virtual governing body to be held on thursday, 4 june 2020 … · 1 day ago · ‘reducing burden...

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VIRTUAL GOVERNING BODY To be held on Thursday, 4 June 2020 at 1pm

A G E N D A

Ref Item Enclosure Led By

Action Required

1. Apologies for Absence

Verbal Dr Crichton For noting

2. Declarations of Interest

Verbal All For noting

3. Minutes of the meeting held on 7 May 2020

Enc A Dr Crichton For approval

4. Matters Arising not on the Agenda

Verbal Dr Crichton For discussion

5. Notification of Any Other Business


Strategy

6. IVF Policy Enc B

Dr Crichton For approval

7. Primary Care Commissioning Committee Terms of Reference

Enc C L Tully For approval

8. Update from Healthwatch regarding Patient Experiences during COVID-19

Video A Goodall For discussion and noting

Assurance

9. Streamlined Quality & Performance Report

Enc D A Fitzgerald & A Russell

For noting

10. Finance Report

Verbal H Tingle For noting

Items to Note

11. ICS CEO Report – May 2020

Enc E Dr Crichton For noting

Receipt of Minutes

12. Receipt of Minutes • Executive Committee – Minutes of the

meeting held on 19 February and 15 April 2020. • Primary Care Commissioning

Committee – Minutes of the meeting held on 12 March 2020.

• Quality & Patient Safety Committee –

Enc F Dr Crichton For noting

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Ref Item Enclosure Led By

Action Required

Minutes of the meeting held on 5 March 2020. • Engagement & Experience Committee –

Minutes of the meeting held on 5 March 2020.

13. Any Other Business


14. Date and Time of Next Meeting Thursday 2 July 2020 at 1pm

For noting

Trusts and CCGs should continue to hold board meetings but streamline papers, focus agendas and hold virtually not face-to-face. No sanctions for technical quorum breaches (eg because of self-isolation)

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Minutes of the Virtual Governing Body

Thursday 7 May 2020 at 1pm

Members Present: Formal Attendees Present:

Dr D Crichton NHS Doncaster Clinical Commissioning Group (CCG) Chairman (Chair)

J Pederson Chief Officer, CCG H Tingle Chief Finance Officer, CCG Dr E Jones Secondary Care Doctor L Tully Lay Member P Wilkin Lay Member S Whittle Lay Member Dr M Khan Locality Lead, Central Locality Dr R Kolusu Locality Lead, East Locality Dr M Pieri Locality Lead, North Locality Dr M Pande Locality Lead, South Locality A Fitzgerald Director of Strategy and Delivery, CCG A Goodall

Healthwatch Doncaster Representative

In attendance:

J Satterthwaite PA to Chair and Chief Officer (Minute Taker)

Action 1. Apologies for Absence

Apologies were noted from :

• A Russell, Chief Nurse, CCG • L Devanney, Associate Director of HR and Corporate Services, CCG • Dr R Suckling, Director of Public Health • P Holmes, Doncaster Council Representative

2. Declarations of Interest The Chair reminded Governing Body members of their obligation to declare any interest they may have on any issues arising at Governing Body meetings which might conflict with the business of NHS Doncaster Clinical Commissioning Group (CCG). Declarations declared by members of the Governing Body are listed in the

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CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: www.doncasterccg.nhs.uk The meeting was noted as quorate. Declarations of interest from sub committees / working groups: None declared. Declarations of interest from today’s meeting: None declared.

3. Minutes From the Previous Meetings held on 5 March and 2 April 2020 The minutes of the meetings held on 5 March and 2 April 2020 were approved as a correct record.

4. Matters Arising not on the Agenda

There were no Matter Arising.

5. Notification of Any other Business

There was no notification of further business to discuss.

6. Delivery Plans A Fitzgerald explained that in April 2019 the NHS Doncaster CCG Governing Body approved the Joint Commissioning Strategy for Doncaster, which set out our joint commissioning journey, with Doncaster Council for a two year period. Since the strategy was approved, the Doncaster Place Plan has been refreshed (October 2019), and a new Joint Commissioning Agreement has been signed off (April 2020). Both of these developments have been reflected in the updated strategic delivery plans. More recently a number of significant operational changes have been made, in light of the Covid-19 pandemic. Some of these changes will inevitably impact on the actions set out within the delivery plans, in some cases accelerating delivery, but elsewhere delaying implementation and delivery. The changes will be reflected on as the system moves towards recovery and Governing Body will be kept informed regarding both the short and longer term. A Fitzgerald requested that the Governing Body approve the revised life stage Delivery Plans for Starting Well, Living Well and Ageing Well. Dr Crichton added that the Delivery Plans have been previously discussed at a Strategy & Organisational Development Forum meeting and improve each year. S Whittle queried how realistic the saving plans are. H Tingle advised that this

http://www.doncasterccg.nhs.uk/

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will be discussed in the Finance Report. The Governing Body approved the revised life stage Delivery Plans for Starting Well, Living Well and Ageing Well.

7. Reducing the Burden and releasing capacity Dr Crichton informed the Governing Body that the Chief Operating Officer of NHS England and NHS Improvement issued a letter on 28 March 2020 to all CCG Accountable Officers and Chief Executives of NHS and Foundation Trusts. The key focus of the letter was about reducing burden and releasing capacity at NHS Providers and Commissioners to manage the COVID-19 Pandemic. In light of the letter, it is recommended to the Governing Body that the following changes and/or timetables are enacted to comply with the requirements of NHS England/Improvement:

CCG Priorities • Oversight meetings:

Oversight meetings with regulators - to be held by phone or video conference, streamlined for COVID-19 and support needs.

• Governance and Meetings:

o Continue to hold Governing Body Meetings, virtually only. o Government social isolation requirements constitute ‘special reasons’ to

avoid face to face gatherings as permitted by legislation and therefore, Governing Body meetings will not be held in public.

o Continue to hold Primary Care Commissioning Committee, Quality and Patient Safety Committee, Executive Committee, virtually only, to discuss critical and urgent business matters.

o Hold Audit Committee meetings, specifically for critical and urgent business matters, and for the consideration of the annual report and annual governance statement, virtually only.

o Hold Remuneration Committee meetings only where critical and urgent business must be made, otherwise delay.

o Do not hold Engagement and Experience Committee (EEC) meetings until further notice and to re-introduce once agreed with the Chair of EEC.

o Do not hold other Board meetings, groups and sub-groups. o No face to face gathering as permitted by legislation. o Timely and effective decision-making to continue, using emergency

decision-making arrangements.

• Annual Accounts and Audit:

o 1 May (noon) - Submit interim assurance checklist. In line with findings of interim certification, advise CCGs when they should

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submit an updated draft of the annual report to support final certification. o An extra-ordinary Audit Committee and extra-ordinary Governing Body will

take place in June, due to the change in date to submit the final annual report, annual governance statement and annual accounts.

o 25 June (5.00 pm) – Full audited and signed annual report, as approved in accordance with the CCG scheme of delegation and signed and dated by the Accountable Officer and appointed auditors, as one composite document.

A full copy of the final Head of Internal Audit Opinion statement as issued by the CCG’s internal auditors. Note this should be submitted as a separate document. A summary version should be included in the CCG Annual Report.

Completed NAO disclosure checklist 2019/20 for final submission (to

support regional certification process)

o 29 June (5.00 pm) – Regions to submit final certification. o 8 July (5.00pm) - CCG’s to publish annual report and accounts on their

website. o By 30 September – CCG should hold a public meeting at which their

annual report and accounts be presented. • Annual Report:

o Requirements to be streamlined, further guidance awaited. o Current requirements are to submit the final draft annual report, approved

by Accountable Officer (and pass to auditors) on 27 April, 12.00 noon. o Submit draft Head of Internal Audit Opinion on 27 April, 12.00 noon. o Submit NAO disclosure checklist on 27 April, 12.00 noon. o The final draft annual report and annual governance statement have

already been prepared and reviewed. This was presented to the Accountable Officer for approval, at a Senior Management Team meeting w/c 20 April 2020.

• Reporting and Assurance:

o Continued Constitutional Standards Reporting:

A&E / Ambulance: to continue nationally and locally. RTT: to continue (financial sanctions for 52+ breaches from 1/4/2020

suspended). Cancer: to continue, focus on referral and treatment volumes (v10

Cancer Waiting Times Guidance modified).

o Returns that will not need to be submitted from 1 April 2020-30 June 2020:

Urgent Operations Cancelled (monthly sitrep) Delayed Transfers of Care (monthly return) Diagnostics PTL

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RTT PTL Cancelled elective operations Audiology Mixed-Sex Accommodation Venous Thromboembolism (VTE) 26-Week Choice Pensions impact data collection Ambulance Quality Indicators (Clinical Outcomes) Dementia Assessment and Referral (DAR)

o Long Term Plan:

Operational Planning has been paused. System by default has been put on hold. Mental Health and Learning Disability / Autism – The NHSE/I

investment guaranteed remains.

o Corporate Data collections streamline / waived / suspended for non-essential data collections.

o CHC Assessments: stop assessments. o Clinical Audit: collections and assessments suspended, except for child

death database. o It is proposed that Corporate Assurance Report and Board Assurance

Framework reports are deferred with exceptions reported by the Associate Director of HR & Corporate Services each month.

o The Audit Committee, at its meeting on 21 May, will receive the draft annual report, annual governance statement and annual accounts, the annual audit committee report 2019-20, committee effectiveness and maturity matrix.

• HR and Staff Related Activities:

o Mandatory training to be reduced where appropriate. o Appraisals and Revalidation:

Suspend appraisals (unless exceptional circumstances) Revalidation deferred by GMC (suspended until further notice) Revalidation extended by NMC by 3 months (further flexibility to be

advised). o CCG Clinical Staff Redeployment: review the need to retain a skeleton

staff and redeploy the remainder to frontline. o CCG Governing Body GP to focus on primary care provision. o Repurposing of non-clinical staff: focus on supporting primary care and

providers. o CCG to enact business critical roles for support, hospital discharge, EPRR

etc. • Data Security and Protection Toolkit:

o The deadline for submission is 30 September 2020.

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• Governance Self-Assessment

While there has been some relaxation of ‘business as usual’ arrangements, public sector bodies are still required to abide by the stewardship requirements of Managing public money. Some early actions and decisions are needed to enable the speeding up of financial transactions while maintaining appropriate controls and governance. The actions are in relation to :

o Schemes of delegation and standing financial instructions (SFIs. o Collecting and coding financial information that is auditable and

evidenced. o Documentation of key decisions. o Review of business continuity plans o Changes to financial processes/ systems to allow this to work.

The Healthcare Finance Management Association (HFMA) has published a self-assessment guide to support organisations maintaining sound and robust governance arrangements during this period. The CCG has undertaken a self-assessment based on this guide and is. This will also be taken through the Audit Committee for discussion.

The Governing Body was asked to: • Note the key areas detailed in the report, as directed by NHSE/I to act upon. • Approve the meeting, governance and reporting requirements. • Approve that the Corporate Assurance Report and Board Assurance

Framework reports are deferred with exceptions reported by the Associate Director of HR & Corporate Services each month.

• Support the Executive Team to enact the requirements as set out in the ‘Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pandemic’ letter issued 28 March 2020.

Dr Crichton advised the Governing Body that it has since been considered beneficial to continue to hold the Strategy & Organisational Development Forum and Clinical Reference Group meetings. Dr Pieri added that the Planned Care Board and the Cancer Programme Board meetings are also continuing to be held. The Governing Body: • Noted the key areas detailed in the report, as directed by NHSE/I to act upon. • Approved the governance and reporting requirements. The meeting schedule

was a point in time and no longer represented the current arrangements as COVID-19 impact had not impacted as significantly as planned.

• Approved that the Corporate Assurance Report and Board Assurance Framework reports are deferred with exceptions reported by the Associate Director of HR & Corporate Services each month.

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• Supported the Executive Team to enact the requirements as set out in the ‘Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pandemic’ letter issued 28 March 2020.

8. Streamlined Quality and Performance Report

A Fitzgerald presented the Quality & Performance Report for noting by the Governing Body. The following key areas were highlighted: NHS Doncaster Clinical Commissioning Group (DCCG) • Patients waiting less than 6 weeks for a diagnostic test – Performance in

March failed to meet the 99% target at 90% Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTHFT) • Patients on incomplete non-emergency referral to treatment (RTT) pathways

(yet to start treatment) should have been waiting no more than 18 weeks – Performance decreased to 89.7% during March and remains below the 92% target. The total waiting list size remains within target. The Acute Trust has undertaken a lot of work to recover performance and it is anticipated that it will be achieved when elective services are resumed.

• Accident and Emergency – Performance improved in March 2020 to 88% but remained below the 95% target

Rotherham, Doncaster & South Humber NHS Foundation Trust (RDASH) • Improving Access to Psychological Therapies (IAPT) – The proportion of

people accessing the service was below the 18.7% target at 15.9% with achievement of the 2019/20 target at significant risk. The CCG has discussed the issues regarding recruitment into IAPT services and additional training places with RDaSH. It is expected that post COVID-19 there will be more patients requiring access to IAPT services.

Dr Jones informed the Governing Body that the Quality & Patient Safety Committee meeting was well attended and everyone across the system is working hard to ensure services are maintained. There are concerns regarding care homes and safeguarding however there is a lot of collaborative work with the Local Authority and providers taking place. A Goodall queried if the Governing Body would welcome sight of some of the patient issues and experiences which Healthwatch Doncaster have been collating. Dr Crichton stated that he would give this careful consideration. The Governing Body noted the Quality and Performance Report.

Dr Crichton

9. Finance Report

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H Tingle presented the Finance Report for noting by the Governing Body. The report sets out the financial position as at the end of March 2020. NHS Doncaster CCG achieved all of its financial targets for 2019/2020. 2020/21 Finance and Contracting Due to the coronavirus outbreak the 2020/21 planning and contracting round was suspended in mid-March. NHS England and Improvement have issued guidance on how CCG’s need to work with providers during the interim period. The following summarises some of the current arrangements – • The CCG’s main NHS providers are being paid on a block basis, the value of

which was determined centrally by NHS England. This is only for contracts that exceed a set value. No other payments will be made to any other NHS providers by the CCG at this time.

• CCG’s are reimbursing their main acute provider for all other contractual activity that they would usually receive from their smaller contracts. For Doncaster CCG this is Doncaster and Bassetlaw Hospital NHS Foundation Trust.

• Primary Care income streams are being protected at 2019/20 levels as a minimum including national Direct Enhanced Service (DES) and Local Enhanced S payments.

• Individual placement costs are still being reimbursed and the CCG is working closely with numerous providers that are having to be flexible in terms of their delivery of care at this time.

• Non NHS providers are being reviewed on an individual basis. Income streams are not guaranteed for this cohort of providers and depend upon the levels of service being provided at this time, and whether they are deemed critical to the Covid-19 response. Providers are being encouraged to seek other government support where necessary.

• Additional funding is available to support the Covid-19 response and returns are being regularly submitted to NHS England on additional costs incurred that are in line with the guidance. Governance around the agreement of additional costs is being maintained in line with usual processes.

• The new Discharge Protocols are also being centrally funded by NHS England including funding for any new packages of care that are initiated during this period in order to safely discharge a patient from hospital or avoid a hospital admission.

This interim position is to be maintained until at least the end of July and further information and guidance is expected on future arrangements. At this stage the CCG has not received any additional allocations other than those specific items highlighted above. The CCG will continue to monitor all expenditure being incurred and will provide further updates at future meetings. P Wilkin commented that the Annual Report reflects the amount of work that has been undertaken and queried if there has been any indication of recurrent investment. H Tingle advised that there has been no indication to date. Discussions are focussed on Phases 1 – 4 of COVID-19:

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• Phase 1 COVID-19 hit. • Phase 2 re-instate services. • Phase 3 Elective Care. • Phase 4 New and modernised NHS. NHS Doncaster CCG is utilising the Independent Sector for urgent cancer surgery. Dr Pande stated that there is currently no provision within General Practice for minor surgery services. H Tingle stated that the CCG is doing what it can to ensure that practices do not suffer a loss of income in line with NHSE published guidance. Dr Kolusu highlighted that the increased use of technology has been advantageous and asked if any thought had been given to making it more robust going forward. J Pederson reported that there will be a national expectation that we will continue its use as we are now. We acknowledge that it will be necessary to hold some face to face meetings however where practicable encourage the use of video consultations. It is a positive outlook to continue the digital revolution. A Goodall informed the Governing Body that Healthwatch Doncaster has conducted a survey with patients on digital consultations including feedback from clinicians which has been shared with Primary Care Doncaster and offered the information to the Governing Body if required. Dr Crichton extended his thanks to the Finance Team for all its hard work over the last financial year. The Governing Body noted the Finance Report.

10. CCG Constitution and Standing Orders – Emergency and Urgent Amendments Dr Crichton presented a paper to the Governing Body for noting of the approved amendments to the CCG Constitution and Standing Orders. Dr Crichton advised the Governing Body that as a result of COVID-19, the Chair and Chief Officer were asked to consider the following: • Amend the CCG Constitution (non-material change) • Amend the Standing Orders (to include virtual meetings of the Governing

Body). The amendments were considered under Standing Order 7.2 – Emergency Powers and Urgent Decisions. Standing Orders NHS Doncaster CCG has a duty to plan for and respond to a wide range of incidents and emergencies that could affect population health or direct patient care. Under the Civil Contingencies Act (2004) the CCG, as a Category Two

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responder has specific duties and standards which need to be met in relation to Emergency Preparedness, Resilience and Response (EPRR) and business continuity plans are in place. At times where business continuity plans are required to be used, the CCG is still required to be properly governed and there are situations where there is a need for sustained business continuity plans to be used, such as for pandemic flu or virus situations or where national emergencies are called. The CCG has in place a Corporate Governance Framework and an approved scheme of matters reserved for the Board and a scheme of delegation. The Standing Orders in place already give us the framework to be properly governed. However, the Standing Orders do not have a provision for holding virtual meetings therefore no formal business may be transacted. Only a record of matters can be discussed: CCG Constitution Amendment The current CCG Constitution prescribes, under 6.1 (d): “hold Governing Body meetings in public (except where we believe that it would not be in the public interest)”. It is proposed to amend the Constitution as follows: “hold Governing Body meetings in public (except where we believe that it would not be in the public interest or for special reasons). The current standing orders do not comprise for the requirement for the Governing Body to meet ‘virtually’. The following addition was proposed to be added to the Standing Orders:

Without prejudice to the power to exclude the public, pursuant to Standing Order 5.13.2 above, the CCG may hold virtual (video conference, telephone conference or similar communications equipment) meetings of the Governing Body and Sub-Committees, under the Public Bodies (Admission to Meetings) Act 1960, for other special reasons and / or under the Civil Contingencies Act 2004 for the purposes of business continuity.

The whole of the proceedings will be where all persons participating in the meeting can hear each other and participation in the meeting in this manner shall be deemed to constitute presence in persons at such meeting. The formal approval of the proposed amendments to the CCG Constitution and Standing Orders will be presented to NHS England, after the formal ‘close-down’ of business continuity by NHSE North East Yorkshire EPRR, due to COVID-19. Approval of the CCG Constitution and Standing Orders The Chief Officer and Chair approved the following amendments. • CCG Constitution, 6.1 (d): hold Governing Body meetings in public (except

where we believe that it would not be in the public interest or for special reasons).

• Standing Orders, 5.13.8 Without prejudice to the power to exclude the public,

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pursuant to Standing Order 5.13.2 above, the CCG may hold virtual (video conference, telephone conference or similar communications equipment) meetings of the Governing Body and Sub-Committees, under the Public Bodies (Admission to Meetings) Act 1960, for other special reasons and / or under the Civil Contingencies Act 2004 for the purposes of business continuity.

The whole of the proceedings will be where all persons participating in the meeting can hear each other and participation in the meeting in this manner shall be deemed to constitute presence in persons at such meeting. The Governing Body noted the approved amendments to the CCG Constitution and Standing Orders.

11. COVID-19 response paper J Pederson gave an update on the NHS Doncaster CCG and system operational response to the current COVID-19 Level 4 incident. Due to the scale of the response required, it is not meant to be comprehensive and instead gives an oversight of the key actions and changes taking place across Doncaster and the wider South Yorkshire and Bassetlaw (SY&B) system. Keith Willett and Stephen Grove wrote to all leaders in health and care, 2nd March 2020 to confirm that the current outbreak of a novel coronavirus was resulting in national and international preparations being stepped up and that a level 4 incident had been declared. In declaring a level 4 incident nationally, NHS England and NHS Improvement established an Incident Management Team with an operational Incident Coordination Centre. Both run 7 days a week and work closely with the Department of Health and Social Care, Public Health England and other government departments. All NHS Regions also established an operational COVID-19 Incident Coordination Centre working with the national team and their NHS local organisations, CCGs, other health care providers and Local Resilience Forums (LRF’s). Local Governance The Chief Executive, Doncaster Council is the Chair of Team Doncaster Gold. The Chief Executive, Doncaster Council is also a member of the South Yorkshire LRF. The Accountable Officer, Doncaster CCG is a member of Team Doncaster Gold. The CCG Executive Team lead and take part in other elements of the Team Doncaster Gold Governance structure. The NHS Doncaster CCG Chief Nurse chairs the Health Cell to ensure a co-ordinated response to COVID-19 across the health and care sector with input from senior colleagues in the CCG and in partner organisations. The Health Cell is a daily meeting and has been in place since late February. The CCG Executive Team and Chair also meet daily.

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The SY&B ICS has established a weekly SY&B COVID-19 Strategic Health Coordination Group (SHCG). The Accountable Officer, Doncaster CCG is a member of the group. The group has two main functions:

• To collect issues and problem solve for frontline organisations in SY&B. • To feed up nationally & regionally, to sort as best we can locally - co-

ordinate and plan across organisations. Clinical Governance Further guidance was issued to support the system to free-up management capacity and resources. This guidance is being implemented locally and the Quality & Patient Safety Committee and all contractual Clinical Quality Review Groups will continue to ensure commissioner clinical quality oversight to the changes. Primary Care A Primary Care Cell has been established to support the changes required. The CCG Director of Strategy and Delivery chairs the cell and reports through to the Health Cell and the CCG Executive Team daily meeting. Guidance and standard operating procedures General practice in the context of coronavirus (COVID-19) Version 2.1 was published 6 April 2020. The Primary Care Cell has worked with Primary Care colleagues to support the changes required. There is a huge amount of work taking place. Key headlines include: • Online consultation and digital triage - The move to full triage of patients

and video conferencing consultations. Face to face appointments only if necessary.

• Hot and cold site working - The establishment of a Doncaster COVID-19 Hub (CCHUB) to advise and treat all COVID/COVID symptomatic patients on behalf of Doncaster practices. This ensures that the 38 practices in Doncaster remain cold sites. The CCHUB is delivered in partnership by FCMS and the 38 GP Practices in Doncaster. Local Medical Committee (LMC) and Primary Care Doncaster (PCD) colleagues have also been instrumental in ensuring the success of this significant change to the Primary Care delivery model.

• Shielded patients – Practices have been required to review and update care plans and undertake any essential follow up. All Practices were required to check the centrally generated list of shielded patients and remove or add patients based upon their local knowledge. The Acute Trust was also required to consider this week commencing 13th April 2020. This activity is designed to identify accurately those most at risk and those most in need of coordinated support across health and social care services.

• Stop all non-essential work – A letter was received from Dr Nikita Kanani, Medical Director for Primary Care Director and Ed Waller, Director Primary Care Strategy and NHS Contracts for NHS England/Improvement wrote to all

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practices and CCG’s 19 March 2020. The letter advised that we free up practice capacity to prioritise workload to both prepare for and manage the COVID-19 outbreak and it details the areas of practice work that could be suspended. Practices have been supported to respond to the guidance in the letter and it is expected that freed up capacity will support the running of the CCHUB.

Acute Care Doncaster and Bassetlaw Teaching Hospital NHS Foundation Trust (DBTHFT) colleagues have also been preparing to respond to the COVID-19 outbreak. Simon Stevens, NHS Chief Executive and Amanda Pritchard, NHS Chief Operating Officer wrote to NHS leaders 17 March 2020 to advise on important and urgent next steps. • Non-urgent elective operations - The letter confirmed that all Trusts should

postpone all non-urgent elective operations from 15 April at the latest, for a period of at least three months. Emergency admissions, cancer treatment and other clinically urgent care should continue unaffected. DBTHFT have enacted this guidance.

• Critical Care capacity – DBTHFT colleagues have more than doubled the Critical Care bed capacity from 16 to 38. The Trust can also increase capacity to 82 and potentially 104 Critical Care beds if required. Some of this is dependent on centrally managed resources such as ventilators and other key equipment. These resources are managed on a day to day basis and reflect the changing profile across the country in relation to critical care capacity.

• Maternity - In order to maintain services and mitigate risks in relation workforce, DBTHFT moved the majority of maternity services to a central point within Doncaster Royal Infirmary (DRI). Bassetlaw retained some capacity to support mothers should they attend in an unplanned way.

• Major Trauma -Trauma care has been consolidated at the DRI site (for any patients requiring admission) rather than delivery of trauma service at Bassetlaw DGH and DRI. Agreements are in place and ambulance bypass protocols with East Midlands Ambulance Service. Bassetlaw patients will be admitted and discharged from DRI.

• Minor illness - Minor illness has moved from Mexborough to Doncaster Royal Infirmary’s Urgent Treatment Centre. Mexborough Montagu Hospital is still open for minor injuries. The Same Day Health Centre is still running but mostly via triage and remote consultation.

Community and Mental Health/LD Key headlines include: • COVID-19 Hospital Discharge Service Requirements – Guidance was

published 19 March 2020. The Discharge and Flow Cell, chaired by the CCG Deputy Chief Nurse has worked with partner organisations to support the changes required. The document sets out the Hospital Discharge service requirements for all NHS Trusts, Private Care Providers of acute and community beds and Community Health services and Social Care staff along

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with the requirements for CCG’s and Local Authorities and describes that unless required to be in a hospital, patients must not remain in a NHS bed. The new model went live in Doncaster 6 April 2020. Community health services now have overall responsibility for ensuring the effective delivery of the discharge service and for pathways 1, 2 and 3.

• Managing capacity and demand within inpatient and community mental health, learning disabilities and autism services for all ages Version 1 – was published 25 March 2020. The guidance supports and advises Trusts when developing plans to maximise capacity where needed across mental health and learning disability and autism services.

• Care Homes and Domiciliary Care Providers - A range of guidance has been published in relation to care provision by domiciliary care homes and care homes. NHS Doncaster CCG has worked alongside colleagues within Doncaster Council to both support care providers but also to understand and extend the capability and capacity within care provision. Regular contact for support and engagement has taken place by both organisations. Care providers have also been supported take steps around shielding residents for example the CCG has worked with other providers such as GPs and community nursing services to re-provide care in a way to reduce footfall and therefore reduce risk to residents. There are many examples of actions taken by providers and commissioners. There is now an increased focus on the care and protection of people within care homes. The CCG, alongside the Local Authority and provider organisations, is increasing the support available to care home environments to strengthen their ability around Infection Prevention and Control and ensure that they are in a position to manage outbreaks should they occur. This work is multifaceted and is interdependent with, amongst other things, the emerging swabbing and testing strategies. Wider issues around peer support, wellbeing and mental health support to workers will also need to be considered and strengthened.

SY&B System changes • Paediatrics emergency surgery consolidation - As part of the response to

the covid-19 pandemic, District General Hospitals (DGH) in SY&B are taking a range of measures to increase critical care capacity and deal with workforce shortages. This is having a knock-on effect on the availability of services for children, particularly those in need of surgery or intensive nursing. As part of the pandemic response and incident control, NHS England has directed the NHS to secure healthcare for children and young people, including urgent and emergency surgery, cancer care, paediatric intensive care and the management of urgent and emergency medical care.

SY&B acute providers have responded to this direction by developing a plan

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to move paediatric emergency surgery for children up to 16 and some high dependency paediatric care for the SY&B hospitals and Chesterfield Royal into Sheffield Children’s hospital for the duration of the pandemic. This change came into effect 16 April 2020 and comprises:

o Paediatrics emergency surgery for children up to 16, for all except the

most time critical cases to Sheffield Children’s, on safety grounds and to support the COVID-19 response.

o A small number of additional HDU patients (up to the age of 16), and potentially some CAMHS inpatients and 16-25 year olds requiring ventilation to Sheffield Children’s, for the same reason.

o The development of contingency plans in case any DGH becomes unable to sustain its paediatric inpatient services or Emergency Department and needs to move these to Sheffield Children’s, with monitoring in place to flag if there are major safety concerns for paediatrics services in the DGHs at any point.

The South Yorkshire & Bassetlaw COVID-19 Strategic Health Co-ordination Group (SHCG) supported this action at the meeting dated 14 April 2020. • Out of hours GI bleed consolidation - SHCG asked for a piece of work to

be undertaken to consider risks and a potential consolidation solution for Gastro Intestinal Bleed (GI Bleed) out of hours services. This followed concerns raised by DBTH at the SHCG on 30 March regarding the fragility of their medical rota to support out of hours GI bleed presentations.

o On Friday 10 April Rotherham and Doncaster went live with consolidation

of out of hours emergency GI bleeds at Sheffield Teaching Hospital. o The protocols have been written to ensure that only those patients who

are stable enough to transfer, and who have an otherwise good prognosis i.e. the patient will benefit from scoping, will transfer to STH.

o This is likely to affect 1-2 patients per week. o The protocol has been communicated to clinicians in Doncaster,

Rotherham and Sheffield. o A further meeting with Medical Directors is taking place Friday 24 April to

review and refine if required. The South Yorkshire & Bassetlaw COVID-19 Strategic Health Co-ordination Group (SHCG) supported this action at the meeting dated 14 April 2020. Personal Protective Equipment (PPE) The provision of PPE has remained a challenge both nationally and locally. This has been across all sectors of health and social care. All organisations have been required to work closely together as the guidance on PPE use has evolved and also to understand the various distribution routes. Large organisations have identified leads for PPE. This virtual team are working closely together to maintain levels of PPE in Doncaster and also coordinate and provide mutual aid. Where necessary, the Local Authority and the CCG have worked closely

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together to provide consistent advice and guidance to care homes and other care providers to support the safe, effective and efficient use of PPE. Risk management

The NHS Doncaster CCG Risk Register is being amended to include COVID-19 risks. The COVID-19 risks are managed and actioned via the Health Cell. Executive leads are assigned to each of the COVID-19 risks. Recovery Thoughts are already turning to recovery. It has been agreed that the LRF lead for South Yorkshire is the Chief Executive, Doncaster Council. The SY&B ICS Chief Executive Officer will be the SY&B Health representative. A recovery model will also be initiated in Doncaster by Team Doncaster Gold. Recovery is expected to be enacted through the current governance arrangements. As the recovery model develops, Governing Body will be updated in due course. NHS England also issued correspondence regarding the second phase of NHS response to COVID-18, 29 April 2020. The ask is that all NHS local systems and organisations working with regional colleagues now to step up non-COVID-19 urgent services as soon as possible over the next six weeks.It is confirmed that this should be a safe restart with full attention to infection prevention and control as the guiding principle. Work is now taking place within the Doncaster system to respond to the request and this will be overseen by the Health Cell. The Governing Body was asked to note the operational actions being taken by NHS Doncaster CCG, wider partners and NHS England and NHS Improvement to respond to the COVID-19 pandemic. L Tully queried if there will be an issue with childhood immunisations. The vaccinations and screening services are a priority to re-commence and the offer is there to parents however there is a significant number of parents who do not wish to take their children into surgeries. Dr Kolusu highlighted that secondary care patients are generating investigations for practices for example blood testing. Patients are receiving results and contacting their GP who has no information. Dr Crichton advised that there was an opportunity for this to be discussed in the next Clinical Reference Group meeting. A drive-through phlebotomy service is currently being provided by the Acute Trust located at the Keepmoat Stadium for patients. The Governing Body noted the operational actions being taken by NHS Doncaster CCG, wider partners and NHS England and NHS Improvement to respond to the COVID-19 pandemic.

12. Integrated Care System CEO Report The Governing Body noted the Integrated Care System CEO Report. P Wilkin queried if the Integrated Care System (ICS) financial position was

17

known. H Tingle advised that the ICS has achieved its financial position.

13. Receipt of Minutes The following minutes were received and noted by the Governing Body: • Executive Committee – Minutes of the meetings held on 19 February and 18

March 2020. • Primary Care Commissioning Committee – Minutes of the meeting held on 13

February 2020.

14. Any Other Business There was no other business discussed.

15. Date and Time of Next Meeting Thursday 4 June 2020 from 1.00pm.

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Meeting name Governing Body Meeting date 4 June 2020

Title of paper

Access to Infertility Treatment V11

Executive / Clinical Lead(s) David Crichton, GP and Chair DCCG

Author(s) Karen Leivers, Head of S&D, Planned Care Status of the Report To approve To consider / discuss To note Purpose of Paper - Executive Summary The purpose of this paper is to present the updated Yorkshire and Humber Access to Infertility Treatment policy (V11) for approval. The Yorkshire and Humber Expert Fertility Panel (made up predominantly of Clinicians and fertility experts) are responsible for developing a joint commissioning policy in collaboration with Yorkshire &Humber CCG’s. The Access to Infertility Treatment V10 paper was approved by the Doncaster CCG Governing Body in February 2020. Concerns were later raised with the updated policy following new guidance. Where the policy stated: “Where either member of the couple was required to pay the surcharge, the couple would be ineligible”. Legal advice was sought to determine whether the policy should be further amended and based on the advice, the V11 Policy (Appendix1) was recommended. Background The standard position in the NHS (Charges to Overseas Visitors) Regulations 2015 (amended in July 2017) concerning patients required to pay NHS Immigration surcharges is that they are not entitled to free NHS assistance and funding, for secondary care for fertility investigations and assisted conception. Based on the NHS Regulations 2015, the eligibility criteria currently states (in Access to Infertility Treatment V10) that if one member of a couple is not an ordinary UK resident and covered by an NHS surcharge arrangement, then that couple will not be eligible for secondary care in fertility investigations or for NHS funded assisted conception. In October 2019 there was a national update issued that said ‘Any services required by the ordinarily resident person will continue to be freely available’. Legal advice from Hempsons Health and Social care law firm recommends that the

X

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current policy is updated to include the October 2019 amendments. If we fail to make the changes there is a risk that we would be denying UK residents access to free medical fertility assistance on the basis of whom they are partnered too, despite there being guidance allowing for funding in the 2019 amendments. In addition to the new amendments, the 2006 NHS Act states that “UK residents’ have access to free medical care”. This could mean that challenges could arise from individuals about denying them treatment on these grounds. The Law firm also stated that there is an argument, in which we would be interfering with a person’s right to respect for a family life under Article 8 and right not to be discriminated against under Article 14 of the Human Rights Act 1998. It is made clear that if we do not follow the guidance we will not necessarily be breaching any laws, however we will be subject to queries and challenges regarding our eligibility criteria which are no longer supported by the 2019 NHS update. Proposed Changes Based on the legal guidance and deliberation of the Yorkshire and Humber Expert Fertility Panel it is recommended that we amend the following (V10) text: “Individuals who are required to pay the NHS surcharge are not eligible for fertility investigations in secondary care. Individuals who are required to pay the NHS surcharge are no longer eligible for NHS funded assisted conception. Where there is discordance in requirements to pay the NHS surcharge, assisted conception treatment will not be funded if one partner is not eligible as the policy applies as a couple”. To the following (V11): “The October 2019 Guidance on Implementing Overseas Visitors Regulations says that: ‘Where two people are seeking assisted conception services with NHS funding, and one of the two people is covered by health surcharge arrangements and the other is ordinarily resident in the UK and therefore not subject to charge, the services required by the health surcharge payer will be chargeable. Any services required by the ordinarily resident person will continue to be freely available, subject to the established local or national commissioning arrangements”. Our eligibility criteria for access to assisted conception services relates to couples rather than individuals. Therefore in light of this guidance, to enable the ordinarily resident person to have freely available access to services, where at least one partner is eligible for these services, the couple will be considered as eligible for services.

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Recommendation(s) Doncaster CCG Governing Body is asked to approve and accept V11 of the Yorkshire and Humber Access to Infertility Treatment policy.

Report Exempt from Public Disclosure Yes No If yes, detail grounds for exemption: Impact analysis

Quality impact A Quality Impact assessment was completed for the V10 version in January 2020. This has been revisited in light of V11 changes and no further action is needed at this point.

Equality impact

The Equality Impact Assessment demonstrates a positive and neutral impact for all protected characteristics, excluding age which is positive due to fertility access, however negative as this access is only available to women up to the age of 42. As a women’s age increases the chances of a successful pregnancy decreases.

Tick relevant box

An Equality Impact Analysis/Assessment is not required for this report. x

Based on the minimal changes to the V11 Policy the Jan 2020 EIA is still Validated.

Sustainability impact

The V11 policy is approved for implementation from Jan 2020 to April 2023 and will be actively monitored throughout.

Financial implications

As the proposed changes will include broader access to the NHS funded fertility treatment, financial implications may reflect increased activity and therefore would be monitored following implementation on an annual basis.

Legal implications

After following legal advice as described in the cover sheet no other legal implications are identified.

Management of Conflicts of

Interest Conflicts of interest are managed through the terms of reference at each applicable forum.

Consultation / Engagement

(internal departments,

clinical, stakeholder and public/patient)

Doncaster Engagement Exercise – August 2019-October 2019. Following approval of V11 the Doncaster CCG website will be updated.

Report previously

presented at DCCG Governing Body reviewed public consultation in November 2019 and February 2020

Risk analysis

Risks mitigated through collaborative policy access across Yorkshire and Humber and encompassing Public Consultation.

X

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Corporative Objective / Assurance Framework

• Commissioning high quality, continually improving, cost effective healthcare which meets the needs of the Doncaster population.

• Working collaboratively with partners to improve health and reduce inequalities in well governed and accountable partnerships.

1

Access to Infertility Treatment –

Commissioning Policy Document

Yorkshire and Humber

Adopted by

Doncaster CCG

January 2020 – April 2023

Document Title: Access to Infertility Treatment – Commissioning Policy Document Yorkshire and Humber

Author/Lead Name: Job Title:

Michelle Thompson Assistant Director Women’s and Children’s Services

Version No: V11 Latest Version Issued On February 2020 Supersedes: All previous Access to infertility treatment

policies Date of Next Review:

April 2023

Completion Equality Impact Statement Name: Job Title: Date:

Philippa Doyle Hempsons Solicitors

August 2018

Target Audience: Public

Dissemination: CCG Weekly Bulletin, Internet & Intranet

2

Any locally held old paper copies must be destroyed. When this document is viewed as a paper copy, the reader is responsible for checking that it is the most current version. This

can be checked on http://www.doncasterccg.nhs.uk/about-us/public-information/publications-scheme/our-policies-and-procedures/

APPROVAL RECORD Committees / Groups / Individual Date Consultation: Yorkshire and Humber Expert Fertility Panel 2 March 2017

31 January 2018 25 June 2018 25 January 2019

Hempsons Solicitors August 2018 Ratified by Committees: Doncaster CCG Governing Body November 2019

February 2020

CHANGE RECORD Version Author Nature of Change Uploaded

V10 Y&H Expert Fertility Panel

Version 10 policy changes approved – see Appendix D

Commissioning Policy Statement: Commissioning This document represents the commissioning policy of Doncaster CCG for the clinical pathway which provides access to specialist fertility services. This commissioning policy has been developed in partnership with the Yorkshire and Humber Expert Fertility Panel. It is intended to provide a framework for the commissioning of services for those couples who are infertile and require infertility interventions. The policy was developed jointly by Clinical Commissioning Groups in the Yorkshire and Humber area and provides a common view of the clinical pathway and criteria for commissioning services which have been adopted by Doncaster CCG. Funding The policy on funding of specialist fertility services for individual patients is a policy of Doncaster CCG and is not part of the shared policy set out in the rest of this document. The number of full IVF cycles currently funded by the Doncaster CCG for patients who meet the access criteria set out in the shared policy is 2. This is unchanged from the previous funding policy in March 2016. This policy will be updated in accordance with the review period of the policy or earlier should sufficient changes in practice or evidence base require it. Immigration Health Surcharge; Right to Assisted Conception Services

http://www.doncasterccg.nhs.uk/about-us/public-information/publications-scheme/our-policies-and-procedures/

http://www.doncasterccg.nhs.uk/about-us/public-information/publications-scheme/our-policies-and-procedures/

3

Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017. As a result, from 21 August 2017, assisted conception services are no longer included in the scope of services. However, the October 2019 Guidance on Implementing Overseas Visitors Regulations says that: ‘Where two people are seeking assisted conception services with NHS funding, and one of the two people is covered by health surcharge arrangements and the other is ordinarily resident in the UK and therefore not subject to charge, the services required by the health surcharge payer will be chargeable. Any services required by the ordinarily resident person will continue to be freely available, subject to the established local or national commissioning arrangements’. Our eligibility criteria for access to assisted conception services relates to couples rather than individuals. Therefore in light of this guidance, to enable the ordinarily resident person to have freely available access to services, where at least one partner is eligible for these services, the couple will be considered as eligible for services. Working group membership and Conflicts of Interest See appendices E and F For Further Information about this policy. Please contact your local Clinical Commissioning Group.

4

Contents 1. Aim of Paper .................................................................................................................... 7

2. Background ...................................................................................................................... 7

3. Clinical Effectiveness ....................................................................................................... 8

4. Cost Effectiveness ........................................................................................................... 8

5. Description of the Treatment ............................................................................................ 9

5.1 Principles of Care ......................................................................................................... 9 5.2 The Care Pathway for Fertility Investigation and Referral (fig, 1) ................................ 10 5.3 Definition of a Full Cycle ............................................................................................. 10 5.4 Frozen Embryo .......................................................................................................... 10 5.5 Abandoned Cycles........................................................................................................10 5.6 IUI and DI ................................................................................................................... 10 5.7 Gametes and Embryo Storage ................................................................................... 11 5.8 HIV/HEP B/ HEP C ..................................................................................................... 12 5.9 Surrogacy ................................................................................................................... 12 5.10 Single Embryo Transfer .............................................................................................. 12 5.11 Counselling and Psychological Support ...................................................................... 12 5.12 Sperm Washing and Pre-implantation Diagnosis ........................................................ 12 5.13 Service Providers ....................................................................................................... 12

6. Eligibility Criteria for Treatment ...................................................................................... 12

6.1 Application of Eligibility Criteria ................................................................................... 13 6.2 Overarching Principles ................................................................................................ 13 6.3 Existing Children ......................................................................................................... 13 6.4 Female Age ................................................................................................................ 13 6.5 Pre-Referral Requirements for Assisted Conception……………………………………..15 6.6 Reversal of Sterilisation .............................................................................................. 14 6.7 Previous NHS funded Full Cycles ............................................................................... 14 6.8 Length of Relationship ................................................................................................ 16 6.9 Welfare of the Child .................................................................................................... 16

Appendix A 17 Appendix B 18 Appendix C 19 Appendix D 22 Appendix E 27 Appendix F

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1. Aim of Paper 1.1 This document represents the commissioning policy for specialist fertility services for adults

registered with a Clinical Commissioning Group (CCG) in the Yorkshire and Humber region.

1.2 The policy aims to ensure that those most in need in keeping with current eligibility, are able to benefit from NHS funded treatment and are given equitable access to specialist fertility services across the Yorkshire and Humber Area, by identifying the clinical care pathway and relevant access criteria.

2. Background 2.1 On April 1st, 2013 Clinical Commissioning Groups (CCGs) across the Yorkshire and the

Humber regions adopted the existing Yorkshire and the Humber Fertility policy1. In February 2013 NICE published revised guidance2 which was reviewed and updated in 2016.

2.2 CCGs across the Yorkshire and the Humber agreed to work collaboratively to update the

existing policy in light of the new NICE guidance and changing commissioning landscape.

2.3 In this policy document infertility is defined as:

2.4 Fertility problems are common in the UK and it is estimated that they affect 1 in 7 couples with

80% of couples in the general population conceiving within 1 year, if: • The woman is aged under 40 years and • They do not use contraception and have regular sexual intercourse (NICE 2013) Of those who do not conceive in the first year about half will do so in the second year (cumulative pregnancy rate is 90%).

The remaining 10% of couples will be unable to conceive without medical intervention and are therefore considered infertile.

1 Yorkshire and the Humber Commissioning Policy for Fertility Services, 2010. 2 Fertility: Assessment and treatment for people with fertility problems 2012, NICE Clinical Guideline 156.

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2.5 In 25% of infertility cases, the cause cannot be identified. However, it is thought that in the

remaining couples about 30% of cases are due to the male partner being unable to produce or ejaculate sufficient normal sperm, 30% are due to problems found with the female partner such as failure to ovulate or blockage to the passage of the eggs, and 10% are due to problems with both partners.

2.6 The most recent DH costing tool estimates that there are 98 attendances at a fertility clinic for every 10,000 head of population. In Yorkshire and the Humber, this could range between 4000 and 5000 attendances per year which would result in approximately 1450 couples likely to be assessed as eligible for IVF treatment.

2.7 Specialist fertility services include IUI, ICSI and IVF. They may also include the provision of

donor sperm and donor eggs. The majority of treatment in the UK is statutorily regulated by the Human Fertility and Embryo Authority (HFEA)3. All specialist providers of fertility services must be licensed with the HFEA in order to be commissioned under this policy.

2.8 NICE Clinical Guidelines 156 (2013) covering infertility recommends that:

Doncaster CCG will fund 2 (18-40 years) and 1 (40-42) cycle(s) of IVF treatment. Where an individual feels that they have exceptional circumstances that would merit consideration of an additional cycle being funded by the NHS they should speak to their doctor about submitting an individual funding request to their local CCG.

2.9 In addition to commissioning effective healthcare, CCGs are required to ensure that

resources are allocated equitably to address the health needs of the population. Therefore CCGs’ will need to exercise discretion as to the number of cycles of IVF that they will fund up to the maximum recommended by NICE.

3. Clinical Effectiveness It is considered to be clinically effective by NICE to offer up to 3 stimulated cycles of IVF treatment to couples where the woman is aged between 18 – 39 and 1 cycle where the woman is aged between 40 – 42 and who have an identified cause for their infertility or who have infertility of at least 2 years duration.

4. Cost Effectiveness 4.1 Evidence shows (NICE 2013) that as the woman gets older the chances of successful

pregnancy following IVF treatment falls. In light of this, NICE has recommended that the most cost effective treatment is for women aged 18 – 42 who have known or unknown fertility problems.

3 https://www.hfea.gov.uk/

https://www.hfea.gov.uk/

7

4.2 As research within this field is fast moving, new interventions and new evidence needs to be

considered on an on-going basis to inform commissioning decisions. 4.3 Risks Fertility treatment is not without risks. A summary of potential risks is outlined below:

5 Description of the Treatment

5.1 Principles of Care 5.1.1 Couples who experience problems in conceiving should be seen together because both

partners are affected by decisions surrounding investigation and treatment.

5.1.2 People should have the opportunity to make informed decisions regarding their care and treatment via access to evidence-based information. These choices should be recognised as an integral part of the decision-making process.

5.1.3 As infertility and infertility treatments have a number of psychosocial effects on couples,

access to psychological support prior to and during treatment should be considered as integral to the care pathway.

Risks

• There are risks of multiple pregnancies during fertility treatment, which is associated with a higher morbidity and mortality rate for mothers and babies.

• Women who undergo fertility treatment are at slightly higher risk of ectopic pregnancy. • Ovarian hyper stimulation, which is a potentially fatal condition, is also a risk. The exact

incidence of this has not been determined but the suggested number is between 0.2 – 1% of all assisted reproductive cycles.

• Current research shows no cause for concern about the health of children born as the result of assisted reproduction.

• A possible association between ovulation induction therapy and ovarian cancer in women who have undergone treatment is uncertain.

• Further research is needed to assess the long-term effects of ovulation induction agents.

8

5.2 The Care Pathway for fertility investigation and referral (fig, 1)

People who are concerned about their fertility

Providing information including information about healthy lifestyle interventions for example smoking cessation, weight management, alcohol advice and referral

according to locally commissioned pathways.

Initial advice to people concerned about delays in conception.

Initial diagnostic investigations

Secondary Care

Further Investigation of fertility problems and any appropriate

initial treatment to address identified barriers to conception

Assisted reproduction

(IVF Pathway)

Patie

nts i

n pr

imar

y an

d Se

cond

ary

Care

Patients in tertiary Care (referred to a Specialist IVF

Provider)

Defining infertility and considering onward referral for assisted reproduction if couple meet

eligibility criteria

9

The Care pathway for fertility investigation and referral will take account of NICE guidance. 5.2.1 Treatment for infertility problems may include counselling, lifestyle advice, drug treatments,

surgery and assisted conception techniques such as IVF.

• Providers of specialist fertility services are expected to deliver appropriate interventions to support lifestyle behaviour changes which are likely to have a positive impact on the outcome of assisted conception techniques and resulting pregnancies. Recommendations covering screening, brief advice and onward referral are outlined in NICE Public Health Guidance (PH49) and, specifically in relation to fertility and pre-conception, smoking (PH 26, PH48), weight management (PH27, PH53), healthy eating and physical activity (PH11, NG7) and alcohol (PH24).

• Use any appointment or meeting as an opportunity to ask women and their partners about their general lifestyle including smoking, alcohol consumption, and physical activity and eating habits. If they practice unhealthy behaviours, explain how health services can support people to change behaviour and sustain a healthy lifestyle.

• Offer those who would benefit from this, a referral to local wellbeing services and/or locally commissioned lifestyle services. For those that are unable or do not want to attend support services direct them to appropriate self-help information such as the national ‘One You' website or local websites.

• Record this in the hand-held record or accepted local equivalent.

The care pathway (fig 1) begins in primary care, where the first stage of treatment is general lifestyle advice and support to increase a couple's chances of conception without the need for medical intervention. If primary care interventions are not effective, initial assessment such as semen analysis will take place. Following these initial diagnostics, it may be appropriate for the couple to be referred to secondary care services where further investigation and potential treatments will be carried out, such as hormonal therapies to stimulate ovulation. It may be appropriate at this stage for the primary care clinician to consider and discuss the care pathway and potential eligibility for IVF. It may also be appropriate for healthy lifestyle interventions to be further discussed. If secondary care interventions are not successful and the couple fulfils the eligibility criteria in section 6.0, they may then be referred through to specialist care for assessment for assisted conception techniques, such as IVF, DI, IUI, and ICSI.

5.2.2 IVF involves:

• Controlled ovarian stimulation • Monitoring the development of the eggs in the ovary • Ultrasound guided egg collection from the ovary • Processing of sperm

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• Production of a fertilized embryo from sperm and egg cells in the laboratory • Culture of embryos to blastocyst (if clinically appropriate) • Single embryo transfer (subject to multiple birth minimisation policy) • Use of progesterone to make the uterus receptive to implantation • Transfer of selected embryos and freezing of those suitable but not transferred

The panel will review annually, following the HFEA4 annual review via their traffic light report, any other emerging technologies which may then need consideration for incorporation in this policy.

5.3 Definition of a Full Cycle

5.4 Frozen Embryo Embryos that are not used during the fresh transfer should be quality graded using the UK NEQAS embryo morphology scheme and may be frozen for subsequent use within the cycle. All stored and viable embryos should be used before a new cycle commences. This includes embryos resulting from previously self-funded cycles.

5.5 Abandoned Cycles An abandoned IVF/ICSI cycle is defined as the failure of egg retrieval, usually due to lack of response (where less than three mature follicles are present) or excessive response to gonadotrophins; failure of fertilisation and failure of cleavage of embryos. Beyond this stage, a cycle will be counted as complete whether or not a transfer is attempted. One further IVF/ICSI cycle only will be funded after an abandoned cycle. Further IVF/ICSI cycles will not be offered after any subsequent abandoned cycles.

5.6 IUI and DI IUI and DI are separate from IVF treatment; however, the couple may then access IVF treatment if appropriate.

5.6.1 People with physical disabilities, psychosexual problems, or other specific conditions with

infertility (as defined in section 2.3 Definition of Infertility):



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Where a medical condition exists, such as physical disability up to 6 cycles of IUI may be funded, followed by further assisted conception if required. In some circumstances, IUI may be impractical and so is not a requirement for further fertility treatment.

5.6.2 IUI and DI in same-sex relationships:

Up to 6 cycles of IUI will be funded as a treatment option for people in same-sex relationships, followed by further assisted conception if required.

5.6.3 People with unexplained infertility, mild endometriosis or mild male factor infertility, who are

having regular unprotected sexual intercourse: IUI either with or without ovarian stimulation will not be funded routinely (exceptional circumstances may include, for example, when people have social, cultural or religious objections to IVF), instead couples should try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered, in keeping with current NICE guidance.

5.6.4 Gonadotrophin Therapy - for women with anovulatory infertility, ovulation induction with

gonadotrophin therapy should be funded for up to 6 cycles, with or without IUI depending on the circumstances of the couple.

5.6.5 Donor Gametes including azoospermia:

Patients who require donor gametes will be placed on the waiting list for an initial period of 3 years, after which they will be reviewed to assess whether the fertility policy eligibility criteria is still met. If it is anticipated that there will be difficulty finding a suitable donor exceptionality would need to be considered. At this point consideration may need to be given to sourcing from alternative providers via IFR.

Donor Sperm

Where clinically indicated up to six cycles of donor insemination will be offered. This is dependent on the availability of donor sperm which is currently limited in the UK. The cost of donor sperm is included in the funding of treatment for which it is required, to be commissioned in accordance with this policy and the funding policy of the CCG.

Donor Eggs

Patients eligible for treatment with donor eggs, in line with NICE recommendations, will be placed on the waiting list for treatment with donor eggs. Unfortunately, the availability of donor eggs remains severely limited in the UK. There is, therefore, no guarantee that eligible patients will be able to proceed with treatment.

5.7 Gametes and Embryo Storage The cost of egg and sperm storage will be included in the funding of treatment for which it is required, to be commissioned in accordance with this policy and the funding policy of the CCG. Storage will be funded by the CCG for a maximum of 3 years or until 6 months post successful live birth, whichever is the shorter. This will be explained by the provider prior to the commencement of treatment. Following this period continued storage may be self-funded.

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Any embryos frozen prior to implementation of this policy will be funded by the CCG to remain frozen for a maximum period of 3 years from the date of policy adoption. Any embryo storage funded privately prior to the implementation of this policy will remain privately funded.

5.8 HIV/HEP B/ HEP C People undergoing IVF treatment should be offered testing for HIV, hepatitis B and hepatitis C (NICE 2013). People found to test positive for one or more of HIV, hepatitis B, or hepatitis C should be offered specialist advice and counselling and appropriate clinical management (NICE 2013).

5.9 Surrogacy Any costs associated with use of a surrogacy arrangement will not be covered by funding from CCGs. We will, however, fund provision of fertility treatment (IVF treatment and storage) to identified (fertile) surrogates, where this is the most suitable treatment for a couple’s infertility problem and the couple meets the eligibility criteria for specialist fertility services set out in this policy.

5.10 Single Embryo Transfer Please refer to 5.3 for the definition of a full cycle. Multiple births are associated with greater risk to mothers and children and the HFEA5 therefore recommends that steps are taken by providers to minimize them. This is currently achieved by only transferring a single embryo for couples who are at high risk. We support the HFEA guidance on single embryo transfer and will be performance monitoring all specialist providers to ensure that HFEA targets are met. All providers are required to have a multiple births minimisation strategy. The target for multiple births should now be an upper limit of 10% of all pregnancies. We commission ultrasound guided embryo transfer in line with NICE Fertility Guideline.

5.11 Counselling and Psychological Support As infertility and infertility treatment has a number of negative psychosocial effects, access to counselling and psychological support should be offered to the couple prior to and during treatment.

5.12 Sperm washing and pre-implantation diagnosis

Sperm washing and pre-implantation genetic diagnosis are not treatments for infertility and fall outside the scope of this policy. Prior approval is required.

5.13 Service Providers

Providers of fertility treatment must be HFEA registered and comply with any service specification drawn up by Yorkshire and the Humber Clinical Commissioning Groups.

6.0 Eligibility Criteria for Treatment



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6.1 Application of Eligibility Criteria Eligibility criteria should apply at the point at which patients are referred to specialist care (with the exception of 6.10, which should be undertaken within specialist care). Couples must meet the definition of infertility as described in section 2.3.

6.2 Overarching Principles 6.2.1 All clinically appropriate individuals/couples are entitled to medical advice and investigation.

Couples may be referred to a secondary care clinic for further investigation. 6.2.2 Assisted conception is only funded for those couples who meet the eligibility criteria. 6.2.3. Treatment limits are per couple and per individual. Referrals should be as a couple and

include demographic information for both partners in heterosexual and same-sex couples.

6.3 Existing Children Neither partner should have any living children (this includes adopted children but not fostered) from that or any previous relationship.

6.4 Female Age

Age as a criterion for access to fertility treatments is applied in line with the NICE Clinical Guideline on Fertility which is based on a comprehensive review of the relationship between age and the clinical effectiveness of fertility treatment. The woman intending to become pregnant must be between the ages of 18 – 42 years. No new cycle should start after the woman’s 43rd birthday. Referrers should be mindful of the woman’s age at the point of referral and the age limit for new cycles.

Women aged 40–42 years who meet the eligibility criteria for infertility in Section 2.3, will receive 1 full cycle of IVF, with or without ICSI, provided the following criteria are fulfilled:

• they have never previously had IVF treatment and there is no evidence of low ovarian reserve (defined as FSH 9 IU/l or more (using Leeds assay); OR antral follicle count of 4 or less; OR AMH of 5 pmol/l or less

• there has been a discussion of the additional implications of IVF and pregnancy at this age

• where investigations show there is no chance of pregnancy with expectant management and where IVF is the only effective treatment, women aged between 40-42 should be referred directly to a specialist team for IVF treatment

6.5 Pre – Referral Requirement for Specialist Care 6.5.1 Female BMI

The female patient’s BMI should be between 19 and 30 prior to referral to specialist services. Patients with a higher BMI should be referred for healthy lifestyle interventions including weight management advice. Patients should not be re-referred to specialist services until their BMI is within the recommended range.

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6.5.2 Smoking Status

GP should discuss smoking with couples prior to referral to secondary care, support their efforts in stopping smoking by referring to a smoking cessation programme. People should be informed that maternal and paternal smoking can adversely affect the success rates of assisted reproduction procedures, including IVF treatment.

6.6 Reversal of Sterilisation We will not fund IVF treatment for patients who have been sterilised or have unsuccessfully undergone reversal of sterilisation.

6.7 Previous Cycles Previous cycles whether self-funded or NHS funded will be taken into consideration when assessing a couple's ability to benefit from treatment and will count towards the total number of cycles that may be offered by the NHS. This includes where either person has had a previous cycle with a previous partner.

6.8 Length of Relationship The stability of the relationship is very important with regards to the welfare of children; as such couples must have been in a stable relationship for a minimum of 2 years and currently co-habiting to be entitled to treatment.

6.9 Welfare of the child HFEA guidance concerning the welfare of the child should be followed.

15

Appendix, A

Abbreviations Abbreviations

used

BMI Body Mass Index

DI Donor Insemination

GP General Practitioner

HFEA Human Fertilisation and Embryology Authority

ICSI Intracytoplasmic sperm injection

IUI Intra-uterine insemination

IVF In vitro fertilisation

NICE National Institute of Clinical Excellence

CCG Clinical Commissioning Group

16

Appendix, B

Contents

Term

Definition Further information

BMI The healthy weight range is based on a measurement known as the Body Mass Index (BMI). This can be determined if you know your weight and your height. This is calculated as your weight in kilograms divided by the square of your height in metres. In England, people with a body mass index between 25 and 30 are categorised as overweight, and those with an index above 30 are categorised as obese.

BBC Healthy Living

http://www.bbc.co.uk

NHS Direct

http://www.nhsdirect.nhs.uk

ICSI Intra Cytoplasmic Sperm Injection (ICSI): Where a single sperm is directly injected into the egg.

Glossary, HFEA

http://www.hfea.gov.uk

IUI Intra Uterine Insemination (IUI): Insemination of sperm into the uterus of a woman.

As above

IVF In Vitro Fertilisation (IVF): Patient's eggs and her partner's sperm are collected and mixed together in a laboratory to achieve fertilisation outside the body. The embryos produced may then be transferred into the female patient.

As above

DI Donor Insemination (DI): The introduction of donor sperm into the vagina, the cervix or womb itself.

As above

http://www.bbc.co.uk/

http://www.nhsdirect.nhs.uk/

http://www.hfea.gov.uk/

17

Appendix C, Equality Impact Assessment Title of policy Fertility Policy

Names and roles of people completing the assessment

Philippa Doyle

Hempsons Solicitors

Date of Assessment from – to Review date

Aug 2018 Nov 2019

Feb 2021 April 2023

1. Outline

Give a brief summary of the policy

The purpose of the commissioning policy is to enable officers of the relevant CCG to exercise their responsibilities properly and transparently in relation to commissioned treatments including individual funding requests, and to provide advice to general practitioners, clinicians, patients and members of the public about the fertility policy. Implementing the policy ensures that commissioning decisions are consistent and not taken in an ad-hoc manner without due regard to equitable access and good governance arrangements. Decisions are based on best evidence but made within the funding allocation of the CCGs. This policy relates to requests for specialist fertility treatment.

What outcomes do you want to achieve

We commission services equitably and only when medically necessary and in line with current evidence on cost effectiveness.

2. Evidence, data or research

Give details of evidence, data or research used to inform the analysis of impact

NICE fertility guidance https://www.nice.org.uk/guidance/cg156 (accessed 3/3/17)

3. Consultation, engagement

Give details of all consultation and engagement activities used to inform the analysis of impact

Discussion with panel of experts in Yorkshire and Humber representing commissioners and providers. All changes from the previous policy are in line with NICE guidelines which have had extensive engagement and consultation. See https://www.nice.org.uk/guidance/cg156/history

https://www.nice.org.uk/guidance/cg156

https://www.nice.org.uk/guidance/cg156/history

18

4. Analysis of impact

This is the core of the assessment, using the information above detail the actual or likely impact on protected groups, with consideration of the general duty to;

eliminate unlawful discrimination; advance equality of opportunity; foster good relations

Are there any likely impacts?

Are any groups going to be affected differently?

Please describe.

Are these negative or positive?

What action will be taken to address any negative impacts or enhance positive ones?

Age Yes. IVF is only available to women aged between 18 and 42. As a woman ages the chances of successful pregnancy fall.

Both Action cannot be taken to prevent this it is therefore incumbent simply to ensure clear age limitations are identified

Carers No

Disability Yes. The policy has been enhanced to offer funding to couples who by reason of disability cannot conceive naturally

positive The fact of this new change and opportunity to such couples can be publicised

Sex No

Race No

Religion or belief

No

Sexual orientation

Yes. The policy has been enhanced to offer funding to couples in a same sex relationship without having to demonstrate they have self-funded other trials

positive The fact of this new change and opportunity to such couples can be publicised

Gender reassignment

Yes positive Gender reassignment is specifically referenced in the definition of infertility

Pregnancy and maternity

Yes. The policy enhances the ability to access fertility treatment and the potential

positive

19

to achieve pregnancy

Marriage and civil partnership

No

Other relevant group

5. Monitoring, Review and Publication

How will you review/monitor the impact and effectiveness of your actions

Each CCG to monitor individual funding requests for this procedure and identify if there are issues with the policy which require a policy refresh.

Lead Officer Chief Nurse, Doncaster CCG Review date: April 2021

6.Sign off on behalf of the local CCG

Lead Officer Chief Nurse

Director As above Date approved: May 2020

20

Appendix D, Version Control

VERSION

DATE AUTHOR STATUS COMMENT

V11 Feb 19 H Lewis and M Thompson

Changes to page 3 – immigration health surcharge – reworked following updated advice Moved list of panel members to Appendix for easier access to contents of document

V10 November 2019

M Thompson on behalf of Panel

Changes to: - Page 2 & 3 – Immigration Health Surcharge – sentences reworded - 6.5.2 – Smoking Status – sentences reworded - 6.7 – Previous Self-funded Cycles – titles changed to Previous Cycles -

sentences reworded - 6.8 – Previous Self-Funded Cycles - sentence removed - 6.10 – Welfare of the Child - sentence reworded

21

V9

January 2019

M Thompson on behalf of Panel

Draft Changes to: - Funding - Immigration health surcharge – sentence added - 1.2 - sentence reworded - 2.3 – change of order in sentence in brackets - 5.2 – sentence included after pathway - 5.2.1 – third bullet point, wording changed - 5.2.2 – first two bullet points replaced with Controlled Ovarian

Stimulation - 5.4 – heading changed to Frozen Embryo - 5.6.1 – sentence reworded - 5.6.3 – link to mild male factor infertility removed - 5.6.3 – wording added - 5.6.4 – spelling corrected - 5.6.5 – new paragraph inserted - 5.6.5 - Donor Sperm - sentence reworded - 5.7 – sentence reworded - 6.2.1 and 6.2.2 - swopped around and reworded - 6.5.2 – title changed - 6.5.2 – sentence reworded - 6.9 – sentence reworded

22

v8 June 2018 M. Thompson on behalf of Panel

Draft Changes to:- - 2.3 Definition of Infertility - 5.2.2. – IVF involves – additional bullets added - 5.3 – Definition of cycles – removed sentence in brackets - 5.6.4 - Gonadotrophin Therapy added - 5.6.5 – renumbered – added “all couples” where this is a clinical requirement (to

replace the reference to male azoospermia) added limited to UK Added additional sentence

- 6.5 – title updated to – Pre-referral requirement to specialist care - 6.5.2 – non-smokers section added. - 6.9 – Updated to include the stability of the relationship

v7 Jan 2018 M. Thompson

on behalf of Panel

Draft - Changes to 5.2 pathway - Changes to funding – adding refugees and asylum seekers - Removal of summary of CCGs - 2.3 – clarification of definition of infertility - 6.7 updated to NHS Funded full cycles - 6.10 – added section - Change tertiary to specialist throughout the policy.

23

Review 2017

22.2.17 F Day on behalf of panel

Final draft - changes to the definition of infertility for same sex and patients with psychosexual issues and disabilities to be more clear

- the addition of public health requirements for providers in line with NICE guidance

- clarification of the definition of an abandoned cycle - sections on intrauterine insemination and also egg donation updated in

line with NICE guidance - Addition of People with unexplained infertility, mild endometriosis or mild

male factor infertility, who are having regular unprotected sexual intercourse in line with NICE guidance

- wording changed in various sections based on patient feedback to be more clear, not materially changed in content

- embryo transfer wording updated to reflect NICE guidance - Addition of definition of low ovarian reserve (previously undefined)

https://www.nice.org.uk/guidance/cg156/chapter/recommendations#mild-male-factor-infertility

https://www.nice.org.uk/guidance/cg156/chapter/recommendations#mild-male-factor-infertility

24

Appendix E

Panel Members: (March 2017) Dr Virginia Beckett Consultant in Obstetrics and Gynaecology - Bradford Teaching Hospital FT

Dr Fiona Day Consultant in Public Health Leeds and Associate Medical Director Leeds CCG

Chris Edward Accountable Officer - Rotherham CCG

Dr Steve Maguiness Medical Director - The Hull IVF Unit, Hull Women and Children’s Hospital and honorary contract with HEY

Dr John Robinson Scientific Director - IVF Unit, Hull and East Yorkshire Hospitals FT

Prof Adam Balen Professor of Reproductive Medicine and Surgery - Leeds Teaching Hospitals NHS Trust

Michelle Thompson Assistant Director, Women’s and Children’s Services - NHS North East Lincolnshire CCG

Richard Maxted Service Manager, Directorate of Obstetrics, Gynaecology and Neonatology - Sheffield Teaching Hospital NHS Trust

Dr Margaret Ainger Clinical Director for Children, YP and Maternity - NHS Sheffield CCG

Dr Bruce Willoughby Lead for Planned Care - NHS Harrogate and Rural District CCG

Dr Clare Freeman Medical Advisor to IFR Panel - South Yorkshire and Bassetlaw CCGs

Panel Members (amendments January 2018)

25

Dr Virginia Beckett Consultant in Obstetrics and Gynaecology - Bradford Teaching Hospital FT



Dr Bruce Willoughby Lead for Planned Care - NHS Harrogate and Rural District CCG

Jonathan Skull Consultant in Reproductive Medicine & Surgery – Sheffield Teaching Hospital NHSFT

Karen Thirsk Fertility Policy Manager – NHS England

Brigid Reid Chief Nurse – NHS Barnsley CCG

Helen Lewis Head of Planned Care – NHS Leeds CCG.

Clare Freeman Lead Medical Advisor – Sheffield CCG.

Panel Members (amendments June 2018) Dr Virginia Beckett Consultant in Obstetrics and Gynaecology - Bradford Teaching Hospital FT




Brigid Reid Chief Nurse – NHS Barnsley CCG

Helen Lewis Head of Planned Care – NHS Leeds CCG

Dr Bryan Power (GP) - NHS Leeds CCG

26

Adam Balen (Consultant) - Leeds Fertility

Clare Freeman Lead Medical Advisor – Sheffield CCG

Panel Members (amendments January 2019) Dr Virginia Beckett Consultant in Obstetrics and Gynaecology - Bradford Teaching Hospital FT



Martine Tune Acting Chief Nurse – NHS Barnsley CCG

Liz Micklethwaite Business Manager IFR - NHS Leeds CCG

Commissioner Final Proof Read Panel (Amendments November 2019) Michelle Thompson Assistant Director, Women’s and Children’s Services – NHS North East Lincolnshire CCG

Helen Lewis Head of Planned Care – NHS Leeds CCG

Clare Freeman Lead Medical Advisor – Sheffield CCG

Karen Leivers Head of Strategy and Delivery, Planned Care - Doncaster CCG

Debbie Stovin Commissioning Manager – Elective Care – Sheffield CCG

27

Appendix F Relevant Conflicts of Interest Declared: Dr Steve Maguiness:

IVF in Hull is provided by a private company (ERFS Co Ltd), of which I am a Director and employee.

Prof Adam Balen:

NHS Consultant in Reproductive Medicine and Clinical lead for the Leeds Centre for Reproductive Medicine, which performs all fertility treatments funded by the NHS. Partner in Genesis LLP, the private arm of the Leeds Centre for Reproductive Medicine, which performs self-funded fertility treatments using identical protocols to the NHS. Chair, British Fertility Society. Chair, NHS England IVF Pricing Development Expert Advisory Group. Chair World Health Organisation Expert Working Group on Global Infertility Guidelines: Management of PCOS. Chair, British Fertility Society. Consultant for ad hoc advisory boards for Ferring Pharmaceuticals, Astra Zeneca, Merck Serono, Gideon Richter, Uteron Pharma. Research funding received in the past. Pharmasure / IBSA- Key note lecture at ESHRE 2016 & hospitality to attend meetings. OvaScience- Member of international ethics committee. Clear Blue National medical advisory board. IVI, UK- Chair, Clinical Board

Virginia Beckett FRCO:

I have a private practice where I see fertility patients.

I have received sponsorship from Pharmasure, Ferring & Serono to attend conferences.

of 2

Meeting name Governing Body Meeting date 7 May 2020

Title of paper

Primary Care Commissioning Committee Terms of Reference

(TOR)

Executive / Clinical Lead(s)

Linda Tully Chair of Primary Care Commissioning Committee

Author(s) Helen Harris, Head of Corporate Governance Corporate Services Team

Status of the Report To approve To consider / discuss To note

Purpose of Paper - Executive Summary 1. Introduction The Primary Care Commissioning Committee (PCCC) TOR have been reviewed in line with good governance. The TOR can be reviewed in Appendix 1. 2. Proposed Amendments The Chair of the PCCC recommends the proposed amendments for approval by the Governing Body:

• Members to participate in meetings by telephone or the use of video conference (new section - 11.2.3).

• Notice of Meetings, items of business to be notified to the Chair at least 10 working days. Papers submitted six working days before the meeting takes place. Papers circulated to members at least five working days before the meeting (new section - 11.4).

• Annual Schedule of Meetings to be agreed (new section - 11.5). • Conduct (section 12) moved to section 15.4. • Urgent matters arising between meetings (new section - 13.3). • Terms of reference to be reviewed on a two-yearly basis (section – 19).

Key: New amendments – blue text. Text to be removed – red text and struck-through. 3. Recommendation The Chair of the PCCC is recommending the amended TOR to the Governing Body for approval.

X

of 2

Recommendation(s) The Governing Body is asked to approve the PCCC Terms of Reference.

Report Exempt from Public Disclosure Yes No If yes, detail grounds for exemption:

Impact analysis

Quality impact To ensure primary care functions increase quality. . Equality impact

Meeting the health needs of the population, ensuring patient’s rights of choice are maintained and reducing health inequalities.

Sustainability impact Nil

Financial implications Ensuring efficiency, productivity and value for money are promoted.

Legal implications Nil


Interest N/A


(internal departments, clinical, stakeholder &

public/patient)

Reviewed by Helen Harris, Head of Corporate Governance, Linda Tully, Chair of the PCCC and Associate Director of HR and Corporate

Services Report previously

presented at N/A Risk

analysis N/A Assurance Framework CO2 – 2.1, 2.2, 2.3, CO3 – 3.1

X

Terms of Reference Primary Care Commissioning Committee

1. Introduction 1.1. NHSE has delegated to the CCG authority to exercise the primary care

commissioning functions set out in Schedule 2 in accordance with section 13Z of the NHS Act.

1.2. Arrangements made under section 13Z may be on such terms and conditions

(including terms as to payment) as may be agreed between the Board and the CCG.

1.3. Arrangements made under section 13Z do not affect the liability of NHS

England for the exercise of any of its functions. However, the CCG acknowledges that in exercising its functions (including those delegated to it), it must comply with the statutory duties set out in Chapter A2 of the NHS Act and including:

a) Management of conflicts of interest (section 14O); b) Duty to promote the NHS Constitution (section 14P); c) Duty to exercise its functions effectively, efficiently and economically

(section 14Q); d) Duty as to improvement in quality of services (section 14R); e) Duty in relation to quality of primary medical services (section 14S); f) Duties as to reducing inequalities (section 14T); g) Duty to promote the involvement of each patient (section 14U); h) Duty as to patient choice (section 14V); i) Duty as to promoting integration (section 14Z1); j) Public involvement and consultation (section 14Z2).

1.4. The CCG will also need to specifically, in respect of the delegated functions from NHSE, exercise those set out below: • Duty to have regard to impact on services in certain areas (section 13O); • Duty as respects variation in provision of health services (section 13P).

1.5. The Committee is established as a committee of the Governing Body of NHS

Doncaster CCG in accordance with Schedule 1A of the “NHS Act”. 1.6. The members acknowledge that the Committee is subject to any directions

made by NHS England or by the Secretary of State. 2. Accountability of the Committee 2.1. Budgetary and resource accountability is in line with the CCG Scheme of

Delegation and Standing Orders.

2.2. For the avoidance of doubt, in the event of any conflict between the terms of

this Scheme of Delegation and Terms of Reference and the Standing Orders of Standing Financial Instructions of any of the members, the latter will prevail.

3. Role of the Committee 3.1. Simon Stevens, the Chief Executive of NHS England (NHSE), announced on

1 May 2014 that NHSE was inviting CCGs to expand their role in primary care commissioning and to submit expressions of interest setting out the CCG’s preference for how it would like to exercise expanded primary medical care commissioning functions. One option available was that NHSE would delegate the exercise of certain specified primary care commissioning functions to a CCG.

3.2. In accordance with its statutory powers under section 13Z of the National

Health Service Act 2006 (as amended), NHSE has delegated the exercise of the functions specified in Schedule 2 to these Terms of Reference to NHS Doncaster CCG. The delegation is set out in Schedule 1.

3.3. The CCG has established the NHS Doncaster CCG Primary Care

Commissioning Committee (“Committee”). The Committee will function as a corporate decision-making body for the management of the delegated functions and the exercise of the delegated powers.

3.4. It is a committee comprising representatives of the following organisations:

• NHS Doncaster CCG • NHS England

4. Statutory Framework 4.1. The Committee has been established in accordance with the above statutory

provisions to enable the members to make collective decisions on the review, planning and procurement of primary care services in Doncaster, under delegated authority from NHS England.

4.2. In performing its role the Committee will exercise its management of the

functions in accordance with the agreement entered into between NHS England and NHS Doncaster CCG, which will sit alongside the delegation and terms of reference.

4.3. The functions of the Committee are undertaken in the context of a desire to

promote increased co-commissioning to increase quality, efficiency, productivity and value for money and to remove administrative barriers.

4.4. Establishing Sub-Groups to assist in discharging delegated responsibilities of

the Committee as set out in its Terms of Reference.

4.5. The role of the Committee shall be to carry out the functions relating to the commissioning of primary medical services under section 83 of the NHS Act.

4.6. This includes the following:

• GMS, PMS and APMS contracts (including the design of PMS and APMS contracts, monitoring of contracts, taking contractual action such as issuing branch/remedial notices, and removing a contract);

• Newly designed enhanced services (“Local Enhanced Services” and “Directed Enhanced Services”);

• Design of local incentive schemes as an alternative to the Quality Outcomes Framework (QOF);

• Decision making on whether to establish new GP practices in an area; • Approving practice mergers; and • Making decisions on ‘discretionary’ payment (e.g., returner / retainer

schemes).

4.7. The CCG will also carry out the following activities: • To plan, including needs assessment, primary medical care services in

Doncaster; • To undertake reviews of primary medical care services in Doncaster; • To co-ordinate a common approach to the commissioning of primary care

services generally; • To manage the budget for commissioning of primary medical care

services in Doncaster; 4.8 The Executive Committee will review, consider and recommend to the Primary

Care Commissioning Committee on all service changes to primary care medical services, ensuring the services are in line with the CCG Corporate Objectives, Five Year Commissioning for Strategy, Doncaster Place Plan and the South Yorkshire and Bassetlaw Sustainability and Transformation Plan.

5. Responsibilities

5.1. Strategic Direction

• To oversee the part of the commissioning plan that relates to Primary Care, including needs assessment for safe and sustainable Primary Care Commissioning

• To oversee the development and agreement of primary care contracts • To oversee the development of the Primary care workforce • To identify priorities for consideration by the Engagement and Experience

Committee • To consider implications and oversee implementation of issues arising

from the national, regional and local reviews • To make recommendation to the Governing Body on all issues relating to

Primary Care Development.

5.2. Quality and Performance Management • To oversee the management of the annual budget for the

commissioning of Primary Medical Care services in the relevant area • To oversee individual contract performance on a regular basis –

activity, finance and quality • To oversee the Quality & Outcomes framework (QOF) or local incentive

scheme (LIS) • To agree contract variations and to undertake reviews of primary care

services where appropriate, within delegated limits • To consider contract breaches and appropriate enforcement actions,

offering support where appropriate. • To oversee programme management and delivery of the Quality,

Innovation, Productivity and Prevention (QIPP) programme relevant to primary care

• To oversee the financial management of GP contracts for core and enhanced services.

• In partnership with Quality and Patient Safety Committee monitor delivery against range of KPIs relating to quality as they pertain to Primary Care

• In partnership with the Quality and Patient Safety Committee consider trends relating to Serious Incidents (SI’s), complaints and MP enquiries relating to services commissioned

• To report to the Governing Body as appropriate on issues that need escalation.

5.3 General Issues

• To agree key risks for inclusion in Risk Register for primary care commissioning

• To coordinate issues for/and oversee negotiations with the Representative Body

• The Governing body will receive regular summaries of the work of the Committee through the Corporate Assurance report.

• To consider and act on the ‘conflict of interest’ of General Practitioners with reference to Primary care Commissioning.

6. Delegated Functions 6.1. NHS England has delegated to NHS Doncaster CCG the following functions

relating to the commissioning of primary medical services under section 83 of the NHS Act:

a) decisions in relation to the commissioning, procurement and management of Primary Medical Services Contracts, including but not limited to the following activities: i) decisions in relation to Enhanced Services; ii) decisions in relation to Local Incentive Schemes (including the design of

such schemes);

iii) decisions in relation to the establishment of new GP practices (including branch surgeries) and closure of GP practices;

iv) decisions about ‘discretionary’ payments; v) decisions about commissioning urgent care (including home visits as

required) for out of area registered patients; b) the approval of practice mergers; c) planning primary medical care services in the Area, including carrying out

needs assessments; d) undertaking reviews of primary medical care services in the Area; e) decisions in relation to the management of poorly performing GP practices

and including, without limitation, decisions and liaison with the CQC where the CQC has reported non- compliance with standards (but excluding any decisions in relation to the performers list);

f) management of the Delegated Funds in the Area; g) Premises Costs Directions functions; h) co-ordinating a common approach to the commissioning of primary care

services with other commissioners in the Area where appropriate; and i) such other ancillary activities as are necessary in order to exercise the

Delegated Functions. 6.2 Reserved Functions a) management of the national performers list; b) management of the revalidation and appraisal process; c) administration of payments in circumstances where a performer is suspended

and related performers list management activities; d) Capital Expenditure functions; e) section 7A functions under the NHS Act; f) functions in relation to complaints management; g) decisions in relation to the Prime Minister’s Challenge Fund; and h) such other ancillary activities that are necessary in order to exercise the

Reserved Functions. 6.3 Procurement of Agreed Services a) Doncaster CCG will abide by our statutory responsibilities for all contractual

relationships that fall under the Public Procurement Regulations (2006) and any subsequent legislation. This will include any clinical (healthcare) services defined as Part B under the regulations, of which primary care services are included.

b) Doncaster CCG will consider the benefits of introducing choice and

competition when re-commissioning any of these clinical services and will, at all times, follow Monitor’s substantive guidance around the Procurement, Patient Choice and Competition Regulations for NHS funded services.

7. Sub Groups The Primary Care Commissioning Committee has established the following sub-groups:

• Primary Care Delivery Group • Provider Engagement Group

8. Geographical Coverage The Committee will cover the geographical area of NHS Doncaster CCG. 9. Membership 9.1. Members The Committee shall consist of: Members: • Lay Member with a responsibility for Primary Care Commissioning (Chair) • Lay Member (Vice Chair) • Chief Officer • Chief Finance Officer • Director of Strategy and Delivery • Chief Nurse

Attendees: • Locality Lead clinical leader from the Governing Body • NHS England representative • CCG Head of Quality and Designate Nurse for Safeguarding Children and

Looked After Children • Healthwatch Doncaster representative • Doncaster Health and Wellbeing Board representative • Local Medical Committee representative • CCG-employed Clinical Lead for Primary Care • CCG Primary Care Support Manager • Primary Care Quality Nurse • Associate Director of Primary Care & Commissioning 9.2. The Chair of the Committee shall be the Lay Member with the responsibility

for Primary Care Commissioning. 9.3. The Vice Chair of the Committee shall be a Lay Member. 9.4. Members are required to attend five out of seven scheduled meetings.

Attendance will be monitored throughout the year and any concerns raised by the Chair with the relevant Member.

9.5. Any changes to the membership of the Committee must be approved by the

CCG Governing Body. 9.6. The Committee may include attendees and may call additional experts to

attend meetings on an ad hoc basis to inform discussions. 10. Appointment Of Chair The Chair shall be the Lay Member for Primary Care Commissioning. The Vice-Chair shall be a Lay Member. 11. Meetings and Conduct of Business 11.1. The Committee will operate in accordance with the CCG’s Standing Orders.

The Secretary to the Committee will be responsible for giving notice of meetings. This will be accompanied by an agenda and supporting papers and sent to each member representative no later than three days before the date of the meeting. When the Chair of the Committee deems it necessary in light of the urgent circumstances to call a meeting at short notice, the notice period shall be such as s/he shall specify.

11.2. Quorum

11.2.1. The quorum for meetings shall be four members including a minimum of one Lay Member inclusive of the Chair (or Vice Chair in the Chair’s absence).

11.2.2. If a quorum has not been reached, then the meeting may proceed if those

attending agree but any record of the meeting should be clearly indicated as notes rather than formal minutes, and no decisions may be taken by the non-quorate meeting of the Committee.

11.2.3. Members of the Committee may participate in meetings by telephone or by the use of video conferencing facilities where they are available. Participation by any of these means shall be deemed to constitute presence in person at the meeting.

11.3. Frequency

11.3.1. The Committee will aim to meet formally on a monthly basis initially, and this

will be reviewed during the establishment year to ensure that meetings are scheduled at appropriate intervals which are consistent with the commissioning cycle and which enable it to efficiently discharge its duties.

11.3.2. Meetings of the Committee shall:

a) be held in public, subject to the application of 12;

b) the Committee may resolve to exclude the public from a meeting that is open to the public (whether during the whole or part of the proceedings) whenever publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of that business or of the proceedings or for any other reason permitted by the Public Bodies (Admission to Meetings) Act 1960 as amended or succeeded from time to time.

11.3.3 Members of the Committee have a collective responsibility for the operation of

the Committee. They will participate in discussion, review evidence and provide objective expert input to the best of their knowledge and ability, and endeavour to reach a collective view.

11.3.4 The Committee may delegate tasks to such individuals, sub-committees or

individual members as it shall see fit, provided that any such delegations are consistent with the parties’ relevant governance arrangements, are recorded in a scheme of delegation, are governed by terms of reference as appropriate and reflect appropriate arrangements for the management of conflicts of interest.

11.3.5 The Committee may call additional experts to attend meetings on an ad hoc

basis to inform discussions. 11.4 Notice of Meetings

Items of business for inclusion on the agenda of a meeting shall be notified to the Chair of the meeting at least 10 working days before the meeting takes place. Supporting papers for such items shall be submitted at least six working days before the meeting takes place. The agenda and supporting papers shall be circulated to all Committee members and attendees at least five working days before the date the meeting will take place.

11.5 An Annual Schedule of Meetings shall be agreed at, or before, the last meeting each year in order to circulate the schedule for the following year.

12 Conduct The Committee will conduct its business in accordance with any national guidance and relevant codes of conduct / good governance practice including the Nolan Principles1. 13 Decisions 13.1 The Committee will make decisions within the bounds of its remit.

13.2 The decisions of the Committee shall be binding on NHS England and NHS Doncaster CCG.

13.3 Urgent matters arising between meetings

The Chair and Deputy Chair of the PCCC in consultation with the Chief Officer or Chief Finance Officer, may also act on urgent matters arising between meetings of the Committee. Any actions taken outside the meeting, will be minuted at the next available meeting of the Committee.

14 Voting

14.1 Each member of the Committee shall have one vote.

14.2 The Committee shall reach decisions by a simple majority of members

present, but with the Chair having a second and deciding vote, if necessary. However, the aim of the Committee will be to achieve consensus decision-making wherever possible.

14.3 The Committee will produce an executive summary report which will be presented to Yorkshire and Humber Area Team of NHS England and the Governing Body of NHS Doncaster CCG each quarter for information.

15 Confidentiality and Conflicts of Interest / Standards of Business

Conduct 15.1 All Members are expected to adhere to the CCG Constitution and Standards

of Business Conduct and Conflicts of Interest Policy. 15.2 In circumstances where a potential conflict is identified the Chair of the

Committee will determine the appropriate steps to take in accordance with the CCG’s Conflicts of Interest decision-making matrix. This action may include, but is not restricted to, withdrawal from the meeting for the conflicted item or remaining in the meeting but not voting on the conflicted item.

15.3 All Members shall respect confidentiality requirements as set out in the CCG

Constitution.

15.4 The Committee will conduct its business in accordance with any national guidance and governance practice including the Nolan Principles.

16 Reporting Arrangements 16.1 The CCG Committee will comply with any reporting requirements set out in it’s

the CCG constitution.

16.2 All meetings shall be formally minuted and a record kept of all reports / documents considered.

16.3 The Committee will present its minutes to the Governing Body of NHS

Doncaster CCG. 16.4 The Committee will provide an Annual Workplan to the CCG Governing Body

for approval and an Annual Report. 16.5 The meetings of the Committee shall normally be held in public, save for

where 11.3.2 applies. 16.6 The Committee will annually review and assess its effectiveness and report its

findings to the Governing Body. It will do this by; • Reviewing its terms of reference; • Reviewing the attendance rate of Committee members; • Reviewing its work plan; • Reviewing its performance.

17 Disclosure / Freedom of Information Act (FOI) The CCG senior officer with responsibility for corporate governance will be responsible for ensuring that FOI requirements in relation to the Committee are met. The chair of the committee will seek the advice of the senior officer with responsibility for corporate governance in relation to any matters where an exemption as defined within the Freedom of Information Act 2000 is believed to apply. 18 Links and Interdependencies The Primary Care Commissioning Committee will link, in particular, to the following forums: • Primary Care Delivery Group • CCG Governing Body (Board) • CCG Quality and Patient Safety Committee • Engagement and Experience Committee • Executive Committee • Primary Care Information Group 19 Review Of The Terms Of Reference The Terms of Reference will be reviewed not less than annually on a two-yearly basis and submitted to the Governing Body for approval as necessary. Last reviewed: October 2019 April 2020

1

Meeting name Governing Body Meeting date 4th June 2020

Title of paper

Quality & Performance Report

Executive / Clinical Lead(s)

Mr Andrew Russell, Chief Nurse

Mr Anthony Fitzgerald, Director of Strategy & Delivery

Author(s) Performance and Intelligence Team

Quality Team

Status of the Report To approve To consider / discuss To note

Purpose of Paper - Executive Summary This report sets out the key quality and performance issues to be noted by the NHS Doncaster Clinical Commissioning Group (DCCG) Governing Body which due to reporting restrictions or information potentially identifiable to a patient level have not been included within the main report. This report reflects 2019/20 and 2020/21 performance and delivery areas. Due to the COVID-19 pandemic NHS England and NHS Improvement have reduced routine reporting requirements on NHS Organisations to release capacity and manage responses. Further details on the reporting ceased which have been agreed with DCCG’s main providers can be found here: https://www.england.nhs.uk/coronavirus/publication/reducing-burden-and-releasing-capacity-at-nhs-providers-and-commissioners-to-manage-the-covid-19-pandemic/. As detailed in May, June’s report continues to adopt the national reporting approach. Organisations are now in discussion about recovery and reset of services as per NHS England stage 2 guidance. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/second-phase-of-nhs-response-to-covid-19-letter-to-chief-execs-29-april-2020.pdf

Please note all data is validated and quality checked internally within DCCG and with Providers as necessary. Where there is a data quality concern on any of the data or metrics presented in the following report, this will be stated in the narrative accompanying the data. Measures which also form part of the NHS Oversight Framework have been identified as (OF) within this report. The overall response will impact a number of measures, and the ability of providers

x

2

to report information, in the coming which will be detailed in future reports. The key areas of change, both positive and negative, to note since the last report are: NHS Doncaster Clinical Commissioning Group (DCCG)

Patients on incomplete non-emergency referral to treatment (RTT) pathways (yet to start treatment) should have been waiting no more than 18 weeks – Performance decreased to 82.6% during April and remains below the 92% target (Page 4). The total waiting list size remains within target.

52 week waits – There were 6 Doncaster CCG patients waiting over 52 weeks for treatment at the end of April (Page 9)

Patients waiting less than 6 weeks for a diagnostic test – Performance in April failed to meet the 99% target at 38.2% (Page 9)

Cancer 31 day waits – Performance during Quarter 4 failed to meet the 96% target at 95.0% (Page 15)


Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTHFT)

Patients on incomplete non-emergency referral to treatment (RTT) pathways (yet to start treatment) should have been waiting no more than 18 weeks – Performance deteriorated to 82.2% in April below the 92% recovery trajectory (Page 4)

52 week waits – There were 10 patients at the Trust waiting over 52 weeks for treatment at the end of April 2020 (Page 9)

Patients waiting less than 6 weeks for a diagnostic test – Performance during March 2020 deteriorated to 36.9% below the 99% target (Page 10)

Accident and Emergency – Performance improved in April 2020 to 90.9% but remained below the 95% target (Page 13)

Cancer 31 day waits – Performance during Quarter 4 met the 96% target at 99.1% (Page 15)


Rotherham, Doncaster & South Humber NHS Foundation Trust (RDASH)

Improving Access to Psychological Therapies (IAPT) – The proportion of people accessing the service was below the annual 20.5% target at 17.0% (Page 21)

IAPT 6 weeks RTT – Performance for DCCG patients in RDASH services decreased to 49.4% during March against the 75% target (Page 22)

Other Commissioned Services Yorkshire Ambulance Service – All measures were met during April 2020 (Page 21) Recommendation(s) The Governing Body is asked to:

Note the Quality and Performance Report

3

Report Exempt from Public Disclosure If yes, detail grounds for exemption: Yes No

Impact analysis

Quality impact Positive quality impact from a consistent focus on quality outcomes.

Specific quality impact as identified in the report.

Equality Impact

Tick relevant box

An Equality Impact Analysis/Assessment is not required for this report. x An Equality Impact Analysis/Assessment has been completed and approved by the lead Head of Corporate Governance / Corporate Governance Manager. As a result of performing the analysis/assessment there are no actions arising from the analysis/assessment.

An Equality Impact Analysis/Assessment has been completed and there are actions arising from the analysis/assessment and these are included in section xx in the enclosed report.

Sustainability impact

Nil

Financial implications

Nil

Legal Implications

Nil


Interest

The report is for information – no conflicts of interest identified. It should be noted that some Governing Body members may be

employed in secondary employment by organisations referenced in this report: please see Register of Interests for details.


(internal departments,

clinical, stakeholder and public/patient)

N/A

Report previously

presented at N/A

Risk Analysis Risks are captured in the Executive Summary.

Assurance Framework 2.1, 2.2, 2.3, 2.4, 3.1

x

4

Section 1: National Frameworks and Measures 1.1: NHS Constitution Measures

1.1.1 Referral To Treatment (RTT) Performance (Oversight Framework Measure - OF)

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks

Commissioner Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Doncaster CCG 88.2% 87.2% 86.8% 87.1% 86.5% 87.0% 87.6% 87.7% 87.5% 89.2% 90.5% 89.7% 82.6%

Rightcare Peer Group 88.3% 88.8% 88.6% 88.5% 88.0% 87.8% 87.7% 87.3% 86.4% 86.5% 86.4% 87.3%

Doncaster and Bassetlaw Teaching

Hospitals Foundation Trust (DBTHFT)

87.7% 87.0% 86.6% 86.7% 85.7% 86.4% 87.1% 87.2% 86.8% 88.8% 90.4% 90.1% 82.2%

England 86.4% 86.7% 86.2% 85.7% 84.9% 84.7% 84.6% 84.3% 83.6% 83.4% 83.1% 79.6%

Standard 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92% 92%

5

Performance for Doncaster Clinical Commissioning Group (DCCG) patients at all Trusts was 82.6% in April 2020, below the 92% target. Performance was below control limits suggesting performance is under expected levels for the service. The chart above shows that RTT performance has deteriorated over the last 2 years with 2 clear stages of continual deterioration. Latest performance is above the normal range of the service. The DBTHFT waiting list is validated down to 12 weeks which may have a negative impact on reported performance. Seventeen specialties are failing to meet the 92% standard for DCCG:

Cardiology (83.9%) Dermatology (91.1%) Ear, Nose & Throat (85.2%) Gastroenterology (90.5%) General Medicine (90.2%) General Surgery (81.9%) Geriatric Medicine (86.5%) Gynaecology (88.9%)

6

Neurology (72.5%) Neurosurgery (87.7%) Ophthalmology (86.0%) Other (86.1%) Plastic Surgery (86.7%) Rheumatology (77.3%) Thoracic Medicine (83.2%) Trauma and Orthopaedics (T&O) (73.3%) Urology (80.2%)

The waiting list shape for Doncaster CCG patients at any provider is shown below, highlighting the majority of patients waiting are under 18 weeks, and the patients waiting longer, up to 52 weeks. The CCG monitors the waiting list weekly and is in regular contact with DBTHFT and North Lincolnshire and Goole Foundation Trust for the most up to date position on patients waiting over 38 weeks in order to try to reduce long waiters, including those who may breach 52 weeks.

7

DBTHFT’s April 2020 position deteriorated from 90.1% in March to 82.3% in April. The additional recovery actions planned in April were compromised by the impact of Covid19. Twenty specialties failed to meet the standard at DBTHFT in April:

Cardiology (84.2%) Dermatology (90.3%) Diabetic Medicine (84.0%) ENT (85.8% General Medicine (90.4%) General Surgery (81.5%) Geriatric Medicine (88.3%) Gynaecology (90.6%) Medical Opthalmology (87.6%) Ophthalmology (85.9%) Oral Surgery (73.4%) Paediatric Cardiology (81.5%) Paediatrics (91.8%) Podiatry (80.1%) Respiratory Medicine (85.4%) Rheumatology (74.8%) T&O (72.3%) Upper Gastrointestinal Surgery (65.7%) Urology (78.6%) Vascular Surgery (87.7%)

The majority of routine activity was stepped down in April 2020 due to the Trust’s response to COVID-19 in line with National Guidance. This has severely affected the achievement of the RTT standard and performance will continue to be affected until routine activity increases significantly. The Trust’s ability to offer face to face consultations has been severely compromised due to the need to ensure staff are kept safe and to honour national guidance in relation to patients staying at home.

8

The significant reduction in referrals has also affected the RTT performance by reducing the overall denominator of the waiting list. Each Division has produced a mobilisation plan to outline the proposed timescales for reintroducing routine elective activity in line with national guidance. A full ‘project structure’ has been developed to support the innovations required to undertake elective activity safely and appropriately - for example the roll out of telephone and video consultations It is envisaged RTT performance will be negatively impacted by COVID-19 for the foreseeable future due to the inability to provide pre-COVID levels of routine activity and also the risk stratification of individual patient pathways. Performance improvement will vary per speciality depending on the interdependencies on diagnostics and the need for aerosol generating procedures. These are all being considered as part of the Divisional mobilisation plans. 1.1.2 Waiting List Size (OF)

The expectation nationally has been revised to ensure that the number of patients on incomplete pathways is maintained below or at the waiting list size at the end of December 2019 by March 2020. The number of DCCG patients on incomplete RTT pathways decreased in

9

April 2020 by 1401 patients to 18,534 and continues to achieve target (22370). The Trust is aiming to maintain validation of patients at 12 weeks on the Patient Tracking List (PTL) going forwards.

1.1.3 52 Week Breaches (OF)

52 Week Waits –Incomplete Pathways

Provider Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Doncaster CCG 0 1 1 0 0 1 0 0 1 1 0 0 6

DBTHFT 0 1 0 0 0 3 1 1 1 1 1 1 10

Target 0 0 0 0 0 0 0 0 0 0 0 0 0

DBTHFT are currently reporting 10 persons waiting 52 week or longer for treatment at the end of April 2020. Six of these patients are DCCG patients with 2 breaches in Urology, 2 ENT, 1 Ophthalmology and 1 T&O patient. The full breach reports are awaited from the Trust. The 4 other breaches that DBTHFT are reporting are in T&O and Oral Surgery. DCCG have no other 52 week breaches currently reported. RTT training and improved administrative systems will mitigate against further similar breaches. With routine elective work currently on hold the CCG anticipate that there will be 52 week breaches from April onwards until routine work resumes and the backlog is addressed. As part of DBTHFT recovery plan, the Trust now needs to move urgently to reinstate work to improve underpinning administrative and validation processes, building on progress made before COVID-19.

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1.1.4 Diagnostics (OF)

Patients waiting less than 6 weeks for a Diagnostic test

Commissioner Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

Doncaster CCG 93.7% 97.5% 98.7% 99.3% 98.6% 99.3% 99.2% 98.7% 95.8% 94.6% 99.2% 90.0% 38.2%

Rightcare Peer Group 96.7% 96.7% 97.3% 97.0% 96.0% 95.8% 96.9% 97.0% 95.2% 95.3% 97.3% 91.8% N/A

DBTHFT 93.8% 97.4% 98.7% 99.1% 98.7% 99.3% 99.3% 98.6% 96.2% 95.4% 99.1% 89.9% 36.9%

England 96.6% 96.2% 96.5% 96.8% 96.0% 96.5% 97.1% 97.2% 95.8% 95.6% 97.2% 89.8% N/A

Standard 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99% 99%

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Performance for DCCG in April 2020 decreased to 38.2% of patients waiting less than 6 weeks for a test (4645 breaches) below the 99% target. Performance is below the statistical process control limits on the chart above which indicates performance is outside the normal variation expected for the service. Since March performance has been severely impacted by the COVID-19 situation. DBTHFT’s April 2020 position deteriorated to 36.9% against a standard of 99%. The table below shows the diagnostic modalities that were severely impacted by Covid-19. Due to the National and Local response to COVID 19 from 18th March 2020 the majority of the Trust’s routine activity ceased, limiting their ability to see patients already in the system and those referred in within the 6 week timeframe. Services continued to see urgent and 2ww patients.

Exam Type <6W >=6W Total Performance

Longest Breach (weeks)

MRI 447 1161 1608 27.80% 20

CT 1130 1171 2301 49.11% 52

Non-Obstetric Ultrasound 1202 3093 4295 27.99% 50

DEXA 97 194 291 33.33% 16 (x2)

Audiology 20 245 265 7.55% 16

Echo 343 15 358 95.81% 7 (x2)

Nerve Conduction 15 117 132 11.36% 13 (x2)

Sleep Study 63 0 63 100.00% -

Urodynamic 13 80 93 13.98% 32

Colonoscopy 275 242 517 53.19% 14

Flexible Sigmoidoscopy 91 77 168 54.17% 16

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Cystoscopy 185 117 302 61.26% 16

Gastroscopy 173 411 584 29.62% 17

Total 4054 6923 10977 36.93% -

All routine diagnostic work was stepped down due to the COVID-19 pandemic in line with National Guidance. This has severely affected performance will continue to do so until routine activity increases significantly. The Trust has been particularly challenged in the ability to offer a full, pre-COVID19, diagnostic routine service due to the need to ensure staff are kept safe, and to honour national guidance in relation to patients staying at home. Diagnostic services for ‘two week waits’ and urgent patients continues and primary care have been urged to continue referring patients through these pathways. Teams continue to assess all request cards to ensure urgent patients are seen in order of clinical priority. There is a robust process in place to ensure that no urgent patients are missed, with an internal Standard Operating Procedure in place for clinical triage. Externally, a review of all non-Obstetric Ultrasound has commenced in partnership with Bassetlaw CCG and this will extend shortly to Doncaster. Currently this is the modality with the greatest number of patients waiting.

The Trust is considering how it will open more routine capacity with appropriate cleaning, infection control and social distancing and is working in tandem with divisions, GPs and secondary care referrers to ensure this is a clinically informed process. During this transition period, the Trust to work to manage referrals in the best interests of our patients.

Additionally dialogue is taking place with the Integrated Care System to ensure an equitable approach across the region and to take advantage of capacity offered from other parts of the region.

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1.1.5 A&E attendance to admission, transfer or discharge (OF)

A&E attendances under 4 hours from arrival to admission, transfer or discharge

Provider Apr-19 May-

19 Jun-19 Jul-19

Aug-19

Sept-19

Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20

DBTHFT (all attendances, based on daily reported figures)

90.6% 92.4% 91.4% 90.4% 88.1% 88.7% 90.3% 85.9% 82.3% 84.8% 85.4% 88.0% 90.9%

DBTHFT (Type 1 attendances)

87.7% 90.2% 88.4% 87.7% 84.2% 83.8% 87.8% 82.5% 76.8% 79.4% 80.4% 84.4% 92.5%

England (all attendances)

85.1% 86.6% 86.4% 86.5% 96.3% 85.4% 83.6% 81.4% 79.8% 81.7% 82.8% 84.2% N/A

Standard 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

14

Performance improved again in April to 90.9% of patients being seen and discharged within 4 hours (748 breaches) below the 95% target. April performance remained below the Statistical Process Control limits suggesting that performance is outside normal parameters for the service. COVID-19 has severely impacted both Emergency Departments with departments split into 2 areas to manage 2 simultaneous pathways. Sickness in the consultant and nursing teams has reduced the substantive workforce. Personal protective equipment (PPE) implications (buddying up and donning / doffing) have also caused delays. Although the number of attendances was significantly lower than usual (46% reduction in April 2020), both sites have seen high acuity on type 1 presentations, especially from the COVID-19 pathway.

In the short term the Trust are embedding an emergency assessment unit model at Doncaster Royal Infirmary which will support an improvement in performance towards end of April 2020 by improving flow and reducing crowding in the department. In the medium term a robust action plan previously circulated is still being implemented. This includes all Care Quality Commission recommendations. There is also a plan in place for a senior team presence Monday – Friday until 10pm to ensure new processes around earlier senior assessment and senior review are embedded.

1.1.6 Cancer Measures DBTHFT are participating in the testing phase of the Clinically-led Review of Standards (CRS) for cancer as 1 of 13 sites nationally. As part of the testing there will be a change in reporting with 2 week wait for breast symptomatic reporting no longer provided in this report as part of the requirements of the national testing. An additional Faster Diagnosis Standard will be trialed during this period and is defined as a ‘Maximum four weeks (28 days) from receipt of urgent General Medical Practitioner, General Dental Practitioner or Optometrist referral for suspected cancer, breast symptomatic referral or urgent screening referral, to the point at which the patient is told they have cancer, or cancer is definitely excluded’. The new Faster Diagnosis Standard has an initial test threshold set by NHS England of 80% which will be monitored internally by the Trust and CCG with NHS England and NHS Improvement until the end of the field testing. Work is underway across intelligence teams within the Integrated Care System to ensure that the impact of COVID-19 can robustly be monitored in relation to cancer treatment. Reports are being developed to identify impact on patient choice and clinical decisions specific to the pandemic.

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31-day wait from diagnosis to first definitive treatment for all cancers

Commissioner Q1

19/20 Jul-19

Aug-19

Sep-19 Q2

19/20 Oct-19 Nov-19 Dec-19

Q3 19/20

Jan-20 Feb-20 Mar-20 Q4

19/20

Doncaster CCG 98.1% 96.5% 96.4% 95.9% 96.1% 96.9% 96.2% 98.4% 97.1% 95.2% 94.1% 95.6% 95.0%

Rightcare Peer Group 96.0% 96.2% 96.6% 96.2% 96.3% 96.6% 97.3% 96.9% 96.9% 96.0% 96.4% 96.9% 96.4%

Cancer Alliance 95.0% 97.3% 96.8% 97.2% 97.1% 97.1% 97.8% 96.9% 97.3% 96.1% 96.7% 96.9% 96.5%

DBTHFT 99.8% 97.9% 100% 100% 98.8% 100% 100% 100% 100% 97.8% 99.2% 100% 99.1%

England 96.1% 96.5% 96.1% 95.5% 96.0% 96.2% 95.9% 96.0 96.0% 94.6% 96.3% 96.7% 95.9%

Target 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96% 96%

16

There were 24 breaches in quarter 4 resulting in performance of 95%, below the 96% target. Head and Neck was the tumour group of concern performing at 65%. The 24 breaches were as followed; Out-patient capacity inadequate (12), Other reason (4), Treatment delayed for medical reasons (3), Elective Capacity inadequate (2), Patient choice (2), Health Care Provider initiated delay (1). The longest wait for a treatment in the quarter was 122 days, in the urological tumour group.

The 2019/20 year positon of 96.6% is above the target of 96%.

Nineteen of the breaches occurred at Sheffield Teaching Hospital; the service produced an action plan but much of this has been superseded by the response to COVID-19 since mid-March and it is likely that performance will fall again once deferred pathways (that already had a decision to treat but were deemed safer to wait) are treated post – COVID-19. Many of the initial improvements seen in February/March were the result of a comprehensive review and re-working of the end-to-end booking process. Tracking processes also improved significantly with greater awareness on subsequent pathways, supported by a central Corporate sub and 31 day Patient Tracking List view.

Performance in March 2020 of 95.6% is below the target of 96%. There were 8 breaches in the month, 6 due to out-patient capacity being inadequate, 1 for Patient choice of declining treatment date and 1 'other reason'. The 8 breaches were in Head and Neck (5) and lung (3) Tumour Groups. The longest an individual had to wait for first treatment was 49 days, in Head and Neck due to out-patient capacity issues. These were both for Radiotherapy Treatments. There were 3 patients that were treated on day 33 of their pathway.

It is expected that the effect of the COVID-19 pandemic on treatments will be seen in the coming months as the total number of patients requiring a first treatment is increasing as capacity is reducing.

31 day wait for subsequent treatment

Commissioner Q1

19/20 Jul-19

Aug-19

Sep-19 Q2

19/20 Oct-19 Nov-19 Dec-19

Q3 19/20


19/20 Surgery - Doncaster

CCG 91.2% 100% 95.2% 94.7% 97.0% 96.0% 91.7% 100% 96.5% 92.3% 100% 73.9% 90.2%

Radiotherapy - Doncaster CCG

95.9% 95.7% 92.0% 90.5% 92.8% 93.0% 89.6% 84.6% 89.1% 81.8% 100% 93.0% 91.4%

Target 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94% 94%

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Drug Regimen - Doncaster CCG

99.1% 100% 100% 100% 100% 100% 100% 100% 100% 97.6% 100% 100% 99.0%

Target 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98% 98%

On a quarterly basis, Drug Regimen performed at 98.99%, above target. Both Surgery and Radiotherapy performed below target at 90.2% and 91.4% respectively. The longest an individual had to wait for a subsequent treatment of Radiotherapy was 42 days due to elective capacity. The longest an individual had to wait for a surgical treatment was 78 days as a result of elective capacity being inadequate. Radiotherapy was the only treatment not to meet target over the year. In March 2020, Drug Regimens performed above the target of 98% at 100% whereas both Radiotherapy and Surgery performed below the 94% target at 93% and 73.9% respectively. There were 3 breaches for radiotherapy shared across the following reasons; Elective Capacity inadequate, patient delayed diagnostics or treatment planned an 'other' reason'. The longest an individual had to wait for a subsequent treatment of Radiotherapy was 42 days due to elective capacity. For Surgery, the 6 breaches were categorised as followed; Elective capacity inadequate (4), patient declined treatment appointment and ‘other reason'. The longest an individual had to wait was 78 days as a result of elective capacity being inadequate.

62-day wait from urgent GP referral to first definitive treatment for cancer (OF)

Commissioner Q1

19/20 Jul-19

Aug-19

Sep-19 Q2

19/20 Oct-19 Nov-19 Dec-19

Q3 19/20


19/20

Doncaster CCG 81.9% 83.6% 83.3% 88.7% 85.0% 81.8% 76.9% 78.8% 79.4% 80.8% 65.0% 88.5% 79.2%

Rightcare Peer Group 78.3% 78.4% 78.1% 76.6% 77.7% 77.1% 75.7 77.0% 76.6% 75.0% 73.4% 81.7% 77.0%

Cancer Alliance 79.4% 79.7% 79.1% 80.3% 79.7% 77.0% 77.9% 79.7% 78.2% 75.5% 73.7% 81.2% 77.0%

DBTHFT 83.4% 81.4% 87.0% 95.0% 87.3% 83.9% 87.8% 85.0% 85.5% 82.5% 72.7% 88.2% 82.0%

Sheffield Teaching Hospitals Foundation

Trust (STHFT) 74.1% 78.0% 74.0% 68.0% 73.4% 73.8% 76.8% 74.3% 72.6% 69.8% 70.5% 77.5% 72.9%

England 77.9% 77.6% 78.5% 76.9% 77.7% 77.2% 77.4% 78.0% 77.5% 73.6% 73.8% 78.9% 75.6%

Target 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

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In quarter 4 DCCG achieved 79.15%, below the 85% threshold. There were 44 breaches in the quarter, 20 of those being in Urology. The breach reason 'Other Reason’ and health care provider initiated delay to the pathway were the highest contributing breach reasons with 21 and 9 respectively. The longest wait for a pathway to be completed was 199 days where the healthcare provider initiated the delay to the pathway. 28 of the pathways that breached were at Sheffield Teaching Hospital for treating provider. Head and Neck and Urology were the 2 worst performing tumour groups at 50% and 59% respectively. In 2019/20 DCCG achieved 81.3% against the 85% target. Doncaster CCG performed at 88.5% against the 85% target. There were 9 breaches in the month due to; Other Reason (4), Elective Capacity Inadequate (2), Out-patient capacity inadequate (1), Healthcare provider initiating delay and Complex diagnostic pathway (1). The breaches were in the following tumour groups; Urology (5), Head and Neck (2), Lung (1) and Lower GI (1). In March there were 4 104+ day breaches of 104, 109, 110 and 126, 3 in Urology and 1 Head and Neck. The treating providers for the breaches were: Sheffield Teaching Hospital (2), DBHT and Rotherham FT both (1). Of the 9 breaches, STH was the accountable provider for 6 patients with DBH being accountable for 2 and Rotherham FT the other.

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62-day wait from referral from an NHS screening service or Consultant Upgrade to first definitive treatment for all cancers

Commissioner Q1

19/20 Jul-19

Aug-19

Sep-19 Q2

19/20 Oct-19 Nov-19 Dec-19

Q3 19/20


19/20 Doncaster CCG – screening service

91.7% 85.7% 75.0% 78.6% 80.0% 100% 100% 75.0% 95.5% 77.8% 100% 90% 88.9%

Target 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%

Doncaster CCG – consultant upgrade

72.5% 75.0% 73.3% 40.0% 67.4% 96.9% 60.0% 85.7% 67.9% 78.6% 70.0% 66.7% 71.8%

Screening Service:

There were 2 breaches in March 2020 which resulted in 90% performance against the 90% target. The 2 breaches were in Lower GI and breached due to an 'other' reason and Healthcare Provider initiated delay. The longest an individual had to wait was 94 days, due to health care provider initiating delay.

Quarter’s 4 performance was 88.89%, marginally below the 90% target. There were 4 breaches, all in the Lower GI with 3 of the breaches being associated with the 'other' reason and 1 due to healthcare provider initiating the delay. The longest an individual had to wait was 94 days.

For 2019/20, the Screening 62 day pathway performed at 87.7%, below the 90% target.

Consultant Upgrade:

There were 5 breaches in March, resulting in performance of 66.7% against the 85% target. The breaches were split between the lung and Lower GI tumour group with 4 and 1 breaches respectively. The breach reasons areas followed; Other Reason (3), Out-patient capacity (1) and Complex diagnosis pathway (1). The longest an individual had to wait was 86 Days.

For the quarter, 71.8% performance was achieved, below the 85% threshold. A year to date position of 69.9% was achieved for the year.

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1.2 NHS National Contract Key Performance Indicators

1.2.1 Yorkshire Ambulance Service (YAS)

Aug 19 Sept 19 Oct 19 Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20 Category 1 (Life threatening injuries and illness) target of average time less than 7min

00:06:50 00:06:57 00:07:18 00:07:28 00:07:46 00:06:53 00:07:10 00:08:01 00:07:17

Category 1 target 90% of times less than 15 min

00:11:53 00:12:02 00:12:30 00:12:46 00:13:15 00:11:54 00:12:32 00:13:25 00:12:32

Category 2 (Emergency) target of average time less than 18

min 00:17:14 00:18:26 00:21:50 00:23:11 00:27:11 00:17:55 00:18:50 00:23:53 00:15:16

Category 2 target 90% of times less than 40 min

00:34:56 00:37:35 0:45:14 00:49:02 00:58:00 00:36:39 00:38:27 00:48:52 00:29:18

Category 3 (Urgent) target 90% of times below 2 hours

01:27:31 01:33:37 02:09:54 02:18:58 02:56:47 01:31:24 01:45:19 02:15:01 00:59:40

Category 4 (Less urgent) target 90% of times below 3 hours 02:47:12 02:44:08 02:59:54 02:39:07 03:18:01 02:15:22 02:19:00 02:56:35 01:55:44

Category 5 (Lowest acuity) target 90th centile Target TBC 01:13:43 01:15:28 01:29:49 01:21:09 01:49:08 01:04:35 01:28:13 01:41:53 00:55:55

All measures met target during April 2020. Representatives from YAS continue to attend meetings around joint pathways in Doncaster to ensure that any issues can be addressed and continue to work closely with DBTHFT.

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Section 2: Provider Exception Report The following section of the report details performance by exception (those measures either rated Red or have deteriorated outside of normal range) for each main local provider, namely DBTHFT and RDASH and other commissioned services. Performance is across a range of agreed quality and more traditional “performance” measures. As such the report includes performance as a whole for DBTHFT and Doncaster sites for RDASH, and does not simply relate to services provided to DCCG. Due to the COVID-19 pandemic NHS England and NHS Improvement have directed NHS organisations to reduce routine reporting requirements to free up capacity and manage responses. Some areas agreed with Providers are included below. 2.1 Doncaster and Bassetlaw Teaching Hospitals Foundation Trust (DBTHFT) This section only includes measures in the DBTHFT contract currently not meeting target which are not included in the constitution measures in Section 1. No DBTHFT measures have been identified for reporting during the month. 2.2 Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH) This section only includes measures in the RDASH contract currently not meeting target which are not included in the constitution measures in Section 1.

Measure Month Latest

performance Target Trend Update

Improving Access to Psychological Therapies (IAPT) – Percentage of people entering treatment as a proportion of people with

Mar 2020 (year to date)

17.0% 20.5%

The proportion of people accessing the IAPT service was under target cumulatively for the year at 17.0% against a trajectory of 20.5%. This equates to around 1201 people below target. DCCG and RDASH continue to hold monthly performance meetings to discuss ongoing issues with the service with a focus on the workforce required to meet the current target and step up ambitions set by NHS England for

22

anxiety or depression (OF)

2020/21 onwards. A recovery plan covering short to long term actions has been received from the Trust and will be reviewed within these meetings with appropriate challenge. Within these meetings the impact of Covid-19 has been discussed with the service now offering additional telephone calls and digital interventions. Face to face treatment has been ceased. It has been confirmed that the increase in staffing numbers will go ahead during this period with an increase of 4 staff within the core service and 2 within Long Term Conditions planned to start in May 2020.

IAPT – People referred will receive treatment within 6 weeks (RDASH specific DCCG data)

Mar 2020

49.4% 75%

Performance deteriorated to 49.4% in March 2020 below the 75% target. Staffing issues have impacted on the response time of the service. As above monthly performance meetings are being held with the Trust. It is unclear at present when performance will recover as linked with capacity which should improve from May onwards and no COVID-19. However the 18 weeks access measure of 95% is being met at 98.3%.

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2.3 Other Quality Elements for Inclusion

COVID19

The previously reported structure to support the COVID19 work streams remains in place and working well.

An extensive piece of work has been undertaken by all health providers in coming together to develop a Rapid Discharge Pathway. This has been led by the newly established Discharge Cell. The reason for this is to enable patients to receive a high level of care in the most appropriate setting whilst enabling the Acute Trust to meet the demands of the pandemic. The key focus of the pathway is to identify the most appropriate placements for patients post discharge, identify any specific care needs, how these can be met and by whom. The decision will then be communicated to hospital staff and the patient. Doncaster CCG is leading the Children’s Health Sub Group. The purpose of the group is to support the children’s health response to the coronavirus. The group is providing support, advice and direction to relevant working groups within the COVID19 governance structure to ensure a co-ordinated approach. The scope of the group includes children and maternity services commissioned and provided by the Doncaster health community. It should also be noted that Doncaster CCG reviews each provider health service safeguarding provision at this weekly meeting. The DCCG Designated Professional team is also working with DCST on reviewing protocols in line with COVID19 national guidance.

Doncaster CCG continues to chair the Clinical Quality Review Groups for both DBTH and RDaSH. These meetings continue provide the CCG with the assurance required around areas that continue to be delivered by these organisations.

Primary Care During the current COVID19 pandemic, despite a number of staff working from home being shielded as clinically high risk and a number of staff self-isolating, all practices, including branch sites currently remain open and accessible. Some non-essential services remain suspended until further notice following guidance, however essential care, such as childhood immunisations continue following a screening conversation to assess whether the patient or accompanying parent/carer have any symptoms of COVID-19. All patients contacting their practice are being triaged remotely to assess clinical need and identify any symptoms of COVID-19. Where possible consultations are also being carried out remotely, however face to face consultations with non-symptomatic patients are being carried out if clinically necessary.

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The Covid Community Hub (CCHUB) remains up and running for both remote and face to face clinical assessment and treatment of patients.

National Reporting and Learning System During the current COIVD19 pandemic, NRLS reporting has continued and collated and logged for identification of any local patterns and trends no patterns or trends have been identified. Continuing Healthcare Overall Continuing Healthcare continues to meet and achieve all NHS England’s targets and the team remain in a positive stable position. Please note that quarter one reporting figures will be provided within the July report. The Continuing Healthcare Team within the CCG has currently stood down assessments. The team are currently working 7 days a week as part of the multi-disciplinary team. The team are overseeing the management of nursing bed based discharges and are continuing to do case management, with main focus being hospital avoidance. Care Homes Data is being collected daily by the Local Authority (LA) which provides an understanding of the current position within each of the care homes and identifies hotspots, which are prioritised accordingly. Joint working is currently taking place with the Care Home Liaison Team, which supports professionals to respond and support in relation to COVID19. The intention in the coming weeks is to develop a locality model involving other providers and a range of different professionals to support to each of the care homes in terms of infection, prevention and control, use of equipment. CHC Nurses are an active part of this work and are supporting and easing some of the challenges faced by the care homes. Specialist Placements Since the last report there has been an overall increase of two patients to 38. There are four out of area PICU patients at present, whereas there were none six weeks ago. This does not appear to be a result of the COVID pandemic. Some RDaSH services have operated differently through the pandemic. This may impact the delivery of care for patients in the community who will receive acre in different ways.

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Discharging patients from hospital has been affected by Covid-19 restrictions. Care planning and transitional periods for instance where patients gradually transfer to their new surroundings is not currently possible, and there are a small number of people whose discharge has been delayed due to this. Transformation Care

Care & Treatment Reviews (CTR) Attempts have made in hospital/community settings to have CTR’s and CETR’s via tele / video conference (Microsoft Teams) until the situation changes. This was proving to be difficult initially as many did not have Microsoft Teams installed. However this has improved and recent CTR’s that Doncaster CCG have carried out have been successful.

Safeguarding Safeguarding Adult Reviews / Serious Case Reviews There have been no Serious Case Reviews or Safeguarding Adult Reviews commissioned during this reporting period.

Lessons Learnt Reviews There have been no new Lessons Learnt Reviews commissioned by the Doncaster Safeguarding Adults Board during this reporting period. Domestic Homicide Reviews During this reporting period there have been no reported Domestic Homicide Reviews or requests to consider a Domestic Homicide Review.

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Child Death The child death which was reported in January 2020 remains open to the partnership. The Doncaster Safeguarding Children’s Partnership (DSCP) has identified all relevant children that may inform and / or form part of the review. The rapid review process has been initiated and it is expected that a full Safeguarding Practice Review or Lessons Learnt Review will take place. The national panel will make the final determination in relation to this. Section 3: NHS Oversight Framework (no update available) Due to the COVID-19 pandemic NHS England and NHS Improvement have reduced routine reporting requirements on NHS Organisations to release capacity and manage responses. Due to this, national reporting on the NHS Oversight Framework has been suspended.

Section 4: South Yorkshire and Bassetlaw Integrated Care System Assurance Report (no update available) Due to the COVID-19 pandemic NHS England and NHS Improvement have reduced routine reporting requirements on NHS Organisations to release capacity and manage responses. Due to this further updates on the Integrated Care System are not available at this time.

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CHIEF EXECUTIVE REPORT

May 2020 Author(s) Andrew Cash, Chief Executive Officer Sponsor Is your report for Approval / Consideration / Noting For noting and discussion Links to the STP (please tick)

Reduce inequalities

Join up health and care

Invest and grow primary and community care

Treat the whole person, mental and physical

Standardise acute hospital care

Simplify urgent and emergency care

Develop our workforce

Use the best technology

Create financial sustainability

Work with patients and the public to do

Are there any resource implications (including Financial, Staffing etc)? N/A Summary of key issues This monthly paper from the Chief Executive of the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) provides a summary update on the work of the SYB ICS for the month of April 2020. Recommendations The SYB ICS Health Executive Group (HEG) partners are asked to note the update and Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

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South Yorkshire and Bassetlaw Integrated Care System

CHIEF EXECUTIVE REPORT

May 2020 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System Chief Executive provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System for the month of April 2020. 2. Summary update for activity during April 2020 2.1 Coronavirus (Covid-19): The South Yorkshire and Bassetlaw position There is increasing evidence, both nationally and regionally, that the first peak of Covid-19 has now passed. The numbers of patients needing critical care facilities across the hospitals in South Yorkshire and Bassetlaw (SYB) appear to have now plateaued. There is consensus among partners that the immediate Phase One response to Covid-19 is drawing to a close. Attention is now turning to recovery, restoration and resetting health and care services. Simon Stevens and Amanda Pritchard’s letter to the NHS, issued on Wednesday 29th April, helpfully summarised the next steps for Phase Two, setting-out the current position and proposing new ways for the NHS to remodel health and care services in the coming days and weeks. The NHS remains in a Level 4 National Incident with all the altered operating disciplines that requires. There will be a gradual shift away from this in May as the Phase Two stabilisation period begins which will be in place until the end of June. During this stabilisation phase we will consider how best to restart urgent NHS services across SYB taking into account the needs of the population and the clinical priority of patients that need to be treated the soonest. Phase Three will be August to the end of March 2020. During this period we will conduct a comprehensive planning review and focus on building elective services and managing a potential further Covid-19 spike during the winter. Partners are already starting to take stock of the learning from the changes in ways of working since March as well as the experiences from patients, the workforce, SYB partners and the public. These findings will help to develop a framework to shape future working. Phase Four will be from April 2021 and will focus on recovering and developing the NHS towards the ‘new normal’. To support the early thinking on the SYB approach, a strategic workshop with Chief Executives, Accountable Officers, GPs, Primary Care Networks and the NHS England and Improvement Locality Director took place on 29th April. The basis of the discussions was to set out key principles for the reset process whilst working to ensure the prevention of System inequalities in any reconfiguration of services. It was a helpful exercise with insights and informative contributions from across sectors and the feedback is being used to work up the System response. Special thanks to Major Sam McEvoy, the SYB ICS Military Planner who formulated and facilitated the session. 2.2 Phase One reflections

As consideration turns to Phase Two and beyond, it is important to reflect on the enormous strides that have been made during Phase One. These have been in key areas such as workforce, critical care capacity, extensive partnership working and entering new terrain such as working side-by-side with the military. In SYB, a complex cross-regional development of a new Nightingale Hospital in Harrogate was co-

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ordinated and the realignment of the FlyDSA Arena Sheffield as a local PPE storage facility was supported. In addition, new mobile testing sites in Barnsley, Sheffield and Doncaster opened, alongside the drive-through coronavirus testing facilities at Doncaster Sheffield Airport (DSA) for South Yorkshire and Bassetlaw key workers in health and care, including those employed in the independent sector, police, fire, local authorities and LRF partner organisations. NHS staff testing expanded with Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and The Rotherham NHS Foundation Trust joining Sheffield Teaching Hospitals NHS Foundation Trust laboratory capacity to provide up to 2000 tests a day. Together with the key worker facility at DSA and mobile sites, the region is in a good position to maximise testing and allow staff currently unable to return to work because they or a member of their family or household have symptoms of coronavirus to know whether they do have the virus. The SYB System is also in a good position to widen community testing, especially to organisations that are fundamental to the local economy such as universities and colleges. More than 600 final-year nursing and allied health students from Sheffield Hallam University volunteered to join the NHS workforce and support the Covid-19 pandemic. This includes 376 nursing students who are joining NHS colleagues sooner than anticipated as part of the UK’s response to the virus. The healthcare students are in the final six months of their degrees and will be paid volunteers. In addition to work led by NHS England and supported by the ICS Procurement Hub to source PPE, the Mayor of the Sheffield City Region, Dan Jarvis, issued a call to South Yorkshire businesses to join the efforts to help make life-saving medical equipment. This initiative has seen around 50 businesses come forward, many of which are now supporting ongoing requirements for PPE for the region. 2.3 Supporting care homes In Phase Two the NHS will continue to partner with Local Authorities and Local Resilience Forums to provide mutual aid for care homes. In SYB this will build on work that has been taking place since the beginning of the outbreak. While the numbers of cases and deaths in hospitals are showing a downward trend, it is the opposite in care homes. NHS England is working with all regional providers including the North East and Yorkshire and the Humber Region to implement a new Enhanced Universal Support Offer to Care Homes. This is built around four key Principles: Leadership, Prevention, Additional Clinical Support and Workforce. The Enhanced Offer has been developed in conjunction across a number of key stakeholder groups; CCG Directors of Nursing, Directors of Adult Social Services in Local Authorities, Skills for Care, Primary Care, Public Health, Care Home Providers and others across the region. It provides a clear framework for support to care homes which will complement and, where appropriate, strengthen the support currently offered by these organisations. One of the first additional steps being taken, with regional senior nursing support, is for CCGs to quickly identify clinical leads to work alongside each care home. They will explore practical areas where additional support can be offered such as infection control, PPE training, staff not coming in to work if unwell, staff testing and pausing family visiting. 3. Finance update Based on draft year end results the System has exceeded its financial plan for the year. This has brought in £19m of cash support that would not otherwise have been available had the system not been in balance. This is a very creditable performance for the SYB System which has now exceeded its financial plan in each of the last three years.

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4. Next steps An announcement is expected on Sunday 10th May from the Prime Minister on the Covid-19 lockdown exit strategy. We will use this to underpin our approach building on the transformation work seen in the last few months in SYB to reset the NHS over the coming year in four phases which are outlined above. Andrew Cash Chief Executive, South Yorkshire and Bassetlaw Integrated Care System Date 7 May 2020

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Minutes of the Virtual Executive Committee

Held on Wednesday, 15 April 2020, 9.30am – 11am

Present J Pederson Chief Officer (Chair) Dr D Crichton Chair H Tingle Chief Finance Officer A Russell Chief Nurse A Fitzgerald Director of Strategy & Delivery L Devanney Associate Director of HR & Corporate

Services

In attendance:

J Satterthwaite PA to Chair and Chief Officer

Action 1. Apologies

There were no apologies received.

2. Declarations of Interest The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of NHS Doncaster Clinical Commissioning Group (CCG). Declarations declared by members of the committee are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: www.doncasterccg.nhs.uk The meeting was noted as quorate. Declarations of interest from sub committees / working groups: None declared. Declarations of interest from today’s meeting: Dr Crichton declared a pecuniary interest in Item 6 Urgent and Emergency Care Procurement as he is a local practising GP and his practice is a member of a Primary Care Network in Doncaster. As the information was for noting only and no decisions were to be made, the Executive Committee agreed that Dr Crichton may remain present in the


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virtual meeting for this item. 3. Minutes From Previous Meeting held on 18 March 2020.

The minutes of the meeting held on 18 March 2020 were approved as a correct record. The Executive Committee discussed and updated the Action Log.

4. Matters Arising not on the Agenda There were no Matters Arising.

5. Notification of Any Other Business There was no notification of Any other Business.

6. Urgent and Emergency Care Procurement A Fitzgerald explained that at the November Confidential Governing Body meeting it was agreed that a number of contracts for Urgent and Emergency Care (UEC) services in Doncaster would be procured from 1 October 2020. Services included within these contracts are:

• DRI Front Door Assessment and Signposting Service (FDASS) • Urgent Treatment Centre (including GP Out of Hours Provision) • Doncaster Same Day Health Centre • Emergency Care Practitioner Service In addition, it was agreed that the procurement would also include: • Target cover. • Mexborough Urgent Treatment Centre (UTC) minor illness element. It was also agreed that the specification would reference future developments that may impact on the services included within the specification; these include: • The developing Doncaster CAS • Woundcare services These services have now been tendered for, bids have been received and the scoring and moderation processes are complete. Bids were received from: • Atrumed Urgent GP Clinic • FCMS (NW) Ltd on behalf of the Doncaster Provider Alliance • Herts Urgent Care A bid was also received from One Medical Group Ltd; after taking legal

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advice the decision was made to exclude the bid as they did not submit their financial response schedule before the tender deadline. The bids have been scored. Next Steps

The outcome of the tender process, taking into account all questions asked and answered through all ITT submissions, should result in the following recommended bidder:

FCMS (NW) Ltd, on behalf of the Doncaster Provider Alliance

The recommendation will be discussed and approved at the NHS Doncaster CCG Governing Body meeting on 7 May 2020. Following ratification, all parties who registered an interest in the procurement (including those who declined to tender) will be notified formally of the decision by the South Yorkshire Procurement Service. A formal contract will be drafted and negotiated with the recommended bidders. The contract will take the form of an NHS Standard Contract. Recommended bidders will be asked to mobilise at the earliest opportunity, with an expected Service Commencement Date of 1 October 2020.

A Fitzgerald requested that the Executive Committee: • Note the tender process undertaken and the respective outcome. • Note the recommendation that will be made to the Governing Body

meeting in May 2020. • Note the next steps. A Fitzgerald advised that the contract would be for a period of 5 years plus 2 years. The Committee acknowledged that the procurement outcome will provide further stability within the system and that the external procurement process had worked well and extended their thanks to team who had worked so hard and been involved in the process. The Executive Committee: • Noted the tender process undertaken and the respective outcome. • Noted the recommendation that will be made to the Governing Body

meeting in May 2020. • Noted the next steps.

7. CCG Constitution and Standing Orders – Emergency and Urgent Amendments NHS Doncaster CCG has a duty to plan for and respond to a wide range of incidents and emergencies that could affect population health or direct patient care. Under the Civil Contingencies Act (2004) the CCG, as a

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Category Two responder has specific duties and standards which need to be met in relation to Emergency Preparedness, Resilience and Response (EPRR) and business continuity plans are in place. At times where business continuity plans are required to be used, the CCG is still required to be properly governed and there are situations where there is a need for sustained business continuity plans to be used, such as for pandemic flu or virus situations or where national emergencies are called. The CCG has in place a Corporate Governance Framework and an approved scheme of matters reserved for the Board and a scheme of delegation. The Standing Orders in place already give us the framework to be properly governed. However, the Standing Orders do not have a provision for holding virtual meeting therefore no formal business may be transacted. Only a record of matters can be discussed:

Delegation to Committees – Standing Order 7.3, stipulates: “When the Governing Body is not meeting as the CCG in public session it shall operate as a committee and may only exercise such powers as may have been delegated to it by the CCG in public session.”

Emergency Powers and Urgent Decisions The Standing Orders already prescribe for the Chief Officer and Chair to exercise emergency powers and urgent decisions, as per Standing Order 7.2:

‘The powers which the Governing Body has reserved to itself within these Standing Orders (see Standing Order 4) may in emergency or for an urgent decision be exercised by the Chief Officer and the Chair after having consulted at least two non-officer members. The exercise of such powers by the Chief Officer and Chair shall be reported to the next formal meeting of the CCG Governing Body in public session for formal ratification’.

The following addition is proposed to be added to the Standing Orders:

5.13.8 Without prejudice to the power to exclude the public, pursuant to Standing Order 5.13.2 above, the CCG may hold virtual (video conference, telephone conference or similar communications equipment) meetings of the Governing Body and Sub-Committees, under the Public Bodies (Admission to Meetings) Act 1960, for other special reasons and / or under the Civil Contingencies Act 2004 for the purposes of business continuity. The whole of the proceedings will be where all persons participating in the meeting can hear each other and participation in the meeting in this manner shall be deemed to constitute presence in persons at such meeting.

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The Head of Corporate Governance has consulted the Chair of Audit Committee and Chair of Primary Care Commissioning Committee, as per Standing Order 7.2.1 and can formally confirm that the two non-officers are in agreement of the proposed amendments. L Devanney requested that the Executive Committee approve the following amendments. • CCG Constitution, 6.1 (d): hold Governing Body meetings in public

(except where we believe that it would not be in the public interest or for special reasons).

• Standing Orders, 5.13.8 Without prejudice to the power to exclude the public, pursuant to Standing Order 5.13.2 above, the CCG may hold virtual (video conference, telephone conference or similar communications equipment) meetings of the Governing Body and Sub-Committees, under the Public Bodies (Admission to Meetings) Act 1960, for other special reasons and / or under the Civil Contingencies Act 2004 for the purposes of business continuity.

The whole of the proceedings will be where all persons participating

in the meeting can hear each other and participation in the meeting in this manner shall be deemed to constitute presence in persons at such meeting.

The report will be presented to the next meeting of the Governing Body for noting. The Executive Committee approved the amendments and acknowledged that the report will be presented to the next Governing Body meeting for noting.

8. Policy approval process L Devanney requested that the Executive Committee consider and approve a proposal to roll over any existing policies that are due for renewal up to 30 September 2020 for a period of 12 months unless there was a change in national guidance or in legislation that would require reflection in the policy. The Associate Director of HR and Corporate Services has authority to approve any minor changes to policies and any significant changes will be brought to Executive Committee for approval. The Executive Committee approved the proposal to roll over any existing policies that are due for renewal up to 30 September 2020 for a period of 12 months unless there was a change in national guidance or in legislation that would require reflection in the policy.

9. Performance update A Fitzgerald advised the Executive Committee that due to COVID-19, the

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Living Well Delivery Plan will not be presented at the Governing Body in May however the Quality and Performance Report will still be presented for noting. The Executive Committee noted the update.

10. Escalation of Risk The Executive Committee was informed that the COVID-19 Risk Register will be managed through the Health Cell meetings and will also be incorporated into the NHS Doncaster CCG Corporate Risk Register.

11. Bring forward Agenda Executive Committee May • Liberty Protections Safeguards • Policy Database • Delivery Plans • Corporate Risk Register • COVID-29 update • EPRR Policy June • Community carpel Tunnel Syndrome • Prescribing Incentive • Medicines Management Investment Future Agenda Items • Mental Health Spend • Policy Database • Communications Healthwatch Review Strategy & Organisational Development Forum May • Staff Survey results • Financial system update

Future Agenda Items • Planning through to March • Commissioning CHC Principles • LD Strategy • QIPP Review • Statistical Process Control

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Governing Body May • UEC Sign Off • Delivery Plans • COVID-19 update • Strategic Future Commissioning changes Future Items • Doncaster All Age Learning Disabilities and Autism Strategy • Liberty Protection Safeguard Partnership • IVF Policy • Sign off of commissioning agreements, financial plans, delivery plans • PCCC Terms of Reference • Commissioning Principles for CHC and Individual Placements


Annual Report The Draft Annual Report has been prepared for submission on 27 April 2020. It is proposed that the usual process will take place and an Extra-ordinary Governing Body meeting will be held for sign off of the report prior to publishing on the NHS Doncaster CCG website unless the CCG is instructed not to do so.

13. Date and Time of Next Meeting Wednesday 20 May 2020, 8.30 am – 12.00 noon, Dr Crichton’s Office

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Minutes of the Primary Care Commissioning Committee (Public)

Held on Thursday 12 March 2020 at 12.30pm In the Boardroom, Sovereign House, Heavens Walk, Doncaster, DN4 5HZ

Voting Members Present:

L Tully Lay Member (Chair) S Whittle Lay Member H Tingle Chief Finance Officer J Pederson Chief Officer

Non-Voting Members Present:

C Ogle Associate Director of Primary Care & Commissioning

Dr N Alsindi Clinical Lead for Primary Care & Long Term Conditions

Dr Pande Dr Eggitt

Locality Lead GP LMC

Non Members Present: S Barnes Estates Lead

B Skidmore Nova Nordisk K Roberts Primary Care Manager K Smith Senior Officer – Digital Primary Care

In Attendance:

M Gibbons Primary Care Support Officer

Action 1. Apologies for Absence

Apologies for absence were received from:

• P Barringer NHS England Representative • A Russell Chief Nurse • Z Head Lead Nurse Primary Care Quality • A Fitzgerald Director of Strategy and Delivery

The Group did a round of introductions for S Barnes, Estates Lead and for a member of the public present at the meeting.

2. Declarations of Interest The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of NHS Doncaster Clinical Commissioning Group (CCG).

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Declarations declared by members of the committee are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: www.doncasterccg.nhs.uk The meeting was noted as quorate. Declarations of interest from sub committees / working groups:

• None declared Declarations of interest from today’s meeting

• Declared

As a salaried GP at Bentley surgery Dr Alsindi had a direct financial interest in agenda item 7.3 (Primary Care Estates- Implementation Plan Update). As this item was an update and required no decisions it was agreed Dr Alsindi could remain in the room, but would not contribute to any discussion.

3. Notifications of Any Other Business

• None raised

4. Minutes From Previous Meeting held 13 February 2020 The minutes of the last meeting held on 13 February 2020 were approved as an accurate record.

The minutes were signed by the Chair.

5. Matters Arising not on the Agenda No Matters arising

6. Action Tracker The Committee discussed and updated each item on the Action Tracker. The latest updates can be viewed on the Action Tracker. Dr Alsindi and Dr Eggitt joined the meeting at 12.39pm


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7. Finance and Contracting 7.1 Interim Exception report: Nothing to report 7.2 Audit Report The Audit Report had been presented to the March meeting of the Audit Committee for approval. The feedback from 360 Assurance who had undertaken the Audit was positive. They praised the contract management plan, complimenting the CCG on “the best plan they had seen”, and the utilisation of the CCG ‘s matrix tool for both claiming payments and sharing data. However, The auditors felt that the number of decisions made was low. Only one action was issued: to ensure the consistency of covering papers. This would be mitigated by authors checking previous papers on the same subject and also by the admin team on issuing of the agendas. The Chair congratulated the team for the rating of “substantial assurance”. The Audit Report was noted by the Committee. 7.3 Primary Care Estates- Implementation Plan Update S Barnes & C Ogle presented the Primary Care Implementation Plan Update to the Committee. The Bentley options appraisal is currently being drafted and is expected imminently. Once received an update will be provided to the committee. S Barnes and C Ogle attended the Star Chamber Check and Challenge meeting on 5th March. We were given a rating of amber. The next step is to develop Project Initiation Documents (PIDs) for all schemes by the end of March 2020. Three separate (PIDs) are needed for the PCN Estate Reconfiguration proposal. A separate PID is also needed for a reserve PID for Rossington. The Contents of the report were noted and approved. 8. Quality 8.1 Interim Exception report A Ibbeson presented a verbal Interim Exception Report highlighting:

• Barnburgh Surgery had received its CQC report which rated them as good overall. March TARGET meeting focusing on safeguarding level 3 training had been stood down due to the Covid-19 pandemic. This would be a priority for the next month’s target.

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Post meeting note: TARGET has been stood down for 3 months. 9 Strategy and Planning 9.1 Primary Care Delivery Group TOR The reviewed Primary Care Delivery Group Terms of Reference (TOR) was presented to the Committee. Changes recommended by of the head of Corporate Governance included:

• amendments to quoracy (4 members from different disciplines • TOR review to be completed every 2 years instead of being

reviewed yearly, • Changes in the structure and monitoring tools namely the

Information Sub Group development and PCQ, and the Quality and Performance Framework.

The Committee Approved the revised TOR. 9.2 Primary Care Delivery Plan 2020/21 C Ogle presented the revised draft Primary Care Delivery Plan for 20/21 which had been developed further to include linkages with other plans particularly around mental health and learning disability as well as ageing well. There is further work to be done in terms of the outcomes and work up of QIPP schemes and the Primary Care Delivery Group will finalise the plan for Governing Body sign off. The Committee Approved the Primary Care Delivery Plan 2020/21 for final amendment by the Delivery Group as necessary 9.3 Proactive Care Recommendation K Roberts presented a paper to the Committee outlining a recommendation for the Proactive Care service 20/21. This had been developed in the light of concerns that the CCG could not contract with PCNs. The proposed change (to contract with individual practices) would mean that the CCG would need to monitor each individual practice on a quarterly basis in terms of the 2% proactive care register. This could also add risk should a practice disagree with the PCN / Group of practices direction of travel and withhold funding previously agreed in the specification. The Committee queried whether the Clinical Directors were comfortable with the above changes, and it was confirmed that they are. The Committee approved the proposed approach.

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9.4 Primary Care Commissioning Committee Annual Report The Chair presented the Primary Care Commissioning Committee (PCCC) 2019/20 Annual Report of the Committee, for approval / discussion before the report is submitted to the CCG Governing body and then to NHS England. A Russell suggested that risks are highlighted and covered at a higher level in the Corporate Risk Register. J Pederson also suggested that decisions made throughout the year be highlighted to link back to the audit report. These changes would need to be implemented before the report goes to Governing Body and the decisions made throughout the year. The Committee approved the report, pending changes made for submission to Governing Body. 9.5 GP Contract Update & PCNs C Ogle presented the Contract Update & PCN slides to the Committee to consider / discuss. Before the April payment deadlines individual practices are to confirm sign up to the Network DES. Physical sign up to the Network Agreement or opting out is to be done by 31 May 2020. If PCNs are aware of any practice who is not going to sign up they would need to make the CCG aware, but they have until 31 May 2020 to opt out. Network agreements are to be amended to include other community service providers, Community Mental Health providers and community Pharmacies. Three service specifications have now been published. There is still a lot of work to do in terms of aligning the care homes with the respective neighbourhood networks. There is only 1 care home who doesn’t map to the any PCN. There are six additional roles announced for Primary Care. PCN’s are to submit plans for the use of additional roles funding by the 30 June 2020. There have also been updates to QOF with the number of points increasing from 559 to 567 and 97 points have been recycled. COPD, Asthma and Heart Failure domains have also improved. Dr Eggitt confirmed that at the special conference of LMCs the contract changes had been rejected and a request made that it be suspended entirely for a year. 9.6 Update on online Consultations and Apex K Smith presented the update on online consultations. Currently the

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position is as stated: 24 practices are complete and will be on by the end of today 9 will be completed before the end of March 6 are still to agree a switch on date 1 still needs to do online training Doctorlink are confident they can do 5 implementations per day, this can also be done remotely in light of covid pressures. There are likely to be a number of practices that make use of telephone implementations over the coming weeks to ensure that they are able to meet the national deadline. System one issues have caused some installations to be delayed however there is a work around now in place to ensure that these practices will now be installed, this will just mean that initially the practices will go live in an un-connected state. There are some practices going ahead unconnected. There are a small number of practices who may not implement by 31st March. The ICS Online Consultation group are considering collectively whether or not to breach practices now given that there are no further installation obstacles. Online booking will be discussed outside of committee at the 4pm - 5pm Covid-19 meeting to see how this might assist general practice moving forward. J Pederson suggested that we send practices a letter urgently before the end of the month advising practices that they need to engage with Doctorlink and arrange and complete the required actions/installation before the national deadline. It was agreed that a formal letter would be sent to the outstanding practices advising them of their contractual requirement to offer this service to patients and that any practices who do achieve this would be issued a breach notice. KS 9.6 APEX C Ogle presented a paper on APEX. There are only a few practices where they have completed the full installation. There are a further 14 practices who still need chasing. There is no utilisation data. 4Doncaster are the only PCN who have all practices installed and signed the data sharing agreement. 4Doncaster has been asked if they could trial the enterprise level of data sharing. 9.7 DRAFT Primary Care Delivery Group Minutes 22.01.2020 The committee noted the DRAFT Primary Care Delivery Group meeting minutes held on 22 January 2020. Noting 9.8 DRAFT PEG Minutes January 2020 The committee noted the DRAFT Provider Engagement Group meeting

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minutes held on 29th January 2020. Noting 10. Forward Planner The Committee noted the Forward Planner and amended accordingly. 11. Any New Potential Risks No new risks were identified 12. Any Other Business No items of Any Other Business were raised 13. Date and time of Next Meeting Thursday 9 April 2020, 12.30pm in the Boardroom at Sovereign House. The meeting Closed at 13.30

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Minutes of the Quality & Patient Safety Committee

Held on Thursday 5 March 2020, 9.30 am – 12.00 midday In Boardroom, Sovereign House

Present: Dr E Jones (Chair) Secondary Care Doctor

A Russell Chief Nurse Z Head Lead Nurse Primary Care Quality Dr R Kolusu GP Governing Body Member T Thomas

Quality Assurance Nurse Individual Placements

L Denman Lead Nurse for All Age Individual Placements and Safeguarding Adults

I Boldy Deputy Chief Nurse S Evans (arrived 9.30 am) Transforming Care Specialist Placements

Case Manager M Booth Specialist Rehabilitation Case Manager A Ibbeson Head of Quality & Designated Nurse for

Children’s Safeguarding & LAC G Wood Deputy Designated Nurse for Safeguarding

Children & LAC W Feirn Senior Nurse – Quality & Patient Safety A Stothard Quality & Patient Safety Manager J Rayner Senior Officer for Quality M Hunter Continuing Healthcare Nurse H Joerning Patient Experience Manager A Molyneux (arrived 9.30 am) Head of Medicines Management

In attendance: J Whittaker Senior Corporate Services Support Officer

(Minutes)

Action

1. Welcome, Introductions and Housekeeping The Chair welcomed everyone to the meeting.

2. Apologies Apologies were noted from:

• Dr V Joseph, Consultant in Public Health • A Johnson, Court of Protection/Personal Health Budgets Lead

Practitioner

3. Declarations of Interest The Chair reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of NHS Doncaster Clinical Commissioning Group (CCG). Declarations declared by members of the committee are listed in the

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CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: www.doncasterccg.nhs.uk The meeting was noted as quorate. Declarations of interest from sub committees / working groups: None declared. Declarations of interest from today’s meeting: None declared.

4. Minutes From Previous Meeting held on 7 November 2019 The minutes of the meeting held on 7 November 2019 were approved as a correct record.

5. Action Log Update The Quality & Patient Safety Committee Action Tracker was updated accordingly.

6. Matters Arising not on the Agenda There were no items raised.

7. Notification of Any Other Business • Coronavirus (COVID-19) update

8. Medicines Management Report

A Molyneux presented the report and the key highlights were as follows: Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) – Community Treatment Orders (CTO’s) are causing issues in Primary Care as there have been a number of recent incidents within RDaSH where patients subjected to a CTO have been prescribed medicines outside of those allowed under their CTO. RDASH have asked that the Medicines Management Team (MMT) help facilitate the cascade of this important message to General Practices (GP) and this has been included in the newsletter. A Molyneux advised the Committee of a recent incident where a patient was taking Clozapine but the Primary Care prescriber was not aware of this as this was not on their Summary Care Record and so the missed dose resulted in a relapse in symptoms. This has resulted in joint working between RDASH and the MMT to check if patients receiving Clozapine from RDASH have their Clozapine recorded as hospital only drug in Primary Care. It was felt guidance needs to be strengthened around the recording of medication across multiple systems. Following discussion, it was felt this issue should be reported to NHS Digital and Summary Care Records Team so they are aware a patient has suffered as a result of this as well as via the national reporting learning system. As a local solution,

A Molyneux


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the suggestion was put forward to share this information with K Dowson, Head of Digital across the Doncaster Place, who could then raise at the Interoperability Group for them to be able to look for a wider solution and how we influence this and support all areas. The Committee noted the report and concerns raised.

9. Updated Primary Care Rebate Scheme Policy A copy of the updated Primary Care Rebate Scheme Policy was brought to the Committee for noting. The question was raised as to where within the CCG was this policy being monitored? A discussion was held and it was agreed that the Audit Committee need to be aware and have oversight of this policy as it involves finance and so there is the potential for fraud and so moving forward, this will be added to the Audit Committee Agenda accordingly. Dr Jones commented that the policy was well written and comprehensive and the Committee noted the updates made.

10. Primary Care Quality Report Z Head presented the report and the key highlights were as follows: Proactive Coordinated Primary Care - responses from Quarter Three have now been received and the task and finish group are now in the scoring process. As per Quarter One and Two any Practice where further assurance is needed will be contacted or visited to gain assurance that the service is meeting the criteria provided and offer any additional support where needed. National Reporting and Learning System (NRLS) - in the last quarter we have received 45 reports from 12 Practices. No patterns or trends have been identified and reporting is still on the increase. Case Conference Reporting/Attendance – figures for submissions continue to vary. There were still delays from Social Care Teams submitting the Initial Child Protection Conference requests in a timely manner, which impacts on the number of days’ notice GP’s receive the invite to complete a report. The interim named GP, The Deputy Designated Nurse for Children’s Safeguarding and Looked After Children and the Lead Nurse Primary Care Quality are meeting to look at possible new ways of working and how information from practices can be collected and used effectively and an update will be provided at the next meeting. An audit has recently been undertaken of the number of initial and review reports requested from each Practice over the last six months and the number of reports returned. This data will be analysed and fed back to Practices for discussion. Workforce - the Doncaster General Practice Nurse Awards were held on

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the 6 February 2020 and the nominations for each category were of a very high standard. Positive comments were received from General Practice Nurses, especially around being recognised and valued for their work both within practice and externally.

Care Quality Commission (CQC) – one Practice has been re-inspected and has now received a rating of good overall (previous rating was requires improvement). Wound Care Service - the integrated Wound Care Service for Doncaster patients through the Provider Alliance remains on track to commence on 1 April 2020. The Committee noted the report.

11. Fylde Coast Medical Services Update Report A Stothard provided an overview of the quality and patient safety issues in relation to Fylde Coast Medical Services (FCMS) service provision for the Out of Hours (OOH) and Same Day Health Centre (SDHC) and Urgent Care Centre (UTC). An improvement has been seen in staffing issues, which is really positive. FCMS continue to develop their Quality Report which provides assurance on the safety and effectiveness of the service and the key highlights for noting are as follows:

• There have been five incidents reported regarding agency nurses which are currently undergoing investigation.

• FCMS have been requested to provide the CCG with information on serious incidents so that these can be reported onto the National STEIS system and come through the Incident Management Forum.

• Commissioning for Quality and Innovation (CQUIN) - evidence has been provided and the non-face to face antibiotic prescribing audits have been completed and staff flu vaccinations have achieved the national target of over 80%.

Minor ailments is now up and running at Mexborough Montagu alongside minor injuries. This was re-branded as a UTC and is fully functioning. There has been no reduction in patients accessing the Front Door service and so more data needs to be obtained for further clarity and understanding. The Committee noted the report and the concerns raised.

12. RDaSH Quality Report The report was presented by A Stothard and the key highlights were as follows: Quality Dashboard – there has been a significant improvement in training compliance over the last few months and RDaSH continue to do well with

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the Family and Friends Test, achieving 98% of patients who would recommend the Mental Health Services. CQC – a rating of requires improvement has just been received so an understanding needs to be gained around what the issues are and the CCG will continue to work and support RDaSH to ensure the monitoring of quality is robust and an action plan is currently in development.

Coral Lodge – Coral Lodge has been experiencing some staffing challenges due to staff sickness. A temporary Ward Manager has been put in place and an action plan has been produced. The Head of Quality and Quality and Patient Safety Manager have recently had a walk round of the unit. The Manager provided a good understanding of the work that was going to be undertaken. It was agreed for this to be monitored via RDaSH Clinical Quality Review Group (CQRG) and updates will continue to be provided to the Committee as required. Magnolia – it had been identified through both the CCG CQRG and Finance, Performance and Information Group (FPIG) meetings that the patient group is more complex and now includes more physical neurological complexities that are causing day to day challenges within the service. It should be noted that there have not been any incidents raised to date. It has been agreed that a formal review will be undertaken once this is agreed via the Contract Board. Updates will continue to be provided to the Committee. CQC Inspection – a recent inspection has been undertaken on Windermere. A lot of work has taken place since the last visit and the initial feedback has been positive. There have been some discussions around Windermere being allocated 12 bed occupancy and funding that would be required to provide this. A further update will be provided to the Committee as discussions take place. The Committee noted the report and concerns raised.

13. Doncaster and Bassetlaw Teaching Hospital Foundation Trust Quality Report A Stothard presented the report and the key highlights were as follows: CQC Inspection – Doncaster and Bassetlaw Teaching Hospital Foundation Trust (DBTHFT) have received a rating of good, which is a testament to all the hard work that has been undertaken. The Committee congratulated them on the distinct improvement for achieving good across the board.

Tetanus Immoglobulin – pathways are now in place and no issues have been raised. A Stothard wanted to acknowledge this has been a positive piece of joint working between the organisations in producing a pathway that works across the system.

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The suggestion was put forward to consider feeding back the positive work that has been undertaken to both the Governing Body and/or patient(s) involved?

Duty of Candour – some issues had been raised in relation to recording through datix, which is the incident reporting framework for DBTHFT. A positive approach is being taken and the adherence is increasing through better reporting and this is being monitored via their Clinical Governance team meetings. Maternity and Neonates - the Quality Risk Meeting (QRM) members have agreed to stand down the QRM with the understanding that the CQRG Maternity Sub group will continue to meet and monitor any arising concerns and escalate if required. Recent discussions have taken place between DBTHFT, Spec Comm and the CCG’s regarding Neonates and the provision at Bassetlaw. The main issue is in relation to the mitigated risk of the buddying system to ensure that there is always an appropriate on call medic available within the 30 minute window. It was agreed that there would need to be an agreement between DBTHFT and NHS England/Improvement (NHSE/I) if this continues to be a mitigated risk or if there needs to be consideration of other options. A Russell stated feedback received in CQRG is that that D Black, Medical Director at Spec Comm, has produced a letter which states they accept the current arrangements with a plan to review in a years’ time. The CCG will continue to support discussions between DBTHFT and NHSE/I as required.

The Committee noted the progress that has been made in regards to Maternity as well as the concerns raised regarding Neonates and that we need to commission the right level of service and safety and ensure the new Medical Director at DBTHFT has sight of the nature of the issue.

COVID-19 – DBTHFT continue to work as part of the ‘Place’ response to COVID-19 and the emerging requirements. The Trust has implemented all current guidance and has the required services in place.

CQUIN’s – the Quarter two evidence has been received from the Trust and is currently showing to not meet all of the indicators for Antimicrobial resistance and Urinary Tract Infections (UTI’s) and also for the falls bundle. The latter is mainly due to the ability for clinicians completing falls risk assessments being able to justify the continuation of certain medications that can elevate the risk of falling. This has seen to be a national issue and the CQUIN has been dropped from the 2020/2021 scheme. A Stothard agreed to share the information with A Molyneux. The Committee noted the report and concerns raised.

A Stothard

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14. Liberty Protection Safeguards (LPS) Report I Boldy presented the report and provided an update on the progress in relation to Deprivation of Liberty Safeguards (DoLS).

Suitable preparations are being made for the new legislation and a partnership group has been set up around the development of Liberty Protection Safeguards (LPS). The group will meet on a monthly basis and has appropriate representation across local providers/organisations. The timeline of these meetings will be a year before LPS is introduced. The group will look at the progress and what work streams are required for implementation and the Terms of Reference has been provided to all attendees. The group will report to the Safeguarding Adult Board. An option appraisal paper on Implementation of LPS has been written and will be presented at the CCG’s Governing Body. The Committee noted the report.

15. Continuing Healthcare Report L Denman presented the report which provides an update on the work undertaken and progress made by the Continuing Healthcare (CHC) Team and the key highlights were as follows:

Quarter three has seen a significant reduction in the number of checklist retractions which is seen jointly with Doncaster Council as a positive impact on patients and services users accessing or becoming eligible for completion of a checklist.

Fast Tracks continue to rise year on year and a deep dive has been undertaken due to the number of inappropriate fast tracks that have been coming through. Patients are only to be fast tracked should they physically require care and Dr Kolusu raised he would feed this back to Primary Care.

Appeals continue to be low and we have nearly completed the backlog from NHSE. There are five outstanding, with one appeal being challenged with NHSE. Staffing Issues – Quarter three identified some significant staffing structural changes within the CHC Team. A brand new post has been created and appointed too within the CHC of a Continuing Healthcare Support Worker for Learning Disabilities. The role continues to develop as required to provide support as and when required by the team. Discharge 2 Assess (D2A) – the Patient Experience Manager is currently undertaking a piece of work regarding customer experience and what it is like to go through this process.

Overall, Continuing Healthcare continues to meet and achieve all NHSE’s

R Kolusu

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targets. The team continue to work effectively and appropriately with patient focus remaining their priority.

The Committee noted the report.

16. Individual Placement/Care Home Report T Thomas presented the report and provided the Committee with an update on the progress made in regards to the Individual Placement/Care Home work streams and the key highlights were as follows: Since the last meeting, the LNIPQ and Local Authority (LA) Contracts Team Manager have refreshed the Terms of Reference (ToR) for the Quality and Risk Meeting and revised a RAG rating system for the dashboard that is used in the Multidisciplinary Quality and Risk Meeting. The Quality and Risk Dashboard informs the Quality and Risk Meeting. It identifies monitoring visits, CQC inspections, ratings and subsequent issues. T Thomas explained we continue to be directly involved and work closely with Care Homes to provide support and ensure staff training is uniform across the patch and work is being undertaken with the Workforce and Development Team. Doncaster currently has three Care Homes rated inadequate by the CQC that are discussed at the Quality and Risk Meeting to allow a co-ordinated approach to monitor and support with quality improvements. An independent audit has taken place by 360 Assurance in regards to processes for Care Homes and T Thomas advised the Committee will be informed of the results once received. In regards to the Care Home Tool Kit, Dr Kolusu raised this had not been received by all Care Homes and so T Thomas agreed to re-send the link.

Updates will continue to be provided on the work that is being undertaken.

The Committee noted the report and contents within.

T Thomas

17. Learning Disabilities Mortality Review Report Currently the CCG has eight cases in process and of the eight, six cases are in the process of review, whilst the remaining two are currently suspended due to other investigative processes. The number of cases received into the CCG is manageable due to the allocation of a dedicated ‘reviewer’. The first Learning Disabilities Mortality Review (LeDeR) Learning Group is now up and running. The meeting has been well attended by professionals, care providers and CCG Staff. A system has now been developed that enables ‘on-going’ analysis of the Doncaster cases, so that an annual report can be developed that mirrors

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the format of the two national reports. This will be presented at the next Quality and Patient Safety Committee meeting.

18. Specialised Placements Update Report M Booth presented the report and provided an overview of the work undertaken within the Specialist Placements work stream. In regards to discharge planning, it was anticipated that six patients would be discharged by the end of April 2020. There are currently no out of area Psychiatric Intensive Care Unit (PICU) patients. M Booth notified the Committee of the closure of Coral Lodge to admissions but there are two patients on an informal waiting list, including one stepping down from a secure hospital. It is hoped the normal admissions process can resume in March 2020. The block funding arrangement has now been increased to eight beds, following an analysis of usage over the past three years. The situation is being monitored via existing RDaSH and CCG contractual reviews. A discussion was held regarding the need in Doncaster for specialised rehab supported living and work is on-going in trying to identify appropriate placements. M Booth also informed the Committee of a positive patient story. The Committee noted the report.

19. Transforming Care Programme (TCP) Report S Evans presented the report which details the on-going quality engagement in the Doncaster Transforming Care Programme (TCP). As from 24 February 2020, Doncaster currently has 23 adults identified on the Local Transforming Care Partnership (LTCP) Register. This also now includes Autistic Spectrum Disorder (ASD) patients without a Learning Disability (LD) diagnosis. In terms of adult patients in hospital, discharge plans are in place for all but one. A patient was recently transferred to Croydon to allow them to be close to family and friends. S Evans raised there were a lot of challenges with this case, but the patient seems to be doing well. Dr Jones expressed his thanks to all those involved.

S Evans discussed a complex case in regards to a patient with challenging needs. The CCG have been working collaboratively with NHSE and Nottingham CCG. The patient is now in safe, effective care as of today. Further discussion and consideration by all parties is required to avoid further complications in the future.

On-going work also continues with various CCG’s around commissioner guidance and disputes over responsibility for patients who have been placed in Doncaster from other areas and then require hospital due to

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placement breakdown. There are a number of these cases currently being examined.

I Boldy raised as a result of an incident that happened last year, actions have been produced from NHSE in terms of increasing reviews/visit of individuals along with the development of the whole commissioner model. The requirement for adults is for visits to be undertaken every eight weeks and this is now up and running. The Committee noted the progress and actions/activity of the team and support the action being taken for the challenging cases raised.

20. IPC Report W Feirn presented the report to the Committee which contained an update on:

1. The national requirement to reduce Healthcare Associated Infections

2. Data relating to outbreak of infection during the preceding eight weeks (PLACE)

3. Report on the current and (future) position regarding the Sharps Bins contract

4. Exception report –pressure ulcers 5. Exception report - Immunisation & Vaccination

CDI 2019-2020 – there are no cases in February for Doncaster and the systems and processes in place are working well. Varicella Exposure Neonatal Unit – there has been Varicella exposure with 11 babies on the Neonatal Unit. Blood tests were carried out accordingly on all the babies but no adverse effects were identified. RDaSH Pressure Ulcer Harm Reduction – this has been raised as an area of concern and is being monitored via RDaSH CQRG Meetings and will be escalated to the Committee accordingly.

Sharps Bins – this is on-going and remains on the CCG Risk Register.


21. Safeguarding Quarter Three Report 2019/2020 L Denman presented the report which provides assurance that the CCG is meeting its statutory duties and requirements for safeguarding children and adults. The main highlights are as follows: There have been no new Lessons Learnt Reviews commissioned by the Doncaster Safeguarding Adults Board during January 2020. There is currently one open Safeguarding Adult Lessons Learnt Review however it has been agreed to progress this case up to a Safeguarding Adults Review.

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L Denman raised the recent evacuation of 18 residents with EMI Dementia at a Care Home due to fire issues. A de-brief was provided yesterday and there are lessons learnt from a provider point of view and these issues will be picked up accordingly.

Doncaster CCG continues to meet with Cheswold Park Hospital on a bi-monthly basis to oversee the on-going safeguarding enquiries. A discussion was held on whistleblowing and the question was raised as to whether we have appropriate processes in place to ensure whistle-blowers are safeguarded appropriately and ensure there is no discrimination. There is a sub group which explores this and makes recommendations to the Safeguarding Adults Board. Doncaster has recognised the strong linkages between issues from children and adults and has the intention through a number of its strategic partnership to work in a more integrated “whole family” all-age approach. To further this ambition, the Safeguarding Partnership has developed close structural relationships with the Safeguarding Adults Board. The Committee noted the report and the hardworking designated team who are co-ordinating appropriate activities and managing processes accordingly and the work that is on-going with all agencies in safeguarding and that we want the reporting of safeguarding concerns to be consistent and not hidden.

22. Yorkshire Ambulance Service 111/999 Update A Stothard presented the report and advised for noting is that there were four Serious Incidents (SI’s) reported for Doncaster and the following provides the breakdown of these reported by Yorkshire Ambulance Service (YAS) from January 2019 to December 2019: Accident and Emergency

• One actual/Attempted actual suicide • One treatment delay • One accident/collision

Emergency Operations Centre

• Two Treatment Delays The Committee noted the report.

23. Patient Experience update H Joerning provided an update and advised that some changes have been made to the patient investigation process for Quarter three in terms of evidence and feedback. Four complaints have been received for Quarter three and in terms of contact, an increase of 30 % has been seen since quarter two. The Patient Experience Team is continuing to signpost people accordingly and

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continues to request a copy of complaint responses from other providers.

H Joerning advised work continues to be on-going in terms of why the CCG seems to be the first point of contact for complaints in order to identify any themes/trends.

The Committee noted the update and the on-going work that is taking place.

24. Complaints Policy H Joerning presented the updated Complaints Policy for approval and talked through the amendments made. The Committee noted the amendments and were in agreement to approve the policy.

25. Commissioning Safeguarding Vulnerable People Policy The policy was presented to the Committee for approval and were advised that the policy outlines how NHS Doncaster CCG will fulfil its duty to safeguard and promote the welfare of all vulnerable clients. It is designed to ensure robust structures, systems and standards, which are in accordance with the Doncaster Safeguarding Adults Partnership and Doncaster Safeguarding Children Partnership policies and procedures. The Committee were happy to approve the policy and were aware this will be reviewed every three years or earlier should there be any significant changes.

26. Safeguarding Children and Adults Policy I Boldy presented the Safeguarding Children and Adults Policy for approval and advised the policy sets out the NHS Doncaster CCG arrangements for safeguarding and promoting the welfare of children, young people and adults at risk. The Committee approved the policy and were aware this will be reviewed every three years or earlier should there be any significant changes.

27. Care and Treatment Reviews for Children, Young People and Adults Policy S Evans presented the Care and Treatment Reviews for Children, Young People and Adults Policy for approval by the Committee. The Committee approved the policy and were aware this will be reviewed every three years or earlier should there be any significant changes.

28. Mental Capacity Act and Deprivation of Liberty Safeguards Policy I Boldy presented the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) Policy for approval and advised the policy outlines the roles and responsibilities for Doncaster CCG in respect of the MCA 2005 and DoLS 2009, with other current legislation such as the

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Mental Health Act 1983/2007 and associated decision making processes combined with MCA and DoLS Code of Practice. The Committee were in agreement to approve the policy and were aware this will be reviewed every three years or earlier should there be any significant changes.

29. Caldicott Log & Caldicott Work Plan (Exceptions) There were no issues to raise.

30. Doncaster Serious Incident Themes Report - Quarter Three A Stothard presented the report which provides information on the Serious Incident (SI) themes and trends for Quarter one, two and three 2019/2020 figures as well as providing an update on the work that is taking place around the identified themes and trends. A Stothard stated that reporting continues to be consistent across providers. The main theme of reporting is grade three pressure ulcers (19 in total). The trust has undertaken a lot of work to reduce avoidable pressure ulcer damage. Implementation of the ‘React to Red’ training is well embedded and continues to be provided. Champions on the wards provide leadership and regular audits take place.

A discussion was held regard the Blueteq High Cost Drugs System and that we need to make the process more robust moving forward.

Issues continue to be identified in regards to Ophthalmology and so this will continue to be monitored via the appropriate forums and will be raised at this meeting should there be no improvement in compliance and performance.


31. Incident Management Group Terms of Reference Terms of Reference have been developed for the Incident Management Group (IMG) and the Committee were asked to approve these. The following points were raised:

• Point 3.1 Core Members – to specify Senior Pharmacist in regards to Medicines Management Representative

• Point 11 – LeDeR to be specifically identified. • Point 14 – Disclosure/Freedom of Information Act (FOI) – it was

agreed that FOI Leads do not need to be part of the meeting.

The Committee were happy to approve the Terms of Reference.

M Booth left the meeting at this point.

32. Corporate Risk Register and Escalation of Risks It was noted by the Committee that Sharps Bins will continue to remain on

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the Risk Register until this has been resolved. It was agreed that there were no additional risks to be added following today’s meeting.

33. Quality & Patient Safety Committee Reporting Matrix It was agreed that there were no items to add.

34. Items to escalate to Governing Body/Executive Committee It was agreed for the following items to be escalated from today’s meeting:

COVID-19

35. Minutes of Meetings The following sets of minutes were noted by the Committee:

• Medicines Management Group (MMG) – 10.10.19, 14.11.19, 12.12.19

• Area Prescribing Committee (APC) – 24.10.19, 28.11.19 • Incident Management Group (IMG) – 13.11.19, 27.11.19, 11.12.19,

08.01.20 • Acute Clinical Quality Review Group (ACQRG) – 08.10.19,

12.11.19, 10.12.19, 14.01.20 • RDaSH Clinical Quality Review Group (CQRG) – 16.10.19,

20.11.19, 18.12.19, 15.01.20

36. Any Other Business COVID-19 – A Russell provided an update on the current situation and that the CCG continue to hold daily Doncaster Health Cell meetings, which has representatives from all key partners. The CCG are leading on the health response. The establishment of community testing is progressing and plans are in place to create communal hubs led by FCMS. Updates will continue to be provided accordingly.

37. Date and Time of Next Meeting Thursday 7 May 2020 at 9.30 am – 12.00 midday, Boardroom, Sovereign House

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Engagement & Experience Committee (EEC) Meeting Thursday 5th March 2020 from 10am – 12pm

In Meeting Room 1, Sovereign House

Present : S Whittle (Chair) Lay Member for Patient & Public

Involvement, NHS Doncaster Clinical Commissioning Group (CCG)

P Hemingway A Fitzgerald

Head of Communications & Engagement, CCG Director of Strategy and Delivery, CCG

M Pande K McGuire

G.P, South Locality Lead Patient Experience Administrator, CCG

A Edwards A Smith R Mather

Corporate Governance Manager, CCG Senior Communications & Engagement Officer, CCG Senior Communications & Engagement Officer, CCG

A Goodall

Chief Operating Officer, Healthwatch Doncaster

L Robson Public Health Theme Lead In attendance:

E Price C Keegan K Connolly

Head of Strategy and Delivery – Children and Maternity, CCG Support Officer, Strategy and Delivery, CCG Senior Corporate Services Support Officer (Minute Taker), CCG

Agenda Ref

Subject Action Required By

1. Welcome and Introductions S Whittle welcomed everyone to the meeting and introductions were made.

2. Apologies for Absence S Whittle noted apologies of absence from the following :

• A Coggan - Head of Performance and Intelligence, CCG • H Joerning - Patient Experience Manager, CCG • D Atkin - Doncaster Health Ambassador Group Chair • Dr V Joseph - Public Health Representative

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3. Declarations of Interest S Whittle reminded committee members of their obligation to declare any interest they may have on any issues arising at committee meetings which might conflict with the business of NHS Doncaster Clinical Commissioning Group (CCG). Declarations declared by members of the committee are listed in the CCG’s Register of Interests. The Register is available either via the secretary to the Governing Body or the CCG website at the following link: www.doncasterccg.nhs.uk The meeting was noted as quorate. Declarations of interest from sub committees / working groups: None declared Declarations of interest from today’s meeting: None declared

4. Minutes From Previous Meeting The minutes from the previous EEC meeting, held on 6th February 2020, were approved as a correct record.

5. Action Log Update Both the open & closed action logs were updated :

• 6 actions closed • 2 actions remain open • 5 new actions

The updated open action log will be circulated with the minutes of this meeting.

6. Notification of Any Other Business There were three further items of notification of further business for discussion.

7. Priority Areas – Deep Dive Starting Well Engagement Overview – Maternity Services E Price and C Keegan provided a summary of engagement for Maternity Services to EEC members. The national vision for maternity services across England is for them


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to become safer, more personalised, kinder, professional and more family friendly. Every Doncaster woman should have access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred on their individual needs and circumstances.

Better Births describes how maternity services should be co-produced with Maternity Voices Partnerships (MVPs). An MVP is a team of women and their families working together to review and contribute to the development of local maternity care. In order to address the above NHS Doncaster Clinical Commissioning Group embarked on an exercise to form MVPs across Doncaster, the vision is to build stronger relationships and provide a mechanism for ongoing feedback and co-design.

In January 2020 stage one of the MVPs commenced. Working across all neighbourhoods, Doncaster CCG visited Denaby, Bentley, Balby, Thorne and Central Children’s centres.

In February 2020, we attended all of our MVP groups again to reiterate the support from Doncaster CCG in the starting of the MVP partnerships. We visited a young mums group to gain their thoughts and support for the programme, as well as reaching out to community groups from a minority background (Polish as a first language)

From March 2020, the MVPs will be up and running in Doncaster. A service user chair will be appointed to lead the groups and the CCG will attend where necessary to collate the feedback from the partnership. The groups will be asked to update regularly and invited to feedback to the regional MVP groups.

Doncaster CCG is committed to providing long term support to the MVPs where they feel they need further resource.

We agreed as a CCG to spend time getting to know the women that had agreed to engage with us, not to rush any engagement and to talk openly about what was within our remit to change.

So far, the MVPs have agreed to:

• Attend meetings on a quarterly basis • Manage a [private/closed] Facebook group for the MVP • Work with DBTH and CCG to improve Local Maternity Services

in Doncaster

Our whole work plan will be 100% co-produced. Each action from the MVP will be worked into themes and from the themes an action plan will be developed. From this action plan, a lead will be identified across both the local CCG and Acute trust to drive forward change.

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We will be sharing our plans with our colleagues in Bassetlaw CCG as a mutual commissioner from the acute trust. This joined up approach will allow us to begin working more collaboratively and economically. There will also be a formal launch of the MVP via DCCG and DBTHFT communication portals.

Continuous engagement will continue into 2020/21 as the groups are very much in their infancy.

E Price to update the engagement template and inform H Harris for the annual report.

S Whittle thanked E Price and C Keegan for the very informative update and congratulated them on the engagement work they are undertaking.

E Price

8. Complaints Update K McGuire verbally advised Committee members of the following :

• Awaiting feedback to finalise written report • 4 complaints in quarter 4 around Continuing Healthcare (CHC)

assessments and outcomes

The Engagement and Experience Committee noted the update. S Whittle thanked K McGuire for the information.

9. Healthwatch Update A Goodall provided EEC members with a verbal update on Healthwatch Doncaster and highlighted the following areas:

• Veteran Friendly GP Practices 11 out of 39 practices accredited. R Mather to send information out to all GP practices and EEC members

• Patient Participation Group (PPG) and Primary Care Networks

(PCN) Pilot workshop for PPGs and PCNs

• Young Healthwatch Young Healthwatch Doncaster is developing. Currently visiting maternity units for DBTH and local care homes.

• Voices of Doncaster A project team that work together to discover and recommend the most effective structure to represent the Volantary and Community Faith (VCF) sector in Doncaster. Voices of

R Mather

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Doncaster are committed to sharing their skills, insight and experience gained over many years of working in the VCF sector. A full update will be provided at next month’s meeting.

S Whittle thanked A. Goodall for the update.

10. ICS Update A Fitzgerald provided EEC members with a verbal update on ICS. In the South Yorkshire and Bassetlaw 5 year plan, a commitment to holding public events twice a year before the guiding coalition events were made. These have been booked for Wednesday 25th March and Friday 2nd October. At the March event there will be a marketplace with stalls for the public to view, with information about each ICS workstream and hopefully, also beneficial, a stall for each place. The NHS Doncaster CCG Quarter 4 review will be circulated to EEC members once produced.

A Fitzgerald

11. SYB ICS Engagement Activities

• Gluten Free Prescribing R Mather advised EEC members a consultation company is putting together a report on gluten free prescribing on the products that are available on prescription. The finished report will go to JCOG.

• Children’s Surgery and Anaesthesia Children’s surgery and anaesthesia for under 8 year olds is in the process of being moved to Sheffield Children’s Hospital.

12. Primary Care Campaign – Midpoint Evaluation P Hemingway presented an interim summary of the reach and engagement activity undertaken so far to support and promote the Doncaster primary care campaign to EEC members. In October 2019 the CCG launched a brand new Doncaster Primary Care campaign, based on 18 months feedback, insight and intelligence. The campaign is based on six key themes – addressing issues people have raised:

• Primary Care Networks, choice and access • Health and care professionals • Choosing the right service

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• Importance of self-care • Digital apps, tools and platforms • Making the best use of primary care buildings and estates

The campaign has monthly themes and by the end of March 2020, all six themes will have been covered. The focus of the campaign for the next 18 months will be to use elements of the campaign at regular intervals to encourage behaviour change of how patients and members of the public access primary care services, as well as improving their understanding of what specific service they could/should access when they need health and care support, advice and/or treatment. The Experience and Engagement Committee were asked to note the campaign reach, along with next steps and opportunities for further development. A discussion took place around the local health bus which during February, patients in Doncaster were able to see a GP or nurse in different locations to their normal local practice.

Between 12 and 27 February, GPs and nurses took to the road and provided extra appointments on board the health bus.

Anyone registered with a local practice in Doncaster, were able to turn up and a GP or nurse were waiting to see them.

The bus was parked in 3 different locations:

• Wednesday 12 February - Doncaster Town Centre, Clock Corner, 9am to 4:30pm – successful two days – almost 40 patients seen

• Tuesday 18 and Wednesday 19 February - Carcroft, Asda Car Park, 9am to 4:30pm

• Wednesday 26 and Thursday 27 February - Mexborough Market Place, 9am to 4:30pm

The appointments on board the health bus were in addition to those offered by the More Choice, More Appointments service, where 160 extra hours of additional appointment time is available at one of five locations across Doncaster.

In addition, the health bus not only provided a base for these mobile appointments, it also helped advertise across the borough that extra appointments are available at a number of practices all year round. The Experience and Engagement Committee noted the campaign reach, along with next steps and opportunities for further development.


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• Gypsy and Traveller Project Update A business template from R Mather and V Joseph is going to JCOG in April. R Mather to link with S Chaplin from the Better Care Fund.

• Health Equity in England - The Marmot Review 10 Years On The Health Foundation commissioned Professor Sir Michael Marmot and his team at the Institute of Health Equity to examine progress in addressing health inequalities in England and propose recommendations for future action. Health Equity in England: The Marmot Review 10 Years On was published on the 10 year anniversary of the original publication of the Marmot Review. While there has been progress in some areas since 2010, there is growing evidence that health inequalities are widening and life expectancy is stalling, throughout a decade of austerity. Despite the cuts and deteriorating outcomes some local authorities and communities have established effective approaches to tackling health inequalities. The practical evidence about how to reduce inequalities has built significantly since 2010. There is considerable technical and practical experience about how to reduce health inequalities learned from some local areas. The Engagement and Experience Committee were asked to consider and discuss The Marmot Review 10 Years On Report and identify how these findings may impact patients and members of the public in Doncaster.

• Annual Report The annual report is going to Executive Committee on 18th March and to Governing Body on 7th May. It will come to EEC on 2nd April.

• Annual General Meeting A date in June is being arranged for this year’s meeting.

• Covid-19 Update An ongoing health cell takes place every day from 4pm – 5pm. Plans are in place to create communal hubs led by FCMS. Communications are being led by NHS England.

R Mather

P Hemingway

14. Date & Time of Next Meeting: Thursday 2nd April 2020 from 10am – 12pm in Meeting Room 1, Sovereign House.