equality & Equity Impact Assessment Checklist ....................................................................... 20 Annexe B – Information Security Definitions .............................................................................................. 21


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1.0 Introduction

1.1. Policy and Strategy statement and aim

This document defines the information security management and assurance arrangements in place within the Organisation. It outlines the systems that ensure current information security obligations are met, how changes, performance and incidents are governed. This document acts as both the policy, stating the required standard, as well as the strategy of delivering that standard and the provision of assurance.

Information Security is the management of information to the standards expected in law, contract and regulations. The standard is mandated by the Cabinet Office. It supports the confidentiality, integrity and availability of the information held, processed and the responsibility of the Organisation. It is supported by an assurance process that demonstrates the ongoing management of change, improvements and risks by the Organisation.

1.2. Objectives

This policy and strategy sets out how the Senior Information Risk Owner identifies the resources, priorities and risks required to ensure information security management is carried out to the appropriate standard.

To achieve this, the policy and strategy document sets out:

The organisation’s information security obligations The key aspects of information security across the organisation Where information security impacts on business processes and how assurance is provided The expectation on the management of Information Assets, ICT systems and information to

deliver information security and assurance. The responsibilities of staff in maintaining Information Security

The primary aims of information security are to:

Ensure the confidentiality, integrity and availability of information with the organisation To protect information assets from threats, both internal and external To reduce the risk of a security breach, data loss or breach of confidentiality

2.0 Scope of Policy and Strategy

This is an organisation wide document and applies to all Directorates and all Services provided. Information Security applies to the management of information across the organisation and at all sites. It applies to any information or data accessed remotely, in transition and via the internet. This document is primarily aimed at the management of information security and assurance for electronic information but incorporates the management of information in all other formats within the organisation (a list of key Information Security definitions are contained in Annexe B).

In addition it applies to the management of information commissioned with external partners and Third Parties.


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To provide assurance, an Information Security Assurance Plan for this organisation will routinely report on:

• Information Security Incidents and Events • External Information Security Incidents • Performance • Change Management • Mandatory Controls and Improvements • Information Asset Owner’s Review

This plan will be provided to the Senior Information Risk Owner and will enable the appropriate management of risks, priorities and resource.

All staff must adhere to this policy and managers must ensure that all those working on behalf of the Organisation are aware of the policy, procedures and requirements of ensuring Information Security.

3.0 Governance

3.1. Roles and Responsibilities

Governance and Escalation roles and responsibilities for Information Security are fully outlined in the Information Governance Framework.

The Organisation’s Chief Officer is accountable for information within the organisation, and delegates’ responsibility for the management of information risk to the Senior Information Risk Owner (SIRO), Deputy SIROs and Information Asset Owners. Each have specific responsibilities. The Information Governance Manager is responsible for ensuring a framework for proper governance and assurance is in place.

All staff are responsible abiding by the requirements of Information Security and in discharging their duties in accordance with law, ensuring that the confidentiality and security of information in all formats is maintained and that any disclosure is appropriate and provided to the correct contact point. In this they are supported by the procedures, best practice guidance and the Information Governance Framework.

Details of other relevant policies, protocols and guidelines are also available in the Information Governance Framework.

3.2. Senior Information Risk Owner

The Senior Information Risk Owner is responsible for ensuring there is an appropriate structure and process in place for the management of Information Security. They must ensure that information security is managed and that assurance processes are in place.

3.3. Nominated Information Security Officer (each Network)

Each Network or Supplier of network services is required to nominate an Information Security Officer to contribute and lead the information security assurance plan.


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3.4. All Staff

All staff contribute to the security of information held by the organisation or on its behalf. Staff are responsible for the appropriate use and security of information, ICT equipment and physical security of information they utilise in the discharge of their duties.

All staff are expected to recognise and report Information Security Incidents and Events. These should be highlighted to their line manager and reported to the relevant ICT Helpdesk to ensure they are logged and managed appropriately.

All staff are reminded that access to ICT systems, assets and services are provided for business purposes and their use may be monitored.

4.0 Information Security Assurance Plan

4.1. Overview

The organisation uses several mechanisms to manage information security. These are detailed below and in the Information Governance Framework. It is assumed that all ICT service providers will maintain a list of information security issues, risks and mitigations for discussion with the SIRO.

4.2. ICT Risk Register (by Network)

Risk Registers are maintained for each ICT Network and contribute to the overall Corporate Risk Register through inclusion in the Directorate Risk Register. These are reviewed on a regular basis in accordance with the organisation’s Risk Management and Assurance Framework.

4.3. System Level Security Policies

Each Key Information System (Asset) is required to have a system level security policy that details:

Access control requirement specifications (such as whether two part authentication is required and is in place)

Authorization process for access to the system (user registration and deregistration) Assignment of responsibilities for the system (access, maintain and issue resolution) Details on system design and dependencies. Provisions for reports generated by system utilizes on use and audit logs What system documentation is in place Login controls (e.g. password strength and threshold of failed logins) Backup requirements Back-up data testing arrangements Business Continuity or Back-up plans for system data and software applications Details of UPS technologies or other system continuity support Schedules of tests Input data validation Risk Assessment for the System on key areas


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The policy must detail what security reports are available and who can provide them for the following issues:

Access log files generated by the system Current User overview Account Monitoring (unused accounts etc) Forensic Readiness assessment

The system level policy will be reviewed on at least an annual basis.


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4.3.1 Definition of a Key Information System (Asset)

Key Information Systems (Assets) are defined as:

• Systems which other business critical assets are dependent upon (e.g. Network) • Business Critical • Key Information Assets

4.4. Information Security Incidents

All information Security Incidents will be recorded and reported to the SIRO on a routine basis. The report will note which issues were resolved, which have been escalated as risks and the associated action plan for the management or mitigation of the risk.

4.5. Performance

The performance of Information systems and dependencies will be provided to the SIRO and Director, with responsibility for ICT where applicable, on at least a quarterly basis in line with the requirements in the Performance section. Any risks resulting from performance will be added to the relevant Risk Register in line with the Risk Management and Assurance Framework.

Information Systems consist of but are not limited to:

• Network • Servers • Key databases and datasets (such as SUS) • Email systems • Portable devices (such as laptops, memory sticks)

4.6. Change Management

The SIRO will sign off on the Change Management process for each Network and will be advised on any changes that impact on Information Security. A risk assessment will be provided along with an outline of the proposed project. Details will be provided of the Senior Responsible Officer for the change and Project Board where possible.

It is expected that Information Security Assurance will provided to the SIRO as part of the process of routine management and in good time to effect change.

4.7. Mandatory Controls

Assurance is sought on the mandatory controls in place for Information Assets through a number of measures. It is expected to be part of routine ICT performance reports, for the assets within their control, part of the review and risk assessment of Information Asset Owners and a deliverable of the change management process. The expected levels of mandatory controls are outlined below.

4.8. Information Asset Owner Review

Information Asset Owners are required to provide an annual update to the Senior Information Risk Owner on the management of information assets and risks within their remit. This includes a review of the controls and their effectiveness, on a least an annual basis.


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5.0 Information Security Incidents and Events

5.1. Identifying Information Security Incidents

All information security incidents should be reported to the relevant ICT Helpdesk upon detection. These should be highlighted to the nominated information security officer for the relevant organization and, where appropriate, to the Information Governance function.

5.2. Examples of Information Security Incidents

Information Security Incidents include:

Viruses Inappropriate access to files or folders Use or suspected use of another members of staff’s login (for email, network or system) or

smartcard Suspected or known disclosure of your smartcard Accidental or intentional damage to the accuracy of data Slow computers Pop-Ups Use of unencrypted laptops, USB sticks Leaving smartcards unattended Unattended IT Assets (laptops, USB sticks, etc).

The helpdesk will advise users of any additional steps that are required, including initiating Incident investigation policy and procedure as outlined in the relevant Serious Incident and Investigation Policy and Procedure.

5.3. Escalation of Information Security Incidents or Event

Information Security Incidents must be escalated in accordance with each ICT service’s Information Security Incident Procedure. This procedure must include:

Reporting to the Information Security Officer Recording of details about the information security incident or event to include:

- Number of staff effected - Information Assets (or systems) effected - ICT Assets effected - Cause, or suspected cause, of the incident or event

The response process and associated timeframes The resolution process and associated timeframes How failed resolutions will be escalated and managed

5.4. Response and Resolution

The Information Security Incident Procedure will outline the process and expectations around the response to information security incidents and resolution it will detail:

The actions required of staff reporting the incident or event The Helpdesk teams obligations and response times The criteria for nominating an Incident Co-ordinator The escalation and reporting requirements for the Information Security Officer or nominated

Incident Co-ordinator


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Criteria for declaring a near miss • Criteria for a Serious Incident in Information Security and how to escalate in line with the

Serious Incident Process • The timescales for response and resolution

5.5. Recording and Reporting of Information Security Incidents or Event

Every Information Security Incident, Event or Near Miss must be recorded. Where Call Management Systems are in use, an ability to declare a Helpdesk call an Information Security Incident or to record them under a separate category should be provided.

The details that need to be recorded are:

• Unique Identifier for IS Incident • Date and Timestamp of reporting • Description of the incident • Users, Assets and Information impacted upon • Suspected causes (categorization of incident) • Record of all actions taken in response to the incident • Record of all escalations of the incident (who and when) • Resolution of the issue • Link to formal investigation, if required

Where incidents meet the set criteria they will be reported to the Senior Information Risk Owner. A summary of the incident and its severity must be provided as a minimum with further details available upon request.

These incidents will be reviewed by the ICT team on a regular basis to identify any underlying issues or risks. Any risks will be added to the relevant risk register with an associated action plan. This action plan will be signed off by the relevant Information Asset Owner or SIRO, depending upon the impact.

A report on all information security incidents will be provided to the SIRO on, at least, an annual basis alongside the risk register. This is to ensure assurance is provided that the monitoring, escalation and management of information security incidents is to the required standard.

5.6. Service Provision to other organisation’s

Where ICT services are provided to other organisation’s, Information Security Incidents and Events will be recorded and reported in line with the contract or service level agreement; where appropriate details of these issues will be provided to the SIRO alongside an assessment of their relevance to the organisation.

5.7. Management of CRS Smartcard Incidents

Management of CRS Smartcard incidents will be in line with the current Registration Authority Incident Procedure but will meet the reporting and escalation standards detailed here.


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6.0 External Information Security Incidents and Events

6.1. Provision of service by third parties.

All contracts and service level agreements with external service providers for ICT or other services with information security implications must outline the reporting and escalation process to the organisation. These incidents must be included in the report to the SIRO and must meet the minimum standard outlined in this assurance plan.

6.2. Nominated Contact Point or Security Manager

Where services are provided by a third party, a nominated contact point or security manager must be identified. This post holder will provide updates on issues and resolutions in a timely and appropriate manner to the standard required by the contract or service level agreement.

6.3. Data Protection Act 1998 – Data Processing

Where a third party provides a service that involves the processing of personal data, for either patients or staff, the provision of that service and management of security incidents and events must be included in a contract which meets, as a minimum, the required Department of Health standard.

This will include a data processing agreement. Further details on these requirements and the definition of personal data are provided in the Information Governance Framework.

7.0 Performance

7.1. Measures of ICT Performance

All providers of ICT services will provide report on ICT performance on a routine basis. These will be made available to the SIRO and will be scrutinized in line with the Information Security Framework. These reports will provide details of (for the reporting period):

• The level of performance for different teams and services (for example Network, Voice and Mobile Working)

• Change Control management • Information Security priorities and actions • Network capacity, trends and management • Server capacity, trends and management • The number of helpdesk calls received, resolved and open • Number of User authorised User accounts • Number of User accounts activiated • Number of User accounts deactivated • Number of Information Security Incidents, Events or Near Misses • Lessons Learnt from Information Security Incidents • Compliance Monitoring • Audit findings and reports • Review Meetings • Changes to Controls and system policies


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• System intrusion reports • Virus software effectiveness • User Surveys

7.2. Informatics Performance Measures

Information teams will provided an overview of their performance on information security issues on a regular basis to the SIRO. This will include:

• Number of users with access to patient identifiable data • Number of users activated and deactivated with access to patient identifiable data All performance issues or information security incidents

7.3. Other Security Performance Measures

It is expected that the Estates Management and Security Protocol will outline how physical security will be managed and assurance provided to the SIRO. This will include site security, incident management, office moves, changes and decommissioning.

8.0 Change Management

All new processes, services, information systems, and other relevant information assets are developed and implemented in a secure and structured manner, and will comply with Information Management, Governance and Security accreditation. They will account for data quality, confidentiality and data protection requirements

It is required that the impact of any change is assessed and signed off before the change process is initiated. This change will include:

• A privacy impact assessment for changes impacting on patient or staff data • A security assessment for changes impact on ICT security (network, telephony) or physical

security • A risk assessment on the potential risks of the change incorporating any risks to the delivery of

the change. This risk assessment must balance the benefits of undertaking the change against the risks, and those risks of not undertaking the change.

• A procurement and contract requirement review for any use of third parties for the provision of services impacting on information management or security.

• Further guidance on the change process can be found in the Information Governance Framework.

8.1. Change Management that requires SIRO sign off

Where the following criteria apply SIRO sign off will be required before any Change can commence:

• Any changes that impact upon Key Information Assets or Systems • Any changes that impact on the service provision to significant number of staff • Any changes that impact upon the service provided to customers of the value of

significant value per annum • Any changes that impact upon more than significant number of patients • Any changes with a risk assessment that rate as high than risk score of 15 (See the Risk

Management Process for more detail).


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The precise definition of significant will be set in the Information Governance Framework in agreement with the SIRO.

8.2. Change Management that requires Caldicott Guardian sign off

Where the following criteria apply Caldicott Guardian, for the relevant organisation(s), will be required before any Change can commence:

Where patient records (regardless of format) are impacted Where a privacy impact assessment has indicated a significant change or threat to privacy

8.3. Sign off where these criteria do not apply

Where these criteria do not apply, sign off will be provided by the principle Information Asset Owner effected or the Director acting as Senior Responsible Officer for the project/change.


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9.0 Mandatory Controls and improvements

All Key Information Systems are required to include details on the standard of access controls in place and whether they meet the mandatory controls expected by the Department of Health and Information Security requirements.

Where these controls are not in place this must be reflected in the Risk Assessment and an action plan for improvement detailed.

The following sections outline the mandated safeguards, those required on a risk basis and those that should be documented in access control procedures for information assets.

9.1. Mandated Safeguards

Table 1

Safeguard Information Assets this applies to: Servers should be kept in a physically secure area inaccessible to unauthorised individuals or an encryption solution must be deployed. Encryption is recommended in all cases.

Servers

An encryption solution must be deployed to protect all laptops, computer discs (both internal and external), memory sticks, back-ups and other removable or portable media in line with mandatory requirements and standards.

Mobile devices Laptops, Computer Discs, Memory sticks, back ups and portables

Anti-virus software should be installed on each computer and configured to check all possible sources of infection e.g. CD and DVD-ROMs, USB devices, email, websites, downloaded files etc. The anti-virus software should be kept up to date at all times.

Laptops, Desktops

The operating systems of computers should be regularly updated with published security patches.

Laptops, Desktops, Servers

Drives and ports etc that are unnecessary for the business purposes should be disabled.

Laptops, Desktops

The disposal or destruction of information assets must be managed securely following agreed procedures.

Laptops, Desktops, Portable media In addition: Servers, switches, routers and other devices that record information or data

There must be clearly defined and manageable rules for access and use of the information asset based on the need to know principle.

All information assets through Procedure, Guidelines or Policy


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9.2. Risk Mitigated Safeguards Include

Table 2

Safeguard Information Assets this applies to: Anti-theft measures: Have desktop and laptop computers used in public areas been equipped with anti-theft devices?

Desktop, Laptops

Premises security: Have staff been assigned responsibility for locking doors and windows in locations where an information asset is located? What are the controls for storing assets (eg lockable cabinets), and are they used appropriately by staff?

Physical, assigned responsibility at local level

System classification: Has there been an assessment of the business importance and sensitivity of information to be processed by the information asset and has a classification been assigned to the system and/or its data?

All Information Assets

Backups: Are procedures available to perform and test regular data backups, and is at least one copy of that data stored in a secure off-site location?

Electronic Info Assets

Business continuity: Is there a business continuity plan available and tested in case of a disaster?


9.3. Access Control

Table 3

Safeguard Information Assets this applies to: Unique ID and Password for each user, Network login, System Login, VPN token, authenticator, CRS Smartcard

Electronic

Locked cupboards, pedestals, key room, key held by senior staff member, within locked building, key card access

Physical

Access covered by policy, procedure or guidance; terms and conditions signed by staff member before access or on access; training provided before access


10.0 Information Asset Owner’s Review

Information Asset Owners are appointed by the organisation in line Information Governance Framework. They are supported by the Information Asset Administrators in delivering assurance for the information assets within their remit.

10.1. Asset Management

Information Asset Owners are responsible for the management of assets within their remit. This includes Information Assets, systems, databases and records, in addition to the ICT equipment (desktops, laptops) and services (software) issued to staff within their remit. They must ensure:


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For Information Assets:

• A complete entry in the Information Asset Register must be maintained for all information assets within their remit

• An information risk assessment must be undertaken on the effectiveness of controls on access and use of the asset

• Any significant changes through the asset must go through a change process to ensure its continued integrity and availability

• All ICT equipment and services (including desktops, software licenses) must:

• Be procured through the approved ICT process • Have an identified responsible officer • Have an up-to-date entry in the Asset Register, accounting for any change of responsibility or use

Any contractual obligations resulting from either: Information assets, ICT equipment or services must be registered and managed to the required standard.

10.2. Annual Information Asset Owner Assurance

• The information Asset Owner (IAO) Assurance will detail the following: • Information Assets within the Owners remit • Status of entry on Information Assets Register • Information Risks within remit are identified, managed in accordance with the risk management

and assurance framework • Level of training achieved by staff within the IAOs remit • New starters within the remit (and their level of training) • Number of staff leaving the IAO remit during the period and confirmation that they have

completed the leavers process • The register of staff authorised to access Patient Identifiable Data is up-to-date and access has

been reviewed • Confidentiality spot checks were undertaken, reviewed and actions underway to resolve any

risks as per the Confidentiality Audit Procedure

• Confirming details of the ICT equipment and services within their remit:

• Number of ICT assets and service (software) • Confirmation that each asset is listed on the asset register and is up-to-date • Confirmation that any ICT equipment or licenses from staff leaving the organisation

11.0 Audit and monitoring criteria

11.1. Monitoring of compliance

Compliance with this protocol, framework and procedures are undertaken through the Information Governance Toolkit annual self assessment and an audit undertaken on the level of assurance provided by the submitted evidence.

This policy and strategy will be regularly monitored to ensure it is up-to-date, relevant and continues to support strategic aims and objectives

Table 4 below sets out how we will monitor implementation and utilisation of this Protocol. Document Title: Policy and Strategy – Information Security Issue date: Jun-2013 Document Status: Interim Approved Review date: Jun-2014

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Table 4

Document Audit and Monitoring Table

Monitoring requirements “What in this document do we have to monitor”

The Information Security Policy and Strategy is monitored as part of the Information Governance Toolkit on an annual basis.

Monitoring Method Information Governance Toolkit annual assessment

Monitoring prepared by IG Lead and IG Function (SL CSU)

Monitoring presented to Information Governance Steering Group

Frequency of presentation Annual independent audit, submissions in line with Department of Health Guidance

11.2. Non Compliance

Failure to comply with the standards and appropriate governance of information as detailed in this protocol and supporting procedures can result in disciplinary action. All staff are reminded that this protocol covers several aspects of legal compliance that as individuals they are responsible for.

Failure to maintain these standards can result in criminal proceedings against the individual.

11.3. Disciplinary measures

Failure to comply with the standards and appropriate governance of information as detailed in this policy, supporting protocols and procedures can result in disciplinary action. All staff are reminded that this policy covers several aspects of legal compliance that as individuals they are responsible for. Failure to maintain these standards can result in criminal proceedings against the individual. These include but are not limited to:

• Data Protection Act 1998 • Freedom of Information Act 2000 • Computer Misuse Act 1990 • Common law duty of confidentiality • Human Rights Act 1998

For a full list of relevant legislation and guidance see the Information Governance Framework.

12.0 Review

12.1. Next formal review

Review will take place of the 1st anniversary of adoption and subsequently every three years until rescinded or superseded.

12.2. Latest Version

The audience of this document should be aware that a physical copy may not be the latest version. The latest version, which supersedes all previous versions, is available at the location indicated in the document control section of this document. Those to whom this protocol applies


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are responsible for familiarising themselves periodically with the latest version and for complying with protocol requirements at all times.

13.0 Statement of evidence/references

A full list of guidelines, evidence and references will be provided and maintained in the Information Governance Framework.

13.1. Legislative and Regulatory Environment

• Access to Health Records Act 1990 • Computer Misuse Act 1990 • Copyright, Designs and Patents Act 1990 • Data Protection (Processing of sensitive Personal Data) Order 2000 • Data Protection Act 1998 • Freedom of Information Act 2000 • Human Rights Act 1998 • Regulation of Investigatory Powers Act 2000

13.2. Other References

• DoH Confidentiality NHS Code of Practice. • DoH Information Security NHS Code of Practice • DoH Records Management NHS Code of Practice. • ISO 27001 – Information Security Standard • Report on the Review of Patient - Identifiable Information (Caldicott Report) December

1997

14.0 Implementation and dissemination of document

The Policy and Strategy, once approved by the Organisation’s Board, or delegated group, will be shared with all staff through the all staff email, updated on the intranet, and shared with the organisations Management Board. A team briefing will be provided to support this dissemination.

All staff will be made aware of their responsibilities for Information Security through generic and specific training programmes and guidance. Awareness will be checked on at least an annual basis.

15.0 Annexes


Annexe B – Information Security Definitions


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This is a checklist to ensure relevant equality and equity aspects of policies, protocols or guidance have been addressed either in the main body of the document or in a separate equality & equity impact assessment (EEIA)/ equality analysis. It is not a substitute for EEIA/ equality analysis which is normally required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to see whether the EEIA has covered the ground and to give assurance that the proposals will not only be legal but also fair and equitable and lead to reduced health inequality.

Challenge questions Yes/No DK/NA

Comments

1. Does the document set out the health care needs of the groups intended to benefit from the proposal, including any differences in need in terms of the legally protected or other characteristics (such as socioeconomic position)

NA

2. Does the document set out any known existing inequality in access, quality, experience and outcome of care for populations relevant to the proposal (ie as defined in 1. and in relation to the existing health or care service)?

NA

3. Are there any particular public concerns about equality about the policy area than need to be addressed?

NA

4. Has the policy described any gaps in knowledge about 1 -3, and any action taken to fill gaps (or recommendations for action)

NA

5. Does the document set out risks to equity of access, quality, experience and outcomes including risk of direct or indirect discrimination, and risk to good relations between people of different groups?

NA

6. Does the document describe any specific opportunities to promote equality and human rights, good relations between people of different groups, to enhance participation, etc?

Yes

Additional information to patient on the use of their information and choices.

The policy covers rights under the Data Protection Act 1998 and Human Rights

Act 1998. 7. Does the document describe how the proposal, policy etc

will address the identified inequalities, and NA

8. Does the document make recommendations to mitigate risks and enhance the opportunities to promote equality and equity?

NA

9. Does the document describe how monitoring and reporting will take place to assure equality and equity in the future including to stakeholders. [audit and monitoring table may be used]

Yes

* Race/ ethnicity, gender (including gender reassignment) age, religion or belief, disability, sexual orientation, marriage or civil partnership, pregnancy and maternity. This will include groups such as refugees and asylum seekers, new migrants, Gypsy and Traveller communities; and people with long term conditions, hearing or visual impairments, mental health problems or learning disability


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Annexe B – Information Security Definitions

Term Definition Caldicott Guardian An appointed Board member responsible to the Board for the

implementation and adherence to information governance Principles IAA Information Asset Administrator IAO Information Asset Owner

ICT Information, Communication & Technology IGT Information Governance Toolkit (the official title of the annual assessment

required by Connecting for Health) IM&T Information Management & Technology Information Commissioner (ICO)

The Information commissioner is the duly appointed person responsible for monitoring and ensuring compliance of both the Data Protection Act and the Freedom of Information Act. The ICO has been given legal powers to enforce the Requirements of these acts

Personal Data Personal Data is defined by a piece of information that either on its own, or in connection with other information that the user has or has readily access to can identify a living Individual

PID Personal (or Patient) Identifiable Data

Portable Devices Otherwise referred to as mobile devices, this refers to any device that has no fixed location such as a laptop, mobile phone or camera

Sensitive personal data

This is a list of types of information that are classed in accordance of the Act as sensitive and require further justification for processing data.

SIRO Senior Information Risk Owner (nominated board appointment that has overall accountability for Information Risk Management).

Use of Personal Data

The term use of personal data includes holding such data within the organisation.


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Delivery Committee

Thursday 18th July 2013

Present Dr Helen Tattersfield (HT) Chair, LCCG Dr Faruk Majid (FM) Deputy Chair, Senior Clinical Director, LCCG Dr David Abraham (DA) Senior Clinical Director, LCCG Dr Hilary Entwistle (HE) Clinical Director, LCCG Dr Judy Chen (JC) Clinical Director, LCCG Ray Warburton (RW) Lay Member, LCCG Diana Braithwaite (DB) Commissioning Director, LCCG Alison Browne (AB) Nurse Director, LCCG

Attending Mike Hellier (MH) Head of System Intelligence, LCCG Neil Stevenson (NS) Assistant Director Acute Contracting (Lewisham), SLCSU Nick Brown (NB) Head of Finance and Business Bobbie Fasham (BF) Corporate Services Officer (Minutes)

Apologies Martin Wilkinson (MW) Managing Director (Designate AO), LCCG Dr David Abraham (DA) Senior Clinical Director, LCCG Tony Read (TR) Chief Financial Officer

1. Welcome and Introductions

HT welcomed all to the meeting.

2. Apologies

Apologies were taken and noted.

3. Declaration of Interests

There were no new interests declared.

4(a). Minutes of previous meeting

Minutes of the Delivery Committee meeting on Thursday 20th June were agreed.

4(b). Action Log

The following items were discussed and updated:

May 5.1/5.2: DA reported that a meeting took place on 11th July with John Miell and Richard Martin. It was agreed that a scale of costs for pathology tests would be produced. NS highlighted that there are no national direct access pathology prices. John Miell was keen to look at areas where they may be waste – i.e. vitamin D tests. The aim is to make the best use of the service and make efficiency

ENCLOSURE 14

savings. Educate GPs not to order a test unless it will determine whether or not to refer and encourage the hospital not to reorder tests that have already been done. DA to summarise information for the August Membership Forum. May 10: Artwork and cost agreed. Awaiting installation. Action closed. May 11: Acute contracting seminar arranged for 19.09.2013. Action closed. May 14: JC and HT met with the RCPCH. It was agreed the review would look at the implications of change for the paediatric pathway. JC reported that the maternity group was going to focus on maternity and acute and its name will change accordingly. HE requested that the group make asthma and respiratory conditions a priority. MH highlighted that asthma in under 19s was going up nationally. March 9.2: A system has been established for replying to mental health alerts, James Forrester will collate. Replies came to FLAG on 11th July and will be discussed on quarterly basis at the GP commissioner meeting. 5. Matters Arising There were no matters arising. 6. Month 3 Finance Report NB gave the month 3 finance report. At month 3 the CCG is reporting a financial surplus of £2.071k, £15k below its planned year to date position. At month 3 the CCG is forecasting to deliver its £3.699m planned surplus. The CCG’s revenue resource limit totals £365,012k. Within the allocation the CCG has assumed

- £426k relating to Community Dental Funding which presently sits within Southwark CCG’s allocation

- £424k relating to the transfer of Manley Court from Lambeth to Lewisham These allocations adjustments have been agreed with the relevant CCG’s, awaiting NHS England confirmation. As a PCT, Lewisham received £3.492m funding for Joint Working with the Local Authority. The treatment of this allocation within the new NHS structure is yet to be confirmed and is not reflected within the CCG’s resource limit. The main risk is the acute position. Month 3 shows a £1.5m overspend, the main areas of overspend are within the Lewisham and Kings contracts. The Joint Commissioning budgets are showing an overspend due to the current commitments across continuing care. The AAS underspend is activity driven. HE reported that the service is not publicised well enough and is difficult to access. It was agreed that the service would be publicised on GPi and in the next newsletter including case studies. Action: DB to publicise the AAS service on GPi and in the next newsletter.

2 | P a g e L C C G : D e l i v e r y C o m m i t t e e – D R A F T M I N U T E S

£10.4m has been transferred from the CCG to NHS England following the funding gap of £288m identified across London in relation to acute hospital specialised services. A triangulation exercise is taking place. The CCG’s QIPP schemes are presently in line with plan, however there are emerging risks within:

- GP New Outpatient Referrals - COPD and Other Respiratory - MSK Integrated Pathway

RW commended the clear report and queried what was causing the Kings overspend. NS responded that at M2 Kings were £890k over plan, there are three main reasons:

1. Kings are reporting against the wrong plan, this is being addressed by the CSU 2. Issues with the new maternity pathway, this is being address across LSL 3. Increased emergency and outpatient activity

HT requested that the report is checked for PCT references where this should be CCG. Inherited Cardiac Disease (ICD) Service at LHNT NS presented the report requesting the Committee approves the decommissioning of the ICD service at LHNT. The ICD outpatient service is a nationally designated specialist service and therefore commissioned by NHS England. The 13/14 value of the LHNT service is £129k. In adopting a lead provider model for this service NHS England chose not to directly commission LHNT. NHS England has made GSTT the lead provider. HT asked how many patients this involves and what will happen to them. NS highlighted three possible outcomes:

- NHS England commission the service at Lewisham - GSTT sub-contracts LHNT to provide the service - The service terminates at Lewisham and patients are transferred to GSTT as appropriate

NS highlighted that the decision falls to NHS England who will have to continue funding the service until an alternative and appropriate model is in place. RW stated that if decommissioning we need to ensure our patients still have access to a good service. HE highlighted that if the service was too far removed from where patients are it will be hard to encourage family members to go for screening. Agreed: A contract variation to be made to the CCG contract with LHNT to remove from the contract the ICD outpatient service. InHealth Contract NS presented the report requesting the Committee to make a decision on whether the InHealth contract should be re-procured or decommissioned from 1 April 2014. NS recommended, given that the Department of Health policy is to encourage wide as possible patient choice as well as ensure there are sufficient providers in the market place plus the fact that this is now a zero based contract charged at national tariff, that the InHealth contract is re-commissioned. Other options include partial recommissioning where the CCG chooses which services to procure on an AQP basis or decommission the services.


The options were discussed. MH highlighted that there are a number of over 6 week waiters for diagnostics and this service may be a way of managing this. FM highlighted that the decision must encourage GPs to follow the pathways and expressed concern over the risk of opening up additional points of access is that it creates additional activity and cost. There is a risk that if GPs use InHealth for a test and on that basis refers the provider will want to do their own test. DA asked whether InHealth offered a full service i.e. help interpreting the results of tests if required. DA suggested that where providers are overstretched they are encouraged to use the service directly. NS stated that the majority of InHealth work was done on an NHS site and historically they did provide support to NHS providers. Lewisham Healthcare terminated their arrangement with InHealth in 2012/13 as they felt they had sufficient capacity. HE suggested that the service was recommissioned for the reasons stated but that it was not widely publicised to prevent overuse. JC disagreed that it should not be published due to patient choice and being open with the Membership. HT suggested that only MRI and ultrasound should be recommissioned as these were the only services widely used. HT requested further information on the MRI and ultrasound activity by practice so leads could discuss at a neighbourhood meeting. Agreed: To recommission MRI and ultrasound services (option 2 in the report) Action: NS to provide InHealth MRI and ultrasound activity by practice. 7. Monthly QIPP Monitoring Report DB presented the QIPP monitoring report which provided an overview of the key milestones for each work stream. The following key points were highlighted:

- The CCG is not able to access SUS data, therefore the report contains no activity data, the format, type and timeliness of the data provided by the CSU is still being developed.

- Early indicators suggest that GP 1st Outpatient Referrals and COPD are not on a trajectory to meet their respective QIPP targets. The outpatient strategy will be submitted to the Strategy and Development Committee on 1st August.

- Plan B proposals are being worked on. Physiotherapy is currently being developed and discussions will be held with the Trust.

- A request was made at the Service Redesign meeting for the trust to respond to the CCG’s evaluation of the AAS service.

The Committee noted the progress on the QIPP programmes for 2013/14. It was requested that pressure is put on the CSU to provide the data. 8. QIPP Integrated Case Management – Equality Impact Assessment (EIA) DB presented the EIA Report for the Risk Profiling and Collaborative Care Planning programme. The EIA concludes that there would not be substantial adverse impact on protected groups. RW commended the report and made the following suggestion 4 | P a g e L C C G : D e l i v e r y C o m m i t t e e – D R A F T M I N U T E S

- To go through the three lines of the general equality duty more explicitly and address them • Eliminate unlawful discrimination, harassment and victimisation and other conduct

prohibited by the Act. • Advance equality of opportunity between people who share a protected characteristic

and those who do not. • Foster good relations between people who share a protected characteristic and those

who do not. RW highlighted work that had been done around religion and how this affects people’s approach to disease. JC highlighted that at the Equalities workshop it was agreed that in addition to the 9 protected characteristics the equality duty would also be applied to the economically disadvantaged. 9. Performance Exception Report MH presented the performance exception report on mixed sex accommodation. There are breaches at Kings. MH reported that capital works have started and should be finished in august 2013 to reduce breaches to zero. MH reported on the preparation that was underway in collaboration with NHS England for winter. DA highlighted that the Healthier Communities Select Committee placed more emphasis on patient experience than the 4 hour target. While having a target is good it must be used rationally. 10. Individual Funding Requests DA highlighted a conflict of interest in this item as a paid member of the IFR panel. AB presented the revised report taking into account the Committee’s comments at the June meeting. The Committee requested that £15k per treatment be the agreed limit and anything above this cost would need Governing Body Approval. AB suggested that this is increased to £25k due to the cost of some drugs. The IFR committee would review the drug treatment on an annual basis unless the drug becomes part of NICE guidance. AB highlighted that Lambeth and Southwark hear appeals from Bexley and Lewisham and vice versa. Approved: The Committee approved the terms of reference for the IFR panel, the appeals panel and IFR triage meeting. The treatment limit for drugs to be increased to £25k, with review of the treatment on an annual basis by the IFR panel. The limit for all other treatments to remain at £15k. It was requested that a quarterly report is provided to the Delivery Committee. Agreed: The Committee agreed the membership of the Committees. The Chair and lay members would remain in post for 6 months and then the posts advertised. 11. Information Governance and Information Security Policies MH presented the Information Governance and Information Security Policies. The policies were approved by the Information Governance Steering Group (IGSG). The holding of personal information is limited as a CCG. The IGSG will licence any exceptions i.e. safeguarding. The work programme for Information Governance is:

- Q1 and Q2: Adopt IG policies - Q3: Operate controls: ensure IG mandatory training and other controls are in place


- Q4: Audit controls and second submission of IG Toolkit The Information Security policy defines the information security management and assurance arrangements. It outlines the systems that ensure current information security obligations are met, how changes, performance and incidents are managed. The CCG has raised its first incident relating to Outlook roaming profiles with access to NHS Net accounts. It is thought this will be resolved with the desktop upgrade. JC highlighted that commissioners have a lot of information about other providers. MH responded that it is legitimate for healthcare purposes to see a provider’s publicly available data. Providers should be transparent and it’s important for commissioners to know where improvement is needed so the right support can be provided. RW made the following comments

- The policy focuses on what happens to the information once we have it, this needs to be re-balanced so that the public and staff know what information is being collected and how it is used.

- It needs to be clear what is meant by confidential for example the CCG collects equality and monitoring data which is confidential but almost everyone in the HR team are able to access it.

- More focus on information that is held on portable devices and how the owner needs to be security conscious.

- Include clear information on who should be contacted if there is an issue. 13. Reports from sub-groups FLAG The approved minutes of the FLAG meeting held on 13th June were taken for information. FM highlighted that FLAG looks at quality data from providers as well as local data on a rolling basis and that the information provided is now of a better standard. The group has been strengthened by additional members, Hilary Entwistle and Diana Robbins. Work has been undertaken to improve the quality of District Nursing and improve the communication between providers and GPs. Serious incidents are reviewed monthly; work is being done to look at how to monitor and develop pressure ulcer reporting and management. Feedback from serious incidents escalated to NHS England is being sought and learning implemented. Two recent SIs include the misapplication of DNR policy and a prescription error. The patient who was given the wrong prescription died however it was concluded that this was not as a result of the prescription error. Learning is being implemented. The Health and Safeguarding Group report to FLAG. Information from other bodies i.e. Healthwatch is reviewed quarterly. At the last meeting the quality dashboard was discussed. While the Delivery Committee concluded there was too much detail officers felt the detail was important. JC suggested the report could be themed by areas i.e. acute, maternity, elderly to make it more accessible. JC stated that she was confused where things were fed in i.e. the caesarean section issue. NS was dealing with the correspondence with CQC, LHNT’s quality group and the Maternity group are following up. HE reported that FLAG was aware and included it in the quality report to the Delivery Committee in June however it may not be discussed at FLAG if it is being picked up elsewhere.


Delivery Committee Members were invited to observe a FLAG meeting. 14. Any other business Information: HE reported that one of her patients with a sickle cell crisis was admitted and then admitted again the next day for a review of the previous admission. HE argued that this was part of the same episode of care. NS said he was unable to look at this as it involved patient data and the only way to resolve this was for HE to speak directly to Jo Peck. This is an example of the problems with the new rules around information. Risk Profiling DES: The LMC asked questions on the risk profiling DES. Action: DB to provide an update to the Clinical Directors meeting Welcome Pack for New Doctors: HT asked what stage this was at. Action: DB to follow up on the welcome pack for new doctors. Smoking Cessation: HT asked for an update on the solution being tested to resolve the problem of practices having to enter the data into EMIS and QUIT Manager to go to the August Membership Forum. Action: DB to provide an update to the August Membership Forum Health Visiting Expansion: JC reported that health visitors will be based geographically centred on practices from January 2014. Children Centre’s will host the health visiting teams who will serve 2-3 practices. There will be 1 link within the team. HT requested that a discussion is had with the neighbourhoods to decide how the teams will work out. HE asked for continuity of the Health Visitor doing the baby clinic. 15. Date of the next meeting

The next meeting will be held on Thursday 15th August.


OPEN ITEMS

REF ACTIONS BY WHOM TIMESCALE STATUS/COMMENT July 6.1 Publicise AAS service on GPi and in

the next newsletter DB 31st July 02.08.2013: Confirmation required from HE on what AAS is

currently being accessed. Chris Gadney to contact LHNT as AAS is currently unavailable directly to GPs. Update to be provided at August meeting.

July 6.2 Provide InHealth MRI and ultrasound activity by practice.

NS September

July 14.1 Provide an update on the risk profiling DES to the Clinical Directors meeting

DB 25th July

25.07.2013: Update provided at the Clinical Directors Meeting on 25th July

July 14.2 Follow up on the welcome pack for new doctors

CM-S October

July 14.3 Update the August Membership Forum on the resolution to QUIT Manage/EMIS Web smoking cessation data entry

DB 14th August 08.08.2013: On the agenda for the Membership Forum meeting on 14th August.

June 6 DB to meet with NS to review recommendations made as a result of the review of the 2012/13 LHNT acute contract.

DB/NS August 04.07.2013: DB and NS have developed an action plan with timeframes and deliverables to commence addressing the new work streams and this will be monitored via the regular joint commissioning reviews of the acute contract performance for LHNT. This work has been integrated to underpin the corporate risk register in relation to the specific risk in respect of over performance against contract. It is envisaged this work should support early mitigation where ‘viable/feasible’ against over performance in the areas identified. An update report will be brought back to the committee in August.

June 11 TR to work with Dee Carlin and MO to come back with plan B options for AQP

TR July

May 5.1 1. Changes to the national tariff with regards to pathology testing to be communicated to practices

2. Reduce duplicate testing to form part of an alternative QIPP

DA/NS September 18.07.2013: DA and NS met with John Miell and Richard Martin. It was agreed that a scale of cost for pathology tests would be produced. John Mile was keen to look at areas where they may be waste. DA to provide a summary to the Membership Forum on 11.09.2013.

May 14 HT to raise at the Clinical Strategy HT June 18.07.13: JC and HT met with the RCPCH. It was agreed

Group whether to ask the Royal College of Paediatrics and Child Health (RCPCH) to review the TSA restructure of paediatric services.

the review would look at the implications of change for the paediatric pathway. 20.06.13: RCPCH are producing a business plan. 06.06.13: SE London Clinical Strategy Group expressed positive interest but was not willing to invite a review by the RCPCH. The CCG will still request the review. Sue Eardley, Invited Reviews Department, RCPCH has offered to meet to discuss what the review covered. HT and JC taking forward.

Mar. 5 JC to bring to the Strategy and Development Group a report on the Immunisation Strategy following attendance at the Immunisation Strategy Group.

JC August 01.08.13: Discussed at the Strategy and Development meeting on 1st August. 06.06.13: Deferred until August 16.05.13: JC attended the first meeting of the Immunisation Strategy Group and is discussing with Arun Gupta the possibility of an automated call and re-call system.


Strategy and Development Committee Meeting Thursday 6th June 2013

Members:

Dr Helen Tattersfield (HT) Chair, LCCG Dr David Abraham (DA) Deputy Chair, Senior Clinical Director, LCCG Dr Faruk Majid (FM) Senior Clinical Director, LCCG Dr Arun Gupta (AG) Clinical Director, LCCG Dr Marc Rowland (MR) Clinical Director, LCCG Diana Robbins (DR) Lay Member, LCCG Susanna Masters (SM) Corporate Director Charles Malcolm-Smith (CM-S) Head of Strategy & Organisational Development, LCCG In Attendance:

Jane Miller (JM) Deputy Director, Public Health Neil Stevenson (NS) Assistant Director Acute Contracting, CSU Corinne Moocarme (CM) Associate Director Physical Disability, CCG/LBL Pauline Grant (PG) Carers Strategic Development Officer, LBL Bobbie Fasham (BF) Corporate Services Officer (Minutes) Apologies:

Martin Wilkinson (MW) Chief Officer

1. Welcome and Introductions DA welcomed all to the meeting.

2. Apologies for Absence Apologies were taken and noted.

3. Declarations of Interests There were no new interests declared. 4(a) Minutes of the previous meeting The minutes of the meeting on 4th April were agreed. 4(b) Review of Action Log/Tracker 04.04.2013/6: AG reported that the procurement period was coming to an end. The CCG agreed at the last meeting that it cannot support the additional funds requested. The business case is being reviewed to look at an acute only VPR. It was agreed a formal discussion with Greenwich was required. 07.02.2013/9: Organisational Development Plan to come back to the Strategy & Development Committee on 1st August.

ENCLOSURE 15

5. Outpatient activity at non-LSL providers

NS presented the report looking at outpatient activity at non LSL providers as requested by the Delivery Committee. Key findings included: -

- Activity has remained broadly stable in 12/13 - Ophthalmology has the highest level activity, although this is expected as it is not provided at

LHNT - The biggest external provider is South London Healthcare NHS Trust, followed by University

College London and Moorfields. - GP referral as a source of referral remains the main reason for a first outpatient attendance. It

might be beneficial to work with optometrists and dentists to ensure appropriate referral. AG asked how patients were self referring to ophthalmology. NS explained that this could be a coding error, someone who arrived in A&E and was subsequently seen or a patient who had been seen previously going directly. DR confirmed that on occasions Moorfields do advise patients not to phone their GP but go to them directly. DR highlighted that when given the choice patients often choose based on location and appointment availability, therefore a possible financial saving could be made by bringing common tests into a community clinic. MR highlighted that better communication was needed around the MECS service. If Moorfields is to be a tertiary hospital minor attendances should be reviewed and a plan put in place to change behaviour. SM highlighted that the purpose of looking at this data is to get an overview of patterns of referrals particularly during the changes to acute services configuration and to inform commissioning intentions. Action:

- NS and SM to work on a framework to look at trends of activity for all providers to monitor the strategy

- NS and SM to review the current portfolio of acute providers to inform commissioning intentions

6. Carers Strategy CM and PG presented the joint carers strategy, which sets out the strategic aims and priorities for all agencies working with carers across Lewisham during 2013 to 2016. It identifies four strategic priority areas that are aligned to the five national outcomes for carers. In consultation with carers 10 local priorities for carers in Lewisham have been developed. Consultation included an online and postal survey, consultations at the annual Lewisham Carers day event, face to face meetings small and large facilitated events and workshops. Consideration was given to the draft Care and Support Bill which is likely to become an Act in 2014 and will have significant implications to the way Carers’ services will be delivered. A detailed action plan has been produced, key leads and deadlines to be identified. The action plan will be monitored by the Lewisham Carers Partnership Board. The budget for carers per annum is £2.5m. Of these monies £250,000 goes to Carers Lewisham. PG was commended for the report and work on the strategy. The committee made the following comments

- The level of engagement and consultation was commended - Questions were asked about what has been happening since the previous carers strategy expired

in 2010.

2 | P a g e L e w i s h a m C l i n i c a l C o m m i s s i o n i n g G r o u p : S t r a t e g y & D e v e l o p m e n t C o m m i t t e e

- How to liaise more closely with primary care was discussed, the option to return to the committee or Clinical Directors with options was given. Figures detailing how many referrals were made by practice would be useful.

- Action plan to include clear timescales, priorities and lead contact details - It was suggested that community pharmacy providers were looked at as a source of

referral/promotion of the service. - Accountability of the Carers Partnership Board to be clarified

Taking into account the comments above the committee: -

- Embraced the aims and objectives of the Joint Carers Strategy - Agreed the priorities for the Carers Services - Endorsed the next steps for supporting carers in Lewisham over the next 3 years.

7. Public Engagement Group: Access to Primary Care

Following the meeting of the Public Engagement Group on the 17th May it was agreed that the Chair would bring to the attention of the Strategy and Development Committee for discussion and comment the need for more work to be done around GP access. It was recognised that new and improved systems offering appointments were being tried in some practices but in others unacceptable barriers appear to persist confirmed by feedback from the LINk and national GP survey. HT highlighted discussions at the Clinical Directors meeting on 30th May where it was agreed that Ashley O’Shaughnessy would work with MR to collate information on practice appointment systems to inform the learning event on GP access planned for 18th July. It was agreed that further information on how the public defined access would be useful. It was highlighted that previous legislation requiring a service whereby patients can speak to a health professional within 24 hours and see a GP within 28 hours limits the number of appointments that can be pre-booked. In addition if patients may have to wait longer if they want to see a certain GP. Not everyone needs to see a GP; GPs need to be seeing the right patients at the right time to improve medical outcomes. It was agreed that this issue should be raised with NHS England. Action: HT to meet with David Sturgeon, Jane Fryer and Clinical Directors to discuss Primary Care.

8. Draft Engagement Strategy DR presented the draft engagement strategy highlighting that informing and engaging the public is important for the development of the CCG. Through involving and engaging patients the CCG will be better able to commission high quality services more consistently. The CCG wants to develop into an organisation where everybody recognises and promotes the value of involving patients and the public. Solid plans for engagement mean that we can be sure that patients and the public have a real and demonstrable impact on the decisions the CCG makes. An eight step plan to public engagement has been developed. To ensure the delivery of the strategy a work plan will be developed which will be underpinned by the appointment of a Head of Public Engagement. The approach of moving away from combining engagement of public, members and stakeholders to a focus on the public was commended.


JM commented that it would be good to build on what is already happening in Lewisham and link with the voluntary and community sector who have good links with various communities. There is an interim evaluation of the North Lewisham programme which includes a lot of learning on how to reach communities which could be useful. DR highlighted that the working group set up to develop the engagement strategy involves people from public health, VAL, Healthwatch and the Council. In addition there is a plan to extend three of the Public Engagement Group meetings into Joint Public Engagement Meetings to pursue joint proposals in detail. It was suggested that under the delivery priorities that informing and helping to monitor quality is made explicit. How PEG plans to draw out inequalities and prioritise issues needs to be further developed. It was agreed that the strategy will be brought back to the committee for final review on 1st August.

9. TSA Programme Governance Arrangements SM presented a progress report detailing the governance arrangements being put in place to oversee the implementation of the Secretary of State’s decision regarding dissolution of South London Healthcare Trust and the creation of the Lewisham and Greenwich NHS Trust. A Programme Board has been set up (first meeting held on 23rd May) to ensure the programme delivers the Secretary of State’s decisions. The Programme Board is supported by a Stakeholders Forum, a Patient and Public Advisory Group and an External Clinical Assurance Group. In addition there will be a Clinical Implementation Group to ensure the changes reflect the required standards, deliver safe and sustainable services during transition and beyond. In terms of timescales, nothing can be done that cannot be undone until the outcome of the Judicial Review is known. Business cases are being produced. Organisational changes are being planned for October 2013 with service changes taking place over a 2-3 year period. The next steps will be to decide how and where the CCG should be involved, who represents the CCG at meetings and how feedback is received. Lewisham Healthcare has developed its plan to ensure the safe transaction of the merger of LHNT and QE. A Partner Stakeholder Group is being established and the CCG has been asked to send a representative. HT highlighted that this is a critical group for the CCG to be involved with. The first meeting is planned for the 20th June, HT plans to attend. HT asked where the CSG fitted in and expressed concern that there is the potential for a lot of time to be wasted attending meetings at which the CCG cannot influence or inform the decisions. It was agreed that further explanation of these structures by someone from the TSA was required so the CCG could better understand how best it could participate in these arrangements. It was proposed that the committee met with their counterparts in Greenwich CCG to discuss strategic plans to understand where there is or is not alignment. JM highlighted that the public health teams worked closely together as the populations of Lewisham and Greenwich are becoming similar in terms of deprivation and diversity. Actions

- SM to arrange for someone from the TSA to explain the Programme Governance Arrangements 4 | P a g e L e w i s h a m C l i n i c a l C o m m i s s i o n i n g G r o u p : S t r a t e g y & D e v e l o p m e n t C o m m i t t e e

- A meeting to be arranged with Greenwich CCG counterparts to discuss strategic plans 10. Any Other Business

Public Engagement Group: DR reported that the Patient & Public Involvement and Inequalities Group had agreed to change the name of the group to Public Engagement Group to more accurately reflect what they do. Revised terms of reference will be put to the Delivery Committee. South West London Consultation: SM reported that the CCG had been sent details of the South West London Consultation affecting Croydon, Epsom, Kingston, St George’s and St Helier. Three options are being considered: -

1. Preferred: Croydon, Kingston and St George’s remain as major acute hospitals, Epsom becomes a local hospital with an elective centre and St Helier becomes a local hospital

2. Alternative: Croydon, Kingston and St George’s remain as major acute hospitals, St Helier becomes a local hospital with an elective centre and Epsom becomes a local hospital

3. Least preferred: Kingston, St George’s and St Helier remain as major acute hospitals, Epsom becomes a local hospital with an elective centre and Croydon becomes a local hospital.

It was agreed that SM would write a response highlighting that option three was also Lewisham CCG’s least preferred option due to the proposed configuration changes in SE London. Action: SM to respond to the South West London Consultation. Analysis of Paediatrics: HT reported that the SE London Clinical Strategy Group expressed positive interest but was not willing to invite a review by the Royal College of Paediatrics and Child Health (RCPCH). The CCG can still request the review. Sue Eardley, Invited Reviews Department, RCPCH has offered to meet to discuss what the review covered. It was agreed HT and Judy Chen would take this forward.

11. Date of Next Meeting Thursday 1st August 9:30 – 12:00


REFERENCE ACTIONS LEAD/S DEADLINE STATUS/COMMENT

06.06.2013/5 Outpatient activity 1. Develop a framework to look at trends of activity

for all providers to monitor the strategy 2. Review the current portfolio of acute providers to

inform commissioning intentions

NS/SM August 2013

26.07.2013: Draft Strategic Plan’s Monitoring Framework - is being developed to include both outcomes measures and activity trends for all providers. It will be presented to the Governing Body at its meeting on 5th September. Lewisham’s CCG’s Acute Contract Portfolio – an analysis of the current acute contract portfolio will be completed with recommendations at next Strategy and Development Committee on 7th November 2013

06.06.2013/7 Access to Primary Care HT to meet with David Sturgeon, Jane Fryer and Clinical Directors to discuss Primary Care

HT July 2013 04.07.2013: Meeting took place on 4th July. Access was discussed. Agreed PMS contract could be reviewed.

06.06.2013/9 TSA Programme Governance Arrangements 1. SM to arrange for someone from the TSA to

explain the Programme Governance Arrangements

2. A meeting to be arranged with Greenwich CCG

counterparts to discuss strategic plans

SM August 2013

1. Meeting arranged with Caroline Taylor and Christina Craig for 29th August 12:00 – 13:00.

2. Meeting arranged with Greenwich CCG for Thursday 5th September 9:30 – 12:00.

06.06.2013/10 South West London Consultation SM to respond to the South West London Consultation

SM July 2013 12.06.2013: Completed, letter sent 12.06.2013


04.04.2013/6 Virtual Patient Record Business Case TR to set up a meeting with HT, MW and Annabel Burn to begin the conversation with Greenwich CCG

TR April 2013 04.07.2013: The Governing Body on 04.07.2013 approved the outline Business Case, subject to conclusion of risk management agreements between the CCG and LHNT. 06.06.2013: AG reported that the procurement period was coming to an end. The CCG agreed at the last meeting that it cannot support the additional funds requested. The business case is being reviewed to look at an acute only VPR. It was agreed a formal discussion with Greenwich was still required. 04.06.2013: AG attended the VPR Project Board on 03.06.2013. AG has had informal discussions with Bexley and Greenwich CCGs. Will be discussed further at the Service Redesign meeting on 13.06.2013.

07.02.2013/9 Equalities Actions CM-S to produce amended terms of reference for the PPI and Strategy & Development Committee. CM-S to amend section 3 of the Equalities Action Plan to combine 3.1 and 3.2.

CM-S March 2013 06.06.2013: Organisational Development Plan to come back to the Strategy & Development Committee on 1st August.

25.03.13: Amended ToRs for Strategy and Development Committee included with the papers for the meeting on 04.04.13. PPI ToRs to be completed.

Actions for the equalities action plan will be incorporated into the revised Organisational Development Plan.


SHADOW AUDIT COMMITTEE

Minutes of the meeting held Monday 18 March 2013 Room 1 Cantilever House

PRESENT

Ray Warburton Lay Vice Chair (Chair) Prof Ami David Registered Nurse Dr Suparna Das Secondary Care Doctor Dr Faruk Majid Senior Clinical Director Diana Robbins Lay Member

IN ATTENDANCE

Lesley Aitken Corporate Services Manager (minutes) Sue Exton External Audit Graham Hewett Head of Integrated Governance Tony Read Finance Director David Stacey Internal Audit Martin Wilkinson Managing Director

APOLOGIES

Bill Bryant Acting Deputy Director of Finance (CSU) Martin Bull Interim Deputy Director of Finance (CSU) (from 13/24)

AC13/17 Welcome

Mr Warburton welcomed all to the meeting.

In light of Mr Bryant’s absence and Mr Bull’s late arrival, it was noted that CSU Finance colleagues should prioritise their attendance at future meetings, where the agenda required.

AC13/18 Declarations of Interest

There were no interests declared which would knowingly affect the business of the meeting.

AC13/19 Minutes of the last meeting

The minutes of the meeting held on 11 February were agreed as a correct subject to the seventh bullet point on AC13/02 ‘there needed to be a mention of the Remuneration Committee’ being removed. AC13/20 Action Log and Matters arising

ENCLOSURE 16

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The Glossary of Terms was welcomed, as was a List of Abbreviations, which was tabled at the meeting. Both will be reviewed and updated after each meeting. Both documents will form part of the papers for future meetings. All actions on the log were agenda items at the meeting.

Mr Warburton said that the papers which went to the 13 March Joint Audit Committee would be made available electronically to members.

ACTION: Lesley Aitken

Regarding the NHS Croydon lessons learned report which had been presented to the Audit Committee at its last meeting, Mr Warburton said that one item on the checklist from the report mentioned the Finance Committee. He asked whether it was thought the Delivery Committee had the capacity and time to look at finance and quality targets in sufficient depth and in particular balance sheets and full scrutiny of finance matters. The subject of whether a Lewisham CCG Finance Committee should be held would be reviewed and brought back to the meeting.

ACTION: Martin Wilkinson and Tony Read

It was agreed that the CCG’s committee and meeting structure would be reviewed to look at where assurance and reassurance takes place and to avoid repetition.

ACTION: Martin Wilkinson

AC13/21 Terms of Reference (TOR) Mr Read presented the changes to the draft Terms of Reference as requested by the Audit Committee at the last meeting, these were:

• The Governing Body Nurse member had been added to the membership • The description of the Audit Committee had been broadened to include further

areas such as quality. • The SLCSU (South London Commissioning Support Unit) had been referenced • Reference to the Remuneration Committee had been deleted • Reference to the Statement of Internal Control had been replaced with the Annual

Governance Statement • Quorum rules had been updated to three members with one at least being a lay

member. The Committee ADOPTED the Terms of Reference; these would be reviewed in March 2014. Ac13/22 Readiness for Statutory Duties Report Mr Read gave the verbal report. He reported that there had been two areas in the Finance Governance Toolkit that were not covered in the report to the last meeting:

• Register of interests • Financial policies and procedures not in place

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These had now been adequately covered. The transfer scheme regarding the legal transfer of assets and liabilities from the PCT to CCG, NHS Commissioning Board or Public Health England has to be signed off by the Secretary of State. The Department of Health had commented on the transfer scheme and the CCG had responded. The final sign off by the Secretary of State would be in week beginning 25 March 2013. Regarding the CCG as a receiver, the Governing Body had delegated responsibility to the Chief Officer to sign off, with legal advice from Capsticks, the transfer scheme. A report would come back to the Governing Body. Mr Read explained that some terminated contracts may still have consequences. The terminated contracts would be transferred to the Department of Health Legacy Department. The Committee ACCEPTED the verbal report. AC13/23 Internal Audit Plan; Governing Body Priorities Mr Warburton said that with regard to the Croydon checklist, the area ‘was the Board confident that they, the Audit Committee had received sufficient training on their responsibilities, risk assurance practices, constructive challenge and appropriate monitoring of follow up actions etc’ was, in part, being covered by independent training being arranged for Governing Body members of the Audit Committee. Ms Robbins added that training on the conventions of NHS Finance would be useful for Audit or Finance Committee members. Clarity was needed on all financial reports for full transparency. Mr Read agreed that the skills audit undertaken by Governing Body members highlighted that some respondents were not confident in challenging on a variety of matters including finance. He would produce a package using a web based training tool to address the concerns.

ACTION: Tony Read

Professor David said that it would be helpful to fully understand internal processes. A list of meetings to be held before June would be shared with members.

ACTION: to be arranged with Lesley Aitken

Ms Exton suggested that the minutes of Committee meetings were routinely circulated to Governing Body members. Mr Wilkinson confirmed that issues from the meetings would be summarised and how to incorporate these reports into the Governing Body meeting was being looked into. The verbal report was NOTED

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AC13/24 Internal Audit Plan The Committee were asked to consider the draft audit plan which had been prepared by the Head of Internal Audit using a risk based approach. Mr Warburton asked for assurance of the 2012/13 Internal Audit Plan on the areas:

1. Why the PCT has not paid attention to the NHS Outcome Framework 2. The lack of business cases for QIPP

Mr Stacey responded:

1. This had been looked at by the Cluster. 2. The CCG was looking at the documentation of assumptions.

Mr Read had taken note of the recommendation for QIPP 2013/14 onwards and would look at the production of documentation. There would be external help to look at the risks. Mr Stacey described how the Internal Audit Plan 2013-14 was structured. There was a risk assessment of those functions performed by the CSU and a risk assessment of the CCG’s operations. The risk assessment of the CSU and CCG classifies risks along two axes, one showing whether risks are internally or externally generated; and the other showing whether the risks are known or new /changing. In Section Two of the plan, the key risks facing Lewisham CCG were outlined, showing how they were placed against the two axes. Internal Audit had also looked at the CSU offering. Section Three outlined key risks on systems operated by the CSU for the CCGs. Section Four was a Schedule of Internal Audit review which showed that for 2013/14 the CCG had 147 days of Internal Audit work. These currently were broken down to: 85 - Specific reviews 30 - Review of CSU systems and assurances 15 - Contingency 12 - Planning and recommendation follow up 5 – HIA role and management The suggested high risk (priority) areas were shown as: Acute over performance Lewisham children’s safeguarding Emergency Planning Bariatric waits at KCH Data protection/sharing protocols Responding to the Francis Report Budgetary control

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Performance management by the CSU Scheme of delegation/approval rights There were some areas of commonality across South East London CCGs. Comments were taken from the Committee:

• While there should be an ongoing focus on children’s safeguarding, it was agreed that there should be a strong focus on adult safeguarding towards the end of the year.

• Could the key risks be categorised, such as reputational, risk to patients/quality issues and finance.

• It was asked how the risks were populated and where the severe and important risks were shown

• How to capture how the level of risk could impact on other risks – overlap • To look at the risk from the TSA and reassess • How the membership organisation would add value to issues – this should be

weaved into year 2 or 3. • Need to refine and review terminology of areas • Emergency planning should not be a high risk for the CCG • Regarding confidence in data used for reports such as Integrated Governance. Mr

Warburton queried whether it was reliable and useful in informing the CCG on what it needed to know. He suggested taking 4 or 5 clinical data items and drilling down. The CSU assurance days could be used for this area.

Internal Audit would work with officers on the recommendations from the Francis Report. Mr Stacey said that two pieces of work could be undertaken, either 1) look at retrospectively or 2) look at work undertaken so far and also retrospective work. Mr Wilkinson added that recommendations from the Francis Report would be built into the Quality Assurance Framework. It was explained that the Audit Committee would agree the priorities and the number of days associated with reviews. It was agreed that Mr Read and Mr Wilkinson would, taking into account the comments from the Committee, revise the 2013/14 Internal Audit schedule of audit reviews to be SIGNED OFF by Chair’s action before 1 April 2013. A report would be brought back to the next Audit Committee.

ACTION: Tony Read and Martin Wilkinson

Mr Martin Bull joined the meeting and apologised for his lateness which was due to unavoidable attendance at another meeting. AC13/25 Internal Auditor for 2013/14 Mr Read reported that the CCG’s preferred Internal Auditor for 2013/14 would be KPMG with support from the London Audit Consortium (LAC). This would be the arrangement for the six CCGs across South East London. The Committee agreed that maintaining KPMG and LAC as Internal Audit providers during the coming year was sensible and would provide continuity. The CSU will organise a tendering exercise for the appointment of an

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Internal Audit provider for 2014/15. . The CSU had prepared a specification for Internal Audit services for CCG facing audits. Mr Stacey added that the KPMG would act as Head of Internal Audit, working with London Audit Consortium to project manage delivery. The Committee RECEIVED the verbal report on the Internal Auditor arrangements for 2013/14 and onwards AC13/26 External Auditor for 2013/14 Ms Exton confirmed the scale of fees; for Lewisham they would be £84,800. There was an additional fee of £8,200 for first year additional work but this would be picked up by the Audit Commission. Ms Aitken had contacted all Governing Body members to confirm that there were no known conflicts of interest to obstruct Grant Thornton being appointed as External Auditor. Ms Aitken confirmed that no conflicts had been received. It was likely, for consistency, that Ms Exton would be proposed as engagement lead for Lewisham CCG. The Committee RECEIVED the verbal report on the arrangements for External Auditor service for 2013/14 AC13/27 Summary of the HFMA Audit Commission Handbook and the role of the

Audit Committee Ms Robbins had been requested at the 11 February meeting of the Audit Committee to summarise the HFMA Audit Commission Handbook. She said that much in the handbook was familiar but also out of date. It was noted that there was another revision of the handbook underway for CCGs, which would include case studies and practical tips. The report was all about balance; what to and not to do. She gave a verbal report and highlighted the following: The CCG needs an Audit Committee in order to:

• Give assurance to the Governing Body that systems and processes were working effectively to deal with risk, and supporting the organisations corporate objective

• Continually to review the relevance and rigour of the Assurance Framework and identify key sources of assurance, and review the validity of the data used.

The Committee should:

• Have a systematic approach to identifying risks of deteriorating quality as a result of cuts.

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• To have a broad remit without losing its focus on finance and financial management and how to work with auditors and how to review reports such as clinical audit and counterfraud.

It is not its role to establish or maintain governance processes; act as a Finance Committee; oversee the risk agenda or manage audit functions but would draw assurance from internal and external auditors. The report suggested that the Audit Committee should consider what data ‘would give them comfort’, and ask how these could be captured on the assurance framework. A review of the relevant clinical audit systems, including soft and hard evidence, for the CCG would come back to the Audit Committee, covering the process of how to be made systematic and followed up.

ACTION: Graham Hewett

It was confirmed that Quality Accounts would go to the FLAG and a Governing Body seminar before sign off at the formal Governing Body meeting.

ACTION: Graham Hewett/Lesley Aitken The Committee thanked Ms Robbins for her comprehensive report. AC13/28 Summary of HFMA Accounts Guide for PCTs Dr Majid gave a verbal report on the HFMA Accounts Guide for PCTs; he had previously circulated a paper. The guide was in two parts; an explanation of accounting processes and different sets of accounts. The accounts comprised of four primary statements:

1. Operating Cost Statement 2. Statement of Financial Position (was the Balance Sheet) 3. Statement of Changes in Taxpayers Equity 4. Statement of Cash Flows

There was a recommended timetable for reporting for discussions with auditors, the content of reports should be planned. There was a list of questions to be raised by Non-Executive Directors (NEDs) which should be asked for effective financial management, these included:

• Have the figures changed compared to last year? If there were significant changes, what caused them?

• Are accounting processes policies consistent with what you know and what the PCT does in practice?

• Has the PCT met its targets with regard to revenue resource limit and capital resource limit?

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• Do you expect the PCT to meet its targets based on reports received during the year?

A new version of the Accounts Guide was being developed for CCGs but the principles were the same as for PCTs. It was asked how assurance that questions raised on the process during the year would be given. It was said that some, such as budget control, would be gained through the Internal Audit Plan. These questions would be taken into account during the discussions on whether to hold a Finance Committee.

ACTION: Tony Read/Martin Wilkinson

Where the questions listed should be raised would be reflected in the paper on Committees Mr Read would bring back to the Audit Committee.

ACTION: Tony Read

The Committee thanked Dr Majid for his comprehensive report. Overall, the Committee said that both Ms Robbins and Dr Majid had provided much welcome “food for thought”. AC13/29 Update on CCG Functions Mr Hewett reported that the CCG functions had been divided between Mr Wilkinson and the Directors of the CCG. A paper was being developed and would be presented at the Delivery Committee on 21 March. A policies pack would also be taken to the Delivery Committee for approval and ratification at the Governing Body meeting. The Committee RECEIVED the verbal report AC13/30 Annual Governance Statement 2012/13 Mr Wilkinson reported that this was the PCT Annual Governance Statement for 2012/13 which had been received at the Governing Body on 7 March and the Joint Audit Committees of the PCTs on 13 March where the changes had been accepted. Mr Hewett explained that work was currently underway on a revised version which would be signed off by Mr Andrew Kenworthy the Chief Executive for that period. Further work was being undertaken on the Annual Report by Mr Hewett and Ms Scanlon, Head of Communications. This would then go to the Legacy team for sign off. The process for 2014/15 would be that that the draft Annual Report would come to the Audit Committee in March 2014 with sign off of the Annual Report, Annual Accounts and Head of Internal Audit Opinion in June 2014. ACTION: Lesley Aitken to timetable

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AC13/31 Process and Support for Internal Audit Mr Hewett presented the report which set out the systems and processes put in place to support Internal Audit at the CCG. The Committee NOTED the report for information AC13/32 Working across SEL CCGs on audit and other matters Mr Warburton said that this item was to look at how to ensure that we had joint working across SEL, which included sharing policies with other CCGs thereby reflecting the new world. Ms Robbins asked if we needed to know whom we should collaborate with and what on. Comments given were:

• A suggestion to share where there is over-riding patient care, such as safeguarding • Do we have joint performance committees? • We would commission joint reports from the CSU. Comparative data across CCGs

was useful. • Networks would continue • We should learn from others good practice • There was added value from the joint appointments across Lambeth, Southwark

and Lewisham of Dr Das and Professor David • Our focus would be on the residents of Lewisham

Dr Majid and Mr Warburton would discuss matters before the next meeting of the Audit Chairs.

ACTION: Ray Warburton and Dr Faruk Majid AC13/33 Date of next meeting The next meeting of the Committee would be between 2pm – 5pm on 9 July. Future meetings all to be held 2pm – 5pm: 2013 - 8 October 2014 – 14 January, 25 March, 6 May

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Minute Ref

Action Responsible Person

Timescale Status/Comments

Mar 2013

13/20 Papers that went to the 13 March Joint Audit Committee to be made available electronically to members.

Lesley Aitken April

13/20 Consider whether a Finance Committee should be held taking into account the questions listed under 13/28.

Martin Wilkinson/Tony Read

July meeting

13/20 Review the Audit Committee meeting structure to look at where assurance and reassurance takes place and to avoid repetition

Martin Wilkinson July meeting

13/23 Produce a web based training tool to address the gaps highlighted in the skills audit around challenging.

Tony Read July meeting

13/23 A list of meetings to be held before June to be shared with members.

Lesley Aitken April A list was circulated on 4 April

13/24 Revise the 2013/14 Internal Audit schedule of audit reviews to be signed off by Chair’s action before 1 April 2013. A report to be brought back to the next Audit Committee.

Tony Read and David Stacey

1 April 2013 Report for July meeting

13/27 Review the relevant clinical audit systems, soft and hard evidence, to include the process of how systemised and followed up.

Graham Hewett July meeting

13/27 Quality Accounts to go to the FLAG and a Governing Body seminar before sign off at the formal Governing Body meeting.

Graham Hewett/Lesley Aitken

June The Quality Accounts were signed off at the Delivery Committee.

13/28 Paper on Committees to be brought back to the Audit Committee to include where the questions

Tony Read July meeting

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listed under 13/28 should be raised. 13/30 Timetable of Annual Report and Accounts signoff

to be produced. Lesley Aitken April

13/32 Discuss Working across SEL CCGs on audit and other matters before the next meeting of the Audit Chairs.

Dr Majid / Ray Warburton

Feb 2013

13/01 The Statement of Responsibilities to be circulated.

Sue Exton Circulated.

13/03 A glossary of terms and abbreviations to be included with meeting papers

Lesley Aitken March meeting

13/04 Croydon lessons learned – to email Mr Warburton with their priorities from the checklist

Governing Body Audit Committee members

For March meeting

13/05 Regarding closing down of the PCT and opening of CCG – IA was working with the CSU for the Joint Audit Committees to say how this would be managed. A report to come back to the Committee.

Internal Audit March meeting

13/05 The updates Readiness for Statutory Duties report would come back to the Committee

Martin Wilkinson/Tony Read

March meeting

13/07 Draft Internal Audit Plan for 2012/14 to be circulated for discussion.

Internal Audit

13/08 A response to the Consultation on appointment of External Auditor to be drafted and sent.

Tony Read for Martin Wilkinson

Verbal report back to meeting

13/10 Appointment of Internal Audit service – to obtain a clear line from the SEL Chief Finance Officers

Tony Read to brief Ray Warburton

Verbal report back to the meeting

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13/12 Assurance on the transfer schemes and the issues for the received organisations to be brought to the next meeting.

Tony Read March meeting

13/13 A summary of the HFMA Audit Committee Handbook to clarify the Audit Committee’s role to come back to the next meeting. A summary of the PCT HFMA Accounts Guide to come back to the next meeting.

Diana Robbins Dr Faruk Majid

March meeting

Verbal report Verbal report

13/14 The explanation given at the Committee on the process for the BAF and Risk Registers to given to the Governing Body

Graham Hewett March Governing Body meeting

On Governing Body agenda

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