AGENDA NHS Leeds CCG Governing Body Meeting · 25/07/2018 · Governing Body Meeting Date:...

AGENDA NHS Leeds CCG

Governing Body Meeting

Date: Wednesday 25 July 2018

Time: 13:15 – 17:00

Venue: Thackray Medical Museum, Beckett Street, Leeds, LS9 7LN

Please note: agenda timings are approximate

Item Description Lead Paper Time

GB 18/32

Welcome and Apologies Purpose: To record apologies for absence and confirm the meeting is quorate.

Gordon Sinclair

N

13:15

GB 18/33

Declarations of Interest Purpose: To record any Declarations of Interest relating to items on the agenda: a) Financial Interest

Where an individual may get direct financial benefit from the consequences of a decision they are involved in making;

b) Non-Financial professional interest Where an individual may obtain a non-financial professional benefit from the consequences of a decision they are involved in making;

c) Non-financial personal interest Where an individual may benefit personally in ways that are not directly linked to their professional career and do not give rise to a direct financial benefit, because of the decisions they are involved in making; and

d) Indirect Interests Where an individual has a close association with another individual who has a financial interest, a non-financial professional interest or a non-financial personal interest who would stand to benefit from a decision they are involved in making.

Gordon Sinclair

N

GB 18/34

Questions from Members of the Public Purpose: To receive questions from members of the public

Gordon Sinclair

N 13:20

GB 18/35

Minutes of the Governing Body meeting held on 23 May 2018 Purpose: To receive the minutes for approval

Gordon Sinclair Y 13:30

GB 18/36

Matters Arising Purpose: To consider any matters arising that are not considered elsewhere on the agenda

Gordon Sinclair N 13:35


GB 18/37

Action Log Purpose: To review the outstanding actions


GB 18/38

'70 Years of the NHS' a special digital programme Patient Voice – 70 Years of the NHS in Leeds Purpose: To receive a patient experience film to inform the Governing Body’s decision making

Phil Corrigan Jo Harding

N

13:45

RISK GB 18/39

Corporate Risk Register Purpose: To receive the corporate risks for review

Sabrina Armstrong

Y 14:00

GB 18/40

Governing Body Assurance Framework Purpose: To receive the Governing Body Assurance Framework for review

Sabrina Armstrong

Y 14:10

STRATEGY GB 18/41

Risk Management Strategy Purpose: To receive the risk management strategy for approval

Sabrina Armstrong

Y 14:20

GB 18/42

CCG Strategic Plan Purpose: To approve the CCG Strategic Plan

Tim Ryley Y 14:30

GB 18/43

Commissioning Transactional and Transformational Improvements in General Practice from the Leeds GP Confederation Purpose: To approve the investment relating to the Confederation Business Case

Tim Ryley Y 14:40

BREAK FOR 5 MINUTES

COMMITTEE CHAIRS SUMMARIES GB 18/44

Audit Committee – 4th July 2018 Purpose: To receive the summary for information and assurance

Peter Myers Y 15:00

GB 18/45

Primary Care Commissioning Committee – 24th May 2018 Purpose: To receive the summary for information and assurance

Sam Senior Y

GB 18/46

Remuneration & Nomination Committee – 20th June 2018 Purpose: To receive the summary for information and assurance

Sam Senior Y


GB 18/47

Quality & Performance Committee – 11th July 2018 Purpose: To receive the summary for information and assurance

Stephen Ledger Y

COMMISSIONING & FINANCE GB 18/48

Integrated Quality & Performance Report (IQPR) Purpose: To receive the IQPR and consider any issues escalated by the Quality & Performance Committee

Tim Ryley / Jo Harding

Y 15:10

GB 18/49

Finance Report Purpose: To receive the finance report for information

Visseh Pejhan-Sykes

Y 15:25

GB 18/50

CCG Financial Control, Planning and Governance Self-Assessment Purpose: To receive the assessment for information

Visseh Pejhan-Sykes

Y 15:35

GB 18/51

Chief Executive’s Report Purpose: To receive an update on key issues from the CCGs’ Chief Executive

Phil Corrigan Y 15:45

GB 18/52

Policy Approval:

i. NHSE Guidance : Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs

ii. Flash Glucose Monitoring Commissioning

Policy

iii. Anti-Fraud, Bribery and Corruption Policy

Purpose: To receive the policies for approval

Jo Harding Jo Harding Visseh Pejhan-Sykes

Y

15:55

GOVERNANCE GB 18/53

Approval of Amendments to Constitution Purpose: To approve amendments to the Constitution


GB 18/54

Questions from Members of the Public Purpose: To receive questions from members of the public

Gordon Sinclair N 16:15

GB 18/55

Forward Work Programme 2018/19 Purpose: To receive the programme

Gordon Sinclair Y

16:25

GB 18/56

Any Other Business Gordon Sinclair

N 16:30


Exclusion of the public - it is recommended that the following resolution be passed: "That representatives of the press and other members of the public be excluded from the remainder of the meeting, having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest" GB 18/57

Confidential Minutes of the Governing Body held on 23 May 2018 Purpose: To receive the minutes for approval


GB 18/58

Approval of Full Procurement Plan 2018/19 Purpose: To receive the full procurement plan for approval

Visseh Pejhan-Sykes

Y 16:40

GB 18/59

Unplanned Care and Rapid Response Strategy Purpose: To receive an update on the strategy and approve the proposed approach to procurement

Sue Robins Y 16:50

Items for Information IFI1. West Yorkshire & Harrogate Joint Committee of Clinical

Commissioning Groups

Gordon Sinclair Y

Dates of Future Meetings: Wednesday 26 September 2018, 2pm Wednesday 28 November 2018, 2pm Wednesday 30 January 2019, 2pm Wednesday 27 March 2019, 2pm

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Agenda Item: GB 18/44 FOI Exempt: No

NHS Leeds CCG Governing Body

Date of meeting: 25 July 2018

Title: Chair’s Summary – Audit Committee meeting held on 4 July 2018

Lead Governing Body Member: Peter Myers, Lay Member and Chair – Audit Committee

Category of Paper Tick as

appropriate

()

Report Author: Peter Myers, Lay Member and Chair – Audit Committee

Decision

Discussion

Information

Approved by Lead Governing Body member (Y/N):

EXECUTIVE SUMMARY:

This report provides the NHS Leeds CCG Governing Body with a summary of items discussed and outcomes and risks identified at the Audit Committee meeting held on 4 July 2018.

RECOMMENDATION: The Governing Body is asked to: (a) RECEIVE the report.

Description of key items of business discussed and key outcomes

1. Please note that this is a brief summary of the items considered and decisions taken at

the meeting of the Audit Committee meeting held on 4 July 2018. Further information can be obtained by reference to the minutes of that meeting.

Finance

2. The Committee considered the latest CCG Financial Position. Balanced plans have been submitted to NHS England (NHSE), with a city-wide Quality, Innovation, Productivity and Prevention (QIPP) target of 3%. A key risk continues as QIPP remains unachieved. For 2018/19, a risk reserve is held to mitigate this; however, the CCG’s financial position moving forward is untenable without the realisation of QIPP.

3. Members were informed that there is a risk that the Agenda for Change pay increases

will not be funded for CCGs. The estimated cost for 2018/19 is £662,000. A paper will be brought to the next Audit Committee meeting, detailing running costs, to be subsequently discussed at EMT and Governing Body. The Committee noted the risk with the CCG’s ability to absorb the pay increases.

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4. With regards to Commissioning for Value (CfV), the Committee was informed that 89

projects have been identified. It was anticipated that 10-15 would progress. All of the projects will be examined to ascertain financial benefits. The target for the Programme is £34m. External audit was satisfied with the figure, but queried how the process would be implemented.

5. Members received an update regarding HMRC issues. The CCG is awaiting a response from the HMRC concerning the review of Leeds West CCG payments to Governing Body members via GP Practices and the outstanding PAYE liability and National Insurance payments. A provision for the potential liability was made in the 2017/18 accounts. Further potential VAT liabilities have been provided for in the 2017/18 accounts relating to the Kier lead provider framework contract.

6. Members were updated on International Financial Reporting Standard 16 (IFRS 16)

Accounting for Leases, which will come into effect in 2019/20. As implications are potentially significant, NHS bodies are being encouraged to start preparing for changes immediately. Prior to Governing Body on 25 July 2018, consideration will be given to the need to add Accounting for Leases to the risk register.

7. With regards to Financial Control, Planning and Governance Self-Assessment for Quarter 1 2018/19, Financial Control had been identified as amber, while QIPP and CSU Support were red.

Risk Management

8. The Committee received an overview of the risk management process and an update

on current risk. Of 53 active risks, three have been reduced to amber and two have a risk score of red 16. These are:

Risk 532: Commissioner and/or Lead provider fails to achieve the operational standard for the 18 week Referral to Treatment Time;

Risk 339: Cancer under-achievement of 62 day urgent GP referral to treatment standard overall at LTHT

9. Members received the draft Risk Management Strategy for Leeds CCG. It was agreed

that a discussion on risk appetite should be included in the Governing Body’s work plan for the year.

Internal Audit

10. The Committee received an update on progress against the Internal Audit Plan and

approved proposed amendments to the timings of some audits. Two audits had been issued as final: Contract Management as Significant Assurance and Primary Care Incentive Scheme (LWCCG QIPP) as Limited Assurance. With regards to the latter, the Committee expressed concern that GP Practices had received full payment of £706,119 prior to evaluation and signing off by the Primary Care Commissioning Committee (PCCC). Members agreed that this issue would be highlighted to PCCC.

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11. With regards to Internal Audit Recommendations, 19 recommendations are open, nine

of which have revised target dates. Six of these relate to the Business Continuity Plan, with the remaining two being the Information Governance Training Strategy and Adult Continuing Healthcare. The Committee was informed that the last recommendation regarding Quality Assurance had recently been completed.

External Audit

12. The Committee received the External Audit Fee of £57,500. Members reviewed the required Annual Audit Letters for the three predecessor CCGs. No concerns were raised.

Counter Fraud

13. The Committee discussed the Counter Fraud Progress Report for 2018/19. Members were informed of an investigation into an allegation of fraud at a GP surgery in the CCG area. The loss has involved the surgery’s funds and not NHS monies.

14. Members reviewed the Annual Counter Fraud Report 2017/18 and discussed two standards that had been partially met.

15. The draft Counter Fraud Plan for 2018/19 was approved by the Committee. Pharmacy fraud was identified as an emerging risk. Provision has been made for fraud training for Governing Body members.

Policy Review

16. The Committee reviewed the Anti-Fraud, Bribery and Corruption Policy and recommended approval by the Governing Body.

Governance

17. The Committee received the Registers of Interests, Gifts & Hospitality and Procurement Decisions.

18. The Committee received details of one procurement waiver over £100,000.

Audit Committee Forward Work Programme 2018/19

19. Members were informed that the External Audit Plan and Fee would be produced in February 2019.

Strategies/Policies approved

The Audit Committee:

recommended the approval of the Risk Management Strategy to the Governing Body

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recommended the approval of the Anti-Fraud, Bribery and Corruption Policy to the Governing Body.

Items of positive assurance or issues to be raised with the NHS Leeds Governing Body

The Audit Committee highlighted the following:

failure to achieve the QIPP requirement remains a risk

the CCG’s ability to absorb the Agenda for Change pay increases as a risk

the full payment of £706,119 made to GP Practices in May 2018, prior to full evaluation of the Incentive Schemes and the signing off by the PCCC

the outstanding Audit Recommendations relating to Business Continuity, Adult Continuing Healthcare and the Information Governance Toolkit

Prior to Governing Body on 25 July 2018, consideration will be given to the need to add Accounting for Leases to the risk register.

Any additional comments

There are no additional comments.

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Title: Chair’s Summary – Primary Care Commissioning Committee meeting held on 24 May 2018

Lead Governing Body Member: Sam Senior, Lay Member and Chair – Primary Care Commissioning Committee


appropriate

()

Report Author: Sam Senior

Decision

Discussion

Information


EXECUTIVE SUMMARY:

This report provides the NHS Leeds CCG Governing Body with a summary of items discussed and outcomes and risks identified at the Primary Care Commissioning Committee meeting held in common on 24 May 2018.


Description of key items of business discussed and key outcomes

1. Please note that this is a brief summary of the items considered and decisions taken at

the meeting of the Primary Care Commissioning Committee (PCCC) meeting held in common on 24 May 2018. Further information can be obtained by reference to the minutes of that meeting.

General Practice Forward View (GPFV) Delivery Plan Update

2. The Committee was updated on the 10 high impact changes in the GPFV Delivery Plan. These are based on reports aiming to release time to care. Clinical navigation was discussed which involves training reception staff to direct patients to the appropriate services.

3. Currently, 82% of the Leeds population has some form of extended access services.

There is confidence that the target of covering 100% of the population will be reached. There was a discussion regarding how the 12 hubs will link with Local Care

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Partnerships and Neighbourhood Teams.

Equitable Funding Review Update

4. The Committee was presented with the Equitable Funding Review, which agreed that the current modelling in each CCG be rolled forward into 2018/19 with a proportion based on a City-wide formula. Members approved the principles of the scheme.

Estates Summary

5. The Estates Summary identified total demand as requiring £1m annually. Of the 36 proposals, 14 were recommended for approval. The Committee approved the recurrent costs of £469,000, noting the VAT, as recommended by the Primary Care Estate group.

Individual Practice Update

6. Members were informed that Radshan Medical Centre has now completed its closure, with all patients being allocated to practices less than two miles away.

7. A number of expressions of interest have been received for Swillington Health Practice.

8. Cottingley Surgery has been issued with a temporary contract with Alternative Provider

Medical Services (APMS) until September 2018, when the practice will become Bramley Village Health and Wellbeing Centre.

9. The Committee was informed that evaluations for Middleton Park Surgery and New Cross Surgery were now closed. A consensus meeting had been scheduled for the end of May 2018.

10. The Highfield Medical Centre has been taken over by a new partnership and will be re-inspected. It will be changing its name to Bramley Village Health and Wellbeing Centre. The contract has been amended.

Primary Care Integrated Quality Performance Report (IQPR)

11. The Committee was informed that the IQPR had been renamed Practice Quality Improvement Dashboard. A Care Quality Commission (CQC) update had identified 97% of practices as Good or Outstanding, with 2% Requiring Improvement and 1% as Inadequate.

Primary Care Finance Update

12. The Committee was informed that the final finance report for 2017/2018 had been approved. The report noted an accrual of £1.3m for provision around a LIFT building. The budget for management charges has been devolved to NHS Property Services.

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Revised Risk Report

13. The Committee requested that two additions be made to the risk register: the date when the risk was added; and a commentary box including a timeline indicating how the risk is being managed. The Committee will be cited on all current risks; high amber and red will be brought to the Committee for review.


Items of positive assurance or issues to be raised with the NHS Leeds Governing Body

Julianne Lyons (JL) declared financial professional interest in her capacity as a General Practice partner at a member practice and confirmed her future attendance as a non-voting member at PCCC meetings. As this represented a direct conflict of interest, which is recorded on the register of interest, JL agreed to remove herself from the table and not be involved in the decisions around agenda items 18/10 and 18/11.

Any additional comments

THIS PAGE IS INTENTIONALLY BLANK

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NHS Leeds CCG – Governing Body Meeting


Title: Chair’s Summary of the Remuneration & Nomination Committee meeting held on 20 June 2018

Lead Governing Body Member: Samantha Senior, Lay Member – Primary Care Co-Commissioning / Deputy Chair


appropriate

()

Report Author: Laura Parsons, Head of Corporate Governance & Risk

Decision

Discussion

Information

Approved by Lead Governing Body member (Y/N): Y

EXECUTIVE SUMMARY:

1. This report provides the Governing Body with a summary of items discussed at the Remuneration and Nomination Committee meeting held on 20 June 2018.


Description of key items of business discussed

Ratification of Urgent Decisions The Committee ratified a number of urgent decisions which had been approved, in relation to pay for some clinical posts, pay for the Senior Strategic Adviser post which was temporary up to the end of July 2018 and a payment in lieu of notice. Agenda for Change Pay Award The Committee received a summary of the nationally negotiated pay proposals for staff employed on Agenda for Change terms and conditions. Members were made aware of the potential financial risk of meeting the pay award, should the CCG’s allocation not be increased to account for this. In relation to employees not on Agenda for Change terms and conditions, the Remuneration and Nomination Committee have already agreed salaries and it was confirmed that there was no intention to revisit this during 2018/19. However, pay will be reviewed for 2019/20. Benchmarking data relating to clinical Governing Body members will be provided at the next meeting, alongside the gender pay gap report. The Committee also agreed to receive an update in relation to the Agenda for Change Pay Award.

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Compulsory Redundancy Business Case A compulsory redundancy business case was approved.


N/A

Items of positive assurance or issues to be raised with the NHS Leeds CCG Governing Body N/A

Any other Comments

N/A

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Title: Chair’s Summary of Quality & Performance Committee Meeting held on 11 July 2018

Lead Board Member: Dr Steve Ledger, Lay Member, Assurance and Chair – Quality & Performance Committee


appropriate

()

Report Author: Dr Steve Ledger, Lay Member, Assurance and Chair – Quality & Performance Committee

Decision

Discussion

Information

Approved by Lead Board member (Y/N): Y

EXECUTIVE SUMMARY:

1. This report provides the NHS Leeds CCG Governing Body with a summary of items discussed, outcomes and risks identified at the Quality & Performance Committee meeting held on 11 July 2018.


Description of key items of business discussed

1. Please note that this is a brief summary of the items considered and decisions taken at the meeting of the Quality & Performance Committee on 11 July 2018. Further information can be obtained by reference to the minutes of that meeting.

Actions from Previous Meetings

2. The Committee received assurance that the West Yorkshire and Harrogate Joint Committee now have a risk register in place and this will be reported through the Chief Executives report to the Governing Body.

3. The Committee received a further update in relation to the Equality Delivery System as the previous meeting had concluded there was limited assurance on the paper provided. The Committee was assured that equality work outside the EDS2 workstreams would be reported through the annual Public Sector Equality Duty report. Additional assurance and clarification was provided to the Committee and it was agreed that the update now provided reasonable assurance.

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Integrated Quality & Performance Report (IQPR)

4. The Committee was informed that the performance against Referral to Treatment Time continues to be marginally under the standard of at least 92% of patients beginning treatment within 18 weeks of referral. NHS Leeds CCG has oversight of a detailed recovery plan and has confidence that this is being actioned.

5. Members were informed that a recent CQC unannounced visit to Leeds Teaching Hospitals Trust (LTHT) has resulted in a rating of ‘requires improvement’ for St James’s Hospital. The overall rating for the Trust remains at ‘good’. The Clinical Quality Review Group (CQRG) will monitor the actions taken and seek assurance from the Trust. The Committee is in receipt of the minutes from this group for information at each meeting.

6. It was agreed that the Leeds System Recovery Plan and the Leeds System Winter Plan would be added to the forward plan for the September Quality & Performance Committee.

Providers Under Enhanced Surveillance

7. The Committee received a summary of the providers that were currently under Routine+ Surveillance, Enhanced Surveillance and Formal Action, and the actions being taken as a result.

CCG Risk Register 8. The risk register was presented. The Committee noted that the full risk register provides

controls and assurances.

9. In relation to red risk 339 (62 day cancer target performance for LTHT), the Committee registered continuing concern regarding the lack of improvement in the late referrals into LTHT from other trusts. Members were informed that the West Yorkshire Association of Acute Trusts (WYAAT) would provide support alongside the Cancer Alliance to try and improve performance.

Patient Experience Framework

10. The Committee received the Patient Experience Framework for approval and was informed that the framework provides an overview of the processes that are in place to collate, review and analyse patient experience feedback.

11. Members acknowledged the framework as an excellent piece of work to encapsulate everything into one place, highlighting the difference between patient experience and patient engagement.

12. The Committee was assured that the impact of the patient experience framework will be evidenced through the quarterly patient experience update report which would be presented to the Quality & Performance Committee.

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Patient Experience Quarter 4 Update

13. The Committee received the quarterly patient experience update report for quarter 4.

Members suggested that it would be helpful to align the information to the IQPR and suggested triangulation through performance, safety and quality.

14. Members noted that this was an evolving report but were very supportive of the format and content.

Commissioning for Value Framework

15. The Committee received a progress update in relation to the Commissioning for Value Programme. Members considered the key areas that they would like to see at Quality & Performance Committee in future reporting and how the Committee are sighted on quality impacts within future proposals.

16. The Committee recognised that quality impact assessments should now be completed for all business cases through the Commissioning for Value process.

17. Members acknowledged that the direct line of assurance from the Commissioning for Value Delivery Board is to the Governing Body, however the Quality & Performance Committee would seek assurance that suitable and robust processes are in place for assessing the quality impact of schemes.

18. It was agreed that further discussion in relation to quality improvement would be discussed at the October Governing Body Workshop to influence the forward work programme and the Committee noted the progress made to date.

Care Home Quality Update

19. The Committee was assured that all of the 14 recommendations within the internal audit action plan had now been completed, full assurance had been gained and the surveillance tool is in place.

Information Governance Update

20. The Committee received a summary update on Information Governance and General Data Protection Regulation (GDPR) compliance within the CCG.

21. Members were informed that two thirds of staff have now been trained on GDPR and further sessions have been set up to capture remaining staff members.

22. One area of concern was highlighted in relation to the Information Asset Register, however the Information Governance team would be meeting with Directors to take this piece of work forward.

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23. The Committee was informed that 83% staff had completed Information Governance training which was above the 80% target, however the aim would now be 90%. The Committee acknowledged that the report provided reasonable assurance.


N/A

Items of positive assurance or issues to be raised with the NHS Leeds CCG Governing Body

The Committee wishes to highlight the following issues:

Reasonable assurance had been gained in relation to the Equality Delivery System

Full assurance had been gained in relation to the Care Home Quality Audit

Any other Comments

It was agreed that a discussion should take place via the Director of Nursing & Quality with Healthwatch regarding their possible role on the Quality & Performance Committee.

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Date of meeting: 25th July 2018

Title: The Integrated Quality and Performance Report

Lead Governing Body Members: Sue Robins, Director of Commissioning Jo Harding, Director of Nursing and Quality


appropriate

()

Report Author: Various

Decision

Reviewed by EMT/SMT/Date: n/a

Discussion

Reviewed by Committee/Date: Quality & Performance Committee, 11th July 2018

Information

Checked by Finance (Y/N/N/A - Date): n/a


Leeds Health & Wellbeing Strategy Outcomes – that this report relates to

1. People will live longer and have healthier lives

2. People will live full, active and independent lives

3. People’s quality of life will be improved by access to quality services

4. People will be actively involved in their health and their care

5. People will live in healthy, safe and sustainable communities

Corporate Impact Assessment: Does the Report have any of the following key implications? - Insert brief commentary or refer to body of report or N/A

Statutory/Legal/Regulatory/Contractual requirements

N/A

Financial Implications N/A

Communication and Involvement Issues N/A

Workforce Issues N/A

Equality Issues including Equality Impact assessment

N/A

Environmental Issues N/A

Information Governance Issues including Privacy Impact Assessment

N/A

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EXECUTIVE SUMMARY:

This report provides assurance to the organisation that we are delivering against the requirements of the NHS Mandate and Constitution which embed the priorities of our local populations. Where performance falls below the expected standards, remedial action is described.

The narrative provides an update by exception on key themes and current issues and should be read in conjunction with the dashboards. The dashboards provide a high-level view of how the CCG is progressing in delivering is strategic objectives. The dashboards included with this report are:

NHS Constitution and Operational Planning

Quality and Safety

Commissioning for Quality and Innovation (CQUIN)

The indicators and metrics in each dashboard have been chosen to provide a balanced view for each sector. Please note that the metrics are flexible and may change depending on sustained performance.

NEXT STEPS:

The key actions which will be undertaken in relation to performance are as follows:

To continue to closely monitor the commissioner and provider-led actions in relation to areas of underperformance.

The key actions which will be undertaken in relation to the development of the IQPR are as follows:

To continue working closely alongside colleagues in local and citywide commissioning teams, Informatics and Quality in the development of the report and identification of local measures.

RECOMMENDATION:

The Governing Body is asked to:

a) RECEIVE AND REVIEW the IQPR dashboards; discuss the information, note the current areas of underperformance and mitigating action

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PURPOSE OF REPORT

1.1 This report provides assurance to the organisation that we are delivering against the

requirements of the NHS Mandate and Constitution which embed the priorities of our local populations. Where performance falls below the expected standards, remedial action is described.

1.2 The narrative provides an update by exception on key themes and current issues and should be read in conjunction with the dashboards. The dashboards provide a high-level view of how the CCG is progressing in delivering is strategic objectives. The dashboards included with this report are:

NHS Constitution and Operational Planning

Quality and Safety


1.3 The indicators and metrics in each dashboard have been chosen to provide a balanced view for each sector. Please note that the metrics are flexible and may change depending on sustained performance.

2. SUMMARY OF KEY PERFORMANCE ISSUES

2.1 Planned Care and Long Term Conditions

Referral to Treatment Time performance continues to be marginally under the standard of at least 92% of patients beginning treatment within 18 weeks of referral. The focus at Leeds Teaching Hospitals NHS Trust (LTHT) continues to be on outpatient improvements and the restarting of more elective surgery after the shortage in bed capacity in previous months.

The number of patients waiting in excess of 52 weeks for treatment (since being referred) continues to increase predominantly due to capacity issues post-winter 2017/18. We anticipated this position and submitted an increasing trajectory (until June-18 - a forecasted high of 75 patients) as part of the NHSE planning round for 2018/19. LTHT are exploring surgical opportunities with other local NHS providers and are attempting to address staffing constraints to create additional capacity to address the backlog in certain specialties. Surgical waits for spinal surgery has continued to grow although capacity from the Independent Sector has been identified.

Capacity shortfalls during March and April (linked to a variety of issues including bank holidays, snow days and other staffing shortages) led to both two week wait cancer standards not being achieved. Almost 60% of all 2-week breaches were for patients urgently referred for evaluation/investigation of "breast symptoms" (where cancer was not initially suspected). There are significant workforce shortages nationally in breast imaging, which has made it very difficult to source additional capacity to catch up. Saturday clinics without imaging for young patients and male patients where imaging is not routinely required are now being delivered and

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advanced nurse practitioners are picking up a wider caseload to help ease this pressure.

A range of issues impacted upon the three 62-day cancer measures during April-18, each contributing a small number of breaches across a wide range of specialties. Individual pathway recovery plans have been drafted for all Clinical Service Units and are monitored by the LTHT Cancer Board.

All LTHT services are now available on the electronic referral system (e-RS) other than a remaining few cancer pathways which will be published by 9th July. LTHT will then be ‘Paper switch off’ compliant (a requirement for the end of September-18). We will continue visits to practices with high levels of non-compliance to support in system improvement.

2.2 Unplanned Care

The operational standard for A&E waiting times is that 95% of patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department. However, in February 2018 NHS England announced a temporary suspension of the standard and issued guidance outlining a requirement to achieve 90% between April and September 2018, "...with the majority of providers achieving the 95% standard for the month of March 2019, and that the NHS returns to 95% overall performance within the course of 2019". Therefore, we are currently monitoring performance against a 90% standard. In May 2018, Leeds Teaching Hospitals NHS Trust achieved the required 90% performance standard.

Winter 2017/18 highlighted some significant challenges facing the Leeds system in terms of capacity, demand and process across the system. With a particular focus on improving whole system flow the Leeds System Recovery Plan has been developed and agreed by the System Resilience Assurance Board and the Partnership Executive Group. The plan brings together all partner agencies with the aim returning people to their homes as soon as it is safe to do so promoting recovery and improving their experience.

In April-18, Yorkshire Ambulance Service (YAS) failed to meet the 7-minute average for responding to calls from people with life-threatening illnesses or injuries. However, they did manage to respond to this category of call within 15 minutes for 90% of all calls of this type received. YAS failed to meet both the 18-minute average response target and 40-minute response target for 90% of emergency call types. YAS ambulance turnaround times across Yorkshire are reported to be lowest in Leeds due to robust systems and processes at both LTHT sites.

YAS have reviewed the impact of the Ambulance Response Pilot (ARP) and are now planning operational reviews to implement the identified actions to improve delivery. Actions include the implementation of a lower acuity transport fleet to free up resource for emergency calls.

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2.3 Mental Health and Learning Disabilities

The national standard for Improving Access to Psychological Therapies (IAPT) access in 2018/19 is for 19% of the prevalent population to access the service in the reporting year. This equates to almost 1.6% of this population accessing IAPT support each month (approximately 1,600 - 1,700 people). In April 2018, less than 1,100 people accessed IAPT support in Leeds. This is due to workforce capacity being below the level required to reach this target.

To address the current level of underperformance, we have implemented a recovery plan with the service provider. Action includes supporting staff to make swift and efficient clinical decisions in the hub and ameliorating system barriers to efficient working and introducing an online self-booking option which negates the needs for patients to go via the screening hub to access step 2 support (now live). Longer-term, the service will be re-procured for a start date of October-19 which will also support in addressing current capacity issues.

IAPT recovery underperformance in April-18 was the result of a large number of patients who had not responded to invites to commence treatment being discharged from the service. Had this exercise not taken place, performance would have continued to be above 50%. The waiting time for support at step 3 was lengthy and believed to be the reason why people were not responding to offers of support. Therefore, additional resource has been commissioned by the CCG to reduce the waiting time to start treatment.

2.4 Children’s and Maternity

Both waiting times for referrals to the eating disorder services measures met the desired performance levels in Q4 of 2017/18 for Leeds North and Leeds South and East CCGs. Due to small numbers, performance has been suppressed for this quarter for Leeds West CCG.

2.5 Continuing Healthcare (CHC)

Leeds CCG did not achieve the required performance associated with the two Continuing Healthcare Quality Premium measures in 2017/18. Referrals have increased by up to 50% of historical levels and with an increase in frail elderly patients being cared for in outlying wards there has also been an increase in inappropriate referrals for patients whose level of need is low and are unlikely to be CHC eligible, increasing unnecessary workload. The New National Framework provides clearer explanation of when not to complete a Checklist / referral for CHC, therefore training all frontline Health and Social Care staff will commence from August in the use of the new CHC tools.

Until patients can be transferred out of hospital to assess for long term care need / CHC, achieving the required level of performance will remain a challenge. Reduced care home with nursing capacity especially for some conditions further challenges achievement. A trial of the 5Q care test tool commenced 25th June. This is a clinical tool that enables early identification of potential NHS responsible patients that can then be transferred to Community Care Beds.

6

2.6 Neighbourhood Care

Community Care Beds are currently significantly under occupancy with almost 20% of bed capacity being available. This appears to be an exception not just in 18/19 to date, but also when taking into account previous years. There has been full occupancy in the majority of providers between December 2017 and April 2018, however occupancy levels have been lower with some provides due to temporary closures and demobilisation of patients under the old contract.

Commissioning leads are working closely with contract leads to consider where benefits could be realised. For example providers meeting the costs of additional 1:1s as a result of significant savings from FYE. Further work is being undertaken to analyse this year’s seasonal variation in order to mitigate in future.

2.7 Proactive Care and Population Commissioning

Whilst we have continued to make slow but steady progress in the existing PHB cohorts and Continuing Health have plans in place to make PHB the default delivery model from March 2019, we are actively exploring extending the PHB offer to new cohort groups, including end-of-life and mental health S117 patients. As part of the personalisation agenda for Leeds we are working with the health and care partnerships team to look at opportunities for expanding PHBs across the city. We are working with the service lead to explore opportunities to offer PHB’s to service users who access renal dialysis transportation.

Leeds Wheelchair Service has started to offer Personal Wheelchair Budgets (PWBs) from 1st April 2018. A phased approach to implementation has been adopted, starting with face-to-face clinics. Approximately half of all new referrals are managed via the telephone and PWBs will be offered via this route once HR changes and training are complete. Once fully implemented, the PHB numbers will significantly increase to approximately 300 new PHBs per quarter, thereby enabling us to meet our March 2019 target (540 PHBs).

3. COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) – 2017/18 Q4 UPDATE

3.1 The CQUIN scheme is intended to deliver clinical quality improvements and drive transformational change. With these objectives in mind the scheme is designed to support the ambitions of the Five Year Forward View and directly link to the NHS Mandate and it now focuses two areas covering Clinical quality and transformational indicators, and supporting local areas by providing consideration to Sustainability and Transformation Plans.

3.2 NHS England has revised the guidance for 2018-19 national CQUIN scheme. The revised guidance has clarified the year 2 data indicators and has suspended the proactive and safe discharge indicator on the basis that there are multiple initiatives supporting the discharge agenda. The money available for this CQUIN indicator has been split for LTHT across their other CQUIN indicators and for LCH a new indicator regarding the transition from children’s to adults mental health services has been agreed. The 0.5% risk reserve CQUIN has been withdrawn and included in the engagement CQUIN.

7

3.3 Leeds Teaching Hospital NHS Trust has met all CQUIN indicators by end of quarter 4 with

two exceptions. CQUIN 1a, improvement of health and wellbeing of NHS Staff, was only partially met. The CQUIN required a 5% point improvement in two out of three questions on the staff survey relating to staff health and wellbeing. The Trust has achieved a significant improvement of 9% in one question but unfortunately did not achieve a 5% increase in either of the other two questions and therefore only part payment will apply.

3.4 CQUIN 2, reducing the impact of serious infection (antimicrobial resistance and sepsis), was the other indicator not to be fully achieved. There are four elements to this CQUIN two of which were met, one was partially met and one was not met. The challenges in achieving the requirements of 2b, timely treatment of sepsis in ED, have previously been highlighted by the Trust and the national debate about the appropriateness of the one hour goal continues. Whilst it is recognised that prompt treatment is important literature shows that good outcomes can still be achieved even if the one hour target is not met. However, it is recognised that extended delays, particularly beyond four hours is far from ideal and the Trust is focusing hard on consistently achieving the one hour target.

3.5 Progress during the year has been noted and the number of patients receiving IV antibiotics within one hour has improved from 61% in Q1 to 77% in Q4, against the CQUIN target of 90%. The current ‘median wait’ for IV antibiotics within ED is 41 minutes and 57 minutes for inpatient wards. During Q4 a piece of work was undertaken to better understand the reasons for delays in administering antibiotics and the results are currently with the NHS Improvement Academy for analysis.

3.6 The second indicator of CQUIN 2, reduction in antibiotic consumption, was not met. The Trust submitted mitigating circumstances due to the in-year challenges experienced by all hospitals in England. The most commonly used IV antibiotic in England became unavailable from April to July 2017, then at a much reduced level since then. There have not been enough alternatives in the supply chain to permanently switch to alternatives. Many of the solutions have meant using two or three antibiotics in place of piperacillin-tazobactam, which has made meeting the total antibiotic and carbapenems reduction targets challenging. Nationally, only 32% of acute trusts were meeting the CQUIN for total antibiotic at Q3 and 50% for carbapenems.

3.7 Due to the evidence submitted the CCG has accepted the mitigating circumstances and not applies a financial penalty for not achieving this CQUIN indicator.

3.8 Leeds Community Healthcare NHS Trust met all of the CQUIN indicators for Q4 except for 1a, which was partially met. One question on staff experiencing MSK problems achieved the 5% point increase required but the second question relating to health and wellbeing only achieved a 4% point increase and therefore partial payment was applied.

3.9 Leeds and York Partnership Foundation Trust fully achieved one of the CQUINS in Q4. For CQUIN 1a (staff health and wellbeing) only one of the three staff survey questions evidenced a 5% point increase. Indicator 1c, improving uptake of front line clinical staff, was also only partially met as the performance threshold was not achieved resulting in only a 25% payment.

8

3.10 Goal 3, improving physical healthcare to reduce premature mortality in people with serious

mental illness (PSMI), was partially met. National audit results evidenced that community services performance met the threshold for 100% of payment and inpatient performance met the threshold for 75% payment, therefore a 25% penalty payment was applied. The development of a shared care protocol between the Trust and primary care is being developed and ongoing discussions to overcome the obstacles continue with support from the CCG.

3.11 Goal 5, transitions out of children’s and young people’s mental health services, was only partially met but no financial penalty was applied due to evidence of mitigating circumstances. This is a joint CQUIN between the sending organisation (Leeds Community Healthcare NHS Trust – LCH) and the receiving organisation (Leeds and York Partnership NHS Foundation Trust). The issues flagged have since been addressed and this is now within LCH contract as a CQUIN for 2018/19.

3.12 Preventing ill health by risky behaviors (alcohol and tobacco), goal 9, overall was partially met. Three out of the two indicators were met but smoking screening and advice underachieved, a partial penalty was achieved. The Trust has an appointed physical health lead to focus the prevention work as part of this CQUIN.

3.13 The CCG has implemented a revised internal CQUIN approval process to ensure that CQUIN milestone submissions and approval are within a set timescale and financial penalties, where applicable, are applied consistently. This process has been approved by all providers and will ensure input from clinical governance, quality, commissioners, contractors and finance teams.

4. NEXT STEPS

4.1 The key actions which will be undertaken in relation to performance are as follows:

To continue to closely monitor the commissioner and provider-led actions in relation to areas of underperformance.

4.2 The key actions which will be undertaken in relation to the development of the IQPR are as

follows:

To continue working closely alongside colleagues in local and citywide commissioning teams, Informatics and Quality in the development of the report and identification of local measures;

5. RECOMMENDATION


a) RECEIVE AND REVIEW the IQPR dashboards; discuss the information, note the

current areas of underperformance and mitigating action.

Indicator Tables

NHS Constitution and Operational Planning Measures Page 2‐3

Quality and Safety Page 4

Commissioning for Quality and Innovation (CQUIN) Page 5

RAG Rating

92.5%

88.0%

85.0%

Interpreting Trends

'Green' performance would be ≥ 92%

'Amber' performance would be 87.4% ≤ x < 92%

'Red' performance would be < 87.4%

Performance measures shown to be 'Amber' should still be interpreted as

underperforming ‐ a RAG rating has only been applied to serve as a visual guide

to understand how close performance is to the expected standard.

They should not be interpreted as being currently within a tolerance level.

Trend analysis is currently based upon comparing the latest performance with

the performance in the previous period.

A green arrow represents an improvement in performance

An amber arrow represents no change in performance

A red arrow represents a deterioration in performance

The Integrated Quality and Performance Report

Report Period: April 2018

Contents

Report Key

Note: The RAG rating applied within this report is based upon calculating a limit

of 5% higher/lower relative to the expected standard/target.

For example, if the expected Standard is a minimum of 92%...

Measure Period Target Leeds

North

Leeds S&E Leeds

West

Leeds Leeds (YTD) Leeds

Trend

NHS Constitution

RTT ‐ Incomplete Pathway Apr‐18 92% 90.9%

RTT ‐ 52 Week Waits Apr‐18No more

than 2344

Diagnostic Waiting Times Apr‐18 99% 99.4%

Cancer ‐ 2 Week Wait Apr‐18 93% 80.3%

Cancer ‐ 2 Week Wait (Breast) Apr‐18 93% 37.0%

Cancer ‐ 31 Day First Treatment Apr‐18 96% 97.8%

Cancer ‐ 31 Day Surgery Apr‐18 94% 97.3%

Cancer ‐ 31 Day Drugs Apr‐18 98% 100.0%

Cancer ‐ 31 Day Radiotherapy Apr‐18 94% 100.0%

Cancer ‐ 62 Day GP Referral Apr‐18 85% 82.2%

Cancer ‐ 62 Day Screening Apr‐18 90% 79.2%

Cancer ‐ 62 Day Upgrade Apr‐18 90% 71.9%

A&E

A&E Waiting Times: % 4 hours or less (LTHT ‐ All Types of A&E) May‐18 90%* 90.2%

AmbulanceAmbulance Calls Closed by Telephone Advice

(Hear & Treat ‐ YAS Trust Total From Sept17 onwards)Jan‐18 7.2% 7.0%

Incidents Managed Without Need for Transport to A&E

(See & Treat ‐ YAS Trust Total From Sept17 onwards)Jan‐18 23.5% 22.7%

Mental Health

Dementia ‐ Estimated Diagnosis Rate May‐18 66.7% 73.3%

IAPT Access (YTD) Apr‐18 1.6% 1.0%

IAPT Recovery Apr‐18 50% 49.4%

IAPT Waiting Times ‐ 6 Weeks Apr‐18 75% 92.5%

IAPT Waiting Times ‐ 18 Weeks Apr‐18 95% 99.2%

EIP ‐ Psychosis treated within two weeks of referral Apr‐18 50% 85.0%

Waiting Times for Routine Referrals to CYP Eating Disorder Services ‐ Within 4

Weeks (Rolling 12 Months)2017/18 Q4 60% 96.0% 90.6% * * n/a

Waiting Times for Urgent Referrals to CYP Eating Disorder Services ‐ Within 1

Week (Rolling 12 Months)2017/18 Q4 95% 100.0% 100.0% * * n/a

Other Commitments

e‐Referral Coverage May‐18 80% 85.6%

Personal Health Budgets (per 100,000) ‐ YTD 2017/18 Q436.1

(Leeds)22.3 16.2 16.5 17.8

Children Waiting no more than 18 Weeks for a Wheelchair 2017/18 Q4 92% 90.9% 93.3% 94.7% 93.7% 95.2%

Extended access at GP services (Full Provision) May‐18100% by

Oct 201873.0%

LD Patient Projections

Reliance on Inpatient Care for People with LD or Autism ‐ CCGs (All Length of

Stays)2017/18 Q4 18 21

Reliance on Inpatient Care for People with LD or Autism ‐ CCGs (Length of

Stay of 5 Years and Over)2017/18 Q4 n/a 10

Reliance on Inpatient Care for People with LD or Autism ‐ NHSE All Length of

Stays)2017/18 Q4 23 20

Reliance on Inpatient Care for People with LD or Autism ‐ NHSE (Length of

Stay of 5 Years and Over)2017/18 Q4 n/a 10

NHS Constitution and Operational Planning MeasuresPerformance Measures (1 of 2)

Measure Period Target Leeds

North

Leeds S&E Leeds

West

Leeds Leeds (YTD) Leeds

TrendQuality Premiums (QP)

Cancers diagnosed at early stage (detected at stage 1 and 2)12 months to

2016/17 Q4

54.9%

(Leeds)54.6% 52.8% 53.6% 53.6%

Overall experience of making a GP appointment 2017/18 Q4 tbc 74.5% 69.6% 78.7% 74.9%

NHS CHC eligibility decision made within 28 days 2017/18 Q4 >80% 49.6% 57.9% 57.1% 55.1% 56.0%

Full NHS CHC assessments taking place in an acute hospital setting 2017/18 Q4 <15% 21.3% 24.4% 27.3% 24.5% 16.5%

Recovery rate of people accessing IAPT services identified as BAME Mar‐1843.1%

(Leeds)57.1% 54.6% 55.6% 55.6% 51.6%

Proportion of people accessing IAPT services aged 65+ Mar‐189.7%

(Leeds)3.1% 6.7% 2.0% 3.6% 4.2%

Whole health economy ‐ E. coli blood stream infections (12 months) Apr‐18 481 44

Whole health economy ‐ collection and reporting of a core primary care data

set for all E coli BSI from Q2 2017/18‐ n/a

Antibiotic prescribing for UTI in primary care ‐ Trimethoprim: Nitrofurantoin

prescribing ratio*

12 months to

Mar 20180.67 0.39 0.40 0.33 0.37

Antibiotic prescribing for UTI in primary care ‐ number of trimethoprim items

prescribed to patients aged ≥70 years*

12 months to

Mar 201811,803 1,787 2,585 2,660 7,032

Prescribing in primary care ‐ items per STAR‐PU*12 months to

Mar 20181.161 0.987 1.090 0.929 1.002

Reported to estimated prevalence of hypertension (%) 2017/18 Q457.6%

(Leeds)58.0% 60.0% 55.0% 57.5%

No data currently available

NHS Constitution and Operational Planning MeasuresPerformance Measures (2 of 2)

in period YTD in period YTD in period YTD in period YTD

Patient Safety

Serious Incidents n/aApril ‐ May

201813 13 7 7 12 12 5 5

Never Events n/aApril ‐ May

20182 2 0 0 0 0 0 0

Mortality Rate (Standardised Hospital Mortality Index) 1.00Oct‐16 to

Sep‐170.992

MRSA Blood Stream Infection 0 Apr‐18 0 0

Clostridium difficile Infection (YTD)

(* CCG)249 Apr‐18 25 25

Classic Safety Thermometer (Harm Free Care) 94.0% May‐18 95.0% No Data 99.0%

Mental Health Safety Thermometer (% feeling safe) 88.1% May‐18 88.4%

Patient Experience

Friends and Family Test (% recommended) ‐ A&E 86.7% Apr‐18 87.7% 87.7%

Friends and Family Test (% recommended) ‐ Inpatient 95.8% Apr‐18 92.9% 92.9%

Friends and Family Test (% recommended) ‐ Outpatient 93.9% Apr‐18 94.2% 94.2%

Friends and Family Test (% recommended) ‐ Maternity Antenatal 96.8% Apr‐18 97.6% 97.6%

Friends and Family Test (% recommended) ‐ Maternity Birth 97.2% Apr‐18 97.4% 97.4%

Friends and Family Test (% recommended) ‐ Postnatal Ward 95.0% Apr‐18 93.0% 93.0%

Friends and Family Test (% recommended) ‐ Postnatal Ward (Community) 97.9% Apr‐18 100% 100%

Friends and Family Test (% recommended) ‐ Mental Health 88.8% Apr‐18 90.4% 90.4% 83.3% 83.3%

Friends and Family Test (% recommended) ‐ Community 95.6% Apr‐18 95.8% 95.8%

Friends and Family Test (% recommended) ‐ See and Treat/Non‐Conveyance (YAS) 90.2% Apr‐18 No Data No Data

Friends and Family Test (% recommended) ‐ Patient Transport Service (YAS) 90.9% Apr‐18 No Data No Data

Complaints ‐ Total Received n/a Mar‐18 846 14 204 14 212 15 858 YAS

Staffing

Staff Turnover variable Apr‐18 no data no data 12.50%11.8%

(YAS)

Sickness variable Apr‐18 4.10% no data 4.80% 7.07% YAS

Performance Measures

Quality and Safety

Measure Target /

Nat Av

Period LTHT LCH LYPFT Other*

National Measures

Improving staff health and wellbeing

Improvement of health and wellbeing of NHS staff 2017/18

Healthy food for NHS staff, visitors and patients 2017/18

Improving the uptake of flu vaccinations for frontline clinical staff 2017/18

Reducing the impact of serious infections

Timely identification of patients with sepsis in emergency departments and acute inpatient settings 2017/18 Q1 Q2 Q3 Q4

Timely treatment of sepsis in emergency departments and acute inpatient settings 2017/18 Q1 Q2 Q3 Q4

Assessment of clinical antibiotic review between 24‐72 hours of patients with sepsis who are still

inpatients at 72 hours.2017/18 Q1 Q2 Q3 Q4

Reduction in antibiotic consumption per 1,000 admissions 2017/18 Q1 Q2 Q3 Q4

Improving physical healthcare to reduce premature mortality in people with serious mental illness (PSMI)

Improving Physical healthcare to reduce premature mortality in people with SMI: Cardio Metabolic

Assessment and treatment for Patients with Psychoses2017/18 Q1 na na Q4

Improving Physical healthcare to reduce premature mortality in people with SMI: Collaboration with

primary care clincians2017/18 na Q2 Q3 Q4

Improving services for people with mental health needs who present to A&E

Improving services for people with mental health needs who present to A&E 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Transitions out of Children and Young People’s Mental Health Services

Transitions out of Children and Young People’s Mental Health Services (CYPMHS) 2017/18 Q1 Q2 Q3 Q4

Offering Advice and Guidance

Advice & Guidance 2017/18 Q1 Q2 Q3 Q4

e‐Referrals

e‐referrals 2017/18 Q1 Q2 Q3 Q4

Supporting proactive and safe discharge

Supporting proactive and safe discharge 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Preventing ill health by risky behaviours – alcohol and tobacco

Tobacco screening 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Tobacco brief advice 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Tobacco referral and medication 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Alcohol screening 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Alcohol brief advice or referral 2017/18 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Improving the assessment of wounds

Improving the assessment of wounds 2017/18 Q1 Q2 Q3 Q4

Personalised care and support planning

Personalised care and support planning 2017/18 Q1 Q2 Q3 Q4

Ambulance conveyance

Proportion of 999 incidents which do not result in transfer of the patient to a Type 1 or Type 2 A&E

Department2017/18

NHS 111 referrals

Local Measures

End to End Reviews 2017/18

Mortality Reviews 2017/18

Patient Transport Service Patient Portal 2017/18

Operational Pressures Escalation Levels Framework 2017/18

High Volume Service Users 2017/18

Patient Education 2017/18

Partially met

Met

Met

Partially met

Met

Partially met

Met

Partially met

Q3 Q4

Q1 Q2 Q3 ‐

Partially met

One Medical Group

(Walk‐in Clinic)

Q1 Q2 Q3 ‐

Mental Health Ambulance

Yorkshire Ambulance Service

Measure Period Acute


Measure Period

Community Care Home

Partially met

Met

Partially met

N/A

The Leeds Alliance

(co‐located services)

(unavailable)

Q1 Q2

Q4Q3Q2Q1

Q1 Q2 Q3 Q4

1

Agenda Item: GB 18/49 FOI Exempt: N

NHS Leeds CCG Governing Body Meeting


Title: Finance Report for 3 months ended 30th June 2018

Lead Governing Body Member: Visseh Pejhan-Sykes


appropriate

()

Report Author: Judith Williams

Decision

Reviewed by EMT/SMT/Date: N/A

Discussion

Reviewed by Committee/Date: N/A

Information

Checked by Finance (Y/N/N/A - Date): N/A










Financial Implications

Communication and Involvement Issues

Workforce Issues


Environmental Issues


2

EXECUTIVE SUMMARY: This report provides an update on the financial performance of NHS Leeds Commissioning Groups for the three months to 30th June 2018 and the expected outturn position for the 2018-19 financial year. The CCG is currently forecasting a breakeven position and is on target to achieve key financial targets, but a key risk is that QIPP targets, totalling £34.3m, are not met. Resources are being put into the Commissioning for Value programme to ensure that there is a robust process in place to review all commissioning expenditure and monitor QIPP plans. For 2018-19 a risk reserve is held to mitigate this however the CCG's financial position moving forward is untenable without the realisation of this QIPP requirement. In year, 2018/19, running costs budgets have been set at £14.6m, against an allocation of £17.4m. A condition of the merger of the 3 Leeds CCGs was a 20% (£3.48m) recurrent reduction in running cost expenditure to support system transformation. The required part year effect savings in 2018/19 total £2.84M (16.3%), and the CCG is on target with in year budgets to achieve this. However, moving into 19/20 and beyond, as a result of the costs of national pay award, the CCG will need to identify further recurrent resource of £0.7M. The Department of Health and Social Care (DHSC) have indicated that there will be £20M of additional resource to support NHS England/CSUs and CCGs to fund the pay award, based on expected fair shares of the £20M it is expected that the additional funding will be insufficient to cover the expected cost. The prime reason for this is the need to fund ‘incremental drift’ (the cost of staff progressing through agenda for change grade increments) After allowing for the estimated DHSC support, the required saving from 2019/20 is expected to be in the region of £0.5M (3.5%) of existing structures/costs. The Governing Body is requested to support the need to identify a 3.5% recurrent saving on running costs from 2019/20 and delegate the management of this to the CCG Executive Management Team.

NEXT STEPS: Updates on the 2018-19 financial position will continue to be presented to the Governing Body and/or Executive Management Team (EMT) on alternate months to ensure that the CCGs’ financial position is formally reported and reviewed each month under the CCGs’ governance arrangements.

RECOMMENDATION: The Governing Body is asked to:

(a) NOTE the Month 3 financial position (b) SUPPORT the need to identify a 3.5% recurrent saving on running costs from

2019/20 and DELEGATE the management of this to the CCG Executive Management Team

(c) DISCUSS, COMMENT and HIGHLIGHT ACTIONS required to progress and report to the next meeting of the Executive Management Team

NHS Leeds Clinical Commissioning Group

Finance Report for the Three Months ended 30th June 2018

Page 1

Financial Performance Report 30th June 2018

NHS Leeds Clinical Commissioning Group At 30th June 2018 At Year End

2018-19 RAG RAG

CCG Expenditure does not exceed planned level GREEN GREEN

Programme spend less than allocation GREEN GREEN

Running costs spend less than allocation GREEN GREEN

Delegated Co-commissioning less than allocation GREEN GREEN

Planned Surplus in year GREEN GREEN

QIPP RED AMBER

Clear identification of risks against financial delivery & mitigations GREEN GREEN

Delivery of Mental Health Investment Standard GREEN GREENBetter Payment Practice Code - to pay 95% of valid invoices by due date or within 30 days of

receipt of a valid invoice, whichever is later GREEN GREENCash at bank balance within 1.25% of the monthly amount requested or £250k, whichever is

greater GREEN GREENAssessment of internal and external audit opinions on the timeliness and quality of returns N/A N/A

Overview 30th June 2018

This report provides an update on the financial performance of NHS Leeds Commissioning Groups for the three months to 30th June 2018 and the expected outturn position for the 2018-19 financial

year.

The CCG is currently forecasting a breakeven position and is on target to achieve financial targets, but a key risk is that QIPP targets, totalling £34.3m, are not met. Resources are being put into the

Commissioning for Value programme to ensure that there is a robust process in place to review all commissioning expenditure and monitor QIPP plans. For 2018-19 a risk reserve is held to mitigate this

however the CCG's financial position moving forward is untenable without the realisation of this QIPP requirement.

Running costs budgets have been set at £14.6m, against an allocation for running costs of £17.4m. A condition of the merger of the 3 Leeds CCGs was a 20% (£3.5m) reduction in running cost

expenditure to support system transformation. The CCG is on a trajectory towards this over the next two years. This is at the same time as agenda for change pay rises have been agreed nationally, and

the risk that these will not be funded for CCGs. The CCG is on target to meet the part year savings in 2018-19, but cost improvement programmes will be required from 2019-20 onwards.

Page 2

Financial Position Summary 30th June 2018

NHS Leeds Clinical Commissioning Group

Revenue Expenditure 2018-19 Budget Actual Variance Budget Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000 £'000Programme Services

Acute Services 145,257 145,257 0 580,604 580,604 0 0

Mental Health Services 33,695 33,695 0 134,782 134,782 0 0

Community Health Services including Childrens Services 37,757 37,665 -91 136,934 136,920 -14 54

Continuing Care Services 13,980 13,982 1 55,922 55,782 -140 -139

Prescribing and Primary Care Services 39,619 39,619 0 158,562 158,562 0 197

Other 1,500 1,355 -145 6,068 5,590 -478 -478

Primary Care Co-Commissioning 29,242 29,242 0 111,589 111,589 0 0

Total Programme Services 301,050 300,815 -235 1,184,460 1,183,829 -631 -366

RUNNING COSTS 3,639 3,639 0 14,555 14,555 0 0

RESERVES 5,762 5,997 235 22,886 23,517 631 366

CCG Net Expenditure 310,451 310,451 0 1,221,901 1,221,901 0 0

Allocations 30th June 2018

NHS Leeds Clinical Commissioning Group Allocations

Allocations 2018-19

£'000 £'000 £'000 £'000

Opening Baseline Allocation 1,088,029 17,402 112,484 1,217,915

Subtotal Month 1 Adjustments 475 44 0 519

Subtotal Month 2 Adjustments 0 0 0 0

Subtotal Month 3 Adjustments 4,362 0 -895 3,467

Closing Allocation 1,092,866 17,446 111,589 1,221,901

M03 allocations:

Annual Variance

movement from

previous month

Year To Date Annual

As at Month 3

Running CostsCo-

commissioning

IN YEAR

ALLOCATIONProgramme

£1080k as the lead for Leeds Transforming Care Programme, as an upfront payment for net inpatient reductions from April 2016 to the March 2018 UNIFY trajectory, made on basis that if robust plan

not in place the funding will be clawed back in M04.

As advised by NHSE, £895k transferred non recurrently between Primary Care Co-Commissioning Delegated Budgets and Primary Care budgets within general programme allocation to support the GPFV

work in respect of online consultations, care navigators and an element of extended access. Additional non recurrent allocation of £1307k for extended access to General Practice for practices within

LSE and LN boundaries (LW element now within baseline).

Quarterly non recurrent allocations received for diabetes (to go to LTHT and LCH) (£169k) and latent TB work (£30k), and a number of other small allocations.

Mental health funding for liaison (£250k) and perinatal community services (£372k) received and will go to LYPFT

Page 3

Risks and Mitigations 30th June 2018

NHS Leeds Clinical Commissioning Group Allocations

Risks and Mitigations 2018-19 Full Risk Value

Description of Risk £'000Acute overperformance, 52 week waits Acute Services 11,947Transforming care partnership, out of area, elective funding, impact of agenda for change on

provider contracts Mental Health 4,232New community beds service, Equipment service,impact of agenda for change on provider

contracts Community Health 1,310

Care home fees Continuing Care 556

Prescribing, including for new community beds and no cheaper obtainable stock Primary Care 5,500

CSU Stranded costs Running Costs 200

Total Risks 23,745

Description of Mitigation £'000Contingency held 6,096

Reserves held 17,649

Total Mitigation 23,745

CCG Net Exposure 0

Risks are reviewed on a monthly basis, and are currently fully covered by the contingency and the reserves

Full Mitigation

Risk Area

Page 4

Acute Services 30th June 2018

Budget Actual Variance Budget Forecast Variance

£'000 £'000 £'000 £'000 £'000 £'000Leeds Teaching Hospitals NHS Trust 104,591 104,591 0 417,941 417,941 0

Mid Yorkshire NHS Trust 6,812 6,812 0 27,246 27,246 0

Harrogate Foundations Trust 6,781 6,781 0 27,123 27,123 0

Bradford Foundation Trust 1,309 1,309 0 5,234 5,234 0

York Foundation Trust 687 687 0 2,748 2,748 0

Other NHS Trusts 1,036 1,036 0 4,143 4,143 0

Non contract Activity 1,711 1,711 0 6,844 6,844 0

Non NHS Acute 10,599 10,599 0 42,395 42,395 0

Urgent Care 11,732 11,732 0 46,929 46,929 0

Total Acute Services 145,257 145,257 0 580,604 580,604 0

All plans are in place and data flowing as expected, we now have two months data but there is insufficient data to forecast an outturn position, refined forecasts will be available from month 4 based on

a full quarter of data.

Meetings are scheduled over the next month to ensure the Aligned Incentive Contract is working to its full potential and that staff are aware of the change of contract mechanism with Leeds Teaching

Hospitals.

AnnualYear To DateNHS Leeds Clinical Commissioning Group

Page 5

Mental Health Services 30th June 2018


£'000 £'000 £'000 £'000 £'000 £'000Leeds and York Partnership Foundation Trust 24,229 24,229 0 96,918 96,918 0

Tees Esk and Wear Valley NHS Foundation Trust 275 262 -13 1,099 1,099 0

Bradford District Care NHS Foundation Trust 40 40 0 160 160 0

Independent/Voluntary Sector/LCC 1,259 1,272 13 5,035 5,035 0

Learning Disabilities 6,607 6,607 0 26,428 26,428 0

IAPT 290 290 0 1,158 1,158 0

Mental Health Specialist Services 698 698 0 2,794 2,794 0

Mental Health NCAs 134 134 0 534 534 0

Mental Health Other 164 164 0 655 655 0

Total Mental Health Services 33,695 33,695 0 134,782 134,782 0

At Month 3, Mental health and Learning Disabilities continues to be forecast to budget. There is a financial risk regarding the Transforming Care trajectory, Elective funding and S117 approvals. We are

continually reviewing these risks and the processes surrounding these services with Commissioning colleagues.

The CCG has received a financial transfer from Specialised Commissioning of £1.080m to partly mitigate the TCP risk, however this is subject to claw back if the trajectory is not achieved. The CCG is

working in partnership with LYPFT to further understand what the CCG spends and how investments can be reshaped in the context of limited resources and competing demands for services.

NHS Leeds Clinical Commissioning Group Year To Date Annual

Page 6

Community Health Services 30th June 2018


£'000 £'000 £'000 £'000 £'000 £'000Leeds Community Healthcare NHS Trust 24,131 24,110 -21 96,440 96,440 0

Voluntary Sector/Local Authority 4,675 4,676 0 18,702 18,703 1

Community Beds 3,009 3,016 7 12,036 12,065 29

Hospices 4,492 4,413 -79 4,653 4,626 -27

Reablement 702 702 0 2,807 2,807 0

Safeguarding 181 179 -2 735 716 -19

Sub Total Community Health Services 37,190 37,096 -94 135,373 135,357 -16Children's Services excluding Continuing Care 566 570 3 1,560 1,563 2

Total Community Health Services including Childrens 37,757 37,665 -91 136,934 136,920 -14

Community beds overspend is due to the extension of the Pennington Court service to the end of July, following the phased introduction of the new community beds contract. Hospice forecast

underspend relates to an element of budget not now required, higher year to date underspend is due to budget phasing . Safeguarding underspend relates to a staff vacancy and an underspend on non

pay.


Page 7

Continuing Care Services 30th June 2018


£'000 £'000 £'000 £'000 £'000 £'000Continuing Healthcare (CHC) 8,894 8,961 67 35,575 35,842 266

Continuing Healthcare Personal Health Budgets (PHBs) 1,361 1,468 107 5,443 5,871 428

Funded Nursing Care (FNC) 2,203 2,141 -63 8,813 8,427 -386

Children Continuing Care including PHBs 357 359 2 1,429 1,429 0

Continuing Healthcare - operational 619 584 -35 2,475 2,335 -140

Neuro-rehab 547 470 -77 2,187 1,878 -309

Total Continuing Care Services 13,980 13,982 1 55,922 55,782 -140

Continuing care services are demand led services, and so forecast will fluctuate throughout the year. Overall forecasting an underspend of £140k across all areas of CHC, an increase of £57k from the

previous month. This change relates to ongoing staffing vacancies within Continuing Healthcare operational. Other forecast under/overspends are activity related, based on information available at this

point in time. Underspend on FNC is consistent with previous years. Personal Health Budgets are to become the default delivery mode for CHC homecare from April 2019, so anticipate a trend of an

increasing forecast outturn. Childrens CHC is forecast to budget based on current cases, but there is a risk that new ventilation packages will be agreed (to take children out of acute hospital care to be

cared for at home by the LCH team, however no funding follows from acute). Risk of around £200k. Neuro rehab patients are actively managed. Year to date underspend based on current caseload,

some of whom are short term and will be discharged soon increasing the forecast underspend at year end. Additional patients are forecast as and when they come in and the care plans are high cost

and so can cause significant swings.

AnnualNHS Leeds Clinical Commissioning Group

Year To Date

Page 8

Prescribing and Primary Care Services 30th June 2018


£'000 £'000 £'000 £'000 £'000 £'000Prescribing 32,003 32,004 0 128,013 128,013 0

Ex centrally funded drugs 854 854 0 3,414 3,414 0

Oxygen contract 292 292 0 1,168 1,168 0

Prescribing staff 382 382 0 1,597 1,597 0

Primary Care Schemes 5,090 5,090 0 20,362 20,362 0

Primary Care Staff 192 192 0 800 800 0

Clinical Leads 187 187 0 735 735 0

Primary Care - GP IT 618 618 0 2,473 2,473 0

Total Prescribing & Primary Care Services 39,619 39,619 0 158,562 158,562 0

Annual

Primary Care: National GP Forward View allocations are now in place for 2018-19 for extended access, care navigators and online consultations, set as a mixture of a non recurrent transfer from

Primary Care Co-Commissioning allocations, an element within the recurrent base allocation, and an additional non recurrent allocation.

Prescribing: April data has now been received and is flowing as expected through the merged Business Services Authority report. The work around setting budgets at practice level is nearly finalised

following review from GP practices, and will be input to the national system in early July.

NHS Leeds Clinical Commissioning Group Year To Date

Page 9

Other Services 30th June 2018


£'000 £'000 £'000 £'000 £'000 £'000Non acute commissioning - LIDS 193 193 0 770 770 0

Proactive Care and transformational projects 937 860 -77 3,748 3,443 -305

Cancer Projects -6 -6 0 -25 -25 0

Programme Staff - Transforming care/out of area 37 31 -6 155 147 -8

Programme Staff - Sustainability and transformation programmes 317 274 -43 1,205 1,145 -60

Programme Staff - Nursing and Quality 23 4 -20 215 111 -104

Total Other Services 1,500 1,355 -145 6,068 5,590 -478

Year To Date

Proactive care includes social prescribing (£1.6m) which currently is still in the form of 3 separate schemes, but the intention is to reprocure a citywide service from September 2019. Underspend relates

to an element of this scheme. Transformational projects includes support for Healthy Futures and the Leeds plan. Cancer projects is externally funded and so nil net budget. Underspend of £25k from

2017-18 given back through allocations process, resulting in negative budget, which will be offset when receive this years allocation but Q1 allocation has not been transferred as yet. Staffing

underspends relate to vacancies, and staff on secondment who have not been replaced.

NHS Leeds Clinical Commissioning Group Annual

Page 10

Primary Care Co-Commissioning 30th June 2018


£'000 £'000 £'000 £'000 £'000 £'000GMS 6,785 6,785 0 27,140 27,140 0

PMS 11,911 11,911 0 47,642 47,642 0

APMS 1,067 1,067 0 4,270 4,270 0

Premises cost reimbursements 5,052 5,052 0 14,933 14,933 0

Primary Care NHS Property Services Costs - GP 0 0 0 0 0 0

Other premises costs 56 56 0 222 222 0

Enhanced Services 717 717 0 2,867 2,867 0

QOF 1,897 1,897 0 7,588 7,588 0

Other GP Services(inc PCO) 1,759 1,759 0 6,928 6,928 0

Delegated Contingency 0 0 0 0 0 0

Reserves 0 0 0 0 0 0

Total Primary Care Co-Commissioning 29,242 29,242 0 111,589 111,589 0

The Primary Care co-commissioning payments are flowing and are in line with the budget set. Three Practices were missed off the PMS payment run by Primary Care Support England in June; this was

spotted and rectified by the CCG. The error was escalated to NHS England.

Year To Date AnnualNHS Leeds Clinical Commissioning Group

Page 11

Running Costs 30th June 2018

Budget Actual Variance Budget Forecast Variance£'000 £'000 £'000 £'000 £'000 £'000

Pay 2,252 1,969 -283 9,229 9,013 -216

Non Pay/Income 1,386 1,670 283 5,326 5,542 216

Total Running Costs 3,639 3,639 0 14,555 14,555 0

There are a number of vacancies at the end of June, many are in the process of being recruited to, but some will still be held at year end. Budgets have been uplifted for the recently confirmed pay

award, phased to match the way in which this will be paid. The Commissioning Support services contract with eMBED essentially ends in March 2019. A joint programme board has been set up to

manage the transition, which most likely will involve the in-housing of critical services, some of these being re-provided in partnership with local organisations in Leeds. The final merger costs and

accomodation reconfiguration costs are now coming through as expected.

As a condition of the merger, the CCG is required to achieve a recurrent 20% saving on its annual running cost allocation from 2019/20 onwards, a saving of £3.48M. The required part year effect

savings in 2018/19 total £2.84M (16.3%), and the CCG is on target with in year budgets to achieve this. However, moving into 19/20 and beyond, as a result of the costs of national pay award, the CCG

will need to identify further recurrent savings of £0.7M. The CCG is expecting increased resource from the Department of Health and Social Care however, this is unlikely to be sufficient to cover the

total impact of staff progression through Agenda for Change scale points. The shortfall is expected to be in the region of £0.5M (3.5% of pay budgets). Governing Body is requested to support the

need to identify a 3.5% saving and delegate the management of this to the CCG Executive Management Team.


Page 12

Consolidated Statement of Financial Position 30th June 2018

30th June 2018 31st March 2018

£'000 £'000

Current AssetsTrade & Other Receivables 3,727 3,556

Cash & Cash Equivalents 73 291

Total Current Assets 3,800 3,847

Total Assets 3,800 3,847

Current LiabilitiesTrade & Other Payables: (75,070) (63,132)

Borrowings 0 0

Provisions (1,423) (1,448)

Total Current Liabilities (76,493) (64,579)

Total Assets less Current Liabilities (72,693) (60,732)

Non-current LiabilitiesProvisions (1,260) (1,348)

Total Non-current Liabilities (1,260) (1,348)

Total Assets Employed (73,953) (62,080)

Financed by Taxpayers’ EquityGeneral Fund (73,953) (62,080)

Total Taxpayers’ Equity (73,953) (62,080)

Page 13

1




Title: CCG Financial Control, Planning and Governance Self-Assessment

Lead Governing Body Member: Visseh Pejhan-Sykes, Chief Finance Officer


appropriate

()

Report Author: Rosemary Reynolds, Deputy Chief Finance Officer and Judith Williams, Head of Financial & Management Accounting

Decision

Reviewed by EMT/SMT/Date: n/a

Discussion

Reviewed by Committee/Date: Audit Committee 4th July 2018

Information

Checked by Finance (Y/N/N/A - Date): Y














N/A



N/A

2

EXECUTIVE SUMMARY: The Financial Control, Planning and Governance Self- Assessment template has been designed by NHS England in conjunction with the Financial and Resilience Working Group (FRWG). The purpose of the template is to provide assurance that there are adequately designed and effective financial controls and governance processes in place to mitigate risk. The self-assessment is designed to consider the overall control environment and covers financial control, planning and governance. The assessment is required to be submitted to NHS England Area Team on a quarterly basis, reported to the next available CCG Governing Body meeting and will be used as an indicator of risk.

NEXT STEPS: The draft self-assessment for quarter 1 2018/19 had a deadline for submission to NHS England Area Team of 29 June 2018. The final submission was endorsed by Audit Committee on the 4th July, 2018. The self-assessment will be reviewed by the CCG and a draft submitted to NHS England on a quarterly basis in line with NHS England reporting requirements and will be submitted to Audit Committee for subsequent endorsement and Governing Body for information.

RECOMMENDATION: The CCG Governing Body is asked to:

(a) NOTE the CCG quarter 1 2018/19 CCG Financial Control and Governance Self–

Assessment

Period Q1 <<Select Period

Completion Overview

Assessments 52

Completed 52

Incomplete 0

Error N

Dashboard Summary % Score

Detailed Financial Planning 100%In year Financial Performance 100%

Contracts 100%

System-wide Performance 75%

Financial Control 86%

Risk Management 100%

Audit 100%

Finance & Investment Committee 100%

Governing Body (GB) 100%

Capability and Capacity 100%

PMO Function (QIPP) 67%

CSU Support 50%

Sign off details

Name Email Contact Number

Completed by Rosemary [email protected] 843 2946

Signed off by Phil Corrigan [email protected] 0113 843 5505

Signature

mailto:[email protected]


1

Agenda Item: GB 18/51 FOI Exempt: N



Title: Chief Executive Officer’s Report

Lead Governing Body Member: Phil Corrigan, Chief Executive


appropriate ()

Report Author: Phil Corrigan, Chief Executive

Decision


Discussion


Information













Workforce Issues




2

EXECUTIVE SUMMARY: Update on the Leeds Health and Care Academy The Leeds Health and Care Academy has been developed and funded by the three main NHS providers in Leeds, Leeds City Council and Leeds CCG to create one Leeds workforce with the best skills. A full report (appendix 1) has been compiled to provide an update as to how this project has been developing and the next steps. CCG Improvement and Assessment Framework (IAF) – Annual Assessment The IAF for 2017-2018 assessed the Leeds CCGs individually as we were still three statutory bodies even though working in a formal partnership. We’re delighted to say that each CCG maintained their overall status as Good (green rating). The quality of leadership was rated Green star. NHS England has commended us on maintaining our good performance over a challenging year and thanked us for our focus on making improvements for local people. Thanks go to all CCG staff for their hard work over the last year. Ratings can be viewed on the NHS England website. Contribution from Chief Finance Officer Commissioning Support Services Contract with eMBED 2018-19 constitutes the final year of the contract between Leeds CCG and eMBED commissioning support services for all service lines apart from Business Intelligence, for which the contract term runs until March 2020. NHS Leeds CCG and eMBED have already agreed Programme and Project Management arrangements to see through the options reviews and the safe transition of services into 2019-20. eMBED have already indicated that they will be flexible about the migration and transition process, and if required will run the closing of services process into Q1 of 2019-20 to ensure that services to the CCG are not interrupted. Our contract management Board governance arrangements have already commenced, with Project Management teams nominated and engaged and actions identified.. A full programme management schedule supported by a detailed business case outlining options and recommending our preferred arrangements from March 2019 will be prepared over the summer, ready for a formal decision in September. The CCG is liaising also with the West Yorkshire and Yorkshire and Humber CCGs to co-ordinate decisions and the impact of those decisions on the future of their Commissioning Support services on a wider footprint – recognising that the issue of all forms of assets currently vested in the eMBED contract will need detailed and sensitive discussions and decisions. The Governing Body will receive regular updates via the Chief Finance Officer’s reports as the Senior responsible Officer for the CCG on the project.

https://www.england.nhs.uk/commissioning/regulation/ccg-assess/iaf/

3

Contribution from Director of Operational Delivery Leeds Gypsy and travellers services (GATE) Leeds GATE are one of the eight national winners of the GSK (King’s Fund) 2018 National Impact award (ceremony last month - the award comes with a £30,000 donation, plus free training and development programme and GSK IMPACT Awards Development Network membership). Leeds GATE was the only winner in West Yorkshire and one of the two from the North of the country. Ellie Rogers from Leeds GATE said: “The work we did under the Third Sector Health Grants definitely had an impact on achieving this award and we are really chuffed the work will continue under the CCG. Thanks for all your support. “ Transforming Care Programme NHS Leeds CCG and Leeds City Council continue to work closely together to support people with learning disabilities under the national Transforming Care Programme. We have recently refreshed our joint plans and further aligned our teams. We have a programme of Care and Treatment reviews for around 42 people with learning disabilities currently within a forensic or locked rehabilitation establishment. We are also working across West Yorkshire and Leeds will lead the commissioning of a forensic outreach service for patients coming out of a forensic or locked rehabilitation facility into the community who would benefit from ongoing specialised support. Urgent Medicines supply- NUMAS Around 2% of all calls to 111 are concerning prescriptions. Across West Yorkshire we have a Pilot of NUMAS (NHS urgent medicines advanced service) running until September 2018. Patients with urgent medicines supply issues are referred by 111 to participating community pharmacies to be prescribed emergency supplies of medications. Across West Yorkshire in the last 12 months, 11,000 items have been dispensed. Bank holiday periods are particularly busy. The top three medications supplied in this way are Ventolin, Sertraline for respiratory conditions and Lansoprazole for gastrointestinal conditions. The project is currently funded through the national Pharmacy integration fund and NHSE. The project is reported through the West Yorkshire Urgent Care programme board. Contribution from Head of Communications and Engagement “TARGET” Event The CCG hosted its first city-wide primary care conference on the afternoon of 21st June 2018 at Leeds United Conference Centre. This event was organised as part of TARGET (Time for Audit, Review, Guidelines, Education and Training) and was a celebration of successful primary care collaboration. We brought together around 750 delegates from across general practice and its wider health and social care partner organisations. This was a fast-paced event which heard presentations on the day from 10 diverse projects on the themes of partnership working, social prescribing, supporting self-care and developing

4

quality improvement expertise. For the key note speech we welcomed Dr Robert Varnam, Head of General Practice Development, NHS England, who spoke about the strengths of primary care and his vision for the future. We also held a poster exhibition in order to highlight other collaborative work going on across the city; the runner up was ‘Caring Hands’ and the winner was ‘Otley Leg Club’. The event was well received and much positive feedback was captured live on social media which can be reviewed here: https://www.leedsccg.nhs.uk/target-leeds-conference-2018/. We are preparing a report to include the results of the evaluation and any impact on other services over the coming weeks. Seriously resistant campaign showcased nationally Natasha Noor and Shak Rafiq from our communication and engagement team were invited by the organisers of the antibiotic guardian conference to be keynote speakers at their annual event to talk about the seriously resistant campaign we have been running in the city. Over 100 leading figures working to combat the threat of antibiotic resistance heard more about our campaign. As a result we have been asked by a number of national organisations to share our resources as well as any insights and evaluation. In June members of the Health and Wellbeing Board added their support for the campaign. National communications development steering group Shak Rafiq, our communications manager, has been asked to take on the role of joint senior responsible owner – alongside Rachel Royall, Director of Communications for NHS Digital – for the equality and diversity workstream. This workstream will look to increase recruitment, retention and promotion of staff from a range of diverse background working as communications and engagement professionals within the NHS. The national communications development steering group has been established by NHS Improvement and NHS England as part of the communications development programme. Social prescribing Social prescribing services are currently delivered by three different schemes Connect Well (CW), Connect for Health (CFH) and the Patient Empowerment Project (PEP), which are contracted until August 2019. Once the current contracts come to an end, NHS Leeds CCG intends to commission a city wide social prescribing service model for Leeds. Engagement is being undertaken with local people to understand what they value about the service and what they would like to see improved so that future city wide service meets their needs. Frailty In Leeds approximately 32,000 people are living with frailty. As the CCG is moving towards an outcome base commissioning model we wanted to understand what outcomes matter to people living with frailty, their carers and those at end of life. With the support of the third sector organisations we engaged with 134 people living with frailty and carers. The feedback from the engagement will be used to identify an existing PROM (person-reported outcome measurement) tool or to develop a bespoke tool to measure the outcomes of care for people living with frailty, people at end-of-life and their carers. The tool will help commissioners understand if interventions are helping people to live healthier lives.

https://www.leedsccg.nhs.uk/target-leeds-conference-2018/

5

Frailty test bed NHS Leeds CCG, Bradford City CCG and Bradford District CCG are working together to bid for money to ‘test’ interconnected devices as part of the NHS innovation ‘test beds’. As part of the bid we have carried out engagement to understand the views of local people. The engagement aimed to ‘support the application to become a ‘test bed’ site by providing the bid with information about people’s experience and views on using technology to increase independence and slow the progression of frailty’. We worked with local GPs and the VCFS to identify and engage with a small group of people who are frail and their carers about their use of technology to maintain independence. We carried out interviews and focus groups across Bradford and Leeds and spoke to 19 people to develop a short report to inform the bid. If successful, we will carry out further engagement to ensure that patients and carers are involved developing the test bed site. Volunteer programme Our move to one CCG provided a good opportunity to reflect on and improve the way we support patient assurance and engagement at all levels in the CCG. The move to the CCG volunteer programme from the Patient Champion programme is a direct result of feedback from patient champions and our commissioners. Both patients and commissioners had fed back that our patient champions needed and deserved more support. We used this feedback to design the CCG Volunteer programme which ensures that all our volunteers are properly supported and mentored in any of the work they do. We’re pleased to say that we had a fantastic response to our CCG volunteer recruitment and have now recruited 12 CCG volunteers to the programme. We involved Healthwatch Leeds in the recruitment to ensure that the process was fair and transparent. The CCG believes that these people will continue the good work of our patient champions and keep patients at the heart of our decision making. Key Messages from the West Yorkshire & Harrogate Joint Committee of Clinical Commissioning Groups

The key messages from the recent meeting of the West Yorkshire & Harrogate Joint Committee of CCGs are attached at Appendix 2. Risk Management Arrangements for West Yorkshire & Harrogate Members have previously requested information relating to the risks reported at West Yorkshire & Harrogate level. The Joint Committee reviewed its refreshed assurance framework, identifying the significant risks as at 29 May 2018, at its meeting on 5 June 2018. A copy is attached at Appendix 3. There were 4 risks scored at 15 or above after mitigation:

Cancer waiting times - financial penalties

Elective care/standardisation of commissioning policies - potential resistance to proposed changes - pace of implementation

Members agreed to receive details of risks scored at 12 and above at future meetings.

6

RECOMMENDATION: The Governing Body is asked to: (a) RECEIVE the Chief Executive’s report

1

Leeds Health and Care Academy - Partner Board Briefing June 2018

1. Introduction This report has been produced by the Leeds Health and Care Academy (hereafter ‘Academy’) project and intended recipients are Boards/Executive Groups of Leeds Teaching Hospitals NHS Trust, Leeds Community Health Care Trust, Leeds & York Partnership Foundation Trust, The Leeds Clinical Commissioning Group Partnership and Leeds City Council, these being the bodies that have initially funded the project. The last update was provided in March 2018 and that provided a background to the Academy, progress of the project and specific details of the approved workstreams that the Academy will deliver. This is a new information giving report with the following aims:

a) Update the partner Board on the background to the Academy and the progress of the project to date

b) Specifically highlight the development of the Academy structure and form and the work on understanding the people and financial resources that exist in partner organisations against the Academy workstreams

c) Explain the next steps of the Academy project and how partner Boards will be engaged, both

for information and on future decisions related to resourcing 2. Vision and Values

The project has developed and approved the following vision and is founded upon the vision and values for the Academy:

Appendix 1

2

3. Workstreams

The workstreams, set out as ‘delivery’ and ‘enabling’ were approved at the Project Board on 5.2.18 and reported to LAHP Board 13.2.18.

4. Progress Since March 2018 the Academy project has:

a) Made steady progress against all of the workstreams engaging people from across the system to have outputs ready for September 2018

b) Started the process of detailed mapping of the people and financial resources that exist within each partner organisation that is aligned to each of the workstreams for when the Academy goes live and in the longer term - this process has been initiated and is being completed as a collaboration between the project team and L&D departments in partner organisations

c) Started to develop the Academy structure/form - this was discussed in detail during the Project Board meeting held on 7.6.18 where the partners reinforced their commitment to the Academy and agreed that in readiness for becoming operational the Academy should appoint a new post of Academy Director - a further discussion on this is planned for the Partnership Executive Group (PEG) on 13.7.18. This will include consideration as to how this, (and on-going transition costs) could be resourced through existing Leeds Plan funds and fit with strategic workforce capacity across the city.

3

d) Gone live with an Academy website and approved the distinct branding for the Academy which reflects our position as a Leeds Academic Health Partnership (LAHP) project and links it with the Leeds Health and Wellbeing Strategy.

e) Marketed the Leeds Health and Care Academy Conference to be held on the 18.7.18 - this will engage colleagues in learning and development roles throughout the Leeds health and care system with the development of the Academy, along with providing a networking and CPD opportunity.

5. Next Steps The project is entering a critical period as it comes towards the end of the Planning and Implementation stage - the next steps are:

a) Complete the detailed mapping of the people and financial resources that exist within each partner organisation - each organisation has been asked to have this signed off by the HR Director or another person with equivalent authority by the end of June 2018

b) Discuss the funding arrangements for the Academy Director at PEG on the 13.7.18 along with

any transitional funding to move the Academy from the Planning and Implementation stage into the Operational stage of the project

c) Consider the Academy structure/form with partners and the relevant staffing and risk share arrangements around learning and development people and budgets with a target of having these approved by the Project Board on 24.7.18

d) Develop detailed proposals and assess impact with each partner organisation for individual partner Board approval and agree timescales.

6. Recommendations The partner Board is recommended to:

a) Acknowledge progress made to date on the Leeds Health and Care Academy project

b) Note the decision in principle of the Project Board to appoint an Academy Director once funding is agreed

c) Await further information that specifies the financial and people resourcing with the objective of gaining partner Board sign off

Note

The Joint Committee has delegated powers from the WY&H CCGs to make collective decisions on specific, agreed WY&H work programmes, including mental health, urgent care, cancer and stroke. It can also make recommendations to the CCGs. The Committee supports the wider HCP, but does not represent all of the partners. Agenda papers and further information are available from the Joint Committee web pages: http://www.wyh-jointcommiteeccgs.co.uk/ or contact Stephen Gregg, Governance Lead [email protected].

West Yorkshire & Harrogate (WY&H) Joint Committee of Clinical Commissioning Groups

Summary of key decisions

Meeting held in public on Tuesday 5 June 2018

Joint Committee governance

The Joint Committee noted changes to its work plan agreed by the member practices of each CCG. The changes clarified the decisions that the CCGs had delegated to the Joint Committee.

The Joint Committee: Noted the revised Joint Committee work plan, reviewed the significant risks to the delivery of its work plan and approved the Joint Committee Annual Report.

Improving outcomes for people with CVD and diabetes

Dr Youssef Beaini, Clinical Lead, Bradford Healthy Hearts and Sue Baughan, representing the Academic Health Science Network, presented recommendations from the WY&H Clinical Forum that the CCGs work together to reduce the number of strokes and heart attacks. The work included identifying and treating people with high blood pressure more effectively and improving treatment with statins. This would help prevent long-term ill health and contribute to the WY&H target of reducing CVD incidents by 10% by 2021.

The Joint Committee recommended to the CCGs that they:

1. Adopt this WY&H-wide improvement project. 2. Identify a clinical and a project lead to work with the Clinical Lead and central project team. 3. Support the reporting arrangements to measure impact at CCG and WY&H level.

Urgent and emergency care

Martin Pursey, Head of Contracting and Procurement for Greater Huddersfield CCG, presented a recommended approach to procuring out of hours primary care medical services across West Yorkshire. The recommendation was to extend the current service to enable the service to be integrated effectively with the Integrated Urgent Care and Clinical Advisory Service.

The Joint Committee: Agreed to negotiate a direct award of contract to Local Care Direct (LCD) to expire on 31st March 2020.

Complex and severe obesity

Michelle Turner, Director of Quality for Bradford City and Districts CCGs and Programme Director for Bariatric surgery, presented recommendations from the WY&H Clinical Forum to improve outcomes for people with severe and complex obesity by commissioning more Tier 4 bariatric surgery. A collaborative approach was proposed, including a new service specification. CCGs were recommended to work towards providing surgery to 4% of those patients likely to be ‘eligible and accepting of surgery’ and work with acute trusts on how any additional capacity could be provided.

The Joint Committee recommended to the CCGs that they:

1. Have a new service specification for WY&H for Tier 4 bariatric services which the CCGs commission collaboratively once financial values have been agreed. This may include, depending on the financial implications, additional capacity.

2. Ask the West Yorkshire Association of Acute Trusts (WYAAT) to consider how to respond to a collaborative commissioning approach against a single service specification for WY&H

3. Ask WYAAT to consider how best to meet any additional capacity required from the CCGs.

http://www.wyh-jointcommiteeccgs.co.uk/

http://www.wyh-jointcommiteeccgs.co.uk/


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omm

ittee

will:

Mon

itor t

he p

rinci

pal r

isks

that

thre

aten

the

achi

evem

ent o

f the

STP

out

com

es c

over

ed b

y th

e Jo

int C

omm

ittee

’s w

orkp

lan.

Eva

luat

e th

e co

ntro

ls in

tend

ed to

man

age

thes

e pr

inci

pal r

isks

.

Eva

luat

e th

e as

sura

nce

acro

ss a

ll ar

eas

of p

rinci

pal r

isk.

Iden

tify

posi

tive

assu

ranc

es a

nd a

reas

whe

re th

ere

are

gaps

in c

ontro

ls a

nd /

or a

ssur

ance

s

Put

in p

lace

pla

ns to

take

cor

rect

ive

actio

n w

here

gap

s ha

ve b

een

iden

tifie

d in

rela

tion

to p

rinci

pal r

isks

.

Ris

ks a

re g

iven

a s

core

of 1

-5 fo

r lik

elih

ood

and

1-5

for i

mpa

ct. T

hese

sco

res

are

then

mul

tiplie

d to

giv

e th

e to

tal r

isk

scor

e. T

he

fram

ewor

k id

entif

ies

risks

with

a s

core

of 1

5 or

mor

e, a

fter m

itiga

ting

cont

rols

and

ass

uran

ces

have

bee

n ta

ken

into

acc

ount

.

Not

e:

This

is th

e fir

st ti

me

that

the

popu

late

d fra

mew

ork

has

been

pre

sent

ed to

the

Join

t Com

mitt

ee. T

o gi

ve th

e C

omm

ittee

ass

uran

ce

that

the

fram

ewor

k is

cal

ibra

ted

corre

ctly

and

is re

porti

ng ri

sks

at th

e co

rrect

leve

l, si

gnifi

cant

risk

s sc

ored

at b

elow

15

have

als

o be

en in

clud

ed in

this

firs

t ite

ratio

n.

Appe

ndix

5

2

Sum

mar

y of

risk

s 29

.05.

18

STP

outc

ome

cove

red

by

wor

k pl

an

Ris

k to

del

iver

ing

the

outc

ome

Initi

al

Scor

e Li

kelih

ood

x im

pact

(W

ithou

t co

ntro

ls)

Con

trol

s an

d as

sura

nces

Cur

rent

Sc

ore

Like

lihoo

d x

impa

ct

(With

co

ntro

ls)

Plan

ned

miti

gatin

g ac

tions

1.Jo

int C

omm

ittee

deci

sion

-mak

ing

Jo

int C

omm

ittee

dec

isio

ns

are

robu

st, w

ith a

ppro

pria

te

publ

ic a

nd p

atie

nt

invo

lvem

ent,

clin

ical

en

gage

men

t and

qua

lity

assu

ranc

e.

1.1

Dec

isio

ns ta

ken

by th

e C

omm

ittee

ar

e no

t pro

perly

and

law

fully

de

lega

ted

by th

e C

CG

s or

are

not

m

ade

with

app

ropr

iate

clin

ical

, pub

lic

and

patie

nt e

ngag

emen

t, re

sulti

ng in

le

gal c

halle

nge

and/

or re

puta

tiona

l da

mag

e.

20

(4 x

5)

M

atte

rs d

eleg

ated

to

the

Join

t C

omm

ittee

set

out

in th

e w

ork

plan

, ag

reed

by

CC

G m

embe

r pra

ctic

es in

M

ay 2

017

W

ork

plan

refre

shed

in 2

017/

18 a

nd

subm

itted

to C

CG

mem

ber p

ract

ices

for

appr

oval

.

Lay

Cha

ir an

d M

embe

rs

M

eetin

gs h

eld

in p

ublic

Cov

erin

g re

ports

to C

omm

ittee

requ

ire

PPI

and

clin

ical

eng

agem

ent t

o be

hi

ghlig

hted

.

Clin

ical

For

um p

rovi

des

clin

ical

inpu

t.

Lay

Mem

ber A

ssur

ance

Gro

up

Q

ualit

y an

d E

qual

ity Im

pact

A

sses

smen

t pro

cess

es in

eac

h C

CG

.

12

(3 x

4)

C

onfir

m to

Joi

nt C

omm

ittee

that

CC

G m

embe

r pr

actic

es h

ave

form

ally

agr

eed

refre

shed

wor

k pl

an a

nd C

omm

ittee

vot

ing

arra

ngem

ents

.

CC

G m

embe

rs re

view

the

wor

k pl

an

perio

dica

lly a

nd a

gree

any

new

mat

ters

to b

e de

lega

ted

to th

e Jo

int C

omm

ittee

.

Rev

iew

MoU

prio

r to

its e

xpiry

dat

e of

31

Mar

ch

2019

.

Est

ablis

h La

y M

embe

r Ass

uran

ce G

roup

as

a fo

rmal

par

t of t

he J

oint

Com

mitt

ee g

over

nanc

e ar

rang

emen

ts .

D

evel

op c

omm

on a

ppro

ach

to q

ualit

y an

d eq

ualit

y im

pact

ass

essm

ent a

cros

s W

Y&H

C

CG

s.

.

2.Ca

ncer

N

ew s

trate

gic

appr

oach

es

to c

omm

issi

onin

g an

d pr

ovid

ing

canc

er c

are.

2.1

Nat

iona

l con

ditio

ns im

pose

d on

re

ceip

t of 2

018/

19 C

ance

r Tr

ansf

orm

atio

n Fu

nds

base

d on

lin

kage

with

per

form

ance

aga

inst

62

day

CW

T st

anda

rd h

ave

resu

lted

in

25%

fina

ncia

l pen

alty

impo

sed

on a

t le

ast Q

1 an

d Q

2 al

loca

tions

. C

heck

poin

t bas

ed o

n M

ay/J

une/

July

pe

rform

ance

pre

sent

s op

portu

nity

to

reco

up s

ome

of th

e lo

ss o

r ris

k of

fu

rther

loss

.

25

(5 x

5)

W

ork

prog

ram

mes

for

Ear

ly d

iagn

osis

an

d Li

ving

with

and

Bey

ond

Can

cer

repr

iorit

ised

and

agr

eed

by A

llianc

e B

oard

and

NH

S E

ngla

nd.

20

(4 x

5)

C

ompr

ehen

sive

CW

T R

ecov

ery

Pla

n in

pla

ce

and

mon

itore

d by

Allia

nce

Boa

rd.

Pl

ans

repr

iorit

ised

to in

corp

orat

e al

l CW

T re

late

d de

liver

able

s in

18/

19 P

lann

ing

Gui

danc

e.

R

egul

ar lo

cal (

DC

O) a

nd re

gion

al tr

ipar

tite

cont

act t

o m

axim

ise

oppo

rtuni

ties

for l

earn

ing

and

shar

ing

good

pra

ctic

e

3.M

enta

l Hea

lth

Agr

ee a

sin

gle

oper

atin

g m

odel

for t

he m

anag

emen

t of

acu

te a

nd p

sych

iatri

c in

tens

ive

care

uni

t (PI

CU

) be

ds

A

gree

a s

tand

ard

com

mis

sion

ing

appr

oach

to

acut

e an

d PI

CU

ser

vice

s an

d a

com

mitm

ent t

o pe

er

revi

ew lo

cal c

risis

ser

vice

s.

N

o re

leva

nt ri

sks

on th

e P

rogr

amm

e ris

k re

gist

er.

.

3

A

gree

pla

n fo

r the

pro

visi

on

of c

hild

ren

and

youn

g pe

ople

inpa

tient

uni

ts,

inte

grat

ed w

ith lo

cal

path

way

s.

4.St

roke

A

gree

con

figur

atio

n of

H

yper

Acu

te a

nd A

cute

st

roke

ser

vice

s

4.1

Pro

vide

rs m

ay n

ot b

e ab

le to

im

plem

ent t

he la

test

stro

ke g

uide

lines

du

e to

lack

of a

vaila

ble

and

appr

opria

tely

ski

lled

wor

kfor

ce a

ble

to

deliv

er n

ew m

odel

s of

car

e re

sulti

ng

in v

aria

nce

in s

troke

out

com

es a

cros

s th

e W

est Y

orks

hire

& H

arro

gate

fo

otpr

int.

N

ew G

uide

lines

circ

ulat

ed to

all

mem

bers

of t

he g

roup

& im

plic

atio

ns o

f im

plem

entin

g ne

w g

uide

lines

will

info

rm

new

mod

els

of c

are

& c

are

path

way

s.

Tr

ust r

epre

sent

ativ

es a

re re

porti

ng b

y ex

cept

ion

wor

kfor

ce/o

pera

tiona

l pr

essu

res/

conc

erns

.

Ris

k sc

ores

of 1

2 w

ere

refe

renc

ed in

th

e st

roke

repo

rt to

Joi

nt C

omm

ittee

of

CC

G’s

(4/7

/17

& 7

/11/

17)

T&

F G

roup

hav

e co

ntrib

uted

to

deve

lopm

ent o

f STP

LW

AB S

trate

gy

12

(3 x

4)

LW

AB w

orkf

orce

lead

now

atte

ndin

g T&

F gr

oup

& le

adin

g th

e w

orkf

orce

wor

k st

ream

.

LWAB

wor

kfor

ce le

ad h

as re

ceiv

ed a

cop

y of

th

e st

anda

rdis

ed p

athw

ay &

wor

king

with

C

linic

al W

orki

ng G

roup

to e

nsur

e w

orkf

orce

&

care

pat

hway

dev

elop

men

ts a

re a

ligne

d. I

n ad

vanc

e of

this

they

are

liai

sing

with

clin

ical

co

lleag

ues

to g

ain

a cl

inic

al p

ersp

ectiv

e on

pr

ovid

er w

orkf

orce

prio

ritie

s fo

r act

ion.

SY&

B St

roke

Lea

d at

tend

ed T

&F g

roup

(1

6/1/

18) &

it w

as a

gree

d th

e W

Y&H

wor

kfor

ce

lead

will

liai

se w

ith S

Y&

B &

Hum

ber C

oast

&

Val

e st

roke

lead

s to

iden

tify

oppo

rtuni

ties

to

lear

n &

sha

re fr

om n

atio

nal &

Y&

H w

orkf

orce

de

velo

pmen

ts.

M

eetin

gs w

ith h

ospi

tal p

rovi

ders

con

tinue

to

dete

rmin

e th

e im

plic

atio

ns o

f im

plem

entin

g im

prov

emen

t ini

tiativ

es.

W

orkf

orce

, fin

ance

and

bus

ines

s in

tellig

ence

ou

tput

s pr

esen

ted

to T

&F 2

5/4/

18 a

nd

info

rmin

g ou

r wor

k

4.2

Hyp

er A

cute

Stro

ke s

ervi

ces

acro

ss

the

Wes

t Yor

kshi

re a

nd H

arro

gate

fo

otpr

int m

ay e

xper

ienc

e op

erat

iona

l re

silie

nce

issu

es d

ue to

inab

ility

to

recr

uit a

nd re

tain

app

ropr

iate

ly s

kille

d w

orkf

orce

dur

ing

the

trans

form

atio

n tra

nsiti

on p

erio

d re

sulti

ng in

em

erge

ncy

com

mis

sion

ing

arra

ngem

ents

bei

ng im

plem

ente

d in

ad

vanc

e of

new

mod

els

of c

are

bein

g ap

prov

ed a

nd im

plem

ente

d.

R

isk

scor

e of

12

wer

e re

fere

nced

in th

e st

roke

repo

rt to

Joi

nt C

omm

ittee

of

CC

G’s

( 7/

11/1

7)

O

pera

tiona

l res

ilienc

e is

sues

are

bei

ng

addr

esse

d vi

a ex

istin

g co

ntra

ctua

l ro

utes

via

the

Lead

CC

G.

T&

F G

roup

rece

ive

notif

icat

ion

of

oper

atio

nal p

ress

ures

& w

ill re

view

ou

tcom

e of

dis

cuss

ion

betw

een

rele

vant

pro

vide

r & L

ead

CC

G w

ith a

vi

ew to

ens

urin

g ou

tcom

e/le

sson

s le

arne

d in

form

futu

re tr

ansf

orm

atio

n op

tions

.

Loca

l/nat

iona

l dev

elop

men

ts a

re a

st

andi

ng a

gend

a ite

m to

enc

oura

ge tw

o w

ay d

ialo

gue

betw

een

orga

nisa

tion

repr

esen

tativ

es &

the

WY&

H

Pro

gram

me

deve

lopm

ents

.

Cro

ss b

ound

ary

impa

cts

are

info

rmin

g ou

r wor

k S

Y&

Bas

setla

w, H

umbe

r C

oast

and

Val

e an

d W

Y&H

Stro

ke

Lead

s ar

e in

regu

lar d

ialo

gue

to e

nsur

e op

portu

nitie

s to

lear

n an

d sh

are.

12

(3 x

4)

Fu

rther

mee

tings

hav

e be

en s

ched

uled

with

W

YAA

T co

lleag

ues

and

othe

r key

sta

keho

lder

s to

info

rm th

e ne

xt s

teps

.

4

5 Ur

gent

and

em

erge

ncy

care

Inte

grat

ed u

rgen

t car

e se

rvic

es

A

gree

the

spec

ifica

tion

and

busi

ness

cas

e (in

corp

orat

ing

futu

re

arra

ngem

ents

for N

HS

111

an

d G

P ou

t of h

ours

se

rvic

es).

A

gree

the

com

mis

sion

ing

and

pro

cure

men

t pro

cess

to

del

iver

ser

vice

s fro

m

2019

onw

ards

.

111

Pro

cure

men

t

5.1

Ris

k of

a c

halle

nge

bein

g su

bmitt

ed

due

to th

e na

ture

of t

he p

rocu

rem

ent

whi

ch c

ould

resu

lt in

a d

elay

in

times

cale

s as

soci

ated

with

del

iver

y of

th

e pr

ogra

mm

e

25

(5 x

5)

R

egul

ar d

iscu

ssio

ns to

be

held

at

stee

ring

grou

p m

eetin

gs a

nd

Pro

gram

me

Boa

rd m

eetin

gs to

mon

itor

this

on

an o

ngoi

ng b

asis

9 (3

x 3

)

Non

-con

flict

ed c

linic

ians

to b

e so

ught

to b

e in

volv

ed in

the

wor

k st

ream

gro

ups

and

the

form

al p

rocu

rem

ent p

roce

ss in

clud

ing

the

proc

urem

ent e

valu

atio

n pa

nels

and

dia

logu

e se

ssio

ns

5.2

Ther

e is

the

risk

that

the

nat

iona

l ta

rget

of 5

0% (a

s st

ipul

ated

by

NH

S

E)

will

not

be

reac

hed

20

(4 x

5)

B

idde

rs w

ill n

eed

to b

e as

ked

how

they

in

tend

to m

eet t

his

targ

et d

urin

g th

e IT

PD

sta

ge

9 (3

x 3

)

The

spec

ifica

tion

wor

kstre

am w

ill ne

ed to

ad

dres

s th

is th

roug

h th

e IT

PD

que

stio

n se

tting

an

d di

alog

ue m

eetin

gs w

ith b

idde

rs

5.3

Ther

e is

a ri

sk o

f sys

tem

inte

grat

ion

&

inte

rope

rabi

lity

(from

a c

linic

al a

nd

patie

nt p

ersp

ectiv

e) a

s th

e re

gion

al

prov

ider

will

be

requ

ired

to in

terfa

ce

with

circ

a 60

loca

l CA

S pr

ovid

ers

25

(5 x

5)

Th

e sp

ecifi

catio

n w

ill n

eed

to b

e cl

ear

on s

yste

m in

tero

pera

bilit

y. T

his

will

ne

ed to

exp

lore

d in

gre

ater

det

ail

durin

g bo

th th

e IT

PD

and

ITC

D s

tage

s of

the

proc

urem

ent

9 (3

x 3

)

The

IM&

T w

orks

tream

will

nee

d to

add

ress

this

th

roug

h th

e IT

PD

/ITC

D q

uest

ion

setti

ng a

nd

dial

ogue

mee

tings

with

bid

ders

. The

sp

ecifi

catio

n w

ill n

eed

to b

e ad

apte

d

6 El

ectiv

e C

are/

s tan

dard

isat

ion

of

com

mis

sion

ing

polic

ies

Dev

elop

and

agr

ee

com

mis

sion

ing

polic

ies,

in

clud

ing:

P

r e-s

urge

ry o

ptim

isat

ion

(sup

porti

ng h

ealth

ier

choi

ces)

;

Clin

ical

thre

shol

ds a

nd

proc

edur

es o

f low

clin

ical

va

lue;

Elim

inat

ing

unne

cess

ary

follo

w-u

ps;

E

ffici

ent p

resc

ribin

g.

6.1

Ther

e m

ight

be

resi

stan

ce to

som

e of

th

e pr

opos

ed c

hang

es fr

om s

ome

stak

ehol

ders

(e.g

. pol

itici

ans,

the

publ

ic)

25

(5 x

5)

D

evel

op a

stro

ng s

take

hold

er

man

agem

ent a

ppro

ach

as p

art o

f the

co

mm

unic

atio

ns &

eng

agem

ent

stra

tegy

Con

side

r the

nee

d fo

r con

sulta

tion

and

type

of c

onsu

ltatio

n w

here

ther

e ar

e si

gnifi

cant

ser

vice

cha

nges

requ

ired .

15

(3 x

5)

P

roac

tive

com

mun

icat

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1

Agenda Item: GB 18/52i FOI Exempt: No


Date of meeting: 25.07.2018

Title: NHSE Guidance : Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs

Lead Governing Body Member: Jo Harding, Director of Quality and Safety


appropriate

()

Report Author: Gaye Sheerman-Chase

Decision

Reviewed by EMT/SMT/Date: SMT 15.05.2018

Discussion

Reviewed by Committee/Date: Presented at CCF 28.06.2018

Information











Yes

Financial Implications Yes

Communication and Involvement Issues Yes

Workforce Issues No


Yes see section 9 of CCF paper and information below

Environmental Issues No


No

2

EXECUTIVE SUMMARY:

NHS England (NHSE) have published national policy guidance for CCGs, which recommends restricting prescribing for conditions suitable for self-care. Following approval in principle at SMT, it was recommended that the paper was presented at CCF to gain clinical support. At the CCF meeting on 28 June 2018 the NHSE guidance gained clinical support for the recommendations to be implemented in Leeds. The paper and power point that were presented at CCF are attached as Appendix 1 and 2, and they include a summary of the NHSE guideline and Leeds CCG implementation plans. The action for the Medicines Optimisation Commissioning team, agreed at that meeting: Members were supportive of the guidance. It was agreed that the potential impact on health inequalities should be clarified when the guidance is presented to the Governing Body. This paper provides additional information to address the question of the potential impact on health inequalities as requested by CCF.

NEXT STEPS: Following approval from the Governing Body to implement the NHSE guidance in Leeds we will work with all organisations represented at Leeds Area Prescribing Committee and the Communications team to formally launch the guidance citywide during September (proposed week beginning 17.09.18).


a) APPROVE the implementation of the NHSE Guidance: Conditions for which over the counter items should not routinely be prescribed in primary care; and b) APPROVE the proposed 12 month Assessment of Impact of the NHSE guidance.

3

Main Report

1. SUMMARY

1.1 CCF requested the potential impact on health inequalities should be clarified when the guidance is presented to the Governing Body.

2. BACKGROUND

2.1 . Results of the local consultation, assessment of equality impact and engagement report is available here: https://www.leedsccg.nhs.uk/content/uploads/2017/03/Prescribing-engagement-report-FINAL-VERSION-1.pdf

2.2 NHSE undertook wide ranging public consultation before publishing their guideline. This is covered in the document : Conditions for which over the counter items should not be routinely prescribed in primary care: Equality and health inequalities full analysis form, which is available at: https://www.england.nhs.uk/publication/conditions-for-which-over-the-counter-items-should-not-be-routinely-prescribed-in-primary-care-equality-and-health-inequalities-full-analysis-form

3. PROPOSAL

3.1 For clarification the sections of the NHSE guidance relevant to reducing the risk of health inequalities which will support clinicians and the residents of Leeds, state there are situations where general exceptionality exists, in particular : “Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care.”

“Individual patients where the clinician considers that their ability to self-manage is compromised as a consequence of medical, mental health or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected, if reliant on self-care. To note that being exempt from paying a prescription charge does not automatically warrant an exception to the guidance. Consideration should also be given to safeguarding issues.”

3.2 The guidance contains other general exceptions, and includes clinical exceptions in individual conditions; please refer to the full guidance or the attached power point for details.

https://www.leedsccg.nhs.uk/content/uploads/2017/03/Prescribing-engagement-report-FINAL-VERSION-1.pdf


https://www.england.nhs.uk/publication/conditions-for-which-over-the-counter-items-should-not-be-routinely-prescribed-in-primary-care-equality-and-health-inequalities-full-analysis-form



4

3.3 Members of CCF requested clarification of the situation for care home residents. It is the view of the Medicines Optimisation team that they will not be adversely impacted by this guidance as the care homes already have “Homely Remedy “ policies which allow them to administer some items which are covered by the guidance (with authorization from the persons general practitioner). As the residents in general would not be able to access other items covered by the policy, and the staff are not able to purchase such items on the patients behalf, any items not included on the Homely Remedy Policy would be prescribed by the relevant health care professional.

3.4 Members of CCF also requested clarification regarding the situation for children attending

nurseries and schools. The recommendation in these cases is that OTC products can be administered in these situations using the directions agreed with the child’s parent or guardian they do not need to prescribed by a clinician. The aim here will be to work with nurseries and Education Leeds to ensure they are aware of the changes in OTC product prescribing recommended in the guidance, and that they therefore update their current templates/ standard policies to reflect the changes in national guidance.

4. NEXT STEPS

4.1 Following approval from the Governing Body to implement the NHSE guidance in Leeds we will work with all organisations represented at Leeds Area Prescribing Committee and the Communications team to formally launch the guidance citywide during September. The communications team have recommended the week beginning 17 September 2018

4.2 We propose to assess the impact of implementing the guidance after 12 months. This will include a review of prescribing levels of the items included in the guidance and an assessment of the impact on prescribers and their patients.

. 5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 As per CCF paper 6. FINANCIAL IMPLICATIONS AND RISK 6.1 Implementation of the guidance should reduce the prescribing spend on OTC products in

Leeds and in the longer term it is believed that increasing the residents ability and confidence around self-care will reduce the demand on primary care for appointments for minor conditions, or where self-care is appropriate, which will allow clinical time to be spent more appropriately on Long Term Condition (LTC) management etc.

7. COMMUNICATIONS AND INVOLVEMENT 7.1 As per CCF paper

5

8. WORKFORCE N/A

9. EQUALITY IMPACT ASSESSMENT 9.1 As above 10. ENVIRONMENTAL N/A .

11. RECOMMENDATION

The Governing Body is asked to: a) APPROVE the implementation of the NHSE Guidance: Conditions for which over the counter items should not routinely be prescribed in primary care; and b) APPROVE the proposed 12 month Assessment of Impact of the NHSE guidance.

1

Appendix 1

Agenda Item: CCF18/09 FOI Exempt: N

NHS Leeds CCG Clinical Commissioning Forum Meeting

Date of meeting: 28th June 2018

Title: NHS Leeds CCG response to the publication of ‘NHSE Guidance for CCGs: Conditions for which over the counter items should not routinely be prescribed in primary care’

Lead Governing Body Member: Jo Harding, Executive Director of Quality & Safety


appropriate

()

Report Author: Gaye Sheerman-Chase, Gillian Chapman

Decision

Reviewed by EMT Date: 15.5.18

Discussion


Information



Joint Health & Wellbeing Strategy Outcomes – that this report relates to








Yes, possibly, see section 5

Financial Implications Yes, possible reduction in prescribing cost

Communication and Involvement Issues Yes, see section 7



Yes, see section 9



N/A

2

EXECUTIVE SUMMARY: NHSE have published national policy guidance for CCGs, which recommends restricting prescribing for conditions suitable for self-care. Following approval in principle at EMT, this paper is to inform the forum of the recommendations made in the above NHSE guidance and to gain clinical support for the recommendations to be implemented in Leeds. A summary of the NHSE guideline and Leeds CCG implementation plans are included in the attached presentation.

OTC ppt_v4.pptx

NEXT STEPS: The Commissioning Medicines Optimisation Team (CMOT) proposes to implement the NHSE guidance in Leeds without adaptation. The policy will apply across the city including out of hours services, community clinics, services run by Leeds Community Healthcare and Leeds City Council. Leeds Teaching Hospitals will apply the guidelines where feasible in A+E and outpatients.

To minimise the impact on patients, prescribers, GP practice staff and other healthcare professionals the CCG will have a co-ordinated implementation plan for Leeds including a comprehensive communications strategy and support for GP practices.

RECOMMENDATION: The Clinical Commissioning Forum is asked to:

(a) INPUT and COMMENT on the implementation in Leeds of national NHSE

recommendations contained in the document ‘Conditions for which over the counter items should not routinely be prescribed in primary care’.

3

1. SUMMARY 1.1 Following approval in principle at EMT, this paper is to inform the forum of the

recommendations made in the NHSE guidance ‘Conditions for which over the counter items should not routinely be prescribed in primary care’ and to gain clinical support for the recommendations to be implemented in Leeds.

1.2 In order to make best use of NHS resources and to promote self-care, rather than reliance

on GP services, some CCGs across England have already introduced local restrictions on the prescribing of over the counter (OTC) medicines for minor conditions. The objective of the NHSE guidance is to support CCGs in their decision-making in this area, to address unwarranted variation, and to provide clear national advice to make local prescribing practices more effective. NHSE expects CCGs to take individual decisions on implementation locally, ensuring they take into account their legal duties to advance equality and have regard to reducing health inequalities.

1.3 The guidance states that NHSE ‘expect CCGs to take the proposed guidance into

account in formulating local polices, unless they can articulate a valid reason to do otherwise, and for prescribers to reflect local policies in their prescribing practice’.

1.4 Details of NHSE guidance for CCGs is here: https://www.england.nhs.uk/wp-

content/uploads/2018/03/otc-guidance-for-ccgs.pdf 2. BACKGROUND 2.1 To date Leeds CCG has not implemented any policy to restrict prescribing of OTC

medicines but, during 2016, Leeds North CCG (LNCCG) lead on this area of work and produced the document “Guidance to reduce prescriptions for minor conditions, other conditions suitable for self-care, gluten free products and branded prescribing” as part of the Leeds wide STP work. It proposed encouraging self-care for conditions where treatment is not required, and restricting prescribing for minor conditions suitable for OTC treatment (broadly similar to the conditions included in the NHSE guidance).

2.2 The CCG undertook extensive local consultation about their proposal and 82% of the 3200

responders agreed that GPs should not routinely prescribe OTC medicines; however, implementation has been on hold pending publication of the NHSE guidance.

2.3 The Leeds proposal “Guidance to reduce prescriptions for minor conditions, other

conditions suitable for self-care, gluten free products and branded prescribing” is available here: https://www.leedsccg.nhs.uk/content/uploads/2017/03/OTC-guidance-document-FINAL-2.pdf

Comparison of The Leeds OTC Guidance and the NHSE guidance

Leeds guidance NHSE guidance 1. Covers conditions suitable for self-care.

Conditions included that are not covered 1. Includes 33 minor conditions where

treatment either not required, or the

https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf

https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf

https://www.leedsccg.nhs.uk/content/uploads/2017/03/OTC-guidance-document-FINAL-2.pdf

https://www.leedsccg.nhs.uk/content/uploads/2017/03/OTC-guidance-document-FINAL-2.pdf

4

by NHSE are: a. Vaginal thrush (the MOT still

consider this could be a suitable condition, for cases fitting criteria for OTC sale)

b. Scabies c. Gluten Free (GF) food

condition is suitable for self-care using OTC medicines.

GF prescribing is not in scope of this guidance

2. Exceptionality: Very limited general exception guidance. There is a general statement on exceptionality, recommending it should be based on ‘clinical factors and not be influenced by socio-economic aspects such as the ability to purchase’.

2. Covers general exceptionality in some detail, but is clear that entitlement to free prescriptions does not imply exceptionality. Allows exceptionality ‘where the clinician considers that (the patient’s) ability to self-manage is compromised as a consequence of social, medical or mental health vulnerability’. Also clearly lists clinical exceptions in individual conditions.

3. Included products of little clinical value that should not be prescribed. Products included that are not covered by NHSE are:

a. Camouflage cosmetics

3. Recommends restrictions on probiotics and vitamin and mineral supplements.

4. Generic prescribing. Includes a statement that generic drugs will be prescribed unless there is a clinical or financial reason (including branded generics).

4. Not in scope of this guidance

2.4 New legislation is expected to enforce restrictions in gluten- free food prescribing later this

year and restrictions on camouflage cosmetics need to be included in wider discussions around the General Cosmetics Exceptions and Exclusions policy. The Medicines Optimisation Provider Team will work with Practices to ensure that the most cost effective medicines are prescribed, whether they be generics or branded generics, to support best use of NHS funds. Potential generic savings reports from NHSBSA will be monitored by the commissioning MOT.

Scope

2.5 All primary care services will be expected to adhere to the guidelines once implemented, including out of hours services through Local Care Direct, the Minor Injuries Units, Walk in Centres and Community clinics. Services run by Leeds Community Health or Leeds City Council will also be included.

Leeds Teaching Hospitals will apply the guidelines where feasible in A+E and outpatients. In- patients will continue to have all medication prescribed, but continuation of the prescription will need to be reviewed once discharged.

2.6 Minor Ailment and Pharmacy First schemes: The Pharmacy First Scheme contract ends 31.3.19 and will be reviewed prior to that date. The Minor Ailment Scheme is managed by NHSE. In the interim period qualifying people may continue to get medicines free of charge via these schemes.

5

2.7 The intention is that the CCG will review the Pharmacy First contract for 2019-20 and conditions that are covered by the NHSE guidance will not be included in future contracts.

3. PROPOSAL

3.1 The Commissioning Medicines Optimisation Team (CMOT) proposes to implement the

NHSE guidance without adaptation 4. NEXT STEPS 4.1 Implementation

To minimise the impact on patients, prescribers, GP practice staff and other healthcare professionals the CCG will have a co-ordinated implementation plan for Leeds including a comprehensive communications strategy and support for GP practices. The CCG has set up a task and finish group to oversee implementation strategy, including representation from the Medicines Optimisation Teams, senior LCH and LTH pharmacists, the clinical lead for Medicines Optimisation and a representative from Community Pharmacy West Yorkshire.

1. NHSE have indicated that they will be producing a range of national resources to aid prescribers and inform the public over the coming months. To date 29.5.18 a Quick Ref Guide for HCPs has been released.

2. The CMOT and Communications Team intend to wait for national resources to become available rather than produce local resources. Further local adaption of national materials can be made if required.

3. Guidance will be put on to Leeds Health Pathways and the internet for ease of access for practice and community pharmacy staff. This will include:

a. Addition of an ‘OTC’ page on Leeds Health Pathways (LHPs) b. The majority of commonly prescribed OTC medicines will be made GREY – ‘Not to

be routinely prescribed for conditions suitable for self-care’ eg antihistamines. c. Some OTC medicines with little evidence to support their use will be classified as

Black Light eg. Urine alkalising sachets for cystitis d. Adding links to the OTC page from individual medicines entries on the LHPs Traffic

Light List. e. Information on licensing of OTC medicines to ensure GPs are aware of situations

where an OTC sale is not permitted. E.g. beclomethasone nasal sprays may only be sold to adults over 18 years. (NB NHSE is also producing support on this).

f. Links to printable advice for the public for conditions included in the guidance. g. A Frequently Asked Questions function to clarify any points as they are raised.

4. In Primary Care Optimise Rx messages will trigger messages on clinical systems to remind

prescribers of Traffic Light classification, OTC policy and exemptions relevant to individual products.

4.2 Timescale

https://www.england.nhs.uk/wp-content/uploads/2018/05/over-the-counter-quick-reference-guide.pdf


6

Timescale for implementation will be dependent upon:

Date of final approval by NHS Leeds CCG

When NHSE supporting materials become available

Production of launch materials for Leeds in conjunction with Communications Team

When guidance on LHP for clinicians and the public can be put in place When all resources are in place we plan to launch citywide at a date agreed with Leeds Area Prescribing Committee (LAPC).

5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 GPs may have concerns that implementing this policy will compromise their contractual

obligation to provide treatment for their patients. The GMC has published a view on the GP position in referring a patient for self-care: ‘Prescribing’ is used to describe many related activities, including supply of prescription only medicines, prescribing medicines, devices and dressings on the NHS and advising patients on the purchase of over the counter medicines and other remedies. It may also be used to describe written information provided for patients (information prescriptions) or advice given. https://www.gmc-uk.org/-/media/documents/Prescribing_guidance.pdf_59055247.pdf If a patient complained to NHS England that their GP practice was not prescribing something they needed, and the GP practice was implementing NHS England’s own guidance, we don’t see how they could be criticised.

6. FINANCIAL IMPLICATIONS AND RISK 6.1 The cost of prescribing on medicines that could be used to treat the conditions covered in

the guidance will be tracked from EPACT data and a decrease in spend would be expected. Total spend for the three Leeds CCGs from March 17 to February 18 was £3.7million, however it is difficult to predict the size of the expected reduction at this point, due to the uncertain impact of the NHSE general exceptions.

7. COMMUNICATIONS AND INVOLVEMENT 7.1 NHSE have indicated that they will be producing a range of national resources to aid

prescribers and inform the public over the coming months. To date (29 May 2018) a Quick Ref Guide for HCPs has been released.

The Commissioning Medicines Optimisation Team and Communications Team intend to wait for national resources to become available rather than produce local resources. Further local adaption of national materials can be made if required.

Guidance will be put on to Leeds Health Pathways (and the internet) for ease of access for practice and community pharmacy staff. This will include:

a. Addition of an ‘OTC’ page on Leeds Health Pathways (LHPs) b. Adding links to the OTC page from individual medicines entries on the LHPs Traffic

Light List.



7

c. Information on licensing of OTC medicines. d. Links to printable advice for the public for conditions included in the guidance. e. A Frequently Asked Questions function to clarify any points as they are raised.

In Primary Care Optimise Rx messages will trigger messages on clinical systems to remind prescribers of Traffic Light classification, OTC policy and exclusions.

8. WORKFORCE 9. EQUALITY IMPACT ASSESSMENT 9.1 Results of the local consultation, assessment of equality impact and engagement report is

available here: https://www.leedsccg.nhs.uk/content/uploads/2017/03/Prescribing-engagement-report-FINAL-VERSION-1.pdf. NHSE undertook wide ranging public consultation before publishing their guideline.

10. ENVIRONMENTAL

10.1 Not applicable.

11. RECOMMENDATION The Clinical Commissioning Forum is asked to:

(a) INPUT and COMMENT on the implementation in Leeds of national NHSE

recommendations contained in the document ‘Conditions for which over the counter items should not routinely be prescribed in primary care’.



Building healthier communities

Conditions for which over the counter items should not routinely be prescribed in primary care: NHSE Guidance for CCGs

June 2018


Background

In the year prior to June 2017, the NHS spent approximately £569 million on

prescriptions for medicines which could otherwise be purchased over the

counter (OTC) from a pharmacy and/or other outlets such as petrol stations or

supermarkets.

• The NHSE guidance is to support CCG decision-making in this area, to address unwarranted

variation, and to provide clear national advice to make local prescribing practices more

effective.

• Some CCGs have already introduced restrictive prescribing policies for OTC medicines

The expectation from NHSE is that CCGs will reflect the guidance in their local

prescribing policies and that prescribers will follow local policy.


The Guidance

‘Conditions for which over the counter items should not routinely be prescribed in primary care: NHSE Guidance for CCGs’ covers three areas:

1. 2 items of limited clinical effectiveness which should not be routinely prescribed.

2. 8 minor, self-limiting conditions for which treatment is not usually required;

3. 27 minor conditions in which self care should be promoted;

• General and condition specific exclusions are defined.


1. Items of limited clinical effectiveness which should not be prescribed

1. Probiotics e.g. Vivomixx capsules, VSL#3 sachets

• Implementation will not change current Leeds prescribing policy.

• VSL#3 sachets will continue to be available for the conditions covered by the Amber guideline on LHPs, ie pouchitis.

• For all other indications, eg Irritable bowel; probiotics are Black Light and prescribing should not occur.

2. Vitamins and minerals.

• Maintenance multivitamins, or low dose vitamin D, should not be routinely prescribed.

• Where a clinical deficiency or insufficiency is diagnosed prescribing is still permitted (and medicines are often POMs) e.g. Ferrous sulphate for iron deficiency anaemia, or high dose colecalciferol for Vitamin D deficiency / insufficiency.


2. Self–limiting conditions for which treatment is not usually required

1. Acute Sore Throat

2. Infrequent Cold Sores of the lip.

3. Conjunctivitis

4. Coughs and colds and nasal congestion

5. Cradle Cap (Seborrhoeic dermatitis – infants)

6. Haemorrhoids

7. Infant Colic

8. Mild Cystitis

N.B. General exemptions do not apply to the above.


3. Minor Conditions Suitable for Self- Care. Patients should be advised to purchase treatment over the counter.

1. Mild Irritant Dermatitis

2. Dandruff

3. Diarrhoea (Adults)

4. Dry Eyes/Sore (tired) Eyes

5. Earwax

6. Excessive sweating (Hyperhidrosis)

7. Head Lice

8. Indigestion and Heartburn

9. Infrequent Constipation

10. Infrequent Migraine

11. Insect bites and stings

12. Mild Acne

13. Mild Dry Skin

14. Sunburn

15. Sun Protection

16. Mild to Moderate Hay fever/Seasonal

Rhinitis

17. Minor burns and scalds

18. Minor conditions associated with

pain, discomfort and/fever. (e.g. aches and

sprains, headache, period pain, back pain)

19. Mouth ulcers

20. Nappy Rash

21. Oral Thrush

22. Prevention of dental caries

23. Ringworm/Athletes foot

24. Teething/Mild toothache

25. Threadworms

26. Travel Sickness

27. Warts and Verrucae


General Exclusions • Patients prescribed an OTC treatment for a long term condition (e.g. regular pain relief for chronic

arthritis).

• For the treatment of more complex forms of minor illnesses (e.g. severe migraines that are unresponsive to over the counter medicines).

• For those patients that have symptoms that suggest the condition is not minor (i.e. those with red flag symptoms for example indigestion with very bad pain.)

• Treatment for complex patients (e.g. immunosuppressed patients).

• Patients on prescription only treatments (NHSE clarification: If a patient normally requires a POM to treat a minor condition, example fexofenadine for hay fever, they will not be expected to revert to self care).

• Patients prescribed OTC products to treat an adverse effect or symptom of a more complex illness and/or prescription only medications should continue to have these products prescribed on the NHS.

• Circumstances where the product licence doesn’t allow the product to be sold over the counter to certain groups of patients. This may vary by medicine, but could include babies, children and/or women who are pregnant or breast-feeding.


General Exclusions

• Patients with a minor condition suitable for self-care that has not responded sufficiently to treatment with an OTC product (NHSE clarification: A patient may be asked to purchase a different OTC medicine, if the first choice was not effective, but the policy doesn’t prohibit the GP prescribing a POM if they believe clinically indicated).

• Patients where the clinician considers that the presenting symptom is due to a condition that would not be considered a minor condition.

• Circumstances where the prescriber believes that in their clinical judgement, exceptional circumstances exist that warrant deviation from the recommendation to self-care.

• Individual patients where the clinician considers that their ability to self-manage is compromised as a consequence of medical, mental health or significant social vulnerability to the extent that their health and/or wellbeing could be adversely affected, if reliant on self-care. To note that being exempt from paying a prescription charge does not automatically warrant an exception to the guidance. Consideration should also be given to safeguarding issues.


Condition Specific Exclusions

• Some conditions have condition related exclusions (listed in the guidance) e.g. Ringworm or athletes foot treatments should be prescribed for patients with history of lower limb cellulitis or lymphoedema; cold sore treatments should be prescribed to immunocompromised patients; sun protection can be prescribed if covered by ACBS criteria.

• OTC medicine licenses may limit the people to whom pharmacies can sell medicines to eg beclometasone nasal spray can only be sold to over 18’s, hydrocortisone cream cannot be sold for application to face, most medicines cannot be sold to pregnant women.


Consultations Results

• Between March and July 2017 the Leeds CCGs Communications Team conducted a public consultation on the Leeds proposal to restrict prescribing of gluten-free foods, branded medicines and medicines available over the counter.

• 3259 people responded, 88% from the general public.

• 82% agreed that we should not routinely prescribe OTC medicines

• Feedback included: • Expressed concerns about protecting vulnerable group

• More information should be available to the public to support self care


Proposed Implementation of NHSE Guidance • NHSE are producing national resources for health care professionals and the

public to aid implementation.

• If introduction of the guidance is supported guidance will be available on LHPs for prescribers to include:

• Links to NHSE recommendations including exclusion criteria

• Licensing guides

• Links to patient information

• FAQs

• The Traffic Light List and Leeds Formulary will be updated with any changes in classification.

• Optimise RX prompts will be ‘switched on’ which will trigger when prescribing medicines that form part of the OTC guidance.


Proposal

CCF to give clinical support to the recommendation that Leeds CCG incorporate the NHSE national guideline in our local prescribing policy

1

Agenda Item: GB 18/52ii FOI Exempt: N



Title: Flash Glucose Monitoring Policy

Lead Governing Body Member: Jo Harding, Director of Quality and Safety


appropriate

()

Report Author: Jo Alldred

Decision

Reviewed by EMT/SMT/Date: 3rd May 2018

Discussion

Reviewed by CCF Date: 28th June 2018

Information

Checked by Finance (Y/N/N/A - Date): November 2017












Workforce Issues




2

EXECUTIVE SUMMARY: This policy, Appendix 1, has been supported by SMT on 3rd May and the Clinical Commissioning Forum on 28th June. Freestyle Libre (FSL) is a sensor-based system that continually measures glucose levels in interstitial fluid (not blood), and can be used for patients 4 years and older with diabetes mellitus. Freestyle Libre (FSL) is currently the only Flash Glucose Monitoring (GM) product available on the UK market. The system comprises a sensor and a reader and aims to reduce the number of finger pricks a patient has to perform. It does not provide real-time continuous glucose monitoring or a hypoglycaemia alarm, so does not predict a hypoglycaemic attack. The reader is usually supplied free of charge by the manufacturer, and up until recently, the majority of patients have been buying the sensors from the company. However, in line with our Insulin Pump Policy, there are a small number of adult patients in Leeds (~10) for whom we are funding the sensors. We are also funding for a number of paediatric patients through the Insulin Pump Policy On 1st November 2017, FSL sensors became available to prescribe on the NHS. Based on the current drug tariff price, the cost of the sensors per patient for 1 year is £910. The cost of finger pricking 8 times a day varies from ~£300 – 500/year, depending on products used. The use of the FSL does not remove the need for finger pricking, but it can reduce the number of finger pricks per day. In October 17, the Regional Medicines Optimisation Committee (RMOC) produced guidance on its use which many CCGs have adopted (see Appendix 2). Currently, there is no evidence that Flash GM reduces the overall cost of monitoring glucose levels. It is too early to identify the effects on the longterm outcomes of diabetics. The DVLA still requires finger prick testing before driving (it does not currently accept FSL as a valid alternative). The CCG has worked with the diabetes specialists at LTHT to produce a policy for the use of Flash GM within Leeds. The policy covers which patient groups are considered essential and which are desirable i.e. Flash GM may be an advantage to the patient, but are not currently considered to be cost effective.

NEXT STEPS: If the policy is approved it will be launched within LTHT. The CCG will request regular updates regarding its implementation and impact on clinical outcomes. Once approved, the Policy will then be incorporated into the wider CCG Insulin Pump Policy.

3


(a) APPROVE the Freestyle Libre/ Flash Glucose Monitoring Commissioning Policy

4

Main Report:

1. SUMMARY

1.1 Flash Glucose Monitoring (GM) is a sensor-based system promoted for use in diabetic patients. Many patients prefer this system as it avoids the needs for numerous finger pricking, although it does not completely remove this need. The only product currently on the market is Freestyle Libre (FSL) which became available on NHS prescription on 1st November 2017.

1.2 There is insufficient clinical evidence to support its use in well-controlled diabetics, however, there are some specific groups where it may prove beneficial. This policy has been developed by working with the clinical specialists at LTHT with the aim to improve the management of these specific groups of patients.

2. BACKGROUND

2.1 The FSL system comprises a sensor and a reader and aims to reduce the number of finger pricks a patient has to perform. It does not provide real-time continuous glucose monitoring or a hypoglycaemia alarm, so does not predict a hypoglycaemic attack. The reader is usually supplied free of charge by the manufacturer, and up until now, the majority of patients have been buying the sensors from the company. However, in line with our Insulin Pump Policy, there are a small number of adult patients in Leeds (~10) for whom we are funding the sensors. We are also funding for a number of paediatric patients through the Insulin Pump Policy.

2.2 In October 2017, the Regional Medicines Optimisation Committee (North) published

national guidance on the use of FSL within the NHS. The Leeds policy was based on this guidance, and adapted to reflect local opinion.

3. PROPOSAL 3.1 The policy outlines the specific groups of patients within whom the CCG supports the use

of Flash GM. The policy also describes the education and training required, the responsibilities of the specialists and the patient, the stopping criteria and the prescribing arrangements for supply.

By assigning a RED traffic light status to the drug, it can only be prescribed by the specialists, not in primary care. This ensures the specialists can monitor the impact of this intervention closely, as well as ensuring there is no creep in primary care prescribing for patients outside the groups identified within the policy.

5

4. NEXT STEPS 4.1 If this policy is approved, the specialists will develop the relevant paperwork and systems to

manage these patients. The CCG will request regular updates regarding its implementation and impact on clinical outcomes.

Once approved, the Policy will then be incorporated into the wider CCG Insulin Pump Policy.

5. STATUTORY/LEGAL/REGULATORY/CONTRACTUAL

5.1 N/A. 6. FINANCIAL IMPLICATIONS AND RISK

6.1 See policy paper.

7. COMMUNICATIONS AND INVOLVEMENT 7.1 Throughout the development of this policy we have engaged with Diabetes UK. The

specialists have engaged and reported to Diabetes UK forums. We have kept the CCG website updated with our status and answered numerous FOI requests regarding our progress and commissioning position.

8. WORKFORCE

8.1 N/A.

9. EQUALITY IMPACT ASSESSMENT 9.1 We have considered all potential groups of patients, and based the policy on available

evidence and advice from specialists. . 10. ENVIRONMENTAL

10.1 N/A.

11. RECOMMENDATION


a) APPROVE the Freestyle Libre/ Flash Glucose Monitoring Commissioning Policy

Leeds Flash Glucose Monitoring Proposed Criteria 20th February 2018 (Agreed at meeting Jo Alldred, Bryan Power and Mike Mansfield)

Appendix 1 April 2018

Draft Proposed Criteria for the Funding of Flash Glucose Monitoring (FlashGM) in Paediatrics and Adults in the NHS in Leeds

The criteria proposed in this position statement has taken in to account the previous proposal from the diabetes team at LTHT and also the subsequent national position statement from the Regional Medicines Optimisation Committee (RMOC) from its meeting in October 2017. It also takes in to account the Diabetes UK consensus guideline of November 2017 and the guideline of the Association of British Diabetologists (ABCD). The proposed criteria recognise the cost of provision of Flash GM, but also potential savings to be made from the reduced use of blood glucose monitoring strips. The only Flash GM device currently available is the Freestyle Libre device. The monitoring device is usually provided free of charge to the patient. The cost of the sensors is currently £960/pt./yr. General Principles

NHS Leeds CCG does not routinely commission the use of Flash GM.

Flash GM is only commissioned for:

Patients with Type 1 diabetes mellitus (except in pregnancy), and; Aged 4yrs and older, and; Under specialist diabetes care, and; using multiple daily injections of insulin, or insulin pump therapy, and; Whom the specialist considers the use of the device will be cost effective.

General Statements

Patients with diabetes starting FlashGM, insulin pump treatment and/or continuous glucose monitoring will agree and sign an explicit contract of use which includes the criteria for continued funding and for discontinuing treatment.. The contract will also detail consent needed to collect data to audit outcomes including usage of standard blood glucose strips, which may be collected by both secondary and primary care.

The contract will include the education and training to be provided to the patient on the use of Flash GM and the continued requirement of engagement by the patient. It will also outline the appropriate supply route.


The patient / carer will be expected to download and analyse their data on a regular basis and they will receive appropriate training to be able to do this before starting the Flash GM. Each patient will be advised how often to analyse their data and how to identify any trends.

Any patient not undertaking the appropriate education and training, not analysing their data regularly, or not maintaining continued engagement as outlined in the criteria below, will risk having their Flash GM being discontinued.

FlashGM will be provided through the Leeds hospital specialist diabetes team only as a RED drug i.e. Freestyle Libre sensors will not be prescribed by general practitioners in Leeds.

When patients transfer from paediatrics to adults, their treatment regime will be maintained and will be reviewed in the young adults diabetes service.

The previously agreed policy “Insulin Pumps and Glucose Monitors in Adults, Children and Young People Policy” remains in place and active. It is not proposed to replace this document, but it will be reviewed to ensure clarity and consistency in the commissioning position. This proposal will add to that policy.

In exceptional circumstances, the IFR process will remain available for patients who do not fulfil the criteria below, but whom the clinician feels have exceptional reasons for requiring Flash GM.

Proposed Criteria The draft criteria below are in suggested order of clinical priority. It is important to identify and prioritise cohorts in order of clinical priority, benefit and economic effectiveness in order to assist commissioning considerations. The estimated number of patients is the total potential risk, but this does not take into account the fact that some patients don’t want to start Flash GM, and that some patients will stop due to non-compliance with the criteria, or intolerance of the device. Because of this, potential costs have not been included as it is not possible to predict how many patients will start on or remain on the Flash GM. Plus not all patients will start on the device on Day 1. As an estimate, if every patient did start on Day 1 and remained on the device with no withdrawals, the total cost pressure would be in the region of £1.1million. Most references are suggesting approx. 50% maintenance rate, so the actual cost pressure is likely to be around the £500,000 mark.


The following people with diabetes would be offered a Flash GM device and sensors to monitor glucose control:

Essential Criteria

Estimated pt. numbers /yr.

1. People with type 1 diabetes who have 2 or more hospital admissions per year due to diabetic ketoacidosis or hypoglycaemia.

Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic no longer than 6months after initiation, and at 12 months to ensure goals are being met, then at least annually thereafter. Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments AND (iii) reduction in number of hospital admissions in the following 12 month period compared to the 12 months before FlashGM started or a significant improvement in HbA1c is demonstrated as defined in criteria 3. Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) no reduction in hospital admissions for DKA or hypoglycaemia Duration of funding: could be ongoing so long as above criteria continue to be met and so long as person with diabetes wants to continue and is maintaining a clinical benefit.

<30

2. Women with pre-existing diabetes of any type and any age (but not gestational diabetes) who are pregnant.

Clinical review of outcome improvement would be as follows as diabetes antenatal clinic appointments every 1-4 weeks during pregnancy Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments AND (iii) only while pregnant (see duration of funding below). Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) no longer pregnant Duration of funding: for the duration of the pregnancy and up to a maximum of 1 month post-delivery only.

<70 at any one time (~93/yr.)


3. People with type 1 diabetes who fulfil NICE criteria for insulin pump therapy (i.e. cannot sustain HbA1c < 70 mmol/mol OR are having recurring hypoglycaemia needing 3rd party assistance)

Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic no longer than 6months after initiation, and at 12 months to ensure goals are being met, then at least annually thereafter. Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments AND (iii) at 4 months has achieved treatment goal. Where indication is HbA1c >70 mmol/mol then treatment goal is a reduction in HbA1c depending on pre-intervention HbA1c: Pre-FlashGM HbA1c (mmol/mol) Goal HbA1c to continue FlashGM

>100 reduce by at least 15 mmol/mol 70-100 reduce by at least 10 mmol/mol <70 reduce by at least 5 mmol/mol

Where indication was recurring severe hypoglycaemia then treatment goal is reduced frequency of severe and all hypoglycaemia compared to before FlashGM and improved Clarke and Gold hypoglycaemia awareness score. Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) not achieving treatment goal at 4 months and at 12 months Duration of funding: could be long term so long as above criteria continue to be met and so long as person with diabetes wants to continue and is maintaining a clinical benefit

>600

4. People with type 1 diabetes with good clinical reasons for needing to do finger prick glucose tests 8 or more times a day. (Note however that this does not currently include frequent testing required by DVLA) Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic no longer than 6months after initiation, and at 12 months to ensure goals are being met, then at least annually thereafter. Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments AND (iii) at 4 and 12

~ 50


months has used 80% fewer standard glucose monitoring strips (for patients who need to do extra tests to fulfil DVLA requirements a reduction in usage of strips will still be expected) Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) at 4 months and at 12 months has not reduced standard glucose testing strip use by 80% ( significant reduction still expected for DVLA) Duration of funding: Could be long term if criteria for continued funding are being met and as long as person with diabetes wants to continue and is maintaining a clinical benefit.

5. People with type 1 diabetes who have been using Freestyle Libre (ie self-funded or as part of research project) who otherwise fulfil any of the criteria 1, 3, 4 or 6, for starting flash glucose monitoring and who accomplished the relevant treatment goal for that criterion. Clinical review of outcome improvement would be as follows: Review in diabetes clinic at 4 months and 12 months to ensure goals being met and at least annually thereafter. Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments AND (iii) at 4 months and 12 months continues to achieve the relevant treatment goal as under criteria 1, 3, 4 or 6 above Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) not achieving treatment goal at 4 months and at 12 months Duration of funding: could be long term so long as above relevant criteria continue to be met and so long as person with diabetes wants to continue and is maintaining a clinical benefit

Unknown, but estimate 50-100

6. Women with Type 1 diabetes intensifying glucose control as part of a pre-conception plan to minimise foetal risk.

Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic at 4 months and 12 months to ensure goals being met Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) not achieved a reduction in HbA1c of at least 5mmol/mol (iii)


failure to attend 2 diabetes clinic appointments without valid reason OR ( iv) not achieving treatment goal at 4 months and at 12 months OR ( v) no longer planning conception OR ( vi) not using data from FlashGM to inform diabetes self-care. Duration of funding: until no longer planning conception. Ongoing use of flash glucose monitoring should be reviewed if conception is not achieved within 2 years.

Desirable Criteria

Estimated pt. numbers /yr.

7. People with type 1 diabetes and on a pump with good self-management including appropriately frequent blood glucose testing who still have and HbA1c above 70 mmol/L.

Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic at 4 months and 12 months to ensure goals being met

Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments AND (iii) at 4 months has achieved treatment goal.

Treatment goal is a reduction in HbA1c depending on pre-intervention HbA1c: Pre-FlashGM HbA1c (mmol/mol) Goal HbA1c to continue FlashGM

>100 reduce by at least 15 mmol/mol 70-100 reduce by at least 10 mmol/mol <70 reduce by at least 5 mmol/mol

Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) not achieving treatment goal at 4 months and at 12 months Duration of funding: Duration of funding: could be long term so long as above criteria continue to be met and so long as person with diabetes wants to continue

? Included in cohort in no.3

8. People who have recently developed hypoglycaemia unawareness but not having severe hypoglycaemia. a) Adults

<20


Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic at 4 months

Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments and frequent contact with diabetes specialist team in the weeks after starting FlashGM AND (iii) making progress at improving hypoglycaemia awareness but still at significant risk

Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) no progress in improving hypoglycaemia at 4 months OR (iv) hypoglycaemia awareness has returned to normal

NB Gold and Clarke tools used to assess and grade hypoglycaemia awareness (as per NICE NG17 Type 1 diabetes).

Duration of funding: 4 months maximum. If still unaware of hypoglycaemia, an insulin pump should be considered. b) Paediatrics

Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic at 4 months

Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments and frequent contact with diabetes specialist team in the weeks after starting FlashGM AND (iii) making progress at improving hypoglycaemia awareness but still at significant risk

Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) no progress in improving hypoglycaemia at 4 months OR (iv) hypoglycaemia awareness has returned to normal

NB Gold and Clarke tools used to assess and grade hypoglycaemia awareness (as per NICE NG18 Type 1 diabetes).

Duration of funding: 4 months maximum. If still unaware of hypoglycaemia, an insulin pump or real-time continuous glucose monitoring with alarm should be considered, as clinically appropriate.

~100

9. People with insulin-treated diabetes, in a community setting, who require third parties to carry out monitoring and where conventional blood testing is not possible

Est: 50-100


Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic at 4 months and then at least 6 monthly Criteria for continued funding: (i) scanning occurs at least 4 times a day AND (ii) attending all clinic appointments and frequent contact with diabetes specialist team in the weeks after starting FlashGM Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) failure to attend 2 diabetes clinic appointments without valid reason OR (iii) data from FlashGM not used inform care of the person with type 1 diabetes. Duration of funding: review every year

10. Women with Type 2 insulin-treated diabetes as part of a pre-conception plan to minimise foetal risk.

Clinical review of outcome improvement would be as follows: Telephone review at 4 weeks to make sure device working and being used appropriately and scanned at least 4 times a day. Review in diabetes clinic at 4 months and 12 months to ensure goals being met Criteria for continued funding: (i) person with diabetes is scanning sensor at least 4 times daily AND (ii) attending all clinic appointments Criteria to end funding: Any of the following (i) not scanning sensor at least 4 times daily OR (ii) not achieved a reduction in HbA1c of at least 5mmol/mol (iii) failure to attend 2 diabetes clinic appointments without valid reason OR ( iv) not achieving treatment goal at 4 months and at 12 months OR ( v) no longer planning conception OR ( vi) not using data from FlashGM to inform diabetes self-care. Duration of funding: until no longer planning conception. Ongoing use of flash glucose monitoring should be reviewed if conception is not achieved within 2 years.

Max. of 40 at any time.

Notes:

Criteria 1-8 are the criteria previously suggested by the LTHT diabetes team with some modification and clarification

Criteria 1, 3, 4, 8 and 10 comprise the recommendations of the NHSE Regional Medicines Optimisation Committee recommendations.

Regional Medicines Optimisation Committee (RMOC)

Flash Glucose Monitoring Systems

Position Statement

The Regional Medicines Optimisation Committee (North) reviewed the use of the flash glucose monitoring system, Freestyle Libre®, at its meeting on October 26th 2017. The advice of this group to Area Prescribing Committees is as follows: Until further trial data is available, it is recommended that audit data on the use of Freestyle Libre® is collected through its use in limited and controlled settings where patients are attending for Type 1 diabetes care. It is recommended that Freestyle Libre® should only be used for people with Type 1 diabetes, aged four and above, attending specialist Type 1 care using multiple daily injections or insulin pump therapy, who have been assessed by the specialist clinician and deemed to meet one or more of the following:

1. Patients who undertake intensive monitoring >8 times daily 2. Those who meet the current NICE criteria for insulin pump therapy (HbA1c

>8.5% (69.4mmol/mol) or disabling hypoglycemia as described in NICE TA151) where a successful trial of FreeStyle Libre® may avoid the need for pump therapy.

3. Those who have recently developed impaired awareness of hypoglycaemia. It is noted that for persistent hypoglycaemia unawareness, NICE recommend continuous glucose monitoring with alarms and Freestyle Libre does currently not have that function.

4. Frequent admissions (>2 per year) with DKA or hypoglycaemia. 5. Those who require third parties to carry out monitoring and where conventional

blood testing is not possible.

In addition, all patients (or carers) must be willing to undertake training in the use of Freestyle Libre® and commit to ongoing regular follow-up and monitoring (including remote follow-up where this is offered). Adjunct blood testing strips should be prescribed according to locally agreed best value guidelines with an expectation that demand/frequency of supply will be reduced. Freestyle Libre® is an innovative new device that has the potential to improve quality of life for patients and support self-management. However, at the present point in time there are significant limitations in available clinical trial data and economic analysis that make it difficult to make an appropriate judgment as to its place in therapy. The following concerns were noted with regard to the clinical evidence and costing information supplied:

Trials contain only small numbers (n=700) of patients with well controlled Type 1

diabetes.

Limited trial duration (6-12 months only)

Limited data comparing to Continuous Glucose Monitoring

Limited or no data of use in unstable patients, pregnancy, young people and children.

Projected reductions in finger-prick testing are unrealistic given the need to test before driving (current DVLA requirement) and during illness.

Costing information with regard to testing strips does not recognize significant reductions that have already been achieved in this area of prescribing.

The RMOC is aware that clinics using Freestyle Libre® are already collecting audit data and would strongly support all clinics to work collaboratively (potentially through the Association of British Clinical Diabetologists) to maximize learning about this new intervention and measure its impact in individual patients. We suggest information is collected on the following:

1. Reductions in severe/non-severe hypoglycaemia 2. Reversal of impaired awareness of hypoglycaemia 3. Episodes of diabetic ketoacidosis 4. Admissions to hospital 5. Changes in HbA1c 6. Testing strip usage 7. Quality of Life changes using validated rating scales. 8. Commitment to regular scans and their use in self-management.

We recommend that if no improvement is demonstrated in one or more of these areas over a 6 month trial then the use of Freestyle Libre® should be discontinued and an alternative method of monitoring used. References: NICE Medtech Innovation Briefing [MIB 110]: FreeStyle Libre® for glucose monitoring NICE July 2017. Available at https://www.nice.org.uk/advice/mib110 ABCD Type 1 Diabetes Clinical Collaborative: Information to help a formulary case for Freestyle Libre System October 2017. Available at https://abcd.care/getting-freestyle-libre-your-formulary Diabetes UK. Diabetes Facts and Stats Version 4 Revised October 2016. Accessed 17/10/2017 via https://www.diabetes.org.uk/Documents/Position%20statements/DiabetesUK_Facts_Stats_Oct16. pdf

https://www.nice.org.uk/advice/mib110

https://abcd.care/getting-freestyle-libre-your-formulary

https://www.diabetes.org.uk/Documents/Position%20statements/DiabetesUK_Facts_Stats_Oct16.

1

Agenda Item: GB 18/52iii FOI Exempt: N



Title: Anti-Fraud, Bribery and Corruption Policy

Lead Governing Body Member: Visseh Pejhan-Sykes, Chief Finance Officer


appropriate

()

Report Author: Steve Moss, Local Counter Fraud Specialist

Decision


Discussion

Reviewed by Committee/Date: Audit Committee 4 July 2018

Information















N/A



N/A

2

EXECUTIVE SUMMARY: The Local Counter Fraud Specialist completed a review of the CCG’s Anti-Fraud and Corruption Policy. The revised policy complies with NHS Counter Fraud Authority’s requirements and also serves to reinforce the arrangements that are in place at the CCG and provides clarity on the work that is done by the Counter Fraud Team. The aim of the policy is to inform staff of the importance of fraud work in protecting the organisation’s assets from financial crime and provide guidance on what fraud is, what everyone’s responsibility is regarding preventing fraud, bribery and corruption and how to report suspicions of fraud, bribery and corruption. The Policy has been reviewed and approval recommended by the Audit Committee on 4 July 2018.

NEXT STEPS: The revised policy will be uploaded onto the CCG website once approved by the Governing Body.

RECOMMENDATION:


a) APPROVE the Anti-Fraud, Bribery and Corruption Policy

ANTI–FRAUD, BRIBERY AND CORRUPTION POLICY

Version: 1.0

Ratified by: NHS Leeds CCG Governing Body

Date ratified: TBC

Name & Title of Originator/Author(s): Visseh Pejhan-Sykes, Chief Finance Officer Steven Moss, Local Counter Fraud Specialist

Name of Responsible Committee/Individual:

Audit Committee

Date issued: June 2018

Review Date: July 2020

Target Audience: All NHS Leeds CCG Governing Body Members, Employees and Members

The on-line version is the only version that is maintained. Any printed copies should, therefore, be viewed as ‘uncontrolled’ and as such may not necessarily contain the latest updates and amendments.

POLICY AMENDMENTS

Amendments to the policy will be issued from time to time. A new amendment history will be issued with each change.

Version No. Issued by Nature of amendment

Approved by & date

Date on Intra Internet

Contents Section Page No. A guide to ‘do’s and don’ts 1 1. Introduction 2

1.1 General 2 1.2 Aims and objectives 2 1.3 Scope 2

2 Policy statement 2

2.1 Policy statement 2.2 Impact Analysis 3

3 Definitions 3 3.1 NHS Counter Fraud Authority 3 3.2 Fraud 3

3.3 Bribery and corruption 4

4 Roles and responsibilities 5 4.1 Chief Executive 5 4.2 Chief Finance Officer 5 4.3 Internal and external audit 6 4.4 Human Resources 6 4.5 Local Counter Fraud Specialist 6

4.6 Managers 7 4.7 All employees 8 4.8 Information management and technology 8

5. The response plan 8

5.1 Bribery and corruption 8 5.2 Reporting fraud, bribery or corruption 8

5.3 Sanctions and redress 9 6. Review 10

6.1 Monitoring and auditing of policy effectiveness 10 6.2 Dissemination of the policy 10 6.3 Review of the policy 10

7. Related Policies 10

8. External References 10 Referral form 11

1

NHS fraud, bribery and corruption: dos and don’ts. A guide for NHS Leeds CCG FORM 1 FORM 1 FORM 1

DO Report your suspicions immediately All referrals will be professionally investigated and confidentiality will be respected.

Note your concerns If it helps, record details such as what you have seen or heard, when this happened and who was involved.

Refer to the anti fraud, bribery and corruption policy on the intranet If you are unsure about what fraud, bribery or corruption is, guidance is available on the intranet. Alternatively, contact your Local Counter Fraud Specialists who will be happy to advise and

support you.

DO NOT Be afraid of raising your concerns Never be afraid to speak up about your suspicions even if you are unsure. We would rather investigate a suspicion which turns out not to be right rather than miss the chance to effectively deal with any wrongdoing.

Confront the person you think may be committing an offence or speak to anyone other than those listed below

This could alert the person and give them the opportunity to hide what they have been doing.

Investigate this yourself Never attempt to gather further information yourself unless it is about to be destroyed. This is because evidence must be obtained in line with strict legal requirements by a Local Counter Fraud Specialist. If in doubt, please call for advice.

Please report any concerns you have immediately by either

Directly contacting the Local Counter Fraud Specialist (LCFS), Your Local Counter Fraud Specialists are Marie Hall & Steven Moss who can be contacted by telephoning 01904 725145 & 01904 725166 or emailing [email protected] & [email protected] or

Contacting the NHS Fraud and Corruption Reporting Line free on 0800 028 40 60. Calls will be treated in confidence and investigated by professionally trained staff or you can report to them online by visiting www.reportnhsfraud.nhs.uk or

Contacting the Chief Finance Officer.

Tackling fraud


http://www.reportnhsfraud.nhs.uk/

2

1 Introduction 1.1 General This document sets out NHS Leeds Clinical Commissioning Group’s (the CCG) policy and

provides guidance and advice to employees in dealing with fraud or suspected fraud. This policy is supported and endorsed by the Governing Body and senior management and sets out the arrangements in place for concerns regarding suspected fraudulent activity to be raised by employees or members of the public and how they will be dealt with.

The CCG does not tolerate fraud and bribery within the NHS. The intention is to eliminate all NHS fraud and bribery as far as possible and the CCG is committed to taking all necessary steps to counter fraud and bribery in accordance with guidance and advice issued by NHS Counter Fraud Authority. This includes seeking appropriate disciplinary, regulatory, civil and criminal sanctions against fraudsters and where possible recovery of losses.

1.2 Aims and objectives The purpose of this document is to provide guidance to staff on what fraud is, what

everyone’s responsibility is to prevent fraud, bribery and corruption and how to report suspicions of fraud, bribery or corruption. Specifically:

Improve the knowledge and understanding of everyone in the organisation,

irrespective of their position, about the risk of fraud and bribery within the organisation and its unacceptability.

Assist in promoting a climate of openness and a culture and environment where staff members feel able to raise concerns sensibly and responsibly.

Set out the CCG’s responsibilities in terms of the deterrence, prevention, detection and investigation of fraud and bribery.

Ensure the appropriate sanctions are considered following an investigation, which may include any or all of criminal prosecution, civil prosecution and/or internal/external disciplinary action (including professional/regulatory bodies)

1.3 Scope

This policy applies to all employees and members of the CCG, including seconded, temporary and agency staff, as well as consultants, vendors, contractors, and/or any other parties who have a business relationship with the organisation. It will be brought to the attention of all employees and form part of the induction process for new staff. It is incumbent on all of the above to report any concerns they may have concerning fraud and bribery.

2 Policy statement 2.1 NHS Leeds Clinical Commissioning Group is committed to taking all necessary steps to

counter fraud and bribery. To meet this objective, the CCG has adopted NHS Counter Fraud Authority’s national strategic approach to tackling crime against the NHS which encompasses: - Strategic Governance. - Inform and Involve those who work for or use the NHS about crime and how to tackle it.

- Prevent and Deter crime in the NHS to take away the opportunity for crime to occur or to re-occur and discourage those individuals who may be tempted to commit crime.

- Hold to account those who have committed crime against the NHS.

3

Operationally the organisation’s Local Counter Fraud Specialist (LCFS) will produce an annual Counter Fraud Plan for activity which will reflect this strategic approach and which will be formally approved by the Chief Financial Officer and presented to the Audit Committee. All employees have a personal responsibility to protect the assets of the organisation, including all buildings, equipment and monies from fraud, theft, or bribery.

The CCG expects anyone having reasonable suspicions of fraud to report them. It recognises that, while cases of theft are usually obvious, there may initially only be a suspicion regarding potential fraud and, thus, employees should report the matter to their LCFS who will then ensure that procedures are followed.

The CCG’s policy is that no individual will suffer any detrimental treatment as a result of reporting reasonably held suspicions. The Public Interest Disclosure Act 1998 came into force in July 1999 and gives statutory protection, within defined parameters, to staff members who make disclosures about a range of subjects, including fraud and bribery, which they believe to be happening within the organisation employing them. Within this context, ‘reasonably held’ means suspicions other than those which are raised maliciously and are subsequently found to be groundless.

Malicious allegations will be subject to a full investigation and appropriate disciplinary action. All suspicions reported will be investigated by the LCFS in accordance with the NHS Anti-Fraud Manual and where appropriate sanctions, which may include any or all of criminal prosecution, civil prosecution, internal or regulatory disciplinary action and financial redress will be sought.

2.2 Impact Analysis Equality As a result of performing the screen analysis, the policy does not have any adverse effects on people who share Protected Characteristics and no further actions are recommended. Sustainability As a result of performing the assessment the policy does not have any effects in terms of sustainability.

3 Definitions 3.1 NHS Counter Fraud Authority

NHS Counter Fraud Authority is a special health authority charged with the identification, investigation and prevention of fraud, bribery and corruption within the NHS. Its service delivery model focuses upon standard setting, bench marking and assurance to enable local NHS organisations to take corrective action as appropriate.

3.2 Fraud

Fraud is defined as “wrongful or criminal deception intended to result in financial or personal gain, causing the loss or risk of loss to another”.

4

Prior to the introduction of The Fraud Act 2006 it was necessary to prove that a person had been deceived and for the fraud to have been successful under various legislative acts. Following its introduction the focus is now on dishonest behaviour and the intent to make a gain for themselves or another or to cause a loss to another or expose them to a risk of loss. There are several specific offences under the Fraud Act 2006; however there are three primary ways in which it can be committed that are likely to be investigated by the LCFS: a) Fraud by False Representation (section 2) – lying about something using any

means, e.g. by words or actions on a timesheet or application form / CV. b) Fraud by Failing to Disclose Information (section 3) – not disclosing something

when you are under a legal obligation to do so, e.g. failing to declare a conviction, disqualification or commercial interest when such information may have an impact on your NHS role, duties or obligation.

c) Fraud by Abuse of Position (section 4) – where there is an expectation on the individual to safeguard the financial interest of another person or organisation, e.g. a carer abusing their access to patient monies, or an employee using commercially confidential NHS information to make a personal gain.

It should be noted that successful prosecutions under the Fraud Act 2006 may result in an unlimited fine and/or a potential custodial sentence of up to 10 years.

3.3 Bribery and corruption

Bribery is defined as “The offering, giving, receiving, or soliciting of something of value for the purpose of influencing the action of an official in the discharge of his or her public or legal duties”. Corruption is defined as “where someone is influenced by bribery, payment or benefit in kind to unreasonably use their position to give some advantage to themselves or to another”. On the 1st July 2011, the Bribery Act 2010 became law and introduced new offences in relation to bribery and corruption. The generic term “corruption” is accommodated into this Act. The main offences are listed below and a person is guilty of an offence if either of the following applies:

Section 1 - Offences of bribing another person –

a) Offers, promises or gives a financial or other advantage to another person, and (b) Intends the advantage - (i) To induce a person to perform improperly a relevant function or activity, or (ii) To reward a person for the improper performance of such a function or activity (c) Knows or believes that the acceptance of the advantage would itself constitute the improper performance of a relevant function or activity.”

Section 2 Offences relating to being bribed – (a) Request, agrees to receive or accepts a financial or other advantage and intending that, in consequence, a relevant function or activity should be performed improperly (whether by the recipient or another person)”

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A simple example would include a candidate for a job offering the interviewer tickets to an event in order to secure the position. Under the Bribery Act 2010, two offences would be committed; one by the person offering the bribe and one by the person receiving the bribe. Section 7 Failure of commercial organisations to prevent bribery – (The Corporate Offence) (1) A relevant commercial organisation (a commercial organisation includes all NHS bodies), is guilty of an offence under this section if a person associated with it bribes another person intending – (a) To obtain or retain business for the organisation or (b) To obtain or retain an advantage in the conduct of business for the organisation.

Two simple examples of this would be: i) Where an act of bribery has occurred, for a director, manager or officer of an organisation to ignore the act or acts of bribery within the organisation. Under the Bribery Act 2010, the corporate offence would have been committed. ii) Where an act of bribery has occurred, it was subsequently established that the organisation employing the individual failed to have adequate procedures in place to identify and prevent the act of bribery by its employee. Again, under the Bribery Act 2010, the corporate offence would have been committed.

4 Roles and responsibilities 4.1 Chief Executive The Chief Executive has the overall responsibility for funds entrusted to the CCG as the

accountable officer. This includes instances of fraud, bribery and corruption. The Chief Executive must ensure adequate policies and procedures are in place to protect the CCG and the public funds entrusted to it.

4.2 Chief Finance Officer

The Chief Financial Officer (CFO) is provided with powers to approve financial transactions initiated by departments across the CCG. As part of this role the CFO is responsible for the maintenance and implementation of detailed financial procedures and systems which incorporate the principles of separation of duties and internal checks. The CFO will report annually to the Governing Body on the adequacy of internal financial control and risk management as part of the Governing Body’s overall responsibility to prepare an Annual Governance Statement for inclusion in the CCG’s annual report. The CFO will ensure the LCFS, or specialist investigators, are given access to staff and records where required / necessary. The CFO, in consultation with NHS Counter Fraud Authority and the LCFS, will decide whether there is sufficient cause to conduct an investigation, whether the Police and External Audit need to be informed and, depending on the investigation outcome, authorise any prosecution or other sanctions to be pursued. The CFO or the LCFS will consult and take advice from Human Resources if a member of staff is to be interviewed or disciplined. The CFO or LCFS will not conduct a disciplinary investigation, but the employee may be the subject of a separate investigation by HR.

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The CFO will, depending on the outcome of investigations (whether on an interim/on-going or a concluding basis) and/or the potential significance of suspicions that have been raised, inform the Chair of the Audit Committee of cases, as may be deemed appropriate or necessary. The CFO is also responsible for informing the Audit Committee of all categories of loss.

4.3 Internal and external audit

The role of internal and external includes the review of internal controls and systems and the provision of an opinion and assurance on their adequacy and effectiveness. Internal and External Audit have a duty to bring any incident or suspicion of fraud, bribery or corruption to the attention of the CCG’s LCFS.

4.4 Human Resources

When Human Resources staff are advised of suspected cases of fraud, bribery or corruption, they undertake to advise the LCFS as soon as possible. Workforce staff and the LCFS will liaise during the conduct of any investigation to ensure information is shared, duplication avoided and the actions of neither party compromises each other’s work. The CCG’s Human Resource Lead will be responsible for invoking all elements of the disciplinary process in respect of suspension from duty and / or dismissal. It will, however, be the responsibility of the LCFS at all times to investigate, interview or gather evidence associated with any suspected fraudulent activity. As far as is practically possible, the disciplinary process will only be invoked after discussions between Human Resources and the LCFS on the needs / merits of the case but it is recognised that there will be occasions when suspension of a member of staff is considered paramount.

4.5 Local Counter Fraud Specialist

The LCFS is responsible for taking forward all anti-fraud work locally in accordance with national standards and reports directly to the Chief Finance Officer.

The LCFS will work with key colleagues and stakeholders to promote anti-fraud work and effectively respond to system weaknesses and investigate allegations of fraud and corruption. The LCFS will investigate allegations of fraud and corruption in accordance with the instructions of NHS Counter Fraud Authority. The LCFS will play an active part in raising fraud awareness and enforcing the message that fraud within the CCG is not acceptable and will not be tolerated. The LCFS will provide regular updates on counter fraud work to the Chief Finance Officer and the Audit Committee and is responsible for all external reporting requirements. An annual report will reflect the work undertaken to deliver the agreed annual counter fraud plan which will have been developed to reflect both the NHS Counter Fraud Authority’s strategic approach and local risk assessments undertaken by the LCFS in respect of fraud, bribery and corruption. The LCFS will also work with the CCG in the annual review of the CCG’s compliance with the counter fraud standards and the completion of the annual Self Review Tool.

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4.6 Managers

All managers are responsible for ensuring that policies, procedures and processes are adhered to and those within their local area kept up to date. Managers have a responsibility to ensure that staff are aware of fraud, bribery and corruption and understand the importance of protecting the CCG from it.

As part of that responsibility line managers need to:

Inform staff of the CCG‘s standards of business conduct, declaration of interest and anti-fraud and bribery policies as part of their induction process, paying particular attention to the need for accurate completion of personal records and forms

ensure that all employees for whom they are accountable are made aware of the requirements of the policies

assess the types of risk involved in the operations for which they are responsible

ensure that adequate control measures are put in place to minimise the risks. This must include clear roles and responsibilities, supervisory checks, staff rotation (particularly in key posts), separation of duties wherever possible so that control of a key function is not invested in one individual, and regular reviews, reconciliations and test checks to ensure that control measures continue to operate effectively

be aware of the organisation‘s Anti-Fraud and Bribery Policy and the rules and guidance covering the control of specific items of expenditure and receipts

identify financially sensitive posts

ensure that controls are being complied with

contribute to their director’s assessment of the risks and controls within their business area, which feeds into the organisation‘s and the Department of Health Accounting Officer’s overall statements of accountability and internal control.

Managers will also be responsible for the enforcement of disciplinary action for staff who do not comply with policies and procedures. If any instances of actual or suspected fraud, bribery or corruption are brought to the attention of a manager, they must report the matter immediately to the LCFS taking note of anything they hear or see relating to the suspicion including dates, times, descriptions, etc. It is important that managers do not investigate any suspected or actual frauds themselves as a case can be jeopardised if evidence is not collected in the proper manner. Evidence also includes witness statements. In view of the complexity and importance of complying with all the conditions of the Police and Criminal Evidence Act 1984 (PACE), Line Managers or other staff must not carry out any investigations or interviews. Managers must co-operate fully with the LCFS and provide any evidence required during the course of the enquiries, including statements.

4.7 All employees

All employees of the CCG are expected to adhere to the policies and procedures of the CCG and to the Public Sector Values (Nolan Principles). Staff must comply with the national guidance contained in HSG(93)5 “Standards of Business Conduct for NHS staff”, the CCG’s Standards of Business Conduct Policy and Declaration of interests and potential conflicts of interest policy. All employees should also be aware of their responsibility to protect the CCG from crime, and in doing so protect the assets of the CCG, including information and goodwill, in addition to property. Where an employee suspects there has been fraud, bribery or corruption they must report the matter to the nominated LCFS or Chief Finance Officer or via one of the reporting channels available through NHS Counter Fraud Authority identified below.

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Under no circumstances should an employee attempt to investigate suspected or actual incidents of fraud, bribery or corruption themselves as this could jeopardise any potential criminal investigation and subsequent prosecution.

Staff who are involved in or manage internal control systems should receive adequate

training and support in order to carry out their responsibilities. 4.9 Information management and technology The Computer Misuse Act (1990) made three new offences:

• Accessing computer material without permission, e.g. looking at someone else's files.

• Accessing computer material without permission with intent to commit further criminal offences

• Altering computer data without permission, e.g. to hide misappropriation

The fraudulent use of information technology will be reported by the Head of Information Service to the LCFS.

5 The response plan

5.1 Bribery and corruption

In response to the Bribery Act 2010 the CCG has put in place what it considers to be proportionate and adequate procedures to address the level of risk it has assessed that it may face. The CCG’s Declaration of interests and potential conflicts of interest policy and Standards of Business Conduct policy provide guidance and details on staff responsibilities relating to conduct, particularly in relation to commercial sponsorship (including posts), gifts, honoraria and charitable donations and conflicts of interest and how to declare them. This policy and other relevant policies such as the Procurement Policy are available to staff on the CCG’s website.

5.2. Reporting fraud, bribery or corruption

Suspected fraud can be discovered in a number of ways, but in all cases it is important that staff are able to report their concerns and are aware of the means by which they are able to do so. All staff should report their suspicions to the LCFSs or the Chief Financial Officer. The LCFSs are authorised to treat concerns raised in the strictest confidence and anonymously if so requested. A referral form can be found below (form 2) and on the CCG’s extranet site. To report any suspicions of fraud and/or corruption please contact Steven Moss or Marie Hall, via the following: E-mail: [email protected] or [email protected] Post: Steven Moss/Marie Hall, Internal Audit, Park House, Bridge Lane, Wigginton Road, York, YO31 8ZZ. Phone: 01904 725145 or 01904 725166



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If staff, for any reason, feel unable to report the matter internally, or wish to remain anonymous, they prefer to call the NHS Fraud and Corruption Reporting Line on 0800 028 40 60 between 8am and 6pm Monday to Friday or report online at www.reportnhsfraud.nhs.uk This would also be the suggested contact if there is a concern that the LCFSs or the Chief Financial Officer themselves may be implicated in suspected fraud, bribery or corruption. The LCFSs will inform the Chief Financial Officer if the suspicion seems well founded and will conduct a thorough investigation. Reports received will be investigated by the LCFS in a professional manner aimed at ensuring that the current and future interests of the CCG and the suspected individual(s) are protected. The latter is equally important as a suspicion should not be seen as guilt to be proven. Where it is the wish of the individual to report suspicions anonymously this will be respected. However, the Governing Body will always encourage individuals to give their name as this allows suspicions to be acted upon with greater effectiveness and efficiency. It is recognised that individuals may wish to raise concerns / suspicions that may be erroneous or unsubstantiated and the LCFS will conduct sufficient enquiries to establish whether or not there is any foundation to the suspicion raised. If allegations are found to be malicious they will considered for further investigation to establish their source and if related to a CCG employee disciplinary action may be instigated. The guide included in the appendix (form 1) provides a reminder of the key contacts and a checklist of the actions to follow if fraud, bribery and/or corruption, is discovered or suspected. Managers are encouraged to copy this to staff and to place it on staff notice boards.

5.3 Sanctions and redress

Sanctions

Where a staff member is suspected of fraud, bribery or corruption or any other illegal act the CCG will determine on the appropriate disciplinary action, in accordance with its Disciplinary Policy and Procedure.

It should be noted that the duty to follow disciplinary procedures will not preclude consideration of the application of other available sanctions. The full range of sanctions is:

Criminal – whereby proceedings may be brought against alleged offenders and the case heard in Court with the view to obtaining a criminal conviction, an appropriate fine, imprisonment, confiscation, compensation order and award of costs.

Civil – whereby proceedings are undertaken to recover money or assets fraudulently obtained including interest and costs.

Disciplinary – whereby the employee will be dealt with internally via Human Resources and, where the individual is a professional, it may also be necessary to notify their professional body for the matter to be dealt with externally.

It should be recognised that whist each sanction stands-alone potentially all three could be pursued. The decision on the sanctions to be pursued will be determined by the Chief Finance Officer in conjunction with the NHS Counter Fraud Authority and the Crown Prosecution Service as appropriate.

http://www.reportnhsfraud.nhs.uk/

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Redress

The seeking of financial redress or recovery of losses will always be considered in cases of fraud, bribery and corruption that are investigated by the LCFS or the NHS Counter Fraud Authority where a loss is identified. As a general rule, recovery of the loss caused by the perpetrator will always be sought. The decision will be made in the light of the particular circumstances of each case by the Chief Finance Officer in conjunction with the NHS Counter Fraud Authority and the Crown Prosecution Service as appropriate.

6 Review 6.1 Monitoring and auditing of policy effectiveness

The Audit Committee is responsible for monitoring the effectiveness of this policy to provide assurance to the Governing Body that the business of the CCG is being conducted in line with this policy, the associated policy documents, relevant legislation and other statutory requirements. Continuous monitoring is essential to ensuring that controls are appropriate and robust enough to prevent or reduce fraud. Arrangements might include reviewing system controls on an on-going basis and identifying weaknesses in processes. Where deficiencies are identified as a result of monitoring, the CCG should explain how appropriate recommendations and action plans are developed and how any recommendations made should be implemented.

6.2 Dissemination of the policy

The organisation’s Anti-Fraud and Bribery Policy should be available to all members of

staff. The policy will be disseminated to all line managers to ensure staff are aware of the policy. The policy should also be available via the CCG’s website.

6.3 Review of the policy

This Policy will be reviewed by the LCFS every two years, or sooner where changes in legislation require it.

7 Related Polices

Whistleblowing Policy Standards of Business Conduct Policy (which includes gifts and hospitality and commercial sponsorship) Code of Conduct for Managers

Disciplinary Policy Declaration of Interests

8 External references Fraud Act 2006

Bribery Act 2010 NHS Counter Fraud Authority The Computer Misuse Act 1990

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If you wish to report a potential fraud, bribery or corruption please print out and complete this form, and post it to the Local Counter Fraud Specialist, York Teaching Hospital NHS Foundation Trust, Internal Audit, Park House, Bridge Lane, Wigginton Road, York, YO31 8ZZ

YOUR DETAILS

It is not necessary to provide your contact details; however it is possible that more information may be required in order for any investigation to take place. All reported incidents will be investigated, and where appropriate the offenders prosecuted. As a result the Police may also be contacted. All concerns will be treated sensitively and in the strictest confidence. You will not suffer any recriminations as a result of raising a reasonable and justified suspicion.

Your Name: ……………………………………………………… Address: ……………………………………………………… Telephone: E-mail:

SUSPECT DETAILS

Name: Description:

FRAUD, BRIBERY OR CORRUPTION DETAILS Location:

Details: (Please attach any available information) Signed: Dated: The CCG Local Counter Fraud Specialist will undertake to acknowledge receipt of this referral within 5 working days unless otherwise requested.

(please continue on a separate piece of paper and attach if necessary)

1




Title: Constitutional Amendments

Lead Governing Body Member: Sabrina Armstrong, Director of Corporate Services


appropriate

()

Report Author: Laura Parsons, Head of Corporate Governance & Risk

Decision


Discussion


Information











The CCG is required to have robust governance arrangements





N/A



N/A

2

EXECUTIVE SUMMARY: 1. At the last meeting, the Governing Body approved terms of reference for the Audit,

Remuneration & Nomination and Quality & Performance Committees.

2. Members were also informed that the CCG Constitution includes reference to a Finance Committee, Clinical Commissioning Forum and Patient Assurance Group. It is proposed that these Committees are removed from the CCG Constitution as Governing Body Committees.

3. It is proposed that finance functions will be overseen by the Governing Body, therefore a

Finance Committee is not required. A Commissioning for Value Delivery Board has also been set up which will report to the Executive Management Team. The Governing Body will receive regular updates on Commissioning for Value and will also be asked to approve any investments over £1.5m, in line with the operational scheme of delegation.

4. It is recognised that a Clinical Commissioning Forum (CCF) is required to ensure appropriate clinical advice and input into commissioning proposals and this will be a key part of the Commissioning for Value process. Therefore the forum will continue to exist as an advisory group.

5. The Patient Assurance Group (PAG) will also continue to exist as an advisory group to

ensure that all phases of the commissioning/decommissioning cycle are developed with appropriate and sufficient public engagement plans and activities. This is being developed with input of the Lay Member – Patient and Public Involvement who will chair the Group.

6. The CCF and PAG are key elements of the Commissioning for Value framework and

business cases will not be able to progress without appropriate input from these forums.

7. There are also some further minor amendments proposed to the Constitution, to ensure that it remains up to date. A full list of amendments is attached at Appendix 1 and the full Constitution including tracked changes is available on request from the Corporate Governance team.

NEXT STEPS: 8. If agreed, the proposed amendments will be presented to the Council of Members for

agreement prior to submitting to NHS England for final approval.


(a) AGREE the proposed amendments to the Constitution for agreement by member

practices and approval by NHS England.

SUMMARY OF PROPOSED AMENDMENTS TO NHS LEEDS CLINICAL COMMISSIONING GROUP CONSTITUTION – JULY 2018

Page 1 of 1

Page No Paragraph Reference

Summary of change made

7-10 3.1.1 Updates to member practice list to reflect changes to practice names etc.

11 4.2 4.3

Updates to values and aims to reflect the CCG Strategic Plan

17 5.2.7 Change from ‘committee’ to ‘group’ to reflect that the Patient Assurance Group will be an advisory group rather than a committee

26 6.6.1 (d) Correction of typographical error

27 6.6.2 (i) ii) Change of title from Clinical Director to Medical Director

28-29 6.6.4 (d), (e) and (f)

Removal of Finance Committee, Patient Assurance Group and Clinical Commissioning Forum as Governing Body Committees

36 7.16 Change of title from Clinical Director to Medical Director

47-51 Appendix B

Updates to member practice list to reflect changes to practice names etc.

57 2.2.7 Update title from Secondary Care Consultant to Secondary Care Specialist Doctor to ensure consistency

59 2.2.10 Change of title from Clinical Director to Medical Director

60 3.1.2 Removal of reference to Finance Committee, Patient Assurance Group and Clinical Commissioning Forum as Governing Body Committees

62 3.8.1 Correction of typographical error

1

GOVERNING BODY FORWARD WORK PLAN 2018/19

ITEM JULY SEPT

NOV JAN MAR Lead

Officer

STANDING ITEMS

Welcome & apologies X X X X X Chair

Declarations of interest X X X X X Chair

Minutes of previous meeting X X X X X Chair

Matters arising X X X X X Chair

Action log X X X X X Chair

Questions from members of the public X X X X X Chair

Patient Voice X X X X X JH

PERFORMANCE

Chief Officer’s Report X X X X X PC

Integrated Quality & Performance Report X X X X X TR / JH

FINANCE

Finance Report X X X X X VPS

Approval of Annual Report & Accounts VPS

Approval of Annual Budget X VPS

CCG Financial Control, Planning and Governance Self-Assessment

X X

X X VPS

STRATEGY

Strategic Review:

- CCG Strategy

- Leeds Health & Care Plan

- West Yorkshire & Harrogate STP

X X X X X

PC

Commissioning for Value Update X X X X TR

CCG Operating Plan X TR/VPS

People & OD Plan X SA

Winter Plan X SR

RISK

Governing Body Assurance Framework X X X X X PC

Corporate Risk Register X X X X X PC

STATUTORY DUTIES

Assurance on delivery of Statutory Duties X Various

GOVERNANCE

Approval of Procurement Plan 2018/19 X VPS

Approval of Business Cases/Investments over £1.5m (as required)

Various

Chair’s Summary of Committee Meetings X X X X X Committee Chairs

2

ITEM JULY SEPT

NOV JAN MAR Lead

Officer

Committee Terms of Reference

X Committee Chairs

Committee Annual Reports

X Committee Chairs

Approval of Governing Body Appointments / Reappointments (as required)

Chair

Approval of amendments to Constitution (as required)

X

Chair

Forward Work Plan X X X X X Chair

Policy Approval (as required) Various

Review of Operational Scheme of Delegation X VPS

WY&H Joint Committee of CCGs – 06/03/2018

Page 1 of 5

West Yorkshire & Harrogate Joint Committee of Clinical Commissioning Groups

Minutes of the meeting held in public on Tuesday 6th March 2018

Kirkdale Room, Junction 25 Conference Centre, Armytage Road, Brighouse, HD6 1QF

Members Initials Role and organisation

Marie Burnham MB Independent Lay Chair

Fatima Khan-Shah FKS Lay member

Richard Wilkinson RW Lay member

Dr James Thomas JT Chair, NHS Airedale, Wharfedale and Craven CCG

Dr Akram Khan AK Chair, NHS Bradford City CCG

Dr Andy Withers AW Chair, NHS Bradford Districts CCG

Helen Hirst HH Chief Officer, NHS Bradford City, Bradford Districts and AWC CCGs

Dr Alan Brook ABr Chair, NHS Calderdale CCG

Dr Matt Walsh MW Chief Officer, NHS Calderdale CCG

Dr Steve Ollerton SO Chair, NHS Greater Huddersfield CCG

Carol McKenna CMc Chief Officer, NHS Greater Huddersfield CCG and North Kirklees CCG

Dr Alistair Ingram AI Chair, NHS Harrogate & Rural District CCG

Amanda Bloor ABl Chief Officer, NHS Harrogate & Rural District CCG

Philomena Corrigan PC Chief Executive, NHS Leeds CCGs Partnership

Dr David Kelly DK Chair, NHS North Kirklees CCG

Dr Phillip Earnshaw PE Chair, NHS Wakefield CCG

Apologies

Dr Jason Broch JB Chair, NHS Leeds North CCG

Dr Alistair Walling AWa GP Clinical Lead, NHS Leeds South & East CCG

Dr Gordon Sinclair GS Chair, NHS Leeds West CCG

Jo Webster JW Chief Officer, NHS Wakefield CCG

Emma Fraser EF Programme Director, Mental Health

Ian Holmes IH Programme Director, WY&H STP

In attendance

Lou Auger LA Director of Delivery, West Yorkshire, North Region NHS England

Karen Coleman KC Communication Lead, WY&H STP

Stephen Gregg SG Governance Lead, Joint Committee of CCGs (minutes)

Anthony Kealy AKe Policy Lead, WY&H STP

Martin Pursey MP Head of Contracting, Greater Huddersfield CCG

Jonathan Webb JWe Director of Finance, WY&H STP

14 members of the public were also in attendance.


Page 2 of 5

Item No. Agenda Item Action

39/18 Welcome, introductions and apologies

MB welcomed all to the meeting and reminded everyone of the role of the Joint Committee. Apologies were noted. MB highlighted the sustainability benefits of paperless meetings and that many Committee members would be using electronic devices to access agenda papers.

40/18 Open Forum

MB invited members of the public to ask questions about items on the agenda. 4 members of the public asked questions. MW responded on elective care and standardisation and CMc on urgent care:

Elective care and standardisation

Q. How would the supporting healthier choices programme be commissioned, funded and provided?

A. The aim was to build capacity in existing organisations and collaborate at local level across WY&H. The emphasis was on prevention, choice and directing people towards the most appropriate care to produce better outcomes. It was too early in the process to consider possible approaches to tendering and contracting.

Q. How was the Academic Health Science Network involved and would advertising and digital technology play a part in encouraging behaviour change?

A. We are working closely with the AHSN, which has significant expertise in behaviour change. Advertising and digital technology would both be used to encourage healthier lifestyles.

Q. How was the programme addressing the risk that access to eye and orthopaedic procedures would be restricted?

A. Clinicians would continue to make decisions about access, on the basis of the needs of individual patients. The programme would not change this.

Urgent and emergency care

Q. Concern that the re-procurement of integrated urgent care services would lead to the break-up of the NHS.

A. Partners in Yorkshire and the Humber were responding to a national specification. Whatever service model was selected, the aim was to secure greater integration of NHS services, not fragment them.

Q. Was evidence from previous Vanguard projects being used to shape the design of services?

A. Yes, the aim was to learn from all of the available evidence and spread best practice.

MB said that the questions would also be taken into account in the relevant agenda items. The full questions and written responses would be provided after the meeting and would be published on the Joint Committee webpage.

SG

41/18 Declarations of Interest

MB asked Committee members to declare any interests that might conflict with the business on today’s agenda. There were no additional declarations.


Page 3 of 5

42/18 Minutes of the meeting in public – 9th January 2018

The Committee reviewed the minutes of the last meeting.

The Joint Committee: Approved the minutes of the meeting on 9th January 2018.

43/18 Actions and matters arising

The Joint Committee reviewed the updated action log. There were no matters arising.

The Joint Committee: Noted the action log.

44/18 Mental Health

HH presented the report. She highlighted how MH providers were working together to share beds and improve access to local services. CCGs were reviewing commissioning plans, working to reduce variation and establish common levels of community services across WY&H. Each CCG was now leading on a specific area of work.

HH also highlighted:

Work to improve collaboration on providing locked rehabilitation units. Proposals for alternative models would be brought back to the Joint Committee.

The development of a new Child and Adolescent Health services (CAMHs) pathway aimed at improving community provision and reducing the use of tier 4 beds.

Collaborative work which was leading to a richer commissioning picture of learning disabilities, adoption services and dementia.

HH noted the need to assess the overall value for money of services. Reducing out of area placements and increasing the availability of local services improved VFM, but there was a need to reinvest savings into community based services.

In response to a question from PC, HH recognised the need to understand the case mix for CAMHs, particularly in relation to eating disorders. Responding to questions from FKS, HH advised that local authorities and the police were involved in a number of workstreams. HH would ask the MH team to advise on how the programme was ensuring a focus on the needs of young people and BME communities.

HH noted that work to reduce out of area placements was driven by direct patient experience. A lot of local public engagement was taking place at local level, but that there was further work to do at WY&H level. MB noted the good progress being made by the MH workstream and welcomed the focus on learning disabilities.

HH

The Joint Committee:

1. Noted the report and endorsed continued collaborative commissioning work to support the delivery of the mental health programme.

45/18 Urgent and emergency care

CMc presented the report. In WY&H, the Joint Committee had delegated authority from the CCGs to agree future arrangements for 111 and Urgent Care services. CMc had previously advised the Committee that NHS England required all CCGs to have an Integrated Urgent Care (IUC) programme by 1 April 2019.


Page 4 of 5

The report today sought approval to undertake a formal procurement process. The current NHS 111 contract with the Yorkshire Ambulance Service (YAS) ended in March 2018. A one year interim contract was being negotiated with YAS for 2018 -19, and it was recommended that there also be allowance for a 6 month extension to ensure service continuity and minimise risk.

The work was being overseen by the Y&H Joint Strategic Commissioning Board (JSCB), which had sought expressions of interest from prospective providers. The JSCB recommended a structured dialogue approach. MP advised that this approach enabled discussion with potential providers to define and refine the service model. This was particularly important given the complexity of delivering services in 3 STP areas across Y&H.

RW welcomed the structured dialogue approach, but also noted the potential risk of destabilising YAS. CMc acknowledged the risk and that steps were being taken to mitigate it. MP noted that work was ongoing to ensure the continuity of current services at the same time as managing the commissioning process.

Responding to questions from SO, MP noted that the aim was to ensure a collaborative approach to the provision of GP Out of Hours services. In relation to a Clinical Advice Service, MP noted the difficulties in integrating a range of providers, but the aim was to ensure a fully integrated service. The time needed to complete the procurement process would only become clearer when the number of interested providers was clearer.

LA noted the deadline of April 2019 for putting the service in place. She felt that there was a need to increase pace, which might need additional resource.

AW asked whether other STP areas had agreed the proposal. CMc advised that CCGs in other STPs would need to take the proposal through their individual governing bodies. Work was ongoing with the urgent care leads in the other STP areas to minimise the risks. In response to a question from DK, MP said that the WY&H urgent and emergency care workstream was exploring options for GP out of hours services and would link into the commissioning process

ABr asked whether proposals shared by providers in a structured dialogue were subject to ‘commercial in confidence’ restrictions. MP said that this would depend on the nature of the proposal, but that the overall approach would encourage sharing, so as to arrive at the optimum service model. Responding to a comment from SO, LA acknowledged the need for NHSE to clarify the commissioning approach to dental services.

HH asked queried the total financial resource that was available and the financial model that was being applied. MP confirmed that the presumption was that there would be no additional monies. There might be flexibility between the components, but this would be within the overall affordability envelope. The Finance workstream was developing the detail.

LA

The Joint Committee:

1. Ratified the recommendation of the Commissioner- only JSCB that the appropriate route to market is through a competitive procurement process and instruct the JSCB to implement this decision.

2. Ratified the recommendation of the use of a dialogue based process to deliver the service model.

3. Ratified the recommendation to negotiate an interim contract with the current 111 provider for 18/19 that has the ability to be extended for six months as a means of mitigating any risks relating to continuity of service, should unavoidable slippage occur.


Page 5 of 5

4. Noted the risks associated with the procurement process and supported the core team to mitigate these.

46/18 Elective care and standardisation of commissioning policies

Matt Walsh presented the report, noting the need to maintain focus and resist pressures to expand the scope of the programme. A Programme Director had been appointed and the Programme Board enjoyed good involvement from CCG commissioning managers. 2 Lay members were being sought.

He presented proposed high level eye care and musculoskeletal / elective orthopaedic pathways and proposals for Procedures of Limited Clinical Value (PLCV) and prescribing. The aims of the programme included changing the relationship between people and services and developing local capability to reduce unnecessary dependency on hospital care and improve outcomes.

There were governance risks attached to the ‘Do once and share’ approach to new policies. Robust equality and quality impact assessments would be important and Joint Committee would need to develop an agreed approach. AW noted a potential role for the Clinical Forum. MW would bring back proposals for initial discussion in a Joint Committee development session.

MW noted the need to explore the detail of the financial efficiency opportunities of £50m that had been identified. He said that the primary driver of the approach would be to improve quality.

SO noted the need to develop capacity for high volume eye care procedures in the community, and to ensure that specialised care was available in acute hospital settings. He highlighted an error in the orthopaedic pathway diagram.

FKS supported the ambition to improve quality and reduce variation and asked if exemptions would be applied to mitigate any adverse effects on individuals. MW said that the programme had a strong focus on the effects of poverty and addressing health inequalities. Clinicians would continue to focus on the individual needs of patients.

ABr supported the objectives of the programme, highlighting the need to address the workforce issues that were leading to capacity problems in some hard pressed specialties. MW acknowledged that the need to work closely with the STP workforce programme.

MW

The Joint Committee agreed: 1. The high level pathway for eye care. 2. The consideration of emergency eye care services where these interface

indivisibly with planned care services for eye health. 3. The high level pathway for elective orthopaedic services. 4. The recommendation to exclude non-clinical services from the PLCV work

programme. 5. The clinical inclusion, exclusion and prioritisation proposals for the PLCV

programme. 6. The ‘Do Once and Share’ approach to delivery of the PLCV programme. 7. The proposals for the ongoing development of the prescribing programme.

47/18 Any other business

There was none.

Next Joint Committee in public – Tuesday 5th June 2018, Kirkdale Room, Junction 25 Conference Centre, Armytage Road, Brighouse, HD6 1QF.

AGENDA NHS Leeds CCG Governing Body Meeting · 25/07/2018 · Governing Body Meeting Date:...

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Transcript of AGENDA NHS Leeds CCG Governing Body Meeting · 25/07/2018 · Governing Body Meeting Date:...