Chair’s Report - March 2018

The last few months have seen immense pressure on all NHS services, nationally, regionally and locally as we have experienced and continue to experience a challenging winter season. The demand on our services continues and I am proud of the contribution our organisation has made, and will continue to make, to the wider health and social care system across Wirral. HEART Awards Our committed staff demonstrate their professionalism and care on a daily basis and it has therefore been a pleasure to announce the shortlist for our annual HEART awards; my first as Chairman of this organisation. These awards recognise the superb work of our services and teams and this year we received over 100 nominations across 7 categories. We are all looking forward to the awards ceremony on 16 March 2018 and I extend my thanks to Board colleagues, staff, and public members from across the Trust that were part of the judging panels; not an easy job but I am sure completed with such fairness and enthusiasm! Good Luck to all those shortlisted and many congratulations to every team and individual that received a nomination, itself a tribute to outstanding performance. I continue to be impressed and proud of this organisation and have really appreciated having the opportunity to begin a programme of leadership walkrounds, visiting both clinical and corporate teams. The enthusiasm and dedication of our staff and the range of services and care provided is impressive. Council of Governors We were pleased to welcome our new governor colleagues to an induction session at the end of January 2018, providing them with an introduction to the Trust and their important role as governors. We are indeed fortunate to enjoy the commitment and enthusiasm of all our governors and we look forward to working with our new colleagues over the coming months. In mid-February we had a full Council of Governors meeting where we shared progress on the development of our future plans and strategic direction. We have been delighted with the engagement we have had with key stakeholders, including our governors, in the development of our strategy and recognise the valuable insight this gathers. As we approach the end of the financial year 2017/18, the development of our Annual Report & Accounts and our Annual Quality Report is a key focus. The governors’ Quality Forum has discussed the quality indicators to be included in the Quality Report and we were pleased to receive consensus and approval from the full Council of Governors on the mandatory and local indicators which will be tested by our external auditors as part of their audit plan. We were also joined at the meeting by our new external auditor’s colleagues from Ernst & Young, who are already working well with key colleagues across the Trust. CQC Inspection I reported in January 2018 that the Trust had responded to an annual Provider Information Request (PIR) from the CQC and we have since been advised that the CQC will be inspecting Trust core services and conducting a well-led inspection between now and the end of March 2018. We welcome this opportunity to share all of the good work the Trust delivers to the local community with the inspection team.

Non-Executive Director appraisals We will shortly be approaching the annual appraisal window for the organisation and the Chief Executive and I will be starting the process with the appraisals of members of the Board of Directors. I will be sharing the outcome of NED appraisals with the Lead Governor and members of the Remuneration & Nomination sub-group in May 2018. Director of Nursing & Quality Improvement Importantly, I would like to recognise our colleague Sandra Christie, who will be leaving the Trust at the end of March 2018 to start her retirement after 35 years in the NHS. Sandra has been a highly respected figurehead in the Community Trust since its establishment in April 2011 and particularly following her appointment as Director of Nursing & Quality Improvement in 2013. I know Sandra will be missed by many across the organisation for her leadership, clinical knowledge and incredible commitment. On behalf of the Board of Directors and the Trust, I wish Sandra well as she embarks on a new and, I am sure, very interesting and varied new chapter in her life. Good luck Sandra and thank you for everything that you have done for the Trust and the people of the Wirral, especially your comradeship and fundamental drive for quality care at all times. Healthy Wirral - Healthy Wirral Partners Board The drive to optimise services across the Wirral by utilising joined up working is gaining some pace. A decision to appoint an Independent Chair to oversee and guide the process has been made and an appointment is about to be made. The Independent Chair will report to a group of Wirral Chairs (the two commissioners, the three providers and the two GP federations) and the shortlisted candidates will be interviewed on 1 March 2018 by these chairs to make an appointment. Professor Michael Brown CBE DL Chair 1 March 2018

Report from the Council of Governors - Lead Governor

1. As Lead Governor, I am keen to ensure that the Board of Directors receives a regular update on the work of the Council of Governors.

2. The Council of Governors met in mid-February 2018 and we were delighted to welcome our new colleagues following their initial induction at the end of January 2018.

Staff Governor Fiona Fleming, Senior Communications Officer

Public Governor (Wallasey) Dr Paul Ivan Public Governor (Birkenhead) Angela Gill

3. The meeting was informative with some key updates provided to the Council of Governors particularly on the development of the Trust’s new strategy and agreement was reached on the local indicators to be tested as part of the Trust’s Annual Quality Report.

4. A number of governor colleagues including myself have taken part in the judging for the annual

HEART awards. This year the number of nominations received was incredible making the judging even more of a privilege but even more difficult. Our thanks to members of the Board for chairing the judging panels so well and to the Communications & Marketing Team who lead and oversee the whole process with such professionalism and enthusiasm. It is a privilege to be part of this process and on behalf of the Council of Governors I extend our congratulations to everybody that received a nomination and the best of luck to all those shortlisted.

5. At our Council of Governors meeting in mid-February we received a briefing on the forthcoming CQC inspection of the Trust. Whilst we do not expect to be involved in the inspection I would like to acknowledge this important event for the Trust. As Lead Governor I believe this is an opportunity for the staff of this organisation to demonstrate the high quality and effective care they are delivering, in often challenging circumstances, every day to the people of Wirral. I know the staff are looking forward to having the opportunity to share their experiences and best practice to the CQC inspection team and I believe the members of the Board and senior managers will fully engage in the well-led element of the inspection demonstrating the sounds systems and processes in place to ensure this Trust continues to deliver to the expectations of regulators, commissioners and most importantly the public.

6. We are looking forward to the next meeting of the Your Voice in late March 2018 to welcome

new members to the group including representatives of the social care community, new governor representation from our Birkenhead and Wallasey constituencies and our colleagues from Healthwatch. This group will begin to consider our key membership engagement activities for the forthcoming year to ensure we (the governors) have the opportunity to effectively represent the views of the members and the wider public.

7. The Board of Directors is asked to note this update.

Irene Cooke Lead Governor

1 March 2018

Chief Executive’s Report - January 2018

Meeting Board of Directors Date 7 March 2018 Agenda item 8 Lead Director Karen Howell, Chief Executive Author(s) Alison Hughes, Director of Corporate Affairs

To Approve

To Note

To Assure

Link to the Board Assurance Framework (strategic risks) Please mark against the principal risk(s) - does this paper constitute a mitigating control?

Our Patients and Community Our People Our Performance

Quality and safety including addressing

inequalities is not maintained or improved

Lack of, or ineffective engagement and 2-way communication with staff

& governors

Failure to respond to system changes and the requirements of the NHS Five Year Forward View

Patient experience is not systematically collected, reported or acted upon

Failure to maintain a competent, engaged and resilient workforce that

feels trusted, listened to and valued at work within a changing environment

Failure to deliver the efficiency programme

and achieve all the relevant financial statutory duties

Inability to deliver the benefits of integration

within the defined timescales

Failure to provide quality training and supervision

and opportunities for career development for

all staff

Inability to sustain performance against

contractual and financial targets

Link to strategic objectives & goals - 2017-19

Please mark against the strategic goal(s) applicable to this paper Our Patients and Community - To be an outstanding trust, providing the highest levels of safe and person-centred care We will deliver outstanding, safe care every time

We will provide more person-centred care

We will improve services through integration and better coordination Our People - To value and involve skilled and caring staff, liberated to innovate and improve services We will improve staff engagement

We will advance staff wellbeing

We will enhance staff development

Our Performance - To maintain financial sustainability and support our local system

We will grow community services across Wirral, Cheshire & Merseyside

We will increase efficiency of corporate and clinical services

We will deliver against contracts and financial requirements

Link to the Organisational Risk Register (Datix) No direct link to any organisational risks on the risk register. This report provides an overview of key developments across the organisation which may have associated risks recorded on the risk register; these would be reported as part of the Integration Performance & Risk Report to the Board of Directors.

Has an Equality Impact Assessment been completed?

Yes No

Paper history Submitted to Date Brief Summary of Outcome

The Chief Executive’s report is a regular report to the Board of Directors.

Chief Executive’s Report - March 2018

Introduction 1. The purpose of this report is to appraise members of the Board of Directors on developments

of national interest, and issues relating to the local health and social care economy, particularly those that may impact upon the Trust, and its further development.

2. This report also intends to provide a brief overview of the communications and engagement

activities undertaken by the Chief Executive, both internally and externally and any forthcoming events.

3. Finally, this report includes a summary of business conducted through the Executive

Leadership Team meetings during January & February 2018. 4. I also include the Executive briefing for January & February 2017, for noting at

appendix 1.

National news and developments Secretary of State for Health and Social Care

5. Following the prime minister’s Cabinet reshuffle in early January 2018, Jeremy Hunt is continuing his six-year stint as health secretary with the expanded title of secretary of state for health and social care. This reappointment means Mr Hunt is almost certain to become the longest-serving senior health minister since the NHS was created.

NHS Improvement and NHS England closer alignment

6. At a board meeting in January 2018, the Chair of NHSI summarised developments in the closer alignment of the work of NHS England (NHSE) and NHS Improvement (NHSI), including cross representation on each other’s boards.

7. The NHSI board has appointed David Roberts (deputy chairman, NHSE) as a non-voting associate NED on a two-year term from February and Richard Douglas (NED, NHSI) will join the NHSE board in a similar capacity.

8. Richard and David will co-chair the NHSE/NHSI Joint Finance Committee to ensure that both organisations have a common understanding of the financial targets and performance of the health system as a whole.

9. NHSI and NHSE intend to have two joint board meetings in 2018, which are planned for May and September.

NHS providers’ deficit position

10. Latest figures reveal worsening provider deficit. Trusts are expected to end 2017/18 with a deficit of £930m, far more than the £496m target set by ministers and NHS bodies at the beginning of the year.

NHS Providers briefing on Accountable Care & STPs

11. It was announced at the end of January 2018 that NHS England and the government would delay the creation of the first Accountable Care Organisations (ACOs) until a national consultation could be held on the issue.

12. Jeremy Hunt, in response to the Commons Health Select Committee, said that he expected NHS England’s national public consultation on the draft ACO contract, which will be released in spring of 2018, to explain what ACOs are and are not and detail the terms of the contract.

13. ACOs emphasise place and population rather than specific organisations or groups, and aim to

improve some of the issues surrounding the link between health and social care.

14. NHS Providers has produced a background briefing which brings together information on the development Sustainability and Transformation Partnerships (STPs), Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs).

15. This briefing (attached at appendix 2) draws on national policy information and includes;

• the national policy story so far, as ‘plans’ evolved into ‘partnerships’ • definitions of key terms associated with STPs, accountable care, and new care models • five conditions for success based on NHS Providers discussions with trusts • NHS Providers’ position and information on the support trusts can access

Consultation on draft health and care workforce strategy 16. Health Education England (HEE) has published ‘Facing the facts, shaping the future, a draft

health and care workforce strategy for England to 2027’. This follows the secretary of state’s commitment at the NHS Providers annual conference in late 2017 that for the first time the health and care system would have a long-term national workforce strategy.

17. A consultation on the draft strategy will run until Friday 23 March 2018 and the final version of the strategy will be published in July 2018.

18. HEE is proposing a set of six high level principles that will underpin future workforce decisions:

• Securing the supply of staff, with particular attention on the supply of the UK workforce in order to lessen the need to recruit staff from other countries.

• Enabling a flexible and adaptable workforce through investment in education and training of new and current staff. While recognising that NHS professionals have distinct roles, HEE has acknowledged there is scope for blending clinical responsibilities which can be rewarding for staff.

• Providing broad pathways for careers in the NHS, with structured career opportunities to enable staff to progress both within and between professions.

• Widening participation in NHS jobs, so that people from all backgrounds have the opportunity to contribute and benefit and the NHS workforce of the future more closest reflects the populations it serves.

• Ensuring the NHS and other employers in the system are inclusive modern model employers, with flexible working patterns, career structures and rewards. Part of this involves addressing the changing expectations of all generations who work in the NHS.

• Ensuring that service, financial and workforce planning are intertwined. Alignment across these areas is intended to foster realism alongside creativity in considering what the workforce can contribute to a new or changing service.

Cavendish coalition publish Brexit impact feedback from NHS Employers

19. NHS Providers, NHS Employers and The Shelford Group, under the umbrella of the Cavendish Coalition, have published the views of NHS trusts about the impact of Brexit on staffing leading up the outlined agreement between the UK and the EU on citizen’s rights in December 2017.

20. Since the referendum result, the Coalition has been tracking the views of NHS trusts about how

the UK’s withdrawal from the European Union will affect their ability to hire and retain staff through its quarterly Brexit impact survey.

21. The group have conducted four surveys since the referendum result in June 2016 and will be continuing to run these surveys throughout 2018.

22. The below infographic records feedback up until June 2017 and highlights a growing concern that Brexit will have a negative impact on ability to hire staff.

23. On this theme, new workforce data reveals 100,000 NHS posts are vacant; NHS Improvement’s quarterly statistics released show that more than 8% of NHS Posts are vacant, including one in ten nursing roles.

‘Five Year Forward View’ for Community Services 24. The Kings Fund has published a report clearly stating that NHS England should publish a ‘Five

Year Forward View’ for community services and the sector should be given ‘priority’ for additional NHS funding.

25. The report also suggested that any additional money for the NHS should be given to the sector to “tilt” the balance of funding between community and acute services. It goes on to say that it is not “credible” to shift existing funding from acute hospitals due to the pressures on them, but community services should have “priority” in the allocation of additional funding. The report also concluded that there were “severe workforce shortages” in community services, and said the number of district nurses working in the NHS fell by 20% between July 2014 and July 2017.

26. We understand that NHS Providers is working with the NHS Confederation and Community

First to establish a new community network which will ensure that there is a strong voice for community services, promoting their voice and helping to develop their links with the rest of health and social care. We welcome this support.

27. Furthermore, the Community Services CEO network is in regular contact via e-mail and webinar on this topic, and believes that the lack of a plan is not only hugely disappointing but has the real potential to slow down or feter innovation and required service redesign.

Planning guidance 2018/19 published 28. The new planning guidance has been published and is a refresh of plans already prepared

under the two-year NHS Operational Planning and Contractual Guidance 2017-19. It sets out detail of how additional funding from the November 2017 budget will be allocated and the developments in national policy in respect of system level collaboration.

29. We will be submitting our draft operating plan on 8 March 2018 with final approved plans to be submitted by 30 April 2018.

30. I attach at appendix 3 a useful briefing from NHS Providers on the implications of the planning guidance.

Winter resilience 31. The pressures on the health and care system during winter have been well publicised. NHS

England performance data reveals 150,000 patients have waited for longer than 30 minutes in ambulances before being admitted to A&E this winter. The CQC has rescheduled some routine inspections of NHS acute services, GP practices and urgent care services in response to increased pressure on the system.

32. We have continued to play our part in supporting the Wirral system during this challenging winter period. All the efforts and commitment by the workforce has been recognised and resulted in performance significantly improving with Wirral being the top performing system for A&E across Cheshire & Merseyside. This has been acknowledged nationally by NHSE and NHSI with feedback requested on what has worked well to share with other systems. My sincere thanks are extended to everybody who has supported the system during winter and particularly for the close collaborative working with colleagues at Wirral University Teaching Hospital.

Kirkup Review into Liverpool Community Health 33. The independent review was commissioned by NHS Improvement (NHSI) following concerns

raised about care delivered at Liverpool Community Health NHS Trust (LCH) during November 2010 to December 2014.

34. The review found that the trust experienced significant failings in care quality, including an inexperienced management and director team. The review found that the trust was focused on its pursuit of Foundation Trust status and achieving very significant cost savings required by its commissioners.

35. The review also examined the role of external bodies responsible for overseeing the trust suggesting that they all had sufficient indication of the problems at the trust to prompt a more complete examination of its services.

36. Whilst the review examined LCH specifically, its recommendations are likely to impact on the sector as a whole, including the role of national bodies. We welcome this review and are carefully reviewing its recommendations and will be discussing them as part of our on-going programme of board development. We will also be keen to receive further briefings from NHS Providers who will be monitoring the wider implications of the recommendations.

37. The briefing from NHS Providers is attached at appendix 4.

Local news & developments Quarterly Review Meeting (QRM) with NHS Improvement 38. The Executive Team and I had a very positive check point meeting with NHSI in

mid-February where the regulator tests and challenges us on our performance; financial, activity and quality. These meetings are increasingly also focused on the development of place-based system working across Wirral and Cheshire, and how we are playing our part with partner organisations to improve and sustain NHS and social care services for local people.

39. NHSI continue to be assured and complementary by the services we deliver and the trust’s financial management in these challenging times. The work the trust has done to support the system during a challenging winter period was also acknowledged.

HEART Awards shortlist announced

40. We were delighted to publish the short list for our annual Heart Awards and look forward to the

awards ceremony on 16 March 2018. I extend my congratulations to everyone who received a nomination this year. Our judging panels had a harder task than ever before with over 100 wonderful nominations to read, digest, discuss and agree upon.

Admin review - organisational lessons learned 41. Following the completion of the Admin Review across the organisation we held a lessons

learned exercise with key stakeholders including Joint Union Staff Side, those directly affected by the review and HR representatives.

42. The purpose of the meeting was to discuss organisational learning that has arisen from the change process; the key actions have been made available to all those directly affected by the review and my thanks to all those involved for supporting this change process.

Appraisal cycle

43. We will shortly be starting our annual appraisal cycle having reviewed the timetable from

previous years. I will be commencing Executive Leadership Team appraisals from the beginning of April 2018 with the Chairman also conducting Non-Executive Director appraisals. The window for the rest of the organisation will be open from April - June 2018.

Joint Union Staff Side Chair

44. Becky Smith has been appointed as staff side Chair.

45. We welcome Becky’s valuable contribution as a member of JUSS over the last few years and look forward to working with her as Chair.

46. Our thanks to Di Moore who has been Chair of JUSS since February 2017 and has provided

valuable leadership. Staff Council Chair 47. We also extend congratulations to Fiona Davies who has been appointed as the Joint Chair of

Staff Council and offer our sincere thanks to Tom Meade who has stepped down following his appointment as Chair in July 2016.

Urgent and Emergency Care Review 48. Throughout February, Wirral CCG invited views from the public and local stakeholders on the

review of Urgent Care services locally. They have spent time in the Walk-in Centres to gather views and opinions and they have also had an online survey open to all Wirral residents which closed on 28 February 2018.

49. These engagement events precede the formal Urgent Care consultation that will launch in spring 2018.

Winter resilience - playing our part

50. As previously recognised the pressure during winter on our health and social care system has been significant and I would therefore like to recognise the continued efforts of our staff in continuing to raise and sustain Wirral’s urgent care performance.

51. Sometimes, when we are extremely busy it is easy to misinterpret the importance of achieving targets and patient care. And whilst achieving targets is important for a variety of reasons, the most important reason is that people receive the care they need when they most need it, and staff feel they can deliver services safely and with dignity.

CQC Inspection

52. Following the completion of our annual Routine Provider Information Request in November/December 2017, we have received confirmation that the CQC will be inspecting the trust through an unannounced and short-notice inspection of core services, an announced inspection of GP OOHs and a well-led inspection. The well-led inspection will take place at the end of March 2018 and the GP OOHs inspection on 6 & 7 March 2018. The inspection of our core services will take place at any time before the well-led inspection.

53. We welcome this inspection; we have great teams, amazing staff and provide excellent care to our community. We know our services and teams are looking forward to having the opportunity to share their story, celebrate what they do and demonstrate how they provide high quality care and support to the people of Wirral, to the inspection team.

54. My thanks are extended to the teams who are already working closely with the CQC inspection team to ensure all appropriate arrangements are made in advance and that their requirements are fully met.

Strategy refresh

55. We will be finalising our strategy refresh over the next month and were pleased to have the opportunity to share our plans and strategic intentions with the Council of Governors in mid-February. The involvement and engagement we have enjoyed from board level to front-line staff and with stakeholder organisations has been incredibly useful.

56. In reviewing our strategy we have also completed a review of our key strategic risks which will form the basis of our Board Assurance Framework for the next financial year.

0-19 Health and Wellbeing Hub launched 57. Congratulations to our 0-19 team in Wirral on a very successful launch event for their new

Health and Wellbeing Hub for school aged children, young people and their families. The event was well attended by professionals from across Wirral.

58. The Health and Wellbeing Hub provides a safe and confidential environment to discuss health-related topics including: healthy eating, weight management, sleep behaviour, bed wetting, behavioural concerns, emotional wellbeing, confidence/self-esteem and lifestyle advice, as well as signposting and referrals to other services as required.

Welcoming Lyn Romeo, Chief Social Worker (Adults)

59. Wirral’s Adult Social Care Conference took place in early February and we were delighted to welcome Lyn Romeo, Chief Social Worker for Adults (England) at Department of Health as keynote speaker. Lyn’s visit was a fantastic opportunity to share what a great story we have here in Wirral and what we have achieved. Key messages focused on the strengths of social workers and how their contributions are vital to improving outcomes for people, not just meeting targets, but really looking at how people’s lives are better

Sustainability & Transformation Plans - NHS Cheshire & Merseyside Health & Care Partnership

60. Following my update in January 2018 confirming the appointment of a VSM Director of HR to support me in the role of Strategic Workforce Lead for Cheshire & Merseyside, I am pleased to confirm that Chris Samosa has now started in post. I will also be interviewing for a Director of Nursing post in mid-March 2018.

61. The Cheshire & Merseyside Health & Care Partnership Workforce Programme Board will have its inaugural meeting in March 2018.

62. During March I will also be meeting with the Executive Chair, Mr Andrew Gibson, and the SRO Mel Pick up to provide a status report on the Local Workforce Action Board (LWAB), the development of the workforce strategy and the work plan for 2018/19.

Healthy Wirral 63. The collaborative working across the Wirral system through the Healthy Wirral programme

continues and there will be a further ‘lock-in’ session in early March to further progress the key work streams identified and develop the 3 year system sustainability plan.

64. The respective Chairs will be interviewing for the Independent Chair on 1 March 2018 and I was part of the interview panel to appoint to the Programme Manager role.

Wirral Integrated Providers Partnership Board (WIPPB) 65. The Wirral Integrated Providers Partnership Board (WIPPB) has drafted its terms of reference which

will be approved at the next meeting in March 2018.

66. The primary function of the WIPPB has been defined as focusing on the design and delivery of a range of outcome-based services, including their performance and quality. The WIPPB will oversee the development of population-based care delivery ensuring the aim of effective and sustainable place-based care systems are created and maintained.

67. The WIPPB will report to the Board of Directors of each respective organisation and directly to the Healthy Wirral Partners Board via myself as the Chair.

Congratulations!

68. Our congratulations are extended to Joanne Kerr who has been successful in her application to become a Fellow of the Institute of Health Visiting (FiHV).

69. This scheme not only recognises professional achievement, but also identifies and delivers a country wide group of expert and confident health visitor leaders who can work with the Institute and their employers to help strengthen local professional capacity. Well done Joanne!

Thank you and farewell!

70. I would like to add my heartfelt thanks and best wishes to Sandra Christie, Director of Nursing & Quality Improvement who will be retiring from the trust at the end of March 2018.

71. Since I came in to post the support and reliable counsel I have received from Sandra has been

greatly appreciated and valued. Sandra’s consistency, loyalty and professionalism have been exceptional and held in high regard. Sandra leaves a robust legacy including that of developing and supporting our incoming Director of Nursing & Quality Improvement, Paula Simpson.

72. When needed Sandra has been a friend and a confidante to me and for this I am grateful. I am sure I speak for all of the Board when I say Sandra will be greatly missed. I wish her love, laughter, happiness and success in whatever she chooses to do next.

Communications and Engagement 73. I continue to enjoy a programme of communications and engagement activities locally,

regionally and nationally and since last preparing my report I have been involved in a number of local and regional events and meetings.

74. I was pleased to be invited to attend the Wirral Council Cabinet meeting in January to give a

presentation to members on the work of the Trust and specifically the benefits we are realising following the integration of Adult Social Care. The discussions were incredibly useful providing an opportunity for us to consider the challenges and opportunities we face together in Wirral. Following this meeting I have also met with the interim Director of Strategy & Partnerships at Wirral Borough Council to discuss the opportunities of a fully integrated neighbourhood plan.

75. I attended the Cheshire & Merseyside Health & Care Partnership Acute Sustainability Programme Board in mid-January 2018 and I appreciated the opportunity to meet with the interim CEO of Cheshire East Council in January to discuss the progress of our 0-19 contract.

76. As reported in January 2018 I have been delighted to meet with the CEO of Age Concern Wirral and I was thrilled that we were able to arrange our first Exec to Exec meeting with colleagues from Age UK in late January to discuss opportunities and areas for joint working. This was an incredibly refreshing and engaging meeting and we look forward to continuing to build on this relationship.

77. Finally I attended a very useful session at The Innovation Agency to conduct a ‘deep dive’ of The King’s Fund review of the adoption and spread of innovations in the NHS.

Summary of Executive Leadership Team (ELT) business 78. The following is a summary of issues discussed by ELT during January & February 2018

together with subsequent reporting routes through the board and committee structure.

• Regular updates are provided to ELT as follows:

- Five Year Forward View progress through NHS Cheshire & Merseyside Health & Care Partnership, which is reported to the Board of Directors through this report and board development sessions.

- The system’s response to the demands on Urgent Care Services with a weekly review of the SitRep for all Walk-in Centres and the A&E department at Arrowe Park

- Plans being put in place to ensure winter resilience - Integration and system-wide planning for Healthy Wirral, the status of which is reported to

each meeting of the Board of Directors - On-going business development opportunities and any re-tendering of services including

the financial, workforce and quality/safety impact, reported through Business Development Report to the Board of Directors

- Review of staff suggestions submitted following our invitation to all staff as part of our workforce resilience and wellbeing action plan

• During January & February, further specific topics discussed by ELT have included: - CCG draft commissioning strategy 2018-21 - The Director of Nursing & Quality Improvement handover plan

- The approach to CIP planning and service transformation for 2018/19 - Trust strategy refresh and review of strategic risks - Community Services benchmarking reports 2017 - Wirral’s Health & Wellbeing Board Pharmaceutical Needs Assessment (PNA) - NHSI guidance on the Annual Report and Annual Quality Report - Standard quality schedule for sub-contracts - Deployment of single sign-on software throughout the organisation - GP OOHs NQR data submission - CQC inspection preparation action plan

• At ELT/SLT in January 2018 the group received a very useful presentation on Wirral Whole

System Capacity & Demand Modelling. In February 2018 ELT/SLT received a presentation on ‘Organisational governance and your role in providing assurance to the board’.

Conclusion 79. I hope you find this report interesting and helpful and it provides a clear description of the

national, regional and local environment within which we are working and the key activities underway to address our priorities.

Karen Howell Chief Executive Alison Hughes Director of Corporate Affairs 1 March 2018 GLOSSARY: CCG Clinical Commissioning Group WUTH Wirral University Teaching Hospital NHS Foundation Trust NHSI NHS Improvement NHSE NHS England CQC Care Quality Commission LWAB Local Workforce Action Board ELT Executive Leadership Team SitRep Situation Report WIPPB Wirral Integrated Providers Partnership Board

Executive BriefingJanuary 2018

Performance figures for December 2017

4.9%

£1914k - target£1793k - actual

Target = 4%Green = 68Amber = 12Red = 11

Green = 8Amber = 1Red = 0

Quality Goals

Green

Amber

Red

Red

Amber

Green

Red

Performance Figures

The trust reported a £819k surplus at the end of December, rated green as it’s better than plan. CIP overall is red as we saved £1,793k against a £1,914k target. The Finance and Use of Resources Metric remains level 1 (the highest rating), but in order to retain this it is essential that CIP remains a high priority. Focus must remain on ensuring that CIP schemes set for this year deliver and that there is continued effort to identify further savings both for this year and to carry through into 2018/19.

Sickness absence reduced during December to 4.9% (from 5.3% in November) and a significant decrease from 6.2% this time last year.

We continue to maintain good overall progress with 68 KPIs reporting as green. There are action plans in place to support those on red. Thank you for your continued hard work.

At the end of December the trust was 81% compliant for statutory and mandatory training and remains amber. We need to hit 90% to achieve this goal so please ensure all training for both you and your teams is up to date.

CQC Inspection: Feb - March 2018

Our CQC inspection will be in two parts:

1. The well-led inspection from 27-29 March 2018 will consist of a week of interviews with all members of the Board of Directors

2. An unannounced inspection of at least one core service will take place any time between now and the well-led inspection AND a short notice (24 hours) inspection to the rest of our core services.

We will ensure we keep all of our services, teams and staff up to date with the latest information and share important key messages to help with preparations. As a trust we have a good story to share, with great teams and amazing staff providing excellent care.

Executive Briefing - January 2018

Incident Reporting

What would a great day at work look like?

CIP and service planning

When things go wrong in care, it’s vital incidents are reported to ensure learning can take place. By learning, we mean people working out what has gone wrong and why, so that effective and sustainable actions are taken locally to reduce the risk of similar incidents occurring again. Staff reporting incidents helps protect patients from avoidable harm by increasing opportunities to learn from mistakes and where things go wrong.

All staff are responsible for reporting incidents in a timely manner. This is to ensure all incidents are appropriately managed and investigated, based on their severity, and to ultimately learn and make changes to improve safety for patients, staff, visitors and contractors.

We’ve recently seen a fall in incident reporting and everyone is reminded that incidents involving a high level of patient harm or an SUI should verbally be reported to the line manager and DATIX form completed as soon as practicable and within 24 hours. Other incidents should be reported within 1 working day. Please make sure these time scales are shared in your team and all incidents reported.

We are aware of the pressure you are all currently under and the impact it may have on your wellbeing. We want to ensure we are doing all we can to help and support you. With immediate effect we are putting in place a number of ways to help with the day to day problems of IT issues/time pressures, and opportunities to provide feedback:

1. Launching IT Trouble-Shooting SessionsBook a dedicated session for IT to come and see you and your team, listen to your IT problems and resolve as many as possible there and then. Contact Ian Hogan, Deputy Director of IM&T: Ian.hogan@nhs.net

2. Support to cancel all non-critical meetings and visits in January and FebruaryIf you have meetings in your diary that could be postponed without affecting KPIs or quality, please know you have our full support to do so. Hopefully this will help increase capacity.

3. Call for Staff SuggestionsWhat would a great day at work look like? What do you need to make that happen? We want to hear your ideas about what we could start doing, stop doing or what we should continue doing to help support you and look after your health and wellbeing. Please email wcnt.communications@nhs.net with your suggestions.

This month, service transformation plans for 2018/19 will be Quality Impact Assessed so they can be implemented by April 2018. There are £2.2m of transformational savings identified, a great achievement at this early stage.

As part of the national planning process, we soon expect to have our trust CIP target confirmed (so far service level targets have been based on our estimate of the savings required). We will then see how close our 2018/19 plans are to this figure and know what we need to close the gap. Based on feedback, next year we’ll start our transformation planning earlier, with a summer event to share our strategic direction, share good ideas and celebrate our successes.

We will shortly upload a series of ‘Focus On’ articles to StaffZone and will highlight them weekly in staff bulletin. Please can all staff read these and ensure you are familiar with the policy documents and strategies mentioned. We are also producing a CQC checklist for all service leads. When you receive this please review the key actions to ensure you are ready should your service receive an unannounced or short-notice inspection.

Finally all teams will receive a poster confirming your operational lead, your clinical lead and the ‘Freedom To Speak Up’ Guardian and all staff will receive a wallet-sized card reminding them how to raise concerns. Please don’t wait until the inspection to raise any issues or concerns! If there’s something you think we should know, please speak to your line manager or a Freedom to Speak Up Champion (details on StaffZone)

Executive BriefingFebruary 2018

Performance figures for January 2018

6.2%

£2,227k - target£2,033k - actual

Target = 4%Green = 70Amber = 10Red = 11

Green = 8Amber = 1Red = 0

Quality Goals

Green

Amber

Red

Red

Amber

Green

Red

Performance Figures

The trust reported a £1,086k surplus at the end of January, rated green as it’s better than plan. CIP overall is red as we saved £2,033k against a £2,227k target. The Finance and Use of Resources Metric remains level 1 (the highest rating), but in order to retain this it is essential that CIP remains a high priority. Focus must remain on ensuring that CIP schemes set for this year deliver and that there is continued effort to identify further savings both for this year and to carry through into 2018/19.

The sickness absence rate for the trust for the month of January was 6.2% which is an increase from 4.9% in December. The rate remains above the trust target of 4.0%, and above the rate reported for the same period last year (5.2%). The year to date figure is 5.0%. Sickness absence levels remain a significant concern and is recorded as an organisational risk on the trust’s Risk Register.

We continue to maintain good overall progress with 70 KPIs reporting as green. There are action plans in place to support those on red. Thank you for your continued hard work. At the end of January the trust was 82% compliant for statutory and mandatory training and remains amber. We need to hit 90% to achieve this goal so please ensure all training for both you and your teams is up to date.

Bribery and corruption

The trust’s Anti-Fraud, Bribery and Corruption Policy has been updated and is available on StaffZone. The policy outlines key roles and responsibilities of all staff and highlights awareness in relation to the risk of fraud, corruption and bribery. All staff are advised to familiarise themselves with the policy ensuring they are aware of the instructions on reporting suspected incidents.

Please also remember to declare any interests you may have including outside employment, receipt of gifts and hospitality and sponsorship. Staff may not see a potential conflict but caution is always advised. Declaration of Interest forms can be found on Staff Zone and should be returned to Corporate Affairs.

Executive Briefing - February 2018

Uploading photographs to social media

Managers guide for raising and escalating concerns

Data Protection

In a recent incident staff shared photographs from a social event in the workplace on social media, but in the background of the photograph patients name could be seen on an office whiteboard.

Please remember if you refer to your work or study on social media you need to demonstrate respect and professionalism towards all your patients or service users by respecting their right to privacy and confidentiality. This is regardless of whether you believe that there is a risk they could be identified. Sharing confidential information online can have the potential to be more damaging than sharing it verbally due to the speed at which it can be shared and the size of the potential audience.

It is important to remember that although some information may not directly breach a patient’s right to confidentiality when anonymised, people may still be identifiable. It is also important to realise that even the strictest privacy settings have limitations. This is because, once something is online, it can be copied and redistributed.

Having a positive reporting culture, where open dialogue is part of normal every day practice, is key to the delivery of safe and compassionate care. Raising concerns can save lives, jobs, money and the reputation of professionals and organisations. Staff may raise issues about patient care, health and safety, or other types of malpractice such as fraud. Sometimes the concern raised may need to be directed to another area of the business eg, HR. Other issues raised will need more detailed conversations with the individual(s) concerned to determine the seriousness of the situation and identify what action will need to be taken.

Make sure you are aware of and understand the organisation’s Raising Concerns policy (Freedom to Speak Up) (GP51) and your responsibilities as a manager when handling and escalating concerns raised by staff and that your team are all aware of the policy and know who our Freedom to Speak Up Guardian is.

Further guidance and practical steps can be found on StaffZone including contact details for the organisation’s Freedom to Speak Up (FTSU) guardian, Brian Simmons - briansimmons1@nhs.net, and the Freedom to Speak Up team.

We have recently had several incidents which relate to information being added to the wrong patient or service user’s electronic record. Personal information held by the trust is an important and valuable asset.

Sharing personal information between service areas and partner agencies is vital for the provision of co-ordinated and seamless care of individuals. Legislation does not prevent the sharing of information but places important rules and safeguards that must be observed. The Caldicott and Data Protection policy describes the roles, responsibilities and principles for ensuring that personal information is handled in a lawful and correct manner.

All staff must also ensure that they record information accurately in both manual and electronic records and that they report all information governance related incidents on Datix ie, contact made with wrong patient, inappropriate referrals, duplication of patient records.

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STPs AND ACCOUNTABLE CARE background briefing

Briefing

14 January 2018

1 NHS PROVIDERS Briefing

Key points●● NHS trusts support the principle of collaboration at the heart of the STP/ACS approach;

it provides one solution to the challenges facing health and care by focusing on local system partnerships rather than isolated activity by any single organisation.

●● Trusts are leading, and contributing to, the development of STPs/ACSs, and ACOs across the country and will continue to play a pivotal leadership role in many local areas.

●● Key examples of the changes underway in some areas include the development of more strategic approaches to commissioning, through the merger of clinical commissioning groups (CCGs), integrating commissioning with local authorities and the emergence of ACOs, as well as the integration of services, horizontally and vertically, between providers.

●● However, the pace of change varies considerably across the country largely dependent on whether areas have a history of strong relationships on which to build. We look forward to working with the national bodies to ensure that all STPs receive the support they need to develop, particularly those areas which are progressing more slowly.

●● The national bodies must be clear about the core aims of STPs and ACSs and avoid overloading them, for example, with requests to monitor and deliver new policy aims.

●● We need an honest conversation about how to develop governance and accountability mechanisms which support system-level partnerships and complement the statutory obligations of their component organisation – in the case of trusts, the unitary board. We also need to ensure public engagement and consultation on plans for change.

●● We need to develop a shared understanding about the terms used in relation to accountable care, particularly the definition of an ACO, as set out by the Department of Health (DH) and NHS England. Local partners must be clear about the contractual and partnership models underpinning new and integrated approaches.

As part of our new programme on sustainability and transformation partnerships (STPs) and accountable care, this briefing brings together an overview of how national policy has evolved to promote system-based collaboration, including the development of STPs, accountable care systems (ACSs) and accountable care organisations (ACOs). It includes:

●● the national policy story so far, as plans evolved into partnerships●● definitions of key terms associated with STPs, accountable care, and new care models●● five conditions for success based on our conversations with trusts●● NHS Providers’ position and information on the support trusts can access from us.

2 NHS PROVIDERS Briefing

Trusts will recall the genesis of STPs as sustainability and transformation plans which NHS and care organisations were asked to develop collaboratively in new footprints as part of the planning guidance1 at the end of 2015. These plans were designed to address the core gaps set out in the Five year forward view2 of improving health equity, closing the financial gap, and reducing unwarranted variation in quality.

Plans for the 44 STPs which now exist across England were published by December 2016 and involve trusts and foundation trusts, CCGs, specialised providers, primary care, local authorities including social care and public health, and sometimes private and voluntary sector provision.

In March 2017 NHS England published Next steps on the Five year forward view (Next steps)3 which made clear the expectation that STPs evolve as long-term partnerships rather than time limited plans, as well as an ambition for STP footprints to become ACSs and for some geographical areas to develop ACOs.

Trusts’ experiences of developing, and contributing to, the development of their STP or ACS vary considerably depending on a range of factors. These include: the quality and history of local relationships; leadership capacity; the financial and operational challenges facing the health economy and its component organisations; the size and nature of the population; and the geographical challenges inherent in some of the footprints.

Those systems progressing at pace often benefit from a more manageable population size, coterminous boundaries between (some if not all) partners, fewer organisations in the footprint and a natural geographical boundary, consistent with how patients access services in that area. However, local leaders from STP and ACS areas where plans are more advanced uniformly point to a history of trusted partnership working as the foundation for their achievements and future aspirations. They often describe the STP/ACS process as adding momentum to existing plans. Other areas will require more time upfront to build trust, form relationships and move towards the collective agreement of aims and objectives.

1 https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

2 https://www.england.nhs.uk/publication/nhs-five-year-forward-view/

3 https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

STPs...are a pragmatic effort to ensure that the different organisations in a geography plan together and integrate services rather than each individual component – be it the hospital, the GPs, the mental health trusts and the social care – ploughing their own furrow and thinking that the net effect of that will be good things happening for patients...STPs are simply a convenient process for driving that kind of integrated population-oriented planning and care delivery.

Simon Stevens, chief executive, NHS England, in response to a question from Maggie Throup MP at the health select committee as to whether STPs were ‘a silver bullet’, 10 October 2017

From plans to partnerships 1

3 NHS PROVIDERS Briefing

In July 2017, NHS England published a progress dashboard4 for STPs in which five were rated outstanding, 20 advanced, 14 making progress and four needs most improvement.5

There has been some turnover of STP leads during their short lifetime. However, at the time of writing there were 19 provider chief executive leads, 15 CCG leads, four local authority leads and six independent leads.6 Fulfilling the role of STP lead and contributing to an STP requires significant leadership time. Consequently some STP leads, including trust chief executives, are adopting the STP lead role full time.

Governance and the art of the possible The move towards locally-based collaboration rather than competition as the key driver of improvement in the system marks a significant shift in national policy, not least given that much of the latter is underpinned legislatively by the Health and Social Care Act 2012. While the current legal frameworks certainly do not prevent partnership working and integration in different forms, this makes for a complex environment for trusts, and their partners, to navigate.

STPs have no legal status and derive their decision making powers from the statutory bodies which comprise them. Reconfiguring services in health and care is always controversial and despite the high-level parameters for public engagement within the Next steps document,7 this remains a challenge and a source of media and political attention locally and nationally. For example, although Labour has consistently supported devolution and the integration of health and care, they have concerns about the development of STPs and ACOs8 on the grounds they are not based in statute and, in their view, could open the NHS up to privatisation, an argument which is gaining ground.

The Next steps document also sets out some expectations with regard to governance. This includes the requirement that each STP forms “a board drawn from constituent organisations...including appropriate non-executive participation, partners from general practice, and in local government wherever appropriate”. In addition, “formal CCG committees in common or other appropriate decision making mechanisms [should be created] where needed for strategic decisions between NHS organisations”.9

We know that developing the governance mechanisms to underpin local relationships and support the legal duties for decision making and accountability in the component partner

4 https://www.england.nhs.uk/systemchange/sustainability-and-transformation-partnerships-progress-dashboard-baseline-view/ (accessed 11 Dec 2017)

5 https://www.england.nhs.uk/publication/sustainability-and-transformation-partnerships-progress-dashboard-baseline-view/ (accessed 12 Dec 2017)

6 https://www.england.nhs.uk/stps/view-stps/#mids

7 https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf (p.34-5)

8 https://labourlist.org/2017/12/jon-ashworth-toxic-privatisation-agenda-destroys-the-soul-of-our-nhs/ (accessed 11 Dec 2017)

9 https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf (p.34)

1

4 NHS PROVIDERS Briefing

organisations remains a priority for trusts.10 Many trust boards have raised issues about how best to ensure non-executive and governor engagement in the STP process, as well as clinical engagement. In addition to recent publications such as The art of the possible with Hempsons, NHS Providers will share existing practice with regard to governance more widely this year as part of our STPs and accountable care programme.

A vehicle for change? There is no doubt that STPs, ACSs, and ACOs are seen nationally as the mechanism to deliver the aspirations of the Five year forward view including returning the system to financial balance. Our analysis from speaking with trusts is that STPs are being used locally as a catalyst to:

●● plan and deliver the local reconfiguration of services

●● helpfully support discussions on day-to-day operational collaboration for instance on winter planning

●● as a means of driving and locally overseeing new models of integrated care.

However there is also concern from trusts that STPs are also being asked by the national bodies to act as:

●● The default footprint to deliver national policy. Initiatives and increasingly funding are now passed down for delivery at STP footprints. Recent examples include the introduction of system control totals with the ability to apply to NHS Improvement and NHS England to adjust organisational control totals as long as the system target is met; the allocation of capital funding for 18/19 to the eight ACSs; and monitoring requests relating to workforce; and

●● An additional layer of performance management with a strong encouragement for STPs to monitor and manage finance and performance at a system levels.

10 Research from the HFMA shows majority of CCG and provider finance managers have concerns about governance and this reflects feedback from our members: https://www.hfma.org.uk/publications/details/nhs-financial-temperature-check-briefing-november-2017 (accessed 18 Dec 2017)

In a challenged local health and care economy our partners are committed to the destination and the benefits for our population but we’re discovering the best route to get there. We do need an honest conversation about governance and what is possible in the existing frameworks.

Sue Harris, Director of Strategy and Partnerships, Worcestershire Health and Care NHS Trust, and Communications and Engagement Lead, Herefordshire and Worcestershire STP

1

5 NHS PROVIDERS Briefing

Our view is that there is considerable variation in different STPs’ capacity to deliver on all of these expectations at pace.

In those areas with established partnerships, the renewed focus on collaboration is certainly fueling significant structural change, not least the development of a more strategic approach to commissioning. This includes mergers of CCGs,11 or arrangements whereby several CCGs appoint a shared accountable officer12 and the development of integrated commissioning arrangements with local authorities.13

In addition, there is a trend towards the consolidation of provider organisations through new alliances and groups, or proposed merger both to tackle financial challenges and to reduce unwarranted variation in quality standards. The extent to which an STP/ACS drives this degree of change will vary considerably but in some areas they are becoming a natural vehicle for conversations to tackle deep seated issues such as:

●● developing a more preventative and population health-based approach

●● moving care closer to home

●● improving pathways for clinical services through horizontal and or vertical integration

●● managing pressures on the ambulance service

●● delivering efficiencies through integration of back office and clinical services across a number of providers (horizontal integration).

Clearly those STPs/ACSs with more established relationships will rightly be keen to negotiate more freedoms and flexibilities in exchange for taking on collective responsibilities for finance and performance at a system level. However other STPs lack the relationships, mandate or infrastructure to deliver such a challenging range of priorities so quickly.

It is also important to remember that the NHS has always delivered across a number of footprints and will continue to do so. As such, the STP will play an important role but will not always be the optimum mechanism for delivery. For example, specialised and ambulance services operate to a wider population on regional and sub regional footprints which are larger than an STP; at the other end of the spectrum much of the frontline integration of health and social care is taking place on sub STP footprints in place-based or neighbourhood systems; and some initiatives will continue to be delivered by individual organisations.

11 https://www.hsj.co.uk/commissioning/mapped-ccg-mergers-shared-leaders-and-link-ups-with-councils/7016646.article (accessed Dec 19 2017)

12 https://www.hsj.co.uk/nhs-bromley-ccg/new-leader-named-for-five-ccgs-and-stp/7021300.article (accessed 19 Dec 2017)

13 https://www.hsj.co.uk/workforce/council-chiefs-to-take-on-leadership-of-several-ccgs/7021284.article (accessed 19 Dec 2017)

1

6 NHS PROVIDERS Briefing

2It has become clear over recent months that the terminology and acronyms used to describe collaboration and accountable care approaches are not always fully understood or are being used interchangeably. Here we offer definitions and commentary on the most commonly used concepts to support a shared understanding and effective communication.

Population healthGiven the focus on prevention at the heart of the Five year forward view approach it is natural that STPs/ACSs should be developed with the aspirations of population health in mind. In some local areas this will mean widening partnerships to address the wider determinants of health – housing, education, transport and access to services. The King’s Fund defines population health as “addressing the health outcomes of a defined group of people, as well as the distribution of health outcomes within the group so that health equity – the avoidable differences in health between different parts of the population – is a core part of understanding population health.”14

How far STPs and ACSs are able to move to population health approaches in the short term will depend on shared understanding and analysis of the issues facing their population, and the ability to take stock and invest in new ways of working rather than be drawn into operational imperatives. As Chris O’Neill, Director of Humber Coast and Vale STP puts it, “We are trying to encourage providers and their partners to think ‘future state’ – with an increasing, collective focus on population health rather than organisational targets.”

Trusts also recognised the importance of wider partnership working in delivering a more outcome-focused, population-based approach. Many cited the importance of relationships with primary care and local government in particular. For instance, Jade Renville, Trust Secretary, Taunton and Somerset NHS Foundation Trust commented: “Our STP senior responsible officer is from local government and engagement with the council, social care and wider services has been a core benefit of the partnership to date.”

14 https://www.kingsfund.org.uk/publications/what-does-improving-population-health-mean (accessed 4 December 2017)

[STPs are] clearly...not going to be something that solves every problem that we face in the NHS, but they are a very important part of our long-term strategy for the NHS, which is to move the centre of gravity in our healthcare system to one where prevention is taken as seriously as curing disease. That means tackling issues upstream in an out-of-hospital context, investment in mental health, general practice and other out of hospital services where it is much cheaper to address issues than if you wait until people need expensive hospital treatment.

Rt Hon Jeremy Hunt MP, Secretary of State for Health (10 October 2017, oral evidence, health select committee)

Are we speaking the same language?

7 NHS PROVIDERS Briefing

2Accountable care systems (ACS) The Next steps document describes an ACS as “an ‘evolved’ version of an STP that is ‘working as a locally integrated health system...in which NHS organisations (both commissioners and providers), often in partnership with local authorities, choose to take on clear collective responsibility for resources and population health”15 either on the STP footprint or, more likely, a smaller, sub STP footprint.

In return for increased responsibilities as a system, an ACS will have access to new freedoms and flexibilities. These include: the development of a system-level performance scorecard; a system-level control total; the potential for CCGs to have delegated decision rights in respect of primary care, mental health and specialised services; transformation funding; and support from NHS England and NHS Improvement to develop new ways of working. The national bodies are also working with ACSs to develop an approach to system-level oversight and a governance maturity tool to assess the level of freedoms an ACS should enjoy, in complement to existing, institutionally-focused regulation.

NHS England has identified the following eight areas to lead the development of ACSs. They have each developed a memorandum of understanding with the national bodies.

1 Frimley Health including Slough, Surrey Heath and Aldershot 2 South Yorkshire and Bassetlaw, covering Barnsley, Bassetlew, Doncaster,

Rotherham and Sheffield3 Nottinghamshire, with an early focus on Greater Nottingham and Rushcliffe4 Blackpool and Fylde Coast with the potential to spread to other parts

of the Lancashire and south Cumbria at a later stage5 Dorset6 Luton, with Milton Keynes and Bedfordshire7 Berkshire West, covering Reading, Newbury and Wokingham8 Buckinghamshire

In addition to the Manchester devolution arrangements,16 Surrey Heartlands will receive support to integrate health and care in a devolution agreement. Further ACSs are expected to be confirmed by NHS England and NHS Improvement in 2018.17

15 https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf (p.35-6)

16 https://www.greatermanchester-ca.gov.uk/homepage/59/devolution

17 https://www.england.nhs.uk/accountable-care-systems/ (accessed 6 Dec 2017)

8 NHS PROVIDERS Briefing

2Accountable care organisations (ACOs) The King’s Fund sums up the emergence of accountable care as “relatively new”, originating in the United States and representing “the most recent manifestation of well-known integrated systems, such as Kaiser Permanente.” They identify three common characteristics of accountable care organisations: “firstly, that they involve a provider or an alliance of providers which collaborate to meet the needs of a defined population, secondly, that the providers take responsibility for a budget allocated by commissioner(s) and thirdly, that the ACO works under a contract that specifies the outcomes and objectives it is required to deliver within a given budget, often extending over a number of years.”18

In the Next steps document, NHS England describes the potential for an ACS to evolve into an ACO. In practice, and depending on patient populations and local relationships, presumably an ACS could also develop more than one ACO within its footprint.

Given the varied connotations of the term accountable care organisation it is important to focus on what the development of an ACO means for health and care within the English NHS. NHS England states that an ACO occurs “where the commissioners in that area have a contract with a single organisation for the great majority of health and care services and for population health in the area.”19 A recent DH consultation20 on the development of the existing accountable care contract21 makes clear that the two vanguard models, multi-speciality community provider (MCP) and integrated primary and acute care systems (PACs) could also be considered as accountable care organisations.

Our understanding is therefore that the development of an ACO requires the creation of a strategic commissioning function procuring one organisation to take responsibility for delivering outcomes for a given population, within an agreed budget, over an agreed timeframe. Within this, the contracted organisation would adopt tactical commissioning responsibilities and deliver particular services with a range of different partners.

As the ACO contract can only be let to one provider, there is a clear opportunity for trusts to adopt a leadership role in collaboration with partners in this regard. Commentators recently suggested that existing trusts and foundation trusts, or a newly formed trust, could be the legal entity for developing an ACO.22 In addition, DH is seeking to make minor amendments to ten regulations by February 2018 to allow for the development of ACOs (for example to allow GPs to stay on their existing contracts within an ACO, and to set out how NHS pensions would apply for staff in an ACO).23

18 https://www.kingsfund.org.uk/publications/accountable-care-organisations-explained

19 https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf (p.37)

20 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/643714/ACO-contract-reg-changes-consultation-1.pdf

21 https://www.england.nhs.uk/new-business-models/publications/

22 https://www.hsj.co.uk/commissioning/new-form-of-nhs-organisation-planned-for-first-acos/7021292.article? (accessed 18 Dec 2017)

23 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/643714/ACO-contract-reg-changes-consultation-1.pdf (p.4-5)

9 NHS PROVIDERS Briefing

2Given the complexity of these changes, the indications are that the national bodies do not envisage working with many ACOs in the short term. In fact NHS England acknowledges that only “a few areas are on the road to developing an ACO” (often where an MCP or PACs vanguard project has progressed successfully), that this process takes years and involves a complex procurement process and a different approach to risk management.24 The national bodies have confirmed they are currently working closely with four local areas where a procurement process to establish an ACO is underway.

Despite the definitions above, trusts and their partners are understandably adopting the language of accountable care in different ways and pursuing similar outcomes and objectives through partnerships and alliances. While this makes sense where it helps to drive collaborative, patient-centred behaviours, it is important to ensure clarity is maintained on the legal, contractual and governance frameworks underpinning the approach.

Vanguards and new care models National funding and support for the new care models originally announced in the Five year forward view comes to an end at the end of this financial year. However, at local levels, work continues both within and outside of the official programme to develop more integrated models of care for patients. The achievements of many of the vanguards have been acknowledged, not least in reducing hospital admissions25 and the learning from the programme should inform the development of STPs, ACSs and ACOs.

Moreover many of the STPs/ACSs seen to be progressing well include and involve new care models already in operation. In some areas this adds another level of complexity to STP and ACS plans but in many local areas it will make sense to develop or pilot integration at sub-STP levels.

The following provides a reminder of the main vanguard new care models:

24 https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf (p.37)

25 https://www.hsj.co.uk/emergency-care/vanguard-areas-saw-lower-activity-growth-last-year-analysis-shows/7021004.article (accessed 11 Dec 2017)

In West, North and East Cumbria we are identifying and promoting the collaborative behaviours we know will support the development of accountable care, and we are doing it from existing resources. We are establishing a joint executive team and developing joint non-executive positions between the two major provider trusts in our ACS to support this endeavour.

Daniel Scheffer, Joint Company Secretary for Cumbria Partnership NHS Foundation Trust and North Cumbria University Hospitals NHS Trust

10 NHS PROVIDERS Briefing

2The multispecialty community provider model (MCP) focuses on moving specialist care out of hospitals and into the community. Groups of GP practices work together and collaborate with other health and social care professionals to provide a range of primary, community, outpatient, mental health and social care services. MCPs build on an understanding of population health needs and ultimately might take on contractual responsibility for the health budget for their whole population. As set out above, this model is considered to be a form of ACO.

Integrated primary and acute care systems (PACS) have a similar population health focus to MCPs, but they also join up hospitals with primary, community and mental health services to improve the coordination of care and move care out of hospital where it is appropriate to do so. Under the PACS model, a single entity – typically a lead provider – would take responsibility for the health needs of the whole population and the delivery of health care services. As set out above, this model is considered to be a form of ACO.

Acute care collaboration (ACC) vanguards link local acute hospital providers together to improve the clinical quality and financial sustainability of care services. The organisational form of these models ranges from collaborative to contractual and can include consolidation. The scope of their services includes hospital groups in which several providers work collaboratively under a single group structure and formal joint working arrangements; multi-service networks in which several providers work collaboratively to provide a range of clinical and non-clinical services; and single service networks in which networks of trusts and their clinical teams work on a specific service.

For example, Matt Graham, Programme Director, West Yorkshire Association of Acute Trusts, describes the approach in the West Yorkshire and Harrogate Health and Care Partnership: “ The West Yorkshire Association of Acute Trusts (WYAAT) is an acute care collaboration between the six acute trusts in West Yorkshire and Harrogate and we have established a committee in common of chairs and chief executives to oversee the collaboration. Although WYAAT was created before the STP process, it has become a core part of the WYH Health and Care Partnership. The lead chief executive for WYAAT sits on the partnership’s leadership executive and other chief executives lead partnership workstreams. WYAAT provides a natural delivery mechanism for a number of system-wide programmes both to deliver efficiencies and improve the quality of services for patients. As part of the partnership, we are using WYAAT to build a bottom-up approach, based on eliminating unwarranted variation through strong clinical involvement, to tackle a range of issues, from back office efficiencies, through networked clinical support services, to transformation of clinical services”.

Enhanced health in care homes vanguards aim to improve older people’s quality of life and healthcare. NHS services work closely with care home providers, local authorities and the voluntary sector to join up health, care and rehabilitation services, optimising the health of elderly residents.

In order to deliver the five principles set out in the Keogh review, urgent and emergency care vanguards are also improving the coordination of services to reduce pressure on A&E departments.

11 NHS PROVIDERS Briefing

From our conversations with trusts involved in STPs at all levels of development, the common enablers we have identified can be summarised as follows:

●● The quality of relationships between all key players in the local system: GPs, local authorities, CCGs, acute, mental health, ambulance and specialist providers – alongside consideration of the voluntary and private sectors.

●● The quality and capacity of local leaders and their ability to engage and mobilise the wider workforce, including clinicians, and engage with the public. Many people mentioned how difficult it is to find the capacity and resource to drive change until it becomes ‘the day job’.

●● A collective commitment to prioritise the needs of patients and the system at the expense of the individual institution, based on a shared understanding and analysis of local challenges.

●● A ruthless focus on a small number of practical priorities and a drive for practical improvements on the ground in chosen priority areas, rather than just trying to build a grand plan.

●● A culture of pragmatism meets continuous improvement. Trying new things, learning and making improvements if it doesn’t work.

In terms of enablers, the starting point for any collaboration is trust. Resources to invest in a change management process, and to explore flexibilities in how we make best use of our valued workforce at a system level would also be of benefit.

Jane Tomkinson, Chief Executive, Liverpool Heart and Chest NHS Foundation Trust and Senior Responsible Officer for the cardiovascular strand of the Cheshire and Merseyside STP

In West, North and East Cumbria, we are lucky to have a relatively simple, decluttered landscape with a manageable number of partners. We have one system-wide vision, which has improving population health at the heart of it. We have developed eight place-based, integrated care teams in our ACS as the focus for building our population health management system. We are also encouraging our staff to ‘think without walls’ and developing system-wide enabling strategies to support them in this such as organisational development, information management and technology, and a shared and consistent improvement methodology.

Ramona Duguid, Programme Director, West, North and East Cumbria Integrated Health and Care System – ACS/ACO

Five keys to success 3

12 NHS PROVIDERS Briefing

4In summary, STPs are clearly developing at different paces across the country. Those involved in the ACS model or developing an ACO are progressing well. Other areas need additional time and resource to invest in relationship building to underpin new partnerships.

We fully support the principle of collaboration underpinning the STP process and the move to develop accountable care models which will improve and integrate services for local populations. We welcome the focus on population health approaches and a clear acknowledgement from government and the national bodies that the solutions to the challenges facing health and care services in England lie in system-based solutions rather than isolated activity by individual organisations. We also welcome the opportunities for local leadership generated by STPs/ACSs and the emergence of ACOs in some parts of the country. We strongly support the national bodies’ acceptance that depending on their starting point, different parts of the country will develop their approaches at different paces and in different ways.

It is clear that NHS trusts are, rightly, playing a key role in both leading and contributing to new partnerships to improve outcomes and address the challenges set out in the Five year forward view of improving health inequity, improving quality and reducing the financial gap.

However in order for trusts, their partners and the wider public to reap the rewards of the significant resource, leadership time and energy invested in the STP and ACS process, it is essential to remain realistic about the scale of the ask of STPs and their component organisations. We must ensure that both trusts and the STPs they contribute to are set a deliverable task within the available funding envelope. These new partnerships and approaches, however well intentioned, are developing within a legislative framework and a system architecture set up for different times and a competitive rather than collaborative approach which will create additional complexities to navigate – locally and nationally. As the recent legal challenge demonstrates, it is important that the national bodies have a convincing public narrative in support of the approach.

During the development of STPs, we have raised concerns about the pace of change expected and the multiple priorities asked of STPs by national bodies. While we welcome the investment and support that NHS England and NHS Improvement are offering to well-established partnerships, it is only fair to providers, their partners and taxpayers that support (and funding) is offered to STPs at all stages of development. It would be wrong to penalise those populations where STPs are developing at a slower pace, for a range of legitimate reasons.

We also have concerns about the increasing tendency for STPs to become the default footprint for delivering national policy initiatives when they do not have the mandate, statutory authority, or infrastructure to deliver. On the other hand, we accept that more established and progressive partnerships will benefit from negotiating additional freedoms and flexibilities with the national bodies.

While STPs and ACSs are an understandable and pragmatic solution to the complex challenges facing the health and care system, it is important not to lose sight of the fact that

NHS Providers’ view

13 NHS PROVIDERS Briefing

4statutory responsibilities in the system still lie with individual organisations, notably trusts, and CCGs. We look forward to working with trusts and the national bodies to ensure that the governance arrangements at a system level complement the statutory accountabilities of provider boards and other organisations. We also recognise the importance of non-executive engagement, clinical engagement and public consultation on new proposals at organisational and system levels.

We look forward to working with trusts and their partners, the national bodies and partner organisations such as the NHS Confederation, the Local Government Association, NHS Clinical Commissioners and think-tanks to help capture and share the learning from the development of STPs/ACSs, and ACOs. We hope our new programme of influence and support in this space will both support our trusts and help fuel debate about the next steps for system-level collaboration and accountable care.

14 NHS PROVIDERS Briefing

In the next six months we will be setting out a programme of support for members around STPs, ACSs and ACOs which will build on the learning from a shared programme of support (with NHS Confederation, NHS Clinical Commissioners and the Local Government Association) for the vanguard programme and include:

●● briefings, blogs, articles and case study publications with a clear focus on sharing practice and understanding of the trust provider perspective

●● publications such as our Provider voices series to capture the range of views on STPs, ACSs and accountable care and fuel debate

●● the development of our work on governance mechanisms to support STPs, ACSs and ACOs

●● maximising opportunities to use our existing networks, development offers and events to showcase case study examples and offer a safe space for providers to share achievements and concerns, include our board development programme, GovernWell, and executive and non-executive induction, annual conference, Governor focus conference and the governance conference

●● in addition, we look forward to exploring how our existing partnership with the NHS Confederation, NHS Clinical Commissioners and the Local Government Association can develop new and more bespoke offers of peer-based support for those STP areas voluntarily seeking additional help.

Support for trusts

@NHSProviderswww.nhsproviders.org

© Foundation Trust Network 2018

For more information: www.nhsproviders.org/stps-and-accountable-care

Your feedback on this briefing and the

development of our wider offer is very welcome – to share your learning so far or offer feedback on our approach, please contact

head of strategy miriam.deakin@nhsproviders.org

Suggested citation:NHS Providers (December 2017), STPs and accountable care: background briefing.

5

mailto:Adam.Wright@nhsproviders.org

Reports from the Sub Committees of the Board January & February 2018

(including board development sessions) Meeting Board of Directors Date 7 March 2018 Agenda item 9 Lead Director Karen Howell, Chief Executive Author(s) Non-Executive chairmen of the committees

To Approve

To Note

To Assure

Link to the Board Assurance Framework (strategic risks) Please mark against the principal risk(s) - does this paper constitute a mitigating control?

Our Patients and Community Our People Our Performance

Quality and safety including addressing

inequalities is not maintained or improved

Lack of, or ineffective engagement and 2-way communication with staff

& governors

Failure to respond to system changes and the requirements of the NHS Five Year Forward View

Patient experience is not systematically collected, reported or acted upon

Failure to maintain a competent, engaged and resilient workforce that

feels trusted, listened to and valued at work within a changing environment

Failure to deliver the efficiency programme

and achieve all the relevant financial statutory duties

Inability to deliver the benefits of integration

within the defined timescales

Failure to provide quality training and supervision

and opportunities for career development for

all staff

Inability to sustain performance against

contractual and financial targets

Link to strategic objectives & goals - 2017-19

Please mark against the strategic goal(s) applicable to this paper Our Patients and Community - To be an outstanding trust, providing the highest levels of safe and person-centred care We will deliver outstanding, safe care every time �

We will provide more person-centred care

We will improve services through integration and better coordination Our People - To value and involve skilled and caring staff, liberated to innovate and improve services We will improve staff engagement

We will advance staff wellbeing

We will enhance staff development

Our Performance - To maintain financial sustainability and support our local system

We will grow community services across Wirral, Cheshire & Merseyside

We will increase efficiency of corporate and clinical services

We will deliver against contracts and financial requirements

Link to the Organisational Risk Register (Datix)

Each committee monitors risk within its remit, as identified in the BAF and Risk Register.

Has an Equality Impact Assessment been completed?

Yes No

Paper history Submitted to Date Brief Summary of Outcome

The committee reports are regular monthly reports to Board.

Briefing from the Chairman of Quality and Safety Committee Purpose

1. This is a report from the Quality and Safety Committee meetings held on Wednesday 17 January and 21 February 2018. The trust board is asked to note the key decisions and recommendations agreed in the meetings by the Quality and Safety Committee.

Significant agenda items from 17 January 2018

2. The committee received the Chairman’s briefing and welcomed confirmation of the forthcoming CQC inspection. An update was provided on the trusts wound care clinical governance assurance framework advising that a wound care steering group and a pressure ulcer review team would be established in each hub for the review of community acquired grade 2 pressure ulcers; this was recognised as a proactive response approach to pressure ulcer management.

3. The committee received and thanked Amanda Ball for an informative and enjoyable presentation on the quality improvement project undertaken to improve patient experience and KPI performance within the wheelchair service.

4. The committee received the Quality and Patient Experience report for December 2017

noting the areas of quality improvement and any quality and patient safety issues identified. The committee noted in particular the significant decrease in incident reporting resulting in a special cause variation; it was noted that this had been escalated to the Clinical Governance Assurance Group. The committee was advised that action was being taken in-month including communication via Executive Briefing to remind staff why incident reporting is important in relation to patient safety and improving patient care.

5. The committee received the risk report noting no new high-level risks reported with an

update provided on the current risks. In relation to discharge planning (ID1647) the committee were assured that improvements were being seen and the trust had participated in a MADE event with the hospital trust from which an action plan was being developed.

6. The committee approved (subject to the comments noted being addressed) the Risk Strategy to travel to the Board of Directors for final ratification.

7. The committee received and were assured by several Q3 assurance reports including Raising Concerns, complaints and concerns and claims.

Significant agenda items from 21 February 2018

8. The committee received the Chairman’s briefing and noted that the trust took part of a social work conference at the Floral Pavilion on 07 February 2018, led by the Chief Social Worker, Lyn Romeo. The conference focused on integration and safeguarding and our Associate Director of Social Care was invited to be part of the conference panel.

9. The committee received the Quality and Patient Experience report for January 2018 noting

the areas of quality improvement. The overall FFT score for the trust was 98%. A significant increase in trust wide incident reporting was noted and harm free care was at 97.75%. National Quality Requirements (NQRs) looks at response times for telephone advice and face to face contacts within GPOOH. NC updated the committee regarding NQR performance and provided assurance that an improvement action plan is in place.

10. The committee received the risk report noting three new high level risks relating to; implementation of the exelicare system in the sexual health service, pressures in staffing transfer to assess beds and performance against GPOOH NQRs.

11. The committee received and approved the updated Medicines Optimisation Strategy 2018-

2021. 12. The committee received and were assured by several Q3 assurance reports including

Quality Strategy, Mortality Learning from Deaths, IPC, Safeguarding and the CQC assurance reports. The committee welcomed the development of learning from deaths dashboard to support open, transparent reporting within the trust.

13. The committee received a comprehensive quality impact analysis relating to nursing

transformation and were assured that a strong governance structure is in place to ensure that changes are managed safely.

14. The committee received the annual plan of clinical audits and continuous quality improvements scheduled for 2018/19.

15. That following policies were approved: • First Aid Policy (HS12) • Mobility Scooter Policy GP53 • Occupational Road Risk Policy HS19 • Incident Management Policy GP08 • Safeguarding Adults Policy SG01 • Infection Prevention and Control Policy ICP1

Any formal recommendations

16. No formal recommendations were made.

Chris Allen Chair Quality and Governance Committee 01 March 2018

Briefing from the Chairman of

Education and Workforce Committee Purpose 1. This is a brief report from the committee meetings held on 3 January (December

meeting held virtually), 24 January and 28 February 2018.

2. The board is asked to note the key issues identified by the committee for communication to the board, pending receipt of these formal minutes.

Significant agenda items from 3 January committee 3. The following key agenda items were discussed:

• Risk Management Report - December 2017 • Workforce Report - November 2017

Outcomes and actions agreed

4. The committee received the risk management report noting one new high level risk had

been escalated during the reporting period relating to mandatory training compliance within GP Out of Hours (OOH). It was noted that this had been discussed at QSC with further assurance on the action taken given to members including the interim MD investigating other systems and aligning to them when GPs have completed training. With regard to the risk relating to GP OOH cover further detail was provided in response to queries raised on the action plan. It was noted that this action plan was being monitored via Executive Leadership Team (ELT) and would be updated accordingly to reflect a follow up visit conducted by the interim MD and COO to the service on 19 December 2017.

5. The committee received the monthly Workforce Report. The completion of mandatory

training was highlighted as an emerging concern; committee members were advised and assured that a month on month increase had been seen but there remained two hotspots namely community nursing and GP OOHs. It was noted that mandatory training uptake is monitored monthly via the Learning & Development Group (the summary of which is reported to the EWC) and at the weekly Operations & Governance group. The non-attendance/cancellation of places was also being reviewed and would be included as a summary to the committee in the next workforce report.

6. In relation to the updates on organisational change, committee members reflected that

the virtual meeting did not allow for detailed discussion however further information regarding the changes and implications of the Community Nursing & Specialist Leadership redesign was requested for the next meeting. The workstream groups established were noted with questions posed about the engagement with staff on the work of these groups; members were advised that a successful meeting had taken place with staff on 13 December and a co-design approach was being taken.

7. The collective grievance in Adult Social Care was noted and it was confirmed that it had now been closed with further detail provided in relation to the delays. The level of sickness absence in Sexual Health was also noted with a question asked if this was in relation to recent challenges; it was confirmed that the absences were related to

musculoskeletal and gastrointestinal reasons and are not linked to stress; reflecting the patterns across the rest of the trust

Significant agenda items from 24 January committee

8. The following key agenda items were discussed:

• Staff Story - Be Happy • People Strategy Assurance Report (Quarter 3) • Risk Management Report - January 2018 • Workforce Report - December 2017 • Workforce Plan Update (Quarter 3) • Phase 1 Nurse Transformation Management Changes • Education and Training Report (Quarter 3) • Dignity At Work Policy (HRP04)

Outcomes and actions agreed 9. The committee received a staff story describing the Be Happy tool in use with school

nurses to improve the emotional health and wellbeing of children and young people. The committee received feedback from the CEO having seen the tool ‘in action’ and was pleased to hear its impact and the benefits of staff pursuing new ideas.

10. The committee received the quarterly People Strategy Assurance Report. A summary

of progress against each of the key themes and goals from the strategy was provided. It was requested that further information be provided on staff recognition and initiatives for wellbeing in the report. The committee received further updates on the work on-going to address concerns raised in relation to staff morale predominantly via Staff Council. It was confirmed that a resilience action plan had been developed with ELT and the Senior Leadership Team (SLT), supported by the Wellbeing Group. This included IT troubleshooting sessions, a staff suggestion scheme to be owned by ELT and wider listening events to engage staff on how we can improve their work experience.

11. It was reflected that walkrounds had not raised issues about the organisation not being a ‘listening organisation’, the issue related more to how we respond and take action. This was recognised and the importance of context was crucial as well as the important role of line managers. The walkrounds at Tier 2 level were raised and it was noted that the board development session in early February would provide an opportunity to review and agree next steps.

12. The committee received the Risk Report and noted there were no new high levels risks

reported. The existing risks were noted and particularly in relation to the MSK contract and the complexities around workforce planning linked to the potential additional activity.

13. The committee received the monthly Workforce Report for December 2017. The

committee were advised that key themes from organisational learning would be reported to the committee in future, in line with relevant policies. It was noted that this had been discussed with Joint Union Staff Side (JUSS) and would be managed via JUSS/Operational meetings and subsequently reported to the committee. The sickness absence rates were noted and committee observed the trends reported in the run chart. It was also noted that a number of organisational change processes were in progress across the organisation.

14. The committee received the Workforce Plan Report for Q3 for assurance noting the

progress against the workforce plan and in relation to strategic workforce development. The draft NHS workforce strategy published by HEE in December 2017 was noted; it was acknowledged that local plans were important to consider the workforce supply across the system. As the SRO lead for workforce, the CEO encouraged an opportunity to be robust in our response to the publication of the strategy. The impact of larger economies was acknowledged and as such it was confirmed that Cheshire & Merseyside would respond and it had been suggested to the AO of the CCG that Wirral provide a collective response. Further information in relation to nurse recruitment and retention was discussed acknowledging the pressures in the (national) system and the significant staff shortages being experienced.

15. It was confirmed that a date had been confirmed with one of the GP Federations to

look at nursing workforce to create a flexible workforce for the future. Further detail on the professional standards for key professional groups was also noted.

16. The committee received a paper confirming the phased approach to changes to divisional leadership and the management structure of the Children & Wellbeing division. The committee were provided with further assurance on the realignment of the Sexual Health service to the Urgent & Primary Care Division. It was also noted that the Sexual Health lead would take a lead on the wellbeing, self-care and prevention agenda for the organisation as part of the implementation of the trust’s long-term strategy.

17. Further detail on the proposed changes to community nursing and specialist nursing

were provided; it was noted that the consultation with staff would conclude on 24 January 2018. The importance of transformation support to support the delivery of the ambitious programme was noted along with plans to report progress to the three principle committees during January and February. The committee welcomed the update provided.

18. The committee received the report to provide assurance on the implementation of the

Education, Training and Development Plan. In particular the committee noted that mandatory training had remained static at 81% and further detail on withdrawals and DNAs was noted in the appendix with a further discussion on the reasons identified. As a result the committee was advised that solutions were being investigated based on recommendations from staff; for example teams would be supported to allocate a CPD afternoon, different and more flexible approaches to the delivery of training. It was therefore expected to achieve the required target uptake from April 2018 and reducing the withdrawals and DNAs in community nursing. Further detail on career pathways, new roles and apprenticeships was noted and the learning infrastructures and available resources.

19. The committee approved the updated Dignity at Work Policy with revisions. The

‘Appeal - Stage 3’ section (p13) was discussed and further discussion was requested on the practice going forwards to involve Non-Executive Directors. It was noted that JUSS had requested the option for NED involvement. It was also noted that the addition to the stage to allow for a NED from another NHS organisation was to bring the policy in line with the grievance policy.

Significant agenda items from the February committee

20. The following key agenda items were discussed:

• Staff Story - Winter Resilience • Risk Management Report - February 2018 • Terms of Reference - Education & Workforce Committee • Workforce Report - January 2018 • Monthly Agency Expenditure and NHS Agency Rules Monthly Overrides 1 - 31

January 2018 • NHS National Staff Survey Results 2017 • HEE in the North West Local Education Provider Report 2017/2018 Self-Assessment

Report and Action Plan for Non-Medical Learners • Education, Training and Development Policy (GP46) • Volunteer Policy (GP22)

Outcomes and actions agreed 21. The committee received a Staff Story from the Unplanned and Primary Care Division

regarding their approach to Winter Resilience. The committee reflected on the level of activity reported in the story, particularly over the New Year period and discussed the use of What’s App as a staff engagement tool. It was noted that good practice would be shared widely and the principle of developing a social media tool for staff engagement was being explored as part of the People Strategy.

22. The committee received the Risk Management Report and noted that no new high level risks had been added. The risk relating to sickness absence continued to be monitored by the committee and would be discussed under the Workforce Report. It was noted that a risk regarding staff morale had been added to the Risk Register by the Director of Human Resources and Organisational Development, but was not showing. This would be investigated.

23. The committee reviewed and approved the updated Terms of Reference for the

Committee. 24. The committee received the monthly Workforce Report and noted the increase in

sickness absence to 6.2% in January 2018. It was noted that the primary cause was seasonal coughs, colds and flu like symptoms and that this was a peak that was experienced annually during the winter months. The uptake of the Flu jab was discussed and it was noted that only one member of trust staff had formally been recorded as having Flu. Further work would also be undertaken to analyse the levels of absences related to MSK and the uptake of manual handling training.

25. The monthly Agency Expenditure Report was presented to the committee for the first

time, having previously been reported to Finance and Performance Committee (FPC). The committee were assured by the process both for approval of agency use and the continued focus on the financial aspect of agency usage at FPC. The impact of winter pressures were described in terms of the need to respond to short term commissioner requirements, which could only be achieved by use of Agency. It was agreed this should be noted in future reports.

26. The committee received the Trust’s results from the NHS National Staff Survey for

2017 accompanied by analysis and proposals for key approaches to action planning. These results are subject to an embargo until 6 March 2018 and are therefore not

discussed in detail in this summary due to the circulation of papers being before the publication date. A full report with a final action plan will be submitted to March committee.

27. The committee received the Health Education England North West Local Education

Provider Report and noted the self-assessment undertaken. This provides an overall assessment of our current quality plans and developments in supporting non-medical education and will be used as part of HEE overall assessment as to the effectiveness of quality of education and training. It was noted that two objectives were assessed as green, with four rated amber and two red. Actions to address areas for development were noted and discussed. The positive responses from student evaluations were noted and it was agreed this success should be communicated across the trust.

28. The committee received and approved the revised versions of the Education, Training

and Development Policy and the Volunteer Policy. Any formal recommendations

29. There were no formal recommendations from any of the three committees. Murray Freeman Chair of Education & Workforce Committee

Briefing from the Chairman of Finance and Performance Committee Purpose 1. This is a brief report from the virtual committee meeting for December 2017 and actual

committee meetings held on 31 January 2018 and 28 February 2018.

2. The board is asked to note the key issues identified by the committee for communication to the board.

Significant agenda items from the December committee: 3. The December committee was held virtually with questions and queries submitted individually

by committee members and responded to centrally by the Chief Finance Officer. The following key agenda items were issued in the papers:

• Risk Management Report • Finance & Activity performance • Contractual Performance • Transformation and CIP position

Outcomes and actions agreed 4. The committee noted there were no new high-level risks but some risks had reduced without

explanation. The committee agreed that future risk reports would include an explanation to support reduced risk scores. The risk score of risk 1316 had reduced and this was challenged given further slippage reported in the CIP. Committee members noted that while CIP slippage may increase the associated risk that is of concern is achievement of the Control Total and there was sufficient non-recurrent slippage/savings to ensure the control total would be achieved. The committee also discussed the reducing risk 1391 given the further delay to the MSK Prime Provider contract signature. This was a timing issue with the announcement of the delay coming after papers were prepared.

5. The committee noted that the financial position remained in line with plan and the risk rating remained at 1. The committee noted rising pay costs in GPOOHs and requested an update. The increased slippage in the CIP was noted but assurance was given that this was anticipated with the forecast outturn and related to the fact the CIP was profiled towards the latter half of the year. The forecast outturn scenarios were noted and a query rose with regard to cost pressures and CIP slippage yet forecasting to meet the control total and plan. Slippage in reserves that are currently accrued to, was identified as the assurance for achieving the plan. An update on progress in the MSK Prime Provider development was requested and a response circulated. An overspend in relation to telephony costs was highlighted and explained as relating to data usage as more staff utilise mobile working technology. The committee were assured that the capital expenditure forecast was achievable given that many of the resource intensive schemes would be provided by contractors.

6. The committee received the Contract Performance Report and received assurance relating to

HIV testing in the Sexual Health Service. The committee requested assurance regarding the potential risk of financial penalties associated with continued underperformance against Adult Social Care KPIs. The committee was assured that there were no specific financial penalties in the contract for KPI performance although there were triggers for a performance notice to be issued and this had not been breached. The committee requested clarity on Cheshire East 0-19 incentive payments and it was agreed a review was required how this risk is monitored and reported.

7. The committee received the Transformation and CIP report noting a behind plan position and

requested a detailed plan for Nursing Transformation. This will be presented at the January committee meeting. The committee noted the requirement for a tightening of procedures around the signing of QIAs and the commencement of schemes.

8. The committee noted the action plan within the minutes of the Integrated Performance Group and sought assurance on the IT issues. Assurance was provided.

Any formal recommendations 9. There were no formal recommendations other than those mentioned above.

Significant agenda items from the January committee: 10. The following key agenda items were issued in the papers:

• Risk Management Report • Finance & Activity performance • Contractual Performance • Transformation and CIP position • Sustainability • SLR reporting update • IM&T Strategy update • GPOOHs update

Outcomes and actions agreed 11. The committee noted that the previous high-level risk ID1391 associated with MSK had been

increased again due to financial and workforce implications with further delays to the new Prime Provider contract. Mitigating actions were noted. In relation to ID1635 an updated position was provided on sub-contractual arrangements and further detail on the reduction of the risk. The committee was also advised of concerns that were being fully investigated in relation to the Sexual Health service. The committee was assured by the information reported in relation to risks.

12. The committee received the monthly finance and activity performance report for December 2017 noting the reported surplus position. The committee noted the position in relation to the agency cap and acknowledged the anticipated year end position. It was acknowledged that in order to scale up appropriately for winter plans there had been some difficulty in recruiting social care staff and therefore greater reliance on agency staff which could have an impact on the cap. An update was provided on the status of the Capital Expenditure Programme. Further assurance was requested and given on the IPT programme and an update was also provided on the laptop refresh programme with assurance given that it would be completed in January 2018. The opportunity to issue smart phones to front-line staff was also acknowledged along with confirmation this was being discussed with Divisional Managers. The risks were noted with particular attention drawn to the LGPS liabilities and the committee requested this be added to the risk register.

13. The committee received the Contractual Performance Report and noted the overall strong performance. The position associated with the incentivised KPIs in the Cheshire East contract was noted along with assurance that there is a good relationship with commissioners there. It was confirmed and welcomed that the commissioners were intending to recommend an extension to the contract on a fixed term for a further 2 years. The increase in red KPIs associated with the sexual health contract was noted and significant concerns reported in relation to data quality issues in the Excelicare system. The committee was advised that intense scrutiny of these reported concerns was underway and reported daily to the COO with escalation to the risk register

14. The committee received the CIP and Transformation report which included the current gap for 17/18 together with the potential impact on control totals. The report also updated plans for 18/19. The committee acknowledged the significance of the Nursing Transformation

Programme and noted the detailed gantt chart appended to the report. Further assurance was requested on the delivery of the 18/19 plans and it was noted that rigorous monitoring was in place and reviewed weekly through operations & governance meetings.

15. The committee received and approved the Sustainability report noting the excellent achievements reported including the achievement of ISO14001 accreditation for SCHC.

16. The committee welcomed a presentation on the Trust Information Gateway and the dashboard to be adopted in committees. A further update on SLR/PLICs was also provided.

17. The committee received an update on the IM&T strategy operational plan noting progress being made and the number of projects in progress. The committee asked for assurance that the IT fundamentals were in place to support clinical services and also acknowledged the increasing dependency on IT across the organisation. It was acknowledged that following the roll out of SystmOne and laptops it was now timely to revisit equipment with staff and the functionality of other devices with system suppliers; for example the opportunity to adopt tablet technology for front-line staff was highlighted. The MIAA review was noted as having provided Significant Assurance.

18. The committee received a report providing assurance following two consecutive months of overspends within the GPOOH service. The committee were assured that controls were in place and were being monitored carefully.

Any formal recommendations 19. There were no formal recommendations other than those mentioned above.

Significant agenda items from the February committee: 20. The following key agenda items were issued in the papers:

• Risk Management Report • Finance & Activity performance • Contractual Performance • Transformation and CIP position • Service Line Reporting • GPOOHs Performance and National Quality Reporting (NQR) • Stoma Products CIP • MSK update on income pressure • Estates Strategy update • Electronic Access Pass Policy

Outcomes and actions agreed 21. The committee received the risk management report noting two new high-level risks and one

risk that had been reduced during the reporting period. The committee were advised that whilst progress had been made with the Sexual Health risks the risk rating would remain 16 as work continued. The reduced risk related to the MSK contract; an update was provided noting the delay reported in the anticipated contract sign off date although the anticipated go live date for the service change remained the end of April 2018.

22. The committee received and were assured by the monthly finance and activity performance report for January 2018 noting the surplus position which was better than plan. The I&E margin risk rating was highlighted with confirmation that the variance from plan score remained at level 2 but assurance was given that the average score remained 1 across the 5 Use of Resources criteria. The position in relation to the incentivised KPIs in East Cheshire was discussed and confirmation given that the contract was being carefully reviewed following meetings with the commissioners and that the financial position reported was a prudent assumption. The agency cap YTD spend was noted and the committee was assured that close monitoring was on-going including notification to NHSI at the recent Quarterly Review Meeting; the committee noted the

impact of additional winter pressures on the agency cap and were advised that as winter beds were decommissioned less agency resource would be required. It was also noted that based on the current performance a score of 2 would likely be achieved against the agency cap metric however the committee was assured that the overall use of resources rating would not be affected. The committee also noted that a monthly paper would be submitted to the Education & Workforce Committee to monitor agency spend against the cap; this was reviewed at the meeting on 28 February 2018. The non-pay expenditure position was noted and the most significant areas of overspend discussed. The committee noted the activity data report and in particular the increase in community nursing activity set against the increased sickness rate reported to EWC; this was acknowledged as a potential increasing pressure. The activity levels at Eastham WIC were noted and a quality concern highlighted if activity levels had returned to previous planned levels despite reduced operational hours.

23. The committee received the report providing assurance on contractual KPI performance for M10 noting a detailed update on the grey KPIs.

24. The committee received and noted the report on the current performance of the 17/18 CIP noting a behind plan position of 8.7%. The committee sought assurance that with two months remaining of the financial year the target could be achieved; it was advised that savings could be made from elsewhere to ensure the control total was met including releasing some unused reserves if required. The detail of slipped schemes was noted and an update provided including the full nursing transformation project plan. The committee were advised that the CIP target for 18/19 would be determined in the next week as the control total and revised STF had now been confirmed and financial plans were being developed.

25. The committee received the updated SLR report for M9 noting that it would now be prepared on a monthly basis. The committed discussed significant loss making service lines and next steps. The committee welcomed the level of detail provided and acknowledged SLR as a useful tool providing excellent insight for committee members.

26. The committee received a report on GPOOH and NQR reporting following presentation at the Quality & Safety Committee where it was agreed to share the detail with the Finance & Performance Committee due to the less than favourable position on performance. It was noted that an action plan had been agreed and was being closely monitored through ELT. The committee asked for further detail on all regulatory submissions seeking assurance that the Trust had appropriate mechanisms in place to ensure appropriate and required submissions.

27. The committee received a report on the Stoma product CIP providing further information on the slippage of the scheme whilst providing assurance on the continuation of the pilot.

28. The committee received a report noting the challenges faced by MSK Physiotherapy due to the contract changes implemented by the CCG but noting assurance that these issues would be addressed through the new sub-contracting arrangements with WUTH during 18/19.

29. The committee received a quarterly update on the implementation of the estates strategy noting the good work completed and the acknowledgement received from NHSI on the progress the Trust had made. The continued pressure on patient parking on the SCHC site was highlighted and the committee was advised that a potential solution involving number plate recognition was being investigated by ELT. It was confirmed that a full QIA and EIA would be completed before any further progress was made.

30. The committee received a new Electronic Access Pass Policy for approval that applies to SCHC, VCHC and Eastham Clinic. The detail of the policy was discussed and a number of actions agreed; the committee did not approve the policy based on some minor additions but welcomed receiving a revised version via e-mail or at the next meeting in March 2018.

Any formal recommendations 31. There were no formal recommendations other than those mentioned above. Beverley Jordan Chair, for the August Finance & Performance Committee 02 March 2018

Briefing from the Chairman of Audit Committee Purpose 1. This is a report from the Audit Committee meeting held on Wednesday 14 February 2018. Significant agenda items 2. The Audit Tracker Tool was presented confirming the progress made against the 2017-18 audit

plan. The committee discussed the implementation of recommendations and suggested the tool include a RAG rating to indicate when recommendations are approaching deadline dates and detail in the cover paper any recommendations that are ‘at risk’ of completion during the next quarter. The committee also acknowledged the work of the committees of the board in receiving action plans associated with reviews of limited assurance and the groups within the governance structure that support the implementation of recommendations.

3. The Board Assurance Framework was presented to the committee and further detail in relation to specific principal risks was discussed. It was noted that a review of the principal risks was underway following ELT and board development sessions; this work was aligned to the organisation strategy refresh. The committee noted that the revised principal risks would be presented to the Board of Directors in March 2018 with the BAF fully revised for the new financial year.

4. Mersey Internal Audit Agency (MIAA) provided a regular update on internal audit reviews

according to the approved Internal Audit Plan for the financial year. The completed reviews and those in progress were noted. The committee discussed the annual service reviews completed in previous years and requested further detail to understand the services that had been reviewed.

5. Ernst & Young (EY) presented the Audit Planning Report to provide the committee with a basis

to review the proposed audit approach and scope for the 2018 audit in accordance with relevant legislation and to ensure alignment with the committee’s expectations. The report provided a summary of EY’s assessment of any key issues and was well received by the committee members. The committee noted that audit materiality had been set at 1% of the Trust’s operating expenditure and supported this on the basis of it being reassessed throughout the audit process and it being the first year EY were completing the audit for the Trust.

6. An update on the anti-fraud plan was provided to the committee setting out the work completed during 1 December 2017 - 5 February 2018 and highlighting activities and outcomes for committee attention. The committee noted the proposed actions in relation to the NHS Counter Fraud Authority assessment action plan and acknowledged that the Managing Conflicts of Interest Policy (GP7) reviewed at the committee in November 2017 had been subsequently approved by members and would be submitted to the public Board of Directors for final ratification on 7 March 2018. The committee was assured that communication of the policy was underway through ELT, SLT and Executive briefing and would be included in the staff bulletin on 9 March 2018 following the meeting of the Board of Directors. The committee noted the top 10 types of fraud and requested a summary on those that have been assessed through the anti-fraud plan and those that would be included in the forthcoming plan

7. The committee received tender waiver applications approved for noting and to provide

assurance that the processes followed complied with local guidelines as described in the Trust’s Standing Financial Instructions.

8. The committee also received the security update report noting incidents reported and the

outcome of an MIAA inspection on NHS Protect security standards.

Any formal recommendations 9. There were no formal recommendations.

Brian Simmons Chair, Audit Committee 1 March 2018

Briefing from Board Development Session - February 2018

Purpose

1. This is a brief report to record the key topics discussed and the information shared at a board development session held on 7 February 2018.

2. The Board of Directors meets on a bi-monthly basis for dedicated development time to consider key strategic items and support organisational planning.

Key topics discussed

7 February 2018 3. The Board received updates and shared information on a number of key topics through a full

day development session.

4. An update on the plans for the CQC inspection of the Trust’s core services and the well-led inspection was provided. The board noted the timelines and welcomed the inspection noting the depth of information provided as part of the annual Routine Provider Information Request at the end of 2017. The Board of Directors received assurance that all services were aware of the forthcoming inspection.

5. The Board received an update and a first draft of the revised trust organisation strategy to

discuss and comment on, following recent board development discussions and wider engagement activities with front-line staff, key stakeholders and governors.

6. In considering the revised organisation strategy, the Board of Directors also reviewed the key strategic risks to be monitored as the principal risks in the Board Assurance Framework. The Board acknowledged the initial work completed by members of the Executive Leadership Team and valued the opportunity to consider the risks in the context of the changing environment in which the trust is and will continue to operate. The Board noted that the revised risks would be brought forward to the next meeting of the Board in March 2018 to support the refresh of the BAF ahead of the new financial year.

7. The Chief Operating Officer provided a presentation on the Better Care Fund and the

implications for the trust highlighting the importance of supporting and leading effective system working.

8. The Board were joined by Hill Dickinson LLP and the Trust’s Information Governance Manager to provide a briefing of the readiness for the new GDPR legislation. The Board welcomed the information and were assured that an action plan was being monitored through the Information Governance Group.

9. The Deputy Director of Finance, Head of Business Intelligence and the Income & Costing Accountant joined the Board to provide an interactive session on the Trust Information Gateway (TIG) focusing on the committee and board dashboards to be used to monitor and track performance against key indicators. The web-based tool was extremely well received with members of the Board welcoming the detail and ability to understand performance in an engaging manner.

Alison Hughes Director of Corporate Affairs

1 March 2018

Briefing from the Chairman of Staff Council Purpose 1. This is a brief report from the meeting held on 25 January 2018. The ratified minutes of that

meeting will be presented formally to the Board in due course. Significant agenda items 2. The following key agenda items were discussed:

Staff Council Member Items

• Staff Council Chair and Vice Chair Board Items

• Executive Briefing • Update on Bids, Tender and Organisational Change • CQC Inspection • Mandatory Training • Wellbeing/Resilience • Car Parking at St Catherine’s • Nursing Transformation • Outstanding Care Accreditation • Update on Leadership For All • Communications Update • Staff Awards

Outcomes and actions agreed 3. The group confirmed that Tom Meade, Staff Council Chair, would be standing down in this role

but would remain as Staff Governor. Fiona Davies would take on the role of Staff Council Chair and Debra Ollerhead would carry on the role as Vice Chair. The whole of Staff Council thanked TM on behalf Staff Council and the Board for his tremendous commitment to the Chair role.

4. The Chief Operating Officer provided an update on the current bids, tenders and organisational change and included an update on the: Phlebotomy, MSK and Primary Care Mental Health contracts.

5. The Deputy Director of Nursing provided an update on the CQC Well Lead Inspection which

would be taking place from 27-29 March and confirmed there would also be a short notice inspection and an unannounced inspection taking place. A communications plan was in place to keep staff informed and packs have been distributed to all bases with posters and checklists. Staff Council members were encouraged to attend the Staff Focus Groups if they wished.

6. The Deputy Director of Nursing highlighted that the trust was still showing an amber rating for

completion of mandatory training currently at 81%. Following a staff suggestion monthly CPD sessions have now been organised in Community Nursing to allow staff to complete their mandatory training and meet as a team. This could be replicated in other areas.

7. The Director of Corporate Affairs provided an update on the forthcoming Staff Awards. To date

98 nominations had been received. Judging panels would take place and shortlisted nominees would be announced on Staff Zone. The event would be taking place at the Leverhulme Hotel, Port Sunlight on Friday 16 March.

8. The Director of HR & OD reported that in response to feedback from the previous Staff Council meeting regarding morale and work pressures, an action plan has been implemented to support staff wellbeing. This included the offer of IT troubleshooting sessions, cancellation of any non-urgent meetings, Tier 2 Patient Safety Leadership walkrounds have been stood down and reinvigoration of the staff ideas and listening events. Full details were shared in the Chief Executive’s Blog. Staff Council members welcomed this response.

9. Staff Council raised a query regarding timescales for the laptop replacement programme as some staff were experiencing issues with older laptops. The Director of HR & OD confirmed that there was a laptop replacement plan and battery replacement plan in place which would be shared with staff to manage any uncertainty.

10. The Director of HR & OD updated that building work was due to begin on the perimeter wall of

the Staff Car Park at St Caths which would result in the loss of 10 car parking spaces. Some key meetings were being moved out of St Caths to other venues particularly on Tuesdays and Wednesdays when the car park was at its busiest.

11. Staff Council fedback that some managers were not supportive in releasing staff to attend Staff

Council meetings and were not recognising the value placed on staff council. The Chief Operating Officer agreed to tweet after Staff Council had finished and agreed to raise this issue at the weekly Operations meeting.

12. The Chief Operating Officer updated that a transformational plan for Community Nursing had

been developed looking at working productively, better work life balance and getting leadership right. The first phase would include redesign of job roles of hub managers and team leaders to flatten job roles. The consultation finished yesterday and there have been some suggestions which would be responded to.

13. The Deputy Director of Nursing reported that the Outstanding Care Accreditation had now been

tested with four teams and had received positive feedback.

14. It was agreed that key messages from the meeting would be shared with staff via the Staff Bulletin.

Any formal recommendations 15. There were no formal recommendations. Tom Meade Staff Council Chair Jo Harvey Director of HR & Organisational Development Staff Council Co-Chair January 2018