board part i - wandsworth ccg · (p.23) zr/rg 10:40 20 ... no interests declared over and above...

Board Part I

MEETING13 September 2017 10:00

PUBLISHED8 September 2017

W A N D S W O R T H C C G P A G E 1 O F 2

Board AgendaDate 13/09/2017 Time10:00 MR 1/2

Meeting of the Wandsworth CCG Board

Held at 73-75 Upper Richmond Road, East Putney SW15 2SR,

Wednesday, 13th September 2017, at 10:00

P A R T A | M E E T I N G O P E N S T A R T D U R A T I O N

A01 Apologies, Declarations, Quorum 10:00 5 mins

A02 Clinical Chair’s Opening Remarks NJ 10:05 5 mins

A03Minutes – 14th June 2017: Approval and

Status of Actions (p.5)NJ 10:10 10 mins

A04 Items for AOB NJ 10:20 00 mins

P A R T B | D E C I S I O N S & D I S C U S S I O N S

B01 Clinical Focus – Diabetes (p.16) JP 10:20 20 mins

B02West Wandsworth Locality Annual Report

(p.23)ZR/RG 10:40 20 mins

B03 STP update (p.33) SB 11:00 30 mins

P A R T C | M A N A G E M E N T R E P O R T S

C01 Executive Report (p.56) NJ/JB 11:30 10 mins

C02 Performance Report (p.59) JA 11:40 10 mins

C03 eRS Capacity Alerts at St George’s JA 11:50 10 mins

C04 Finance Report (p.66) NM 12:00 10 mins

P A R T D | B O A R D G O V E R N A N C E

D01 Summary Minutes:

Audit Committee

Finance Resource Committee

Integrated Governance Committee

Primary Care Committee

12:10 10 mins

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]


D02 AOB and Other Matters to Note 12:15 5 mins

D03

Open Space: Public’s Questions

Members of the public present are invited to

ask questions of the Board relating to the

business being conducted. Priority will be

given to written questions that have been

received in advance of the meeting

NJ 12:25 10 mins

P A R T E | M E E T I N G C L O S E

E01 Clinical Chair’s Closing Remarks NJ 12:30 5 mins

E02 To resolve that the public now be excluded

from the meeting because publicity would be

prejudicial to the public interest by reason of

the commercially sensitive or confidential

nature of the business to be conducted in

the second part of the agenda

E03 Part II Agenda items:

No substantive items

Next meeting of the Board: 11th October 2017, 10:00-12:30 East Putney

Going Green …

As part of our commitment to sustainability, Wandsworth CCG will no longer print out

papers for meetings in future. Meeting papers will be available on the website.

Clinicians and managers who attend meetings at our offices will be sent papers in

advance to print off if they need to, rather than copies being available in meetings.

If you do not have access to printing facilities and require a printed copy please let us

know at least 24 hours prior to the meeting.

Part A: Meeting Open

Page

1. Part A: Meeting Open 4

1.1. A01 Apologies, Declarations, Quorum

1.2. A02 Clinical Chair's Opening Remarks

1.3. A03 Minutes 14th June 2017: Approval and Status of Actions 5

1.4. A04 Items for AOB

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Minutes of a meeting of the Clinical Commissioning Group held on 14th June 2017

Present: Nicola Jones (NJ) CCG Lead (Chair)James Blythe (JB) Managing DirectorJames Murray (JM) Chief Finance Officer Stephen Hickey (SH) Lay Member Governance Carol Varlaam (CV) Lay Member Patient and Public InvolvementChris Savory (CS) Lay Member FinanceZoe Rose (ZR) Joint West Wandsworth Locality LeadJonathan Chappell (JC) Joint Battersea Locality LeadMike Lane (ML) Wandle Locality LeadAnthony Farnsworth (AF) Director Commissioning Julie Hesketh (JH) Director Quality and Corporate AffairsAndrew McMylor (AM) Director Transforming Primary Care John Atherton (JA) Director Performance ImprovementHouda Al-Sharifi (HAS) Director of Public Health

In attendance:Jamie Gillespie (JG) Healthwatch WandsworthSandra Allingham (SA) (Minutes)

17/048 Apologies for AbsenceReceived from Sarah Blow, Andrew Neil, Neil McDowell, and Liz Bruce. The meeting was quorate.

17/049 Declarations of InterestNo interests declared over and above those previously recorded on the Register.

17/050 Minutes of the previous meeting held on 10th May 2017The Minutes were agreed as being an accurate record.

17/051 Matters Arising17/039 Healthy London Partnership (HLP) – It was agreed that this would be included as a regular item on the Board Agenda to provide updates. Future papers to the Board will also clearly indicate where specific areas of work are included in the HLP programme.

17/052 Effective Commissioning InitiativesCCGs have previously set policies to support the Effective Commissioning arrangements, based on available evidence. The application of thresholds exists as part of that function. However, the absence of policies leaves a lack of transparency around access to treatment. It was acknowledged that not all treatments are equally effective, therefore, clear and transparent policies are essential to support effective commissioning. The recent initiative to bring together all of the SWL CCGs into having one set of commissioning thresholds and policies in common, recognises that process.

There have been two stages in the process – to bring together existing policies on a range of fifty-nine procedures across the SWL CCGs, to be used consistently; and, through the Committee in Common, to reach agreement on what treatments would be included, and how to communicate with the public and providers. To date the work has largely been to consolidate and harmonise existing policies. The next

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steps were outlined in the paper.

The Board was asked to note the report, and agree that Wandsworth representation on each of the sub-groups and other committees would be finalised outside of this meeting.

Comments and questions were invited from members of the Board:

Patient and public involvement – There were plans for inclusion of patient reps on the Task and Finish groups, and also around communication to ensure transparency regarding the proposals. It was noted, that this may not be a sufficient level of involvement. A general information campaign would be beneficial as part of the process – patient representation on committees was not sufficient. It was important and appropriate to undertake engagement in order to capture patient experience.

The Committee in Common decision regarding the policies should be made in public, and inform the public regarding the interventions.

Engagement with GPs – Clinical leads from the three Localities have been involved in clinical reviews of the ECI and pathway developments, and from a governance and compliance perspective. A number of discussions have been held with Members in each of the Localities with information provided on the review. There is confidence that GPs are sighted on this work, with broad support for the review, and consistency across the CCGs welcomed.

Some Trusts will still be dealing with a number of different policies, which will present an on-going challenge. It was important to try to achieve a balance between national policy and local funding arrangements – ensuring policies are enshrined in local thresholds will assist with that.

Wandsworth representation on group one – Membership of the groups has been suggested, this information can be checked with Nicola Williams as the clinical lead.

Thresholds for interventions in group three need to be absolutely transparent to ensure that decisions are made on a clinical basis.

Any recommendations for changes to thresholds would need to be very explicit that these relate to clinical effectiveness and priorities.

The initiative had been discussed with SWL Directors of Public Health, who supported the approach. It was noted that the Public Health input had been provided on an interim basis, and if further input was required this would need to be included in the Public Health offer. It was noted that provision for Public Health expertise was included in the proposals.

Decisions taken, particularly where there would be low effectiveness, or marginal outcomes, would need to be clear and open in communications.

In summary of the discussion, the Board approved the process, and agreed for Wandsworth representation on committees to be confirmed outside of the meeting. The need to further strengthen the process for patient and public engagement was noted.

AF

17/053 Local Delivery Unit and SWL AllianceThe discussion would focus on the development of the Local Delivery Unit (LDU) more than the SWL Alliance, particularly around four areas – staffing; clinical commissioning leadership; system and process; infra-structure. The following key points were noted:

A single Executive Team was now in place for the LDU.

Staffing - There were on-going discussions around structures. A number of changes would be required across each directorate. Many of the changes were

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obvious in order to make the best use of the available resource and to do things once where appropriate.

The structure around the Commissioning directorate was more complex. The substantive Director would not come into post until July. Both Wandsworth and Merton CCGs held commissioning lead roles, and had established relationships with their individual boroughs around integrated services. There were over forty members of staff within the directorate, dealing with a range of issues, which would need to be undertaken on different levels for the CCG, LDU, and Alliance.

Clinical Leadership - A structure was required to continue to support clinical commissioning. Potential opportunities for work across the two CCGs were being looked at, where possible and appropriate. If potential changes could not be identified, the separate arrangements for clinical leads in both CCGs would continue, with changes to be made over time.

Timescales – Potential changes to structures were currently being worked through for the directorates, and direct reports only to the Commissioning Director for week commencing 10th July. Formal consultation with staff will commence at the end of July. A Staff Forum will also be established. A separate consultation on the rest of the Commissioning directorate will be put in place.

System and Process – Changes will be made to some of the current systems and processes. Joint Executive Management Team meetings are now in place, which has brought together the previous Management Team arrangements. It has been agreed to bring together the Strategy and Planning, and QIPP financial management processes into a single Recovery Group, and Strategic Planning Group.

Infra-structure – Estates and office IT were being reviewed on a wider SWL Alliance level. Options were being considered regarding office locations for all organisations that sit in the Alliance.

Estates – Working across two offices has proved to be challenging for staff as well as Directors. A single principal base would be preferred. It was important to retain a base in both boroughs to provide a facility for meetings and accommodate the competing pressures on clinical leads – this could possibly be located alongside a partner organisation. The IM&T work is being done alongside the estates work to make the best use of estates and to encourage agile working.

Governance and Constitution – A Board Seminar was scheduled for July to continue the review of committees, and looking at the potential to harmonise where possible. Any changes to the Constitution will require a formal process. Work was being done across the Alliance to review Constitutions. A new way of working was anticipated to be in place for end September/October, ahead of next year’s planning round.


Costing information – There is no scope to increase the running costs of the CCGs. Existing QIPP plans and expected efficiencies are already in place in both CCGs - the structure review was a way to do this more appropriately. It was stated at the beginning of the process, that no redundancies were anticipated, and this has been re-iterated. Areas have been identified where existing skills can be used more efficiently across the two CCGs. There is a significant provision in the QIPP that savings on corporate costs will be made, but these still need to be worked through. It was noted that the cost of the Alliance and the STP Programme Office would also need to be built in. A paper was anticipated for presentation to all CCG Boards in July regarding costs and governance arrangements, and what was being provided from that resource

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and financial envelope.

Cost savings must be made, but it was important not to pare back to a level where the CCG was not properly resourced. Work was currently being done to review the establishment of both CCGs to ensure a clear understanding of what was currently available and how best to transition that into the new structure.

It was important to utilise estates as effectively as possible, but it was important for clinicians and the public to retain a Wandsworth base.

It was important to recognise that staff will be unsettled during this change. There was a need to provide support to all members of staff and to get communications right.

Relationship with Healthwatch – The LDU will expect to engage with both Wandsworth and Merton Healthwatch on issues that have a direct local impact for patients. There should be no impact on commissioning of services from the development of the LDU. The close relationships with Healthwatch will continue to be maintained. The Executive Team will work on behalf of both Wandsworth and Merton CCGs, and the existing relationships would not need to change.

The CCGs remain the statutory bodies at borough level. The formation of the LDU enables work to be done once, where appropriate, ensuring no duplication of effort. The statutory bodies will still make decisions.

Engagement with patients and stakeholders will continue to be local. The local focus on engagement was important.

The change to the LDU structure has been explained to GP Members, explaining that this relates to the back-office function of the CCG, with no changes to the governance role of the CCG.

The next update should include a positive statement regarding clinical engagement and leadership, and patient and public engagement, and what this will mean in practice.

The Board noted the content of the report.

17/054 Board Assurance FrameworkThe report was presented to the Board on a quarterly basis, providing an update on the risks based around the corporate objectives. The report highlighted risks that had been closed, and new risks opened, since the previous report, and any changes in risk scores.


It was noted that it could be useful to look at the individual risk scores overall to get a sense of how the ratings are reflected, as scoring of individual risks can be subjective.

Concentration and ownership of risks, and ways to ensure these are managed appropriately should be taken into account to ensure that individual directors are not over-loaded with high rated risks.

It was acknowledged that the risk registers in both Wandsworth and Merton CCGs would need to be reviewed. Consideration may be required of whether some of the risks should be aggregated from a strategic perspective. A review of corporate objectives and strategic risks across the LDU would be useful.

It was noted that there was a range of risks relating to SGH. The current risks would be updated to ensure that these are appropriately reflected and controls identified.

A review of the BAF, before being presented to the Board, may be useful.

It was acknowledged that some further work was required to ensure the risks reported in the BAF accurately reflect the current position, with the potential for an JH

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Exec review to be considered further.

The Board noted the risks as reported, and approved the report.

17/055 Clinical Focus – Planned CareNicola Williams (NW) attended the meeting. The paper provides a summary of progress of the Planned Care Delivery Board. At a meeting of the Delivery Board the previous day, five of the seven work plans had been signed off. Clinical leadership from the CCG and St George’s Hospital (SGH) had been engaged in the development of the overall plan, which was now moving from being a commissioner hypothesis to being grounded in more practical proposals and potential for improvement. Work would continue to ensure that the data required was meaningful, which could be used to reconcile and quantify impact of the schemes. This remains a work-in-progress.

Planned Care includes outpatient attendance, and elective planned surgery. It also includes patient journeys, where significant improvement can be made from primary care, through to community services, and secondary care. Good meetings have been held with primary and secondary care clinicians, with the aim for patients to be seen quicker and in better settings.


Delivery of schemes in 17/18 – It was expected that the schemes will be delivered in the current year, but it was not yet clear if this will be at the scale originally anticipated. Areas of significant risk have been highlighted in the QIPP programme. Significant progress has been made, but there had been some slippage on the anticipated schedule, some of which was due to the acknowledged operational issues at SGH.

Referrals to other Trusts – The aim is for pathways to work for all Wandsworth patients. It was expected that patient satisfaction would increase following changes made to pathways.

The main drivers are to provide better quality care, more cost effective care, improve waiting times, and address issues relating to SGH estates. A programme approach is being implemented to do this. Primary care will also be required to change enormously to implement the right pathways and it was important to keep over-sight of that. This was a long term programme in order to achieve the right outcome.

Primary care resource – The GP Federation was working with all practices on how to deliver a different model of care for Diabetes, and phased implementation plan.

NJ thanked NW, on behalf of the Board, for the immense amount of work put in to get the work to this stage. It was important to keep sighted on Planned Care and Urgent Care going forward.

17/056 Executive ReportTwo areas from the report were highlighted:

Trust and Commissioning Assurance Board (TCAB) – This was a bi-lateral meeting held with SGH Executive Team, to gain exceptional assurance outside of the contractual assurance process. There had been some discussion on whether this should now sit within the contractual assurance process. There were a number of challenges and complexity in reporting in a number of different places – any requests for assurance should be effective.

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If agreed this meeting would not continue, there would need to be a clear expectation with Regulators that they would be required to clearly identify where assurance was being taken forward to make sure that all responsibilities were appropriately landed. Discussions around this would continue.

Neurodevelopmental Pathway – There was an underlying pressure around referrals into this pathway, which had significantly increased in recent years. A number of proposals had been discussed London-wide on the criteria that should be applied for diagnosis – no change was being made at this time. There was provision to continue the current pathway for the next twelve months. Significant further engagement would be required with other providers. Assistance had been sought from the National Autistic Society to provide support in taking this forward.


Alliance Staff Conference – The conference invited attendance from all employed members of CCG staff within the Alliance. A copy of the Agenda could be circulated once available.

The content of the report was noted.

JB

17/057 Performance ReportThe report provided a summary of 16/17 performance, an update on performance in month one of 17/18, and a look forward at new targets not previously reported against.

16/17

Mental Health – Good performance against most of the targets. Some issues regarding IAPT (Improving Access to Psychological Therapies) recovery rates, and there was some concern regarding mobilisation of the new service.

Cancer – Delays in two-week wait referrals. Progress was now being made, with action plans in place to mitigate some of the delays. Improvements had also been seen in admin processes.

RTT (Referral to Treatment) – Some work was being done across the Alliance on what specialties could be taken from SGH to be done elsewhere. This would be for specialities where there was currently no available clinical capacity at SGH. NHS England (NHSE) was also providing support to address issues around the electronic referral system.

A&E – SGH performance had been good in relation to other London Trusts. Further work was being taken forward.

Work was being done to review the format of the report to provide a broader perspective on performance.


Trend information – A period of reflection was appropriate. This would be considered in the review of the report format.


JA

17/058 Finance ReportA verbal update was provided as there was limited data available for month 1. A review had been done on reporting across the Alliance, with a standard report being developed.

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Final accounts for 16/17 had now been published. The Annual Accounts and Annual Report had been submitted in accordance with timescales. 17/18 would be significantly more challenging, and the focus of work was now moving to the current year. Wandsworth and Merton CCGs were now working across the LDU on existing QIPP plans.

A reference was made to recent national press regarding a capped expenditure process. The LDU was not a part of that process, but was shadowing behind it. The process and timescale was to focus and review all QIPP plans in the CCG to ensure all plans were aligned, with potential stretch identified, a common risk assessment, and adequate resources. The move to a system-wide process would be done in July. Any opportunities to simplify the transactional process would be taken forward. A similar STP exercise would also be done with providers in order to maximise the potential to achieve financial balance.

The update was noted.

17/059 Sustainability and Transformation Plan UpdateThe first meeting of the Wandsworth and Merton Local Transformation Board was scheduled the following day. This was the vehicle below STP level to take forward many of the STP elements and look at how this will come together in a local system for integrating health and social care, and enable discussions to become a wider system.

17/060 2016/17 Annual Report and Annual AccountsThe 2016/17 Annual Report and Annual Accounts had now been published following the lifting of purdah.

It was noted that the Annual Report and Annual Accounts had been reviewed by the Audit Committee. Following External Audit review, a positive opinion was received. The Committee acknowledged the improvement in the format of the Annual Report from previous years. The Annual Report and Annual Accounts were recommended to the Board for approval, with some minor amendments to be made prior to submission.

A summary version of the Annual Report would be available at the Annual General Meeting in September.

17/061 Summary MinutesThe content was noted.

17/062 Open SpaceNo questions had been submitted ahead of the meeting. Comments and questions were invited from members of the public:

Planned Care – How can areas, outside of those previously identified, be raised for inclusion?

Response: There are a number of other clinical areas that could be considered, and one of the tasks of the Delivery Board to manage is how additional areas of work, not currently identified, can be considered. Already there was some pressure from different quarters for services to be included. Proposals from officers would need to be submitted on how this could be resourced.

17/063 Any Other BusinessNone.

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There being no further business, the meeting closed at 12:20.

Date of next meeting: 5th July 2017

ACTIONS

Ref No. Item Lead

17/052 Effective Commissioning Initiatives - Wandsworth representation on group one to be checked with Nicola Williams as the clinical lead.

AF

17/054 Board Assurance Framework - Further work to be done to ensure the risks reported in the BAF accurately reflect the current position, with the potential for an Exec review to be considered further.

JN

17/056 Executive Report - Alliance Staff Conference – A copy of the Agenda to be circulated once available.

JB

17/057 Performance Report – Inclusion of trend information to be considered in the review of the report format.

JA

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LOG OF DECISIONS AND ACTIONS

Meetingdate

MinuteNo. Item Lead Decision Action Target

Date Progress DateCompleted Conflicts of Interest Action to manage

ConflictsRequest for Chair's

Action Apologies Quorate

6/14/2017

17/052 Effective Commissioning InitiativesAF Board approved the process and agreed for Wandsworth rep on committees to be confirmedMembership of groups to be confirmed ASAP None None No action required SB. AN, NM, LBYes

17/054 Board Assurance Framework JH Board approved the report

Further work required to ensure risksreported accurately reflect the currentposition, and potential Exec review to beconsidered

17/055 Clinical Focus - Planned Care AF/NW Updates on Planned Care and UrgentCare to be scheduled ASAP

17/057 Performance Report JA

Inclusion of trend information to beconsidered for inclusion in new format ofthe report ASAP

17/058 Finance Report JM17/059 Sustainability and Transformation PlanJB17/060 2016/17 Annual Report and Annual AccountsJB

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Summary of discussion from Part II of the Board meeting held on 14th June 2017

Feedback was received from the members of the Board on the Part I meeting.

The Board received a confidential verbal update on the issues around Referral to Treatment delays.

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Part B: Decisions and Discussions

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2. Part B: Decisions and Discussions 15

2.1. B01 Clinical Focus - Diabetes 16

2.2. B02 West Wandsworth Locality Annual Report 23

2.3. B03 STP Update 33

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Strictly Confidential 1 Board Intelligence Hub template

Diabetes Programme ReportAuthor: Clare Elliot Sponsor: Rebecca Wellburn & Josh Potter Clinical lead: Neil Bamford Date: 6th Sept 2017

Executive Summary

Context

Wandsworth diabetes programme has clinical oversight and is the responsibility of the

Wandsworth Diabetes Clinical Reference Group (CRG), ultimately reporting into the Planned

Care Programme Board. The programme of work is wide and covers Type 1 and Type 2 diabetes

and for some projects there is national funding available to deliver the objectives. Many aspects

of diabetes care are addressed, from pre-diabetes to in-patient care, patient education,

professional education and workforce policy and from podiatry to primary care.

Questions this paper addresses

1. What the various diabetes projects are.

2. What the projects objectives are.

3. Who is involved.

Conclusion

1. There are 7 diabetes projects:

New community model of care

Diabetes prevention

Digital patient education pilot

Increased diabetes in-patient specialist nurses

Improved foot health

Patient education

2. The objectives of the work are to improve patient’s outcomes: a measure of improved

health, better value for money, reduced in-patient spells, reduced amputations and an

increase in the number of patients managed in their own GP practice, rather than at an acute

trust.

Input Sought

We would welcome the board’s recognition of the work done to date and its ongoing support.

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The Report

What is the Diabetes Programme Working to Achieve?

The diabetes work is a broad programme covering a number of projects each with the aim of improving the

outcome of those with diabetes. Diabetes is a growing issue in the borough of Wandsworth with increasing

numbers of patients being diagnosed with Type 2. More recently it has been identified that a great number

of people in the borough are also at risk of diabetes.

The objectives of the diabetes programme are to improve patient’s treatment targets, increase the number

of patients completing education, reduce length of stay, reduce amputations and reduce the number of

patients being seen as out-patients at an acute trust.

The Diabetes CRG that oversees the diabetes programme has been working for some time to develop an

integrated model of care that would improve patient care in the borough through significant change in the

service model. The Diabetes CRG membership has oversight of the developments and includes

representatives from patients, Diabetes UK, Merton CCG, public health and SGH and is led by the CCG

clinical lead for diabetes, Dr Neil Bamford.

The diabetes programme manages the following projects:

New community model of care

Diabetes prevention

Digital patient education pilot

Increased diabetes in-patient specialist nurses

Improved foot health

Patient education

During quarter 3 of 2016/17, the CRG worked will colleagues across SWL to bid for and was successful in

receiving funds in three areas: foot health with the Multi-Disciplinary Foot Team bid, inpatient specialist

nurse with the Diabetes In-Patient Specialist Nurse bid and in Patient Education. These are all two year

projects. More recently the CRG joined Merton, Richmond and Kingston to bid for funds from the Health

Innovation Network to test digital education. Funding has recently been made available for this short term

project.

The Diabetes Projects

Each of the projects has its own plan, aims and milestones, all of which contribute to the wider objectives

of improving diabetes care to deliver better patient outcomes.

New Community Model of Care

A specification to deliver an integrated diabetes service was signed off in the autumn of 2016, it proposed a

significant change in the service model. The proposals are wide reaching and significant in scale. The

expectation is that a substantial amount of outpatient activity that is currently being undertaken at St

George’s Hospital will move out of the trust and be managed in the community. The model proposes a shift

of diabetes care out of hospitals into the GP practice, with responsibility for the patient’s care being held by

the GP who is better able to coordinate their care holistically as part of their whole health care

management. Primary care will be supported by diabetes specialist nurses and a consultant in order to

deliver on this model.

The activity delivered by the community diabetes specialist nurses (DSNs) and the specialist nurses at

Queen Mary’s Hospital (QMH) Roehampton will also shift from under the remit of SGH. A substantial

change in the way diabetes is managed in primary care will underpin the new service model.

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The GP Federation have responsibility for scoping out the work that needs to be undertaken in order to

establish the new service model. The GP Federation (The Fed): Battersea Healthcare Community Interest

Company, are supported by the CCG with project management capacity and consultant sessions to

undertake this work. The Fed will produce a report on their findings and make recommendations on the

gaps in provision and how these may be addressed.

Initially, GPs will be supported through education, mentorship and skills training to provide a standard level

of primary care management of diabetes. The National Diabetes Audit shows that the delivery of patient

care in Wandsworth is varied, in order to improve patient outcomes we need to have a consistent high

standard of care; it is recognised that this will take some time to address.

The Fed have undertaken a diabetes education needs questionnaire which identified that the range and

level of previous education varies greatly and there are key priority areas of development. An education

event for all practices included a case study based interactive teaching session on medicines operations,

based on the recently launched CCG guidelines. Following the education event, practices were required to

develop and implement a practice based action plan on improving diabetes care, including identifying all

patients who may be of concern and developing actions plans to address those concerns.

Deep dive visits are underway in ten practices, this involves a clinical review of complex and less complex

patients to provide further information on the range and size of the diabetes issues that need to be

addressed and identifying good practice that can be shared. Dr Roni Saha, consultant diabetologist at St

Georges Hospital leads this work, supported by pharmacist Raj Dhir.

During September, Community Diabetes Specialist Nurses will move from the SGH acute contract into the

Multi-Specialty Care Provider contract. The transfer of this staff cohort is currently underway.

Diabetes Prevention

The National Diabetes Prevention Programme is led by Wandsworth and Richmond Public Health team; the

pharmacy group Reed Momenta provide the education and the programme is coordinated by the HIN on

behalf of South London. Patients are identified as at risk of developing diabetes by primary care and

referred to a nine month course of behaviour change where participants learn about the importance of

exercise, good nutrition and maintaining a healthy weight.

The programme has started small in Wandsworth with test case practices having taken part. Plans are now

in place to increase the number of people referred to the programme across all GP practices with an

incentive of approximately £100 per practice with the view to reach maximum referrals to the nationally

funded programme.

The aim of the project is to reduce the number of people developing Type 2 diabetes in the future.

Outcomes across the country have been positive with a high completion rate reported and attendees

having reduced their weight during the course of the education.

Digital Patient Education Pilot

Working with Merton, Richmond and Kingston, Wandsworth CRG were recently successful in securing £10k

to support a test of digital patient education. One practice in each borough will work with the digital

education provider Oviva to refer their patients for remote education. Oviva, provide Nice aligned

structured electronic education with ongoing behaviour change support. Access can be via apps, phone,

video or face to face.

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The aim of the pilot is to identify if digital education is more likely to be accessed by those who do not

normally access patient education and consequently the practices involved will be asked to refer those

patients who are known not to attend patient education, ie. Working men aged from 25-50.

The outcomes of the project will identify not only the benefits of providing digital education but also if the

education reaches an audience that has previously been difficult to attract.

The project is planned for a duration of 9 months.

National Funding

NHS England have made funding available to improve diabetes care in a number of areas. South West

London CCGs worked jointly on three of the four areas to bid for this money and were successful in

securing additional funding for:

Diabetes Inpatient Specialist Nurses (DISN)

Multi-discipliary Foot Teams (MDFT)

Patient Education (jointly across South London)

Bids were requested for projects of two years in duration. Funding has been confirmed for 17/18 and

ongoing funding confirmation for 18/19 is expected during quarter three.

Increased Diabetes In-patient Specialist Nurses

Wandsworth CCG will receive during 2017/18 & 18/19 an additional £657k to increase the number of DISNs

at St Georges hospital. The funding will cover:

Level 2017 2018

Band 8a 0.3 WTE 0.3 WTE

Band 7 1 WTE 1 WTE

Band 6 2 WTE 3 WTE

Band 3 0.5 WTE 0.5 WTE

The aim of the project is to improve the inpatient care and treatment of diabetic patients, reduce length of

stay and improve patient outcomes.

South Bank University have been commissioned by Wandsworth CCG to provide generic education to the

new staff and to undertake robust analysis of the impact both positive and negative, short and long term of

introducing new clinical staff to the teams.

The bid was considered innovative by the national team in its joint working to introduce junior members of

staff across SWL who would then be upskilled to develop a new workforce and reduce the ‘robbing Peter to

pay Paul’ principle that destablises neighbouring trusts when recruiting locally.

SGH and neighbouring trusts are currently recruiting to the new posts. Capital Nurse are supporting the

recruitment with the use of their logo.

Improved Foot Health

The MDFT bid covered a broad range of projects that would see a reduction in amputations and reduced

length of stay. Wandsworth CCG will receive £774k across 17/18 and 18/19 to:

Create a Multi Disciplinary Foot Team (MDFT)

Introduce a Charcot foot hub

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Test virtual 7 day working

Improve data collection and sharing

Standardise discharge across SWL

Introduce a ‘Foot A&E’

Improve the joint working of secondary care and SGH as a tertiary centre

SGH are developing job descriptions and developing job plans to fill the additional posts, are in the process

of establishing the requirements of a Charcot foot hub and fully establishing the MDFT. A SWL podiatry

workshop is scheduled for September 13th where trusts, providers and commissioners will agree plans for

implementing the system wide work.

Patient Education

South London’s Health Innovation Network (the HIN) coordinated a joint bid for national funding across the

12 CCGs in South London. The project is wide reaching in its scale and covers a number of projects that will

improve patient education in Wandsworth and beyond:

The Diabetes Education Hub

The procurement of centralised referral management coordinating referrals across South London

will provide support to patients in understanding the reason for their referral and finding the most

suitable structured education course for them. The hub will enable patients to be referred to

education in other boroughs allowing a wider choice of provider, location and times.

Information on all education sessions provided by SGH is currently being collected to feed into the

procurement. An equality impact assessment is underway and issues around data sharing are being

investigated.

Increased diabetes education

Part of the funding is dedicated to the provision of additional education for both Type 1 & Type 2

diabetes. The CRG will assess the current education provided to determine how best to increase

activity and reach a wide an audience as possible.

Further, Wandsworth CCG are undertaking a pilot of digital education to assess the value and cost

effectiveness of a new way of delivering education, this is covered on page 3.

My DESMOND is on-line top-up education for those who have already undertaken DESMOND

training. The modules are free and discussions with SGH are underway to make this additional

education available.

Provision of professional education

The HIN are undertaking a scoping exercise to understand the many professional education

programmes available and their benefits. One such package is being tested by GPs via a shared

licence that gives a general understanding of the modules available from this provider.

Workforce Support

To encourage NHS organisations to enable their staff to attend patient education, we will be

working with our large NHS employers such as SGH, CLCH and NEL CSU to change policies and

support their staff to take the time to attend training. This element of the programme has yet to

begin.

Project Governance

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The diabetes programme is one of the Wandsworth, Merton and SGH Planned Care Projects and as such

reports into the Planned Care Programme Board. Much of the work that is being undertaken cuts across

both Merton and Wandsworth.

The Diabetes CRG hold the clinical scrutiny for the work; the group is a stakeholder forum for clinicians,

patients and those who work in diabetes. The group overseas the major project areas and provides CCG

representation to the retinal screening program. Attendees include Diabetes UK, Wandsworth diabetes

academy, the Health Information Network and local community services.

Those projects funded by NHSE report quarterly into NHSE with an update on the achievement of agreed

milestones. Funding is released on the basis of milestone achievement.

The digital education pilot reports milestone achievement into the HIN, a full report at the end of the pilot

is required.

The GP Fed report monthly into the Multi-Specialty Review Group and provide an update at the CRG, a full

report on their findings and recommendations for progress are scheduled for September.

Is the programme on budget?

Due to late approval from NHSE on the bids, the MDFT and DISN projects are all forecast to underspend in

year one. However, the project teams are identifying how this funding could otherwise be spent to improve

diabetes as underspends are likely to be clawed back by NHSE.

Is the programme on track to deliver the planned benefits?

All milestones have been hit so far and all projects are scheduled to deliver according to their original

timescales.

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For Reference

Edit as appropriate:

1. The following were considered when preparing this report:

The long-term implications Yes

The risks Not applicable

Impact on our reputation Not applicable

Impact on our patients Yes

Impact on our providers Yes

Impact on our finances Yes

Equality impact assessment Yes

Patient and public involvement Yes

Please explain your answers:

The risks are covered in the individual project risk registers.

The impact on the reputation is considered positive.

1. This paper relates to the following corporate objectives:

Commission high quality services which improve outcomes and reduce

inequalities Yes

Make the best use of resources, continually improve performance and deliver

statutory responsibilities Yes

Continually improve delivery by listening to and collaborating with our patients,

members, stakeholders and communities Yes

Transform models of care to improve access, ensuring that the right model of care

is delivered in the right setting Yes

Develop the CCG as a continuously improving and effective commissioning

organisation Yes

2. Executive Summaries should not exceed 1 page.My paper does comply

3. Papers should not ordinarily exceed 10 pages including appendices.

My paper does comply

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W A N D S W O R T H C C G P A G E 1 O F 1 0

Strictly Confidential Board Intelligence Hub template

West Wandsworth Locality Update Author: Tanya Stacey Sponsor: Andrew McMylor Date: September 2017

Executive Summary

Context This paper provides the CCG Board with an update about the West Wandsworth locality. The paper provides a description of the methods of engagement with member practices and other stakeholders, the ongoing work to improve quality in Primary Care and the locality investment initiatives which are underway.

Question(s) this paper addresses 1. How has the locality engaged with key stakeholders? 2. How is the locality working toward improving quality in Primary Care? 3. How has the locality investment budget been utilised?

Conclusion 1. The locality engages with member practices through the provision of Member Forums, Joint

Locality Members Forums, Practice Manager Forums and a weekly newsletter. The locality engages with local patients through the Locality Patient Consultative Group. Third Sector organisations are engaged with through the ‘Seldom Heard and Community Group Visit’ initiative.

2. The locality is engaging with the Members Quality Engagement Scheme and has recently supported practices through the CQC inspection process.

3. The locality investment budget is being utilised to develop locality initiatives in the following areas; Breast Cancer Screening, Mens Health, Childhood Immunisations, Social Prescribing, TB testing.

Input Sought We would welcome the board’s input regarding the continued direction of travel for the West Wandsworth Locality.

W A N D S W O R T H C C G

M E R T O N C C G P A G E 1 O F 1 0

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The Report F U R T H E R C O N T E X T

The West Wandsworth Locality covers the areas of Roehampton and Putney, and the eight practices that lie in these areas (see figure 1). The April 2017 GP registered population for West Wandsworth was 84,137. Public Health anticipate the Wandsworth population to increase by 18% between 2011 and 2025. West Wandsworth consists of a diverse demographic population, ranging from Thamesfield, an area of low deprivation with an older population, to Roehampton an area of higher deprivation and a younger population. The largest age group registered in West Wandsworth are 19-64 year olds. The 24-34 year age group forms the largest proportion of the population in Wandsworth and is significantly higher compared to the national average. While sharing many of the same health priorities as the rest of Wandsworth, Public Health analysis demonstrates that West Wandsworth also presents a range of different challenges. For example, West Wandsworth has a higher prevalence of Coronary Heart Disease, COPD, Cancer and Depression compared to the Wandle and Battersea localities. Figure 1: West Wandsworth Practices

Practice Name List Size (as of April 2017)

Inner Park Road Practice (n.b closed May 2017) 2,152

Danebury Avenue Surgery 3,101

The Alton Practice 3,867

Roehampton Surgery 5,913

Mayfield Surgery 6,227

Tudor Lodge Health Centre 7,233

Chartfield Surgery 12,488

Heathbridge Practice 17,299

Putneymead Medical Centre 25,857

The locality has two joint Clinical Leads and a Management Lead who work together to ensure the smooth running of the locality, providing support to practices to enable delivery of local priority areas. The Clinical Leads, Dr Rumant Grewal and Dr Zoe Rose, were elected by the locality members for a 3 year term which began April 1st 2016. Figure 2 below outlines the core locality meetings and their representation; Figure 2: West Wandsworth Meeting Cycle

Members Forum Attendees (10 meetings/year)

Locality Clinical Leads Practice Commissioning Leads Public Health

Locality Management Lead CCG Prescribing Team Community Pharmacist

Locality Patient Representative

Managment Team Attendees (monthly meetings)

Locality Clinical Leads Locality GPs x 2 Locality Management Lead Public Health

Patient Consultative Group

(6 meetings/year)

Practice Managers Forum

(monthly)

Practice Nurse Forum

(In Development)

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1. How has the locality engaged with key stakeholders?

1.1) Member Practices

Members Forums: Monthly Members Forums are attended by representatives from each of the locality practices, Public Health, Medicines Management and a member of the Locality Patient Group. During these meetings discussions aim to inform future commissioning decisions, both in the locality and borough-wide.

Practice Managers Forums: The monthly Practice Manager Forum is attended by the Locality Management Lead and a member of the local GP Federation. This forum is an opportunity to engage with the Practice Managers.

Weekly Updates: A weekly email is sent to Practice Managers, GPs and Practice Nurses, providing information both specific to the locality and Wandsworth-wide. This communication is well received by the practices.

Joint Localities Members Forum (JLMF): JLMFs are held biannually. These events bring member practices from the three localities together to discuss borough wide issues. The most recent events focussed on areas such as; the South West London STP, Supporting demand management and referrals, the GP Forward View and 10 High Impact Actions, the CCGs position as delegated commissioners and primary care quality.

1.2) Locality Patient Consultative Group West Wandsworth has an active Locality Patient Consultative Group (PCG), currently formed of nine members from six practice patient groups. The group has engaged with a range of topics over the year, providing feedback about proposed strategy plans and input into the development of local services (see Figure 3). The group also provides input into the locality investment initiatives. Furthermore, the Putney Wellbeing Friends initiative (see section 3.2)4) has been developed and led by a member of the patient group. Figure 3: Patient Group Discussion Areas

CCG Strategy Consultations Information

Delegated commissioning

End of Life Care

Multispecialty Community Provider (MCP) Model

111 & Out of Hours Service

Healthwatch

Roehampton Partnership

Productive PPI

Patient Online

Wandsworth Self-Management Service

Wandsworth Wellbeing Hub

AirText Service

Wandsworth Foodbank

1.3) Seldom Heard and Community Groups Over the last four years GPs have been encouraged to visit seldom heard and community groups to create links and further understand the role of these groups and how they may be beneficial to their patients. During this time, West Wandsworth GPs have visited a wide variety of groups as shown below:

Groups visited

Adult Dyslexia Support Group, Arabella Drive Learning Disability Centre, Ashmead Care Centre (Dementia Patient Group), Douglas Bader Rehabilitation Centre, Open House, Regenerate Rise, Thomas Pocklington Trust, Wandsworth Asian Women’s Group, Wandsworth Deaf Access Forum, Wandsworth Foodbank

GPs have reported benefiting from the opportunity to improve their knowledge of local third sector services that they can then signpost their patients to. In July 2017, Dr Rumant Grewal and Rebecca Wellburn (Director of Commissioning & Planning) presented to the Putney Society at an event entitled Transforming Healthcare in our Local Area. This event provided an update on local services and described the South West London Sustainability Transformation Plan.

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1.4) Clinical Reference Groups (CRGs) A number of locality GPs are engaging, on behalf of West Wandsworth, with CRGs including diabetes, children’s services, cardiovascular disease, cancer, stroke, dementia and substance misuse. 1.5) Providers As a significant number of patients attend Kingston Hospital, the locality is represented by local GPs on the Kingston Hospital Council of Governors and the Kingston Hospital Clinical Quality Review Group. 1.5)1. Queen Marys Hospital, Roehampton

The locality is working with St Georges Hospital Foundation Trust (SGH) to enhance the provision of the Acute Admissions Avoidance (AAA) pathway at the Queen Mary’s Hospital site. The locality leads have worked with SGH to develop a Consultant Geriatrician led Rapid Access Clinic (RAC) at Queen Mary’s hospital. The service launched in October 2016 and offers GPs the opportunity to access a rapid assessment of elderly patients in the community who have clinical and/or functional deterioration. The clinic provides a Consultant Geriatrician assessment service and investigations can be arranged on site, with the aim of providing an alternative to attendances at A&E and acute admissions. The Locality Leads have also aided development of a Consultant Geriatrician Hotline which improves

access to specialist Geriatrician advice for local GPs. This service aims to contribute to the avoidance

of an acute admission to hospital and enhance the quality of care for frail older patients.

2. How is the Locality Working toward Improving Quality in Primary Care?

2.1) Members Quality and Engagement Scheme The Members Quality and Engagement Scheme (MQES) supports delivery of the CCG Quality agenda within Primary Care in conjunction with the borough wide Quality Contract (which is delivered by the GP Federation on behalf of the CCG). The scheme will support the continued engagement of practices with the CCG as commissioners and members, whilst working to reduce variation and provide assurance of delivery of specific quality areas. All eight West Wandsworth practices have signed up to the scheme. Action plans are submitted throughout the year to provide evidence of working towards improved quality in Primary Care and continued engagement.

2.2) Care Quality Commission (CQC) Inspections All West Wandsworth Practices have received a CQC inspection over the course of the past year. The results of these inspections are outlined in figure 4 below; Figure 4: CQC Ratings

Practice Overall Rating

Domain

Safe Effective Caring Responsive Well Led

The Alton Practice

Good Good Good Good Good Good

Chartfield Surgery


Danebury Avenue Surgery


The Heathbridge Practice


The Mayfield Surgery


Putneymead Medical Centre

Good Good Good Good Outstanding Good

Roehampton Surgery

Requires Improvement

Good Requires

Improvement Good Good

Requires Improvement

Tudor Lodge Health Centre


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Where the CQC report has identified areas for improvement, Practices have been supported by the Locality Manager, Locality Clinical Leads and the Practice Support Team. The Practice Support Team are a multidisciplinary team comprised of GPs, Practice Managers and Practice Nurses, who facilitate discussions with Practice members to identify areas of good practice and areas where improvements could be made. They are also able to offer targeted support to address specific issues where required. Following their initial rating of ‘Requires Improvement’, The Roehampton Surgery have taken part in a second inspection for which we are awaiting publication of the report.

2.3) Inner Park Health Centre Closure Following the retirement of the single-handed GP Partner at Inner Park Road Health Centre, the Practice ceased to operate in May 2017. In collaboration with NHS England, the Practice was supported throughout the closure process and the dispersal of their patient list. This included holding a walk-in event at the Practice where the CCG and NHSE were available to answer any patient queries. GP Resilience Funding was also made available to support neighbouring Practices who saw an increase in their list sizes during the list dispersal.

3. How has the locality investment budget been utilised?

3.1) Locality Investment Budget

Each locality receives a budget to fund projects which are specific to the needs of the local population. In 2016-17 and 2017-18, West Wandsworth received £63,000 to invest in locality schemes. Suggestions from member Practices, Public Health and the Locality Patient Group were reviewed by the Locality Management Team and assessed against criteria which included need, equality, benefits and feasibility. 3.2) Locality Investment – Current Initiatives

3.2)1. Patient Advice Service

The Patient Advice Service launched in West Wandsworth in July 2016 and is currently being provided by Citizens Advice Bureau Wandsworth. The service intends to shift social support needs from GPs to more appropriate community based resources resulting in a reduction in the length of time GPs spend on non-clinical issues and a reduction in frequent attendances. Outcomes for patients include improvements in mental wellbeing and quality of life. Impact is measured through client and GP questionnaires. Where a GP identifies a patient in need of social welfare advice they can refer them directly to the dedicated West Wandsworth Advisor at the Citizens Advice Bureau. The needs of the patient are assessed within 3 working days and they will be given information, advice and signposting via telephone. Where appropriate, a face to face appointment will be made to offer more specialist advice. During the first year of operation, 155 patients were referred to the service, of which 80% had a disability or long-term condition and over 60% had experience of a mental health issue. Benefits and tax credits are the most common issue that clients sought advice on, followed by housing issues and debt (see figure 5).

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Figure 5: Advice Areas

Client questionnaires found that 100% of clients were ‘happy’ or ‘very happy’ with the service received, the information received and the advice they received. Clients also reported that their levels of stress and physical illness were reduced following their contact with the Patient Advice Service. Additional comments provided by clients are shown below; 3.2)2. Men’s Health (Barbershop Initiative)

Men are less likely to attend general practice for routine appointments and screenings. There is evidence that using a “male environment”, such as a Barbershop, away from the more accepted clinical setting helps reach sections of the population that are less likely to attend GP practices and so may help to address health inequalities. Public health data demonstrates that the difference between observed and expected prevalence of

hypertension is significant in Wandsworth (observed 8.3% vs. expected 19.1%) yet hypertension is one

of the most preventable causes of morbidity, disability and mortality. In light of this, this project focused

on hypertension and its health implications through accessing a client group within a barbershop.

The pilot engaged 2 barbers in the Roehampton area, one who catered mainly for African-Caribbean

customers and another who had a predominantly White-British customer base. A Nurse trained in

motivational skills visited the barbershops weekly to offer mini health checks to customers waiting to

have their hair cut.

The Nurses involved in the pilot project saw 280 people, of which;

60% (169) agreed to have a blood pressure check

85% (237) were under the age of 50

25% (70) were smokers

19% (33) were referred to their GP for further advice/tests

0

10

20

30

40

50

60

Benefits Housing Debt Other* Employment Wellbeing and

Community

Care

Enquiries by Advice Area

*'Other' areas include; Immigration, Nationality & Asylum, Legal,

Financial Services & Capability or Discrimination issues

I’m so glad my GP referred me to the

advice service as it

really helped!

It made me see its

okay to ask for help

and there’s light at the end of the tunnel

The advisor was

very helpful and

kind. She provided

an excellent service!

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All men seen also took part in a general health and lifestyle discussion. The Nurse found that 59

participants were at risk of developing CHD and 60 were at risk of developing diabetes. Those at risk

were provided with specific advice about modifying their lifestyle to reduce this.

3.2)3. Cancer: Breast Screening

The NHS Breast Screening Programme invites all women aged 50-70 for breast screening once every three years. The aim of breast screening is to detect breast cancer at an earlier stage, often before the woman is aware of any problem which can lead to simpler and more successful treatment. During 2015-16 all West Wandsworth practices had their patients called for routine Breast Screening. Figures from the previous round of screening showed a low uptake within the locality so we worked in conjunction with the Southwest London Screening Centre to improve uptake. A new EMIS alert was developed and uploaded within practices which provided a reminder that an eligible patient was due to be called for screening, thus encouraging an opportunistic conversation about the process between clinician and patient. All Practices also received a visit from the Southwest London Screening Nurse who encouraged Practices to recall patients who do not attend (DNA). Following this process, feedback from GP Practices was positive; they reported the new EMIS alert and the support received from the locality and the SWL Screening Centre to be useful. An improvement in breast screening recall rates was also evident; on average Practices recalled 185 patients (range 0-416, see figure 6). Figure 6: Breast Screening Recall Rates

Practice Name Number of Breast Screening Recalls Recorded

The Chartfield Surgery 416

Putneymead Group Medical Practice 392

The Roehampton Surgery 256

Mayfield Surgery 180

Tudor Lodge Health Centre 115

Heathbridge Practice 81

Danebury Avenue Surgery 38

The Alton Practice 0

Inner Park Road Health Centre (nb closed May 2017) 0

TOTAL 1478

Average per Practice 185

The main aim of this initiative was to try to embed sustainable good practice regarding breast cancer screening processes. Although we did not see a significant increase in the uptake of screening during the 2015-16 round, this remains to be an area of focus for the locality and we will continue to find new ways to support practices during the upcoming 2018-19 round. We are now working closely with the MacMillan Cancer Research Facilitator to determine additional methods of improving uptake. 3.2)4. Putney Wellbeing Friends

The Putney Wellbeing Friends initiative is being led by a member of the West Wandsworth Patient Consultative Group. Following initial investment from the West Wandsworth locality investment budget, Public Health are now providing ongoing funding. The model aims to support the current mental health services in the Putney area by meeting identified local needs. The initiative improves the accessibility of services by providing an open-access, volunteer-led service within the community at Putney Library and via ‘pop-up’ stalls at a number of local events. Over twenty local volunteers, who have received training in Mental Health First Aid, utilise the Wandsworth Wellbeing Hub and the Books on Prescription service to provide a social prescribing/signposting service for people who are experiencing mild mental health challenges. Local West Wandsworth GPs have been actively referring patients to the service.

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The service aims to contribute to the following outcomes and indicators: - Mental health and wellbeing improvement - Reduction in GP attendances - Positive experiences of care - Reductions in social isolation.

3.2)5. Childhood Immunisations

The childhood immunisation initiative was developed in response to the suggested actions resulting from a childhood immunisation survey which was circulated to all West Wandsworth practices. The locality management team undertook the survey in response to public health data which highlighted that West Wandsworth had some of the lowest uptake levels within Wandsworth and was not meeting recommended targets for childhood immunisation.

The initiative aimed to assist all West Wandsworth practices to increase uptake levels for childhood immunisations in accordance with the latest national schedule & Cover of Vaccination Evaluated Rapidly (COVER) programme and reach target levels of immunisation for herd immunity (95%). To achieve this, we provided each Practice with individual visits from a specialist IT Lead and an experienced Immunisation Nurse. The IT Lead developed precision ‘call and recall’ searches to run automatically within practices to maximise time scales and opportunities to vaccinate eligible children. The IT Lead and Lead Nurse have now completed initial and follow up visits with practices where they implemented the new system and tailored it to the practices individual needs. They are also offering ongoing support, guidance and tools for successful implementation. Practices have reported making changes to their Practice systems and processes following the visits, for example a number of Practices are now running fortnightly or monthly searches leading to a more proactive call and recall system. All Practices are also implementing an SMS reminder system. Although Practices have now begun to implement changes, it is too early to provide an evaluation of the impact on vaccination rates. Analysis of Immunisation data will continue over the course of a 12 month period to allow observation of any seasonal fluctuations. 3.3) Locality Investment – Initiatives under Development

3.3)1. Latent Tuberculosis Infection Testing and Treatment

Tuberculosis (TB) rates in England remain high and are associated with significant morbidity, mortality

and costs. The onset of TB can be difficult to detect with significant diagnostic delays. Late diagnoses

are associated with worse outcomes for the individual, and in the case of pulmonary TB, with a

transmission risk to the public. Following the successful pilot of a TB initiative in the Wandle locality, it

has been decided to roll out the programme to the West Wandsworth locality. The aim of the initiative

is to increase the number of people screened and treated for latent TB among eligible migrant at-risk

populations in GP settings in order to improve early detection and reduce the incidence of TB in

Wandsworth.

3.3)2. Social Prescribing Clinic Pilot Although not funded through the locality investment budget, West Wandsworth are also engaged with a social prescribing clinic pilot. A Community Navigator from the Wandsworth Wellbeing Hub holds a social prescribing clinic once a week at Putneymead Medical Centre. The Community Navigator provides a face to face signposting service for patients who are referred from the Primary Care Team. The aims and objectives of this pilot are as follows;

• Develop an effective social prescribing pathway between Primary Care and the Wellbeing Hub. • Improve the health and wellbeing of patients through providing access to non-medical support. • Increase social prescribing as a first line treatment for symptoms of mild anxiety and depression

and other common mental health problems. • Improve skill mix in Primary Care and reduce clinical workload by providing patients with

community navigation in the most appropriate setting. • Monitor patient outcomes and feedback to the CCG to inform future commissioning.

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• In the longer term, reduce avoidable costs, including A&E attendances and hospital admissions.

Outcomes are being monitored using the well-validated Wellbeing Star measure and through ongoing monitoring of primary and secondary care usage.

C O N C L U S I O N

West Wandsworth will continue to work closely with member practices, local patients, the public and other relevant stakeholders. We will continue to develop and deliver local initiatives which focus on local priorities, concentrating on achieving positive outcomes for the local population. Supporting Practices to manage the changing demands in Primary Care also remains a key focus for the Locality team.

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For Reference Edit as appropriate:


The long-term implications [Yes /No /Not applicable] The risks [Yes /No /Not applicable] Impact on our reputation [Yes /No /Not applicable] Impact on our patients [Yes /No /Not applicable] Impact on our providers [Yes /No /Not applicable] Impact on our finances [Yes /No /Not applicable] Equality impact assessment [Yes /No /Not applicable] Patient and public involvement [Yes /No /Not applicable]


All of the above areas are considered during the ongoing work of the locality, for example the impact of locality investment initiatives on the above areas are continually monitored and assessed. We also engage with stakeholders and work with the PPI team to ensure we are considering the impact on our patients.


Commission high quality services which improve outcomes and reduce inequalities [Yes /No /Not applicable]

Make the best use of resources, continually improve performance and deliver statutory responsibilities [Yes /No /Not applicable]

Continually improve delivery by listening to and collaborating with our patients, members, stakeholders and communities [Yes /No /Not applicable]

Transform models of care to improve access, ensuring that the right model of care is delivered in the right setting [Yes /No /Not applicable]

Develop the CCG as a continuously improving and effective commissioning organisation [Yes /No /Not applicable]


The West Wandsworth locality utilises the opportunity to develop locality initiative investment projects (in conjunction with key stakeholders) to work toward reducing inequalities, improving performance in primary care and to continually develop the CCG at a local level.

3. Executive Summaries should not exceed 1 page. [My paper does / does not comply]

4. Papers should not ordinarily exceed 10 pages including appendices. [My paper does / does not comply]

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South West London Sustainability and Transformation Partnership

SWL Programme Update September 2017

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Introduction

2

This report provides an update on the major work programmes across the south west London Sustainability & Transformation Partnership (STP), as of September 2017. This update is the first in a new series of regular reports to CCG Governing Bodies, Local Transformation Boards, Health and Well Being Boards, Trust Boards, Local Authorities and wider stakeholders across SW London. Comments are welcome on the format, content and channels for dissemination for future reports to ensure that this is a robust and useful report.

Summary highlights for September:

• A refresh of SW London STP strategy is being undertaken in order to ensure we move towards local planning and delivery to keep people healthy and out of hospital, and to ensure that delivery is centred around the Local Transformation Boards.

• Local Transformation Boards (LTB) and new ways of working across Local Delivery Units (LDUs) continue to be embedded to lead the development and delivery of the local health and care models.

• 5 Year Forward View programmes across SW London in Urgent & Emergency Care, Cancer, Primary Care and Mental Health are beginning to ramp up with delivery plans submitted in June and detailed implementation planning now underway.

• In addition, further work continues in delivering a common approach to Musculo-Skeletal Services (MSK) and Effective Commissioning Initiative across SWL as well as agreeing a delivery plan for Maternity to meet the Better Births recommendations.

• Enabling programmes in Digital, Workforce and Estates are focusing on supporting the transformation required across SW London, including – becoming a national digital exemplar, implementing the Electronic Referral System (ERS), establishing a Local Workforce Action Board and developing common approaches to estates development and monitoring.

• A new approach for Communications and Engagement is to be taken to shift the focus locally into the four Local Transformation Board areas. This will include strengthening engagement with local Healthwatch organisations, Overview and Scrutiny Committees and patient groups.


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• The Sustainability and Transformation Partnership for SW London, which includes the NHS and local authorities is currently refreshing its strategy.

• Since the publication of the SW London STP document in November 2016, we have held a series of public engagement events and more in-depth conversations with our stakeholders. As a result, the STP programme Board is now updating its approach and primary focus.

• We want to strengthen the focus on keeping people healthy. Getting involved earlier, as soon as vulnerable people start to become ill at home. We want to stop people from becoming more unwell and give them the right support at home so that they don’t need to be admitted to hospital. We know that being in hospital can in some cases lead to either a reduction in people’s independence, or even getting an infection. If people do go to hospital, we want to get them home, so they can recover more quickly in their own bed, with the right care and support.

• To achieve this focus on keeping people well, the SW London STP recognises that a local approach works best. The NHS working jointly with Local Authorities and local people within boroughs, will plan care based on people’s health and care needs from local-communities upwards. We want to move the conversation on, to be about planning and delivering care in these four health and care partnership areas:

• Kingston/Richmond

• Sutton

• Croydon

• Merton/Wandsworth

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DRAFT

Refresh of SW London Sustainability & Transformation Partnership (STP) strategy


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• We will also be working with our partners in Surrey, and London borders. By the end of November these health and care systems will have reviewed the feedback from local people over the last 6 months, analysed their local data and identified their challenges. They will then set out how they plan to work together to improve services for local people, and be clinically and financially sustainable into the future.

• We will now take advice from the local stakeholders and build on engagement to date to involve local people in planning services going forward. If any proposals would mean significant change, the statutory organisations would of course consult local people, with advice from our Overview and Scrutiny groups in each area, and our Health Watch partners.

• Since the October 2016 version of the STP was published, NHS leaders have now stated that all hospitals in South West London will continue to be needed in future, but that not all these hospitals will need to provide the same services that they do today.

• In November, we will publish an updated and refreshed strategy document that will consolidate this view and strengthen our major focus on working together in local health and care partnerships, to keep people well and out of hospital.

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Refresh of SW London Sustainability & Transformation Partnership (STP) strategy


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Local Transformation Boards (LTB) Update

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Updates on Local Transformation Boards (LTBs)

• LTBs are in place and meeting on a monthly/bi-monthly basis for each local delivery unit (LDU), with core representation at senior clinical and management level from respective CCG, Local Authority, Acute, Community Health, Mental Health, GP Federation/Collaborative, Healthwatch, and Voluntary sector organisations .

• All LTBs have been developing their terms of reference and ways of working.

• The focus of the LTBs have included:

• Croydon: agreeing the out of hospital health and care model business case.

• Sutton: reviewing progress of the development of the health and care model, beginning to look at accountable care system model. Continued work on activity and financial modelling.

• Merton & Wandsworth: reviewing demographic growth analysis, and progress of planned, emergency, and primary care model developments. Continued work on activity and financial modelling.

• Kingston & Richmond: reviewing progress of the development of the health and care model, the LTB workplan, and initiation of work on how to develop an accountable care system.


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DRAFT

Urgent & Emergency CareSWL Urgent & Emergency Care Transformation & Delivery Board• Since April 2017, significant progress has been made

to strengthen the leadership and governance for the Urgent & Emergency Care programme across SWL. A&E Delivery Board Chairs (AEDB) were consulted on a draft proposal to establish a SWL Urgent & Emergency Transformation & Delivery Board (UECTDB) which had its first meeting in May and has since met on a monthly basis.

• The Board brings together the AEDB Chairs, Acute Trust Chief Executives, Executive Leads, Clinical Leads and is chaired by Jonathan Bates, Senior Responsible Officer for Urgent Care.

• The Board oversaw the development of the SWL Urgent and Emergency Care(UEC) Delivery Plan which was submitted to NHS England at the end of June. The Board is looking at areas where learning and good practice can be shared and disseminated across local AEDBs and where we can work on improvements that can be addressed collectively across SWL.

6

SWL UEC Delivery PlanThe SWL UEC Delivery Plan outlines the priorities for 2017/18-18/19, in line with national and regional expectations to transform urgent & emergency care and get A&E performance back on track.The priorities include: NHS 111 and 111 Online, GP extended access, Urgent Treatment Centres, ambulance demand management, improving care for the frail elderly, improving hospital flow, Mental Health Crisis Care and Care Homes. Work is underway in all these areas, including:

• A SWL London Ambulance Service (LAS) working group has been in place since May with a focus on demand management across SWL.

• Developing the current 111 Integrated Urgent Care service across SWL to meet the requirement for increased clinical cover by a GP.

• Designation of Urgent Treatment Centres continues, with 3 facilities still to be designated. A further SWL stock-take is to be carried out by the end of Summer.

• A UEC Leads forum is also being set up to support the sharing of learning and also to support and inform a SWL approach where this is appropriate.

• Working with the London Collaborative to build local expertise and local leadership to transform services.


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CancerCancer performance across SWL

• Delivery of the 62 day standard across SWL remains strong and above trajectory. There remains challenges for meeting the 2 week waits at St Georges Hospital and there is a possibility that this will impact the 62 day standard into the Autumn.

• The Cancer System Leadership Forum, which includes Trust Operational Leads and CCG Cancer Commissioning Managers, continues to implement the 62 day sustainability programme.

• Work continues across SWL to recover performance against the 6 week standard for diagnostics.

SWL Cancer Delivery Plan

• The SWL STP Cancer programme is working alongside Royal Marsden Partners Cancer Vanguard to deliver improvements to cancer services across SWL and NWL STPs.

• A delivery plan and transformation funding bids were submitted to NHS England in March 17. Transformation funding has now been secured for Early Diagnosis, with further funding for Stratified Follow-up and the Recovery Package is due to be released by the Autumn.

• The SWL Cancer Delivery Group, which includes CCG and Trust Cancer Clinical Leads and Commissioning Managers, previously agreed the major priorities for joint working across SWL including prostate cancer stratified follow-up, improving bowel screening uptake and implementing the recovery package.

7

Prostate Cancer Stratified Follow-up• SWL Cancer leads have agreed a clinical pathway and model

for primary care led follow-up for stable prostate cancer patients, building on the pathway already in place in Sutton and Croydon.

• Early engagement with Surrey and London-wide LMCs is in train. They have signalled support for the pathway and work will continue to negotiate consistent pricing.

• A business case and draft service specification has been developed.

• Acute Trusts are reviewing the processes and patient cohort to identify likely activity figures.

• Transformation funding has been agreed and due to be released in the Autumn.

Improving bowel screening uptake• All CCGs continue to drive improvements to bowel screening

with a range of incentive schemes and initiatives in place. • The SWL Cancer Delivery Group is working with RM Partners,

Transforming Cancer Services team and other partners such as Cancer Research UK and the St George’s screening centre to agree a SWL approach for accelerating these improvements through use of the Cancer transformation funding.


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Primary Care

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Primary CareThe primary care programme submitted a delivery plan to NHS England in June 2017, this set out our strategy and delivery plan in a number of key areas aligned to the GP Forward View. Achievements from the first three months of the financial year include:

• Working closely with CCG Primary Care Lead colleagues to ensure that each CCG was providing extended general practice access for its patients. Significant progress has been made and now all 6 CCG’s are providing some form of extended access to general practice 8am-8pm, 7 days a week.

A workforce group has been established to support the transformation of primary care and they have completed the following work:• A workforce audit, which was completed by 37 practices across SWL, to understand demand for primary care and how skill

mix could be used to manage demand in new ways. The results will be used to support transformation of the primary care workforce.

• Croydon, Sutton and Wandsworth bids for the clinical pharmacist programme have been successful, with an aim to extend this across SWL in the remaining part of the year.

• The move towards locality working has been supported through workforce modelling, discussions at individual CCGs, and aligning the primary care workstream with other areas of the out of hospital transformation programme.

• To support practices in managing demand, we were successful in securing resource for 3 cohorts of practices to be part of the productive general practice programme. Practices involved will have the opportunity to work with external change and Quality Improvement specialists to support them to become more efficient and release capacity. Learning from the programme will be shared across SWL.

• We have also begun to explore increasing the use of technology in primary care, such as online consultations, and held a roadshow to understand the solutions available in the market. Our patient group is informing this work through discussions about what patients want from technology solutions.


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Mental Health

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Mental Health

• The Mental Health programme has moved quickly since April 2017. The programme now has dedicated programme support and submitted a delivery plan to NHS England at the end of June. The SWL Mental Health Network is overseeing the work to implement this delivery plan.

• Key priorities of the plan include: Children & Adolescent Mental Health Services (CAMHS), perinatal mental health, improving access to psychological therapies (IAPT), community and crisis services, dementia, forensic services and suicide prevention. Ensuring mental health is embedded within the work of each transformation workstream to drive integration of physical and mental health is a theme running throughout the work.

Progress to date includes:

• Developing a service model for community perinatal mental health services across SWL, which would meet best practice guidance set out by Royal College of Psychiatrists. A bid for funding has been produced which will be submitted to the Community Perinatal Mental Health Services Development Fund in September 2017. This service will dramatically improve quality of care offered to women and their families during pregnancy and in the first year after birth.

• St Georges, Croydon, St Helier, and Kingston bids to improve psychiatric liaison services were all successful. From April 2018, all SWL acute hospitals will be compliant with “Core 24” standards, improving the care for people with mental health needs presenting at A&E.

• SWL work to support the London-wide agenda around Health Based Places of Safety is ongoing; testing the case for change and options locally, ahead of London wide pre-consultation engagement beginning in autumn 2017.

• The South London Mental Health Partnership (made up of SWLStG, SLaM and Oxleas) have successfully bid to pilot new models of care for adult forensic and Children & Adolescent Mental Health Services (CAMHS). These new models of care aim to transform the pathways, ensuring high quality care is available locally and that investment is used efficiently across the whole pathway.

• Work is underway across SWL to produce local suicide prevention plans, which will be complete by end of December 2017. Plans will draw on local and national best practice and identify things that should be done once across SWL e.g. work with the transport and river networks.


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Integrated Community Care

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• SWL is delivering the transformation of community based services through our four Local Delivery Units. This work is driven and overseen by the Local Transformation Boards (LTBs)

• LTBs are in the process of developing their models of care, setting out how they will improve and develop integrated community based care. This work involves developing the narrative plans, as well as modelling the activity and financial impact of the plans

• Whilst the work is being driven locally, there are a number of common areas of priority across the four LTBs. These include: integrated locality teams, intermediate care and crisis response, enhancing health in care homes, and end of life care

• Progress to date from the LTBs includes:• Implementation of pilots to test new care models and ways of working, for example:

o Multi-disciplinary GP practice huddles are being assessed in Croydon, to form the basis for new ways of working in integrated locality teams.

o Multi-disciplinary working, including health clinics for older people, are being assessed in Kingston and Richmond.

o Community health and social care teams are being brought together in Sutton’s Wallington locality o Work is underway across SWL to share learning from the Sutton Care Home Vanguard to implement the best

practice interventions across the rest of SWL. o Work continues across SWL to embed the best practice in end of life care including identifying priority areas

for joint working across SWL.• These examples of new ways of working across community based teams will drive the further development and refining

of LTB plans, with learning being shared across SWL. • A tool has been developed which will support LTBs to understand the activity and financial impact of their plans for

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Planned careThe 6 SWL CCGs have agreed joint investment in Medicines Optimisation, including initiatives to:

• Get better value for money for high cost drugs prescribed in secondary care by working with hospital colleagues to optimise high cost drug pathways and improve the procurement of high cost drugs.

• Get better value for money from our primary care drug spend by supporting patients with their self care where approriate and working with prescribers to reduce prescribing of items which are less cost effective

• Support care homes to reduce the significant waste of prescription items which are paid for from primary care prescribing budgets• Support patients and carers to take control of their care and their medicines by reducing over-ordering of items which are not

needed and may, for example, expire before they are needed, checking prescription items before leaving their community pharmacy and training GP practice staff on the prescription reordering process

• Work with specialist colleagues to reduce the variation and price differences we have across SWL in the products available to patients for Oral Nutritional Supplementation (ONS) , Stoma, Continence and Wound Care.

The 6 CCGs are also working together on the ‘Effective Commissioning Initiative’

• The Effective Commissioning Initiative (ECI) policy contains a list of surgical procedures that are effective treatments only when certain clinical criteria are met. This is to ensure that patients receive the most appropriate care they require and that NHS funds are spent most effectively for the population of SWL .

• CCGs in SWL updated the ECI policy individually and signed these off in their Governing Bodies in Q4 of 2016/17. Although considerable similarities remained variation increased leading to inequality in access to surgical procedures listed in the ECI policy and leading to implementation challenges for providers .

• Variations are being aligned in a new ECI policy for SWL, which is due to be discussed and finalised by the Committee in Common of CCGs on 16 November.

11Start well, live well, age well

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Planned Care - Musculo-Skeletal (MSK) Musculo-Skeletal (MSK)

• The output from the Musculo-Skeletal (MSK) workshop in July was for 6 CCGs to agree a shared direction of travel:

• All to achieve an integrated MSK1 Single Point of Access with Triage2 by the end of 2017/18

• For CCGs to work together and achieve as much commonality as possible in terms of specification and delivery

• Work together to identify and look at how to close gaps in the system, for example Pain Management, and also how to support patients to self-manage their condition better.

• This direction of travel was supported by the Clinical Board on 3rd August and a paper on how best to achieve a fully integrated MSK service across SWL is currently being drafted with support from senior clinicians and commissioner planned care leads.

• Work is ongoing to identify more areas in Planned Care where we may wish to undertake work on a SW London basis. Ears Nose and Throat is currently being discussed.

1: Integrated MSK includes Physiotherapy, Pain Management, Rheumatology and Trauma/Orthopaedics2: Triage in this context is clinical assessment of an inward referral to decide the right treatment


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Maternity

• Since April, the SWL Maternity Network refreshed its terms of reference to become the SWL Local Maternity System (LMS), as required by NHS England in line with the national commitment to deliver the Better Births recommendations for improving maternity services by 2020/21.

• The SWL LMS is led by Ann Morling, Director of Midwifery, CHS and Dr Anu Jacob, SWL Clinical Lead for Maternity. The LMS membership comprises Heads of Midwifery, Obstetric Clinical leads, CCG Maternity Clinical leads, Commissioning Managers, Local Authority, Patient and Public representatives as well as representatives from Obstetric Anaesthesia and Neonatology.

• All Trusts in SWL are piloting “My Maternity Journey in SW London” which provides consistent information on local maternity services, the maternity pathway and supports women to make informed choices about their care. This work is being undertaken as part of the NHS England funded Pioneer for Choice and Personalisation which runs to April 2018.

• Planning is underway to develop a delivery plan for the SWL Local Maternity System to respond to the national maternity review. The delivery plan is due to be submitted to NHS England by October 2017.


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Digital

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SWL Digital Programme • Locally led and supported at a SW London level, we are working hard to build on last year’s first Local Digital

Roadmap. In the last three months we have set in train a number of pan SWL initiatives.

• We have a new whole system SWL Digital & Technology Board with representation from all acute, mental health, primary social and community care partners across SWL

• For 2017/18, we obtained sponsorship at the first SWL leadership conference, to prioritise 3 Digital SWL initiatives:

• To pursue support and funding for SWL to become England’s first place based national digital exemplar (GDE) • To deliver the nationally led electronic Referral System (eRS) across primary and secondary care services• To ensure our citizens and patients have access to digital applications that facilitate and support self care and

service signposting.

• Having written and submitted two digital business cases this year, we are going to support all our systems to be connected and extend access and input to shared care records across SWL.


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Workforce

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• The priority since April has been to move from strategic planning to implementation. The joint Local Workforce Action Board (LWAB) with Health Education England has been re-launched.

• A delivery plan has been agreed that includes discrete workstreams on Recruitment and Retention and Prevention and Wellbeing plus joint work with the mental health, primary care and UEC programmes to address the workforce issues arising from their plans. Two programme managers have been recruited and commenced work in mid-August.

• Our priorities for the next three months are to:

o Prepare for commissioning of pan-SWL training in Making Every Contact Count and Social Prescribingo Scope employers’ involvement with the Mayor’s Healthy Workplace Charter, encourage new participants,

identify and scale up relevant initiatives to support progress through the stageso Develop an action plan based on the recommendations of the new Recruitment and Retention working group

and commence implementation o Support the Mental Health programme team to develop a local mental health workforce plan as required by the

national plano Commence scaling up of various local mental and physical health initiativeso Develop workforce plans with remaining STP programmes


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Estates

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• The SWL Estates Board meets monthly, bringing together estates leads from all partnership organisations. The SWL estates delivery plan is under consultation and due to be agreed by partners by September.

• SWL estates leads support a strategy to ensure land and property in use across the health and social care system is fit for purpose, accessible and drives value.

• Estate use needs to be assessed and monitored to achieve efficiencies and avoid extra requirement for additional capital investment. SWL estates leads are developing tools and options to support Local Transformation Boards in this process.

• Local Transformation Boards will lead on confirming local estates needs following on from the confirmation of local health and care models from November 2017.

• Bids for a possible autumn allocation of capital are to be prepared by early September. Funding availability is subject to demonstration of proposals which are transformational for services and secure value for money.


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Finance

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• As part of the STP ‘refresh’, top level 2017/18 operating plans are now being modelled at Local Transformation Board level

• LTBs are expected to complete health and care modelling by 30 September 2017

• Growth rates and savings will be reviewed against original STP assumptions

• Updated bids for capital funding to be submitted to NHSI on 11 September 2017: main criteria for assessment will be how transformational schemes are, how they support delivery of the STP and return on investment. Bids need to fully worked up business cases with supporting evidence.

• Financial management at SWL level ongoing: monitoring of QIPP and CIP delivery, SWL financial position and risk, reporting to monthly Finance & Activity Committee and to NHS England and NHS Improvement via regular assurance meetings


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DRAFT

SWL Governance Boards updates

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Update from the STP Programme Board • STP Programme Board met on 20th July• Support was given on the proposed future model of the Clinical Board• Updates on the four national programmes were received; UEC, Primary Care, Cancer and Mental Health• Health Care Model updates were received from the four Local Transformation Boards• A draft refreshed narrative and approach to the STP was received by the Board, which outlined the next phase of

communications and engagement• The Board received an update on the Epsom & St Helier estates engagement process• Support was given to the revised STP Leadership arrangements, a new Quartet arrangement was approved which is the

Senior Responsible Officer (Sarah Blow), A Local Authority Representative (Ged Curran), A Provider representative (John Goulston) and a Clinical Chair (Dr Naz Jivani)

• Feedback from the Finance & Activity Committee from 14th July was received

Update from the SWL Clinical Board• Clinical Board met on 3rd August• Agreement was reached on the core functions and on the revision membership of the Board• The Clinical Board gave approval to progress with a standardised approach to MSK across SW London• A paper was presented on the Epsom & St Helier clinical model, long term estates engagement. The Board acknowledged

the paper and supported the principles outlined• STP Clinical Standards paper with which each SWL acute trust should meet was received and reviewed. The Board gave

recommendations on content changes with particular focus on acute medicine and paediatrics• Mandate was given to a SW London wide ENT approach to modeling, similar to MSK. The first step being a workshop

being set up to determine the scope


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DRAFT

Communication and Engagement Planning for the STP

Communications and Engagement

• The focus for communications and engagement will now shift locally into the four Local Transformation Board areas.

• We will build on the involvement of Health Watch, Overview and Scrutiny Committees and citizen/ patient representative groups in developing these communications and engagement plans going forward and have already had some helpful conversations with some Health Watch and Community Voluntary Service groups.

• This a good opportunity to re-focus the communications and engagement locally, and think strategically about what outcome we want to achieve from an integrated communications perspective around these areas :

o clinical and staff engagement, o patient and citizen engagement o public affairs and stakeholder managemento media, social media and campaigns.


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Summary of current thinking• A local approach works best for planning health and care

• The best bed is your own bed – lets keep people well and out of hospital

• Care is better when it is centred around a person, not an organisation. Clinicians and care workers tell us this.

• Likely to mean changes to services locally - we are not proposing to close any hospitals

• We need to show people how it works better with local examples

• Involving people at local level

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DRAFT

Forward look – Autumn 2017

21

SWL Commissioning Intentions 2018/19 • Preparations are now underway for the commissioning and contracting round 2018/19. It has been agreed by Directors

of Commissioning that SWL Commissioning Intentions will be developed to reflect the Delivery Plans for Urgent & Emergency Care, Primary Care, Cancer and Mental Health and other local plans agreed this year. SWL Commissioning and Contracting Intentions will be finalised by 30 September

Urgent & Emergency Care • A&E Delivery Boards are preparing Winter Plans by early September. This includes a number of initiatives such as

implementing front-door streaming and improving hospital flow processes including implementing the SAFER bundle.• There is a national expectation that NHS 111 Online will begin to be implemented during Autumn – Winter. SWL will be

expected to implement an online system which will triage symptoms and signpost patients to the most appropriate service.

Cancer• Continued work to launch projects in early diagnosis, including improving bowel screening uptake.• Anticipated release of funding during Autumn for stratified follow-up to support primary care led follow-up for prostate

cancer.

Maternity• Delivery Plan against Better Births national maternity review to be further developed through the SWL Local Maternity

System and shared with LTBs, ahead of submission to NHSE in by end of October.


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DRAFT

Forward look – Autumn 2017

22

Primary Care• Prepare a bid for the next round of International GP Recruitment, support further bids for the clinical pharmacist

programme• Agree Memorandums of Understanding with practices successfully selected for resilience funding and support any

future work required• Rollout model of 111 direct booking into GP extended access hubs and pilot practices, and implement pilots for redirect

from A&E to the hubs • Engage with practices on primary care at scale, and share learning from the “time for care” initiatives with all practices.• Locality working – Support planning and implementation of primary care at scale initiatives from interested practices.

Integrated Community Care • Development of more detailed implementation plans for the full roll out of the out of hospital health and care model

across Croydon• Work to understand the finance and activity impact of developing initiatives e.g.

Setting up of finance and activity groups with senior level finance representation from LTB members to provide oversight and ratification of activity and finance impacts

Development of an activity and financial impact modelling tool by the SWL STP Programme team to support LTBs quantify the impact of their proposed care models in a consistent manner across LTBs

Planned Care• SWL ECI Policy version 2.0 to be signed off by CCGs in November• Continued work on MSK model for SWL, and further exploration of the ENT pathway.


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Part C: Management Reports

Page

3. Part C: Management Reports 55

3.1. C01 Executive Report 56

3.2. C02 Performance Report 59

3.3. C03 eRS Capacity Alerts at St George's

3.4. C04 Finance Report 66

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Executive ReportAuthor: Sandra Allingham Sponsor: Nicola Jones / James Blythe 13/09/2017

Executive Summary

Context

The report provides information on the following items for information:

Management Team Summary

Wandsworth CCG Clinical Chair

Annual General Meeting

Input Sought

The Board is asked to note the content of the report.

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [ X ]

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The ReportManagement Team SummaryA summary of the main issues discussed by the Management Team in the period following the previous Board meeting is outlined below:

Performance

St George’s University Hospital Foundation Trust

Quality and safety issues

SWL Commissioning Alliance

Wandsworth CCG Clinical Chair

We are pleased to confirm that following the conclusion of a ballot of the membership in

July, Dr Nicola Jones has been re-elected as Chair of NHS Wandsworth CCG for a further

term of three years. Whilst Nicola was the only candidate to put herself forward, over 116

members of the CCG’s GP community took the time to vote, which is reflective of the well-

deserved strength of support from the membership she continues to enjoy.

Annual General Meeting

Our Annual General Meeting (AGM) is being held on Wednesday 20 September 2017 from 2pm to 4:30pm at our headquarters: SWISH building 73 Upper Richmond Road, East Putney, SW15 2SR. At the meeting we will present our annual report and accounts, as well as our plans for the current year. We will also be running a market stall event with information on a wide range of projects happening in Wandsworth including Self-Management, Healthy London Partnership, Healthwatch, GP Online Services, and more.

This event will be streamed live from our website so if you cannot attend in person you can watch the AGM online via the following link: https://join-emea.broadcast.skype.com/wandsworthccg.nhs.uk/180a6137dcb242a999a940748ec9a3e1 . You can also get involved by sending in questions before the date via email or you can ask questions on the day in person or online via the live streaming site or by tweeting us (@NHSWandsworth) and including the hashtag #WandsAGM17.

Use of the Seal

The corporate seal has not been applied since the previous report.

Conclusion

The Board is asked to note the information on the items above.

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https://join-emea.broadcast.skype.com/wandsworthccg.nhs.uk/180a6137dcb242a999a940748ec9a3e1

https://join-emea.broadcast.skype.com/wandsworthccg.nhs.uk/180a6137dcb242a999a940748ec9a3e1

mailto:[email protected]


For ReferenceEdit as appropriate:


The long-term implications [Not applicable]

The risks [Not applicable]

Impact on our reputation [Not applicable]

Impact on our patients [Not applicable]

Impact on our providers [Not applicable]

Impact on our finances [Not applicable]

Equality impact assessment [Not applicable]

Patient and public involvement [Not applicable]


The content included in the report relates to items for information only.



inequalities [Not applicable]


statutory responsibilities [Not applicable]


members, stakeholders and communities [Not applicable]


is delivered in the right setting [Not applicable]


organisation [Not applicable]


The content included in the report relates to items for information only.

2. Executive Summaries should not exceed 1 page. [My paper does comply]


[My paper does comply

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Performance Report (Month 3) and

CCG IAF Year End Assessment 2016/17

Author: Iain Rickard Sponsor: John Atherton Date: 13 September 2017

Executive Summary

This paper summarises performance at Month 3 (June 2017) against NHS Constitution performance indicators, subject to available data. The paper provides an overview of key performance challenges across the first quarter of 2017/18, a summary of the reasons why issues occurred and the commissioner and provider actions to mitigate them.

In July 2017 NHS England published annual performance assessments of CCGs for the financial year 2016/17. The paper provides an update on the Wandsworth CCG annual assessment undertaken by NHS England and derived from performance indicators across a number of areas including delivery against mandated performance standards, an assessment of CCG leadership and financial management.

The CCG is working with St. George’s University Hospitals NHS Foundation Trust to better inform GPs of likely waiting times for first outpatient appointments. The paper provides an update on the capacity alerts system that is being added to the Electronic Referral System (eRS) system.

The CCG has established a new Commissioner and Provider Performance Meeting with St. George’s University Hospitals NHS Foundation Trust to provide assurance of the delivery of operational performance against the national NHS Constitutional, service delivery indicators and agreed trajectories. The terms of reference have been agreed and the first of the new monthly meeting took place in August.

Question(s) this paper addresses1. What is our current performance against the NHS Constitution indicators and what are the

drivers?

2. What is our overall NHS England rating for 2016/17 and how does this compare to last year?

Also what is our rating in the Dementia, Cancer and Mental Health clinical priority areas and

how does this compare to last year?

3. How will eRS capacity alerts operate to support demand and capacity management at St.

George’s University Hospitals NHS Foundation Trust?


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2 Week Cancer Wait 90.72% 93.65% 94.48% 94.00% 92.77% 86.94% 93.52% 88.41% 88.45% 88.01% 78.81% 79.40% 74.01% 77.43% 93%

2 Week Cancer Wait (Plan) 93.04% 93.03% 93.04% 93.04% 93.03% 93.04% 93.05% 93.03% 93.05% 93.08% 93.02% 93.08% 93.03%

2 Week Cancer Wait:

Breast Symptoms85.79% 93.75% 93.29% 94.37% 98.57% 96.67% 92.72% 97.14% 91.52% 91.88% 84.77% 88.89% 76.56% 84.39% 93%

2 Week Cancer Wait:

Breast Symptoms (Plan)93.33% 93.26% 93.18% 93.02% 94.12% 93.98% 93.90% 93.83% 93.67% 93.59% 93.04% 93.04% 93.04%

31 day Cancer Wait:

1st definitive treatment98.73% 97.56% 98.18% 98.59% 98.25% 95.89% 97.22% 100.00% 97.26% 96.43% 95.59% 98.88% 97.30% 97.40% 96%

31 day Cancer Wait:

1st definitive treatment (Plan)97.01% 96.97% 96.97% 96.97% 96.92% 96.92% 96.88% 96.88% 96.88% 96.83% 96.00% 96.00% 96.00%

31 Day Cancer Wait:

Subsequent treatment (Surgery)100.00% 100.00% 100.00% 100.00% 90.00% 100.00% 87.50% 100.00% 100.00% 100.00% 87.50% 95.00% 93.33% 92.16% 94%

31 Day Cancer Wait:

Subsequent treatment (Surgery)(Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 94.12% 94.12% 94.12%

31 Day Cancer Wait:

Subsequent treatment (Chemotherapy)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 97.06% 97.67% 100.00% 100.00% 100.00% 100.00% 100.00% 98%

31 Day Cancer Wait:

Subsequent treatment (Chemotherapy) (Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 98.00% 98.00% 98.00%

31 Day Cancer Wait:

Subsequent treatment

(Radiotherapy)

100.00% 93.75% 97.92% 100.00% 96.77% 95.00% 100.00% 97.14% 96.97% 97.06% 96.15% 97.06% 95.83% 96.43% 94%

31 Day Cancer Wait:

Subsequent treatment

(Radiotherapy) (Plan)

97.30% 97.37% 97.37% 97.44% 97.44% 97.44% 97.50% 97.50% 97.56% 97.56% 94.00% 94.00% 94.00%

62 Day Cancer Wait:

GP Referral80.00% 93.02% 79.31% 84.09% 83.87% 80.56% 85.00% 82.35% 88.57% 81.25% 87.10% 75.56% 82.35% 80.91% 85%

62 Day Cancer Wait:

GP Referral (Plan)82.50% 85.37% 85.00% 85.00% 85.71% 85.00% 86.36% 85.71% 86.36% 86.84% 85.00% 85.00% 85.00%

62 Day Cancer Wait:

Screening service100.00% 100.00% 50.00% 33.33% 83.33% 100.00% 100.00% 75.00% 100.00% 66.67% 100.00% 90.91% 90%

62 Day Cancer Wait:

Screening service (Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 90.00% 90.00% 90.00%

62 Day Cancer Wait:

Consultant Upgrade100.00% 100.00% 80.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 80.00% 50.00% 77.78%

No

thresholds

62 Day Cancer Wait:

Consultant Upgrade (Plan)100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Ca

nc

er

Wa

its

Jun-16KPI / Measure Jul-16 Aug-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17Sep-162017-18

Target

2017-18

YTDMar-17 Apr-17 May-17 Jun-17Theme

0%

50%

100%

Jul-16 Aug-16Sep-16Oct-16 Nov-

16

Dec-16 Jan-17 Feb-17 Mar-

17

Apr-17 May-

17

Jun-17 Jul-17

0%

50%

100%

150%


16


17

Apr-17 May-

17

Jun-17 Jul-17

92%

94%

96%

98%

100%

102%


16


17

Apr-17 May-

17

Jun-17 Jul-17

80%

85%

90%

95%

100%

105%


16


17

Apr-17 May-

17

Jun-17 Jul-17

94%

96%

98%

100%

102%


16


17

Apr-17 May-

17

Jun-17 Jul-17

90%

95%

100%

105%


16


17

Apr-17 May-

17

Jun-17 Jul-17

0%

50%

100%


16


17

Apr-17 May-

17

Jun-17 Jul-17

0%

50%

100%

150%


16


17

Apr-17 May-

17

Jun-17 Jul-17

0%

50%

100%

150%


16


17

Apr-17 May-

17

Jun-17 Jul-17

MRSA reported infections 0 0 0 1 0 0 0 0 0 0 0 0 0Zero

tolerance

C. Difficile reported infections 5 3 6 8 5 5 2 2 3 3 1 2 6

Mixed Sex Accommodation (MSA)

(Number of breaches)0 2 0 1 0 1 1 0 0 1 0 3 1 5

Zero

tolerance

Mar-17 Apr-17 May-17Feb-17

Qu

ali

ty

KPI / Measure Jan-17Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jun-17 Jul-172017-18

YTD

2017-18

Target

Current Performance – Month 3 (June 2017)

A&E All Types 94.45% 93.20% 92.66% 92.01% 91.96% 88.91% 86.87% 90.44% 89.94% 91.64% 90.63% 92.94% 91.72% 91.72% 95%

A&E All Types (Plan) 91.42% 92.78% 92.97% 92.56% 92.61% 91.47% 92.64% 92.14% 92.24% 89.39% 91.03% 91.98% 93.29%

18 Weeks RTT Incomplete Pathways 91.48% 91.14% 90.96% 90.55% 90.21% 89.31% 90.72% 91.36% 90.67% 89.90% 90.36% 90.08% 89.59% 89.98% 92%

18 Weeks RTT Incomplete Pathways (Plan) 91.13% 91.30% 91.46% 91.79% 91.81% 91.96% 91.95% 92.08% 92.39% 92.04% 92.01% 92.00% 92.00% 92%

>52 week waits Incomplete 3 1 3 5 10 6 8 7 4 4 3 6 5 18 0

> 6 Weeks Diagnostic Waits 0.93% 0.66% 0.70% 0.72% 0.60% 1.69% 3.28% 1.93% 2.42% 3.51% 2.70% 2.59% 2.80% 2.88% 1%

> 6 Weeks Diagnostic Waits (Plan) 1.00% 1.00% 1.00% 1.00% 1.00% 0.99% 1.00% 0.99% 1.00% 1.00% 1.00% 0.99% 0.99%

Aug-16 Sep-16 Nov-16Jul-162017-18

TargetTheme KPI / Measure

A&

E Q

ua

lity

Pre

miu

m

18

We

ek

s R

efe

rra

l to

tre

atm

en

t

an

d D

iag

no

sti

cs

Oct-16 May-17Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 Jul-172017-18

YTDJun-17

80%

85%

90%

95%

100%

Jul-16 Aug-16Sep-16 Oct-16Nov-16Dec-16 Jan-17 Feb-17 Mar-

17

Apr-17 May-

17

Jun-17 Jul-17

88%

89%

90%

91%

92%

Jul-16 Aug-16 Sep-16 Oct-16Nov-16Dec-16 Jan-17 Feb-17 Mar-

17

Apr-17 May-

17

Jun-17 Jul-17

0%

1%

2%

3%

4%

Jul-16 Aug-16 Sep-16 Oct-16 Nov-16Dec-16 Jan-17 Feb-17Mar-17Apr-17 May-

17

Jun-17 Jul-17

W H A T H A S G O N E W E L L ?

MRSA & C. Difficile There were no cases of MRSA bacteraemia reported in June. There were two reported cases of C-Difficile in June, both of which were community acquired and identified at St. George’s University Hospitals NHS Foundation Trust (SGH). This brings the YTD total cases of C-Difficile to six which is under the YTD target of 12.

Cancer 31-day waits

The CCG achieved the 31-day wait target for 1st definitive treatment and subsequent treatments in all areas except for surgery.

A&E Waiting time

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SGH achieved an outcome of 92.12% in June, up from 89.68% in May for All Types A&E attendances. This is marginally above the Trust’s Operating Plan improvement trajectory target of 92.00% for the month. However, July’s performance is 89.76% which is below the operating plan target of 93.3% for the month.

Breaches of the four hour standard in July were predominately due to bed management, waiting for specialist opinion and capacity issues within ED. The Trust has initiated the Unplanned & Admitted Care Programme as a successor to its Flow Programme. This is focused on front door streaming, ED processes, ambulatory care and inpatient / discharge processes. The Trust have also initiated a weekly performance data review meeting for the senior clinical and operational team in ED. Work is ongoing to develop increased capacity for ambulatory care referrals with full implementation by late 2017.

W H A T H A S N O T G O N E W E L L ?

18 Weeks Incomplete RTT

SGH suspended reporting on RTT in July 2016. A recovery plan remains under development and will be available by mid-September. The plan will focus on five key aspects of recovery: validation; operational delivery (treating long wait patients); PTL management; outsourcing and demand & capacity modelling. A commissioner led Task & Finish group is in place and focused on delivery of outsourcing and alternative providers to further improve the activity position.

Although SGH is currently excluded from national reporting, the CCG did not achieve the 92% incomplete standard in June with an outcome of 90.08% (1,124 breaches) down from 90.36% (1,097breaches) in May. T&O and Ophthalmology were specialties with significant challenges. Chelsea and Westminster did not meet the target at provider level. Guy’s & St. Thomas’ met the target at provider level, but not for Wandsworth CCG patients.

Patients waiting 52+ weeks

Further to the overall performance position above, there were a total of six Wandsworth CCG

patients waiting over 52 weeks reported at the end of June. Of these six breaches, two were

reported occurring at Imperial (2x T&O), one at King’s (Neurosurgery), two at Kingston (1x ENT

and 1x Ophthalmology) and one at Moorfields (Ophthalmology). The priority for all long waiters

is to agree a date for treatment for each patient as soon as possible. Each patient is subject to a

clinical review to make sure that their care plan is appropriate in view of the time they have waited

for treatment.

Diagnostic waits

The CCG did not achieve the 99% within 6 weeks diagnostic waiting time target in M3 with an

outcome of 97.41%, up slightly on May’s performance of 97.30%. In June this was due to 136

breaches out of 5,243 diagnostic waits. Significant breaches occurred in the following test: 33

Cystoscopy breaches, 25 Gastroscopy breaches, 25 Audiology breaches and 12 urodynamic

breaches. 109 of the 136 breaches occurred at SGH of which there were 31 Cystocopy, 24

Audiology Assessments, 19 Gastroscopy, 11 Urodynamics and 10 Echocardiography. SGH

failed the standard at trust level with an outcome of 97.4% (197 breaches out of 7,584 waits) up

from 96.7% (248 breaches) in May. The Trust has a recovery plan in place, which is

predominately focused on sourcing additional capacity, and expects to meet the standard by

the end of September 2017. Key actions will focus on validation of the QMH site data and

continuing with Urodynamics capacity development.

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SGH have undertaken a review of diagnostic tests to assess demand, capacity and backlog.

There are a series of actions to address any imbalances in demand and capacity and make

available additional clinic slots. The principal areas of concerns regarding capacity are non-

obstetric ultra sound, audiology and computed tomography. The CCG continues to work with

the Trust to review the pace of recovery and availability of additional capacity where current

demand exceeds test capacity.

Mixed Sex Accommodation

There were three MSA breaches for Wandsworth CCG in June, 2x at Imperial and 1x at UCLH.

At Imperial breaches relate to a change in practice in the use of side rooms in the intensive

care unit (ICU). UCLH reported that this MSA breach was caused by a patient waiting to exit

ITU.

Cancer 2 week waits and 62-day waits

The CCG did not achieve the 93% 2 week standard with performance of 74.0% due to 229

breaches out of 881 pathways. 10 at Chelsea & Westminster 2x capacity, 1x delay in workup

and 7x patient choice. One at UCH for patient choice. One at RMH for patient choice. 217 at

SGH predominately related to administrative and capacity issues. In relation to 2 week wait

Breast Symptomatic, the CCG did not achieve the standard with 76.6% due to 15 breaches

out of 64 seen: one at Royal Free for patient choice, 14 at SGH 10x capacity and 4x patient

choice.

The CCG did not achieve the 62 day wait 85% standard with performance at 82.4% due to 6

breaches out of 34 pathways. Three breaches occurred at SGH: 2x delay in workup, 1x

complex diagnostics. Two breaches were shared between SGH and the Royal Marsden for

inter-trust no information. One breach was shared between Kingston and St. George’s for

delay in work up. There was one 100+ day patient breach in June shared between SGH and

the Royal Marsden for inter-trust no information.

The cancer waiting times issues occurred due to issues with administrative process,

administrative capacity and clinical capacity. SGH have developed an action plan to address

cancer waiting times which focuses on improved processes and the sourcing of significant

additional clinical capacity. The Trust will also ensure that actions in the plan align with

London’s improvement actions such as reducing the median waits for first event,

implementation of optimal pathways for lung and prostate and confirmation that 62 and 31 day

cancer wait PTLs are in place and updated daily and formally reviewed.

IAPT - Recovery Rate

The recovery rate in M3 was 40.9%, which is below the national target of 50% and the previous

year’s performance. The Wandsworth IAPT service was re-procured and the new service model,

which commenced in May 2017. The service mobilisation has been affected by some workforce

and recruitment issues. The CCG commissions a service that is open to patients with higher

needs (up to cluster 7), which is not common to all services. Access and recovery rates are under

review with the provider and an action plan has been developed with a projected performance

recovery date of end of September.

Electronic Referral System (eRS) Capacity Alerts

SGH has significant capacity constraints in certain specialties, which have created considerable

backlogs of patients on waiting lists. Wandsworth CCG are working with SGH to consider alternative

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referral pathways for new referrals to the Trust and offering suitable cohorts of patients, who are

currently on the waiting list, treatment at alternative providers.

Alternative Referral Pathways Historically, hospitals with higher levels of elective demand than they cope with have limited options

for stabilising their services. Neighbouring providers may be in a position to treat some of these

patients, which would alleviate pressure, but without a mechanism for actively “re-directing” these

patients to other providers, such a change in referral flows is difficult to implement operationally.

The CCG are working to support redirection through two related work streams that are set out below:

Local System Capacity Tool

A system capacity tool has been developed by the CCG. The tool reports the average waiting times

for new outpatient appointments at local Trusts, together with the overall number of patients who are

on waiting lists and yet to be treated at those Trusts. The reports focuses on waiting times by a

range of specialities at Chelsea & Westminster, Epsom & St Helier, Guy’s & St Thomas’ and

Kingston Hospital.

The average wait is generated using the latest available data, which is usually 2 months behind the

publication month.

NHS England and the Behavioural Insights Team (BIT) eRS Capacity AlertsThe Behavioural Insights Team (BIT) is working with NHS England to create a tool that will help Trusts move demand away from their services during periods of waiting times pressure. Specifically, this work focused on ways of enhancing the user interface of the e-Referrals Service (ERS) to lower referrals to pressured trusts. The tool was trialled in Barking & Dagenham, Havering and Redbridge (BHR) CCGs in 2016, with the objective of spreading referrals away from specialties at Barking, Havering and Redbridge University Trust (BHRUT) a trust with significantly higher demand than available capacity.

The trial introduced red ‘Limited Capacity’ alerts, which warn GPs and their practice teams about long waiting times for certain services. It also introduced green ‘Good Capacity‘ alerts to attract attention to alternative services where waiting times were shorter but quality is comparable. BHR CCG identified four specialties which were targeted with these alerts. During the trial of the alerts, the BIT tracked the providers where patients booked for treatment after their GP practice made a referral. There was no communications shared with GPs before or during the trial.

The trial had a significant impact on referral rates. When red alerts were in place 38% fewer patients were referred to BHRUT. There was however no statistically significant impact of the green alerts was found meaning that GPs referred to other providers but not the green highlighted providers.

The trial successfully identified a mechanism for diverting patients away from a Trust, but did not identify one for attracting them to specific alternatives. Patients not referred to BHRUT instead went to a variety of providers in north east and north central London.

SGH are engaged in the local roll out of this initiate and are working with the CCG, NHSE and BIT. They have agreed to capacity alerts being placed on ENT and General Surgery clinics. There is an ongoing discussion regarding the inclusion of Dermatology, Plastic Surgery and Gynaecology. The NHS England and BIT are working with providers across SW London to source ‘Good Capacity’ alerts.

The go live date is to be confirmed but will be in place by mid-September at the latest and will run for an initial period of 3 months. Unlike the BHR CCGs trial, Wandsworth GPs have received communications about the capacity alerts process. The launch will be supported by further

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communications to GPs. NHS England has also made further support available to SW London CCGs from 29 August to increase eRS utilisation rates.

CCG IAF Year End Assessment 2016/17 The CCG Improvement and Assessment Framework (CCG IAF) provides a focus on assisting improvement alongside the statutory assessment function of NHS England. The Framework includes a set of 60 indicators. At the end of the financial year there is a process to derive an overall year end assessment for each CCG. Assessments are derived using an algorithmic approach and further details are published on the MyNHS website.

Wandsworth CCG was rated “Good” in 2016/17 review, released in August 2017, which is an improvement over the 2015/16 rating of “Requires Improvement”. The overall rating recognises improvements in performance and against national averages. Wandsworth CCG scored in the top quartile nationally against 19 indicators and in the bottom quartile against seven. This balance is better than in 2015/16 when the CCG scored in the top quartile against three indicators and scored in the bottom quartile against nine. Performance against smoking status at the time of delivery and delayed transfers of care remains in the top quartile. With the exception of ‘Injuries from falls’, none of the indicators in the bottom quartile in 2015/6 remain there this year, which demonstrates progress in these areas.

The 2016/17 ratings for three of the Clinical Priority Areas (Dementia, Cancer and Mental Health) have been released. While the overall rating categories have changed, the table below highlights improvements in all but three areas. The only area where performance has dropped is IAPT recovery rate. An assessment of the three remaining Clinical Priority Areas (Diabetes, Learning Disabilities and Maternity) is expected later in the year.

NHS Wandsworth CCG

YearOverall Rating

Indicator Ratings

DementiaEstimated diagnosis rate for people

with dementia

% of patients diagnosed with dementia whose

care plan has been received a face-to-face

review in the preceding 12 months

2015/16Top

performing72.4% 82.6%

2016/17 Outstanding 76.9% 85.1%

Cancer

% new of cases of cancer

diagnosed at stage 1 and 2

as aproportion of all new cases

of cancer diagnosed

% of people with an

urgent GP referral

having first

definitive treatment

for cancer within 62

days of referral

% of adults diagnosed

with any type of cancer in a year

who are still alive one

year after diagnosis.

% of responses, which

were positive to the question "Overall, how

would you rate your

care?"

2015/16Needs

Improvement 49.9% 83.3% 70.5% 87.8%

2016/17 Good 51.8% 84.1% 71.6% 87.8%

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Mental Health

% of

people who

finished

IAPT

treatment

moving to

recovery

% of people

with first

episode of

psychosis

starting

treament with a

NICE-

recommended

package of

care treated

within 2 weeks

of referral

%compliance

with a self-

assessed list of

minimum

service

expectations for

Children and

Young People’s

Mental Health,

weighted to

reflect

preparedness

for

transformation.

%compliance with a self-

assessed list of minimum service

expectations for Crisis Care, weighted to

reflect preparedness

for transformation.

Percentage

compliance with a

self-assessed list of

minimum service

expectations for Out

of Area Placements,

weighted to reflect

preparedness for

transformation.

2015/16Needs

improvement 45.4% 70.4% 45% 90% 88%

2016/17 Good 40.8% 71.3% 100% 90% 90%

Input Sought

The Board is asked to note (i) the current performance against the NHS Constitution Standards for June and the commissioner work in relation to demand and capacity at SGH (ii) the progress made in the IAF indicators and Clinical Priority Areas and (iii) that there are work plans in place to address any indicators currently appearing in the bottom quartile of the IAF and any clinical priority area indicators rated as red or amber.

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Finance ReportAuthor: Jack Rodber Sponsor: Neil McDowell Date: 13/09/2017

Executive Summary

Context

Wandsworth CCG has a resource limit of £479m and is expected to achieve a 0.5% in year

surplus position in line with NHS England business rules. This report looks at the latest

position as at month 4 (July 2017) based on month 3 acute and month 2 prescribing data.

The other business rule requirements are for us to not exceed our expenditure target on the

administration costs used to manage the CCG.

Questions addressed in this report

1. What is the CCG’s year to date financial performance against the approved budget?

2. Is the CCG on target to meet the planned £2.179m financial surplus at year end?

3. Implications around financial governance, strategy, performance and risk.

4. Can we keep running costs within the target set?

5. How are we progressing against our savings target?

Conclusion

1. The CCG is on course to meet its target surplus of £2.179m.

2. As at month 4 we are behind on our savings plan and have forecast that we will not

achieve the full plan.

3. We expect to meet the running cost target

Input Sought

The decision we would like from the Board is:

To note the contents of the report

Input Received

This paper has been reviewed by the Finance & Resources Committee on 30 August

2017.

W A N D S W O R T H C C G P A G E 1 O F [ X ]W A N D S W O R T H C C G P A G E 1 O F [

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The Report

Looking Back

W H A T H A S G O N E W E L L ?

The CCG is on course to achieve a balanced Financial Position and achieve the

planned financial surplus at year end.

We are on course to meet the running cost target.

W H A T H A S N O T G O N E W E L L ?

At this early stage of the financial year there is very limited information available to

review the financial position.

More information will be available to review the financial position in future months.

NHSE have indicated a potential budget shortfall of £1.199m on the Primary Care

Delegated Commissioning.

£223k of this shortfall was identified by the CCG in 16/17 and has been funded.

The remaining £976k will be resourced through additional QIPP and other

mitigating savings.

Looking Ahead

O P P O R T U N I T I E S ?

The LDU are reviewing structures and accommodation which should identify

additional savings going forward.

We are identifying additional QIPP opportunities to make up for the shortfall in the

2017/18 QIPP plan.

R I S K S O R C O N C E R N S ?

Managing acute performance

If we don’t manage performance then this will limit our ability to manage within the

resource limit in 17/18 and meet the business rules set. In addition this will have a

knock on effect into 2018/19 planning.

Non delivery of QIPP

Delayed implementation of QIPP schemes has been identified as a risk in 17/18.

Delivery of QIPP is essential for the future financial health of the CCG

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In Conclusion

C O N F I D E N C E ? I M P L I C A T I O N S ?

I am confident that the financial position

outlined in this paper is accurate based on

available information and reflects the risks

moving forward.

The CCG is on course to achieve a

balanced Financial Position and achieve

the planned financial surplus at year end.

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Data DashboardSee following PowerPoint slide pack.

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For ReferenceEdit as appropriate:


The long-term implications Yes

Ensuring that we understand cost drivers that will impact on future years

The risks Yes

Mitigations against a number of risks have been considered and implemented

where appropriate. Future risks have also been identified with mitigations in

place to manage should they materialise.

Impact on our reputation Yes

By not achieving the targets set would have an adverse impact on our

Organisational reputation.

Impact on our patients Yes

Insufficient funding or poor planning would impact on our ability to commission

services in an efficient way.

Impact on our providers Yes

Prompt payment, accurate reflection of activity and finance

Impact on our finances Yes

Throughout the report

Equality impact assessment Not applicable

Patient and public involvement Not applicable



inequalities Yes


statutory responsibilities Yes


members, stakeholders and communities Not applicable


is delivered in the right setting Yes


organisation Yes


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3. Executive Summaries should not exceed 1 page. [My paper does comply]


[My paper does not comply]

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Wandsworth Clinical Commissioning Group

Finance Report –July 2017 (Month 4)

Neil McDowell – Director of Finance

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Wandsworth Clinical Commissioning GroupBoard- August 20172 08/09/2017

1. Finance Scorecard

2. Key Indicators

3. Month 3 Financial Position

4. Summary Financial Position

5. Risks and Mitigations

6. Acute Commissioning

7. Non-Acute Commissioning & Primary Care

8. Running Costs and Corporate

9. QIPP

10. Financial Statements

11. Appendices

Contents

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Wandsworth Clinical Commissioning Group08/09/2017 Board - August 20173

Financial Strategy Financial Performance• SWL Collaborative Commissioning programme work is

ongoing to deliver system transformation plan.• Local Transformation Board, with Finance and Activity

subcommittee, has been established to deliver the strategy for Wandsworth and Merton LDU

• 2017/18 is year 2 of the 5 year notification of allocations. Years 4 and 5 are “soft” allocations.

• 0.5% of the 1% non recurrent reserve cannot be committed in 2017/18

• Contracts have been agreed but with significant QIPP outside of these plans.

• SWL system-wide control totals (both CCG and provider) have been issued as well as just CCG-specific.

• Plan to achieve the in year target surplus of £2.18m (0.5%)• QIPP target is not currently forecast to be met but is

mitigated by using reserves and holding back investments, where necessary.

• Contract values agreed with all main providers, but significant levels of acute performance are being seen at month 4.

• The cost of specialised activity transferring from NHSE to the CCG has to date been in excess of the allocation transfer.

• Continuing healthcare, a significant pressure in 2016/17, is currently performing below plan for 2017/18.

• Overall there is no variance from plan.• We are forecasting to meet the running cost target.

Financial Governance Financial Risk• Annual internal audit plan for 2017/18 has been agreed• Board Assurance Framework has been updated in

March 2017.• With the formation of the Merton & Wandsworth Local

Delivery Unit a review of meetings and governance is being undertaken.

• Financial Recovery Group and Savings & Delivery Group (focus on QIPP) both now meet across Wandsworth and Merton CCG

• Financial ledger system has limited capability to do detailed analysis.

• Further issues may emerge around acute contracting which may impact on our ability to achieve the target surplus. Further mitigations will be developed to ensure that flexibility is built into the position.

• 2017/18 QIPP delivery represents a significant risk due to size of the programme, and the lack of reserves left to offset any further non-delivery.

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2 Key IndicatorsJuly 2017

The table above is showing that at month 4 the only area of real concern is around acute financial performance and this is predominantly driven by the expectation that QIPP will not deliver to plan.

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• Whilst we now have acute data for the whole of Quarter 1, it is still too early to forecast with any real certainly. However at this point in the year, we still expect to achieve the target surplus set (£2.179m)

• There is a risk that QIPP will not deliver the full £21.5m of gross savings (£17.5m net) required to deliver the planned surplus.

• Part of the mitigations for this is an assessment of any slippage on the investments, but through Financial Recovery Group (FRG) and Savings and Delivery Group (SDG), all opportunities are being explored to identify additional QIPP and stretch existing schemes which are performing well.

• Acute contracts remains the main area of pressure, predominantly driven by the change in the identification rules for specialised commissioned activity, but also non-achievement of QIPP and underlying activity growth.

• Continuing healthcare now appears to have stabilised and we expect this area to underspend against the plan.

• There are only two months of prescribing data so this is difficult to forecast but we are assuming this will operate to plan and achieve its QIPP targets.

• Delegated primary care budgets is showing an overspend. This is because we have set budgets based on the primary care allocation whereas we know that expenditure will be in excess of this.

• Investments are in place to meet the mental health investment standard.

• We still plan to meet the running costs target.

3 Month 4 Financial PositionJuly 2017

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4 Summary Financial PositionJuly 2017

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Note: There is a potential risk relating to the impact of IR (Identification Rules). An assessment of the position at St George's indicates that additional costs of £2.2m are being incurred largely relating to the Neurosciences - Neurosurgery and Neurology - with a corresponding reduction in costs for NHSE. Potentially there may be similar issues at other Trusts and we are working to understand the overall impact. Once the position is understood more clearly discussions will be held with NHSE relating to resources.

5 Risks and MitigationsJuly 2017

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6 Acute CommissioningJuly 2017

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• Based on month 3 data, acute commissioning is showing a £6.2m forecast outturn (FOT) overspend at month 4 against a budget of £220.5m. This assumes a high level of delivery of acute QIPP, including £7.5m which is not currently incorporated into provider SLAs. However note the mitigation around investments to offset this potential pressure.

• This £6.2m overspend is driven by St George’s (£3.0m), Chelsea & Westminster (£1.1m) and Royal Marsden (£0.6m), partially offset by underperformance (£0.4m) at QMH.

• The St George’s contract is showing a forecast overspend of £3.0m (YTD £0.7m), which has worsened by £0.5m compared to the forecast in M3. The forecast reflects an extrapolation of the year-to-date (YTD) service level agreement (SLA) overspend and assumes some QIPP will not deliver.

• Month 4 YTD overspends for St George’s total £1.4m and include Outpatients (£1.1m - due in part to non-achievement of a high QIPP target, but also underlying growth), Critical Care (£0.4m) and A&E (£0.3m).

• However, initial analysis suggests there are cost pressures observed at St George’s attributable to former NHS England Specialised Commissioning activity for which responsibility has passed to the CCG in 2017/18 due to a change in Identification Rules (IR). This issue is most significant in Neurology & Neurosurgery, especially emergency admissions for strokes. This cost pressure has been excluded from both the YTD position and the forecast outturn whilst we work to understand the reasons behind this.

• Early analysis suggests that the Chelsea & Westminster overspend is a combination of maternity activity and emergency admissions and the assumption that these will continue.

• Royal Marsden FOT is an £0.5m adverse variance, against a plan of £1.3m. The main driver for the overspend is critical care and emergency. To note that this contract was still in dispute but has now reached agreement.

• The position has also deteriorated from the previous month for a number of other providers, including Imperial (now £0.5m FOT), Guy’s & St Thomas’ (£0.4m), Kingston (£0.3m) and Moorfields (£0.3m).


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• Early stage of the year means that acute data is still not robust enough to draw clear conclusions from, with issues around Identification Rules still making the underlying pressures unclear.

• Early indications are that emergency activity at St Georges is low against the plan but this is still to be validated.

• All contracts have now been agreed with acute providers with Royal Marsden the last one to agree.

• QIPP plans have not been removed from agreed plans in their entirety but we continue to work with the acute provider and other stakeholders to get these implemented. Expectation is that this will be in the form of actual delivery rather than adjusting the plan.

• There are risks around the new identification rules for specialised commissioning in that the allocation adjustment received (if any) may not reflect the actual activity coming through.

• Similarly the new HRG4+ tariff may give rise to case mix changes not anticipated when agreeing the plan. Analysis is underway to identify areas where this may be the case.


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7 Non-Acute Commissioning and Primary CareJuly 2017

Non-Acute Commissioning

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Primary Care

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• For Non-Acute Commissioning, an underspend of £1.5m is forecast at M3 (YTD £0.3m).

• Although it is still early in the year Continuing Care is not showing the same pressures as in 2016/17 and at M4 Adults’ CHC and FNC budgets are forecast to deliver a £1.8m underspend against budget.

• However, this is offset by a new pressure of £0.7m FOT caused by Children’s CHC following the termination of the block arrangement with St George’s and a move to paying the real cost on a case-by-case basis.

• To note that within the FOT we have made an assumption that the new provider of community adult services from October 2017 will be inheriting a large number of vacancies. The new MCP contract with the GP Federation includes a clause which means the CCG can claw back some of this underspend non recurrently. To note though that the new provider is encouraged to fill all vacancies at the earliest opportunity which may affect this estimate.

• There is YTD overperformance of £0.3m across all the AQP contracts. These contracts sit within the “Other non-acute” line of the table. H

• Prescribing is expected to achieve its planned level of QIPP, but an additional saving is expected due to the new reduced price for Pregabalin, which is expected to save the CCG £0.5m in 2017/18.

• Other primary care budgets are also forecast to break even, although the co-commissioning budget detail received from NHSE indicates a net £450k shortfall, leading to a requirement to achieve savings elsewhere to mitigate this pressure.


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8 Running Costs and CorporateJuly 2017

To note that as at month 4 we are expecting to meet our running cost target.

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• Following a rigorous QIPP challenge meeting a potential gross underperformance of £2.79m was identified for Wandsworth.

• Several opportunities for project stretch and transfer were identified. Programme leads have been tasked with developing realistic plans. The newly formed joint LDU Savings & Delivery Group will be supporting leads and scrutinising plans. Many of the mitigations will rely on working closely with St George’s to deliver on transformation.

• See appendix 2 for detailed QIPP plan.

9 QIPPJuly 2017

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This balance sheet snapshot reflected payments to be made on 1st August (in month 5). Therefore cash position above is not correct. Real cash position is a surplus of £97k as per Cash Drawdown slide

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10 Statement of Cash FlowsJuly 2017

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10 Cash Drawdown to Month 4July 2017

• We have met the cash target set which is to ensure we are within 0.5% of the cash drawdown at the beginning of the month.

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• Regarding the NHS England debts: the £1.7m relates to GP IT Capital, ETTF (Estates & Technology Transformation Fund) schemes, the SMS Messaging project and the EMIS Anywhere/EMIS Mobile scheme; and the £562k relates to the Kinesis ETTF scheme and the GR Mobility project. £1.5m of this was paid on 15 August, and no problems are anticipated with collecting the remaining debt..

• The CCG debts are mostly recharges for Walk In Centre and Urgent Care Centre activity. There is a risk that we will not be able to collect the £28k that is overdue by >6 months.

• The non-NHS debt primarily relates to a £250k invoice to Richmond CEPN which we are still awaiting payment for.

10 Analysis of Aged Debt Month 4July 2017

Aged debt M3 Aged debt M4

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On most criteria we are achieving the target of 95%. However note that we are falling just short in July against the in-month, by number metric for payments to NHS organisations.

This is primarily due to a number of St George’s invoices that had been approved in June but were held over until July for payment due to the account being in credit.

Note that credit notes have been excluded from the analysis, which is different from the presentation in previous months.

10 Better Payment Practice Code (BPPC)July 2017

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11. APPENDICES

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The Resource Limit reflects the amount of money the CCG has available to commission services (programme) and to run the CCG (admin). The highlighted items are all new at Month 4.

Appendix 1 – Month 3 Revenue Resource LimitJuly 2017

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Appendix 2 – QIPP Plan at month 31.

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Part D: Board Governance

Page

4. Part D: Board Governance 95

4.1. D01 Summary Minutes: 96

4.1.1. Audit Committee 96

4.1.2. Finance Resource Committee 100

4.1.3. Integrated Governance Committee 102

4.1.4. Primary Care Committee 105

4.2. D02 AOB and Other Matters to Note

4.3. D03 Open Space

4.3.1. Members of the public present are invited to ask questions of the Boardrelating to the business being conducted. Priority will be given to writtenquestions that have been received in advance of the meeting.

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COMMITTEE FEEDBACK FORM

Committee: Audit Committee

Meeting date: 21st April 2017

Main items discussed: Tender Waiverso ITo Primary Care Accesso Continuing Health Careo Internal Audit

SWL Alliance

Internal Audit

External Audit

Counter Fraud

Year End Process and draft Annual Report

Decisions: Tender Waivers – All of the tender waivers had previously been presented and discussed at the Finance Resource Committee (FRC), with approval of the proposals agreed. The Audit Committee was asked to review the decisions taken by the FRC. Following discussion of each Single Tender Waiver, the Committee agreed that the each of the decisions taken by the FRC had been appropriate.

The Committee noted that there had been a number of Single Tender Waivers for consideration over recent months. Recurring issues were highlighted around the need for flexibility in contracts, length of contracts, and forward planning. It was agreed that these issues would be taken to the Contract Procurement Management Group for consideration. It was agreed that the contract register would come to the Audit Committee for review.

Particular points to note:

SWL Alliance – An update was provided on the work currently in place and the potential to bring meetings together to discuss joint business and separate issues.

Internal Audit Update – An update on work to date was received. The work plan for 16/17 had been completed, with the final three reports included in the paper. The work plan for 17/18 had been reviewed by Committee members, with work to scope and arrange timings for the audits commenced. The content of the report was noted.

External Audit – An update was provided to the Committee. The interim audit had been completed, with good progress made. One issue had been flagged regarding the Capital Service Auditor Report (SAR), which was expected to be a negative assurance as per last year.

Counter Fraud Update – An update was provided to the Committee. Two submissions were made to NHS Protect during 16/17. The overall rating

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for Wandsworth was green, with two standards rated as red. The content of the report was noted.

Year End Process and draft Annual Report – The draft Annual Report was reviewed, with a number of comments noted for inclusion in the final report.

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Committee: Audit Committee – Extra-Ordinary meeting

Meeting date: 24th May 2017

Main items discussed: 2016/17 Annual Report and Annual Accounts

Decisions: 2016/17 Annual Report – The Annual Report for 2016/17 was presented for approval by the Committee. Changes from the previous draft report were highlighted. The Committee approved the Annual Report to be recommended for approval by the Board.

2016/17 Annual Accounts – The accounts were presented for approval by the Committee. The External Auditors Report provided clean opinions across the board. One issue was flagged to the Committee regarding CCG reliance on outsourced functions, which would need to be considered. Following discussion, the Committee approved the Annual Accounts to be recommended to the Board for approval.

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Committee: Audit Committee

Meeting date: 21st July 2017

Main items discussed: SBS Service Auditor Report

CSU Service Auditor Report

Internal Audit

External Audit

STP Update

Decisions: None.


SBS Service Auditor Report – The report set out the findings and recommendations from the national audit commissioned by NHSE, including detail of all tests undertaken, the four exceptions noted, and management response. The Committee discussed the previous around a mis-payment of an invoice, stating that it remained unsatisfied that concerns had not been addressed in this report. This would continue to be pursued.

CSU Service Auditor Report – The report highlighted the testing that had been carried out with five exceptions noted, none of which related to Wandsworth. The Committee noted the report, which was generally reassuring, with no concerns raised. Other potential risk areas were to be considered for testing, where these overlap with CSU capabilities, in order to gain assurance that the right mechanisms and mitigations are in place.

Internal Audit – An update was provided on the work undertaken to date, and progress in implementation recommendations. A benchmarking report was provided for information. The Committee stated that a paper should go to the Board meeting in September to highlight the new data protection changes from May 2018.

External Audit – The report provided an indication of what the shape of the 17/18 will be. However, the year-end process and timetable had not yet been published. The External Audit team would work across both Wandsworth and Merton CCGs.

STP Update – The paper previously discussed at the Finance Resource Committee was presented, outlining the current position. It was agreed that a paper would come to the October meeting, outlining the current position, implications around governance risk, and role of other Audit Committees.

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Committee: Finance Resource Committee

Meeting date: 20th June 2017

Main items discussed: Budget Setting Update 17/18

Month 2 17/18 Financial Position / QIPP Assurance Report 2017/18

PMS Financial Modelling Options

STP Update

Procurement Update

St George’s Position

Single Tender Waiver

Decisions: None required.


Budget Setting Update 17/18 – An update on the budgets, previously approved in March, was presented focusing on acute and non-acute areas.

Month 2 17/18 Financial Position / QIPP Assurance Report 2017/18 – An update on the current position was provided, noting the risk around primary care and delivery of QIPP, with Planned Care reporting a shortfall of £2.4m. It was noted that performance around Continuing Health Care had now stabilised.

PMS Financial Modelling Options – The majority of Wandsworth practices are PMS, with eight being GMS. The paper outlined a number of options to address the identified cost pressures. It was noted that there was a discrepancy between Merton and Wandsworth PMS funding. A paper outlining the full PMS offer would be brought to the July meeting for ratification.

STP Update – An update was provided to the Committee on the Capped Expenditure Process (CEP), which was a national process. The Programme Board had agreed for more robust systems to be put in place. A system-wide meeting was scheduled in July, following which the position should be clearer. Further information would be provided to the meeting in July.

Procurement Update – The Committee received a paper on Single Tender Waivers to provide assurance that an appropriate process was in place. It was agreed that the paper would be updated to be presented to both the Audit Committee and Executive Management Team.

St George’s Position – The Committee received a verbal update on the Trust’s current position.

Single Tender Waiver – A Single Tender Waiver was required to be raised through the ECI process for BlueTeq. The Richmond GP Federation would do this on behalf of SWL.

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Committee: Finance Resource Committee

Meeting date: 18th July 2017

Main items discussed: Royal Hospital Neuro Disability

PMS Review

Month 3 17/18 Financial Position

QIPP Report

St George’s Position

STP Update

Decisions: PMS Review – The Committee was asked to consider the proposed PMS Review for recommendation to the Primary Care Committee. The paper highlighted the potential cost pressure to the CCG, with potential identified sources to mitigate the risk. The CCG has been working closely with the LMC in the development of the proposed review. Following discussion, the Committee supported the approach and recommended the proposed offer for approval by the Primary Care Committee.


Royal Hospital Neuro Disability – A verbal update was provided outlining the current arrangements to provide primary care for the identified cohort of patients. An emergency caretaker contract has been put in place with Putneymead practice for up to twelve weeks, following which an APMS contract was expected to be put in place.

Month 3 17/18 Financial Position – An update on the current position was provided, including control totals, financial governance, QIPP position, and the underlying recurrent position. It was noted that, while performance remained on the right side of the line currently, further recurrent savings would be required to offset any additional use of contingency reserves, which would have a negative impact on the underlying recurrent position. The main areas of risk included Cancer two week waits, Diagnostics, RTT, and Specialised Commissioning allocation adjustment. The content of the report was noted.

QIPP Report – The report highlighted a shortfall of £3.5m identified against the £17.5m net QIPP plan. Further work was being done to review the overall plan. A focused discussion around QIPP was scheduled for the next Executive Management Team meeting. The Committee remained concerned regarding the ability to achieve the QIPP target.

St George’s Position – The Committee received a verbal update on the Trust’s current position.

STP Update – An extract was provided from a paper submitted to the Finance and Activity Group. It was noted that the Croydon and Richmond CCGs financial plans have now been agreed, which will be played back into the overall SWL position.

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Committee: Integrated Governance Committee

Meeting date: 16th May 2017

Main items discussed: Safeguarding Update

Safeguarding – Approach to Child Safeguarding Training

Integrated Governance Report

Royal Hospital for Neuro Disabilities

SGH Quality Account 2016/17

Elective Care Recovery Programme Update

Decisions: Safeguarding – Approach to Child Safeguarding Training – The paper set out a recommendation for primary care training every eighteen months to two years to ensure that all practitioners were up-to-date. Following discussion, it was agreed that training should be provided to GPs on a two-yearly basis, with the clear message that every GP is required to undertake six hours of training over three years, therefore, additional training could be required in order to comply with Regulators.


Safeguarding Update – The report provided an update on a number of areas. During the discussion, it was noted that the work to resolve contractual issues regarding child health checks was vital, with escalation, if required, to ensure the contract was signed and accountability in place.

Integrated Governance Report – The report provided an update on performance with particular focus on the following areas: risks, Information Governance, finance, performance, and quality.

Royal Hospital for Neuro Disabilities – An update was provided on the current position regarding GP provision for patients, following the resignation of the current GP. Further meetings were being held with the Hospital, with a paper to be submitted to Management Team for discussion.

SGH Quality Account 2016/17 – The draft Quality Account had been received from the Trust, with a request for comments from the CCG. During the discussion a number of points were noted, which would be fed back to the Trust. The draft indicators were supported.

Elective Care Recovery Programme Update – A verbal update on the work was provided. A number of key actions had been identified at the last meeting to be taken forward. A further update would be provided at the next IGC meeting.

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Main items discussed: Royal Hospital for Neuro Disabilities

Cancer Performance Position


Elective Care Recovery Programme Update

Revision of Conflict of Interest guidance

Decisions: Royal Hospital for Neuro Disabilities (RHND) – Responsibility for providing primary care services for Wandsworth patients in RHND would now fall to Wandsworth CCG. Previously this was provided through Richmond CCG. The CCG is working through the complex arrangements to put in place a care taking arrangement initially, and then a longer term solution. The Committee noted that there was a significant financial risk in inheriting this responsibility. The Committee agreed the approach for an interim solution to be put in place. The Committee requested a progress report to be provided in the Autumn, to include proposals on a new model, quality and performance, financial information, and risk assessment.


Cancer Performance Position – One of the recommendations of the Independent Cancer Taskforce report was to create an integrated cancer dashboard, which indicates where Wandsworth sits alongside other CCGs. The Constitutional standards are operational waiting times targets. Following discussion of the report, the Committee requested a more detailed paper, to include more clinical input, at a future meeting, with a report to then be presented to the Board.

Integrated Governance Report – The report provided an update on performance with particular focus on the following areas: risks, Information Governance, finance, acute, Cancer two-week waits, Diagnostics, and quality.

Elective Care Recovery Programme Update – An update on the current position was provided, with particular reference to quality, workforce issues, clinical harm, and RTT (Referral to Treatment). Issues relating to the PAS system at QMH (Queen Mary’s Hospital) were noted.

Revision of Conflict of Interest Guidance – A further update to guidance issued in February 2017 had been published from NHSE. Further details to come to the meeting in July.

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Main items discussed: Learning from IT Incident

Revised Conflicts of Interest Guidance


Community Adult Health Services

Decisions: No decisions required.


Learning from IT Incident – The Committee received reports from NELCSU and the CCG on the learning from the incident on 12th May relating to malicious software, which spread across a number of industries and organisation. The report noted that Wandsworth CCG, GPs, and SGH experienced minimal disruption in comparison with other parts of the country. A number of issues were identified from the incident reviews. The CSU activated the strategic Business Continuity Plan, with sufficient deployment of resources and actions prioritised accordingly. Areas of learning were identified around communication, and access to contact details.

Revised Conflicts of Interest Guidance – Following publication of the guidance in February 2017, NHSE has issued a further update specifically for CCGs. The key changes were noted, and the CCG was required to update the Conflicts of Interest policy by 17th September.

Integrated Governance Report - The report provided an update on performance with particular focus on the following areas: risks, cancer two-week waits, IAPT, Diagnostics, finance, QIPP, performance, and quality. The Committee noted that an in-depth review of risks following transition to LDU development would continue by individual directors. A paper to review the Risk Register was scheduled to come to the September meeting.

Community Adult Health Services – The Committee was informed of a recent increase in the waiting list for the therapies component of CAHS. The waiting time had increased from three to ten weeks, which was in breach of KPIs (Key Performance Indicators). A Contract Performance Notice has been issued to the current provider, with an action plan required to address this issue. The CAHS service was due to migrate to the new provider with effect from 1st October, and it was important to ensure this issue is resolved.

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Committee: Primary Care Committee


Main items discussed: Integrated Primary Care Report

GP Resilience List Dispersal Scheme

Practice Deep Dive Review Report

Finance Report

Decisions: None.


Integrated Primary Care Update Report – The report provided an update on the work of the Primary Care Operational Group, including practice closures, and outcomes from CQC inspections. The Committee noted the content of the report.

GP Resilience List Dispersal Scheme – The scheme had been developed in order to support practices registering patients from practice lists that are being dispersed. All practices have been offered the opportunity to sign up to the scheme. Application of the scheme was highlighted for the two recent practice closures, to provide support for those practices receiving patients from the dispersed lists, for a specified period. The content of the report was noted.

Practice Deep Dive Report Report – A survey had been undertaken across Wandsworth practices, following the due diligence process around delegation of primary care commissioning to the CCG. A detailed questionnaire had been sent out to practices for completion. Visits were also made to practices that had not completed the questionnaire, or where limited information had been provided. This survey provided the opportunity to highlight concerns and issues, as well as identifying areas of good practice. The next steps were outlined in the report. A follow-on report would be presented to the Committee.

Finance Report – The report provided an overview of the current position for both delegated commissioning and primary care. An under-spend of £1.6m was reported in 16/17, predominantly driven by an under-spend in prescribing. Delegated commissioning budgets reported a £300k under-spend.

Some of the detail of the 17/18 budgets was still being worked through with NHSE. There is a pressure against allocation, the detail of which will need to be understood.


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Committee: Primary Care Committee Extra-Ordinary meeting


Main items discussed: PMS Review

Governance arrangements for a Contract Termination under NHS (PMS Agreement) Regulations

Decisions: PMS Review – The Committee was asked to consider and approve the proposed PMS Review offer, for recommendation to the Primary Care Committee. The Finance Resource Committee (FRC) had previously discussed the proposed offer. A shortfall in recurrent funding was highlighted, with the proposed approach to address the funding gap. Following discussion, the Primary Care Committee agreed the PMS Offer.

Governance arrangements for a Contract Termination under NHS (PMS Agreement) Regulations – The Committee was asked to consider and approve a proposed process and governance route, that could be put in place in the event of lack of sign up to the national contract. It was noted that this was a separate process from the PMS Review, but also acknowledged that there was a link between the two processes. This was a standard process, which sets out contractual obligations. It was not expected that this process would be required to be implemented in Wandsworth. The process was already in place across London, and has previously been subject to legal review. The Committee agreed the process.


As above.

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Part E: Meeting Close

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5.1. E01 Clinical Chair's Closing Remarks

5.2. E02 To resolve that the public now be excluded from the meeting becausepublicity would be prejudicial to the public interest by reason of thecommercially sensitive or confidential nature of the business to be conducted inthe second part of the agenda.

5.3. E03 Part II Agenda items: No substantive items

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board part i - wandsworth ccg · (p.23) zr/rg 10:40 20 ... no interests declared over and above...

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