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Warrington Clinical Commissioning Group

Meeting of the Governing Body

Agenda – 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP

MEETING OF THE GOVERNING BODY TO BE HELD ON WEDNESDAY 14th NOVEMBER 2012 AT 1.30 P.M. LARGE CONFERENCE ROOM, THE GATEWAY, SANKEY STREET,

WARRINGTON WA1 1SR

A G E N D A Timings 1.30 Meeting Open for Public

A Apologies for Absence

B Declarations of Interest in Agenda Items

C 1.35 Minutes of Warrington Clinical Commissioning Group Governing Body Meeting held on Wednesday 12th September 2012 (to approve)

N Atkin Enclosure

D Matters arising from the meeting

E 1.40 Chair's Remarks and Questions from the Floor

N Atkin Verbal

F 1.45 Governing Body Member feedback from Federations

GP Federation Representatives

Verbal

G 1.55 Chief Clinical Officer’s Report (for information)

S Baker Enclosure

Quality & Patient Experience: 076/12 2.10 Quality Report

(to approve)

J Wharton Enclosure

077/12 2.20 Corporate Dashboard Finance Report Performance Report

(to note and receive assurance)

I Crossley

Enclosure

Commissioning, Health Strategy and Policy 078/12 2.30 Adult Social Care – Draft Care and Support Bill

(to note)

Joe Blott Warrington Borough Council

Enclosure

Corporate Business & Governance 079/12 2.40 Quality Strategy Refresh

(to approve)

J Wharton Enclosure

080/12 2.50 Engagement, Experience and Communications Strategy Refresh (to approve)

N Armstrong Enclosure


Meeting of the Governing Body

Agenda – 14th November 2012

081/12 3.00 Organisational Development Plan 2011 – 2013 Refresh (to approve)


082/12 3.10 Integrated Strategic and Operational Plan 2012/13 – 2014/15 – Year 2 Update - Refresh (to approve)

S Baker Enclosure

083/12

3.20 Complaints Policy (to ratify)

R Knight Enclosure

084/12 3.30 Update on Safeguarding (to receive assurance)

R Knight Enclosure

085/12 3.40 Risk Management Strategy (to ratify)

R Knight Enclosure

086/12 3.50 Authorisation Report (to note)


Items to Note: 087/12 4.00 Approved Summaries and Minutes of Governing

Body Committees (to note)

Respective Chairs

Enclosure

088/12 4.10 Any Other Business

All

089/12 4.15 Questions from the Floor

090/12 4.20 Date and Time of Next Meeting: Wednesday 9th January 2013 at 1.30 p.m. Large Conference Room, The Gateway, Sankey Street, Warrington

Warrington Clinical Commissioning Group Minutes of Governing Body Meeting 12th September 2012

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Minutes of the Meeting of the Governing Body held on Wednesday 12th September 2012 at 1.30 p.m.

in the The Gateway, Sankey Street, Warrington Present:

Dr. Andrew Davies Chair Dr Sarah Baker Chief Clinical Officer Iain Crossley Chief Finance Officer Dr. Anita Malkhandi GP Governing Body Member - Warrington Alliance Dr. Simon Redfearn GP Governing Body Member - Phoenix Group Dr. Dan Bunstone GP Governing Body Member – Teaching Practices Gareth Hall Lay Governing Body Member Nick Atkin Lay Governing Body Member (Vice Chair) Pat Taylor Local Involvement Network (LINk) In Attendance:

Nick Armstrong Chief Operating Officer Simon Kenton Assistant Director Integrated Commissioning John Wharton Nursing and Quality Lead Sam Lowe Board Administrator (Minutes) There were 8 members of the public in attendance. 061/12 Patient Story

The Governing Body considered a patient story before the meeting commenced.

Action

A APOLOGIES FOR ABSENCE Apologies were received from Linda Bennett, Associate Director of Commissioning, Matthew Cripps, Improvement Director, Rebecca Knight, Head of Assurance & Risk and Maria Austin, Head of Communications.

B DECLARATIONS OF INTEREST IN AGENDA ITEMS There were no declarations of interest in any agenda items.

C

MINUTES OF THE WARRINGTON CLINICAL COMMISSIONING GROUP GOVERNING BODY MEETING HELD ON WEDNESDAY 11TH JULY 2012 050/12 Warrington Clinical Commissioning Group Model Constitution With regard to member’s accountability, this should read the each practice will identify a practice lead. The Board APPROVED the minutes of the meeting as a true and accurate record of the meeting.

Agenda Item No: C


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D MATTERS ARISING FROM THE MEETING

There were no matters arising from the meeting.

E

CHAIR’S REMARKS AND QUESTIONS FROM THE FLOOR Dr. Davies reflected on the summer, with particular reference to the Olympics and Paralympics 2012 and stated that he felt there had been a change in the way Great Britain perceives itself. The Paralympics in particular redefined what disability means and the way the population perceives disabled people. He explained that preconceptions people have about the elderly and young people also needs to change and with the help of the community we can try and overcome these preconceptions, in particular with the help of OPEG (Older Persons Engagement Group) who have a wealth of experience and with the young people in the town who make up the Youth Parliament and other very positive groups. Dr. Davies explained that Jeremy Hunt has now taken over from Andrew Lansley as Secretary of State for Health. Dr. Davies was pleased to announce that Warrington CCG has been successfully shortlisted for two national awards which are the National Association of Primary Care Visions (in the category of Most Advanced CCG) and also the Health Service Journal Awards (in the category of Commissioning Organisation of the Year) and stated that this is a reflection of the hard work that has been done by the CCG team and how well it is engaging with the public and patient groups. Councillor Pat Wright explained that she had brought with her two papers which have come out of the Health & Wellbeing Board around the Local Authority working with their GP Commissioners and the GP Commissioners working with the Local Authority. Action: To be circulated for information Mr. Alf Clemo explained that he has received some concerns from patients around waiting times whilst renovations take place on Wards 4 and 5 at the Hospital. He will be taking these concerns to the Hospital Governor’s Meeting. Dr. Baker thanked him for this information. Action: Mr. Wharton, Nursing & Quality Lead to look into this situation further.

S. Baker J Wharton

F

GP GOVERNING BODY MEMBER FEEDBACK FROM FEDERATIONS Warrington Alliance Dr. Malkhandi presented the Warrington Alliance update to the Governing Body. She explained that there has been no formal federation meeting since the last Governing Body meeting due to their Chair carrying out medical duties at the Olympic Games however work is ongoing within the practices. Phoenix Dr. Redfearn explained that there have been two meetings of the Phoenix Federation since the last Governing Body meeting. At the July meeting, the Federation were visited by Greg Moran from the Public Health department who gave a presentation around cardiovascular screening. The federation also looked at the Care Quality Commission (CQC) registration and how this


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affects them as a provider. They also received a commissioning update, in particular looking at the North West Ambulance Service Pathfinder Guidance. At the August meeting, the federation looked at the Quality Performance (QP) indicators, infection control training, mental health including anti-dementia drugs and data provided by the CCG around emergency admissions and Accident & Emergency attendances. Teaching Practices Dr. Bunstone reported that there have been two meetings since the last Governing Body Meeting which included discussions around the Quality Performance (QP) Indicators, Accident & Emergency referrals, the work completed around the pathways, in particular the Older People’s referrals and the role of Medicines Management Co-ordinator. Mr. Hall asked where the pathway plans are submitted. Dr. Davies explained that the pathway plans are submitted to the Programme Office at the CCG where the actions identified are collated onto a chart and fed back to the Federations. This information is also fed upwards to the Cluster. He explained that this is a good method of collating data and sharing best practice. Dr. Redfearn stated that the Cluster have fed back that the information submitted from Warrington is currently the best in the Cluster. Healthy Warrington Mr. Armstrong presented the Healthy Warrington update. He explained that at their July meeting there was a commissioning update which discussed the draft constitution, an update around the medicines management co-ordinators role, the federation looked at the Cardio-Vascular Disease (CVD) healthcare Local Enhanced Services (LES) and agreed which practices would represent the federations on the CCG QIPP workstreams. Mr. Armstrong advised that the August meeting was the federation’s Annual Education Meeting which took the full Protected Learning Time (PLT) meeting. They looked at the peer review, Quality Performance Indicators, and agreed the process for agreeing a replacement Governing Body Federation representative. It was also agreed that the Chairmanship of the Federation should be that of a six month rolling Chair and that Eric Moore Partnership would take this up as from October.

G

Chief Clinical Officer’s Report Dr. Baker presented her report to update the Governing Body on some of the key issues that have taken place since they last met, highlighting some key areas. Mr. Hall asked about the reference to Board to Board meetings within the report, and asked if this should read Executive to Executive meetings as the Governing Body members will not be attending these meetings. Dr. Baker agreed that the GP and Clinical Leads will be attending the meeting in Halton but not the whole Governing Body and the CCG support team and Clinical Leads will be attending the Hospital meeting. Dr. Baker agreed to look at the terminology used for Board to Board meetings given that the whole Governing Body/Board is not expected to attend.


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The Governing Body NOTED the contents of the Chief Clinical Officer’s report

062/12

QUALITY REPORT Mr. Wharton presented this report to inform the Governing Body of the key developments relating to the quality agenda since the last meeting. Mr. Wharton explained that three key influential documents have been published, and each one highlights the importance of quality in health care provision and strengthens the importance of patient safety remaining at the heart of meeting the domains of the NHS Outcomes Framework. These documents are:

How to Maintain Quality during the Transition: preparing for handover – this report offers clear guidance on the accountability around the roles and responsibilities of healthcare provision, keeping patients safe and ensuring that patients experience and care is good.

Quality in the New Health Care System – Maintaining and Improving Quality from April 2013 – this report advises on ensuring that all patients receive high quality care, putting metrics in place to measure quality and encouraging people to raise concerns without hesitation.

Winterbourne View – Interim Report – this review was set up to improve care and outcomes of people with learning disabilities or autism and challenging behaviours.

Mr. Wharton also reported that the NHS North of England has recently produced three dashboards which are:

Trust Performance Matrix Public Acute Quality Dashboard Performance Matrix

The new Chief Nursing Officer of the NHS Commissioning Board, Jane Cummings, has identified six areas that she believes will be paramount to raising standards of care and ensuring patient safety, and these are included within the report. These areas will form strong foundations on which nursing care will be measured. The Chief Nursing Officer is also eager to raise standards and address the many concerns the public have regarding standards of nursing care. Mr. Hall referred to point 22 of the report which states that the Winterbourne Report asks PCTs and Local Authorities to work together to ensure they assure themselves that the appropriate actions is being taken to improve outcomes for people with learning disabilities. Mr. Wharton confirmed that this work has been completed through the Cluster, looking at each area and making actions. He advised that one patient was identified within our area and this patient has been moved to an area what meets their needs more appropriately. Mr. Kenton reported that a draft report of standards has been produced and this will be taken to the Safeguarding Adults Board to ensure that our arrangements are as robust as possible. Mr. Hall asked how the CCG can aspire to make environments within residential nursing homes better for residents. Mr. Kenton explained that there are 41 residential nursing homes in Warrington which are monitored on a quarterly basis. Mr. Wharton also advised that people looking for residential nursing homes for relatives can ask about timetables, facilities and activities on offer for residents as part of their negotiation with


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prospective homes. Dr. Baker stated that this reinforces what Dr. Davies mentioned in his Chairman’s Welcome around the ageing population. She explained that the Health & Wellbeing Board have an Ageing Well Programme which plans to get feedback from our elderly population, challenge places of residence and set out what is acceptable and appropriate. Mrs Taylor explained that LINk do visit nursing homes on a regular basis where they talk to the residents and relatives and produce a report which is submitted to the Care Quality Commission and the Local Authority. The Governing Body NOTED the report and SUPPORTED the current direction of the quality agenda.

063/12

CORPORATE DASHBOARD Mr. Crossley presented this report to summarise the latest performance against the operational, financial and savings targets. Mr. Crossley advised that the year to date financial performance is in line with the planned year end surplus. He explained that savings plans are taking longer, however a workshop is being run in September with all the key health economy partners to ensure that progress is achieved for the year. Hospital activity is running above plan, however there are a number of meetings planned to address this. Operationally, as at the end of August the national targets set by the Cluster for the CCG and Hospital are showing as green, the only exception being the Annual Health Checks however action is being taken around this. Mr. Atkin asked if approval has been received for the Capital Programme Bid. Mr. Crossley responded that this has not yet been confirmed, however he is not concerned as the assumption is the bid will be approved and therefore schemes are progressing. Mr. Atkin enquired about the progress being made around the Annual Health Checks. Dr. Baker advised that the Primary Care Trust made a strategic decision not to invest in annual health checks when the organisation was in acute financial difficulty. It was also decided that the health checks required re-scoping which has now been done. The new scheme will initially target the most deprived areas of the town and it is anticipated that uptake will be high. Dr. Baker explained that this was a risk taken by the Primary Care Trust and although treatment and intervention for CVD in the town is good, we now need to focus on prevention. She confirmed that additional funds have been provided to the Public Health Department to undertake this scheme. Dr. Davies explained however that many patients will have received this health check through their own GP in the meantime. Mr. Atkin asked about the shortfall between projected savings and actual savings, stating that he is conscious the CCG is about to enter a heavy period due to winter pressures and asked if these projections could be re-visited after the planned workshop with our key partners. Mr. Crossley explained that there will be two follow up meetings after the workshop where plans will be put in place. The Governing Body NOTED the contents of this report.


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064/12

The Potential Impact of the Welfare Reform and Associated Austerity Measures in Warrington Mr. Cullen, Manager of Warrington Citizen’s Advice Bureau attended the meeting to present this report which outlines a number of the changes associated with welfare reform and their impact on Warrington residents, service providers and commissioners. Mr. Cullen advised that there are clear aims for this reform which intend to simplify the process, to tackle worklessness and to reduce benefit dependency. He advised that there are a number of positive things within the reform which include a single point of claim, to reduce bureaucracy, aims to make work pay, better flexibility for hours of work, reduction in child poverty and better support for childcare. However, Mr. Cullen advised that the negatives of the reforms include the following:

Contribution based benefits will be limited to one year which means that some people who are still unfit for work will lose a lot of income and may become in financial difficulty.

Intention to make claims online. Currently only 18% on claimants claim on line however it is the intention to raise this to 80% which is an ambitious target and will create a digital divide for those who do not have access or the ability. This will also require new systems for the Department of Work and Pensions and the Inland Revenue and may cause delays.

Claimants will be paid monthly in arrears Cuts to housing benefits, introduction of under occupancy tax and

benefits will be paid direct to claimant rather than the landlord. Increase in working age to 67 by 2020 which will lead to a rise in

claims for benefits. Mr. Cullen explained that there are concerns about the suitability of the test which deems people suitable for work and there has been a rise in people getting nil points and going to appeal. Each applicant for disability allowance will be subject to independent assessment. Mr. Cullen highlighted that this will impact on GPs as medical evidence will be required for each appeal and may lead to GPs receiving more calls for evidence, support and opinions. Mr. Atkin stated that this is a good report and added to the debate as the Chief Executive of a Housing Association in a neighbouring area. He stated that some families will have a reduction in income by up to 40%. He stated that there will be rises in overcrowding, increased levels of homelessness, impact on the wellbeing of the population, families will be expected to put children in the same room and the size of the room has not been factored in. He explained those most affected by the reforms will be households where there are four children or more, single people and disabled people. There will be an increased need for food banks. He explained that as a direct result of these reforms, most houses being build will be either 1 or 2 bedroomed which does not allow for the needs of growing families. Mr. Atkin stated that the major changes have not yet come in and there is a further £10 billion worth of savings to come in from welfare reforms. Mr. Cullen expressed concerns about the possible rise in suicides during the recession, increasing with the introduction of the reforms. He stated that we


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must support the positives of the reform, but also provide a safety net for our population and encourage partnership working to do so. Mr. Atkin stated that these changes do not only affect people on benefits, they affect working pensions and the self employed. Dr. Malkhandi stated that her practice has already experience a surge in applicants however they are using an electronic assessment tool for nurses to ensure the claimant’s wait is as short as possible. This also ensures that genuine cases for appeal go through quickly but there is minimum impact on the GP practice. Dr. Baker stated that this increased activity will impact on our planning for next year, which will also be the first year where there is no increase in funds for the NHS. She stated that we need to look at what we can do in the town to help communities help themselves more and this is our responsibility as a partner to have conversations with the public in advance of the reform and not protect them from reality. It is our job to do the best we can and to ensure that this is our focus. The Governing Body NOTED the potential impact of the welfare reform and associated austerity measures in Warrington.

065/12

WARRINGTON WELLBEING STRATEGY Mr. Kenton presented this report to seek the endorsement of the report by the Clinical Commissioning Group’s Governing Body. Mr. Kenton also circulated a summary report for the Governing Body to read. Mr. Kenton explained that this strategy is a statutory requirement from April 2013 and is based on the Joint Strategic Needs Assessment and approved by the Health & Wellbeing Board. The Strategy was presented to the Local Authority Board on Monday 10th September. Mr. Kenton explained that housing colleagues, the third sector and other partners worked together and consulted on the Joint Strategic Needs Assessment and identified priority areas for action. The identified priorities are divided into chapters within the strategy which are:

Closing the Gap Building Safe, Sustainable Communities Ensuring the Best Start in Life and Transition into Adulthood Living and Working Well Promoting Wellbeing for Older People

He also explained that key areas for focus are the ageing population, alcohol, mental health & wellbeing, and the need to reduce demand on services over time by focussing on prevention rather than cure. Mr. Kenton stated that the Strategy is supported by an action plan which is reported to the Health & Wellbeing Board and replaces the community strategy. He stated that he hopes the CCG can work to its aspirations. Dr. Davies stated that the strategy is well consulted on and is a good strategy which focuses on the right issues for Warrington, we now need to make it real.


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Dr. Baker advised that the risk is providing services without focussing on prevention and this is something we need to do. She also stated that as partners we need to keep challenging one another to remind each other of what we need to do to achieve this strategy. Mr. Atkin highlighted the table on page 11 which demonstrates the difference in life expectancy between the most and least deprived areas of the town. Mr. Cullen stated that the action plan is critical and it is a real challenge not to be over ambitious. He stated that to build resilience in communities, we need to invest to save and he would be interested to see how the budget is built to support this. Mr. Kenton advised that the Health & Wellbeing Board have a collective use of resources and needs to keep key collaboration at its forefront. Dr. Baker stated that it is not only the public sector’s duty but the whole community’s duty, including local businesses, to build resilience in communities and there is more that can be done. The Governing Body ENDORSED the Warrington Well Being Strategy.

066/12

In Vitro Fertilisation (IVF) Provision and Bariatric Surgery – Local Thresholds Dr. Baker presented this report to assist the Governing Body to consider its position in relation to local access thresholds for IVF and Bariatric procedures. Dr. Baker explained that as part of its strategic recovery process, the Primary Care Trust made a decision to cease funding for IVF and introduce a higher threshold for bariatric surgery. She explained that the context is now changing and it is likely that the NHS Commissioning Board will become responsible for specialist commissioning. NICE guidance has also been issued and is currently subject to consultation. With regard to IVF, Dr. Baker explained that Warrington CCG is one of only three organisations nationwide that does not fund IVF and that recommendation to the Governing Body is that we change the previous recommendation of the PCT and implement a policy of access to one cycle of IVF for newly referred patients meeting the criteria as defined within the current policy and once the NICE guidance is completed, that the CCG follows this guidance from that point. With regard to Bariatric Surgery, the recommendation is that Warrington CCG reconsiders it thresholds for access to bariatric treatment to those of our neighbouring CCGs. Dr. Davies stated that CCG is not an organisation in turnaround and we also need to consider national views. He stated that bariatric surgery can result in a reduction in heart disease and diabetes in future and is a good example of invest to save. Mr. Hall stated that based on the rationale of the PCT in strategic recovery, the decisions were the least clinically damaging way of reducing costs. However although the CCG is not in turnaround, it is still looking at contingencies and asked if could lead to the same cost cutting decisions being made in future. Dr. Baker stating that the CCG is not in financial


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recovery and is only one of three organisations nationally who do not fund IVF. She explained that the CCG would have to be in a more serious financial situation to make these sorts of decisions. Dr. Baker explained that during the last 8 months, the CCG has done a vast amount of work to find alternative pathways and reduce costs. Mrs. Taylor stated that she approves of the proposed change to IVF funding and stated that it is fair for the people of Warrington to have the same opportunities as the rest of the country. Mr. Atkin asked if there is provision in this year’s budget for IVF and Bariatric Surgery. Dr. Baker explained that due to the lengthy timeframe for both procedures, this would be a pressure for next year’s budget and is unlikely to impact on this year’s budget. Dr. Davies stated that the NICE evidence based review indicates that the best economically viable time to carry out bariatric surgery on a patient is the point of best return for the investment, if it is done too early it is high cost and too late could result in an incidence of the condition you are trying to prevent. The Governing Body APPROVED the following: In Vitro Fertilisation (IVF)

That Warrington CCG implement a policy of access to one cycle of IVF for newly referred patients meeting the criteria as defined within the ‘Cheshire, Mersey and West Lancashire – Policy on Fertility Services’ (2006-9 extended)

The Accountable Officer, Chair and Director of Finance to further review and implement any changes to access to IVF when revised NICE Guidance is issued, taking into account resource issues. (This assumes that the responsibility for fertility services including IVF does not transfer to the national Commissioning Board (NCB) and remains with the CCG)

The Governing Body APPROVED the following: Bariatric Surgery

Reinstatement of the thresholds for access to bariatric treatment as recommended by NICE Guidance CG 43 and in accordance with relevant ‘Cheshire and Mersey Procedures of Low Clinical Priority (PLCP) and Prior Approval Policy’ and related local pathways / treatment criteria policies. However the Governing Body agreed that more detailed population projection and financial implication modelling is required in collaboration with Warrington’s Public Health team and this will form part of next year’s planning.

That Warrington Clinical Commissioning Group Governing Body delegate authority to the Accountable Officer, Chair and Director of Finance to implement any changes to bariatric treatment access when the proposed modelling is completed


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067/12

PATIENT TRANSPORT SERVICES PROCUREMENT (PTS) Mr. Britt presented this report to inform the Governing Body of the formal 2012 Patient Transport Services Procurement process and timescale and to request endorsement of the Procurement Board’s recommendation to be ratified on the 14th September 2012. Mr. Britt explained that part of the procurement process is to divide the contractual arrangements between the patient emergency service and non emergency patient transport services. He explained that the successful bidder has now been selected, although we do not at present know who this is until the Board sits on Friday 14th September. This will be followed by an Alcatel period. Mr. Britt explained that the benefits of the new system which are outlined in his report, including extended operating hours which will enable patients to attend early morning appointments. Mr. Britt explained that there will be a small additional cost involved plus a 10% potential performance enhancement added to the projected cost. Dr. Malkhandi stated that this change could mean a significant reduction in “Did Not Attends” (DNAs) and therefore the CCG may need to factor in more patients attending their appointment and the cost of any subsequent treatment/activity. Mr. Britt confirmed that this new approach is designed to minimise missed appointments by also using a text message service to remind patients that they are on their way. Dr Baker agreed that we need to factor this in, in conjunction with the Acute Trust, as this could result in additional activity. Mr. Hall asked why the process is being changed, stating that change is usually made because the system is broken or you are getting more for less money. Mr. Britt explained that this will be a higher specification of service and that there had been lots of complaints about the original service. Dr. Baker explained that previously emergency and non emergency services had been bundled together and a patient could be brought into clinic at 8 a.m. and have to wait all day to be taken home by the patient transport service. This service will be run to a higher specification and will be performance managed. She advised that the management of the contract will need to be explored further. Mr. Hall asked if clinical members were happy to endorse this change and asked if it is worth the money. A discussion took place about the exact level of increase in the cost and whether this represented value for money. Mr. Crossley agreed to discuss this further with Mr. Britt. The Governing Body ENDORSED the successful bidder in advance of the final confirmation on 14th September and the new and separate Patient Transport Service (PTS) Service Level Agreement (SLA) contract for 2013/14. The Governing Body agreed that they would need to further explore the management of the contract. The Governing Body acknowledged the new service specification as outlined in the report.

068/12

SPECIALIST OESOPHAGO GASTRIC CANCER SERVICES PROCUREMENT - NHS MERSEYSIDE Dr. Baker presented this report to advise the Governing Body of the process underway, led by NHS Merseyside, to re-procure Specialist Upper Gastro Intestinal Cancer Services. She explained that the Governing Body needs


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to endorse this to ensure that it is right for the people of Warrington. She also explained that the Governing Body will see more of these types of reports going forward to ensure that no decisions are made without CCG engagement. Dr. Baker explained that there are currently two providers who were asked to agree between themselves which centre would provide specialist cancer services. As they were unable to do so, this has now gone out to procurement. Mr. Atkin asked if there is a significant difference between providers in terms of success. Dr. Baker explained that there are no risks about the safety of either service and it is likely to be the same clinical individuals just working together on one site. Dr. Davies stated that he would like to see more patient experience stories reflected in the commissioning model. The Governing Body NOTED the process underway to re-procure the Specialist Oesophago Gastric Cancer Services. The Governing Body ENDORSED the decision of the Chief Clinical Officer and Director of Finance of Warrington CCG to approve NHS Merseyside’s process for re-procurement of Specialist Oesophago Gastric Cancer Services.

069/12

ASSURANCE FRAMEWORK Mr. Armstrong presented this report to provide an opportunity for the Governing Body to comment on the Assurance Framework. He explained that this was presented to the Audit Committee last week and approved. Since the last Governing Body meeting five new risks have been added which are:

3.2 – failure to change / improve provider service delivery to meet new demands through introduction of the 111 service

4.8 – failure to identify and act on early warnings of a failing by any provider

5.11 – failure to identify appropriate and comprehensive commissioning support services to enable the CCG to fulfil its commissioning responsibilities

5.12 – failure to sustain financial balance due to national calculations for the 111 service penalising Warrington due to being based on higher than average local take up of GP OOH and large numbers of patients referred out of area on PBR basis

5.13 – failure to deliver the agreed QIPP savings plan Mr. Armstrong explained that two of the risks above were those highlighted around 111 at the last Governing Body meeting. He reported that there are no high level risks to report this month. Dr. Davies asked if the high risk threshold has been set at 15, and if so there are currently a number of high risks identified within the Assurance Register. Action: Mr. Armstrong agreed to check this with Mrs. Knight on his return to the office. The Governing Body NOTED the Assurance Framework and the strategic risks identified. They were unable to note that there are currently no high level risks until the action above has been taken.

N Armstrong


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070/12 AUTHORISATION REPORT

Mr. Armstrong presented this report to inform the Governing Body of the activities undertaken by the Chief Operating Officer and management team to work towards Authorisation. Mr. Armstrong reported that a Site Visit Guide and New & Improved Frequently Asked Questions document have been published as part of the two part guide to the CCG Authorisation assessment process. Warrington CCG received its Desktop Summary Report on the 29th August and provided a response to any perceived factual inaccuracies by the deadline of 31st August. The final summary report was received by the CCG this week. Mr. Armstrong stated that this report is a good reflection of the evidence submitted and there will be a panel meeting at the site visit on the 20th September to cover off any queries. An agenda for the site visit has also been received, which has been shared with the Governing Body and identifies six break-out groups. Mr. Armstrong reported that the draft CCG Constitution is now with our legal advisers to formalise and ensure it is in line with the latest regulations and that it is compiled in a way which gives the CCG flexibility whilst meeting national requirements. He explained that some items can come out of the Constitution and into policy documents, such as the Committee Terms of Reference as any changes the CCG wishes to make to the Constitution in future will need to go to the NHS Commissioning Board for approval. Mr. Armstrong explained that the posts for a Specialist Doctor and Registered Nurse to sit on the Governing Body are still outstanding however the CCG has received the applications and are in the process of shortlisting. It is hoped that these additional members of the Governing Body will be in post by October and will be in attendance at the next Governing Body meeting in November. It is also hoped that a replacement GP Governing Body member for the Healthy Warrington Federation will be in place during October. As part of the preparation for the authorisation site visit, the CCG Organisational Development Plan is being refreshed and the revised version will be submitted to the November Governing Body meeting. Mr. Armstrong explained that the CCG has been successful in applying for a grant from the North West Leadership Academy to embed the senior clinician’s role profile tool within the clinical leadership of the organisation. This grant will be used to provide a development programme for the clinical and practice leads. Dr Davies explained that there will be a practice leads meeting tomorrow, 13th September where the group will discuss authorisation, leadership profile, constitution and any other items raised by the practices. The Governing Body NOTED the contents of the report.

071/12

COMMITTEE TERMS OF REFERENCE Mr. Armstrong presented this report to ask the Governing Body to approve the Terms of Reference for the CCG’s Committees.


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Finance & Performance Committee The Governing Body APPROVED the Terms of Reference for the Finance & Performance Committee.

Audit Committee Mr. Hall explained that at the Audit Committee there was a general consensus that the Terms of Reference are light on membership, based on corporate memory. He explained that during the transition, Mr. John Gartside has been acting as Chair of the Audit Committee, however it was agreed that Mr. Gartside should now step down and Mr. Hall has agreed to take on this role in the interim. Mr. Hall stated that the Audit Chair is a big role and the accountability has not changed despite the scale of the organisation being reduced, and therefore the risk to the organisation needs to be flagged and considered. The current Terms of Reference stated that there are four members, and quoracy can be achieved by two members being in attendance at the meeting. Dr. Baker stated that she wants to ensure the CCG has a strong Audit Committee. She has taken advice about whether it would be possible to have an independent chair that is not a member of the Governing Body but has commercial/financial skills which complement those of Mr. Hall and Mr. Crossley. She had been advised that the chair had to be a member of the Governing Body, however this advice would not preclude such an additional independent member, so she was pursuing this option further. Mr. Atkin stated that the national template is minimal with a light structure. He suggested that this could be considered, together with the governance structure and the voting/non voting membership, at the next Board Development Session, following Authorisation. The Governing Body agreed to authorise the Chair, Chief Clinical Officer and the Chair of the Audit Committee to make the necessary changes and bring back a paper to the Governing Body around the Terms of Reference and membership of the Audit Committee.

Quality Committee Dr. Davies asked that the term “Quality Lead” be specified and made more explicit as it is not clear who this person should be. There is also a typographical error in that the alphabetical lists are out of order. The Governing Body APPROVED the Terms of Reference for the Quality Committee subject to the amendment to the document to read “Lay Member with Quality Portfolio” and the final version to be put on the CCG website.

Clinical Forum The Governing Body APPROVED the Terms of Reference for the Clinical Forum.

Remuneration Committee The Governing Body APPROVED the Terms of Reference for the Remuneration Committee.

N Armstrong


14

072/12

SUMMARY OF COMMITTEES OF THE GOVERNING BODY The Governing Body noted the summaries and approved minutes from the Committees. Dr. Davies gave a verbal summary for the Clinical Forum which was held on 5th September where discussions included:

Activity figures which are monitored on the date of discharge Waiting lists Presentation from North West Ambulance Service (NWAS) around

Pathfinder which is being introduced to triage calls and reduce conveyances to hospital. Representative from NWAS stated that they are happy to attend future meetings to provide further information on call levels, time of day and location of calls.

Care at home – again to reduce conveyances into hospital Dr. Davies explained that the dates for the Clinical Forum have now changed to give ample time for summaries to be presented to the Governing Body in future. The Governing Body NOTED the decisions made on their behalf and supported them.

073/12 ANY OTHER BUSINESS Mrs. Taylor explained that a steering group is being set up to look at the introduction of Healthwatch next year and looking at how to get this information out to the public. Mrs. Taylor asked if patient participation groups would be a good way of sharing information. Mr. Armstrong explained that Paul Steele, Public Engagement Officer is pulling together a meeting of the Chairs of the Patient Participation Groups and Mrs. Taylor could link into that. Action: Mr. Armstrong to ask Mr. Steele to contact Mrs. Taylor

N Armstrong

074/12 QUESTIONS FROM THE FLOOR Mr. Alf Clemo stated that it was good to hear the Chief Clinical Officer speaking about working more with the community around prevention and wondered about the funding for this. Dr. Davies explained that the Public Health Department has been allocated funding for prevention and will look at intervening in health conditions earlier, including commissioning primary care to provide screening. Mr. Clemo explained that the Older People’s Forum works with the community to provide services such as blood test and flu vaccinations.

075/12 DATE AND TIME OF NEXT MEETING Wednesday 14th November 2012 at 1.30 p.m. Large Conference Room, The Gateway, Sankey Street, Warrington Signed...................................................................... Dated ...........................

AGENDA ITEM NO. G

Chief Clinical Officer Report Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1


GOVERNING BODY REPORT

DATE OF GOVERNING BODY MEETING:

14th November 2012

TITLE OF REPORT: Chief Clinical Officer Report

PURPOSE OF REPORT: To update the Governing Body on some of the key issues that have not been covered elsewhere in an individual report

To inform the Governing Body of the activities undertaken by the Chief Clinical Officer and senior team since the last report

To seek, if appropriate, the approval of the Governing Body for actions to be taken

REPORT PREPARED BY: Dr Sarah Baker Chief Clinical Officer

KEY POINTS/TEAM BRIEF: To provide information and updates to the Governing Body in relation to:

NHS Commissioning Board Developments Clinical Commissioning Group Developments Commissioning Support Service Developments Other Significant Developments Meetings

RECOMMENDATION TO THE GOVERNING BODY:

The Governing Body is asked to:

a) Note the contents of this report

AGENDA ITEM NO. G


2

DOES THIS REPORT / ITS RECOMMENDATIONS HAVE IMPLICATIONS AND IMPACT WITH REGARD TO THE FOLLOWING: 1. QUALITY 1(a) Patient Safety No

If yes please outline the impact

1(b) Clinical Effectiveness No

If yes, please outline the impact

1(c) Patient Experience (including patient and public involvement) No


2. ADDITIONAL RESOURCE IMPLICATIONS

(either financial or staffing resources) No

If yes, please outline the additional resources required

3. HUMAN RIGHTS, EQUALITY & DIVERSITY REQUIREMENTS No If yes, how will this impact on these requirements

4. GOVERNANCE ISSUES 4(a) Which Strategic Goals does this report support? (please tick)

Improve Healthy Life expectancy for all Reduce inequalities Prioritise earlier interventions in care pathways Continually improve safety, patient experience and effectiveness of commissioned services

Achieve sustained financial balance and ensure sound business practices are at the heart of running a Clinical Commissioning Group

Optimise health outcomes 4(b) Does this report support any of the Clinical Commissioning

Group’s Priority Workstreams? No

If yes, please identify the workstream supported

4(c) Does the report contain any evidence of improved

compliance with Health Care Standards? No

If yes, please outline how compliance be improved

AGENDA ITEM NO. G


3

4(d) Does this report provide the Governing Body with assurance

against one of the risks identified in the Assurance Framework

No

If yes, please identify the Risk Number

4(e) For 2012-13 does this paper contain any legal implications

for Warrington Primary Care Trust? Does it impact upon: No

i. the corporate liabilities facing the Governing Body

ii. the role and functions of the Primary Care Trust

iii. other legal responsibilities (i.e., Data Protection Act)

iv. compliance with the Corporate Governance Manual If yes to any of the above, please outline how below

5. DEVELOPING TOWARDS AUTHORISATION Does this report provide evidence of compliance against an

authorisation domain? Yes

If yes, please tick the domain(s) supported

Clinical focus and engagement Patient, carer and community engagement Quality, Innovation, Productivity and Prevention (QIPP) including service transformation

Governance, financial control, capacity and capability Collaborative commissioning including other Clinical Commissioning Groups, Local Authorities and the NHS Commissioning Board

Leadership and partnership working

AGENDA ITEM NO. G

Chief Clinical Officer Report Warrington Health Consortium Board Meeting 1 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP CHIEF CLINICAL OFFICER REPORT

PURPOSE 1. The purpose of this report is to provide Members of the Governing Body with

information on key issues that have not been covered elsewhere in an

individual report; information on the activities undertaken by the Chief Clinical Officer and

senior team since the last report; and if appropriate, ratify agreements made and seek the approval of the

Governing Body for actions to be taken

NHS COMMISSIONING BOARD DEVELOPMENTS NHS Commissioning Board Formally Established 2. The NHS Commissioning Board was formally established on 1st October. It is

a new independent body with executive powers and exceptional responsibilities. In April 2013 it will take on its full range of responsibilities, and over the next six months will be assessing proposals for authorisation from over 200 new clinical commissioning groups.

3. Primary care trusts and strategic health authorities will retain their statutory

functions and governance arrangements until their abolition on 1 April 2013. More information is available on the Commissioning Board Website.

NHS Commissioning Board Local Area Teams

4. From 1 October 2012, Moira Dumma the new Local Area Team Director took

over responsibilities from Kathy Doran, PCT Cluster Chief Executive. As part of the establishment of the Local Area Team the following appointments to the Cheshire, Warrington and Wirral Local Area Team were announced at the end of October; Medical Director – Dr Kieran Murphy Director of Commissioning Development – Alison Tonge Director of Nursing and Quality – Tina Long Director of Delivery and Operations – Andrew Crawshaw Director of Finance – Russell Favager

Consultation on the NHS Constitution launched 5. The Department of Health (DH) has set out proposals to strengthen the NHS

Constitution for public consultation, with the NHS, patients and public all being asked to take part.

AGENDA ITEM NO. G


6. The main changes proposed cover:

a new responsibility for staff to treat patients not only with the highest standards of care, but also with compassion, dignity and respect;

a new pledge making it explicit that patients can expect to sleep in single-sex wards; and

a new pledge to patients that NHS staff must be open and honest with them if things go wrong or mistakes happen – this ‘duty of candour’ will become a condition in the NHS Standard Contract from April 2013.

7. The changes also make it clearer that:

patients, their families and carers should be fully involved in all discussions and decisions about their care and treatment, including their end of life care;

patients who are abusive or violent to NHS staff could be refused treatment; and

the NHS is equally concerned about physical and mental health.

8. The consultation follows work carried out by the NHS Future Forum on how the Constitution could be strengthened. The Government has accepted the Forum’s recommendations in full and the new proposals reflect this.

9. You can find more information on the consultation on the Department of

Health website. The closing date for comments is 28 January 2013. Responses to the consultation will feed into a revised version of the NHS Constitution, which will be published by April 2013.

Handover and close down guidance for transition to the new health and care system 10. The ‘handover and close down’ guidance has been published by the

Department of Health primarily for strategic health authorities (SHA) and primary care trusts (PCT) transition directors, lead and governance leads. This guidance fits with the transition communications planning for a secure transition to the new health and care system.

11. The transfer of intellectual property rights and related assets document

contains guidance and information on the principles and strategy for the handover of intellectual property rights currently held by SHAs and PCTs that will be transferred to new and existing NHS organisations.

12. The transfer documentation: identifying legal title in assets and liabilities and

completing transfer documentation provides guidance to assist strategic health authorities and primary care trusts prepare the instructions to Department of Health legal for the drafting of the transfer schemes under the Health and Social Care Act 2012. More information is available on the Department of Health website.

AGENDA ITEM NO. G


Healthwatch England Launched 13. Healthwatch England, the new national, statutory consumer champion for

health and social care in England, was launched on 1st October. Healthwatch England exists to ensure the public’s voice is heard at the national level. More information is available on the Department of Health website.

CLINICAL COMMISSIONING GROUP DEVELOPMENTS NHS Warrington CCG Governing Body Appointments 14. NHS Warrington CCG has confirmed 3 new appointments to its Governing

Body since the last meeting in July.

15. Dr Stephen Bentley has been appointed as the Specialist Doctor on the Governing Body. Dr Bentley is well known in Warrington after he spent nearly 30 years working at Warrington & Halton Hospitals. Dr Bentley will combine his role with the CCG alongside work as a Locum Consultant.

16. Mr John Wharton has been appointed as the Registered Nurse on the CCG Governing Body. Mr Wharton will combine his role as Nursing and Quality Lead for the CCG with the Registered Nurse role. John brings a wealth of experience from acute and community nursing.

17. Mr Stephen Sutcliffe will be taking up the Chief Finance Officer post for the CCG. Stephen was previously Director of Finance for Oldham PCT and also has experience of working in both community and acute providers. More recently he has supported the establishment of the Commissioning Support Unit in Manchester and is currently leading work on the implementation of the national finance ledger. Stephen will officially be commencing work with us on the 12th November and he will work together with Iain Crossley up to Christmas to ensure a smooth transition.

18. These appointments now mean that there is only one GP member of the governing body vacant. This is in the process of being filled by a Healthy Warrington Federation GP representative.

Commissioning Awards 19. Warrington Clinical Commissioning Group (CCG) won the Most Advanced

CCG 2012 award at the National Association of Primary Care (NAPC) Vision Awards on Tuesday 30th October. The awards aim to recognise the hard work of clinical commissioners and what their redesigns have achieved for the NHS.

20. This particularly coveted award was presented in recognition of our success

in effecting real change among local GPs, seriously tackling the local NHS structure and achieving solid results on a large scale.

AGENDA ITEM NO. G


21. This is an award for all – GP practices, federations, clinical leads, governing board members, core CCG team, our colleagues supporting us in the commissioning support unit, and our partners Warrington Borough Council, Warrington and Halton Hospital Foundation Trust, Bridgewater Community Healthcare NHS Trust and 5 Boroughs Partnership NHS Foundation Trust, who have contributed to this success.

22. And, last but not least, all the patient groups and individuals who have taken

the time and effort to feed back on their experience of services. This is what enables us to continue to improve healthcare services for local people.

23. We feel that we’ve made huge progress in the 18 months since we formed

and look forward to continuing to work with you all in the future to make a real difference to the lives of Warrington people.

24. Warrington CCG has also been shortlisted for the Health Service Journal

Awards in the category of Commissioning Organisation of the Year. This is the second year in a row that the CCG has been shortlisted for the HSJ awards. The results of this will be announced on 20th November. Clinical Engagement

25. To further strengthen relationships with member practices our first ‘Clinical Leaders’ meeting was held on September 13th. This meeting brings together all Practice Commissioning leads, Governing Body GP members, Federation Chairs and all the individual service Clinical Leads. It is intended that this group will meet quarterly to provide an additional arena for member practices to inform the work of the CCG and be kept up to date with all that clinical colleagues are delivering on their behalf. This supplements the monthly Practice Leads meeting, the monthly Protected Learning Time events attended by all member practices, the monthly Federation meetings, attended by their Governing Body GP member and the weekly information bulletin.

Joint working with Warrington Borough Council

26. I attended a workshop, with Dr Andy Davies and Councillor Pat Wheeler, organised by the Transition Alliance, on 14th September. This explored opportunities for Health and Wellbeing Boards across the region working together to act as a lobbying vehicle for major change. We will continue participating in these discussions to ensure that the wider determinants of health agenda is progressed.

COMMISSIONING SUPPORT SERVICE DEVELOPMENTS Template service level agreement (SLA) for CCGs published 27. The NHS Commissioning Board (NHS CB) has published a template service

level agreement (SLA), along with guidance on how to complete SLAs for use by CCGs procuring commissioning support services.

AGENDA ITEM NO. G


28. The NHS CB has asked CCGs and Commissioning Support Units (CSUs) to

agree and sign the SLAs by the end of November. This will enable both CCGs and CSUs to finalise their staffing structures and recruit in line with the national HR transition process.

Merseyside Commissioning Support Unit Managing Director Appointment 29. The NHS Commissioning Board Authority has appointed Tim Andrews as

Managing Director of Merseyside Commissioning Support Unit (CSU). Tim is currently Managing Director of Cheshire, Warrington and Wirral CSU and will now lead the two organisations.

30. The dual appointment will enable both CSUs to further develop and improve

their service offers and maximise new opportunities for the benefit of customers. This will particularly help with Warrington CCGs collaborative commissioning with Mersey CCGs.

OTHER SIGNIFICANT DEVELOPMENTS Military Veterans 31. The local access and support for the Military Veterans ( MV) was

commissioned using SHA Improving Access to Psychological therapies (IAPT) monies as a 2 year pilot with an independent evaluation to be done by Manchester University. The current pilot is due to finish in April 2013, if it is not re-commissioned. Originally it was thought that the responsibility for Veterans Health care would lie with the National Commissioning Board. However the NCB will now be responsible for the health care of serving personnel and Veterans care will be the responsibility of the 33 local CCGs in the North West.

32. The MV service in the North West provides evidence based, well governed

therapies and is contributing to the body of National evidence around Veterans care. The service is actually an “IAPT Plus” service as it also offers Family therapy, and Psychotherapy (particularly for Veterans who have pre service vulnerabilities) substance misuse support and includes staff expertise in a criminal justice liaison role. It works very effectively in collaborative with a range of Veterans Charities especially Royal British Legion and Combat Stress.

33. In Warrington, local IAPT service is very familiar with MV service; as the MV

service work from their base. From September 2011 - 2012, there have been 31 referrals from Warrington to MV service. Commissioners will attend the event planned by the SHA next week to obtain the relevant information/direction of travel for this service from April 2013 and factor this in strategic planning for Mental Health services.

AGENDA ITEM NO. G


MEETINGS

Meetings attended by the Chief Clinical Officer on behalf of the CCG

34. Since the last report in September the Chief Clinical Officer for the Clinical Commissioning Group has attended the following meetings:

Team to team meeting with Warrington & Halton Hospitals NHS Trust – 6th

September 2012 Wave 1 Clinical Leads Panel Site Visit at NHS Oxfordshire – 18th

September 2012 Protected Learning Time – 27th September 2012 Regional CCG Lead Management Meeting – 28th September 2012 Health Summit – 1 October 2012 Merseyside CCG Network Meeting – 3 October 2012 Informal Stakeholder Event – LAT Director Post – 4 October 2012 OSC – 10 October 2012 CCG Chairs & Chief Officers with Local Area Team Director – 23 October

2012 Integrated Commissioning Board – 24 October 2012 HSJ Award Presentation – 29 October 2012 NAPC Annual Conference – 30 October 2012 Vision Awards – 30 October 2012

RECOMMENDATIONS 35. Members of the Board are asked to:

a) Note the contents of this report.

Dr Sarah Baker, Chief Clinical Officer November 2012

AGENDA ITEM NO. 076/12

Quality Report Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1Q




14th November 2012

TITLE OF REPORT: Quality Report

PURPOSE OF REPORT: The report provides a narrative update on current national, regional and local quality issues which could impact on the Governing Body’s duties of delivering a safe, effective patient journey in line with the Quality Strategy.

The report focuses on the impact that changes may have on;

The duties of Warrington Clinical Commissioning Group

The Providers of NHS care on NHS Standard Contracts

REPORT PREPARED BY: John Wharton Nursing & Quality Lead

KEY POINTS/TEAM BRIEF: Delivering Dignity Commissioning for Quality & Innovation

Schemes 2012-13 Engagement and Learning from Patient

Experience Shared Decision Making Service Visits



Approve the approach to the national report on dignity of care for older people

Note the assurance provided through regular visits to providers

Note the progress in our strategic approach to ‘Engagement & Experience’



2Q

Note the assurance offered in the work being done on the guiding principle of ‘No Decision about me without Me



3Q

DOES THIS REPORT / ITS RECOMMENDATIONS HAVE IMPLICATIONS AND IMPACT WITH REGARD TO THE FOLLOWING: 1. QUALITY 1(a) Patient Safety Yes

To ensure that providers of care are adhering to the contractual obligation of meeting the CCG Quality Strategy in ensuring that patient experience if safe and effective.

1(b) Clinical Effectiveness Yes

That health interventions are carried out by competent and capable practitioners and all health care delivery is improves health outcomes

1(c) Patient Experience (including patient and public involvement) Yes

The patient experience is at the heart of all providers care interventions and should be an integral part of continuing quality improvements




3. HUMAN RIGHTS, EQUALITY & DIVERSITY REQUIREMENTS Yes All patient human rights,-equality and diversity is respected.





Group’s Priority Workstreams? Yes



compliance with Health Care Standards? Yes/No




4Q



Yes/No



for Warrington Primary Care Trust? Does it impact upon: Yes/No

i. the corporate liabilities facing the Governing Body No

ii. the role and functions of the Primary Care Trust No iii. other legal responsibilities (i.e., Data Protection Act) No

iv. compliance with the Corporate Governance Manual No If yes to any of the above, please outline how below


authorisation domain? Yes/No






Quality Report Warrington Health Consortium Board Meeting 5 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP Nursing & Quality Report

Delivering Dignity 1. Delivering Dignity is the final report from the Commission on Dignity in Care

for Older People. The commission was established following the publication in 2011 of a report from the Parliamentary and Health Ombudsman which exposed major failure in the care of older people. The report sets out the Commission’s work and makes recommendations on how to tackle the underlying causes of poor care.

2. The report makes in total of thirty seven recommendations which have been built on what the Commission has termed ‘Foundations of Dignified Care’ and are to be considered ‘Always Events’. These include;

Always treat those in your care as they wish to be treated – with respect, dignity and courtesy

Always encourage both formal and informal feedback for older people and their relatives, carers and advocates to improve the individual’s holistic health care delivery.

Always remember the importance of nutrition and hydration

Always challenge poor practice and learn as a team from the error.

Always report poor practice – the people in your care have rights and you have professional responsibilities to your patients.

3. Work has commenced with our main providers to ensure that these recommendations are being adhered to, with identified examples of good practice being shared. Where providers have not met all the identified areas, action plans have been requested to ensure that early implementation is being driven.

4. The next steps in response to the report is to ensure that we work with the

local authority to progress the recommendations of this report and ensure that all care providers are aware of the content of the report, its recommendations and how these are implemented into practice.

5. In conclusion, the report focuses on how to tackle the underlying causes of

poor care with a follow–up programme of activities which are intended to build on existing good practice. The intent of the programme is based on ensuring that that every patient gets the right care, every time.



6. Legacy Document -The Health & Social Care Act 2012 requires that the reforms to the NHS Landscape are in place by 1st April 2013. Recognising the potential that these structural changes could have on the quality and safety of patient care, the National Quality Board have published Maintaining and Improving Quality During the Transition (March 2011).

7. The document describes the formal handover requirements for Primary Care

Trusts (PCTs) and Strategic Health Authorities (SHAs) during the process of clustering, their functions, to ensure that organisation memory is captured and communicated to the receiving body.

8. To meet these formal handover requirements NHS Warrington, Cheshire and

Wirral Primary care trust cluster are required to produce a document which captures the organisational memory, issues and associated risks in preparation for the final handover to the successor organisation in April 2013.

9. Warrington NHS Cheshire and Wirral Primary Care Trust Cluster have

submitted a plan to the Strategic Health Authority of their intended approach to the handing over of quality matters to successor organisations. In line with guidance, a first draft of the quality handover document has been drafted. The final version of the document will be presented to NHS Cheshire, Warrington and Wirral Primary Care Trust Board in Spring 2013.

10. In order for the first draft of the quality handover document to be produced

quality profiles have been created from each provider of NHS Care. Within Cheshire, Warrington and Wirral, quality profiles have been produced in conjunction with Clinical Commissioning Groups which have already been delegated responsibility for quality.

11. The profiles will contain key documents which will evidence the quality

monitoring of each of our main providers current provider status in a number of key areas is also required such as safeguarding, performance against the Commissioning for Quality and Innovation Schemes (CQUINS) as well as the provider’s patient survey results and any known risks and associated mitigations.

12. It is imperative that good engagement with our providers is the key to

ensuring that the development of the handover document gives a true and accurate view of the provider’s organisation. Meetings have been established with each provider to discuss the process and review and agree the draft quality profile of the first version of the handover document.

13. There will be regular discussions with provider organisations to ensure that

their profile will be kept ‘live’ for regular updates, working towards and in preparation for the final handover in April 2013

14. The Nursing & Quality lead of the Clinical Commissioning Group has met with

the main providers and further meetings are time-tabled to work towards updating their profiles with an expectation that final versions will be concluded



for presentation to the final NHS Cheshire, Warrington and Wirral Primary Care Trust Board Meeting in March 2013.

15. Warrington Clinical Commissioning Group, as the receiving organisation, will

need to receive and adopt all these legacy quality handover documents formally at a Governing Body meeting in March 2013.

Commissioning for Quality & Innovation Schemes 2012-13 16. Commissioning for quality and innovation schemes identify areas for

improvement and innovation and agree clear targets through measurable steps that are monitored. This year the providers are able to earn 2.5% of their actual contract value through achieving the goals agreed with the commissioning organisation.

17. The schemes agreed this year with Warrington & Halton Foundation Trust,

Bridgewater (Warrington Division) and Spire Hospital are all based on improving patient care delivery and developing strategies for patients to access services to help and improve their own health status.

18. Performance against the goals in each of the provider’s commissioning for

quality and innovation schemes are monitored through regular quality and performance meetings with each provider as part of their contract monitoring agreement.

19. There are currently no exceptions to report to the Governing Body. Engagement & Learning from Patient Experience 20. The CCG strategic approach to embed engagement experience and

communication into everything we do to ensure that intelligence from local engagement and learning underpins the further development of the organisation’s culture, that the patient experience is everyone’s business.

21. The established monthly Patient Experience meetings have now commenced,

inviting the provider’s head of patient experience to the monthly meeting to give assurance around what mechanisms are in place to ensure that patient’s experience – good or bad is recorded and remedial plans agreed.

22. The group are working to triangulate from the reporting of complaints, PALS

and providers patient satisfaction surveys where there are themes and trends that are occurring and how these can be improved upon through working in a cohesive way to improve health care delivery for the people of Warrington.

23. The group will not only ensure that we comply with our statutory obligations

under section 242 ‘Duty to Involve’ of the Health and Social Care Act 2006 but proactively seek involvement and engagement through both formal and informal routes.



Shared Decision Making 24. The CCG is highly committed to ensuring that the views of individual patients

are reflected in shared decision making which will be influential in future commissioning decisions.

25. To move this forward, discussions are taking place about how we include the

‘No decision about me without me’ shared decision tools into our contracts with providers. As this intelligence accumulates, it will provide an aggregated view of the choices that our local population are making which will help to inform future commissioning intentions.

26. Discussions have taken place with the local acute provider around how this

can be moved forward and there is the potential for patients to use ‘prompt’ cards in out-patient services to encourage them to ask questions about what they want from their appointment.

27. Depending on the success of this, the potential for rolling this out into

community and primary care bases particularly for patients regularly attending for long term conditions could be beneficial to acquiring the views and suggestions of patients in primary care.

Service Visits 28. The Chief Clinical Officer and the Nursing and Quality Lead have recently

made three service visits. The first to Spire Cheshire (11th October) where good practice was observed in relation to patient care, particularly regarding cleanliness, dignity and respect and good communication towards patients and relatives.

29. On Thursday (1st November) the Chief Clinical Officer and Nursing and

Quality Lead were accompanied by Dr. Anita Malkandi (Governing Body GP) on their visit to the 5 Boroughs Partnership NHS Foundation Trust. The group were escorted around the hospital by Dr. Louise Sell, Medical Director. The visit focused on examining the work that the trust has carried out around Medicine Reconciliation and how improvements with primary care can be made through effective use of IT systems.

30. The visit also highlighted the need to raise awareness in Primary Care of the

work of the Psychological Therapy Department and the reduction of medication.

31. The Quality Lead for the CCG visited the Acute provider on Monday 5th

November and spent time on an acute cardiac ward discussing the improvements which have been made in patient care delivery, particularly around patient documentation and the patient discharge process.



32. The ward was complimented on their cleanliness, and ward organisation. Patients spoken to also complimented the ward and particularly the standards of care which they had received,

33. The Governing Body is asked to:

Approve the approach in response to the publication of the national report on the dignity of care for older people.

Note the assurance provided through regular visits to service providers.

Note the progress being made in our strategic approach to engagement

experience and Communication.

Note the assurance provided in the work towards implementation of the ‘No decision about me without me’.

John Wharton Nursing & Quality Lead November 2012

AGENDA ITEM: 077/12

Corporate Dashboard Warrington Clinical Commissioning Group - Governing Body 14th November 2012

1

WARRINGTON CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT


14th November 2012

TITLE OF REPORT: Corporate Dashboard

PURPOSE OF REPORT: To summarise the latest performance against the operational, financial and savings targets

REPORT PREPARED BY: Iain Crossley Chief Finance Officer

KEY POINTS/TEAM BRIEF: The key points to note are: The year to date Financial Performance is in line

with the planned year-end surplus of c£1.6m. Quality, Innovation, Productivity and Prevention

(QIPP) savings are £4.2m against a planned figure of £7.4m. A multi-agency contingency plan has been developed to alleviate the current financial pressures in secondary care.

NHS Warrington reported 100% of patients being treated within 62 days of Cancer Service Screening referral, and 62 days consultant decision to upgrade their priority status in August 2012. However reported 83.78% of patients being treated within 62 days of an urgent GP referral for suspected cancer, showing performance to have fallen below the 85% threshold. This relates to 6 patients out of 37 breaching the target.

The overall CCG target for admitted, non-admitted, and incomplete referral to treatment pathways within 18 weeks has been achieved in August 2012. However there have been individual specialty breaches in Trauma & Orthopaedic, Neurosurgery, Gynaecology, Respiratory Medicine, General Medicine and Geriatric Medicine.

Warrington and Halton Hospitals NHS Foundation

AGENDA ITEM: 077/12


2

Trust achieved the 95% target in August 2012 for Accident and Emergency four hours or less waiting times (95.22%).

NHS Warrington reported 0 breaches in August 2012 for MRSA.

The diagnostic wait 6 week target has been achieved, however diagnostic activity for both endoscopy and non-endoscopy based tests are above the target threshold. This is in response to the 2012/13 national screening campaigns and has been a service pressure for our Trusts.

The Public Health team are monitoring and managing NHS Health Checks. NHS Warrington Public Health team achieved 476 first invitations and 219 total number of screens completed at the end of August 2012. A Local Enhanced Service has been developed and is currently awaiting approval. 15 practices out of 26 expressing an interest in taking this forward.



1. Note the contents of this report

AGENDA ITEM: 077/12


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3. HEALTH INEQUALITIES No If yes, please outline the effect upon health inequalities



Improve Healthy Life expectancy for all Reduce inequalities

Prioritise earlier interventions in care pathways

Continually improve safety, patient experience and effectiveness of commissioned services

Achieve sustained financial balance and ensure sound business practices are at the heart of running the CCG

Optimise health outcomes 5(b) Does this report support any of the CCG’s Priority

Workstreams? Yes

Covers all corporate performance issues




AGENDA ITEM: 077/12


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5(d) Does this report provide the Board with assurance against one of the risks identified in the Assurance Framework No



for Warrington Primary Care Trust? Does it impact upon: Yes

i. the corporate liabilities facing the Board Yes

ii. the role and functions of the Primary Care Trust Yes

iii. other legal responsibilities (i.e., Data Protection Act) Yes

iv. compliance with the Corporate Governance Manual Yes If yes to any of the above, please outline how below







CORPORATE DASHBOARD - NOVEMBER 2012

Apr May Jun Jul Aug

Target achieved

94.68% 91.78% 95.77% 94.50% 96.74%

Target achieved

9732 8112 7983 8122 9873

Target achieved

540 636 522 580 535

Target achieved

77.86% 74.38% 79.52% 78.48% 75.74%

Target achieved

0.00% 0.00% 0.00% 0.00% 97.20%

Target achieved

94.68% 91.78% 95.77% 94.50% 97.18%

Cancer 62 day waits 85%

92.31% 89.47% 80.49% 88.89% 83.78%

90% Target achieved

100.00% 100.00% 83.33% 83.33% 100.00%

85%

66.67% 85.71% 62.50% 80.00% 100.00%

DIAGNOSTICS

95.71% 96.64% 96.99% 96.83% 0.10%

8783 9054 9080 9081 9103

4266 4773 4037 4908 4499

Commissioner Performance Overview 2012-13 Freq

Apr-Aug YTD

Target/ Plan

Apr-Aug YTD Actual Trend

A&E

A&E% of patients who spent 4 hours or less in

A&EMonthly 95% 94.69%

Comments

Q1 Q2

A&E attendances

Total number of attendances at A&E departments in a month

Monthly

51164 43822

Type 1 number of attendances at A&E departments in a month

42272 2813

AMBULANCE

Ambulance quality - Cat A response times

Cat A response within 8 mins Monthly 75% 77.20%

Cancer 2 week waits

Percentage of patients seen within two weeks of an urgent GP referral for

suspected cancer Monthly

93% 96.69%

CANCER WAITS

Percentage of patients seen within two weeks of an urgent referral for breast symptoms where cancer is not initially

suspected

93% 94.24%

Percentage of patients receiving first definitive treatment for cancer within 62-

days of an urgent GP referral for suspected cancer

Monthly

87.66%

August performance for the Cancer 62 day waits failed to meet target due to 6 patients breaching the 85% threshold. Please refer to the report narrative for more detailed comments on this breach.

Percentage of patients receiving first definitive treatment for cancer within 62-

days of referral from an NHS Cancer Screening Service

90.91%

Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade

their priority status

73.91% Although the YTD position remains below the 85% threshold, August has seen a marked inprovement in performance with 100% meeting the target.

Diagnostic Waits % waiting 6 weeks or more Monthly -1% 0.4%

Despite generally increasing diagnostic activity numbers, our host trust Warrington and Halton have zero patients who have been waiting over 6 weeks. Within other trusts there is 1 patients waiting over 6 weeks for a Non-Endoscopy based test (University hospital of South Manchester FT - Flexi sigmoidoscopy) and 1 patient waiting over 6 weeks for an Endoscopy based test (Liverpool Women's FT -Non-obstetric ultrasound).

Diagnostic Activity

4 x Endoscopy-based tests

Monthly

2467 45101 The planned threshold for August was 516 for endoscopy-based tests and 4126 non endoscopy based tests. Although diagnostic activity is currently exceeding plans, August activity shows to be lower than July’s, and closer to planned activity

figures than previous months. Recent awareness campaigns may explain peaks in activity for certain tests. 11 x Non-endoscopy based tests 19733 22483


Target achieved

0 0 0 2 0

Target achieved

2 1 2 4 3

Target achieved

Target achieved

0 0 0 0 0

447 570 493 560 481

1677 2005 1711 2006 1931

2124 2575 2204 2566 2412

9732 8112 7983 8122 9873

8184 6746 6565 6731 8253

REFERRALS

Please refer to narrative for more detailed comments on the activity lines

2208 2877 2264 2734 2518

Target achieved

3867 5054 4134 4716 4539

0.73% A Local Enhanced Service is now scheduled to be discussed at the October meeting of the Mid-Mersey LMC. Quarter Two figures will be available at the end of October, however it is not anticipated that any significant progress will have been made due to the changes in service provider taking place in this period.0.30%

HEALTH CHECKS

Coverage of NHS Health Checks

% people ages 40-74 who have received a health check

Quarterly

3.0%

0.7%

1.5%

0.3%

CDI 26 12

HEALTH VISITORS

HEALTHCARE ASSOCIATED INFECTIONS

HCAI measure (MRSA & CDI)

MRSA bacteraemia

Monthly

2 2

MENTAL HEALTH

Mental health measures - IAPT

Proportion of people with depression referred for psychological therapy

Quarterly

1.4% 4.95%

Health Visitors Health visitors - No. of WTE on ESR Monthly

4.95%

Proportion of people who complete therapy who are moving to recovery

50% 40.91%

MIXED SEX ACCOMODATION

MSA breaches Numbers of unjustified breaches Monthly Minimal 0

Quarter 1 performance is currently failing to achieve the 50% planned target. The IAPT service provider remains under capacity in terms of staffing. Although we are under target, performance has significantly improved since Quarter four 2011/12. 40.91%

PLANNED CAREFirst outpatient

attendances following GP referral

No 1st outpatient attendances after GP referral

Monthly

12037 2551

Please refer to narrative for more detailed comments on the activity lines

No of elective FFCEs (daycase admissions)

8987 43822

Total No of elective FFCEs 11234 36479

All first outpatient attendances

No of first outpatient attendances 21305 9330

Elective FFCEs

No of elective FFCEs (ordinary admissions) 2247 11881

GP written referrals to hospital

No of GP written referrals

Monthly

13732 12601

Other referrals for a first outpatient appointment

No of other referrals 9630 22310


Target achieved

93.20% 93.90% 93.80% 93.78% 93.13%

Target achieved

0.10% 0.10% 0.10% 0.00% 0.10%

Target achieved

95.22% 95.49% 95.69% 95.22% 96.74%

4 3 2 2 1

1 1 1 1 3

6 5 4 4 4

22 27 22 28 19

Not operational until October

Target achieved

92.59% 90.48% 80.95% 71.43% 92.31%

50.00% 55.56% 25.00% 0.00% 37.50%

Target achieved

1784 2227 1648 2117 1837

REFERRAL TO TREATMENT

RTT waits

RTT - Admitted % within 18 weeks

Monthly

90% 93.56%

RTT specialties breaching the standard

0 In August there was an individual specialty failure in Trauma & Orthopaedics.

RTT- Non-admitted pathways 0In August 2012 there were three specialty fails: Trauma & Orthopaedics, Neurosurgery and Gynaecology.

RTT patients waiting 52+ weeks

RTT - Non-admitted % within 18 weeks 95% 0.08%

RTT - Incomplete % within 18 weeks 92% 95.67%

RTT - Admitted pathways

RTT - Incomplete pathways 0

Four specialties breaching the standard in August 2012. These specialties are Respiratory Medicine, Trauma & Orthopaedics, General Medicine and Geriatric Medicine.

RTT - Incomplete pathways 15

SEASONAL FLU

Seasonal Flu Flu vaccination uptake Monthly

In August 2012 there has been a significant decrease in the total number of incomplete pathways at 52+ weeks to 19. This reflects the general downward trend in the North of England.

STROKE

Stroke/TIA

Stroke - patients spending at least 90% of their time on a stroke unit

Monthly

80% 85.55%

TIA - patients with high risk of stroke who experience a TIA and are assessed and

treated within 24 hours60% 33.61%

TIA screening has proved problematic at Warrington, despite frequent follow up through the SLA contracting process. The issue is two-fold, clinical practice processes are inconsistent and administrative recording has been intermittent. All parties are currently working towards a sustainable improvement.

UNPLANNED CARE

Non elective FFCEs Non-elective FFCEs Monthly 10980 9613

Finance Report for 6 Months to 30th September 2012 14th November 2012

APPENDIX 1

WARRINGTON CLINICAL COMMISSIONING GROUP FINANCE REPORT FOR PERIOD ENDING 30th SEPTEMBER 2012

PURPOSE 1. The purpose of this report is to update members of Warrington Clinical

Commissioning Group’s Finance and Performance Committee and Governing Body on the financial position of the Primary Care Trust for 2012/13.

NHS WARRINGTON FINANCIAL POSITION

2. The financial position at the end of Month 6 is a surplus of £0.843m. This is contributing to a planned surplus position for the 2012/13 financial year of £1.588m and is £0.048m ahead of the plan year-to-date.

3. Current performance will be outlined, in accordance with existing organisational architecture, within the remainder of this report. As the financial year progresses, organisational changes will be reflected.

SOURCE OF FUNDS

4. The current resource available to Warrington Primary Care Trust is £337.395m, which represents an increase of £1.143m from the reported position at month 4. This increase reflects the net impact of the following adjustments:

£000 i. Health Bundle funding – destined for 5 Borough Partnership

Foundation Trust 1,003

Offender Health. Funding for Liaison & Diversion network – destined for 5 Borough Partnership Foundation Trust

140

Emergency non elective performance adjustment (adjustment relating to 2011/12)

(41)

Public Health Support Funds for Local Authorities 78

Total 1,143


SPECIFIC ITEMS RELATING TO FINANCIAL PERFOPRMANCE AS AT MONTH 6 WARRINGTON CLINCIAL COMMISSIONING GROUP 5. The financial performance of the Warrington Clinical Commissioning Group’s

services, against budget year to date, is an over spend of £0.070m.

Acute Service Agreements 6. At the end of September 2012 there is a reported over spend against acute

service agreement budgets of £0.310m. The material variances reported within this can be explained as follows:

7. Warrington & Halton Hospitals FT (£3.138m Adverse) – At month 6 the Warrington and Halton Hospital Foundation Trust (WHHFT) contract is reporting an over spend against plan of £3.1m (£2.5m at month 4), which is based upon full PbR tariff. The major variances reported year to date are as follows: Critical Care £0.734m Day case activity £0.464m Elective in-patient £0.450m Non elective Same Day (BPT) £0.338m High cost drugs £0.320m Outpatients – (FA, FU, Procs & Tel Appts) £0.420m

8. The financial performance for the last 5 months, and year to date, has been

compared with that of the previous year and the planned contract levels for 2012-13. This analysis can be seen in the bar chart below and the graph showing GP referral numbers into Warrington and Halton Hospital Foundation Trust (WHHFT) for the most recent 8 months.


9. NHS Warrington’s financial plan for 2012-13 included a level of contingency for additional acute activity plus a sum for winter pressures. There are also general reserves allocated along with a prescribed amount (0.6% of recurrent revenue resource limit) for strategic change.

10. A significant level of these reserves (£2.888m) has been utilised to offset the over spend against acute service agreements in order to achieve the planned surplus required at month 6. The remaining reserves are not sufficient to support a level of expenditure that continues at the current rate.

11. The contract forecast outturn assumes that the current level of over performance on the main acute contract with Warrington and Halton Hospitals NHS foundation Trust does not increase in the remainder of this financial year.

12. All actions agreed at the multi-agency contingency planning workshop are being implemented as a matter of urgency and are anticipated to be completed by the end of October.

13. Spire Cheshire (£544,000 Adverse) - Activity levels in the majority of

specialties are still significantly higher than those planned year to date. Specialties such as Orthopaedics, Ear/Nose/Throat, General Surgery, and plastics are already above the annual planned activity for the contract. This is highlighted within the table below:

Warrington

Ort

ho

Gyn

ae.

ENT

Gen

Su

rger

y

Plas

tics

Oph

thal

mic

Vasc

ular

Uro

logy

Gas

tro

Total Indicative annual figs 182 91 26 91 19.5 13 6.5 26 13 468 Actual YTD figs 345 51 125 115 59 4 0 25 7 731


14. The 2012-13 contract value for Spire was based upon activity and referral

levels at the end of 2011; however, as illustrated in the graph below, the number of GP referrals into Spire has increased steadily in the last twelve months. Despite August referral levels decreasing significantly the initial figures for September suggest that levels have increased to those experienced in July.

0

20

40

60

80

100

120

140

160

180

Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

Data

Average

Spire - GP Referrals Received [Sept 11 to Aug 12]All Specialties

15. Royal Liverpool & Broadgreen FT (balanced) –the Merseyside contract

agreement for 2012-13 capping payments at contracted levels has resulted in a balanced position continuing to be reflected.

16. The performance of all of the acute service agreements can be seen in

Appendix 5.

Continuing Healthcare 17. There is a risk of significantly increased costs for in-year restitution cases due

to a reduction in the period that claims can be backdated. With effect from the 1st October 2012 claims can only be backdated 12 months (previously they could be backdated to 2004).

18. This change has resulted in an influx of new claims, with approximately 5,000 additional claims across the North West with 200 of those being Warrington patients.

19. Additional resources are being allocated within the Continuing Care Team to review these additional claims. The potential cost of the additional claims has not yet been quantified but £1m is included as a risk and is reflected in the financial position reported.


Prescribing 20. The practice prescribing budgets, using Prescription Pricing Authority (PPA)

data as at month 4, are reporting an overspend year to date of £0.334m; funding has been allocated from reserves to offset this over-performance. Further reserves have been earmarked to support the delivery of QIPP should this level of expenditure.

21. The projected outturn is based upon the required Quality, Innovation, Productivity and Prevention (QIPP) saving in year of £1.475m against 2011/12 outturn levels. Using the latest Prescription Pricing Authority (PPA) data, and a revised cumulative monthly profile, the forecast outturn variance is calculated at £0.6m adverse.

Other CCG Services

22. Expenditure levels within other CCG service areas are lower than budgeted at this stage of the financial year but these are forecast to increase as the year progresses and to be line with the assigned funding. Non Contracted Activity, in particular, has been low for the first two quarters. Business Services are now forecast to be overspent due to continued, and increased, usage of temporary staff to fill vacant posts.

NHS WARRINGTON 23. The financial position of NHS Warrington at month 6 of the 2012/13 financial

year is a surplus of £0.049m against budget. Pharmacy Contract

24. Pharmacy contract payments have increased as forecast in earlier reporting periods. The forecast outturn variance for the contract is now £0.130m adverse. Business Functions

25. The Business Support Unit, including Estates and Information and Communication Technology, is generating the largest underspend against budget at month 6 of £0.155m. Of the reported underspend, £0.066k relates to Information Management & Technology due to unfilled vacancies and savings within network maintenance, and £0.81m within Estates that relates reduced requirements at Orford Park and a reduction in the Estates Service Level Agreement with the 5 Boroughs Partnership Foundation Trust.

Public Health

26. Public Health budgets are underspent, against budget, at month 6, to the value of £0.070m. The majority of this is attributable to the Health Programme budgets, where minor variances against budget for multiple services continue to accumulate. Forecast outturn for this Directorate is a positive variance of £0.050m. An allocation of £0.078m, highlighted within Source of Funds, has been awarded to support to on-going transition of the service into the Local Authority.


QIPP 27. The 2012/13 planned Quality, Innovation, Productivity and Prevention (QIPP)

savings target is £15.277m. It should be noted that the associated funding for these schemes has already been withdrawn from service budgets during budget setting for 2012/13.

28. Quality, Innovation, Productivity and Prevention (QIPP) savings at month 6 are £4.2m against a plan of £7.4m; the shortfall in achieved savings to date has been offset by the utilisation of reserves with the net position being reflected in the financial position to date.

29. Where possible existing Quality, Innovation, Productivity and Prevention (QIPP) schemes are being accelerated to deliver savings earlier and NHS Warrington is working with health economy partners to implement the changes agreed at the contingency planning workshop held in September.

CAPITAL PROGRAMME

30. The Capital Programme for the Primary Care Trust is shown in Appendix 9. 31. NHS Warrington has a total available capital resource of £13.645m. This is to

be spent on Local Improvement Finance Trust (LIFT) Schemes of £11.970m, capital grants of £0.260m and other schemes totalling £1.415m. The only planned disposal for 2012-13 is that of Delenty Drive.

32. The Orford Park Local Improvement Finance Trust (LIFT) scheme has been capitalised under International Financial Reporting Interpretations Committee 12(IFRIC) in May 2012 at a value of £4.897m. This is £0.349m less than expected due to a pharmacy premium being used to reduce the cost of the scheme.

33. The Town Centre Local Improvement Finance Trust (LIFT) scheme was

completed at the beginning of October 2012 and will be capitalised under IFRIC 12. The value in the original plan was £7.110m which was an estimate before financial close; however the figure has now been revised to £7.073m.

RISKS

34. An extract from the Board assurance framework can be seen in appendix 10.

This highlights any financial risks facing the organisation and includes the key controls and assurances in place to mitigate these risks.


CONCLUSION 35. NHS Warrington is still forecast to achieve its target surplus of £1.588m. 36. The Finance and Performance Committee is asked to note the financial

position at the end of September 2012.

IAIN CROSSLEY Chief Finance Officer October 2012

Performance Report Warrington Clinical Commissioning Group Committee Meeting 14 November 2012

1

APPENDIX 2

NHS WARRINGTON CLINICAL COMMISSIONING GROUP PERFORMANCE REPORT FOR PERIOD ENDING 31st August 2012

Purpose

1. This report sets out the progress that has been made against the agreed performance indicators for the period ending 31st August 2012.

Context

2. Warrington Clinical Commissioning Group is responsible for securing improvements in the quality of care and health outcomes for its residents from within its available resources. The group has in place a number of arrangements to assure itself of the progress that it is making towards this goal including the identification and review of key performance issues.

3. This report addresses performance indicators within the following categories

Preventing people of dying prematurely

Cancer

Ensuring people have a positive experience of care Patients seen within the 18 week standards A&E waiting times

Treating and caring for a people in a safe environment and protect them from

avoidable harm Health care associated infections

Finance, Capacity & Activity

Access to hospital services Diagnostic activity

Public Health

NHS Health Checks

Communications and Engagement Incidents, Patient Advisory Liaison Service and Complaints Media Enquiries/Coverage Freedom of Information

4. The report highlights areas of concern in terms of measures that have not been

achieved against the required level of performance for the period under review and the actions that are being taken to improve performance.


2


3

Access to Hospital Service Lead officer: Linda Bennett

5. These include all Integrated Performance Indicators which are monitored as part of the Monthly Activity Return. They include counts of referrals into the system, and in-patient, day case and outpatient activity.

6. The Monthly Activity Report plans are an early part of the annual planning process,

and are updated by more detailed service level agreements with individual Providers. Key Issues

7. In August 2012 there was a small decrease in activity across the board from the preceding month. This decrease could reflect seasonal variation. In comparison to August 2011 however, the summer of 2012 has higher activity in most areas of the MAR. Investigative work on a provider level breakdown has been undertaken to ascertain which providers are breaching their contracted plans. Quarter 1 activity against provider plans indicates the main outliers who were above their indicative plans for the total number of elective First Finished Consultant Episodes (FFCE's) were Warrington and Halton NHS Foundation Trust and Spire Cheshire Hospital.

8. NHS North of England has identified a region wide issue with respect to increased elective referrals and associated inpatient and day case spells. Warrington CCG is working with NHS North of England to understand these variances and what the drivers behind them are.

9. Linda Bennett is leading the contingency plans for Warrington CCG to endeavour to bring referral data back in line with the plan. The small decrease in August is hoped to be the start of a movement back to plan.

10. May 2012 remains the highest month to date in 2012/13 and recent awareness

campaigns may explain peaks in activity, as this was the month following the Bowel Cancer Awareness Month in April 2012.

Key Actions

11. Investigative work continues on a provider level breakdown to ascertain which providers are breaching their contracted plans and why as well looking into whether national screening campaigns have been a contributory factor in this increase.

Accident and Emergency Waiting Times Lead officer: Jim Britt

12. For the month of August 2012, Warrington and Halton Hospitals NHS Foundation Trust (based on the catchment position) achieved 96.74% against the 95% target. This demonstrates a steady improvement in overall performance.


4

Cancer Waits Lead Officer: Kerry Best Key Issues Cancer 62 Day Waits Urgent GP Referral

13. In August, six patients did not receive first definitive treatment within 62 days which resulted in performance below the 85% target. However as performance was good in the first two months of the year, the cumulative position is above the national threshold.

14. Performance dipped due to one patient waiting 91 days at Aintree University Hospital

NHS Foundation Trust. This delay was due to referral between trusts and further tests which were required. At the Clatterbridge Cancer Centre NHS Foundation Trust, a patient waited 157 days due to needing a repeat biopsy, another patient waited 83 days due to change in treatment plan, and one patient waited 78 days due to delay to eGFR results. Two patients also waited 80 days and 166 days due to referral between trusts, again the provider in this case was the Clatterbridge Cancer Centre NHS Foundation Trust,

Cancer Screening Service

15. The performance against this indicator has improved from falling below the 90% target in both June and July 2012, to 100% achievement in August 2012. The year-to-date figure also remains higher than the national threshold at 93.3%.

Consultant Decision to Upgrade Priority Status

16. The percentage of patients receiving first definitive treatment for cancer within 62

days of a consultant decision to upgrade their priority status, achieved 100% in August 2012. This is a significant improvement from previous months which were failing due to very small numbers involved. Previous month’s performance is therefore currently effecting our year to date position which is falling below the 85% threshold.

17. This referral category was the most consistently failed commissioner cancer waiting

times target for the whole of the North of England in Quarter One 2012/13 with 25.5% areas not meeting the 85% threshold.

Diagnostic Activity Lead officer: Jim Britt

Key Issues

18. Diagnostic activity per month has exceeded the plan for each month to date in 2012/13 for both endoscopy and non-endoscopy based tests. The increase in diagnostic activity is reflected in a generally upward trend from April 2011 to June 2012 for many diagnostic tests for other Commissioners in the North West area (Monthly Information Pack – August 2012, Diagnostic Report).


5

19. The vast majority of Warrington CCG commissioned diagnostic activity takes place at Warrington & Halton Hospitals NHS Foundation Trust and, following a performance anomaly in November 2011; all activity has been carried out within six weeks giving a 2012/13 performance of 100% in six weeks at this Trust. This has been maintained despite generally increasing numbers. There have been patients waiting for diagnostic tests for longer than six weeks at the following providers: East Cheshire, Interhealth Group, Central Manchester, Liverpool Women’s and South Manchester in the period April 2012 to August 2012. However, these are only in very small numbers. Liverpool Women’s and South Manchester both had one Warrington commissioned patient waiting over six weeks in August 2012.

Key Actions

20. Recent awareness campaigns may explain peaks in activity for certain tests. For

example, there was a significant increase in endoscopy related tests in May 2012, the month following the Bowel Cancer Awareness Month in April 2012.

Health Checks Lead officer: Rita Robertson Key Issues

21. To the end of July 2012 NHS Warrington has achieved 476 first invitations and 219 total number of screens completed.

22. A Local Enhanced Service has been developed for the delivery of this service and to

date 15 of the 26 GP practices in Warrington have expressed an interest in taking part. The Enhanced Service is now scheduled to be discussed at the October meeting of the Mid-Mersey Local Medical Council.

23. Quarter Two figures will be available at the end of October, however it is not anticipated that any significant progress will have been made due to the changes in service provider taking place in this period.

24. Warrington CCG has requested assurance and a remedial plan from the Public Health team to demonstrate how this target will be achieved in year.

Hospital Acquired Infection Lead Officer: Marioth Manche MRSA

25. In August 2012 NHS Warrington reported 0 MRSA cases for the month, against a planned annual ceiling of 2 cases. Advance information for August did suggest that a community based case would be recorded; however an appeal has been upheld due to technical reasons.

C.Difficile

26. In August 2012 NHS Warrington reported 3 cases of C.Difficile against a planned threshold of 5 for the month. Performance continues to be good, with a year to date position to 12 cases against a threshold of 26.


6

Mental Health Lead Officer: Bal Kaur Improving Access to Psychological Therapies

27. The number of people referred for psychological therapy in Quarter 1 achieved 4.9% against the planned quarterly target of 1.4%. However NHS Warrington is failing to achieve the 50% planned target for the proportion completing therapy and moving to recovery, with a Quarter 1 performance of 46.17%.

28. Figures for Quarter Two will be available at the end of October. Early indications on

incomplete data show that performance may have declined from the Quarter One outturn of 46% due to a decline in the numbers completing treatment and moving to recovery in August 2012. The IAPT service provider remains under capacity in terms of staffing.

29. Warrington CCG has requested a remedial action plan and contract penalties to demonstrate how this target will be achieved in year.

Referral to Treatment – Patients seen within the 18 week standard

Lead Officer: Jim Britt

30. In August 2012 the overall CCG performance (based upon all trusts submitting data

for the CCG registered population) achieved 92.1% of patients being treated within 18 weeks for admitted patients, achieving the 90% target. NHS Warrington also achieved 97.7% for non-admitted patients succeeding in the 95% target, and reported 93.13% for incomplete referral to treatment pathways against a target of 92%.

31. The performance in this area has been mixed for the latest data (August 2012). There was only one specialty failure for admitted pathways in Trauma & Orthopaedics which is the best performance in this financial year. However there has been a significant increase in non-admitted specialty breaches from one to three (Trauma & Orthopaedics, Neurosurgery and Gynaecology). The Neurosurgery specialty breach was caused by one patient as the numbers are generally low. Benchmarking for the North West area shows that in July 2012 the average number of specialty breaches (with those with less than 20 pathways removed) for commissioners was a total of seven. On this same basis Warrington CCG was just below average for July and would be approximately average for August if other commissioner’s performance was to stay the same.

Key issues

32. At specialty level on a commissioner basis for all providers, a total of six specialties have breached the RTT target in August 2012 for all Warrington CCG activity. For admitted care the breach specialty was Trauma & Orthopaedic (78.1%). This specialty was breached at Warrington & Halton Hospitals NHS Foundation Trust and four other providers (all with fewer than 20 pathways each).

33. In non-admitted pathways the CCG failed to meet speciality targets for Trauma & Orthopaedics (93.8%) with breaches at Warrington & Halton Hospitals NHS Foundation Trust and Wrightington, Wigan & Leigh, Neurosurgery (87.5%) at The


7

Walton Centre, and Gynaecology (93.8%) at Liverpool Women’s and Warrington & Halton Hospitals NHS Foundation Trust .

34. For incomplete pathways the CCG failed to meet specialty targets for Respiratory Medicine (88.5%) at Aintree University Hospital and Warrington & Halton Hospitals NHS Foundation Trust. Trauma and Orthopaedics (84.8%) breached at several providers but all apart from Warrington & Halton Hospitals NHS Foundation Trust and Wrightington, Wigan & Leigh had low numbers. General Medicine (89.1%) breached at Warrington & Halton Hospitals NHS Foundation Trust and Geriatric Medicine (67.7%) also Warrington & Halton Hospitals NHS Foundation Trust but the numbers in this specialty were relatively low.

35. On a commissioner basis for Warrington CCG the Warrington and Halton Hospitals

NHS Foundation Trust subset of overall performance, failed to meet the specialty target for Trauma and Orthopaedics (75.3%) in admitted pathways. In non-admitted pathways Warrington and Halton Hospitals NHS Foundation Trust failed to meet the speciality targets for Trauma and Orthopaedics (93.6%) and Gynaecology (94.2%). For incomplete pathways Warrington and Halton Hospitals NHS Foundation Trust failed to meet the speciality targets for Urology (91.7%) Trauma and Orthopaedics (83.2%), General Medicine (88.6%), Geriatric Medicine (65.6%) and Respiratory Medicine (87.6%).

36. Providers are obligated, under terms and conditions of their NHS standard contract, to meet 18 weeks at speciality level for catchment area. However the majority of providers with specialty failures at commissioner level for Warrington CCG also have one or more specialty failures on a provider basis. Where applicable contractual penalties will be applied.

Referral to Treatment – Patients waiting over 52 weeks

37. The number of admitted pathways completed at 52 weeks+ increased in August, showing the highest number of completions in this long waiter category in the period April 2012 to August 2012 for both all providers and the Warrington & Halton Hospitals NHS Foundation Trust sub-set of activity. This indicates that progress is being made in reducing this backlog of 52 week+ waiters.

38. The number of completed non-admitted pathways at 52 weeks+ has remained fairly consistent in the period April 2012 to August 2012 with an average of less than two per month for both all providers of Warrington CCG commissioned activity and also the sub-set of Warrington & Halton Hospitals NHS Foundation Trust activity.

39. In August 2012 there has been a significant decrease in the total number of incomplete pathways at 52 weeks+ (a reduction of nine from 28 in July to 19 in August for all providers, and 26 in July to 17 in August for Warrington CCG commissioned activity at Warrington & Halton Hospitals NHS Foundation Trust). The other two incomplete pathways at 52 weeks+ are at Liverpool Children’s and Robert Jones and Agnes Hunt in August 2012. The North of England Commissioner Performance Report of the 24th August 2012 highlights Warrington CCG as one of 14 CCGs in the North of England with more than 15 over 52 week waiters for July 2012. However the reduction to 19 incomplete pathways at 52 weeks+ for Warrington CCG in August 2012 reflects the generally downward trend for the whole of the North of England.

40. Warrington & Halton Hospitals NHS Foundation Trust have made a commitment to Warrington CCG that there will be no over 52 week waiters from November 2012.


8

41. In August 2012 there were three incomplete pathways on the 51-52 week watch list;

two of these were at Warrington & Halton Hospitals NHS Foundation Trust. Stroke Indicators Lead Officer: Jim Britt

42. Included within the Stroke indicators are two targets, one of which is the 80% target

for stroke patients spending at least 90% of their time on a stroke unit, and the 60% target for patients with a high risk of stroke who experience a TIA and are assessed and treated within 24 hours.

43. NHS Warrington achieved the 80% stroke target with 92.31% in August 2012, and performance has improved with a year-to-date position of 85.55%.

Key Issues

44. The National Stroke strategy was launched in Warrington in Sept 2011 in

collaboration with Whiston Hospital and C&M Stroke Network. After a slow start, principle performance has become consistently compliant in meeting the 80% Stroke target. The 60% TIA target however, remains to be met.

45. In August 2012 NHS Warrington achieved 37.5% against the TIA target, bringing the year-to date position to 33.61%.

Key Actions

46. Meeting the TIA target is being addressed at both provider and referrer level. Warrington & Halton Hospitals NHS Foundation Trust has acknowledged that changes in practices are required to meet the target, which includes additional clinics, and reviews of referral acceptance processes. Equally referrers have been reminded of the correct referral procedure. Compliance is our mutual objective and all parties are working towards a sustainable improvement.

COMMUNICATIONS AND ENGAGMENT

Incidents, Patient Advisory Liaison Service and Complaints

Lead Officer: Marie Montgomery

47. In August 2012 NHS Warrington reported 6 complaints. There have been 49

contacts with the Patient Advice and Liaison Service in August 2012.

Freedom of Information Lead Officer: Helen Anderson

48. In August 2012 the number of Freedom of Information requests received was 19.

Communications & Engagement

PALS 49 Complaints 6 Freedom of Information 19


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Media Enquiries/Coverage Lead Officer: Maria Austin

49. In August 2012 there have been 5 media enquiries and 8 articles published for NHS Warrington.

Pam Broadhead Head of Contracts & Performance, Warrington Clinical Commissioning Group October 2012


Adult Social Care – Draft Care and Support Bill Warrington Clinical Commissioning Group Governing Body Meeting 14 November 2012




14 November 2012

TITLE OF REPORT: Adult Social Care – Draft Care and Support Bill

PURPOSE OF REPORT: To update the Warrington Clinical Commissioning Group Governing Body on the progress of the Draft Care and Support Bill

REPORT PREPARED BY: Joe Blott Executive Director, Neighbourhood & Community Services, Warrington Borough Council

KEY POINTS/TEAM BRIEF: Introduces the Governing Body to the Draft Care and Support Bill

Outlines the key themes emerging Begins debate on impact for Warrington Shares the view of the Health and Wellbeing

Board


The Governing Body is asked to: 1. Note the Report



DOES THIS REPORT / ITS RECOMMENDATIONS HAVE IMPLICATIONS AND IMPACT WITH REGARD TO THE FOLLOWING: 1. QUALITY 1(a) Patient Safety Yes/No


1(b) Clinical Effectiveness Yes/No


1(c) Patient Experience (including patient and public involvement) Yes/No



(either financial or staffing resources) Yes/No


3. HUMAN RIGHTS, EQUALITY & DIVERSITY REQUIREMENTS Yes/No If yes, how will this impact on these requirements





Group’s Priority Workstreams? Yes/No



compliance with Health Care Standards? Yes/No






Yes/No



for Warrington Primary Care Trust? Does it impact upon: Yes/No

i. the corporate liabilities facing the Governing Body Yes/No

ii. the role and functions of the Primary Care Trust Yes/No iii. other legal responsibilities (i.e., Data Protection Act) Yes/No

iv. compliance with the Corporate Governance Manual Yes/No If yes to any of the above, please outline how below


authorisation domain? Yes/No








Adult Social Care – Draft Care and Support Bill

1. NATIONAL PICTURE

The Dilnot Report and the report of the Law Commission shone a spotlight on the challenges the care sector faces and made it clear that we as a nation face few bigger challenges than determining how we will fund the care and support that the most vulnerable and older and disabled people need, what kind of support people should be entitled to, expect and how we should all contribute to building a society which values all citizens and does not see supporting the most vulnerable as a burden. The therefore hugely anticipated White Paper on Social Care was published in June alongside the draft Care and Support Bill and an update on funding. As we know, the Government has not committed to a specific model or level of financial support for the new system, and although it supports the principle of a cap on individuals’ contributions to care, this is in the context of whether ‘a way to pay for this can be found’ As the 4 year funding settlement works through, adult social care is becoming a larger proportion of overall council spend (up 0.8% to 34.2% this year), as council’s respond to a 3% increase in demographic pressure whilst having to balance the 28% reduction to the funding settlement and council tax freezes. The balancing between budget reductions and significant growing demographic pressure is not sustainable and reiterates the urgent message calling for a long term funding solution for adult social care. It is noted that the largest demographic pressure is from people with learning disabilities (£168M) and from older people (£166M) and despite being very similar, learning disability pressures is driven by fewer people.

2. WARRINGTON PICTURE The Council Strategy for 2012-2015 articulates three core pledges:-

To protect the most vulnerable To support the local economy To support strong and active neighbourhoods

Adult Social Care, together with our integrated health and social care commissioning, has a vital role to play in delivering high quality, value for money services which help to achieves these goals. In line with other council’s, adult social care in Warrington has had to make proportionate reductions to its budget (£7.4M). Broadly the savings are to be achieved over 3 main areas:-

Review of eligibility criteria - £2.3M Re-modelling the workforce - £2.1M Reviewing residential and nursing care rates - £1.4M



These broad areas are focussing on 3 platforms of increasing personalisation of care services, driving greater value for money and adopting a preventative approach to social care services. The preventative model is critical to managing our future demand. The current Medium Term Financial Plan made no provision for expenditure in 2012/13 and 2014/15 for social care as a result of demographic pressures. The estimated cost of these pressures in the current year is £2.8M. They are being met primarily through one-off funding such as the Support for Adult Social Care Grant. We have undertaken a review of the potential additional costs as a result of these pressures in 2013/14 and this indicates that costs for adult social are expected to increase by £2M in 2013/14 and a further £2M in 2014/15. This in part reflects the natural demographic demand as outlined earlier but it is being more acutely felt in Warrington, given the greater proportion of older people, particularly in terms of those aged over 80, which is the age at which people become increasingly dependent on support. Long Term Projections of % increase in 65+ Age Group - Warrington 2010 2015 2020 2025 2030 England 0% 13% 23% 35% 51% North West 0% 12% 21% 31% 44% Warrington % Increase 0% 15% 28% 42% 60% Warrington Population 31,800 36,700 40,600 45,000 50,900 Long Term Projections of % increase in 80+ Age Group - Warrington 2010 2015 2020 2025 2030 England 0% 11% 29% 51% 86% North West 0% 10% 28% 48% 81% Warrington % Increase 0% 13% 40% 70% 110% Warrington Population 8,000 9,000 11,200 13,600 16,800 In spite of the increasing numbers of national reports calling for action and policy changes, we await those changes. In the meantime this extra cost falls directly on the Council. Demand on adult social care is inextricably linked to the availability of other services, especially welfare and health. Warrington NHS receives £1200 less per patient than Liverpool as our borough-wide deprivation is considerably less. In addition, the allocation to Warrington is based on a population of 195,000, rather than our actual practice population of 208,000. If Warrington received an allocation based on the England average it would be awarded an additional £11M and if we received an allocation based on the NW average it would have an additional £44M. There have also been some very distressing reports of care standards over the past 12 months (eg Winterbourne View) and this level of scrutiny has brought with it a huge increase in the number of safeguarding referrals in year, 1124 alerts, an increase of 30% on the previous year.

3. ADDRESSING THE ISSUES The issues identified in the preceding paragraphs are not new and we have been working hard over recent years to manage demand through innovative and creative ways.



In February of this year the Executive Board approved a report, ‘Making the Shift’. This report highlighted the need for greater investment and emphasis on prevention and early intervention, about supporting our neighbourhoods to build effective networks and services that keep people connected and supported. We are working with partners to offer improved health, wellbeing and lifestyle opportunities which build on the cultural richness within the Town. It is important that people who receive services can also benefit from being full members of the local community, including living in their own homes, maintaining or gaining employment and making a positive contribution to the communities they live in. As well as specialist or targeted social care services, such as home care, meals support, day services, residential care, equipment and adaptation, to support high level need, we also provide access to a range of lower level, community and universal services such as gym membership, employment support, arts and leisure activities, information and advice and consumer protection. Referred to earlier was the need to ensure the service is cost effective and providing value for money. In 2010/11 (the latest figures we have for accurate comparison) our costs per head were £354.05 which ranks us as the 4th most cost efficient service of the 23 NW local authorities. There is more efficiency still required, however, for example, in reducing the costs of our residential and nursing care outlined in previous correspondence We are also looking to utilise our capital resources and borrowing possibilities to develop a range of extra care and other housing related support services in order to reduce our revenue spend in residential and nursing care.

4. CONCLUSION Improving the health, wellbeing and care of our citizens is of course what we are about in adult social care. We are using the current climate to develop new alliances, building on existing partnerships and putting much effort and spend back down the care and support pathway to try and ensure that the effective personalisation of care and support for those with higher level, on-going needs affordable and deliverable. The Care and Support Bill is currently out for consultation and will begin its formal passage through Parliament in 2013. As such, no formal conclusion can be drawn other than to be aware of and establish the consequences of implementation. Joe Blott Executive Director, Neighbourhood & Community Services Warrington Borough Council


Quality Strategy Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Quality Strategy

PURPOSE OF REPORT: To inform the Governing Body of the refreshed Quality Strategy as part of the Authorisation process.

REPORT PREPARED BY: John Wharton, Nursing & Quality Lead

KEY POINTS/TEAM BRIEF: The Quality Strategy sets out the vision and priorities for ensuring the quality of commissioned services in Warrington. The Strategy has been refreshed as part of the Authorisation process.



Approve the refreshed Quality Strategy



2






















3



No









authorisation domain?





Quality Strategy Refresh – November 2012

1

Quality Strategy 2012/13


2

CONTENTS

Page

Foreword 3

1.Introduction 4

2. Vision and Priorities 5

3. Defining Quality 6

4. Our Quality Objectives 8

5. Governance and Assurance 11

6. Our Strategy for Warrington

14

7. Quality and Outcomes 21

8. Conclusion 23

Appendix A: Action Plan for 2013/14 Appendix B: Terms of Reference for Quality Committee Appendix C: Specific accountabilities


3

FOREWARD

The aim of this Quality Strategy is to ensure the highest quality healthcare services are commissioned and delivered to the people of Warrington. We also seek to ensure that the CCG is recognised by the local population as an organisation which strives to meet their needs. We want to achieve this aim in a way that is recognisable and meaningful to everyone. The fundamental principle of our strategy is to ensure that care is consistently patient focused, clinically effective and safe at all times. We will do this by making quality the primary driver of every aspect of care and focussing on ensuring: Clinical Excellence; Continuity of care; Caring and compassionate staff and services; Clear communication about conditions and treatments; Collaboration between health care providers which is effective

and responsive; Clean and safe environments for care to be delivered; and Commitment to ensuring that patient safety with particular

emphasis on avoiding infection is paramount to care delivery.

We want this quality strategy to strengthen confidence in local care delivery and to assure patients that care is driven by safety, effectiveness and meeting their needs at all times. All our commissioned health care providers are aware that as an organisation we have put quality high on our agenda and that we will be regularly appraising care delivery. By establishing a shared understanding of quality and a commitment to placing it at the very heart of everything we do, we will continually strive to meet the needs of the individual with

healthcare services that are safe, patient centred and clinically effective for every person all of the time. 1. INTRODUCTION The NHS is facing possibly the most significant financial challenge since its inception. The White Paper, ‘Equity and excellence: Liberating the NHS’ sets out the Government's long-term vision for the future of the NHS. The vision builds on the core values and principles of the NHS - a comprehensive service, available to all, free at the point of use, based on need, not ability to pay and it sets out how the NHS will:

Put patients at the heart of everything the NHS does; Focus on continuously improving those things that really matter

to patients; Empower and liberate clinicians to innovate, with the freedom to

focus on improving healthcare services.

The economic downturn means that the NHS will need to make between £15-20 billion savings by 2014 and this will pose a challenge to its leaders on an unprecedented scale, as the age and the expectations of the public continue to rise.

The Department of Health (DH) has set its NHS leaders a ‘quality and productivity challenge’ to use public money effectively and to achieve ‘more for less’, using innovation to drive and embed change. The NHS will need to change the modality of commissioning to reduce waste and establish innovative ways to deliver high quality, cost effective care and treatment across the health and social care system. Warrington CCG is responsible for commissioning services for a registered population of approximately 208,000 patients and for the


4

management of all risks associated with commissioning those health services. The past year has seen developments nationally and regionally that have raised the profile of quality in the NHS and require the CCG to ensure it has a robust Quality Strategy. In addition, we need to ‘raise the bar’ in relation to commissioning high quality cost effective services for Warrington and receive assurance of delivery. This Quality Strategy sets out how the CCG intends to achieve continuous improvement in all commissioned services, reflecting national and local priorities and reinforcing our commitment to the development of validated quality improvement within and between care settings. The Strategy outlines the CCG’s vision of quality, key drivers, ambitions for quality and the proposed infrastructure that will both support and govern this. It provides a quality framework that will underpin the work within and between all of Warrington CCG Clinical Pathways and the work the CCG undertakes in collaboration with key stakeholders to ensure its local population receive quality assured, timely care in the appropriate setting. 2. VISION AND PRIORITIES Warrington Clinical Commissioning Group is a coming together of all the town’s 26 GP Practices. The CCG is responsible for planning NHS care for Warrington, working with local health care providers to ensure that services meet the needs of all our patients. Warrington Clinical Commissioning Group has described its Vision as:

“Excellence for Warrington”

and have committed to: work in partnership to develop the best health services for

people in Warrington contribute to a healthier Warrington for all focus on our Patients work in partnership with the local population recognise external constraints whilst striving for quality

This vision is underpinned by seven key values which are:

Excellence Valuing patients and partners Accountability Partnership in everything Honesty and integrity Open and transparent Courage.

3. DEFINING QUALITY Quality means different things to different people, and accordingly has been defined in many different ways. For the NHS, Lord Darzi pragmatically defined quality as: safety, effectiveness, and patient experience. For the purposes of this strategy quality will be defined as; the continuous improvement in effectiveness, experience and safety of health and social care services for the local population provided within available resources. Quality will be subdivided into the three Darzi domains:

Safety


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Effectiveness (which encompasses cost effectiveness, equality and diversity)

Patient/Service User/Carer experience (which encompasses accessibility, acceptability and appropriateness)

It is also helpful to point out the difference between ‘quality assurance’ and ‘quality improvement’. Quality assurance is the systematic monitoring and evaluation of the various aspects of a service or facility. It is in place to maximise the probability that minimum standards of quality are being attained. Contract monitoring is akin to quality assurance. Quality improvement is focused on increasing the ability to fulfil quality requirements. It involves frequent measurement and testing and adapting of approaches in order to arrive at the best possible process for achieving desired outcomes effectively and reliably. 3.1 Quality - The Key Component of Commissioning The CCG will ensure it is competent and capable to deliver quality along the commissioning cycle, as part of its core business functions, in combination with effective governance systems. The commissioning cycle will follow a simple action cycle; assess, decide, implement, monitor/evaluate. If quality care is the core of what we do, then quality inevitably will be a part of every step in the commissioning cycle.

The commissioning cycle begins with assessments of the current quality achieved by the local delivery system (along pathways, as well as of individual providers). The intelligence also includes knowledge of new best practice guidance (effectiveness evidence base) and innovations to be considered for implementation (e.g. from elsewhere in the field, or research), but also the intelligence about safety and patient experience of individual provider services, including their incidents and risks, and feedback from patients and staff.

The resulting intelligence will be crucial in informing the detailed development of service re-design or changes (e.g. development of new pathways), and the standards and outcome expectations for the new/changed service or pathway. Specific metrics need to be defined and monitored to ensure the desired results are actually being achieved (e.g. in terms of clinical outcomes, patient experience, and costs). This monitoring information in turn contributes to the intelligence required for continuous assurance and quality improvement.

Three Quality Ambitions will provide the focus for activity to support the aim of delivering the best quality healthcare to the people of the Warrington:

Mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making;

There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services; and

The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and we will strive to eradicate wasteful or harmful variations.

3.2 Indicators of Quality

High quality care involves the use of clinical and other quality indicators to measure the quality of commissioned services and


6

highlights areas for improvement and tracks that changes are implemented. Examples of quality indicators are grouped within the three domains as follows:

Domain One SAFETY

Care Quality Commission registration

compliance issues Risk Management (Including Incident

Reporting) Patient safety incidents Serious Incident’s Never Events - National Patient Safety Agency

(NPSA) All Safety Alerts inclusive of NPSA Patient

Safety Alerts (PSAs) Sharing Good Practice Hospital Standard Mortality Rates

Benchmarking Health Care Acquired Infection’s Medicines Management (Including Controlled

Drugs) Information Governance (Clinical Record

Keeping) Safeguarding Children and Adults Contract and Quality reviews Harm Free Care (Safety Thermometer) Engagement with secondary care, Community

Services, Social Care, Mental Health, Hospice

Domain Two EFFECTIVENESS

Benchmarking against NICE recommendations and other evidence

Performance Reports - Monitoring clinical outcomes via clinically driven outcome performance indicators and focused scorecards

Benchmarking against the National Prescribing Centre prescribing indicators at CCG and Practice level

Contract development, approval and monitoring Peer review, appraisal and revalidation Training programmes – obligatory and aligned

to appraisal outcomes Research and Audit

Equity of Access to Services Staff competency programmes (training and

uptake rates) Workforce Statistics (Including

sickness/absence rates) Public Health Informatics Monitoring readmission rates

Domain Three PATIENT/ SERVICE

USER/ CARER EXPERIENCE

Access to Services Complaints and Compliments Cleanliness of Care Environments Mixed sex accommodation Patient Stories Patient/Service User/Carer Feedback Patient/Service User/Carer Surveys Patient Reported Outcome Measures (PROMS) Litigation/Claims Respecting equality and diversity

A number of factors can potentially impact on the monitoring of quality, issues such as moving and shifting the evidence base and expectations, innovation, barriers and the equity of the starting point. Furthermore, inefficient reporting mechanisms, limited resources and sometimes limitations resulting from the absence of quality at the ‘forefront’ of the minds of staff, Senior Management Team and Governing Body (evidenced by absence of quality on agenda items); can all impact on the potential outcomes achieved. 4. OUR QUALITY OBJECTIVES

The strategy has four objectives that should be addressed at every stage of the commissioning cycle. These objectives are:

1. To ensure that commissioned services are safe, personal and

effective.

2. To ensure the right quality mechanisms are in place so that standards of patient safety and quality are understood, met, and effectively demonstrated.


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3. To provide assurances that patient safety and quality outcomes

and benefits are being realised, and to recommend action if the safety and quality of commissioned services is compromised at any stage.

4. To promote the continuous improvement in the safety and quality of commissioned services.

The elements as characterised below set out how the CCG will strive to work with all partners to raise the quality of its commissioned services:

To articulate clearly the desired outcomes for the local

population of Warrington

To determine challenging targets and improvement objectives for achieving successful outcomes.

To have, within and across services, effective arrangements for

evaluating systematically, whether successful outcomes are being achieved.

To ask demanding questions about the performance of services

and to make use of the levers available to drive up quality (e.g. clinical engagement, QIPP, CQUIN’s, contracts, patient experience).

To use the information from evaluation to make continuous and

sustained improvements to achieve successful outcomes.

To ensure that within the commissioning processes of service redesign and service improvement that quality impact assessments are carried out, and that the logic behind commissioning decisions is clearly documented.

To agree the method for embedding a culture of quality in the

organisation.

4.1 Our Partners We can’t achieve any of this on our own and recognise that we are not alone in wanting the best for patients and their carers. Locally there are a number of important groups of people we will work with:

Patients and the public – as they define in part what quality should look and feel like;

Our Member practices – all 26 GP practices help us decide how we run and set our priorities;

NHS Providers – the hospitals and community services that we use.

Warrington Borough Council – we work very closely with our colleagues in public health and social services as often our services work with the same people;

Other CCGs – we recognise that we must work closely together with our peers to ensure services are organised efficiently and are of the highest quality.

4.2 Local Strategies

This strategy should be read in conjunction with the following Warrington Clinical Commissioning Group plans:

Warrington Clinical Commissioning Group Commissioning

Strategic Plan Organisational Development Plan Communication and Engagement Plan IT and Information Plan


8

Performance Management of Serious Incidents Policy Complaints Policy Safeguarding Children and Adults Commissioning Policy Risk Management Policy Integrated QIPP Programme Governance Framework

4.3 National Drivers This year there have been several policy drivers that have a direct impact on quality and assurance.

Equity and excellence: Liberating the NHS

In accordance with the government’s health care agenda we will put the patient at the very heart of commissioning care with patient experience being a pivotal factor in assessing and regulating the quality of patient care. The NHS Outcomes Framework

The first NHS Outcomes Framework builds on the proposals published for consultation in Transparency in outcomes – a framework for the NHS. It sets out the outcomes and corresponding indicators that will be used to hold the NHS Commissioning Board to account for delivering through commissioning health services from 2012/13. It sets direction of travel in the journey towards improving outcomes, and offers an opportunity for the NHS to begin to understand what an NHS focussed on outcomes means for individuals, organisations and health economies. The five domains of the NHS Outcomes Framework are shown below and encompass the three parts of the definition of quality (effectiveness, patient experience and safety):

The Operating Framework 2012/13

2012/13 is the second year of the quality and productivity challenge and the final year of transition to the new commissioning and management system for the NHS. It is therefore a vital period during which NHS leaders will have to respond to four inter-related challenges: the need to maintain our continued strong performance on finance and service quality; the need to address the difficult changes to service provision required to meet the QIPP challenge in the medium term; the need to complete the transition to the new delivery system set out in Liberating the NHS; and the urgent need to ensure that elderly and vulnerable patients receive dignified and compassionate care in every part of the NHS.

Commissioning for Quality and Innovation Framework (CQUIN)

This framework for 2012/13 mandated 2.5% of the contract value to incentivise quality. The importance of recognising and rewarding quality innovation lies at the very heart of raising standards by ensuring that incentives are in place for innovative programmes to improve care quality and standards.


9

Quality Accounts From April 2010, every NHS provider organisation was required by law to report its performance on the quality of care and services, incorporating views of stakeholders, including PCTs and the public. 5. GOVERNANCE AND ASSURANCE

In February 2011, the governance arrangements of NHS Warrington were reviewed to establish Warrington Clinical Commissioning Group as a sub-committee of the Board. Warrington Clinical Commissioning Group now has in place the following structures:

5.1 Quality Committee

The Quality Committee is a sub-committee of the Governing Body. It meets on a monthly basis and its terms of reference state its duties will be: Seek assurance that the commissioning strategy for the CCG

fully reflects all elements of quality (patient experience, effectiveness and patient safety), keeping in mind that the strategy and response may need to adapt and change;

Provide assurance that commissioned services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything the CCG does. This could be extended to include jointly commissioned services;

Oversee and be assured that effective management of risk is in place to manage and address clinical governance issues;

Have oversight of the process and compliance issues concerning serious incidents requiring investigations; being informed of all Never Events and informing the Governing Body of any escalation of sensitive issues in good time;

Seek assurance on the performance of NHS organisations in terms of the Care Quality Commission, Monitor and any other regulatory bodies;

Receive and scrutinise independent investigation reports relating to patient safety issues and agree publication plans;

Ensure a clear escalation process, including appropriate trigger points, is in place to enable appropriate engagement of external bodies on areas of concern;

Provide assurance for the quality of primary care service; Disseminate information to support clinical decision making;

Warrington Health Consortium BoardHealth & Wellbeing Board

Update Reports onMental Health

Learning DisabilityAlcohol

Continuing CareWomen and Children’s

services

Warrington Borough Council

PCT Cluster Board(NHS Board)

Reports ReceivedFinance Reports

QIPP Delivery ReportsProvider Contract delivery reports

Update reports on Planned Care

Unplanned CareCommunity ServicesProvider Prospectus

Commissioning Support SLA Performance Reports

Reports ReceivedPrimary Care Quality

DashboardProvider Contracts Quality

Performance ReportPatient Experience Reports

Risk Register

Internal Audit ReportsExternal; audit reportsCorporate Governance

Manual

Cluster Audit Committee(with Warrington PCT

Section)

Clinical ForumClinical Advice on service re-design

Key PlansJoint Health and Well Being

Strategy for WarringtonJoint Strategic Needs

AssessmentSustainable Communities

Closing the gap

Key PlansWarrington Health

Consortium Strategic Commissioning Intentions

Operating Plan

Reports Received Report

Performance ReportQIPP Delivery Report

Specialist Commissioning Report

Assurance FrameworkOD Plan

HR Report

Neighbourhood Boards

Finance and Performance Committee

Quality Committee

Integrated Commissioning Group

Warrington Health Consortium Audit Committee

Reports ReceivedIntegrated Commissioning

ReportPH Delivery report

Local Delivery PlansLocal Delivery Plans

Health Overview & Scrutiny Committee

Local Strategic Partnership

Cheshire Health Commission

Collaborative CommissioningLead Commissioner

Arrangements

Specialist Commissioning

Mid-Mersey Coaltion(WHHSK)

Medicines Management Board

Collaborative Working across bigger footprints

Phoenix Federation

Health Warrington Federation

Teaching Practices

Warrington Alliance


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Ensure, by the use of benchmarking and clinical evidence, that variations in clinical practice are identified and addressed;

Ensure that the quality schedules for the Providers are informed by clinical benchmarks, clinical evidence, patient reported outcome measures and patient experience;

Ensure that the quality schedules, quality profiles and Commissioning for Quality and Innovation initiatives result in higher quality services;

Receive and approve strategies or annual reports; Ensure oversight and monitoring of:

National Institute for Health and Clinical Excellence

(NICE) guidance Implementation National Service Framework Standards Adherence National Policy development and implementation Safeguarding Adults and Children National & Local review recommendations (Care Quality

Commission or NHS Commissioning Board) National & Local Clinical Audit findings Local and national research and innovation

developments Local and national incident trend analysis Infection control benchmarking analysis Complaints and compliments Serious incident lessons learned evaluations.

Ensure Warrington Clinical Commissioning Group has an

appropriate patient experience and engagement framework in place and that all commissioning decisions are Equality and Diversity compliant.

Ensure the Quality Committee receives regular Information Governance reports, Toolkit, Compliance updates, policies and

other evidence for demonstrating information governance compliance.

See Appendix B for the full Terms of Reference for the Quality Committee. 5.2 Other Groups

Quality is also monitored via a range of other groups. These groups provide regular updates and escalation of concerns to the Quality Committee via reports from the Nursing & Quality Lead, Head of Assurance & Risk and Patient Experience Officer. Serious Incident Review Group The purpose of this group is to scrutinise all reports received from providers (including internal CCG investigation reports) to gain assurance that serious incidents have been appropriately investigated, lessons learned and improvements implemented. Challenges will be sent back to the relevant provider in the event that further assurance is required. The group will also consider any themes and trends that it has identified with a provider. Any issues will be escalated to the relevant provider Contract and Quality meeting and also to the Quality Committee for information and action, where relevant. Patient Experience and Quality Group The purpose of this group is to review all patient experience information available involving the providers of healthcare within Warrington. Information will include reports received directly from patients (via the website, letters, phone calls etc.). The group will


11

also consider information relating to complaints, PALS queries, information from LINks as well as that provided by providers. All information is triangulated to identify any themes, trends or areas that are identified that can be developed to improve the experience of the patient. Regular reports are provided to the Quality Committee. Contract and Quality meetings Each provider has a monthly contract and quality meeting which includes a standing agenda item relating to quality assurance. Specific areas of quality which are discussed include: Serious incidents; Incident management; Safeguarding children and vulnerable adults compliance with

standards; Complaints and PALS information; and

Patient experience surveys and information.

Any information highlighted at the Serious Incident Review Group meetings or Patient Experience and Quality meetings are also raised with providers at this meeting. 5.3 Accountability

Accountability for quality lies with the Chief Clinical Officer and this is delegated to the Nursing and Quality Lead. All staff at all levels have responsibility for commissioning high quality services; however key personnel who are responsible for assurance of providers are detailed below:

Chief Clinical Officer Governing Body GP Quality Lead (Chair of Quality Committee) Governing Body Lay member for Quality Nursing and Quality Lead Head of Assurance & Risk

Accountabilities are also shown at Appendix C 5.4 Early warning systems of a failing Provider It is important that stakeholders work collaboratively to share soft and hard intelligence about providers in a timely and sincere manner. Indeed when individual or systematic quality failures first emerge then it is the duty and statutory responsibility for all supervisory and regulatory bodies to act in a co-ordinated manner to restore a quality service. The quality indicators for the safety, effectiveness and patient experience domains (shown in section 3.2) identify the range of intelligence that can be collated in relation to provision of service. In conjunction with national guidance Review of early warnings systems in the NHS – Acute and Community Services (National Quality Board April 2010), the CCG is working towards establishing its own triggers across the quality indicators which will identify problematic areas which may need an immediate response. 6. OUR STRATEGY FOR WARRINGTON 6.1 Contracting for Quality All commissioned eligible NHS and private providers are registered with the Care Quality Commission (CQC) without conditions, and GP’s will register in April 2013. We will continue to work with regulators and services to ensure that any areas of poor performance are addressed.


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Clinical Quality and Contract meetings

It is a contract requirement that these meetings are held with NHS providers. In Warrington we have agreed to meet every month. There are standing agenda items covering quality; incidents, regulator reviews, complaints, audit results, CQUIN and other performance measures. We also focus on a specific clinical area, each meeting for an in-depth examination. High level exceptions are discussed. Updates from these meetings are received by the Quality Committee.

Clinical Quality and Innovation Scheme (CQUIN)

This nationally-mandated financial incentive mechanism has been in place since 2009 to drive up quality of care in acute providers. Community, mental health and ambulance trusts were brought in the following year, and from 2012/2013 all providers to NHS will have the opportunity to have a CQUIN scheme, Indicators are set at the national, regional and local level in the three domains of patient safety, patient experience and effectiveness. These are agreed on an annual basis with providers and a proportion of the contract value is attached to their achievement, in 2012/2013 it is 2.5% of contract volume, so it is a very strong driver for quality improvement. The CCG has established regular meetings with providers to discuss the CQUIN schemes for next year. These will continue to be monitored at the Clinical Quality and Contract meetings and any exception reports will be submitted to the Quality Committee.

Delivering Harm Free Care

As part of the NHS we all have a personal commitment to make, and to contribute to the improvement of quality of care provided to

patients. Our own individual actions contribute to the wider collective responsibility and accountability of the NHS to demonstrate that effectiveness and safety of care should ensure that patient care is harm free, and that the staff experience of working as part of the NHS is positive. Harms occur every day in the NHS from a variety of sources. We will focus attention on four key harms including pressure ulcers, falls, urinary catheter acquired infections and venous thromboembolism. These are considered to be most commonly experienced by the most vulnerable of patients. The Operating Framework sets out that the NHS Safety Thermometer is an improvement tool that allows NHS organisations to measure harm in these four areas and identifies the proportion of patients who are “harm free”. The national CQUIN associated with this scheme will reward submission of data generated from use of the NHS Safety Thermometer. In order to submit the data there is a need for all providers to have electronic data systems to manage the Safety Thermometer information.

The CCG is working with our providers to establish a sound platform to enable the following to happen.

NHS acute and community providers to deliver 95% Harm Free Care in line with the safety express (through an agreed CQUIN scheme).

All non NHS providers to be engaged in using the safety

thermometer tool in line with the operating framework.

Quality, Innovation, Productivity and Prevention (QIPP) QIPP is the mechanism through which organisations can ensure we are getting patient care right the first time, meaning better care and


13

better value through the reduction of waste and errors and the prioritisation of effective treatments. QIPP is about creating change and improvement, leading differently and in a way that fosters a culture of innovation. Bridgewater Community NHS Trust, Warrington & Halton NHS Hospitals Foundation Trust, 5 Boroughs Partnership NHS Foundation Trust, Warrington Borough Council, and Warrington CCG are working in partnership to deliver an Integrated QIPP Programme across Warrington Health Economy. Halton CCG and Halton Borough Council are partners in delivery of the Integrated QIPP Programme, in relation to service provision on the Halton footprint. There are key interdependencies between the Cheshire, Warrington & Wirral Cluster, Mid-Mersey QIPP and the Warrington and Halton Partnership, as the organisations are all accountable for achieving QIPP efficiencies across the Warrington and Halton health and social care economy. The CCG Governing Body is responsible and accountable for delivering financial balance and related national and local targets for the delegated budgets including QIPP planning assumptions and agreed implementation plans in partnership with its providers and local authority. Ensuring Quality in Services The CCG is constantly striving to ensure quality in the provision of all services across Providers. Some of the existing initiatives include:

Regular contract negotiation meetings with providers Attendance at Provider Root Cause Analysis meetings

Regular walk around Provider organisations to discuss problematic areas, visits include choosing specific areas such as acute hospice community.

CCG Governing Body members discuss patient experience with patients, relatives, staff members and senior provider management team and how it can be improved upon.

The CCG is currently establishing mechanisms to monitor and therefore improve healthcare delivery in primary care. 6.2 Safeguarding Children and Adults

The CCG Accountable Officer for Safeguarding Children and Vulnerable Adults is the Chief Clinical Officer. This responsibility has been delegated to the Head of Assurance & Risk, who is responsible for ensuring that safeguarding arrangements within the CCG are compliant with legislation and guidance. The Head of Assurance & Risk is a member of the Local Safeguarding Children Board and Safeguarding Adults Board in Warrington. Reports are presented to the Quality Committee on a quarterly basis to ensure that the CCG is fully updated on any issues or concerns and the ongoing arrangements for safeguarding. The Quality Committee reviews the data relating to safeguarding performance of all providers. The Designated Nurse for Safeguarding Children and Children in Care chairs the Safeguarding Assurance Group meetings with Warrington and Halton Hospitals Foundation Trust and Bridgewater Community Healthcare Trust. Assurances from these meetings are fed up via the safeguarding quarterly report to the Quality Committee. Assurances for other providers where Warrington


14

CCG is not the lead commissioner are sought at the local Contract and Quality meetings with those providers (and led by the CCG) i.e. 5 Boroughs Partnership Foundation Trust. Any issues with these providers are also escalated to the Quality Committee. 6.3 Serious Incidents and Never Events The Serious Incident Review Group meets on a monthly basis to review all information relating to serious incidents and never events. This group is chaired by the Head of Assurance & Risk and other members include the GP Primary Care Quality leads, Nursing and Quality lead and Chief Operating Officer. The incidents are examined in detail and recommendations are made to the provider when the CCG requires further assurance. A timescale is given for feedback to the queries and if the action plan fails to halt the trends, the CCG will revaluate the quality contract and ensure that the financial clauses of the contract are utilised. An update report is provided to the Quality Committee every two months to ensure that it is apprised of numbers and types of serious incidents and any themes that have been identified that require further action to be taken.

6.5 Cleanliness and Healthcare Associated Infections (HCAI)

The CCG recognises the importance of all clinical areas that are used by the public should meet the high standards required for cleanliness, comfort and safety. All care providers are expected to regularly monitor the standards of cleanliness in these areas and strive to reduce the possibility of infections being acquired through poor hygiene levels.

All providers report on their regular hygiene inspections and any issues related to healthcare associated infection are reported to the Clinical Quality and Contract meetings. In the event of any concerns, an action plan will be requested from the Provider to ensure that levels of cleanliness have met required standards. Any issues in these areas will be escalated to the Quality Committee.

6.6 Complaints The CCG will ensure that all our Providers have systems in place and are compliant with the Local Authority Social Services and NHS Complaints Procedure (England) April 2009 Legislation. In accordance with the Legislation providers will be required to produce a Complaint’s Annual Report and will make this report available for members of the public on request. All Complaints and Patient Advice and Liaison (PALS) concerns are captured and recorded, reports are produced quarterly and are submitted to the Quality Committee. Summary reports are provided for Primary Care where there are concerns regarding the quality of services provided by Independent Contractor/s. The CCG will receive and monitor Provider complaints through reports as specified within the contractual agreements. The CCG will expect the provider organisations to be transparent in presenting areas of concern highlighted by complaints and to provide action plans for any service area/s identified as requiring improvement. This will be monitored through the contract monitoring meetings which will provide assurances to the Quality Committee.

To ensure a 360 degree view of complaints reporting the CCG will expect the provider to take account of their PALS concerns or informal enquires and whilst this soft intelligence is not normally of a


15

serious nature it can contribute to highlighting trends and therefore improve the quality of the provided services.

Assurance from the providers around their complaints procedures is gained through the monthly complaints report which is supplied from the provider to the contract and quality meeting. The report will provide an overview of the areas of care that patients’ or their relatives are dissatisfied with. In some instances, a complaint may lead to the identification of a serious incident. In this event, the provider will be required to report the incident on StEIS (Strategic Executive Information System - national database for serious incident reporting), undertake an investigation and provide the report to the CCG Serious Incident Review Group for review to ensure that the appropriate assurance has been given. 6.7 Patient Experience

The CCG is committed to improving patient experience and fully recognised the importance of patient experience data. The proactive capture, analysis, triangulation and interpretation of information about the experience of patients and carers will be used to inform all planning and commissioning decisions. We have an established patient experience programme – SEE (Safety, Effectiveness and Experience), which is widely publicised and provides a means for people to provide their patient experience feedback through a variety of channels. Through this programme, we actively seek patient stories and the CCG Governing Body, prior to each Board meeting, hear first-hand from a patient with their story. The Patient Experience and Quality Group reviews patient experience data on a system wide basis, agrees on actions to improve patient experience and steers the development of quality improvement across the health economy. Regular patient experience and engagement reports are sent to the Quality

Committee and processes are being put in place to triangulate patient feedback with other performance measures. The flowchart below shows the flow of patient experience data across the appropriate groups and committees.

6.8 Information for Patients

The CCG intends this year to establish a comprehensive website to complement the existing information available to patients. This will include information to help patients manage their condition and also inform them of the pathways of care commissioned by the CCG. NHS Choices provides national and local performance data on services to enable the public to make informed choices of providers; it is the CCG’s intention to direct the public to this information where appropriate.

6.9 National Institute of Clinical Effectiveness (NICE)

The CCG is responsible for ensuring organisational compliance with respect to NICE guidance. NHS providers are expected to take all NICE guidance into account when planning and delivering patient services. Guidance consists of:


16

Quality Standards – which should be used to plan and deliver services as part of a general duty to secure continuous improvement in quality;

Technology Appraisals – The NHS is required as a statutory duty to provide funding and resources for medicines and treatments recommended by NICE TA’s;

Clinical Guidelines; Public Health Guidance; Interventional procedures; and Medical Technologies.

The role of the CCG in relation to quality standards will be to lead the discussions to prioritise locally and ensure all providers are compliant with the standards. In relation to NICE technology appraisals the roles will be to ensure providers are funding and delivering the guidance within nationally defined timescales. A monthly issues template is completed by each provider for discussion at the Clinical Quality and Contract meetings and NICE guidance implementation is included. Any exceptions will be reported to the Quality Committee.

6.10 Effectiveness

Local focus on achieving quality has been based on bringing care closer to home; implementing care strategies that are community based and reducing the reliance on hospital based services. The implementation of Quality, Innovation Productivity and Prevention (QIPP) also focuses on implementing work streams which are pertinent to the needs of the patient but focus on ensuring that the fundamentals of care, safety, experience and effectiveness lie at the heart of quality care provision.

Clinical Audit We consider clinical audit to be a key mechanism to monitor clinical effectiveness, performance, quality of services and demonstrate continuous quality improvement. We will look to agree an annual work programme of audits with our providers based on national and local priorities, which is tightly performance managed. We will look to encourage each provider to undertake outcomes focused audit, using national and local indicators and will utilise the pilots undertaken for Patient Reported Outcome Measures.

Contract and Quality Review Meetings We meet monthly with our main providers to monitor all aspects of quality and receive assurance on the compliance with standards and targets agreed within the quality schedule. These meeting now form the hub of our quality assurance processes.

6.11 NHS Improvement Agencies

There are a large number of national and regional agencies that are preparing to support the NHS quality and productivity challenge; NHS Institute, Improvement Foundation, Kings Fund, and AQuA are examples. We already utilise a number of these agencies and we have plans work with them to identify and promote tools and guidance.

As a subscriber to the Advancing Quality Alliance (AQuA) the CCG is involved in pilot work programmes that promote integrated quality initiatives across the health economy.

6.12 Medicines Management and QIPP

The Medicines Management Team and the Warrington CCG Prescribing Clinical Lead contribute to, and are members of, the


17

Mid Mersey Medicines Management Board (4MB) and its subgroups (introduction of new medicines, development/review of formularies and guidelines, shared care processes, and patient safety issues regarding medicines). The 4MB supports a coordinated health economy approach to managing medicines. The 4MB Board makes recommendations to commissioners and the Medicines Management Team submit the Board recommendations for approval by the CCG at the monthly Quality Committee. A Medicines Management QIPP plan is developed by the Pharmacy Management Team and is reviewed annually. QIPP planning commences late in the previous financial year. The plan is based on key therapeutics topics documents from the National Prescribing Centre (part of NICE) and local recommendations (from 4MB), and includes ideas for generating savings and for improving quality within prescribing. Detailed prescribing data is obtained from the NHS Business Services Authority, via the e-PACT system, and analysed at practice level. The analysis consists of a number of key prescribing indicators, including total expenditure against budget and a breakdown of individual medicines or groups of medicines. Practices are RAG rated in QIPP prescribing areas (against England average data) and this information sent to practices on a quarterly basis. The Pharmacy Management Team (including the prescribing lead) meets fortnightly to discuss the QIPP plan, key prescribing indicators and other prescribing issues. Relevant messages relating to approved prescribing recommendations and safety issues are highlighted to practices through the CCG newsletter and the practice-based medicines management team. The Medicines Management team also supports the CCG to ensure quality of prescribing through, for example, medicines advice to the

CCG and its prescribers, monitoring of controlled drugs, supporting non-medical prescribers and development of Patient Group Directions. 6.13 New Innovations and Developments The NHS Operating Plan 2012/2013 set the agenda for commissioning for Harm Free Care in all care settings. As the Commissioners of local healthcare Warrington the CCG strive to work in partnership with all our Providers and Stakeholders to establish a sound platform to enable this to develop and advance. The fundamentals of Harm Free Care will be followed and the relevant indicators are included on the monthly issues template which is completed by Providers for the Clinical Quality and Contract meetings.

The CCG will also be commissioning for visibility of care and this will require Executive Walkabouts for both Commissioner and Provider to emphasise the ‘Leadership’ responsibility to understand and organise care from the patients ‘perspective. This is already in progress in Warrington, where regular visits have been established. In the event that problems have been identified, the CCG work collaboratively with the Provider to ensure improvements The CCG is accountable and holds a duty to patients and public for the care that is commissioned, and also recognises the need to:

Connect with patients at the point of care Further develop relationships between clinical commissioners

and providers Understand and experience the care environment that has been

commissioned


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The review process itself is robust and has 3 stages as detailed below:

1. Assurance Visit; 2. Collation of evidence of commissioned care, and 3. Repeat within agreed timescale.

The timescale for the review will be dependent upon the findings of the ‘walk around’ and any concerns will be discussed with the Provider when timescales will be agreed and a further visit date arranged. 6.14 Leadership We want to build on the experience of our existing GP and CCG team in a number of ways. As a CCG we outline our approach to leadership and improving leadership within the Organisational Development Plan. 7. QUALITY AND OUTCOMES There were a number of national changes to the Quality Outcomes Framework (QOF) during 2011-12. Whilst NHS Cheshire, Warrington and Wirral approve and sign off individual practice plans for these indicators the CCG will work closely with member practices as some work will be undertaken jointly within federations and supported by CCG teams such as Medicines Management. What are the Quality Outcomes that are important to the CCG? The CCG proposes a robust strategy for improving the outcomes for people who live in Warrington. Using a process of quality assurance, quality improvements and by working collaboratively with our key partners across the whole health economy we aim to reduce preventable morbidity and mortality by:

Improving the safety of the services we commission.

Improving the effectiveness of the services that we commission.

Improving people’s experience of health and social care.

It is our intention to report on the selected outcome measures to demonstrate progress against our key aim of reducing preventable morbidity and mortality.

Success will mean that, for the first time, people in Warrington will have:

The opportunity to comment systematically on their experience of healthcare and its impact on their quality of life;

An assurance that services commissioned by the CCG will be

further improved in the light of what people tell us about their experiences and outcomes;

Support to engage in shared decision-making about their care;

The whole of the health economy committed to patient safety

and, in particular, to avoiding infection and harm, using consistent and reliable improvement methods;

Personalised care plans for those people with the most complex

care needs; and

A guarantee that the CCG will prioritise quality in its agenda, including the use of a new early warning system.


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The proposed outcomes have been drawn from a variety of sources including National Outcomes Frameworks for Health and Social Care. How will the CCG achieve the outcomes?

The CCG Health and Social Care partnerships will drive the implementation of minimum quality standards via the contracting process. This will require providers to work collaboratively, developing effective relationships across patient care pathways and making appropriate links to the QIPP plan.

In particular, the key providers to deliver the quality outcomes for Warrington will be Public Health, commissioned providers and primary care. We recognise the importance of clinical engagement; clinicians who are fully engaged with the partnership will share its aims for safety and care quality and will be committed to helping achieve them. It has been found that high-performing organisations had a number of characteristics in common, including having quality as a core goal, using information to guide improvement, developing organisational skills to support performance improvement, and having learning strategies that test improvement and scale it up when it succeeds (Baker 2011), as cited in the Kings Fund Paper Future of leadership and management 2011. It is imperative that all providers recognise the importance of highlighting any risks to the implementation of quality standards. In the event that a risk is identified, this should be escalated to the contract and quality meetings which take place with each provider. Each provider should have their own risk management policy and framework which they should act within. However, each provider should ensure that their policy contains information about how to escalate any potential risks to implementation of quality standards to the CCG as a commissioner of services. The CCG will review

any risk and make a decision about the need to include the risk on the CCG Risk Register. Each manager within the CCG also has their own responsibility to ensure that any risks are identified for the areas under their remit. In the event that a risk occurs which has not been identified by a provider but still represents a threat to the achievement of a quality standard, this should also be identified as per the Risk Management Policy. The CCG has a Risk Management Policy which describes the process to be followed when identifying, assessing and managing risk. It also describes the need to escalate risks of a certain score to the appropriate Committee for review and discussion. This will ensure that all risk is understood and is dealt with appropriately. 8. CONCLUSION

Warrington CCG has a clear strategic focus and vision for quality improvement and although this strategy is not exclusive, it demonstrates our ambition and actions to take forward the challenging agenda. We will continue to engage our member practices and providers at every level to ensure that commissioned services deliver excellent standards of care and treatment to the population of Warrington. The CCG has a statutory duty to commission and ensure high quality care for the local population and will provide scrutiny of all providers and assure the Governing Body that continuous improvement in quality of care is being achieved. The CCG’s Quality Strategy is above everything, about people. It is for all the people of Warrington and aims to provide everyone with the care and compassion they want and need by enabling their voice to be heard and then commissioning services with them that


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are amongst the safest and most effective in the NHS, and that this is provided reliably to every patient, every time. For the Strategy to be effective further development needs to take place and the clear strategic objectives that underpin the compelling vision still require explicit actions, interventions and desired outcomes. This will be shaped over the coming months by the intelligence received by the Governing Body, and by its own development. The CCG’s ambition is to establish a shared understanding of quality and a commitment to place it at the heart of everything it does. The Quality Strategy represents an important opportunity for all stakeholders to work together for mutual benefit to make health care even better, for everyone, now and into the future, and enhance, by tangible demonstration of personalised, safe and effective care, the reputation of the CCG as a commissioner of health care.


APPENDICES


APPENDIX A Action Plan

Health Strategy 2011-2012

(Based on NHS Outcomes Framework)

Elements of Care Action Time scales Responsibility

Patient Experience

Quality Accounts

To appraise yearly provider quality accounts.

April 2012 J Wharton

(Nursing & Quality Lead) Information for Patients

Ensure that CCG website offers reliable and up to

date information.

Monthly P Steele (Patient

Experience Officer)

Provider assurance Visits Board members will be making ‘drop in’ sessions

to all areas of care delivery.

Monthly J Wharton

Safety

Serious Incidents (SI)

Maintain that assurance is given when serious incidents have been reported by provider

organisations

Monthly R Knight (Head of Assurance and

Risk)

Safeguarding

All contract negotiation will have a strong focus on ensuring safe guarding

vulnerable groups.

Quarterly R Knight

Cleanliness and Healthcare Associated

Infections (HCAI

Monitor that all providers are meeting hygiene

standards

Quarterly J Wharton

Effectiveness

Clinical Audit Encourage providers to undertake clinical

outcomes focused audits.

Quarterly N Fisher / J McCarthy (Primary Care Quality

leads)


Primary Care

Clinical Quality and Contract Review Meetings

Attend meetings to ensure that quality outcomes are being met and improved

upon

Monthly J Wharton / R Knight

Rewarding Quality Ensure that CQUIN incentives are meeting the

metrics for payment

Quarterly J Wharton

Quality and Outcomes Framework

Work closely with Primary care to ensure QOF targets meet quality

markers

Yearly N Fisher / J McCarthy

(Project Manager Alison

Holborn ) NHS Improvement

Agencies

To work with innovative agencies to improve

quality

Monthly N Armstrong (Chief Operating Officer)/

J Wharton

Patient Experience

Assessment of Need To appraise Primary Care data and identify

problematic areas.

Quarterly N Fisher / J McCarthy (Alison Holborn Project

Manager ) Changes in Pathways To work with Mathew

Crips / Cheryl McKay to identify areas where practice can be improved through fiscal management

Monthly N Fisher / J McCarthy (Alison Holborn Project Manager )

Primary Care Development

To work with primary & secondary care to address problematic areas of health that can be delivered in the community

Monthly N Fisher / J McCarthy

(Alison Holborn Project Manager )


APPENDIX B

Terms of Reference for Quality Committee

1. Introduction

The quality committee (the committee) is established in accordance with Warrington clinical commissioning group’s constitution, standing orders and scheme of delegation. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the committee and shall have effect as if incorporated into the clinical commissioning group’s constitution and standing orders. 2. Membership

The committee shall include the following members:

2 Clinical members of the Warrington Clinical

Commissioning Group governing body; 2 CCG primary care quality lead GPs; Accountable Officer; Chief Operating Officer; Quality Lead; and Head of assurance and risk

All of the above members shall have a vote. The chair of the committee will normally be a clinical member of the governing body. If this member is not available then another clinical member of the committee shall chair the Meeting.

The following will be in attendance:

a) An officer identified as Secretary to the Committee.

If unable to attend a Member may request an alternative officer to attend on their behalf. This Alternative Attendee should inform the Committee Chair at the start of the meeting that they are attending to represent to represent a particular Member. This should be recorded in the minutes of the meeting. Alternative Attendees do not have voting rights and cannot be counted as a Warrington CCG governing body member (unless they are a governing body member) when considering if the meeting is quorate.

The Committee may also extend invitations to other personnel with relevant skills, experience or expertise as necessary to deal with the business on the agenda. Such personnel will be in attendance and will have no voting rights.

3. Secretary

The lead governing body member, the Accountable Officer, for the Committee will have responsibility for:

a) liaising with the Chair on all aspects of the work of the

Committee, including providing advice; b) identifying an officer to undertake the role of Secretary; c) overseeing the delivery of the Secretary’s duties. The Secretary of the Committee will be responsible for: a) attending the meeting, ensuring correct minutes are taken,

and once agreed by the Chair distributing minutes to the members and submitting a copy to the Secretary of the governing body (Warrington Clinical Commissioning Group);


b) keeping a record of matters arising and issues to be carried forward;

c) producing an action list following each meeting and ensuring any outstanding action is carried forward on the action list until complete;

d) providing appropriate support to the Chair and Committee members

e) agreeing the agenda with the Chair prior to sending papers to members no later than 5 working days before the meeting;

f) ensuring the Annual Work Programme is up to date and distributed at each meeting;

g) ensuring the papers of the Committee is filed in accordance with Primary Care Trust’s policies and procedures.

4. Quorum A quorum will normally be 4 members, of whom at least 1 has to be a clinical member of the CCG governing body. 5. Frequency and notice of meetings

Meetings will normally take place once a month, normally during the week. An annual planner of meeting dates will be published in April. Papers should be submitted 10 working days before the meeting with papers sent to committee members 5 working days before the meeting.

6. Remit and responsibilities of the committee The Committee is authorised by the Warrington Clinical Commissioning Group governing body:

a) to investigate any activity within its terms of reference and produce an annual work program;

b) to approve or ratify (as appropriate) those policies and procedures for which it has responsibility as listed in the Warrington Health CCG Constitution;

c) to be responsible for ensuring compliance with financial, governance and commissioning arrangements when undertaking its terms of reference (including those listed in the Warrington Health CCG Constitution);

d) to promote a learning organisation and culture, which is open and transparent;

e) to establish and approve the terms of reference of such sub Committees, groups or task and finish groups as it believes are necessary to fulfill its terms of reference.

The specific duties of the Quality Committee will be to:

a) Seek assurance that the commissioning strategy for the clinical commissioning group fully reflects all elements of quality (patient experience, effectiveness and patient safety), keeping in mind that the strategy and response may need to adapt and change.

b) Provide assurance that commissioned services are being delivered in a high quality and safe manner, ensuring that quality sits at the heart of everything the clinical commissioning group does. This could be extended to include jointly commissioned services.


c) Oversee and be assured that effective management of risk is in place to manage and address clinical governance issues.

d) Have oversight of the process and compliance issues

concerning serious incidents requiring investigation (SIRIs); being informed of all Never Events and informing the governing body of any escalation or sensitive issues in good time.

e) Seek assurance on the performance of NHS organisations

in terms of the Care Quality Commission, Monitor and any other relevant regulatory bodies.

f) Receive and scrutinise independent investigation reports

relating to patient safety issues and agree publication plans.

g) Ensure a clear escalation process, including appropriate trigger points, is in place to enable appropriate engagement of external bodies on areas of concern.

h) Provide assurance for the quality of primary care service.

i) Disseminate information to support clinical decision making.

j) Ensure, by the use of benchmarking and clinical evidence,

that variations in clinical practice are identified and addressed.

k) Ensure that the quality schedules for the Providers are

informed by clinical benchmarks, clinical evidence, patient reported outcome measures and patient experience.

l) Ensure that the quality schedules, quality profiles and

Commissioning for Quality and Innovation initiatives result in higher quality services.

m) Receive and approve strategies or annual reports.

n) ensure oversight and monitoring of:

National Institute for Health and Clinical Excellence

(NICE)Guidance Implementation National Service Framework Standards Adherence National Policy development and implementation Safeguarding Adults and Children National & Local review recommendations (Care Quality

Commission or NHS Commissioning Board) National & Local Clinical Audit findings Local and national research and innovation

developments Local and national incident trend analysis Infection control benchmarking analysis Complaints and compliments Serious incident lessons learned evaluations

o) Ensure Warrington Clinical Commissioning Group has an

appropriate patient experience and engagement framework in place and that all commissioning decisions are Equality and Diversity compliant.

p) Ensure the Quality Committee receives regular Information Governance Reports, Toolkit Compliance Updates, Policies and other evidence for demonstrating information governance compliance.


7. Relationship with the governing body

The Committee will have the following reporting responsibilities:

a) to ensure that the minutes of its meetings are formally recorded and submitted to the Warrington Clinical Commissioning Group Governing Body;

b) any items of specific concern, or which require the Warrington Clinical Commissioning Group Governing Body approval, will be subject to a separate report;

c) to provide exception reports to the Warrington Clinical Commissioning Group Governing Body highlighting key developments / achievements or potential issues;

d) to produce an annual report for Warrington Clinical Commissioning Group Governing Body setting out progress made and future developments. This should include a completed annual self-assessment and the identification of any development needs for the Committee.

8. Reporting Groups

The Groups identified below will be required to submit the following information to the Committee:

a) their Terms or Reference for formal approval and review; b) the minutes of their meetings; c) an annual report setting out the progress they have made

and future development.

The groups are:

d) To be confirmed

e) any other Task and Finish Group set up by the Committee to assist them in carrying out their duties.

9. Policy and best practice

The committee will apply best practice in the decision making processes and will have full authority to commission any reports or surveys it deems necessary to help it fulfil its obligations. 10. Conduct of the committee

The committee will conduct its business in accordance with any national guidance, and relevant codes of conduct / good governance practice, for example Nolan’s seven principles of public life.

Members of the Committee have a responsibility to: a) attend at least 75% of meetings, having read all papers

beforehand; b) act as ‘champions’, disseminating information and good

practice as appropriate; Members and Attendees of the Committee have a responsibility

to:

a) identify agenda items to the Accountable Officer / Secretary 12 working days before the meeting;

b) prepare and submit papers for meeting 10 working days before the meeting.

Terms of Reference will normally be reviewed annually and/or on the publication of new guidance/ legislation.


Appendix C - Specific Accountabilities

Ultimate accountability for all Statutory Functions

Mental Health Capacity Act

Responsible for Governance systems and processes, HR, E&D, Health & Safety

Data protection, Information Governance, SIRO, FOI

Safeguarding Children & Adults, SUI Reporting

Complaints FOI

Quality Standards and performance Investigations

AO Controlled Drugs Caldicott Guardian

Nursing Issues

Financial Governance


Engagement, Experience and Communications Strategy Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Engagement, Experience & Communications Strategy

PURPOSE OF REPORT: To inform the Governing Body of the refreshed Engagement, Experience & Communications Strategy as part of the Authorisation process.

REPORT PREPARED BY: Nick Armstrong, Chief Operating Officer

KEY POINTS/TEAM BRIEF: To note the refreshed Engagement, Experience & Communications Strategy.



Approve the refreshed version of the Engagement, Experience & Community Strategy as part of the Authorisation process



2








(either financial or staffing resources) Yes














3



Yes



for Warrington Primary Care Trust? Does it impact upon: Yes



iii. other legal responsibilities (i.e., Data Protection Act) iv. compliance with the Corporate Governance Manual If yes to any of the above, please outline how below







1

Engagement, Experience and

Communications Strategy 2012 – 2015

2

CONTENTS SECTION PAGE

1 Introduction 3 2 Vision and Values 3 3 Empowering patients and People: Our

Approach to Engagement, Experience and Communication

3

4 Engagement, Experience and Communication Objectives

7

5 Tools and Tactics 5.1 Active involvement 5.2 External Communications 5.3 Internal Communications 5.4 Media Relations 5.5 Crisis Communications 5.6 Horizon scanning 5.7 Brand Management 1.1.1.1 5.8 Brand Positioning

9

6 Stakeholders 6.1 Stakeholder Analysis 6.2 Stakeholder Matrix

18

7 Risk Assessment 7.1 SWOT Analysis 7.2 Risks

21

8 Appendix A

Conclusion Delivery Plan

22 23

Appendix B SEE Patient Experience Programme Flowchart

30

Appendix C Warrington Health Forum Terms of Reference

31

Appendix D Media Protocol 34 Appendix E Key Messages 41

Approved April 2012 1st refresh September 2012 2nd refresh October 2012 Next refresh April 2013

3

1. Introduction The 2010 NHS White Paper ‘Liberating the NHS’ signalled a significant change for the NHS, and placed a clear focus on moving to a system built around clinical leadership. This new system would see the development of Clinical Commissioning Groups, taking over the leadership and commissioning role from PCTs. “No Decision about me without me” is a clear statement right at the very heart of the White Paper and Warrington Clinical Commissioning Group (CCG) is committed to making this a reality.

Representing each of the towns 26 GP Practices, the CCG is built around well-established clinical leadership, effective partnership arrangements and has strong foundations in terms of patient and public engagement. GP members have organised themselves into four groups in order to facilitate and enable them to work collaboratively on a range of initiatives and programmes. The CCG has already developed a close working relationship and joint commissioning arrangements with the Local Authority and is a key member of the Shadow Health and Wellbeing Board, in addition to playing an active part in a range of other strategic partnership boards. As a first wave pathfinder, the CCG took the lead responsibility for commissioning the majority of health care services for the people of Warrington with effect from 1 April 2011. It has an established governance structure and a Governing Body which includes four GP members, representing the town’s 26 GP practices and is a formal subcommittee of the Cheshire, Warrington and Wirral Cluster Board, who remain the statutory accountable body until April 2013. In April 2012 Warrington Clinical Commissioning Group entered the final phase of development before becoming, subject to authorisation, the new statutory body responsible for the local health budget. Progress to date has been excellent and the CCG has already established itself as the lead with provider and partner organisations.

2. Our Vision and Values Warrington Clinical Commissioning Group has described its Vision as:

“Excellence for Warrington”

and have committed to; work in partnership to develop the best health services

for people in Warrington contribute to a healthier Warrington for all focus on our Patients work in partnership with the local population recognise external constraints whilst striving for quality

This vision is underpinned by seven key values which are;

Excellence Valuing patients and partners Accountability Partnership in everything Honesty and integrity Open and transparent Courage

3. Our Approach to Engagement, Experience and

Communication The NHS Constitution signalled a move away from targets and central direction towards a system of rights and responsibilities relating to the quality of care; “the NHS aspires to the highest standards of excellence and professionalism in the provision of high-quality care that is safe, effective and focussed on the patient experience” (para 3, p3). This now gives patients legal rights to certain aspects of their care.

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The 2010 NHS White Paper reinforced the rights of the constitution and the need for NHS commissioners and providers to ensure that services are built around, and provided to deliver personalised patient care. The NHS Constitution also states that one of the seven key principles that guide the NHS is that it works across boundaries and in partnership with other organisations. Warrington Clinical Commissioning Group has made a firm commitment to not only fulfil the requirements of the NHS Constitution and the 2010 NHS White Paper, but to really embrace the principles and make ‘no decision about me without me’ a reality for the people of Warrington. We already have established relationships with a range of groups, which feed into the organisation; however, we are aware that many of the current groups we engage with are ‘activity specific’ such as the Older Peoples Forum and Warrington Disability Partnership. We fully recognise the importance of these relationships and the value they bring to the organisation and we are committed to continuing to build on these relationships, at the same time as seeking to widen our span of engagement. We understand that informing and engaging with the public is fundamental for the development of the CCG - effective communication and engagement is about getting the right messages to the right audiences through the most appropriate channels at the most appropriate time. It is to reach out to all sections of the community and ensure that people are supported and informed enough to engage productively and it is a two way process - informing and sharing, listening and responding to incoming communications is essential. We understand therefore that it is vital that the CCG develops its stakeholder relations, including engagement with GPs, and the way in which it seeks and

uses feedback to inform decision making and in developing health services for the people of Warrington. In terms of communication, it is recognised that engagement and communications are intrinsically linked, and that effective communication is a key enabler to support optimum engagement and involvement. Warrington Clinical Commissioning Group is committed to a culture of openness, transparency and honesty, and effective communication will be a key enabler in facilitating this.

We will ensure that our communication mechanisms are fit for purpose. We will continually look to improve our ability to communicate effectively, we will capitalise on our opportunities and will work with our partners and providers to utilise already established routes. We also recognise the importance of the media and we will continue to develop our media relationships, taking a proactive approach to dealing with the media and we will, when necessary defend the organisation and challenge mis-reporting. We will also enhance our capabilities in terms of the use of social media, investing in new technologies, which will further enhance our capabilities in terms of effective engagement and communication. We will also strive to put in place as many mechanisms as possible to actively seek the views and experiences of local people. The 2011/12 Warrington Clinical Commissioning Group Communication Plan set the foundations for how the CCG would develop in terms of engagement and communication and this strategy builds upon what the 2011/12 plan delivered.

This strategy not only reflects the requirements of the NHS constitution and the CCG’s statutory obligations which will be aligned to the legislated changes outlined in the 2012 Health and Social Care Act, but goes much further into building effective engagement into all the work of Warrington Clinical Commissioning Group.

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We have developed clear achievable engagement and communication objectives, as detailed below, which will be supported by the required resources in terms of tools and time. This strategy provides the framework for developing the engagement and communication activities during the transition period and beyond. The detailed delivery plan in Appendix A describes how the strategy will be implemented, including roles and responsibilities, a detailed action plan, and evaluation process. The successful implementation of this strategy will ensure that the CCG progresses through the authorisation process successfully and becomes a leading clinical commissioning group. 3.1 How Patient feedback informs CCG decision making The structure below illustrates the way in which we gather patient experience data via a range of routes and how this data is utilised in order to influence the CCG decision making process. The patient feedback received through the various channels is filtered to • Clinicians • Commissioning Support • Quality Committee • Governing Body This feedback is then considered and taken into account for future commissioning plans

3.2 Patient Participation Groups Patient Participation Groups (PPGs) are one of many ways in which we can increase our engagement with patients and offer a great opportunity to maximise our contact with patients and carers. We have been working with our practices to develop a PPG in every practice, promoting and utilising the National Association for Patient Participation (www.napp.org.uk) tools and guidance. Each PPG has utilised the NAPP best practice Terms of Reference as the basis for developing their own PPG. We will continue to further develop our existing mechanisms of engaging with patients and the public and have already launched a membership scheme, which although in its early stages, will go some way to support our engagement activity and provide a mechanism for wider involvement. Recognising that other key providers also have membership schemes we will seek to work co-operatively with them in our engagement processes to avoid confusion for the patients and public of Warrington. As commissioners we want to ensure that patients feel that they are included in their care and that they have a voice which can directly influence the decisions made by the CCG. We know that our providers

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are committed to providing excellent quality services and have made strategic commitments to improve the quality of their services and improving patients’ experiences of their services. Patient feedback is captured through a variety of channels one method is through Patient Participation Groups within GP Practices. Information captured through the PPG’s can either be submitted through the normal patient experience route or via the PPG representative who sits on the Warrington Health Forum (the Terms of Reference for this group are attached as an appendix). When information from the PPG is captured the patient experience flow chart is followed to ensure that it is treated in the same way as other patient experience feedback. The diagram clearly demonstrates how information captured through the various patient experience channels is fed up to the CCG. Once patient feedback is received and forwarded to the appropriate provider / commissioner, a response from the provider is produced and this is then fed back to the person / group who provided the feedback, this highlights any lessons learnt by the provider and what measures have been put in place to ensure that the issue or incident doesn’t happen again. The methods we use to feedback to the person depends on their chosen method, Email, Face to Face, Focus group, Letter etc. 3.3 Patient Experience Programme (SEE) Safety Effectiveness and Experience The CCG is committed to improving patient experience and fully recognised the importance of patient experience data. The proactive capture, analysis, triangulation and interpretation of information about the experience of patients and carers will be used to inform all planning and commissioning decisions.

We have an established patient experience programme (SEE – Safety Effectiveness and Experience), which is widely publicised and provides a means for people to provide their patient experience feedback through a variety of channels. Through this programme we actively seek patient stories and the CCG Governing Body, prior to each board

meeting, hear first-hand from a patient with their story. Appendix B details the way in which we utilised the feedback obtained through the SEE programme. We also have an established Patient Experience and Quality Group, which reports into the Quality Committee, which is a sub-committee of the CCG Governing Body. This groups reviews patient experience data on system wide basis, agrees on actions to improve patient experience and steers the development of quality improvement across the health economy. It is our intention to extend our capabilities around the collection of patient experience feedback, to ensure that the data being reviewed at the Patient Experience and Quality Group is well rounded and from a diverse range of clinical areas. One example of service change in response to patient feedback is the re-design of anti-coagulant services. Patients told us through feedback that they were not happy with the current service, specifically around the travelling time, parking issues and waiting time within the hospital for what was a very basic procedure. What we did…..The anti – coagulant team held a focus group with a number of patients to discuss how to improve the service. The patients were asked; ‘What kind of service would you like to see?’ The main emerging issues included locally based, easy access, sufficient parking, access for wheelchairs and an appointment system that worked.

A post code search of the current case load was carried out to ascertain where the service was most needed. Grappenhall and Westbrook were identified as areas where a service could be piloted; both have excellent parking facilities and easy access to the clinical areas. The success of the pilot led to the identification of other sites. The outcome….. was that as a result of this patient feedback there are now a number of anti-coagulant clinics in five geographical areas with a further two due to open shortly. The benefits of the service include;

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Patients now have local direct access to the anti-coagulant team who they can contact to discuss any concerns they may have.

The redesign of the service had no financial costs. 1600 patients now access this service locally and no longer

need to travel to the hospital. An early win demonstrating how effective care delivery can

work between the acute and community sector. Now receiving positive patient feedback for this service.

3.4 Warrington Health Forum We have established a Warrington Health Forum, with representation from each PPG, in addition to Links and others. This forum provides the CCG with great opportunities in further developing our relationships with the voluntary sector, charitable sector, local faith groups and other community forums (see Appendix C, for draft Terms of Reference). This group is the sounding board for CCG Governing Body and will be the mechanism by which the CCG engages with regards to the CCGs work programmes. A member of the CCG will be also be part of and attend LINk/HealthWatch meetings to provide regular updates and bring information and questions back to the CCG to provide two-way communications.

4. Engagement, Experience and Communication Objectives The strategy is built around four key objectives, with clear aims and identified desired outcomes, as detailed below;

Objective One

This will be achieved by:

Ensuring the public voice influences and is directly involved in the decisions made by Warrington Clinical Commissioning Group

Actively seeking out patient experience data from a range of sources.

Ensuring that patient experience data is systematically collected and embedded into work programmes.

Using the most appropriate means of communications for the requirements of the audience

Using a wide variety of methods and innovative approaches to engagement

Working closely with hard to reach groups to ensure they have a voice

Using patient experience data and information to inform our work and to work with provider organisations to listen to patients more and act on their feedback

'Closing the loop' by reporting on the impact of public feedback on Warrington Clinical Commissioning Group decisions

Learning from good practice and tried and tested examples of engagement

Outcomes of this objective:

People in Warrington feel they have a voice in the decisions made by the CCG and will be able to identify how they have influenced local

To continue to build continuous and meaningful engagement with our public, patients and carers to influence the shaping of services and improve the health and wellbeing of people in Warrington.

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NHS services. There will be improved patient experience and a reduction in complaints and negative media attention.

Objective Two


Protecting the reputation and promoting the Warrington Clinical Commissioning Group and NHS brand

Developing good media relations and addressing any inaccuracies to prevent misunderstanding and confusion

Ensuring internal and external audiences are aware of CCG and locality developments as well as issues facing the Warrington Clinical Commissioning Group

Providing consistent and timely messages internally and externally to various audiences

Working collaboratively with partners and other NHS organisations in and around Warrington

Outcomes of this objective:

Stakeholders are confident that the Warrington Clinical Commissioning Group is successfully taking over as the lead, with responsibility for commissioning healthcare services and is operating in the best interests of the people of Warrington.

Objective Three


Working with member practices, providers and partners to ensure that public information is accurate and up to date.

Working collaboratively with providers and partners to ensure that messages are consistent and timely.

Working closely with our community groups, including hard to reach groups to ensure that messages and information are being received and are understood.

Continuously scoping new and innovative ways of communicating, making best use of new technologies and digital communication.

Regularly testing out the effectiveness of communications Making language meaningful for staff, public and patients in all

communications

The outcomes of this objective will be:

The people of Warrington will be well informed and will have a good understanding of services and what is available to them. People will have the information they need to help them to improve their own health and wellbeing. Reduction in inappropriate use of services, reduction in DNA’s and increased use of self-care.

Increase confidence, with patients, public, provider and partner organisations in Warrington Clinical Commissioning Group as an effective and responsive commissioning organisation

Develop and maintain effective communication channels to ensure that the people of Warrington have the information they need to enable them to access the right care at the right time, helping them to look after themselves and improve their health and wellbeing.

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Objective Four


Developing and maintaining good media relations

Developing internal two-way communications channels with staff, practice and GP members.

Ensuring internal and external audiences are aware of services developments and successes

Ensuring internal and external audiences are able to feedback information on successes and achievements through accessible routes

Making language meaningful for staff, public and patients in all communications

The outcomes of this objective will be: The CCG will have the support they need to ensure effective relations with the media and clinicians will understand their role and what is expected of them in terms of engagement and communication. CCG member practices and staff feel they can express their opinions and judgment and they feel their contribution is valued. The public will feel valued and informed and will be aware of how they can feedback to the CCG. In order to achieve our objectives, a detailed ‘rolling’ action plan has been developed, as detailed in the Delivery Plan in Appendix A. This action plan details the planned engagement and communication activities that will be undertaken to deliver on the objectives.

It should be noted that this is working document as it is recognised that we are working in a dynamic environment which is continually changing, therefore the action plan will change and flex to meet potential changes. 5. Tools and Tactics Warrington Clinical Commissioning Group will utilise a mixture of approaches, as detailed below to actively seek out the views of our local population and we will ensure that our methods are evidence based and work for our intended audiences. We will ensure that we have the right systems and communication methods in place to ensure timely, relevant communications with each of our internal and external stakeholder groups. This will require a number of different approaches, including:

Events, including partnership engagement events, national events.

Focus groups Community forums Meetings (internal and external) Workshops strategies, plans, reports and other formal

publications Written communications Face-to-face, interpersonal communications Meeting papers and minutes Newsletters Briefings Website / intranet Online Social Media Press releases Paid media and advertising campaigns

Develop a culture within Warrington Clinical Commissioning Group that promotes open engagement and communication within and outside the organisation.

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Warrington Clinical Commissioning Group also recognises the benefits of information technology and will strive to use electronic communications, where appropriate. Warrington Clinical Commissioning Group will also fulfil its statutory obligations to provide information in differing formats on request (e.g. large print, other languages, Braille or audio).

5.1 Active involvement We will proactively seek and will continue to build meaningful engagement with all our stakeholders, including patient and the public and will ensure that relationships are managed and maintained during the transition process and beyond. We have established a new Warrington Health Forum, with representation from each of the practice PPGs, in addition to other members and we will actively seek the views and support of this group in all our engagement activity. We will not only ensure that we comply with our statutory obligations but will proactively seek involvement and engagement, through both formal and informal routes. We will utilise our PPGs, Health Forum and membership scheme to collect feedback on a qualitative and quantitative basis and will expand on the traditional paper based methods, utilising new technologies to collect real time patient experience data. Working with our providers, we will embrace the opportunities which technology and social media bring and will actively collect first hand, real time patient experience feedback , for example, we will utilise vox pops as a means to ask patients about their experience, rather than rely on a set of written questions and answers. It is our ambition that wherever possible, we will be able to hear, directly from patients, in their own words what their experience was.

We will further develop our SEE patient experience programme and will continue to work with the many groups and forums to actively seek feedback. We will also ensure that we continue to utilise and respond to feedback via PALs and complaints and will utilise this data, along with all our other patient experience date to drive and inform our commissioning decisions. Warrington CCG captures patient experience / feedback through a variety of channels which include:

SEE Facebook Twitter Focus Group 1-2-1 Meetings Patient Opinion Patient Choices Working on the Patient Experience Work Programme Health Events Meeting Regular sessions with Vulnerable Adults

The feedback received through the channels can be both positive and negative experiences of people accessing NHS services across Warrington. A patient experience flow chart is in place which clearly highlights what happens when feedback is submitted to the CCG whether it’s negative or positive. This flow chart is in place to allow commissioners and providers to fully understand what happens when feedback is submitted and what we expect from them in regards to them investigating the issue and providing further feedback to us and then

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this feedback is then passed back to the person who provided the information. Any feedback received positive or negative is then escalated as per the graphic on page 6, to the patient experience and quality meeting for further discussion and triangulation against other services for examples PAL, Complaints, LINks etc. the triangulation exercise is carried out to ensure trends are identified early and acted on appropriately where appropriate the feedback / experience will be escalated further to the most relevant committee for example SUI’s group serious untoward incident review group or the CCG Quality Committee. As identified within the patient experience flow chart once feedback is passed onto providers, services we have a clear process to ensure outcomes, responses from providers are passed onto those people who provided the initial feedback / experience this can be done in a number of ways via, face to face, letter, phone, email etc. The Public, Patient Engagement / Patient Experience Officer regularly spends time with Vulnerable adults for example people who have learning disability, homeless, older people etc., this is a great way of engaging with these group who would not normally come forward and engage with health services and provide their experiences of the NHS. When feedback is captured from these groups the flow patient experience flow chart is followed and follow up sessions are arranged to ensure the outcomes are passed back to the groups. The CCG is implementing a patient experience module as part of the Datix resource, this module will ensure the ‘soft data’ submitted is triangulated across PALS, Complaints, Patient Participation Group, GP Practices and via federation meetings and other providers to ensure trends are picked up and acted on accordingly. This facility will allow GPs to register issues during the patient consultation. This will provide additional real time data to the triangulation described above. In addition, GPs will actively encourage

patients to use all of the available feedback mechanisms to reinforce the value we place upon this. Warrington CCG is in the process of developing a Warrington Health Forum. This forum will be made up of representation from the CCG, Patient Participation Group and third sector organisations, this group will be used as another mechanism for ensuring information from practice and community level are captured and fed into the CCG.

5.2 External Communications Patients and the Public General communication with the public will be facilitated via the media, public events and the attendance at the various networks and meetings. We will utilise written, face to face and e-communications and will always ensure that the mechanisms fits the requirements of the audience. In order to ensure clarity of message around what the transition means to the public we have developed a suite is key messages, which will ensure consistency of message throughout all our communication and will ensure clarity on what the reforms mean to patients and the public. We have already introduced a monthly newsletter which is issued to our members, which will be used to provide members with updates and information and as a means to encourage feedback. We will utilise the annual general meeting as a means to promote the CCG and encourage engagement in the business of the CCG. We will work collaboratively with partners and providers to have a presence at a range of events and forums.

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We will utilise the existing communication mechanisms within our partner and provider organisations, for example the LA Wire Magazine and will, where appropriate will work collaboratively with provider organisations to utilise their mechanisms in relation to their members. The CCG use a number of ways to carry out meaningful engagement with the whole community and encourage all groups across the borough to provide their experiences and feedback of using the services we commission. We have developed various resources to ensure the whole community depending on their diverse have the same chance of engaging with the CCG and providing valuable feedback. The methods provided and used by the CCG are:

SEE – Safety, Experience, Effectiveness

Patient Opinion

Patient Choices

Facebook

Twitter

Handheld Devices

Health Events

Meetings

Focus Group

Patient Participation Groups

Warrington Health Forum

Regular attendance at Vulnerable Group Meetings

Local involvement Networks

As previously discussed any information captured through the above is collated in the same process and fed back in the same way.

Partners and Providers We will continue to utilise existing meeting and network arrangements and we will introduce a quarterly high level ‘spotlight’ brief, to highlight key successes, progress on specific programmes of work and to share general news. Publications and literature We will only produce new printed collateral when absolutely necessary and will utilise existing mechanisms within health, LA, provider and community publications to communicate key information. We will, where possible, only produce documents and publications in electronic format. When there is a need to produce information in relation to work streams, this is likely to be low volume and will be produced locally where possible. Web Site Increasingly, people use the Internet to seek information about an organisation, where to obtain help and advice and how to access services. Equally, websites are being used more and more as the means for people providing feedback. We acknowledge the power of web based communications and how we can use the website to help to facilitate involvement in addition to being a means of collecting patient experience data. The CCG has an established high quality, easy to navigate website, we will ensure that as new technologies and capabilities are identified the website if further developed. We will also ensure that the website is maintained regularly and quarterly full reviews will be undertaken.

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We will continue to develop the website in conjunction with staff and other key stakeholders as appropriate. Key messages and information, news and media releases and important publications such as the statutory annual report and duty to involve report will all be published on our web site. We will ensure that the website is accessible to all and that we continually review and test out the functionality to ensure it meets the needs of the public. E-communications We will develop and maintain our electronic communication mechanisms - managing web content and providing content for use on partner and provider sites. We will further develop our capabilities around social media, developing the established Face book and Twitter sites. We will, where possible communicate via visual form, replacing hard copy products with video media. Events We will plan and deliver public events, where required in line with our statutory obligation in terms of public consultation. We will also utilise existing planned events, including events hosted by our partners and providers to communicate key messages and to take advantage of any PR opportunities. Members of Parliament Political support for the CCG is important in raising and maintaining the CCG’s profile and creating awareness. MPs will be regularly briefed on successes and issues within their local constituency.

Face to face meetings with the CCG Accountable Officer and Chair will ensure that relationships with our MPs are maintained and that they are provided with information first hand. We will also ensure that ad hoc briefings are prepared in relation to emerging issues to ensure political support and minimise the risk of MPs being misinformed. We will also continue to ensure that we respond quickly and effectively to requests from the Ministerial Briefing Unit in relation to parliamentary questions etc. and will continue to monitor activity around local issues, PQ’s and responses. This information will be shared with board members within the weekly communication update. Shouting about what we do We will ensure effective marketing and communication of successes, demonstrating and highlighting improvements in health outcomes as a result of commissioning activity. 5.3 Internal Communications CCG Member practices We will continue to utilise the weekly Commissioning Brief to communicate to member practices, GPs and practice staff and will look to further develop this and to continue to encourage two way communication and feedback. We will support the facilitation of events and where required will co-ordinate briefing sessions with GP members on behalf of the CCG Governing Body. We will further develop the ‘protected’ internal facing area within the CCG website to provide a means to share information with staff, practices and GP members and to enable them to share information between themselves.

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There are also a number of emerging processes to support the CCG in its engagement with GP practices. This is so that GP practice staff are aware of our decision making, as well as to support GP practice staff in their local engagement priorities to share with patients. These include:

GP practice buddying scheme Council of Members GP practice visits Future leaders group Additional communications channels

Extranet – an extranet will launch with logins for each GP practice. The extranet will include a virtual library of relevant documents

Engagement toolkit to support practices

Warrington CCG newsletter – a bimonthly newsletter is emailed to all GPs, practice managers and practice nurses, covering the key issues.

E-News – an E-News update for stakeholders including GP practices

Additional communications toolkit of poster and newsletter templates that follow the Warrington CCG brand guidelines will be made available so that all practices can cost effectively produce professional materials.

CCG Staff Our staff and our member practices are our ambassadors and are well placed to promote the work that we do. It is essential that they are kept well informed and up-to-date on developments and initiatives, and are able to contribute to decision making. To be fully effective and achieve the highest success, communications throughout the organisation should be bottom up as well as top down approach. All our staff have a responsibility to promote communications and play their part in this process.

Managers will be encouraged to lead by example to ensure individuals are empowered to improve the way they communicate and share information with others. The Communications Team will ensure that all communication supports a culture of open, honest and effective two-way communications. We will continue to develop our internal communication channels and will ensure that all internal communication channels have effective feedback mechanisms. We will ensure that staff receive timely updates and, will strive to ensure that staff receive important information first hand via face to face briefings and that they are informed of any issues before they are reported in the press. We will utilise the intranet to share key messages from the Accountable Officer, Chair and other board members. We will reintroduce the weekly face to face briefing, encouraging the senior management team to take an active part in sharing information and news. We will also utilise this to encourage staff feedback and as a means to rebut rumours. This weekly briefing will be open to staff who will be employed within the CSS but have identified roles in supporting the CCG. We will also ensure that face briefings are arranged to engage staff directly around plans that affect them directly. We will utilise the global email system to share information with staff which is time critical and will publish a weekly update directly after the weekly face to face briefing to reinforce what has been briefed and to ensure that those staff not in attendance are made aware. All communications will encourage feedback on an on-going basis from our staff and members to ensure they remain effective.

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Board Members It is crucial that the CCG Governing Body members are kept up-to-date of key developments, media coverage and issues. The Communications Team will provide CCG Board members with a weekly communications update, which will include all media activity, political issues (PQ’s etc.) and a high level brief on any emerging issues which may impact on the reputation of the CCG (SUI’s etc.). Intranet site We have developed a new intranet site, which provides the CCG to share information with staff and GP members and will enable staff to access information including policies and protocols. The intranet will be used as a platform to support a common corporate culture, as every user will have access to the same information. The site will be used to host the communications ‘how to toolkit’ to enable staff to access templates, guidance notes etc. The site will also host all corporate information for staff, including policies, procedure etc.

5.4 Media Relations We fully recognise the power of the media and the media, if managed proactively can be one of the most effective means of engaging with the wider public. Our approach when working with the media will be proactive, securing positive coverage in a wide range of publications, local, regional and national, in addition to trade press, online and broadcast. We will hold monthly meetings with local editors and health correspondents, including members of the CCG Governing Body and other senior officers when required. We will ensure that there is weekly one to one contact with the local media and will offer local health correspondents a local induction into the CCG.

A proactive approach We recognise the power of our local newspapers and radio stations across the borough and a significant amount of effort has been made towards building and strengthening relationships with editors and local health reporters. The communications team will provide local media with weekly updates on topical issues and will ensure that one to one weekly contacts are made. We will continue to increase the level of proactive media releases to local media and where appropriate regional, national and trade press. The continued effort on the expose of positive news stories will enhance the CCGs external reputation and will go some way to reducing the impact of negative coverage. Reacting effectively When dealing with reactive issues we will adopt the following principles when dealing with reactive media enquiries:

We will strive to be helpful when meeting media deadlines

Where possible, we will produce any required statement within their required timescales

We will not comment on individual personal details, we will only confirm facts.

We will agree responses with the key staff involved We will not lie or intentionally mislead the media but will

seek opportunities to get our message across We will challenge inaccurate reporting.

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Media Training We have developed a robust Media Protocol (see Appendix B), which ensures the Communications Team are informed of and involved with all media contact. Media training will be vital in broadening the number of spokespeople available to the CCG who have the appropriate skills to maximise media opportunities and protect or enhance the CCGs reputation. We will develop and deliver basic media training and will, where required source specialist media training. Media Monitoring Given the media’s influence and potential impact to the CCGs reputation, it is important that the CCG Governing Body, senior officers and GP members are kept informed of positive and negative media coverage, proactive media releases and reactive enquiries that have not resulted in negative coverage for the CCG. We have put in place mechanisms for monitoring the media and have developed a weekly media brief which will be circulated at the end of each week. Any urgent media issues will be briefed immediately by the communications lead. In order to benchmark and fully understand public perceptions, we will explore, with colleagues from other regional CCGs, opportunities to introduce a more in-depth media monitoring process. 5.5 Crisis Communications In the event of a crisis situation or major incident, effective, timely communications are critical. During transition we will continue to work to our major incident and emergency plan communications plan to meet any generic crisis and will, with the lead for emergency planning develop our communication

plans around, business continuity, major incident and pandemic and heat wave requirements. We have developed a media handling protocol which provides detailed guidelines for dealing with the media both proactively and in a crisis situation. It is important that all staff, CCG Governing Body and GP members adhere to this protocol. 5.6 Horizon scanning We will horizon scan for forthcoming or potential negative or difficult issues and will prepare appropriate responses for any emerging problems. Anticipating how the CCG will need to deal with criticism, for example about financial pressures or contentious commissioning decisions, and ensuring that the CCG are well supported to manage any crises. We will ensure that there is a whole system overview in terms of complaints, MP letters, Parliamentary Questions, negative patient experience feedback and other non-regulatory communication in order to ensure that we are aware of potential emerging issues at the earliest opportunity. 5.7 Brand Management As leader of the local health economy, the reputation of the organisation is critical to successful relationships. Effective management of the CCGs identity and house style is an important element in protecting the organisations reputation and it is important that the CCGs identity is not used inappropriately. In line with our authorisation process the Department of Health have issued the CCG with their official NHS logo and identity – Warrington Clinical Commissioning Group and new templates have all been developed to incorporate the new logo.

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The CCG have also considered the organisations wider identity and have taken on a ‘house style’ which complements the branding and gives the CCG a local identity that links them to public health and local authority partners. The interwoven ring design also reflects the identity of the ‘It's all going on in Warrington campaign’ which was launched in 2011 to promote the rich cultural activities that Warrington has to offer. The interwoven rings have been adapted to incorporate the CCG colours and the CCG vision of Excellence for Warrington has been embedded within the circles. A full suite of templates have been developed as part of a ‘how to toolkit’ which will ensure that the branding and house style are being used in accordance with the Department of Health Brand Identity guidelines. The Communications Team will be the keepers of the CCG brand and will work with staff and teams to ensure the corporate style is implemented in an appropriate manner at all levels. Consistency of message, house style and branding will be monitored through all corporate communications. 5.8 Brand Positioning Our CCG has clearly identified its visions and aims, creating a platform that underpins all engagement and communications activity. Understanding our brand positioning helps Warrington CCG to outline the vision and aims of the clinical commissioning group, as well as identifying the key messages. Our brand identity focuses on health services led by patients, and the relationship between clinicians and patient. This basic understanding of the CCG position should be used to frame our communications messages. Understanding our brand positioning has also enabled us to develop a visual identity and brand guidelines for the CCG as well as producing a communications toolkit with templates for posters,

newsletters and other materials. This is being shared with all of our GP member practices. Brand positioning What we do? Scope: What area of activity are we in? Working with you for better health and care in Warrington Status: What status do we want to achieve? Health services led by the people Why we do it? Ambition: What is our heart-felt ambition? Healthier lives for the people of Warrington Ethos: What are the principles behind our actions? Passionate about your health Compassionate about your care How we do it? Style: How do we go about our business? Reaching out to everyone Focused on you Response: What impression do we want to create? I’m heard, I’m healthier, I’m cared for Focus: Our basis for making decisions The best results for people in Warrington

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6. Stakeholders

Understanding the organisations stakeholders is essential in ensuring that the CCG had a good understanding and can identify those which an interest in the work of the CCG. The CCG has undertaken an exercise to identify all stakeholders and has analysed and categorised the list to identify those with the greatest interest, through to more peripheral individuals or groups. The CCG has made a commitment to ensure that it engages with all stakeholders, however, more resource will be focussed on engaging with those stakeholders with the highest interest and need in order to maintain their involvement and commitment.

6.1 Stakeholder Analysis

POW

ER

Hig

h

Keep satisfied: but not so much that they become bored with messages: WHHFT Members 5 BP Members NHS North of England Local Medical Committees Local Pharmacy Committees

Manage Closely: these are the people to fully engage and make the greatest efforts to satisfy. Member Practices WHHFT – Board 5 BP Board Bridgewater CT Board Local Authority Exec Committee MPs Local Council Members Local Overview and Scrutiny Committees Health and Wellbeing Board Warrington Local Involvement Networks

(LINks)/Health Watch Third sector and patient support groups

(via local CVS organisations) Media

Lo

w

Monitor: do not bore with excessive communication: Other NHS Staff (providers) Local Social Enterprises (if and

when established!) Local Chambers of Commerce Housing Trusts and other public

sector organisations

Keep informed: and engage to ensure no major issues are arising Patients, their carers, families and the

general public CCG Staff

Low High INTEREST

Red – High Power, High Interest – fully engage and satisfy Orange – High Power, Mod Interest – inform, seek approval and satisfy Gold – Mod Power, High Interest – inform and engage Green – Low Power, Low Interest – monitor and inform

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6.2 Stakeholder Matrix The following matrix provides the detail in terms of the stakeholder groups, focussing on communication and engagement processes for each of the stakeholder groups We capture patient experience data from the various groups, focussing particular effort on diverse and vulnerable groups as identified within the JSNA these groups include: As well as the groups identified above we also continually engage with the groups identified within the stakeholder matrix below through various mechanisms, including the SEE Patient Experience Programme, Warrington Health Forum, and specific focus groups in relation to commissioning intentions to ensure patient experience data is captured and acted on.

Stakeholder Group

Groups Identified

Engagement & Communication Priorities

All Stakeholders including Patients & Public

Reputation management and public affairs Campaigning for health priorities Managing the brand and the market Awareness of key health messages Engagement and involvement in decision-making

Access to health services messages Self-care messages

Vulnerable Groups

Homeless Population Learning Disability Groups Disability Groups Domestic Violence Older People Black Minority & Ethnic Groups Alcohol Using Population Drug Using Population Gay, Lesbian & Bisexual Population Children & Young People Carers

Through CCG’s extensive reach via its community engagement teams and tailored engagement tools, including focus groups Communication through partnerships with community organisations Use of interpretive tools – translation clarity of language etc.

Media Local Regional National Specialist

Reputation management Can-do” approach to relationships Preparation of key messages to respond to anticipated issues Clear protocols Media training for key spokespeople Assertive, including use of rebuttal

Unemployed, Obese / Overweight, Most deprived 20%, Smokers, Drug Users, BME, Mental Health, LTC, Children & Young People, Children in Need, Youth Offenders, Not in Education, employment or Training, Carers, Domestic Violence, Older People, Physical Disabilities, Learning Disabilities, Sensory Disabilities, Pregnant Women

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Key Partners Warrington &Halton Hospital Foundation Trust 5 Borough Partnership Bridgewater Community Trust Warrington Borough Council

Other Partners

Third Sector Local Involvement Networks Faith Groups Resident Groups Department of Health National Commissioning Board & LAT Neighbouring CCGS & Local Authorities

Reputation management High quality, timely information to support partnerships Effective engagement and involvement Communications to support their organisation development Communications about access to services

Influencers Local MP’s Councillors

Reputation management Timely, regular briefings – written and face to face to build awareness and support the objectives

NHS Partners

Acute & Specialist Trusts All Other

Reputation management, particularly

Providers NHS North West Department of Health

Independent Contractors

GP’s and practice staff Pharmacists Dentists Optometrics Local Professional Committees, including LMC & LDC etc.

Timely and consistent communications Effective clinical engagement to build awareness and support for strategic objectives and delivery Reputation management

Other NHS & related partners

NHS Direct Health Protection Agency Workforce Confederation Healthcare Commission NHS Alliance NICE Business Services Authority

Reputation management Awareness of key messages Effective engagement & involvement

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7. Risk Assessment 7.1 SWOT Analysis Having reviewed our situational analysis, it has been identified that a number of areas which were identified as being ‘weaknesses or threats’ Strengths Weaknesses Established Governing Body with high level of strategic expertise and a varied skill set. Skilled engagement and communication resource via CWW CSU Good clinical engagement

Continuously changing environment

Opportunities Threats Further enhance member practice engagement Further enhance staff engagement Further enhance clinical engagement between provider and commissioner organisations. Enhance robust working arrangements with partners and providers

Resource within local media organisations – lack of ‘named’ health link. Political challenge Loss of public and clinical engagement and confidence. Loss of staff engagement and confidence, negative effect on staff morale. Diverse and competing demands on time to undertaken the necessary work.

7.2 Risks There are several risks attached to the success of the engagement and communication strategy, as detailed below. Consideration has been given to these risks and the successful implementation of the engagement and communication strategy will contribute to the mitigation of all the risks identified:

Negative media attention around the health bill, ministerial changes and potential impact on the transition and the privatisation of the NHS

Political spotlight drawing NHS finances in to the political

debate locally and nationally.

Confusion due to the amount of information being communicated at any one time via provider and partner organisations.

Loss of local engagement and inability to maintain

relationships during the transition period due to reduction in resource and changing roles and responsibilities.

Competing demands on media space by public sector

organisations. The impact of the transition on staff morale and staff

retention.

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8. Conclusion

The ultimate aim of our communication strategy is that all of the people and patients of Warrington will feel fully informed and involved in all the activities of the organisation, understand our roles and responsibilities and how we work in partnership with our key partners and stakeholders. We will work hard to build a strong reputation for the new organisation and use this opportunity to look for new and innovative ways of connecting with our stakeholders. We are committed to keeping our staff fully engaged and creating a positive organisational culture. We recognise that our staff will be critical in enabling the organisation to meet the challenges ahead and will seek to maximise the fantastic resource that we have in them. This plan outlines the work that we will continue to do in order to ensure that we listen and understand the population’s priorities and aspirations and utilise this knowledge to responsibly and effectively commission on their behalf. The CCG will communicate in a clear, timely and meaningful manner, enabling local people to make informed decisions and take ownership of their own well-being, health and lifestyle; thus enabling us all to work to create excellence for Warrington

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Appendix A

ENGAGEMENT, EXPERIENCE AND COMMUNICATION DELIVERY PLAN Roles and responsibilities Effective engagement and communication is everyone’s responsibility and the CCG Governing Body, member practices, staff, including clinicians and practice staff all have a key role in promoting the work of Warrington Clinical Commissioning Group, the services which it commissions and in raising awareness of health campaigns and initiatives. The engagement and communication lead will ensure that all Warrington Clinical Commissioning Group members and staff are well informed and supported to do this. Key responsibilities The Senior Communications Lead will be responsible for: Developing and managing delivery of the communication &

engagement strategy and action plan. Providing the CCG Governing Body with progress reports and will

also ensure that the board is made aware of any significant issues which will impact on the effectiveness of the strategy and any risk in terms of achieving the objectives.

Providing strategic input to the work of Warrington Clinical Commissioning Group, providing strategic advice on engagement and communication requirements.

Identifying, planning for and responding to emerging issues which may have a detrimental impact on the reputation of the CCG and / or the NHS brand.

Handling of all communication, including crisis communications in relation to serious and untoward incidents.

Handling of all communication, including media activity in relation to major incidents as part of emergency planning arrangements. (this includes on call out of hours support)

Handling of reactive media activity, ensuring appropriate response and timely escalation of issues and where required co-ordinate responses with communication leads from partner and provider organisations.

Oversight of all proactive media activity, and, where required co-ordinate media activity with communication leads from partner and provider organisations.

Co-ordinating activity, where required with communication leads across the partner organisations.

Having a system wide overview of all incoming communication (formal and informal i.e. complaints, MP letters, Parliamentary Questions) and identification and response to emerging issues.

The Public, Patient Engagement / Patient Experience Officer will be responsible for: Delivery of all engagement operational activity identified in the

engagement and communication work plan. Acting as the first point of contact for community and third sector

groups in relation to public engagement activity. Delivery of all patient experience activity identified Provide regular update reports to Warrington Clinical

Commissioning Group Board members Quality Committee and patient experience and quality group and any other committees and meetings as required

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Alerting the communications lead with information around any emerging issues in relation to engagement activity which may impact on the organisations reputation.

Attend a variety of third sector and community group meetings and present updates as and when required

Attend a variety public events across the borough Development and maintenance of the membership scheme Continually monitor the SEE Website, Patient Opinion and patient

choices Supporting and advising commissioning leads and CCG senior

officers with practical engagement support, including the development and implementation of engagement plans.

Warrington Clinical Commissioning Group Governing Body members will be responsible for: Taking the lead and fronting media activity when required, both in

relation to proactive and reactive issues. Lead on the delivery of high level communication to staff, member

practices, GP members, partner and providers. Alerting the communications lead with any emerging issues Supporting the CCG by attendance and involvement in public

events. Warrington Clinical Commissioning Group Clinical Leads, Commissioning Leads and Senior Officers will be responsible for: Alerting the communications lead with any emerging issues. Providing updates to the communication lead for inclusion in

briefings etc.

Leading on engagement and communication activity in relation to specific work programmes.

The communications officer will be responsible for Delivery of all communication operational activity identified in the

engagement and communication work plan. Acting as the first point of contact for media enquiries. Supporting clinical leads, commissioning leads and CCG senior

officers with practical communication support, including the development and implementation of communication plans.

Budget and resources Much of the engagement and communication activity can be delivered at nil additional cost through use of existing resources and channels of engagement and communication. Activity which has been identified as requiring additional budget has been detailed in the action plan. Any activity in relation to specific work streams which have not yet been identified will be fully costed and submitted to the appropriate work stream lead for approval before any activity is commissioned. The CCG has entered into an agreement to source communication support with Cheshire Warrington and Wirral Commissioning Support Unit. The CCG has employed a WTE engagement officer who is responsible for all CCG engagement activity at a local level. The CCG has agreed with CWW CSU that where regional or national communication and engagement support is required in response to issues which cross a bigger footprint than the CCG, then the CSU

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would be required to carry out this type of function on behalf of the CCG. This activity will be costed on request. The CSU has a robust structure for the delivery of the communication services to the CGG, with an identified dedicated lead for Warrington. Evaluation It is important for us to monitor and benchmark performance of engagement and communication activity so that we can ensure that the activity is appropriately tailored and targeted to the relevant audiences, messages and method. The following criteria are suggested as being ways in which we should be able to track performance: formal and informal feedback from stakeholders, to include;

o Patient experience feedback and patient surveys o levels of awareness of the work of Warrington Clinical

Commissioning Group o public perceptions of ability to get involved and influence the

future shape of these services o high level 360 degree feedback – GP members, partner and

provider organisations.

formal and informal feedback from employees o views sought through team meetings, staff briefings and

other engagement events o staff survey o intranet feedback

number of attendees at engagement and consultation events

o internal audiences o external audiences

favourable media coverage

o media evaluation

political temperature o positive political support vs. level of political noise (MP

letters PQ’s)

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A1 - ACTION PLAN

It should be noted that this high level action plan is supported by a detailed operational work plan which identifies the specific operational activity and timescales. The operational work plan is reviewed and monitored and updated on a monthly basis.

Action / Notes Lead / Support

Target Date for delivery

Cost / Resource

Develop Membership Newsletter VN / PS Dec 2011 Nil In House resource only

Visioning Event - Year one NA / PS Feb 2012 Develop engagement and communication operational work plan – linked to quip programmes and other commissioning work streams (plan on a page)

MA / PS April 2012 Nil In House resource only

Develop and implement Media Handling Protocol MA April 2012 Nil In House resource only

Website refresh – update

MA / VN April 2012 Nil In House resource

ACHIEVED IN PROGRESS OVERDUE / DELAYED

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only Intranet development

MA / VN April 2012 Nil In House resource only

Brand and House style development (incl development of Marketing Kit) MA April 2012 £2000 Develop and implement the how to toolkit – including all templates VN End August

2012 Nil In House resource only

Development of the CCG authorisation materials MA / VN May – September 2012

Nil In House resource only

Develop and publish calendar of events PS May 2012 Nil In House resource only

Implement quarterly press briefings MA / VN May 2012 Nil In House resource only

Annual Marketplace event MA / VN / PS

May 2012 £500

Review commissioning bulletin – audit and refresh NA / MA May 2012 Nil In House resource only

Support the development of PPG groups within every practice PS / Practice Managers

June 2012 Nil In House resource

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only Develop and implement a marketing programme for the Patient Experience (SEE) resource and membership scheme

VN / PS July 2012 £1000

Develop media monitoring process MA / VN July / Aug 2012

TBC

Develop and launch Warrington Health Forum MA / PS August 2012


Develop high level engagement and communication weekly brief MA September 2012

Develop and implement quarterly stakeholder ‘spotlight brief’ NA / MA / VN

October 2012


Produce Duty to Involve – Real Accountability Report (statutory document) MA / PS Aug 2012 Nil In House resource only

Develop and implement communication, engagement, experience awareness raising and training programme (incl E&D and dealing with the media)

MA / PS November 2012


Review Communication, Engagement and Experience Strategy MA / PS September 2012


Warrington Health Day MA / PS / VN

June 2013 £2000

Engagement and communication audit

MA Feb 2013 Nil In House

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resource only

Visioning Event – Year one review and Year Two NA / MA / PS / VN

Feb 2013 £2000

Review Membership scheme – audit membership PS / VN March 2013 Nil In House resource only

CCG Annual Report MA / VN April 2013 Nil In House resource only

Audit / review Patient Experience SEE programme. MA / PS / VN

July 2013 Nil In House resource only

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Appendix B

SEE Patient Experience Programme Flowchart

A patient experience survey is submitted through the various channels ‘SEE’, Patient Opinion,

Patient Choices. Facebook, Twitter and comes through to the patient experience ‘Inbox’

Yes

This is then entered onto the ‘patient experience Database.

The information is then transferred onto the Patient Experience template for the Patient

Safety Meeting

Is the Feedback Positive

An auto response is sent out to acknowledging those emails that come through ‘SEE’ and

provides further information on how to make a formal complaint.

No

This story is fed back to the lead

commissioner / Providers

This will then be raised at contract Meetings

with Providers

Patient Story is presented at the Patient engagement & quality meeting. And if needs be a paper will be presented at the Quality Committee

This is then triangulated with PALS, Complaints; SUI’s, Patient Experience to look at other similar

stories with the same providers

All information is kept on an excel spreadsheet for future cross referencing & audit

The information will then be used to inform patient

experience work plan of visits

This story is fed back to the lead

commissioner / Providers

The patient is invited to share their experience / story to the Governing

Body

A patient experience survey ‘SEE’ is submitted as a hard copy through various patient & public

events

This will then be raised at contract

Meetings with Providers

Outcome from the meeting will be sent and recorded on the

database

Has the story got potential for negative

press?

The patient is invited to share their experience / story to the Governing

Body

Is the story a potential PR opportunity?

No Yes No Yes Inform

Communications team

Inform Communications

team

Outcome from the meeting will be sent and recorded on the

database

The information will then be used to inform patient

experience work plan of visits

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Appendix C

Warrington Health Forum – Draft Terms of Reference

Title Warrington Health Forum

Accountable to Warrington Clinical Commissioning Quality Committee

How is accountability demonstrated

Minutes and verbal reports to the Board

Membership Accountable Officers

• Warrington CCG Governing Body Member with lead for engagement

• Lead for engagement (secretary)

• Lead for communications

• Commissioning Manager (or deputy)

Advisory Members

• CVS for 3rd Sector

• Patient Reference Group (where required)

• LINks (with the recognition of their independent role as a “critical friend” in the process)

• Technical or clinical advisors where required

Chair of Group Warrington CCG Governing Body Member with lead for engagement

Secretarial Support Warrington engagement lead

Quorum A minimum of 3 representatives of members will be required to be in attendance for decisions and recommendations to be agreed.

Aim To achieve authorisation the Group will act in an advisory capacity to Warrington CCG Quality Committee and make recommendations to them and take decisions to ensure that there is an inclusive, integrated and consistent approach to engagement and involvement of Warrington population by the functions detailed below:

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Objectives/Functions Statutory Duties and Authorisation Requirements

Act as a resource to support the work of the CCGs in meeting the criteria of the authorisation process relating to engagement

The Group will ensure that the Equality and Diversity requirements are met and that there is reference and alignment to the NHS Constitution

Monitor and advise on patient engagement, ensuring statutory duties are met and which will build on local good practice. This will allow the CCG assurance process requirements to be met.

Planning Engagement and Patient Experience

Taking a proactive approach to planned commissioning processes (e.g. service changes, new service proposals, reviews) by developing a forward plan where information is available in advance. This would involve using the wider networks represented for consultation and engagement support to commissioners.

Discuss and share any concerns raised from the patient experience data and inform the Quality Committee who can agree appropriate action and use data to inform commissioning decisions

Co-ordination, Communication and Relationships

Ensure engagement networks are well co-ordinated and are communicating with each other, minimising duplication

Identifying to design effective ways to enhance relationships between key partner organisations from the statutory, voluntary and faith communities, involved in patient and community engagement across Warrington.

Support the development and work of the locality patient participation groups. Ensuring good communication between locality groups, and the Local Authority and CVS partners.

The group supports the planned quarterly “meet the

commissioner” activities and plays a strong role in promoting

this to their respective networks.

That the CCG engagement lead, works as a conduit to share information to and from the local authority engagement partners and where appropriate alignment of consultation exercises can be undertaken.

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Have a commitment to share best practice and co-ordinate with key partners, the public and other community engagement activity across Warrington.

Monitoring and Reporting

Warrington Health Forum is a working group with a direct accountability and reporting responsibilities to Warrington CCG Quality Committee.

Keep an accurate account of all consultation and engagement outcomes and produce an annual report to be agreed and authorised by both CCG Quality Committee.

The Group will produce notes of each meeting and feedback findings to CCG Quality Committee.

Frequency of Meetings Monthly

Representation It is proposed that Group is made up of representatives from overarching engagement networks in Warrington. This will create a network of networks and it will be supported by relevant officers representing the clinical commissioning and the local authority.

Review The Terms of Reference will be reviewed annually or sooner if deemed necessary

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Appendix D

MEDIA PROTOCOL

Introduction The NHS is constantly under intense media scrutiny, the public has a vested interest in the NHS and its performance. In addition to being a political issue, health is often an emotive one. Whether attracting commendation or controversy it consistently makes headline news. In the interests of effective media relations, both proactive and reactive, it is important that all staff directly or indirectly associated with Warrington Clinical Commissioning Group, including GP member practices adhere to the agreed guidelines set out in this protocol when dealing with the media Efforts should be made to maintain and develop the CCG’s relationship with local and regional media and to improve connections with professional and specialist publications. It should be noted that anyone likely to be linked to the CCG, including CCG staff, member practices and CWW CSS staff who expresses his or her own personal views to the media (whether through the lay press locally or an international peer review journal) should make it clear that these are personal opinions and not necessarily shared by the CCG. Information from any item of printed material could theoretically find its way into the hands of the press (who are also entitled to attend

public meetings) so it is recommended that the potential implications of any CCG communication (including correspondence with patients and staff) are carefully considered in advance. It is important to channel all media handling initially through one central point (The Communications Lead), to avoid confusing journalists and ensure messages are consistent. The CCG should be made aware of national and professional media issues, which may be localised by the Warrington press. Local newspapers, web-based media and radio and television stations should be closely monitored and cuttings or taped records kept of coverage relating to the CCG, to be made available to CCG senior officers Proactive media Press releases will be issued as and when required to actively promote the work of the CCG in a positive light through relevant media, which is one of the most important means through which the organisation’s profile can be raised and understood. Their contents can also be re-focussed for other communications tools, such as the weekly commissioning brief or on the website www.warringtonccg.nhs.uk Press releases and other media work should always be co-ordinated through the CCGs communications lead.

It is advisable to treat all media as equals when issuing information. Showing preference to one title or organisation risks antagonising rivals, who may attempt to discredit the original story by canvassing the views of critics.

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‘Off-the-record’ briefings may be attributed or traced back to the briefer, unless the journalist is expressly told otherwise – and even then there are no guarantees that the confidence will be kept. An ‘off-the-record’ arrangement has no legal standing. Even being proactive around negative issues can often have its benefits. It should earn the respect of journalists and the public for taking an honest, open and accountable approach to a difficult or uncomfortable subject. It should also help ensure that the CCG has more control over the way in which the story first enters the public domain and reduce the need for a reactive stance. It should also be recognised that even a negative issue can contain key messages. Reactive media / crisis management All media enquiries will be responded to in the first instance by the Communications Lead. The Communications Lead will respond immediately to all media enquiries relating to the CCG. They will take full details of the nature of the enquiry and context in which it is being set, to avoid an inappropriate response. It is important to recognise that not all enquiries are negative, however when they are, by taking a proactive approach it is possible to limit the damage caused. The communications lead will negotiate a ‘reasonable’ timescale with the media in which to respond adequately to media enquiries. However, it should be recognised that there are times when a speedy response to media enquiries is vital and that a deadline

means a deadline. The Communications Lead will ensure that the media are kept informed of progress on their enquiry at regular intervals, so that they know whether they can expect an interview or a written statement and what that is likely to contain. This may influence their handling of the story. The CCG should always exercise its ‘right to reply’ to media stories. Although the ‘right to reply’ is not legally enforceable, it is universally accepted by the media as good practice to grant individuals the opportunity to comment on issues affecting them. CCG should avoid using ‘no comment’ at any time. It is important to note that “no comment” may be regarded as a tacit admission of liability by many journalists. Refusal to comment may give journalists licence to portray the CCG in a pejorative light – as does being “unavailable for comment”. Even if a negative situation is in its early stages or inconclusive and more information is required, journalists should be given a ‘holding statement’ to that effect, to avoid pre-empting the outcome. This could, for example, refer to the CCG being “in the process of conducting an investigation, whose findings will be made public once it has been concluded.” It’s important to note that in some circumstances, i.e. if the matter involves legal action it would be prejudicial to comment further, however, a ‘no comment’ should still be avoided. If something has gone wrong, which indisputably finds the CCG at fault, it is better to admit the organisation is in the wrong, apologise if appropriate and explain what action has been taken to prevent a repeat of the situation. This should be better received than a non-

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committal response, which could be seen as the CCG not accepting its responsibility. Responses from the CCG should be accurate and timely, using plain, concise language and avoiding jargon or any points which may be open to misinterpretation. A good journalist should check anything which is unclear. The most important messages in a written statement should be contained in quotes from an appropriate, named individual, which are less likely to be edited or paraphrased. That person should make themselves available for interview if required following the issuing of the statement. The CCG should not attempt to answer to the media on behalf of other organisations, which should be given the opportunity to speak for themselves. If an item criticising the CCG is published or broadcast presenting one side of an argument or inaccurate, then the Communications Lead will seek redress in the first instance with the appropriate editor. It may also be necessary to take prompt action in informing other news organisations of the facts before they ‘lift’ the incorrect information and perpetuate it. News organisations file published or broadcast material which can be published or broadcast again at a later date as ‘an accurate record’ if it goes unchallenged. The communications lead will therefore make a request that the response from the CCG or a correction to be used in the next available bulletin or issue and given equal prominence to the original coverage.

Failure to do so should be grounds for representation to media watchdogs such as the Broadcasting Standards Commission or Press Complaints Commission on the basis that the issue has not been handled in a fair and balanced way. Long-running, high profile or multi-agency issues may require a separate, comprehensive communications strategy, including media handling arrangements. Early Warning System The Communication Lead is responsible for and will ensure that the Accountable Officer and Chairman are kept fully informed of and updated on any issues which are potentially damaging to the CCG’s reputation. Equally, it is important that the communications lead is kept appraised of any adverse issues – whether during the working day or out of hours, whether common knowledge or confidential - in order to advise and support accordingly. Whenever a new policy or procedure with wide reaching consequences is due to be introduced, or a change in leadership is due to be announced CCG staff, practices and GP members should be notified first, before any announcements are made in the media. In the event that information concerning such a policy or procedure or announcement is leaked to the press, it is likely to be presented in a subjective and unconstructive light, which may also be mistaken. It is important, therefore to ensure that every member of

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CCG staff is given the facts as quickly and accurately as possible – preferably before publication or broadcast. It is vital that the CCG observes the Strategic Health Authorities notification mechanism for serious untoward incidents, namely the Strategic Executive Information System (StEIS.) The communications lead will also ensure that the procedure for notifying the SHA’s Director of Communications before an issue hits the press and detail the proposed action. Where appropriate, other partner organisations should also be alerted and a joint approach adopted and the communications lead will co-ordinate any joint response. Media release approvals process All information being released to the media should always follow the agreed approvals process. Proactive media All routine, non-contentious press releases should be approved by:

the source of the information their ‘line manager’ or equivalent if appropriate the communications lead

Reactive / Crisis media Press statements relating to crisis management issues, which could threaten the CCG’s reputation, should always be handled at the most senior level with professional advice and approved by:

the source of the information their ‘line manager’ or equivalent the CCG’s communication lead the Chief Clinical Officer or another senior manager if

appropriate. Spokespeople In certain circumstances, where an interview is required on a non-contentious matter, it may be possible for the interviewee to be the member of CCG staff, an individual from a member practice, who is closely associated with the subject matter, once briefed. For more challenging issues, with wider implications, the Accountable Officer, Chair or member of the Senior Management Team should be designated as media spokespeople for their specific areas. Confidentiality and the use of case stories Warrington Clinical Commissioning Group is committed to preserving service user/patient/carer confidentiality and respects the privacy and dignity of individuals, to which public interest should always be secondary. However, there may be some circumstances in which media coverage would be significantly enhanced by the use of real – life ‘case histories’ – that is personal stories relating to service users/patients/carers, which normally involve a photograph or film footage. Indeed, there are many instances in which the media will not carry a story – particularly one which is heavily based on strategic issues – without a case history, however important the

38

story. Such details add colour and can make an issue more relevant and accessible to the reader or viewer. Any use of case studies, whether in a press release or sourced by the CCG as a result of a press enquiry - would be based on full, informed consent of service users/patients/carers and/or their family members for them to be featured in the media. The consent form at Appendix B1 covers the use of film footage or photographs at a future date by either the media organisation or the CCG. In the event of patients or members of the public actively seeking media attention, it is important to note that they have not waived their right to confidentiality and the CCG should not discuss their case openly even if they choose to. In many cases, any discussion would be prejudicial in the context of an official complaint or legal proceedings. Emergency Planning and Major Incident communications

The communications lead should be among the first people notified in the event of a major incident and will follow the actions required by the Major Incident Plan. The communications lead will be responsible for co-ordinating timely and accurate responses to the media in line with the Major Incident Plan – which could include important public information and appeals for off-duty staff to come into work.

Out of Hours media calls

The proliferation of media titles and the speed of modern news gathering mean that out of hours calls are increasingly becoming the norm. Bank holiday working is also routine for many titles. It should be noted that out of hours calls from the media are no longer restricted to urgent issues. Where communications support is required out of hours the On Call Manager will contact the communications lead. It should be noted that although there is no formal on call arrangements, informal arrangements are in place and the communications lead will respond in the event of an urgent media enquiry which cannot wait until the next working day or in the event of a serious untoward incident or major incident. The communications lead, via the local network of communications leads will ensure that there are ‘mutual’ aid arrangements in place.

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MEDIA PROTOCOL FLOWCHART

STEP ONE All media enquiries, either directly into Warrington Clinical Commissioning Group or via GP member practices member practice should be directed to the Communications Lead: Maria Austin – Tel Mobile 07917738659.

STEP TWO The Communications Lead will log the enquiry and will inform the Accountable Officer

Is the enquiry WCCG specific or does it impact on a provider / partner? YES NO

The communications lead will alert the relevant provider / partner communication leads and agree handling arrangements

STEP THREE The Communications Lead will liaise with the appropriate staff members to formulate the response. The response will be approved via the internal approval process. If the enquiry involves a partner / provider organisation the communications lead will co-ordinate the approval process with the appropriate communication lead/s

STEP FOUR Response will be provided to the media organisation, with if appropriate supporting information. If appropriate an interview will be offered and the communications lead will have oversight of all arrangements.

STEP FIVE The communications officer will monitor the publication. If there is an issue with the publishing of the information the Communications Lead will ensure a timely response to the media organisation and will ensure that the Accountable Officer is informed. The communications officer will include the summary in the weekly communications update for board members.

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Appendix D1

PHOTO/FILMING CONSENT FORM PLEASE TICK APPROPRIATE BOXES BELOW TO INDICATE YOUR APPROVAL.

I, the undersigned agree that my / my child photograph may be used for a range of media (for example: newspapers, newsletters, magazines, television, and websites I have been given a full explanation about possible uses of my: We will not disclose any photographs or information about you without your consent, unless we have a statutory duty to do so in preventing harm to someone else, or to protect you or to prevent or detect crime. We will only store and use information in accordance with our registration under the Data Protection Act 1998. Photograph Name (in caption) Film Footage I therefore understand that my: Photograph Name in caption Film Footage may be used for legitimate purposes i.e. (Annual Reports, website, and exhibitions to promote the work of Warrington Clinical Commissioning Group both now and in the future. I also understand that my: Photograph Name in caption Film Footage may be used by a range of media titles in press articles/TV broadcasts / websites which are seen by the general public, now and in the future. I hereby grant consent, freely given, to the use of my Photograph Name in caption Film Footage Name (Please print) …………………………………………………………….. Name of child (if applicable) Signature: ……………………………………………………………………….. Date: ……………………………………………………………………………..

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Appendix E KEY MESSAGES Overarching Key Message: The government has designed a new system around local decision making to lead to more effective outcomes for patients and more efficient use of services for the NHS. Local decision making

GPs will be working together in groups of practices called clinical commissioning groups. Each CCG will be responsible for its own commissioning and financial decisions.

GPs and other primary care staff have the most regular contact with patients and have the best overall understanding of people’s health and care needs. They already play a key role in acting as their patients’ advocate and coordinating care on their behalf.

By extending this role and giving them the freedom to decide which healthcare services to commission on their patients’ behalf, GPs will be able to use resources in the ways they believe will achieve the best and most cost-effective outcomes.

Working in partnership

GPs will not be working in isolation. Health and wellbeing boards will be set up in local authorities to provide a way to bring together GP consortia with other health and care partners.

Health and wellbeing boards will give a stronger role to local government. Councils and be able to better influence their local health services and make sure the commissioning decisions reflect local priorities and needs. They promote shared decision making between health care, public health and social care.

The NHS Commissioning Board

The system of local Clinical Commissioning Groups will be overseen by a national NHS Commissioning Board, which will sit at arm’s length from the government. It will make sure that CCGs have the capacity and capability to commission successfully and meet their financial responsibilities. The Board will also commission some services directly.

In addition, the NHS Commissioning Board will provide national leadership to improve quality for patients and make sure there is a consistent delivery of outcomes.

What does it mean for the patient?

‘No decision about me without me’ will be the principle behind the way in which patients are treated – patients will be able to make decisions in partnership with their GP about the type of treatment that is best for them. Patients will also have more control and choice over where they are treated and who they are treated by. They will be able to choose their:

- GP - Consultant - Treatment - Hospital or other local health service.

42

Patients will be able to get the information they need, such as how well a hospital carries out a particular treatment, to help them decide on the best type of care. If patients are unhappy with their local hospital, or other local services, they will be able to choose another one to treat them.

Patients will be able to rate hospitals and clinics according to the quality of care they receive, and hospitals will be required to be open about mistakes and always tell patients if something has gone wrong.

Patients will have a strong collective voice through a national body, Health Watch, and in their communities through arrangements led by local authorities.

What does it mean for the public? The public will be able to have more influence over what

kind of health services should be available locally. They will also have greater opportunities for holding to account local services that are not performing well.

They will be able to get more information about how their local health services are performing, such as how well their local hospital carries out a particular operation or treatment.

There will be more focus on preventing people from getting ill – the Public Health Service will pull together services locally to encourage people to keep fit and eat more healthily.

How will the new health and care system be run? Local authorities will be responsible for local health care

priorities, while central government will have much less control over health services.

The NHS will be measured by how successfully it treats patients – for example, whether it improves cancer survival

rates, enables more people to live independently after having a stroke or reduces hospital acquired infection rates.

An independent and accountable NHS Commissioning Board has been established to:

o lead on the achievement of health results o allocate and account for NHS resources o lead on improvements in quality o promote patient involvement and choice.

The Board will also have a duty to promote equality and tackle inequalities in access to healthcare.

Monitor will become an economic regulator to promote effective and efficient providers of health and care, encourage competition, regulate prices and safeguard the continuity of services.

The role of the Care Quality Commission will be strengthened as an effective quality inspectorate covering both health and social care. HealthWatch will represent the views of patients, carers and local communities



1




14th November 2012

TITLE OF REPORT: Organisational Development Plan 2011 – 2013 Refresh

PURPOSE OF REPORT: To inform the Governing Body of the refreshed Organisational Development Plan as part of the Authorisation process.

REPORT PREPARED BY: Dr Sarah Baker, Chief Clinical Officer

KEY POINTS/TEAM BRIEF: The Organisational Development Plan sets out the objectives and areas for development within the CCG. This plan has been refreshed as part of the Authorisation process.



Approve the refreshed Organisational Development Plan.



2






















3



No









authorisation domain?





Warrington CCG Organisational Development Plan 2011-13 1

Organisational Development Plan 2011 to 2013

Refreshed October 2012


CONTENTS

Page

Background and Introduction 2 Our Vision, Values and Objectives 3 Strategic Context – What’s already been done?

Methodology and identifying priorities – What more needs to be done?

Organisational development needs

Appendix 1 - Organisational Development Objectives

Appendix 2 – Self Assessment overview and detailed report

Appendix 3 – Warrington CCG Structure

Appendix 4 – Warrington CCG Governance Structure

Appendix 5 – Warrington CCG In-house Staff Structure

Appendix 6 – Warrington CCG Commissioning Support Requirements

4 9 10 13 15 19 20 21 22


Introduction

Warrington CCG is committed to commissioning high quality care for the people of Warrington. This determination requires us to recognise, embrace and manage change through the development of our people, systems and processes to:

Create a strong and effective learning culture where we constantly and consistently seek to bring about improvement and innovation to enable us to deliver our strategic aims

Devolve accountability and responsibility to operate within policies and principles and to engage individuals, teams, and practices in our ambitions

Understand the context we will operate within in the future e.g. demographics technology, skills shortfalls and leadership capacity

Identify and nurture talent for the future to ensure sustainability.

This document identifies the key organisational development issues and opportunities for the CCG to support the delivery of our strategic goals. It goes on to provide an overview of the strategic direction for organisational development identified by the CCG which will require action over the coming years. It describes the work completed to date to establish the CCG, develop its members, leaders, Governing Body members and supporting team. It then goes on to describe further development required to build on progress and success to date as we continually strive for improvement in both personal and organisational performance.

Organisational development is the process through which an organisation develops its people, systems and processes, to be the best that it can be, to deliver its strategy and to sustain itself over the long term. At the heart of an organisation is a vision and a set of core values. That vision and those values help to shape the organisation’s future form. An organisation’s effectiveness depends on a shared understanding of, and commitment to, the vision and values. Organisational development plans will continue to be developed by the CCG in order to underpin the organisational strategy as the organisation evolves.

The OD Plan performs the following functions:

Identifies organisational strengths and areas for organisational improvement;.

Identifies key organisational development priorities; Underpins the organisational strategy in delivering our vision

and objectives; Identifies the cultural and behavioural changes required to

achieve the necessary transformation required to deliver our strategic objectives; and

Incorporates the development needs identified from the self-assessment for authorisation against the 6 domains.

Organisational Development Objectives

Our key Organisational development objectives are:

Development Needs-To identify our development needs

across the range of knowledge, skills and competencies required to become authorised, and to aspire to excellence.

Governance and Accountability – to put in place systems and processes that will provide assurance that the decision making of the CCG is undertaken within a framework that can be tested against best practice models of NHS Board Governance.

Commissioning plan/process - to put in place the necessary infrastructure to allow the CCG to undertake every component of the commissioning cycle in order that it achieves improved outcomes in health and wellbeing for the people of Warrington. Whether these services are provided in the core CCG team or through service levels agreements with business support suppliers.

Engagement and Partnerships – that the CCG has a comprehensive understanding of the needs and views of all its key stakeholders and has developed relationships that contribute to the delivery of its objectives.

Leadership and Values: that the consortium has clearly articulated values that underpin all organisational business


and that these are demonstrated through the Leadership exhibited at all levels of the organisation from the Governing Body, other clinical leads, the senior support team, members of the core consortium team, the Federation leads and practice leads right through to individual practices.

People – that we put in place those things that will allow us to recruit and retain the range of talent and experience that will allow us to aspire to excellence in all that we do.

Financial Control – to achieve improved health and well being for the people of Warrington within the financial resources available will require strong financial management and control throughout the organisation.

Managing change- to be successful and develop and an efficient and effective organisation and to achieve the service changes required to improve the health and well-being of the people of Warrington we will need significant skills in managing change.

Authorisation

The organisational development objectives support the CCGs

work on the six authorisation domains which are:

A strong clinical and professional focus which brings real added value

Meaningful engagement with patients, carers and their communities;

Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within financial resources, in line with national outcome standards and local joint health and wellbeing strategies;

Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities including financial control as well as effectively commission all the services for which they are responsible;

Collaborative arrangements for commissioning with other Clinical Commissioning Groups, local authorities and the NHS

Commissioning Board as well as the appropriate external commissioning support; and

Great leaders who individually and collectively can make a real difference.

Vision, Values and Objectives

Our Vision, values, and strategic objectives sit at the heart of our Clinical Commissioning Group. To ensure we enabled all our member practices to be involved in creating and agreeing these we undertook a period of engagement from March to June 2011. This included focused sessions at the governing body development meetings, presentation and discussion at Federation meetings; the Clinical Forum; partner organisations; local community groups, and with the Consortium team, including a focused discussion on the vision and values at the Management Team which was followed by a workshop with the wider Consortium team.

As a result of this engagement work, the current vision, values and strategic objectives are shown below. They are an integral part of developing and delivering the strategy and the organisational development plan for the CCG.

Our Vision “Excellence for Warrington”

Working in partnership to develop the best health services for the people of Warrington

Contributing to a healthier Warrington for all

Focusing on our patients

Be different by working in partnership with the local population

Recognise external constraints whist striving for quality


Our Values

Our Organisational values encapsulate the beliefs that are shared among the stakeholders of our organisation. These will drive the culture and priorities and provide a moral framework in which our decisions are made. The vision “Excellence for Warrington” will be underpinned by our core values;

These values are integral to driving the cultural and behavioural changes required to deliver our overarching strategic aims and objectives. We have focused on integrating these values in a way which brings coherence to our actions, behaviours, processes and culture.

Our strategic objectives

Our vision is supported by our strategic objectives. The development of these objectives followed a structured process which incorporated feedback from all key stakeholders, took national and local guidance into account and built upon the knowledge of local health needs and local priority areas.

Context

NHS reforms challenges Clinical Commissioning Group’s to transform themselves into very different organisations to what has gone before. The Clinical Commissioning Group will work in collaboration with all key stakeholders to support an integrated and joined-up system of health and social care, while simultaneously stimulating competition and innovation. We will also demonstrate improvements in long term health outcomes, while maintaining progress on our day to day delivery. Finally we will demonstrate value for money, while meeting demands for wider access and choice, and wider patient and public involvement.

The Clinical Commissioning Group strategy and therefore the organisational development plan has to reflect the environment in which it operates. Business Model Commissioning models have to break new ground, be transformational to deliver better outcomes, be closer to the clients it serves and be less expensive with less bureaucracy, and control health care spending. Marginal changes to systems and structures will not suffice

Our Core Values

Excellence

Valuing patients and partners

Accountability

Partnerships in everything

Honest and Integrity

Open and transparent

Courage

Our Strategic Objectives

Improve healthy life expectancy for all

Reduce inequalities

Prioritise earlier interventions in pathways


Achieve sustained financial balance

Optimise health outcomes


and a fundamental shift in thinking is required. Clinical Commissioning Groups with the leadership of GPs and support from the local commissioning support organisations are developing a new healthcare system which is more patient centred, efficient and effective. To support this new way of working our business model including the commissioning cycle is detailed below

Our business model is based on business process engineering principles. We aim to ensure that every activity drives and adds value to the next activity and that all activity culminates in delivery. The diagram above shows how healthcare reforms move through our business systems with the key decision-making stages set out.

What we have done so far: Diagnostics

The Clinical Commissioning Group development journey started at the end of 2010 with the GP commissioning development group. This group of GP leaders undertook an option appraisal of various governance models, and in consultation with all member practices, recommended a model whereby defined groups of practices (Federations) elected a representative to the Governing Body. These four GPs then appointed a Chair against a competency job description and person specification. Finally the GP members appointed the Chief Officer and Chief Finance officer against job descriptions and person specifications. This group also determined the sub-committee membership and models. The shadow Clinical Commissioning Group was established in February 2011. An initial diagnostic of the shadow CCG governing body was commissioned from Dearden Consulting in January 2011 following appointment of the Governing Body and prior to the launch of the CCG in February 2011. This also included a ‘ This included:

Understanding the team and personalities (including Myers Briggs profiles for the Governing Body members).

Working collaboratively and in partnership using a Generative Relation Star to map key relationships and identify actions related to each.

Corporate accountability and governance. ‘Whole Sum’ event with Warrington & Halton Hospitals

Foundation Trust and Warrington Borough Council as the CCGs key partners to understand each organisation’s perception of their self and each other.

A review of the proposed Governance arrangements was undertaken by the PCT Cluster who authorised devolution of the full commissioning budget to the CCG on April 1st 2011.


On its publication in August 2011 we used the CCG self-assessment tool developed by the Department of Health to assess our development needs, undertaking the exercise as a support team, governing body, and all member practices. The results were reviewed to identify areas of congruence and difference between the different constituents of the CCG as an organisation.

The governing body has regularly used the toolkit to review its progress and inform the priorities for the organisational development plan. Included in appendix 2 is an overview of the baseline scores from the toolkit in November 2011.

The self-assessment overview highlights that we score most positive across all areas but with a particular strength in leadership and capacity. From the detailed report we can see areas where we score highly are strategy development and implementation, leading change and leading a commissioning organisation. However we still require further development on continuous improvement, business intelligence and patient and public engagement. Clinical engagement Clinical engagement has been a key feature since our inception. Throughout autumn 2010 early 2011 we ran a series of Commissioning Workshops. This programme of six monthly evening events took the commissioning leads and other interested practice staff members from all member practices through the commissioning cycle, using case studies, external speakers and local team members to share thinking on best practice in commissioning. The main case studies were based around the real-time issues with which the health and social care economy was faced, at that time being in financial recovery. All GP members of all practices were involved in a workshop in December 2010 that confirmed the governance arrangements proposed by the development group.

These proposals ensured that members aligned themselves to defined groups of member practices (Federations) which then acted as an electoral college to identify the GP Governing Body members. The members were then formally appointed with a job description and detailed person specification, against which their individual development needs were assessed and personal development plans put in place. The role of the GP Governing Body member was defined as; To represent the views of the member practices in their federation. To regularly communicate the work of the Governing Body, the

areas being explored and considered and seek feedback on developments and proposals.

To seek ideas and input from member practices To take a lead on a commissioning portfolio

o Unscheduled Care o Planned Care o Long term conditions and community care o Integrated Care (LD, Mental Health, Intermediate Care

etc) To take a governance lead for finance or quality

Each of the Federations additionally appointed a Federation Chair so that issues GP and primary care provision could be discussed separately from issues of commissioning to ensure clarity about potential conflicts of interest. All practices nominated Commissioning Leads. Practice Commissioning leads meet with the Chair and Chief Clinical Officer on a monthly basis. This is a two way meeting where members share any areas of concern, ideas for development and best practice, and the Chair and CCO update on any areas where specific member input is required.


All practices meet together every month in a Protected Learning Time event where clinical education is undertaken within the priorities of the commissioning agenda. The programme being determined by focussing on areas where change in clinical practice of behaviour is required, either to implement service reconfiguration, change a clinical pathway Over the next six months as the work programme was defined additional clinical leads were appointed against detailed job descriptions to lead specific areas of commissioning;

Children and young people Mental Health Medicines management Unscheduled Care 111 implementation Cancer End of Life

Additionally individual GPs were involved in discrete task and finish groups to take forwards discrete areas of the various work programmes e.g. pathway design groups. The Federation Chairs, Practice Commissioning leads, Governing Board GPs and Clinical Leads meet with the Chair and Chief Clinical Officer on a quarterly basis as a Clinical Assembly. The Clinical Assembly acts as a body where the member practices can scrutinise and inform the work being undertaken by Governing Body members, Clinical Leads and the Support Team on their behalf. It is also the place where decisions are made that are reserved to the membership as per the Constitution. Governance Further to the development of the GP membership of the Governing Body in 2012 we used the nationally recognised appointment process to secure two Lay Members of the Governing Body, one with a lead for

Finance and Performance, and one with a lead for Quality. The Quality lead is also Vice-Chair of the Governing Body. In October 2012 we secured Consultant and Nurse appointments to the Governing Body against the national job descriptions. We have had a representative from LINKS as a non-voting member of the Governing Body since our first public meeting in May 2012. Our governance infrastructure and its relationships with other statutory bodies is shown in Appendix 2 Management infrastructure Defining the management structure of the CCG has been a key task that was undertaken throughout 2011/12. It has been developed to ensure alignment between the commissioning agenda, our objectives and vision, whilst delivering strategic alignment and effective delivery of national and local targets.

The design of the structure began in July 2011 with an initial do / buy / share analysis. This was refined towards the end of 2011 and early 2012 as part of a programme of work with the emerging Cheshire, Warrington and Wirral Commissioning Support Service. This allowed the CCG to confirm the structure in Appendix 3 in July 2012. The CCG will continue to review this structure until March 2013 and will also continue discussions with Halton CCG about possible areas where the CCGs may wish to share some staff or functions. These collaborative commissioning arrangements mean that we have the capacity and capability to discharge all of our expected functions within the running cost allowance of £25 per head of population. Commissioning support needs In determining our internal management resource we defined the services we will require from our commissioning support organisation.. Working in partnership in a co-production approach we agreed the


detailed list of functions for delivery by the Commissioning Support service as described in Appendix 4. these are reflected in our Service Level Agreement. Specific development Initiatives In a short space of time the CCG has already taken great strides forward in its journey to become authorised as a statutory organisation. This has been supported by a range of development and training initiatives

Specific initiatives include: Support and Development for our member practices: A six month GP and practice staff commissioning development

programme Protected Learning time programme

Individual Clinical Leaders Chief Clinical Officer

o NHS Top Leaders Assessment Centre and Development Programme

o Hayes Accountable officer Assessment Centre o National School of Government Accountable Officer

Training o NHS Leadership Coaching

Chair

o Hayes CCG Chair Assessment Centre and Development programme

o Ashridge Business School Fast Track Advanced Management Programme

o Media Skills Training o NHS Leadership Coaching

Chief Finance Officer

o Hayes CCG AO and CFO Assessment centre

o Strategic Finance Cass Business School o Becoming an informed customer PCC

Governing Body Members

o HFMA Modules on Payment by results, Foundation Trusts Financial regime, Budgeting, NHS Finance

o NHS Leadership Coaching o NHS Institute Webinars

Partnering with patients and communities Variation in the NHS GP engagement in commissioning Integration and Commissioning

Improving Outcomes and Values

Federation Chairs and Clinical Leads o Two of the clinical leads have undertaken the North West

Leaders Transforming Leaders Programme Board Development: Initial 2 day development workshop as described earlier Use of National Self-Assessment tool as described earlier Facilitated relationship development workshop with Acute Provider

senior team Board self-assessment, development workshop and observed

public meeting by Deloitte’s with feedback report. Introduction to Finance Deloitte GPCC Authorisation Workshop with McKinsey’s Specific training on Equality and Diversity, CounterFraud, Bribery

and Corruption, Conflicts of Interest CCG Staff A monthly whole team meeting is used to undertake focussed training and development, share the Vision and update all members of the team on progress against objectives.


The programme so far has covered MBTI and team working Team roles Data use and abuse and presentation

Statutory and Mandatory training is undertaken as individuals through e-learning and as a team for some issues such as fire safety and risk management. All training is recorded in a personal training log. Chief Operating Officer and Associate Director of Commissioning are undertaking the Transforming the NHS Leadership Development course of the NHS NW Leadership Academy. Assistant Director of Integrated Commissioning is undertaking the Collaboration for Future Success leadership Programme of North West Employers. Finance lead is undertaking Pathways to Leadership from the Institute of Leadership and Management Lead Nurse, Quality Led completing an MSC in Clinical Quality Contracting Lead completing MSc in Health and Social care Management The key, relevant members of the team have undertaken Root Cause Analysis training in order that all members of the team

can undertake quality reviews. Deprivation of Liberty training. Emergency Preparedness training Control Room management Media skills Negotiation training Procurement, Choice and Competition AQP development Leading Large Scale Change Institute for Innovation and

Improvement MS Project 2007

Developing skills in Microsoft office components for project management

Health economics NW LTC Commissioning Development Programme Customer services training Common Assessment Framework Training Equality and Diversity and Impact assessments Membership of Chartered Institute of Purchasing and Supply

(CIPS) What still needs to be done With the recent appointment of two additional new members we plan to re-visit the Self-Assessment framework to identify further Governing Body development. Governing Body We plan to hold a Governing Body away day in February 2013 to review and reaffirm Vision, Values and Objectives with new members, and to undertake further Board Self-Assessment using the National tool augmented by the Good Governance Framework, and individual member development need assessment using advice from an external agency. We will work with the Local Area Director to identify any areas where she would feel further development is required based on her assurance and performance feedback mechanisms. Clinical Engagement We are conscious that we are a relatively small CCG. Although we have over 60 individual GP members involved in a specified role in commissioning within the town we are aware that further development is required to ensure succession for the current clinical leaders,


We will develop an active talent management approach using the toolkit developed by the North West leadership Academy. We will identify key individuals who may benefit from focussed development input to fit them for future CCG leadership roles. We will introduce a ‘Warrington Fellowship’ where we will support individuals to have a protected time out of practice to work on a specific commissioning project. They will be supported in this by a current GB GP member mentor and a senior management ‘buddy’, with time built in to consider the underlying management theory being applied. Succession Planning Warrington CCG is a lean organisation with each member delivering high performance outputs. There is little flexibility or spare capacity in the structure and succession planning is a feature of strength in such situations, feeding into the risk management process. Succession planning will deliver on three fronts:

Provide immediate cover of key employees during sickness / extended leave / resignations (business continuity / contingency planning)

Provide permanent replacement for individuals who move on or resign

To spot and develop new talent, either for new roles or as the “next generation”

To maintain business continuity, the Chief Clinical Officer and Chair will plan how the sudden loss of key individuals would be covered on a short to medium term basis. These plans will be reviewed on a regular basis. Replacement of key individuals on a permanent basis may be delivered via a different solution to the one above. The Chief Clinical Officer and Chair must be aware of any internal possible candidates that may be developing sufficiently for each key role or whether they require external

recruitment and how this would be undertaken. Again, such plans will be reviewed regularly. The CCG must be ready to react very quickly to such a situation. With regard to a Governing Body member standing down, the CCG should, likewise, have identified the necessary process to follow and have an “off the shelf” solution to hand. In the meantime, individuals that may in future be interested in operating at Governing Body level can we developed through involvement as Clinical Leads or in projects and work that will begin to expose them to this level of the organisation. Summary of Organisation Development needs for the CCG The diagnostic work undertaken has identified priorities which have been mapped against the 6 domains. A more detailed version of the priorities is shown in the implementation plan (Appendix 1). In summary, we have assessed our current Organisation Development needs as: Domain Key Priority 1. A strong clinical and professional focus which brings real added value;

Develop robust processes for mapping clinical leadership talent and identifying talent

Develop the role of the Clinical Assembly meetings (where all 26 practice leads, governing body members and clinical leads meet together) to act more as a group of leaders rather than followers

2. Meaningful engagement with patients, carers and their

Ensure patients and the public understand how to contact and


communities; engage with the CCG

3. Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within financial resources, in line with national outcome standards and local joint health and wellbeing strategies;

Finalise the 2012/13 commissioning (operational plan) including QIPP plan for Board approval

4. Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities including financial control as well as effectively commission all the services for which they are responsible;

Continue to develop the CCG Constitution in response to changes in legislation

Finalise the CCG specific corporate governance manual including scheme of reservation and delegation

5. Collaborative arrangements for commissioning with other clinical commissioning groups, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support; and

Develop further the collaborative work with other Clinical Commissioning Groups and the NHS Commissioning Board

6. Great leaders who individually and collectively can make a real difference.

Continue to develop our governing body as strategic and inspirational leaders.

Continue Governing Body diagnostic and develop action plan accordingly.

Executive Coaching / mentoring opportunities for governing body and senior team.

The Health and Social Care bill marks a strategic shift for commissioning. As a successful CCG we will also need to:

Develop the culture and skills within the organisation to identify and deliver opportunities for cost reduction, service and quality improvement leading to continuous improvement.

Develop skills and competences for clinicians and managers in clinical pathway design and consider social care integration as part of this.

Develop opportunities for joint commissioning and service integration across the health and social care community, linked to our strategic priorities.

Develop as a CCG through use of regional and national offers, such as case managers

5. Next steps Based on the diagnostic assessment completed as part of the diagnostic tool assessment, a number of immediate priorities have been identified and these will be resourced by the CCG Board. These are as follows:

OD interventions planned: Clinical leadership Development Leadership Development for Senior Management Team Leadership Development for Support and Development

Managers

Governance

The role of the Clinical Commissioning Group Governing Body is to provide strategic direction of the organisations business and to ensure that performance is of the highest possible standard. Given the wide ranging and complex agenda that the NHS as a whole is facing the Governing Body has ratified a governance structure through the development of an integrated assurance framework. To ensure robust performance management a number of sub-committees have been developed in line with the national templates


provided by the NHS Commissioning Board. All sub-committees have clear Terms of Reference ensuring ultimate accountability to the Governing Body. The Sub-Committees of the Board and report to teach Clinical Commissioning Group Governing Body meeting. The committee structure is described in Appendix 4.

In order to ensure risks associated with the delivery of this Organisational Development Plan are monitored the Clinical Commissioning Group Board will retain overall responsibility and accountability for implementation and compliance.

Summary

This organisational development plan identifies the overarching areas that the Clinical Commissioning Group wishes to progress in order to achieve our ambition to become a successful and sustainable organisation that commissions services based on population need. The rapidly developing and changing environment means that we will need to continually monitor and review our approach to organisational development as a whole. Through the implementation of this OD Plan we will seek to impact on the culture and development of approach which will be values driven, demonstrating a commitment to learning and continual adaptation.

Ultimately, the shape of our organisation and its culture will be shaped by the implementation of our organisational development plans. These plans support the achievement of authorisation by aligning our vision, values and objectives with our priority healthcare initiatives. By looking at where we are on our journey to authorisation, assessing the gaps in our organisation against where we want to be and by a specific review of our capability and capacity to we seek to deliver our vision for local healthcare to the population that we serve.


Appendix 1 - Organisational Development Objectives Domain Objective Action to Deliver 1. A strong clinical and professional focus which brings real added value;

Develop robust processes for mapping clinical leadership talent and identifying talent

The CCG will adopt the NW Talent Management Toolkit to identify leadership talent. (A.Davies, March 2013)

Develop the role of the Clinical Assembly meetings (where all 26 practice leads, governing body members and clinical leads meet together) to act more as a group of leaders rather than followers

The group will meet on a quarterly basis throughout the year (N.Armstrong, November 2012)

The group will use the Senior Clinicians Role Profile from the NHS NW Leadership Academy to develop practice lead leadership skills and identify skill needs (A.Davies, December 2012 to March 2013)

2. Meaningful engagement with patients, carers and their communities;

Ensure patients and the public understand how to contact and engage with the CCG

Develop the CCG website to ensure it has the functionality to be used as a major engagement tool (N.Armstrong, Jan 2013)

Further develop the CCG membership scheme to ensure it is representative of local community including CCG staff, GP Practices and other partners (P Steele, Dec 2012)

Promote the use of social media as an engagement tool (N.Armstrong, Mar 2013)

3. Clear and credible plans which continue to deliver the QIPP (quality, innovation, productivity and prevention) challenge within financial resources, in line with national outcome standards and local joint health and wellbeing strategies;

Finalise the 2012/13 commissioning (operational plan) including QIPP plan for Board approval

Final version of Commissioning Strategic Plan for 13/14 in response to national priorities to be approved by the Governing Body (S.Baker, Mar 2013)

4. Proper constitutional and governance arrangements, with the capacity and capability to deliver all their duties and responsibilities including financial control as well as effectively commission all the services for which they are responsible;

Continue to develop the CCG Constitution in response to changes in legislation

Implement changes to the constitution as required by changes in legislation or directions prior to April 2013 (N.Armstrong, Mar 2013)

Finalise the CCG specific corporate

governance manual including scheme of reservation and delegation

Complete the final versions of the CCG scheme of reservation and delegation, standing orders and prime financial policies (S.Sutcliffe, Mar 2013)

5. Collaborative arrangements for commissioning Develop further the collaborative work with Continue collaborative arrangements with Mid-


with other clinical commissioning groups, local authorities and the NHS Commissioning Board as well as the appropriate external commissioning support; and

other Clinical Commissioning Groups and the NHS Commissioning Board

Mersey CCGs (S.Baker, Mar 2013) Develop commissioning relationship with NHS

Commissioning Board Local Area Team (S.Baker, Mar 2013)

6. Great leaders who individually and collectively can make a real difference.

Continue to develop our governing body as strategic and inspirational leaders.

Development programme for governing body to take place in development meetings (N.Armstrong, Dec 2012-Mar 2013)

Continue Governing Body diagnostic and develop action plan accordingly.

Deloitte as part of NHS Institute programme to re-run diagnostic analysis of Governing Body including Governing Body skills audit (N.Armstrong, Dec 2012-Mar 2013) Diagnostic self-assessment of the CCG to be completed again to identify needs (N.Armstrong, Feb 2013)

Executive Coaching / mentoring opportunities for governing body and senior team.

Opportunities identified for governing body members through organisations such as NHS NW Leadership Academy and the Clinical Leaders Network (N.Armstrong, Dec 2012-Mar 2013)


Appendix 2 – Self Assessment overview and detailed report


Appendix 3 – Warrington CCG Structure


Appendix 4 – Warrington CCG Governance Structure


Appendix 5 – Warrington CCG In-house Staff Structure


Appendix 6 – Warrington CCG Commissioning Support Requirements

]


Integrated Strategic & Operational Plan 2012/13 – 2014/15 – Year 2 Update Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Integrated Strategic and Operational Plan 2012/13 – 2014/15 – Year 2 Update

PURPOSE OF REPORT: To inform the Governing Body of the refreshed Integrated Strategic and Operational Plan 2012/13 – 2014/15 as part of the Authorisation process.

REPORT PREPARED BY: Dr Sarah Baker Chief Clinical Officer

KEY POINTS/TEAM BRIEF: To note the refreshed Integrated Strategic and Operational Plan 2012/13 – 2014/14 – Year 2 Update.



Approve the refreshed version of the Integrated Strategic and Operational Plan as part of the Authorisation process



2








(either financial or staffing resources) Yes














3



Yes














‘Excellence for Warrington’ Integrated Strategic and Operational Plan 2012/13 – 2014/15

Year Two Update


2

Contents

WHO WE ARE

WHAT WE WANT TO ACHIEVE

CASE FOR CHANGE

ENABLERS

THE FUTURE

Page

Our Vision

Foreword [3

Executive Summary [4]

Our Context

1. Who we Are [5]

1.1 Introducing Warrington [6]

1.2 How we are governed [7]

2. What we want to Achieve [8]

2.1 Core mission and values [9]

2.2 Whole System Transformation [10]

2.3 Making change happen [12]

2.4 How the wellbeing strategy influences our vision [15]

2.5 Our Key Priorities [16]

2.6 Plan on a page [17]

2.7 NHS Outcomes Framework [18]

2.8 Our Key Priorities (Cont’d) [20]

Page

2.9 Cross cutting priorities [23]

2.10 Priority Groups [27]

2.11 Commissioning Principles [29]

3. Case for Change [30]

3.1 Our local needs assessment [31]

3.2 Age profiles [32]

3.3 Deprivation profiles [33]

3.4 Principal causes of mortality [34]

4. Enablers [35]

4.1 Financial management and QIPP [36]

4.2 Supporting strategies [39]

4.3 Supporting strategies and support [40]

5. Our Future [41]

5.1 What the future will look like [42]

3

Foreword

Foreword The Clinical Commissioning Group (CCG) becomes a statutory body as of April 1st 2013. This Integrated Strategic Commissioning and Operational plan sets out a vision and delivery plan to transform the provision of health and care in Warrington, in line with national requirements and local need. It recognises and builds upon all the work undertaken by the predecessor organisation, NHS Warrington PCT, and all partners in the town. It continues the direction of travel to achieve the best possible health outcomes for the people of Warrington. It will promote wellbeing by focusing resources, building on the strengths we have, and working collaboratively to address the challenges we face to ensure that Warrington continues to develop as a place where everyone has the opportunity to be part of the community and reach their full potential. The implementation of this plan will only be achieved through working in partnership with patients, the public, Warrington Borough Council and all our major providers of health and social care. We describe a considerably matured whole-system approach which is beginning to demonstrate the impact of working in this way. In addition our strengthened approach to engaging with patients, the public and

other key groups provides us with assurance that we are heading in the right direction. Working together, we believe that we will be able to meet the considerable challenges we face and succeed in delivering “Excellence for Warrington.” Dr Andrew Davies Dr Sarah Baker Chair Chief Clinical Officer

Working in partnership to develop the best health services for the people of Warrington

Contributing to a healthier Warrington for all

Focusing on our patients

Be different by working in partnership with the local population

Recognise external constraints whist striving for quality

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Executive summary

This is NHS Warrington Clinical Commissioning Group’s (CCGs) strategic plan. It sets out our vision of health and healthcare for the people of Warrington. Our values will guide all that we do. .

Our Core Values

Excellence


Accountability




Courage

We have chosen ten key priorities, based on the health needs of our local population, discussion with patients and the public, feedback from GPs, other senior clinicians and partners. These priorities are where we can make a difference to improving the health of our population by re-balancing the local health economy, education and prevention and effective commissioning. Our key priorities are supported by seven crossing cutting priorities and focused support for vulnerable groups. All of our priorities are aligned to achieve the National Outcomes detailed in the framework. Our whole system transformation programme will ensure that we have the processes in place to achieve our vision • We will be an organisation that ensures that the patient is at

the centre of everything we do. • Our aim is to improve the clinical outcomes for patients in

these areas with an combination of partnership working, a greater emphasis on prevention and redesigning the way services are provided.

• We aim to constantly improve the quality of care through active engagement with all stakeholders and leadership within commissioning processes and have agreed that quality is not just about clinical outcomes but is also about patient experience and effectiveness.

• We have a strong focus on joined up working between health and social care ensuring appropriate care is delivered outside hospitals which should be targeted for more specialist treatments for those that will benefit most.

• Our aim as an organisation is to support member practices to work together and to share best clinical practice and develop a strong communication network with our members.

Our Whole System Vision

“Self-sufficient communities enjoying improved health and wellbeing and better life experiences, who and when they

need them have access to high quality and efficient services”

1. Who we are

This section details our responsibilities and how we are governed.

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Warrington CCG as a locality Warrington Clinical Commissioning Group (Warrington CCG) is a coming together of all GP practices in the Warrington area to enable patients and primary care clinicians to have a greater say in how health services are delivered locally. Warrington CCG was a Pathfinder CCG which gained full delegated authority for £243 million budget during 2011/12 with effect from April 1st 2011. It is currently a Wave One CCG.

We commission health care to the extent necessary to meet the reasonable requirements of:

The 203,000 people registered with the 29 primary care organisations that constitute the CCG;

The 6,000 unregistered individuals living within the boundary of Warrington Borough Council; and

The people present within the boundary of Warrington Borough Council who require emergency care (97% of those living within the borough are covered by our CCG).

Warrington is a relatively compact CCG area with a high proportion of patients registered with our practices living within the local government boundary.

1. Who we are 1.1 Introducing Warrington

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1. Who we are 1.2 How we are governed

Our Governing Body consists of: • GP Chair • Chief Clinical Officer, who is also a GP and also includes: • 4 GPs each representing a defined group of Practices • Chief Financial Officer • two lay members, one with a lead for quality and one for finance • A specialist consultant and nurse • a LINks representative

The Board will be assured of delivery via monthly reporting from the Clinical Commissioning Group Finance and Performance sub-committee. This committee will oversee the implementation and risk management of the delivery of the clear and credible plan. In addition each GP Member of the Governing Body has lead responsibility for a service area aligned to our key priorities. The diagram to the right illustrates how the CCG will be governed. A key organisational development objective, as detailed in the organisational development plan, is to put in place systems and processes that will provide assurance that the decision making of the CCG is undertaken within a framework that can be tested against best practice models of NHS Board Governance.

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2. What we want to achieve

This section sets out our vision and ambition, including how we deliver whole

system transformation and our key priorities for commissioning.

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2. What we want to achieve 2.1 Core mission and values

This core mission is underpinned by our core values: Patients, service users, carers and their families will see: • a difference in service provision with holistic management of care; • models of care based on service user led pathways with no organisational

boundaries and systems that work; • more care delivered closer to home; • individuals supported to better manage their own conditions; • an increased use of technology; • more appropriate signposting to services, particularly in moments of crisis; • increased use of education by all agencies to help people; and • more use of existing support networks such as the family.

These values drive our strategic objectives: To support this we will: • narrow the gap in health needs between the wards of the town. • be driven by a desire to continually improve service quality and outcomes • use evidence based practice to effect whole system change • use sustained patient and public engagement and involvement in review,

development and implementation of pathway and service redesign. • use sustained clinical and provider engagement and collaboration to

redesign and implement pathway and service redesign. • deliver a whole system information strategy will ensure a single care patient

care record with patient access to their information • Improve availability of information to support informed choices • reflect service changes in quality contracts • improve information to target services more effectively

Our Core Values

Excellence


Accountability




Courage

Our core purpose is to turn £250 million of resources into the best possible health outcomes for the people of Warrington.

Our Strategic Objectives

Improve healthy life expectancy for all

Reduce inequalities

Prioritise earlier interventions in pathways


Achieve sustained financial balance

Optimise health outcomes

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The Warrington Whole System Vision was developed through a workshop in February 2012 where key stakeholders and partners came together to explore our shared understanding of the future in the new NHS landscape, and the context of financial austerity. The findings of the workshop are illustrated on the following page.

Recognising the inter-dependence of all priorities, and all organisations, in the delivery of these objectives all partners have signed up to a Whole system Transformation Programme to ensure that we are aligned in our shared purpose.

We are committed to achieving excellence for Warrington in the commissioning and provision of health services, and recognise that we are stronger and more effective when working together, in partnership with public health commissioners, health service providers and the Borough Council.

We will work with colleagues in Public Health, Warrington and Halton Hospitals Foundation Trust, Bridgewater Community Trust, 5 Boroughs Mental Health Foundation Trust, Warrington Borough Council and other stakeholders to address the health needs of the Warrington population. We understand that we need to take a ‘holistic’ approach, which recognises that the causes of ill health are due to a range of factors including deprivation and environmental, and that improvement can only be influenced by a range of responses.

These responses can include effective public health screening and health improvement programmes, such as, for cancer, cardio vascular disease, sexual health and general health checks to identify issues early and provide timely interventions to achieve best patient outcomes. Provision of acute care needs to draw on best clinical practice to achieve quality outcomes by using clear clinically evidenced pathways potentially delivered outside acute settings. We will work with Warrington Borough Council to address the issues and impact of factors, such as, poor housing, deprivation, and worklessness on vulnerable populations.

All partners recognise the significant challenge involved in improving the health, well-being and life chances of Warrington people and the collective and concerted effort needed to close the gap between the areas of the Borough with best and poorest health.

Informed by the new NHS Model for Change we have established robust governance and delivery processes, described in more detail later in this document, to ensure we can .

Our vision for health and health care follows wide ranging engagement with the public, service users, hard to reach groups, clinicians and partners. It is based on the understanding of health needs described in our JSNA and on the range of key drivers in national policy.

2. What we want to achieve 2.2 Whole System Transformation

Our Whole System Vision

“Self-sufficient communities enjoying improved health and wellbeing and better life experiences, who and when they need them have access to high quality and efficient services”

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2. What we want to achieve 2.2 Whole System Transformation (continued)

The picture below illustrates the discussion and outcomes from the Warrington Health Visioning Event in February 2012

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2. What we want to achieve 2.3 Making change happen

Whole system approach to transformational change Our key priorities and proposed approach for 2013/14 are captured in our Plan on a Page. This is very much as described in 2012/13 as all partners recognise that the work we have already started will need at least two years of consistent and persistent transformational change. Informed by the NHS Model of change we have put in place robust systems for governance and operational implementation.

Health Summit To achieve the degree of change necessary requires all key partners and stakeholders to work together in a ‘whole system’ approach to meeting the needs of the Warrington population within the resources available across the whole local health and social care system. The CCG has successfully initiated a high level ‘Health Summit’ group consisting of the Chief Executives / Executive Directors of the Warrington Borough Council, Warrington and Halton Hospitals Foundation Trust, 5 Boroughs Mental Health Trust, Public Health and Bridgewater Community Trust. We are also joined by colleagues from Halton CCG and Halton Borough Council to ensure alignment of commissioning for the majority of patients attending the shared acute provider, Warrington and Halton Hospitals Foundation Trust, and develop further congruence between the community health and social care provision models in both boroughs. The Health Summit has an agreed ‘Concordat for Health and Wellbeing in Warrington’ which states our shared objectives and commits the partner organisations to close collaborative working to transform services across the health and social care system to deliver sustainable change to achieve maximum benefit for the citizens, communities and populations of Warrington, for which organisations can be measured and held accountable for by the other Summit members. We recognise that by having a shared understanding of the collective resources available to the local health and social care economy, we are better able to ensure stable, sustainable and viable local provision by collaboratively shaping services that will promote personalisation, enablement, prevention and promotion of integration of wellness approaches.

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2. What we want to achieve 2.3 Making change happen (continued)

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Warrington & Halton Hospitals Foundation Trust

Bridgewater Foundation Trust

Warrington Health

ConsortiumHalton Borough

CouncilHalton CCGWarrington

Borough Council

Halton OSCWarrington OSC

Mid Mersey QIPP

Halton Health & Well Being BoardWarrington Health & Well Being Board

Warrington Health SummitAgreed Objectives

Working together we will transform services across the health and social care system to deliver sustainable change with

maximum benefits to citizens, communities and populations of Warrington.

We will collaborate in shaping new services for care and support through personalisation, enablement, prediction and prevention and promote integration of wellness approaches

within other programmes to scale up system wide change, in line with the Zagreb Declaration for Health.

We will prioritise and agree a programme of top workstreams supported by detailed action focussed plans which

organisations can be measured against and held accountable by other Summit members. These will be agreed on a

collaborative basis to

Understand the collective financial situation for Warrington’s Health and Social Care economy and to

address this issue on a sustainable basis.

Collate and scrutinise activity and performance data across the economy to implement shifts in activity to

maintain high quality, effective and affordable services.

We will share current and potential challenges in the economy and to develop shared opportunities for cost

reduction and greater efficiencies through potential shared services.

Urgent Care

Long term Conditions

End Of Life

Older People

Mental Health

Children

DelIvery

Groups

Task

and

Finish

Groups

Excel

lence

for

Warring

ton

Programme Office

Warrington Health SummitCEO Group

Strategy Performance Oversight

Transformation BoardCo-ordinated Operational Delivery

Core membership and attendance according to agenda

5 Boros Foundation Trust

Excellence for

Warrington

“Our Health Economy”

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2. What we want to achieve 2.3 Making change happen (continued)

Programme management Multi-disciplinary/multi agency work stream groups have been established to review, redesign, transform and / or re-commission identified services and priority areas. Each programme has clinical Leadership, a dedicated project manager and executive sponsor who may be from any partner agency. These priority work streams each have a detailed programme plan which is monitored and performance managed for delivery against milestones by utilising a comprehensive ‘Programme Office’ that then reports on delivery and achievement through an agreed governance and accountability framework that incorporates each partner’s own governance arrangements. A Transformational Change Board brings all partners together to review the operational implementation of the agreed programme. Business process re-engineering Supported by our member practices, we successfully delivered a turnaround programme in 2011/12. We have continued to build on this success moving towards authorisation in 2012/13 by leading system wide transformation of healthcare in order to improve health outcomes for the people of Warrington and achieve system wide efficiencies. We practice a business delivery process underpinned by a programme approach to drive reform. This ensures that we maintain, • A focus of management and supporting resources on the objectives

and purpose of the organisation; improving the healthcare system and delivering financial sustainability;

• Delivery of prioritised outcomes, such as patient safety in an environment of expenditure reductions;

• Development of proposals in a way that ensures appropriate decision-making;

• Decisions at optimal points in the process to drive delivery; • Actual and timely implementation of decisions made; and • Minimal use of resource on inappropriate/ unnecessary activity,

such as on the development of reform proposals that are not viable or capable of implementation.

Warrington CCG Healthcare Reform Process takes reform, innovation and efficiency proposals from initiation, through case for change development to programme delivery. This process plays a key role in generating ideas for reform and identifying opportunities for innovation and efficiency, both via the market and via pathway and service redesign and consolidation.

Collaboration, Co-Production, Co-operation, Competition, Procurement It is the intention of Warrington CCG to work in collaboration and co-production with our Health Summit partners to utilise innovative, transformational approaches to redesign services to meet local needs. Our aim is a high quality, stable and viable health and social care economy which is robust and resilient, avoiding fragmentation and destabilisation.

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What is our process of reform?

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Wellbeing strategy

Warrington Health and Wellbeing Board was established in 2011 as an early implementer board. It has overseen the development of the refreshed JSNA and, based on the priorities identified, developed a Wellbeing Strategy for the town . Through working together we believe that we can have great ambitions for wellbeing in Warrington. We want Warrington to be a place where everyone can be proud to live, work and do business. We recognise that good health and wellbeing are the underpinning factors necessary for prosperity and a good quality of life. Our aim, therefore, is to promote wellbeing by focusing resources, building on the strengths we have and working differently together to address the challenges we face and ensure that Warrington continues to develop as a place where everyone has the opportunity to be part of the community and reach their full potential. The strategy sets out our long term vision, our principles for working together and the priorities for action that have been identified by the recent borough JSNA. The strategy and the actions leading from it should reach every person, family, community and neighbourhood in Warrington. We are committed to ensuring that this strategy is implemented in such a way that the benefits of good health and wellbeing are available to everyone living and working in Warrington. Wellbeing is a contented state of being healthy, feeling good and being able to cope with the normal stresses of life. In order to achieve wellbeing, people need to be and feel safe, enjoy good physical and mental health, experience financial security, enjoy rewarding employment, have a healthy and attractive environment, be engaged in supportive relationships, and feel involved in their community.

Our Wellbeing strategy provides the overarching umbrella within which the CCG will commission services to help prevent people from dying prematurely. enhance the quality of life for people with long term conditions and to help people recover from episodes of ill-health or injury. Wellbeing Outcomes

The strategy also stated the outcomes it would wish to see achieved by 2015: • See a reduction in the inequality gap between the most deprived and the

least deprived in the borough • An increase in the number of years that people can expect to live • disability-free and enjoying good health • See a reduction in alcohol related harm across the borough, as • measured by a number of indicators • Have an increased understanding of the overall levels of mental health and

wellbeing across the population and understand where to target activity • See an increase in the number of people making healthy lifestyle • choices, as measured by a number of indicators • See a measurable reduction in the gap between people claiming out of work

benefits in the most deprived areas and the rest of the borough • Have achieved a shift in investment towards activity that will progressively

reduce the demand on services, including joint commissioning and multi-agency interventions where appropriate

• Have a system whereby communities are effectively and systematically involved in the design and delivery of services

Again similar outcomes will be reflected throughout this document as described within the NHS Outcomes Framework, Commissioning Outcomes Framework, Public Health Outcomes Framework and Service performance indicators.

2. What we want to achieve 2.4 How the wellbeing strategy influences our vision

Closing the inequality gap

Increasing life expectancy

Reducing alcohol misuse

Improve undertaking of mental health

Joint commissioning and multi agency interventions

Involving communities in design and delivery of services

Building Safe, Sustainable Communities

Ensuring the Best Start in Life and Transition to Adulthood

Living and Working Well

Promoting Wellbeing for Older People

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Key Priorities Our commissioning intentions deliver the priorities set out in the NHS Operating Framework (2012), within the context of our Joint Strategic Need Assessment and Health and Wellbeing Strategy in order to deliver our local priorities (which includes QIPP).

Our response to the national priorities set out in the NHS Operating Framework. Our refreshed commissioning intentions are set out further in this section under ‘key priorities’.

Our integrated strategic and operational plan remains focused on delivering clinical outcomes and reducing health inequalities. To achieve this we are driving a change in culture and behaviour and engaging the whole local health and social care system to transform clinical and supporting services. Plan on a page Our Plan on a Page provides an overview of our total agenda, demonstrating how it links to the National Outcomes Framework, the Heath and Wellbeing Strategy, the JSNA and our local priorities.

Overview of our key priorities Based on the outcome of the JSNA and the priorities identified in the Warrington Wellbeing Strategy, both of which involved extensive consultation with partners and the public, and the Vision event described earlier, we have identified ten key programme areas as the focus of our whole system transformational programme:

These programme areas also form the basis of our CCG QIPP plan and the CIP and QIPP plans of all our partners. Our Resource Plan provides further detail. Cross cutting priorities We have seven areas of crossing cutting work that support our programmes: 1. Reducing inequalities 2. Delivering Outcomes Frameworks 3. Choice and shared decision making 4. Integration of care 5. Quality of information 6. Promoting growth, innovation and research 7. NHS Constitution

2. What we want to achieve 2.5 Our key priorities

Preventing premature deaths

Urgent care programme

Primary care

Prescribing

Planned care

Frail older people

Mental health

End of life

Acute children’s

Long term conditions

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2. What we want to achieve 2.6 Plan on a page

Early interventions

Patient experience

Reduce inequalities

Life expectancy

Health outcomes

Financial balance

Closing the inequality gap

Building Safe, Sustainable

Communities

Ensuring the Best Start in Life and Transition to

Adulthood

Living and Working Well

Promoting Wellbeing for Older People

“Self-su

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mu

nitie

s en

joyin

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and

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and

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the

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the

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s”

Growing Healthy Communities/

breaking cycle of deprivation

Promoting healthy lifestyles

Ageing population

Improving children’s health and wellbeing

Improving healthy life expectancy

Delivering high quality systematic

care

Preventing premature

death

Urgent care programme

Primary care

Prescribing

Planned care

Frail older people

Mental health

End of Life

Acute children’s

Long terms conditions

Strategic objectives

Vision JSNA Wellbeing strategy

Programmes Initiatives

Delivering Outcomes Frameworks

NHS constitution

Choice and shared decision making

Integration of care

Reducing inequalities

Quality of information

Promoting growth, innovation and research

Learning disabilities

Troubled families

Support for carers

Veterans

Prison healthcare

Cross cutting priorities

National priority groups

Health checks, cancer screening and diagnosis, smoking, obesity

Redesigned urgent care model

Primary care quality

Improve quality of prescribing

Pre-op assessment in community, enhanced recovery model

Rapid assessment, self management, Dementia screening, integrated neighbourhood teams

IAPT expansion, LLAMS redesign, RAID

DNAR, anticipatory prescribing, GSF, nursing homes

Integrated children’s services, community midwifery child health breast feeding and health visitors

Early detection, self management, increase awareness

Local disease specific

priorities

Preventing people from

dying prematurely

Enh

ancin

g qu

ality of life fo

r lon

g term co

nd

ition

s

Patients have a positive experience of care

Safe environment, protected from harm Help

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National Outcomes Framework

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Our Priorities Achieving our priority s

We have mapped out our key priorities for the five NHS Health Outcome domains. As part of this commissioning plan NHS Warrington CCG will be assessing the degree to which its health outcome priorities are reflected in its priorities for 2012-13 by working in partnership with a range of partners, including local authorities, to upscale health improvements and tackle the wider determinants.

2. What we want to achieve 2.7 NHS Outcomes Framework

Domain What we will do How this will be measured

Prevent people from dying prematurely

• Primary prevention through vaccination and screening • Universal lifestyle programmes to reduce smoking, alcohol use, substance use

and obesity. • Health checks. • Improved early detection and diagnosis of cancer • Increased update of cancer screening

• Potential Years of Life Lost (PYLL) from causes considered amendable to healthcare

• Life expectancy at 75 for males and females • Under 75 mortality rate from cardiovascular diseases • Under 75 mortality rate from liver disease cancer • One and five-year survival from colorectal cancer • One and five-year survival from breast cancer • One and five-year survival from lung cancer • under 75 mortality rate from cancer

Enhance the quality of life for people with long term conditions

• Integrated QIPP programme to develop a holistic and economy wide system for management of people with long term conditions across organisational boundaries

• Introducing risk stratification to identify the focus of specific interventions • Improving condition management in the community through multi-disciplinary

health and social care teams • Supporting individuals to self manage their conditions wherever possible, • Improving early detection and long term condition diagnostics within primary,

community and A&E settings • Utilising a generic long term condition pathway across all service delivery areas • Increased dementia screening and redesign later life and memory services

• Under 75 mortality rate from respiratory disease • Health-related quality of life for people with long term

conditions • Proportion of people feeling supported to manage their

condition • Employment of people with long-term condition • Unplanned hospitalisation for chronic ambulatory care

sensitive conditions (adults) • Unplanned hospitalisation for asthma, diabetes and

epilepsy in under 19s • Enhancing quality of life for people with dementia

Helping people to recover from episodes of ill health or following injury

• Improvement of TIA screening delivery • Development Universal AF screening • Redesign urgent care model • Integrated children’s service • Continuation of referral criteria for hip and knee replacement and varicose veins • Development of integrated health and social care teams

• Emergency admissions for acute conditions that should not usually require hospital admission

• Emergency readmissions within 30 days of discharge from hospital

• Emergency admissions for children with LRTI • Improving recovery from injuries and trauma • Improving recovery from stroke • The proportion of patients recovering to their previous

levels of mobility/walking ability at 30 and 120 days • Proportion of older people (65 and over) who were still at

home 91 days after discharge into rehabilitation and offered rehabilitation following discharge from acute or community hospital

.

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Ensure people have a positive experience of care

• Use a wide range of methods to capture patent experience • Triangulate feedback with complaints and serious incidences to obtain a rounded

view. • Provide choice to patients through choose and book

• Increase the proportion of NHS patients in Warrington who would rate their experience as ‘good’

• Increase the proportion of doctors, nurses and other staff who would recommend their place of work

• Improving people’s experience of outpatient care, hospitals

responsiveness to personal needs, accident and emergency services, access to primary care services, women and their families’ experience of maternity services, care for people at

the end of their lives and healthcare for people with mental illness

Treating and caring for people in safe environment, protecting them from harm

• Actively monitor all serous untoward incidents • Undertake root cause analysis and wider system reviews in partnership with

providers where required.

• Improve patient safety, reducing Quality Adjusted Life Years lost to NHS patients in Warrington through avoidable harm

• Patient safety incidents reported • Safety incidents involving severe harm or death • Incidence of hospital-related venous thromboembolism

(VTE) • Incidence of healthcare associated infection (HCAI),

MRSA and C. difficile • Incidence of medication errors causing serious harm • Admission of full-term babies to neonatal care • Incidence of harm to children due to ‘failure to monitor’

2.7 NHS Outcomes Framework (Cont’d)

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Long term conditions A key priority for Warrington is to improve services for people and their carers with long term conditions. We aim to move from a reactive hospital based system of unplanned care to a preventative, anticipatory, whole person approach to the treatment of long term conditions.

Long term conditions currently account for 70% of overall health and social care spend with a projected increase. The average annual cost of a person with one long term conditions is £1,000 and this rises to £8,000 for a person with three or more long terms The health and social care system will be unable to sustain the rising prevalence and cost within the current configuration, particularly given the ageing population profile. There is no system wide strategy for managing long term conditions and reconfiguring services to meet the expected increase in demand. Develop and implement a fully integrated long term conditions model that will: • Use a risk stratification tool to identify where to focus specific interventions; • Roll out agreed LTC pathways across all service delivery areas; • Increase social awareness of the signs and symptoms of LTC; • Improve early detection and LTC diagnostics within primary, community care

and A&E settings; • Develop and promote patient self management to support optimal self care

and reduce exacerbations; • Shift the focus of care for clinical teams from disease based to integrated co-

ordination of care for an individual regardless of how many or which LTC they are living with; and

• Care delivered by integrated teams, according to long term condition pathways and based on best evidence.

Urgent care National and regional trends for urgent care admissions are rising; however in Warrington admissions remain 20% over the national average. This together with the projected increase in long-term conditions, dementia and frail elderly demand for unscheduled care is financially unsustainable and requires alternative solutions to hospital based care. Integration is essential to the development of effective urgent and emergency care services .

Our programme aims to redesign urgent care service delivery in order to manage emergency care and reduce inappropriate hospital admissions more effectively. The programme aims to ensure a seamless service for the patient irrespective of which organisation is providing the care or how they enter the system. Mental Health 90% of mental health care is provided within primary care services, and there is anecdotal evidence that there is variation in screening, referral and access to mental health support in primary care. There is some (limited) evidence available locally to highlight the co-morbidity with physical ill-health& that these needs are not addressed. Factors such as substance misuse and ageing population impact on the prevalence of mental health issues in Warrington. The aim of the programme is to promote mental health and wellbeing and prevent mental ill health. The programme aims to promote earlier recognition and improve access to mental health support in primary care. The programme further aims to ensure that people with mental health problems achieve and maintain optimal mental health and physical wellbeing and independence with the right level of support from seamless integrated services. We will also implement the recommendation of the National Dementia Strategy providing integrated services to support people with dementia in holistic way. Planned care Warrington has a significantly lower rate for the total elective spells than the majority of its peers (127.2 spells per 1000 population compared to the highest rate of 163.9). However there is still room to improve some aspects of care such as increase in day case rates extending and enhance recovery and undertaking pre-operative assessment in the community.

2. What we want to achieve 2.8 Our key priorities

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Planned Care (Cont’d) The aim of the programme is to reform how elective care is performed by: • Achieving 75% rate of day case activity in 25 procedure/ intervention areas • (NHS Modernisation Agency); • Develop pre-operative assessment clinics in community settings; • Develop enhanced recovery models; and • Develop opportunities to reform and deliver innovative services to improve • quality and productivity.

Primary care We will aim to improve the quality and decrease variation in primary care. A Primary Care Programme has been established to contribute to reforming health services that improve quality, are innovative, improve productivity and address prevention. The Primary Care Programme Priorities are: • To roll out the National Institute Productive Primary Care Programme in all

practices • To further improve the quality of referrals in order to reduce outpatient activity; • To support practice teams further develop patient self-management, improve

management of long term conditions, integrate community and social care support in order to reduce emergency admissions and A&E attendances;

• To improve the quality of overall primary care management in order to reduce variation and improve patient experience

• To improve patient access to primary care support as appropriate to their need

Prescribing In order to deliver the identified QIPP saving through improved Medicines Management the programme will: • Target common areas across GP prescribing, especially where expenditure is

seen as high compared to local and national average; • Ensure prescribers have access to specialist advice and support from the

medicines management team, and increased clinical lead support; and • Increase support in each GP practice by recruiting medicines coordinators

who will work closely with the medicines management team.

End of life In keeping with the national End of Life strategy, there is a desire to reduce the number of deaths in hospital and reduce the number of admission in the last year if life through better care and planning.

In Warrington, the population of older people is predicted to rise with a 60% increase in people aged over 65 predicted by 2030. 64% of people in the North West have identified home as their preferred place to be at the end of their life against an average of 42% of deaths in the usual place of residence in Warrington. Our programme will develop and implement an integrated approach to formalising best practice so that quality end of life care becomes standard for every patient and carer, whilst taking into account their wishes and preferences. We will do this through: • Agreeing a common language in relation to end of life care; • Promoting understanding of the roles and responsibilities of staff involved in

end of life care; • Ensuring consistent and high quality standard of education and training; • Ensuing that professionals have access to specialist advice; • Ensuring patients and carers have access to services out of hours; • Ensuring effective discharge planning takes place; • Improving communication between professionals, staff and carers; • Improving the universal uptake and delivery of Liverpool Care Pathway, Gold

Standards Framework and Preferred Priorities for Care (PPC); and • Raise awareness of end of life and palliative care services. Acute children The acute children’s programme will improve the health and care of children and young people in Warrington. Warrington's acute hospitals have a high rate of admission for paediatric care and there is a focus towards ‘admission to assess’ which results in a longer length of stay and unnecessary admission for the child. Following a Children’s Visioning Event undertaken in 2011 a recommendation was made to develop more integrated service, with more care delivered in the community and the overall delivery model for children integrated across organisational boundaries.

2. What we want to achieve 2.8 Our key priorities (continued)

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Acute Children (Cont’d) The programme will reduce number of children & young people admitted to hospital through: • Improved pathways for children, young people and families and promote

greater range and use of community based and self-managed care; • Deliver an integrated response to urgent/unscheduled care needs including

development of short stay assessment services and integration of children’s community services;

• Provide care delivered by integrated community paediatric teams, to agreed pathways and based on best evidence; and

• The programme will further address areas of variation as indicated by Atlas of Variation for example.

Frail older people Frail older people occupy c70% of acute hospital beds (with up to 60% of over 65’s in hospital having a dementia co-morbidity), and are associated with c46% of total NHS and c55% of social care expenditure. Frailty is the underlying cause of death in 25% of the population. Rates of unplanned or emergency admissions to hospital amongst the over 65’s are significantly The programme will be based on an integrated service to: • Support pro-active management of the frail older people including those

resident in nursing and residential homes; • Provide rapid assessment for those experiencing acute illness/deterioration; • Support hospital discharge and continuity of care; • Increase social awareness of the signs & symptoms of frailty

• Develop & promote patient self management to support optimal self care & reduce exacerbations

• Shift the focus of care for clinical teams from disease based to integrated co-ordination of care for an individual regardless of what condition they are living with.

Preventing premature deaths This programme is led by Public Health colleagues but as part of the whole system transformation programme described. All over-laps with service change areas identified in the CCG plans are delivered in partnership. Key initiatives are:

2. What we want to achieve 2.8 Our key priorities (continued)

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Ageing Well Falls prevention Winter warm Flu Review of Healthy Activity

Healthy Child Programme School Health Advisor Specification Obesity Breastfeeding FHWR Tobacco Sexual Health Teenage Conceptions

CVD risk Reduction Obesity Alcohol Smoking

Reviewing & re-launch health checks Integration of smoking Cessation, exercise, healthy weight & alcohol Integration of sexual health services Review of alcohol treatment services Tobacco control

Closing the gap Wellbeing Service Improve Intelligence Local Integration Services project Health inequalities partnership project Early cancer identification awareness & screening

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2. What we want to achieve 2.9 Cross cutting priorities


and promoting

equality

Objective

• Provide an assessment of progress in narrowing the inequalities for all domains of the NHS Outcomes Framework and work towards a greater understanding of effective interventions to narrow health inequalities

• Ensure continuous improvement in reducing inequalities in life expectancy at birth (as measured by the Slope Index of Inequality) through greater improvement in more disadvantaged communities.

As noted in the JSNA, Warrington has a significant inequality gradient between its inner deprived areas and the remainder which is relatively affluent. The Slope Index of Inequality models an estimate of the range in life expectancy at birth across the whole population of Warrington, from most to least deprived. Based on death rates in 2006-2010, this range is 9.7 years for males and 7 years for females depending on their level of deprivation. The CCG has ensured that health inequalities is a core part of the Health and wellbeing Board and the Warrington Wellbeing Strategy and provides collaborative leadership in relation to health inequalities particularly through joint work between integrated commissioning and public health. The Joint Strategic Needs Assessment, Wellbeing in Warrington Strategy and the CCG's Commissioning intentions and QIPP plans all have programmes relating to tackling health inequalities as a priority area. The CCG is fully involved in a number of partnership programmes including: • Closing the Gap; • Local Integrated services; • Complex families; • Neighbourhood boards; • Welfare reform; and • Public health transition.

Warrington CCG is taking an active part in supporting all of these programmes. In relation to inequalities we will work with all partners to: • Maintain our focus on “closing the gap” between the most deprived

areas and the rest of the borough; • Work in partnership to identify and, as far as possible, mitigate the

negative impacts of welfare reforms to our communities; • Increase service user involvement in design and provision of services, in

order to ensure that we commission and delver the right services in the right ways to meet the needs of specific groups; and

• Further develop targeted multi-agency interventions to support individuals and families with the most complex needs.

In response to this, given the current increasingly constrained financial picture, the economy partners have reviewed the neighbourhood working models to improve how the service is targeted to address issues of inequality and contribute to closing the gap between the least and most affluent in the borough. The CCG has also commissioned an independently run Cardiovascular Disease health check programme and has launched a Local Enhanced Service (LES) for CVD and reducing health inequalities. The CCG is also launching a Local Enhanced Service (LES) for homeless and vulnerable people who find it difficult to access mainstream care in usual ways. The CCG has recently purchased an information service “Looking Local” which can be made available on digital platforms such as digital TV, Smart Phones, games consoles etc. This will allow us to get health related information to some of our most deprived populations. Research in Scotland shows penetration to these communities is markedly better with this approach than web based or written publication.

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2. What we want to achieve 2.9 Cross cutting priorities


and promoting

equality

Objective

• Provide an assessment of progress in narrowing the inequalities for all domains of the NHS Outcomes Framework and work towards a greater understanding of effective interventions to narrow health inequalities

• Ensure continuous improvement in reducing inequalities in life expectancy at birth (as measured by the Slope Index of Inequality) through greater improvement in more disadvantaged communities.

In order to measure how we reduce the gap in health experience between our various communities we have developed a suite of performance measures. For each criterion we measure the overall Warrington rate, the rate in our 20% most deprived wards and the 80% other, noting the relative gap. By our focussed interventions we would aim to demonstrate the effectiveness of positive investment and provision in areas of deprivation leading to closing the gap. The box below illustrates how we do this, and the range of criteria is described.

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The lines on this chart represent the Slope Index of Inequality, which is a modelled estimate of the range in life-expectancy at birth across the whole population of this area from most to least deprived. Based on death rates in 2006-2010, this range is 9.7 years for males and 7 years for females, we would be looking for this gap to narrow.

Inequality Health Performance Measures, 2012/13

Warrington 512.5 457.6 445.8

20% MD 587.7 - -

80% Other 503.4 - -

Relative Gap 14.4% - -

YTDEngland

Average

Warrington

Average

Monthly/

Quarterly

Targets

2012/13

Hip fractures in over 65s

(DSR per 100,000)

Older

People

• Older people • 65 – 74 mortality rate • Dementia prevalence variation, actual v expected • Disability free life expectancy at 65+ • Excess Winter mortality

• Children and Young people Early access to maternity services • Under 18 alcohol specific emergency admissions • Under 15 smoking prevalence • Under 18 self-harm admissions

• Cross Cutting • % of women invited for breast screening • % adult population 70-75 invited for bowel cancer screening • % people invited for health checks • Hypertension prevalence variation actual v expected • Hospital admissions for alcohol related harm • CVD mortality <75 • Cancer mortality <75 • Lung Cancer mortality <75

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2. What we want to achieve 2.9 Cross cutting priorities (continued)

As stated in the Outcomes Framework a consistent methodology is required to ensure that we can monitor, and therefore manage, our performance to secure continuous improvements in each outcome area. We seek to demonstrate throughout how our plans are based on the needs of the population and our current understanding of the quality of services as demonstrated through benchmarking and patient feedback. We also seek to demonstrate how our plans will help deliver the local contribution to the Mandate given to the National Commissioning Board, and how our plans will improve performance against • NHS Health Outcomes Framework ; • The Commissioning Outcomes ; and • The Public Health outcomes Framework and other service indicators.

Maintaining progress against

the Outcomes Framework

Objective

Ensure continued improvement of health outcomes, as measured by the indicators in the NHS Outcomes Framework, in relation to baselines set out in the technical annex.

The CCG promote the NHS Constitution in all our contacts with the public and aim to provide excellent performance against all the service performance standards. We have reflected this throughout the document. The NHS Constitution can be found promoted on the Warrington CCG website. It is posted up and referred to at all of our public and patient engagements, • Our Vision “Excellence for Warrington” reflects one of the core principles of

the constitution; • Our extremely high use of Choose and Book demonstrates our support for

reflecting the needs and wishes of patients; and • The performance of our system demonstrates how we hold providers to

account for high delivery standards in terms of access and referral to treatment.

NHS Constitution

Objective

Uphold, and where possible, improve performance on the rights and pledges for patients in the NHS Constitution and on the service performance standards.

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As part of the wholesystem transformation programme we have recognised that information transfer, and the IT infrastructure to support it, is a critical enabler. To address this a wholesystem Information Board has been established. The Governing Body is charged with developing an Information Strategy based on the following principles. There are three categorise of information we need to consider. • Information to support commissioning • Information to support patient pathway • Information for patients Any overarching strategy should be based on the following principles. • The patient record should be the prime source of information. • We should aim to develop a system that ensures only one patient

record to which all health and social care providers can input. • The patient/client/carer should only have to answer the same question

once. To support the development and implementation of this strategy a whole system Director of Information has been appointed jointly between Warrington and Halton Hospitals Foundation Trust, Warrington CCG and Warrington Borough Council. Working closely with colleagues in 5 Boroughs Mental Health Foundation Trust and Bridgewater Community NHS Trust they are responsible for ensuring that all information transfers and the supporting IT infrastructure are being developed with a common purpose and aim.


Promoting growth,

innovation and

research

Objective

• To improve patient outcomes and to contribute to economic growth through the life science industries, we will ensure that Warrington CCG promotes and supports participation by NHS organisations and NHS patients in research funded by both commercial and non-commercial organisations; and

• Ensure payment of treatment costs for NHS patients who are taking part in research funded by Government and Research Charity partner organisations; and promote access to clinically appropriate drugs and technologies recommended by NICE, in line with the NHS Constitution.

The Chair of the CCG is the Governing Body sponsor for Innovation and Research. Supported by our Director of Improvement, who we share with West Cheshire CCG, NHS RightCare, and our Commissioning Support Organisation. The CCG works with The Primary Care Research Network North West to support GP practice level research to innovate and improve services. We have a growing number of practices in the town involved in research, including seven live research programmes in 2012. It is the ambition of the CCG to increase this level of participation, as well as spreading the findings from research programmes across the health economy. The Quality committee receives update reports on the level of engagement of our practices in the research network. The research network has a regular presence at all our protected Learning Time events. Given that our main provider is not a teaching hospital we have relatively low number of patients engaged in research trials. However, when Warrington patients are engaged in trials at one of our tertiary centres or through other Government and Research Charity partner organisations then we recognise the need to support ongoing funding and build this in, through our Individual Funding Panel. The CCG plans to use clauses in its contracts with NHS providers to promote participation in research in 2013/14 where appropriate.

Quality of information

Objective

Improve the quality and availability of information about services to Warrington people, with the goal of having comprehensive, transparent, and integrated information and IT, to drive improved care and better healthcare outcomes

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SECTION 5 PUTTING PATIENTS FIRST Securing shared decision making

Integration of both the commissioning and provision of health and social care is a key delivery principle for Warrington. To ensure delivery of this aim the Health and Wellbeing Board has established a sub-committee, the Integrated Commissioning Board. With Warrington Borough Council elected member and CCG Governing Board membership this board oversees those monies across health and social care where joint and integrated services are being commissioned. The range of service commissioning overseen by the board includes: • Mental health • Learning and physical disability • Intermediate Care and Rehabilitation • Carer support • Drugs and alcohol • Children As part of the whole system transformation programme we are working with Bridgewater Community Trust and Warrington Borough Council to re-design service delivery models to provide services wrapped around the patient and their practice with generic integrated health and social care teams who have access to centrally provided specialist services, using technology to provide seamless patient care record across all providers, patient access to their information and better signposting and information. Using tele-medicine wherever possible to decrease the requirement for travel and face to face encounters, and thus improve the patient experience and deploy people and specialist expertise more efficiently.

Integration of care

Objective

Ensure that Warrington CCG promotes and supports the integration of care (including through joint commissioning) around individuals, particularly people with dementia or other complex long-term needs.

Choice and shared

decision making

Objective

Enable shared decision-making, and extend choice and control for NHS patients: This includes: • ensuring we support people to be involved in

decisions about their care and treatment; • extending the availability of personal health budgets to

anyone who might benefit, and; • subject to the outcome of pilots during 2012/13,

ensuring that patients are able to choose from a range of alternative providers if they either have waited, or are likely to wait, for more than 18 weeks after referral to start consultant-led treatment for a non-urgent condition..

The Governing Body and GPs will help to promote shared-decision making in the services they commission empowering patients to have a genuine role in their care and treatment. • Patient choice will be included throughout the care pathway, not just in

primary care but also among providers and when selecting a lead clinician;

• Choice will be pursued where it is in patients’ interest and not as an end in its own right;

• Warrington CCG will work with Warrington Borough Council to offer personal health budgets where appropriate, including the option of direct payments, and joint budgets across health, social care and other services.

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2. What we want to achieve 2.10 Priority groups

Support to carers

Objective

Early identification of a greater proportion of carers, and signposting to information and sources of advice and support; and

Working collaboratively with Warrington Borough Council and carers’ organisations to enable the provision of a range

of support, including respite care.

A range of services are already provided for carers in Warrington. These include carer breaks, support and signposting and counselling service.

Warrington Carers Partnership Board is a multiagency (including Carers) group which strategically lead and oversee the development of carer’s services and support in Warrington. Over the past year The Board has been refreshing the Carers Strategy which is currently out to consultation and will be launched as a joint commissioning strategy for 2012 -2015. Implementation of the action plan will be overseen by the Board.

Warrington and Halton Hospitals NHS Trust have also been working with the Partnership Board to develop a Carers Strategy for the Hospital which links back to the main overarching strategy for the town.

The roll out of personal budgets for carers is inclusive to the Personal Budget Plan led by the Council and we will be exploring the opportunity to link personal budgets and personal health budgets where appropriate.

During 2011/12 a specific engagement exercise was held with the multiagency workforce and carers of people with dementia, this was led by Warrington Borough Council and Warrington CCG. The work was specifically aimed at understand the needs of carers of people with dementia and ensuring that the services commissioned meet their needs. This work was also about combining the major aims of the National Dementia Strategy and the National Carers Strategy to ensure early identification and intervention processes are in place to help and support the carers of people with dementia and the person with dementia themselves to ensure timely support and reduction of the need for crisis intervention.

Troubled families

Objective

Ensure that arrangements are in place to safeguard and promote the welfare of children and young people that reflect the needs of the children they deal with and to protect vulnerable adults from abuse or the risk of abuse.

As a commissioning organisation, Warrington CCG is required to ensure that all health providers from whom it commissions services (both independent and public sector) have comprehensive single and multi-agency policies and procedures in place to safeguard and promote the welfare of children and to protect vulnerable adults from abuse or the risk of abuse, that health providers are linked into the Local Safeguarding Children and Adult Boards and that health workers contribute to multi-agency working. Warrington CCG Chief Clinical Officer is the nominated lead for safeguarding and has delegated this responsibility to the Head of Assurance and Risk. Warrington CCG has a fulltime Designated Nurse for Safeguarding Children and Children in Care and a similar post for Safeguarding Adults. The CCG also has a Designated Doctor for Safeguarding Children and Designated Paediatrician for the Child Death Overview Panel in place. A Commissioning Safeguarding Children and Vulnerable Adults Policy was developed earlier in the year. This policy set out roles and responsibilities for the commissioning organisation and provides clear service standards against which healthcare providers will be monitored to ensure that all service users are protected from abuse and the risk of abuse. An audit tool has been developed which outlines the core safeguarding standards and the components required underpinning the standard. Safeguarding and compliance with standards is also captured as part of all the quality and contract meetings that take place monthly with providers.

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2. What we want to achieve 2.10 Priority groups (continued)

Learning Disabilities is an area that could potentially lead to inequality for those people who have learning disabilities, therefore all providers are commissioned to deliver services which are suitable for patients with learning disabilities. The aim of Warrington CCG is to improve/facilitate access to mainstream healthcare to all patients with learning disabilities. The commissioning of care and support for people with learning disabilities is co-ordinated by the specialist commissioner who sits in the integrated commissioning team, with support from a GP Governing Body member. Services are procured through the Council's integrated contracting team from a range of providers. Priorities to improve health and wellbeing for Warrington citizens with learning disabilities have been identified by a self-assessment process and the joint strategic needs assessment. Progress in improving outcomes is monitored through the Learning Disability Partnership and Integrated Commissioning Board. LD provision in the community is offered via the Access All Areas service, provided by Bridgewater Community Healthcare NHS Trust. This service has seen an increase in activity over 2011/12, with actual activity increasing from planned activity by 27.5%.

Learning disability

Objective

Reduce inequalities for people with learning disabilities. Veterans

Objective

Discharge the Government’s obligations under the Armed

Forces Covenant by working to ensure that the health needs of the Armed Forces community are met, including promoting integration with social care.

The CCG are working closely with the National Commissioning Board Local Area Team to ensure implementation at a local level as appropriate. The CCG has made all practices aware of the improved prosthetics services for veterans announced in Summer 2012. We have publicised the availability of funds that can be accessed by veterans with the support of their NHS Disability Service Centre. The CCG is aware of the planned improvements to commissioning services for the armed forces and veterans as described in “Securing excellence in commissioning for the armed forces and their families”. We will work closely with are Local Area Team to implement any required changes.

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Commissioning Principles We intend to commission health and related services in accordance with the needs of the population as articulated in our Strategic Commissioning Plan, Joint Service Needs Assessment and Joint Health and Wellbeing Strategy. Health commissioning will be led by GPs with support from commissioning staff and a range of relevant business functions e.g. finance, contracting and HR.

Key outcomes from these commissioning intentions include the overriding intention for continuous improvement in the quality of services to be provided whilst achieving financial balance within a challenging economic climate. This will be achieved by utilising evidence based approached and working collaboratively with service providers and associated commissioners on joint commissioning to maximise quality and efficiency and minimise risks to service users and carers. Our overarching aim commits us to:

• A Quality, Innovation, Productivity and Prevention (QIPP) approach to commissioning activities

• An overriding desire to continually improve service quality and outcomes

• Use of evidence based practice to effect change

• Sustained clinical and provider engagement and collaboration to redesign and implement pathway / service redesign

• Using service user / patient engagement and involvement in review development and implementation of commissioning functions

• The essential development of outcome based services, service specifications, quality markers, CQUIN and contracts that can be effectively managed and monitored

• Partnership working with key providers, recognising that by joint working and collaboration with key partners, all stakeholders will benefit from the alignment of aims and objectives that will benefit the entire local health economy

• Consistent use of the National Institute for Clinical Excellence (NICE) Commissioning Outcomes Framework to ensure principles of quality based commissioning approach

• Ensuring effective use of resources and achievement of Value For Money

in commissioning decisions.

2. What we want to achieve 2.11 Commissioning Principles

Collaborative Commissioning Warrington is a member of the Mersey CCG Network. This provides an arena for discussion and agreement about approaches to services improvement or redesign that cross more than one CCG footprint, or where several CCGs have significant percentage of a providers business.

A formal Memorandum of Understanding has been agreed to deliver lead commissioner arrangements within the collaborate partnership.

A key vehicle for the delivery of our commissioning intentions will be effective collaboration between Warrington CCG, service providers, multi-agency partners and service users. It is intended that a framework of multi-agency / multi professional, short/and medium term task and finish groups will be devised to achieve the required progress against the stated commissioning intentions. It is anticipated that monitoring, oversight and implementation of related work streams will be via the Warrington CCG Board structure, Warrington and Halton Hospitals NHS Foundation Trust ‘Transformational Board’, the multi-agency Health Summit and the Health and Wellbeing Board.

In delivering our responsibility for working with the National Commission Board, we will work with the local area Director and her team to ensure alignment of our commissioning intentions and plans for specialist commissioning. In so doing, we will work closely with the Clinical Senate and Networks.

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3. Case for change

This section sets out the factors driving our plans for change in healthcare in Warrington. These factors are based upon data from our strategic needs assessment tells us.

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3. Case for change 3.1 Our local needs assessment

The needs of our community

The Joint Strategic Needs Assessment (JNSA) was refreshed in 2011/12 and overseen by Warrington’s Health and Wellbeing Board which is an early implementer and acknowledged national leader in collaborative leadership. The document highlights a number of areas in which Warrington is doing well:

In relation to health outcomes and the impact of major diseases: • Life Expectancy is increasing for Warrington residents, and the gap between

Warrington and England has reduced for males; • The internal inequalities gap in life expectancy associated with deprivation

has also reduced for males in the town; • The overall gap in death rates between the more deprived and more affluent

areas of Warrington has reduced; • The rate of new cancers in Warrington is lower than the average for England;

and • Cancer death rates locally are reducing and are in keeping with England. Looking at health related behaviours and individual lifestyle factors: • Smoking rates have decreased and are similar to the average for England; • Emergency admissions to hospital for alcohol specific conditions decreased

in 2010/11. This follows previous year on year increases and is likely to be in response to the focussed work in A&E; and

• The percentage of mothers smoking during pregnancy is low in Warrington The number of people cycling in Warrington has increased since 2004.

Improvements required The assessment below highlights areas where improvement is needed. These are summarised in the table below, with further detail provided later in this document and the JSNA itself:

Population

Rising population – current resident

population 198k, registered 207,900

Small but increasing BME

population.

Smaller than average projected

increases in working age population

Considerable increases in older

populations forecast

Population ageing more quickly than

average with 9.8% increase in 65 to

74 year olds and 5.1% increase in

over 75s in the last 5 years

Deprivation

Levels not changed since 2007

Slightly more areas in worst 20%

nationwide

Closing the Gap area not changed

Housing

Percentage of non-decent homes

lower in Warrington

Affordability an issue

Fuel poverty increasing issue in

many areas of the borough, linked to

excess illness in winter

Worklessness

Levels of worklessness lower in

Warrington than England

Rates increasing

Issue of worklessness being

entrenched in some areas

The outcomes of the JSNAs undertaken in 2008 and 2011 were similar - our local priority health need areas remain virtually unchanged:

• Respiratory

• Cardio-vascular disease

• Alcohol misuse

• Cancer early diagnosis

• Lifestyle issues: Smoking, Obesity.

Funding for needs is based on static population figure but actual increase of 4,600 over the last 5 years

Population ageing more quickly than average with 9.8% increase in 65 to 74 year olds and 5.1% increase in over 75s in the last 5 years.

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3. Case for change 3.2 Age profiles

Ageing registered patients

The chart and table below set out the age profile of our current registered patient population and the projections for growth. The growth of patients aged over 75 is predicted to grow at a faster rate than the total population. This shows that we have an ageing patient population. This predicted trend is reflected across England.

Old age illness and impact

Age is a risk factor for most diseases with the prevalence rates of most conditions rising with increasing age.

Mortality rates increase with increasing age and vary by gender. Age specific mortality rates for Warrington show that locally older people experience a greater excess burden of ill-health compared with the average for England, and the health of older people across Warrington as a whole is worse than the national average (as measured by mortality rates). The excess death rates in Warrington amongst the older population make a substantial contribution to the gap in life expectancy between Warrington and England. The most substantial contribution to the gap is amongst the 70+ age groups, and the excess burden in these groups far exceed the average for other areas experiencing similar levels of disadvantage to Warrington. In all people aged 65+, the most common broad underlying cause of death is circulatory diseases (37%), followed by cancer (25%) and respiratory diseases (16%). Older people attending A&E are more likely to be admitted to hospital, than those in younger age groups. Within Warrington unplanned admissions in the population as a whole are currently 25% higher than the average from England. Amongst the population aged over 65 rates are approximately 27% higher and trend analysis shows that rates have been increasing over recent years. Since 2001, rates within Warrington have been significantly higher than England, with rates increasing further over the last 3 financial years (2008/09 to 2010/11).

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Deprivation

There are considerable inequalities in Warrington. The JSNA noted that overall deprivation across Warrington has worsened slightly since 2007, and that it remains concentrated in certain sections of the population.

11 Local Super Output Areas (LSOA) fall within the most deprived 10% nationally and 24 LSOAs within the least deprived 10% nationally.

Impact of deprivation

The JSNA found the impact of deprivation on the health of people living in affected areas is significant:

Smoking There is considerable variation in smoking prevalence rates across the borough and amongst different population groups. The overall pattern is consistent with deprivation. Trend analysis suggests that smoking prevalence is increasing amongst the most deprived populations locally. Overall, the percentage of mothers smoking during pregnancy is low in Warrington. However, high rates of smoking during pregnancy have been observed in the more deprived areas of the borough. Alcohol Hospital admission rates due to alcohol related harm are highest amongst our more deprived populations. Emergency admissions to hospital are also higher from these areas. Mental Health The incidence of mental illness is higher in deprived neighbourhoods. Children The impact of deprivation on the health and wellbeing of children in Warrington is great, and includes: • lower breastfeeding initiation and continuation rates when compared to

national figures. Initiation rates are very low in the more deprived areas; • Practices serving the most deprived 20% of the population had the lowest

uptake rate of the pre-school booster in 2010/11; • A link between deprivation and obesity prevalence has been identified,

obesity prevalence is higher in the more deprived areas of Warrington; • Teenage conception rates are linked to deprivation, with more deprived areas

experiencing higher conception rates; and • Admission rates are significantly higher in the more deprived areas, with the

inner wards of Warrington experiencing significantly higher rates of admission compared to Warrington overall.

Unintentional hospital admissions Admission rates are significantly higher in the more deprived areas, with the inner wards of Warrington experiencing significantly higher rates of admission compared to Warrington overall.

3. Case for change 3.3 Deprivation profiles

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3. Case for change 3.4 Principal causes of mortality

Local disease specific health priorities

The diagram below evidences the main causes of death in Warrington between 2008 to 2010. The local disease specific health need priority areas remain virtually unchanged since 2008. These are:

JNSA priorities

Based on this mortality data, the JSNA describes six priorities for attention by all partners across the town:

Responding to this challenge

Based on these priorities, our core programmes seek to address aspects of both these causes of death and the systemic issues that

are currently limiting the efficacy of health interventions. We have developed ten programmes, which, as a whole, address all of the local health needs in Warrington. These are supported by a range of other priorities, both local and national, together with activities that underpin our declaration of compliance with the self

certification areas.

Growing Healthy Communities/ breaking cycle of deprivation

Promoting healthy lifestyles

Promoting healthy ageing

Improving children’s health and wellbeing

Improving healthy life expectancy

Delivering high quality systematic care

Respiratory

Cardio-vascular disease

Alcohol misuse

Cancer early diagnosis

Lifestyle issues: smoking, obesity

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4. Enablers

This section details the plan and strategies that will enable us to deliver our vision, including financial management and QIPP.

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Financial Challenge and Delivering QIPP

The CCG will ensure there is robust financial and commissioning governance and processes in place to commission services that demonstrate best value for the public purse whilst meeting the health needs of the area. As part of this process the CCG will establish an audit committee and internal and external audit arrangements to ensure that assurance can be given to both the governing body of the CCG and the public of Warrington to probity.

The CCG is fully aware of its statutory requirement to operate within allocated resources and will take all action necessary to meet this obligation.

The 12/13 budget for Warrington Primary Care Trust is £334,537,000. A resource and applications statement is included on the 2012/13 financial plans signed off by the StHA. This statement includes the PCTs £15.2m QIPP programme for 2012/13, these QIPP savings have been applied to the planned budget figures.

The CCG does not have any recurrent investment funds available to invest in new services. Any funding implications to support strategic initiatives will need to be identified from the following funding sources:

• Utilising non-recurrent funds to pump prime schemes and to cover double running costs during service re-design

• Utilising freed up resources that accrue in the future from service-redesign initiatives.

• Reducing costs in current service budgets and re-deploying resources to other health priorities where appropriate

• Stopping or reducing services where appropriate and re-deploying the resource in to other health priorities

The 2012/13 financial plan has set aside 2% of recurrent funding for non recurrent expenditure purposes. It is expected that SHA clusters will hold these funds for this expenditure until appropriate business cases have been approved. The non-recurrent cost of organisational and system change during 2012/13 will need to be met from the 2%.

QIPP is a key component of the CCG going forward. The responsibility for delivering £15.2m of 2012/13 QIPP is already delegated to the CCG and delivery of this is clinically led.

Benchmarking data from many sources including, Better Care Better Value; Standard Admission Rates; Programme Budgeting, alongside audit data and other reports i.e. ‘The Atlas of Variation’ provide evidence that QIPP savings can be targeted in Warrington.

Areas include:

• Preventing premature deaths;

• Urgent Care Programme;

• Primary Care;

• Prescribing;

• Planned Care;

• Frail Older People;

• Mental health;

• End of Life;

• Acute Children’s;

• Long Term Conditions

Linking in with the CCG priorities it is developing the transformational programme for strategic change that will enable the whole system to achieve the savings required.

Application of the “priority shifts” we have committed to at the Warrington Health and Wellbeing Board will also play a part..

The achievement of QIPP is vital in the short term to ensure that when the shadow CCG becomes a statutory body in 2013 we are in a strong financial position.

4. Enablers 4.1 Financial Management and QIPP

WHO WE ARE


THE FUTURE

CASE FOR CHANGE

ENABLERS

38

The achievement of QIPP is vital in the short term to ensure that when the shadow CCG becomes a statutory body in 2013 they are in a strong financial position. QIPP programmes The Quality Innovation Productivity Programme plan will be delivered over the next 3-5 years. Warrington CCG QIPP efficiencies will come from the following:

Level 1 Local Initiatives - Target Quality Innovation Prevention Plan savings by practice have been set in relation to their shares of acute contracts.

Level 2 Quality Innovation Productivity and Prevention (QIPP) savings - These programmes of transformation are delivered in partnership with others within the local health economy. Most of the initiatives described within our commissioning intentions fall into this category.

Level 3 programmes -We are working with colleagues from consortia in Knowsley and Halton plus St Helens, Knowsley Hospitals Trust, 5 Boroughs Partnership Mental Health Trust and Bridgewater Community Trust to identify potential for QIPP gains across the mid-Mersey footprint.

Warrington CCG’s QIPP Programme will increase the pace of delivery in order to improve services for patients and ensure a strong grip on service and financial performance is maintained. Patients and clinicians are at the centre of planning and decision making in our QIPP programme ensuring an outcomes approach to service delivery that improves the service to patients and meets essential standards of care.

The QIPP challenge for the Warrington health economy has identified the need to achieve transformational savings of £20,487m over the next three years. We will build on the successful delivery of our £15 million QIPP programme in 2011/12. To achieve the efficiency savings and quality improvements for 2012/15, we will continue to focus on delivering transformational change through clinical service redesign across the Warrington health economy working in partnership with our acute, community and primary care providers.

We aim to deliver continual improvement. Through collaboration with regional and national networks and programmes as well as its on-going focus on service reviews aims to learn from initiatives that are successful elsewhere, adapting and improving them into their own plans accordingly.

Financial Assumptions over the next three years

The CCG has based its financial assumptions on guidance contained in the 2012/13 Operating Framework as well as using past experience to model a broad range of financial scenarios.

The assumptions made in the medium term financial model for the next three years and are broad assumptions at this stage as investment priorities and commissioning intentions will develop over the next 12-18 months.

Key financial intentions for the next three years are as follows:

• To achieve recurrent balance in each of the years

• Deliver a one per cent surplus

• Maintain a contingency amounting to two per cent of recurrent revenue funding which will be deployed non-recurrently to support change

• To deliver the QIPP programme using savings and dis-investments to re-invest in service priorities

Transformational QIPP

Programme 2013/14 £000

2014/15 £000

Primary Care 500 400

Non-Clinical Services and Cross Cutting 400 300

Supporting Long Term Conditions 600 400

Pathway Redesign 1,000 1,610

Total Transformational Programmes 2,500 2,710

4. Enablers 4.1 Financial Management and QIPP (continued)

WHO WE ARE


THE FUTURE

CASE FOR CHANGE

ENABLERS

39

Financial Scenario Planning

Three scenario planning models have been developed to help identify the financial impacts for the base case, a best case, and a down-side case scenario.

It must be stressed that these figures are indicative at this stage. Funds will only be available for investment if recurrent balance is achieved in 2012/13 and the 2012/13 QIPP programme (and subsequent years) is delivered on a recurrent basis. Therefore these scenarios contain early planning assumptions and must be treated with caution . The following measures also underpin the financial assumptions as follows: There are significant reductions in acute hospital activity Shift Care to be provided in the most appropriate setting

A number of assumptions have been made in the scenario models ,these are broad assumptions at this stage as investment priorities and commissioning intentions will develop over the next 12 to 18 months. Base Case The base case assumes CCG allocations will grow by 2% per annum, however activity growth is also assumed to grow at a rate of 1.6%. Population growth is not assumed and tariff-and non-tariff prices will deflate by 1.5% on average per annum.

In 2013/14 resource growth is assumed to be £8.2m and new CCG running costs funds are assumed to be £5.2m re the move to published indicative running costs. Overall expenditure growth is assumed to be £1.3m. Delivery of QIPP is then assumed at £2.5m leaving an amount for investments and commissioning intentions of £5.8m in order to achieve the required surplus.

In 2014/15 resource growth is assumed to be £6.0m. Overall expenditure growth is assumed at £1.2m. Delivery of QIPP is assumed to be £2.7m leaving an amount for investments of £6.0m in order to achieve the required surplus.

In the base case scenario, QIPP savings must be made in order to fund commissioning intentions and unforeseen financial risks. In 14/15 there are funds available for investment even before QIPP savings have been made. Best Case The best case scenario contains the same assumptions as the base case scenario with the exception that activity growth is assumed to be 0.8% less, therefore only 0.8% activity growth per annum.

This increases the overall amounts available for investment to £6.8m in 2013/14 and £12.4m in 2014/15, an increase of £1m and £2m respectively in each of these years when compared to the base case scenario.

In the best case scenario there is a larger level of funds available for investment even before QIPP savings have been made. The best case scenario will allow the CCG to go further and faster in pursuing its commissioning priorities. Down-Side Case The down-side case scenario contains the same assumptions as the base case scenario with the exception that there is no resource growth assumed.

This decreases the overall amounts available for investment to -£0.5m in 2013/14 and -£2.1m in 2014/15, a decrease of £6.3m and £8.1m respectively in these years when compared to the base case scenario.

In the down-side case scenario expenditure growth is higher than resource growth so a minimum of £3.0m and £4.8m QIPP savings must be made in 13/14 and 14/15 respectively in order to achieve financial balance. Further QIPP savings over and above these levels will need to be made in order for any re-investment funds to be available.

4. Enablers 4.1 Financial Management and QIPP (continued)

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40

4. Enablers 4.2 Supporting strategies

Our plans We have developed robust supporting plans to enable us to successfully delivery out commissioning plan. These include:

• Information technology and information plan

• Patient experience and public engagement strategy

• Risk management framework

• Quality strategy

• Organisation development plan

Informatics as a Cross-Cutting Programme Informatics is seen as one of the Clinical Commissioning Group key cross cutting priorities. It has a role in:

• Delivery of CCG and Cluster strategies (including QIPP)

• Ensuring delivery of national priorities set out in the Operating Framework

• Supporting the transition process

Patient experience and public engagement We have developed a engagement strategy which contains full details of our approach.

Some of the examples of the work of our engagement and experience team are:

• Dying matters engagement

• Work with vulnerable groups

• Delivered patient experience programme

• Town centre Orford Park engagement

Risk management

We have identified that the biggest risk to the financial strategy remains the ability of the local health economy to deliver the QIPP plans. They began in 2011/12 in recurrent financial balance and a combination of cost reductions and limiting the impact of demographic changes will ensure that this continues.

There are a number of key variables that may affect the financial outlook:

• Further growth in hospital care activity in excess of planned levels;

• Potential financial impact of reductions in centrally funding budgets;

• NHS reorganisation and the transformational costs; and

• Growth in costs of both continuing healthcare and learning disabilities as a result of financial pressures on the Local Authority.

Our risk profile will be managed by our risk management framework.

Contracting for quality Our quality strategy details our approach to ensuring quality in the services we commission.

Warrington CCG ensures the delivery schedules of the quality and safety targets by setting these out within its agreed contract

All of the indicators within these schedules are performance managed closely as part of the routine monthly Contract Monitoring arrangements and action plans agreed where breaches occur.

Our GP Governing Body Members attend the monthly contract meetings and take a lead role in maintaining and ensuring the quality of the services we commission as part of our business as usual throughout the QIPP Programme.

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41

4.5. Enablers 4.3 Supporting strategies and support

Workforce Assurance Our Organisational Development plan details our organisational development objectives. These are: • Development needs; • Governance and Accountability; • Commissioning plan/process; • Engagement and Partnerships; • Leadership and Values; • People; • Financial Control; and • Managing change. The key workforce assurance themes must demonstrate triangulation between workforce, finance and activity to support the “One Single Integrated Plan” framework with transition and service visions for CCGs to deliver alignment and assurance of the vision. Commissioning Support Service We have developed our Management structure to ensure strategic alignment between commissioning agenda, our objectives and vision whilst delivering strategic alignment and effective delivery of national and local targets. Defining the management structure of the CCG has been a key task that was undertaken throughout 2011/12. The design of the structure in July 2011 with an initial do/by/share analysis. This was refined towards the end of 2011 and early 2012 as part of a programme of work with the emerging Cheshire Warrington and Wirral Commissioning Support Service. This allowed the CCG to confirm the structure that can be found in our Organisational Development Plan.

We believe this structure has sufficient capacity and capability to effectively deliver the agenda within the nationally defined budget of £25/head.

The CCG will continue to review this structure until March 2013 and will also continue discussions with Halton CCG and Warrington Borough Council about possible areas where joint working may produce further effectiveness and efficiency.

WHO WE ARE


THE FUTURE

CASE FOR CHANGE

ENABLERS

5. Our Future

Through delivering our commissioning priorities we will achieve our vision. The flowing page details what the public and patients can expect over the in the short and medium term.

43

Over the next two years: • We will work with our partners and stakeholders to deliver a holistic approach

which improves the health of the public • Our performance against the NHS Outcomes Framework and NHS

constituent will continually improve; • The use of screening and early interventions will provide the best outcomes

from patients; • Patient experience surveys carried out in services that we commission will

show an improving trend; • Shared decision making will be the norm – so that patients are clear on the

options available to them and they can as a result make decisions in partnership with their clinician;

• We will communicate with our patients in an open, transparent and honest way. Our communication will be enhanced through a range of innovative mechanisms including social media;

• Admission to hospital should only happen when the care needed requires a patient to see a specialist and where other options have been explored first;

• Information will be routinely published around the clinical commissioning group achieving financial balance each year.

;

5. The Future 5.1 What the future will look like

As a result of our plan patients and the public can expect to see over the next 3-5 years: • Provision of quality services that are patient focussed and offer value

for money; • We will continue to work with the local authority to deal with factors

that impact on ill health, such as deprivation and poor housing; • Working with partners to reduce inequalities in areas of deprivation

and promote healthy lifestyles; • Improved access to services and reduced waiting times; • Reduced admissions to hospital by avoiding unnecessary admissions; • A better a preventative, anticipatory, whole person approach to long

term conditions will be in place; • Mental health and well being will be promoted with an aim to prevent

mental ill health; • Quality end of life care is standard for every patient; • Improved health and care of children in Warrington; • We will provide focused service delivery and support to vulnerable

groups such as carers, veterans and prisoners.

WHO WE ARE


THE FUTURE

CASE FOR CHANGE

ENABLERS


Complaints Policy Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Complaints Policy

PURPOSE OF REPORT: To present the CCG Complaints Policy to the Governing Body for ratification

REPORT PREPARED BY: Rebecca Knight Head of Assurance & Risk

KEY POINTS/TEAM BRIEF: CCG Complaints Policy for implementation



1) Review and discuss the CCG Complaints Policy;

2) Ratify the CCG Complaints Policy



2


Reporting and investigation of complaints is imperative to the safety of patients in Warrington.


Reporting and investigation of complaints may identify lessons to be learned which may improve clinical effectiveness


Patient experience may not always be positive and result in a complaint being made. Learning from such incidents is imperative to improving patient experience and preventing such incidents from occurring in the first place



If yes, how will this impact on these requirements







All






3



No














Complaints Policy Warrington Clinical Commissioning Group Governing Body Meeting 4 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP COMPLAINTS POLICY

INTRODUCTION 1. Warrington CCG has a responsibility to ensure that it has

arrangements in place for handling complaints, which are compliant with the statutory framework for complaints handling.

2. This Complaints Policy has been developed to ensure Warrington CCG is compliant with the statutory framework and to enable the CCG to analyse and act upon information arising from complaints to translate into priorities for improvement in services, access and outcomes.

3. The full Policy is attached for reference at Appendix A.

UPDATES TO THE POLICY

4. The Policy has been updated to reflect the changes in the commissioning of health services. This now identifies who can raise a concern or complaint and under which circumstances.

5. The Policy identifies that Cheshire and Merseyside Commissioning Support Unit provides the PALS and Complaints service on behalf of Warrington CCG.

6. Guidance is now included for persistent or unreasonable complainant behaviour.

RECOMMENDATIONS 7. The Governing Body Committee is asked to:

a) Review and discuss the newly developed Complaints Policy; and b) Ratify the Complaints Policy.

Rebecca Knight Head of Assurance & Risk

Complaints Policy (Listening, Responding and Learning from Views and Concerns) Version 1.0

Ratified By NHS Warrington Clinical Commissioning Group Governing Body

Date Ratified Author(s) Head of Assurance & Risk Responsible Committee / Officers

NHS Warrington Clinical Commissioning Group Governing Body

Date Issue Policy number RM/POL/005

Intended Audience All NHS Warrington Clinical Commissioning Group employed staff

Impact Assessed

Further information about this document:

Document name Complaints Policy(Listening, Responding and Learning from Views and Concerns)

Category of Document in The Policy Schedule

Corporate

Author(s) Contact(s) for further information about this document

Head of Assurance & Risk [email protected] 01925 843709

This document will be read in conjunction with

Incident Reporting, Management and Review Policy Disciplinary Policy and Procedure Individual and collective grievance and disputes policy and procedure Freedom of Information Act Policy Health Records Policy Equality and Diversity Policy Claims Handling Policy Communications & Engagement Strategic Plan Dignity at Work Policy Health and Safety Policy Policy for the Management of Public Interest Disclosure (Whistleblowing) Violence and Aggression Policy

Published by

NHS Warrington Clinical Commissioning Group Millennium House 930-932 Birchwood Boulevard Birchwood Warrington, WA3 7QN Main Telephone Number: 01925 843600 Main Email Address: [email protected]

Copies of this document are available from

Website: www.warringtonccg.nhs.uk

Copyright © NHS Warrington Clinical Commissioning Group, 2012. All Rights Reserved

Version Control: Version History: Version Number Reviewing Committee / Officer Date

0.1 NHS Warrington Clinical Commissioning Group Quality Committee 16.10.12

0.2 Head of Assurance & Risk (amendments made following comments at Quality Committee) 22.10.12

1.0 NHS Warrington Clinical Commissioning Group Governing Body 14.11.12

Complaints Policy Listening, Responding and Learning from Views and Concerns Draft Version 1.0 October 2012 Page 1

Complaints Policy Listening, Responding and Learning from Views and Concerns Draft Version 1.0 October 2012 Page 1

Contents

PAGE

1 INTRODUCTION 1 2 WHAT OUR COMMITMENT MEANS 1 3 SCOPE AND PURPOSE OF THE POLICY 2 4 WHAT IS A COMPLAINT? 2 5 WHO CAN COMPLAIN? 2 6 TIME LIMIT FOR MAKING A COMPLAINT 3 7 MANAGEMENT OF COMPLAINTS 3 8 RESPONSIBILITIES FOR COMPLAINTS

ARRANGEMENTS 3

9 STAGES IN THE COMPLANTS PROCEDURE 3 9.1 Local Resolution 3 9.3 Health Service Ombudsman 4 10 UNREASONABLY PERSISTENT AND UNREASONABLE

COMPLAINANT BEHAVIOUR 4

11 KEY PERFORMANCE INDICATORS 5 12 13 14 15

IMPLEMENTATION AND MONITORING TRAINING REVIEW AND REVISION ARRANGEMENTS FURTHER GUIDANCE AND READING APPENDIX 1 Complaints Process Map

APPENDIX 2 Risk Assessment Matrix

APPENDIX 3 Guidance for dealing with unreasonably persistent, or unreasonable complainant behaviour

5 5 5 6 7 8 9

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Complaints Policy Listening, Responding and Learning from Views and Concerns Version 0.1 October 2012

1. INTRODUCTION

1.1 The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 allow the flexibility to adopt a unified two stage complaints procedure across Health and Social Care.

1.2 NHS Warrington Clinical Commissioning Group is committed to proactively building continuous and meaningful engagement with the public and patients to shape services and improve health. We view complaints as a positive opportunity to learn from and improve the way in which we carry out our functions and improve patient experience.

2. WHAT OUR COMMITMENT MEANS

2.1 We are committed to proactively building continuous and meaningful engagement with the public and patients to shape services and improve health.

2.2 We will manage complaints in accordance with our statutory obligations; our stated vision, goals, promises and objectives.

2.3 We will ensure that complaints are managed promptly and efficiently, are properly investigated and that complainants are treated with respect.

2.4 We will comply with the Health Act 2009 and the NHS Constitution and ensure that patients have the right to:

Independent Complaints Advocacy Service

have any complaint about NHS services dealt with efficiently and to have it properly investigated;

know the outcome of any investigation into their complaint;

take their complaint to the independent Parliamentary and Health Service Ombudsman, if they are not satisfied with the way their complaint has been dealt with by us.

2.5 We will ensure that there are systems in place so that that patients, relatives and carers who complain:

have suitable, accessible information about how to feedback on the quality of services and raise complaints;

are treated equally and will not discriminated against because of race, ethnic origin, nationality, gender, culture, religion or belief, sexual orientation, age, disability or marital status;

are assured that we act on any concerns, and where appropriate, make changes and improvements to service delivery and care

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2.6 The above requirements form our obligations on which to ensure good

complaint handling, promoted by the Parliamentary and Health Service Ombudsman’s Principles for Remedy in investigating and handling complaints.

3 SCOPE AND PURPOSE OF THE POLICY

3.1 The purpose of this policy is to outline the way in which complaints will be handled, it does not duplicate issues, which are clearly set out in the guidance and legislation, but adapts and supplements these to meet local needs.

3.2 This policy sets out the scope of the complaints procedure within NHS Warrington Clinical Commissioning Group and the steps that will be followed.

3.3 This policy has twin aims:

to resolve complaints more effectively by responding more personally and positively to individuals who are unhappy;

to ensure that opportunities to learn and improve quality of services and care are not lost

3.4 The scope of this policy does not apply to, amongst others, any complaint:

by third party organisations about contracts arranged by NHS Warrington Clinical Commissioning Group under its commissioning arrangements;

made by an employee relating to their employment;

which is being, or has been investigated, by the Parliamentary and Health Service Ombudsman

4 WHAT IS A COMPLAINT?

4.1 A complaint is an expression of dissatisfaction. NHS Warrington Clinical Commissioning Group utilises the Patient Advice and Liaison Service to resolve verbal concerns by the next working day and to provide advice on how to complain.

5 WHO CAN COMPLAIN?

5.1 A concern or a complaint may be raised under this policy by anyone:

(a) who is receiving, or has received, NHS treatment / services which are commissioned by the CCG, including hospital services and community services within Warrington.

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(b) or a relative or friend on behalf of the patient, if they have been given permission to act; and who is affected by or likely to be affected by the action, omission or decision of the responsible body which is the subject of the complaint.

5.2 The main services commissioned by Warrington CCG include:

Warrington & Halton Hospitals Foundation Trust

Bridgewater Community Healthcare Trust

5 Boroughs Partnership Foundation Trust

St Rocco’s Hospice

Spire Cheshire Hospital

5.3 From April 2013, the NHS Commissioning Board Local Area Team will be responsible for managing complaints services for complaints regarding independent contractors (GPs, pharmacists, dentists and opticians) as the NHS Commissioning Board is the statutory body responsible for contracting these services and complaints about these services fall outside of this policy. The NHS Commissioning Board will be developing its own complaints policy and process.1

5.4 In addition, the link below takes you to a commissioning factsheet produced by the NHS Commissioning Board. This sets out the services to be commissioned by CCGs, NHS Commissioning Board, local authorities and Public Health England.

http://www.commissioningboard.nhs.uk/files/2012/09/fs-ccg-respon.pdf

6 TIME LIMIT FOR MAKING A COMPLAINT

6.1 The time limit for making a complaint is normally within 12 months of the incident. However discretion can be applied to vary this time limit where it is considered appropriate.

1 NHS Commissioning Board, Task and Functions: Securing Excellence in Commissioning Primary Care, Annex 2, June 2012

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7. MAKING PATIENTS AND THE PUBLIC AWARE OF OUR COMPLAINTS ARRANGEMENTS

7.1 It is important that all our patients and members of the public are aware of how to complain. To ensure this, this policy will be published on our website.

All GP practices will advertise in accessible language how to make a complaint.

Complaints are an important part of understanding the patient experience and as such will be considered as part of the triangulation process which brings together feedback from a range of sources to inform:

Clinicians

Commissioning Support

Quality Committee

Governing Body

Outcomes, lessons learnt and response to complaints will be reported regularly to the Quality Committee and Governing Body. These reports will be available to the public when posted on our website.

8 MANAGEMENT OF COMPLAINTS

8.1 Complaints will be managed by Cheshire, Warrington and Wirral Commissioning Support Unit in accordance with the agreed process in Appendix 1.

8.2 The principles of Being Open, which encourage truthfulness, timelines and clarity of communications will be observed when investigating, analysing and changing practice as a result of complaints.

9 RESPONSIBILITIES FOR COMPLAINTS ARRANGEMENTS

9.1 It is the responsibility of all staff to be receptive to all forms of feedback, including complaints and appreciate that such information is an essential element of good governance.

9.2 As Accountable Officer, the Chief Clinical Officer of Warrington Clinical Commissioning Group is responsible and accountable for ensuring:

overall implementation, monitoring and effectiveness of the policy;

allocation of resources to provide compliance with the policy;

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Managers are aware of their responsibilities and comply with the policy.

9.3 NHS Warrington Clinical Commissioning Group has purchased its Patient Advice and Liaison and Complaints Service from the Cheshire, Warrington and Wirral Commissioning Support Unit through a Service Level Agreement arrangement.

10 STAGES IN THE COMPLAINTS PROCEDURE

Local Resolution

10.1 To achieve our first aim which is to resolve complaints more effectively by responding more personally and positively to individuals who are unhappy; we will make every effort to ensure that:

we try to solve that problem personally and immediately;

all verbal concerns that cannot be resolved by the next working day are recorded as complaints;

if the complaint cannot be resolved by the next working day an Individual Complaints Action Plan is drawn up in conjunction with the person making the complaint;

complaints are graded using the risk assessment matrix Appendix 2 to ensure the appropriate level of investigation is undertaken;

all complainants are offered an opportunity to discuss their complaint and asked what they think needs to happen to resolve it;

complaints are dealt with flexibly, with the aim of achieving the desired outcome if that is possible, as early as possible;

timescales for dealing with complaints are as short as realistically possible and complainants are kept informed if they cannot be met.

10.2 To achieve the second aim which is to ensure that opportunities to learn and improve are not lost, we will ensure that:

all complaints that are resolved immediately are recorded and resolutions shared;

every complaint is scrutinised so that we understand what went wrong and how we can do better next time;

the lessons from complaints are discussed at senior management level;

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records are analysed and any common themes are also discussed at senior management level;

senior managers make decisions about how improvements can be made;

those decisions are followed through and monitored to make sure they are implemented.

Health Service Ombudsman

10.3 If the complainant remains dissatisfied with the actions undertaken following the investigation and the response received; they have the right to ask the Health Service Ombudsman to review their complaint. Where a complaint is referred to the Ombudsman any information received as part of their investigation may be used to assess the organisation’s performance. The Health Service Ombudsman is independent of the NHS.

11 UNREASONABLY PERSISTENT AND UNREASONABLE COMPLAINANT BEHAVIOUR

11.1 Unreasonable and unreasonably persistent complainants are those complainants who, because of the frequency or nature of their contacts, hinder the consideration of their own, or others, complaints.

NHS Warrington Clinical Commissioning Group has guidance for dealing with persistent, serial or unreasonable complainants. The guidance is contained in Appendix 3 and should only be implemented by Cheshire, Warrington and Wirral Commissioning Support Unit following advice from the Chief Clinical Officer.

12 KEY PERFORMANCE INDICATORS

Number of complaints acknowledged in 3 working days – Performance Target to achieve 100%.

Number of complaints responded to within timescale agreed with complainant – Performance Target to achieve 100%.

Number of complaints notified by the Ombudsman (second stage) where further recommendations have been required, in relation to the Complaints Procedure – Performance Target Nil.

Number of agreed outcomes which results in effective change of patient experience – Performance Target to achieve 100%.

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13 IMPLEMENTATION AND MONITORING

13.1 A PALS and Complaints report will be produced on a quarterly and annual basis by the Cheshire, Warrington and Wirral Commissioning Support Unit for the CCG. The reports will triangulate PALS and complaints data with quality and safety data.

13.2 Reports will be presented and discussed at the Patient Experience and Quality Group and Quality Committee of the CCG, in order to:

Monitor arrangements for local complaints handling;

Consider trends in complaints

Consider complaints data in relation to patient experience data, quality and safety data and identify any trends to inform the commissioning and improvement of services; and

Consider within the data above, the numbers of complaints which the CCG considers are upheld to identify what lessons can be learned and the improvements that can be made as a result.

14 TRAINING

14.1 Complaints Training is identified as mandatory and forms part of the Corporate Induction Programme. More in-depth training is provided for managers who investigate and prepare draft responses to complaints.

15. REVIEW AND REVISION ARRANGEMENTS

15.1 This policy will be reviewed every 5 years or less as a result of a change in legislation, guidance or operating processes.

16. FURTHER GUIDANCE AND READING

16.1 This document has been produced with reference to the following documents:

The Local Authority Social Service Complaints (England) Regulations 2009

http://www.opsi.gov.uk/si/si2009/uksi_20090309_en_1

Guidance to the Regulations: Listening, responding, and improving: a guide to better customer care.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_095408

Ombudsman’s Principles for:

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Good complaint handling -

www.ombudsmanorg.uk/improving_services/principles/complaint_handling?index.html

Good Administration -

http://www.ombudsman.org.uk/improving_services/principles/good_administration/index.html

Remedy -

http://www.ombudsman.org.uk/improving_services/principles/remedy/principles_remedy.html#pr

NHS Constitution

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093421

Health and Social Care Act 2008

http://www.dh.gov.uk/en/Publicationsandstatistics/Legislation/Actsandbills/HealthandSocialCareBill/index.htm

National Patient Safety Agency – Being Open Guidance

http://www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/beingopen/

Standards for Better Health

http://www.cqc.org.uk/

Complaints Policy Listening, Responding and Learning from Views and Concerns Version 1.0 September 2012

APPENDIX 1

Complaints Process Map

Patient Safety Incidents Notified about NHS Care Provided through NHS Standard Contracts and APMS Contracts

Ch

esh

ire

CSS

Key

Potential serious incident – Not

StEISable

Identify level of harm/potential harm

Actual and Potential Harm Graded

as Moderate and Above & poor patient experience

Low Harm/Potential Harm

incident

Identified Trends shared

with Provider for Investigation

and Response on the 1st of the month

Request to Provider for Investigation and Response

re Identified Trend and notifier informed

Major and Above Incidents Managed

via the Serious Incident Process & CCG to be

notified verbally – Same day, within office hours

CCG notified verbally – Same day, within office

hours

Day 15 of month - Response from Provider

Intelligence Reports CCG

Review previous harms & identify if incident will be

sent straight to the Provider

Incident flagged over to be sent to the Provider on the 1st of the month

Request response individually from Provider

within 2 working weeks

Reponse received from Provider

Head of Quality CCG – To be notified weekly of

these incidents

No TrendIdentified

- Incident noted

Notifier informed of response

Output Business Intelligence

Response noted for next

Serious Incident Group

Receipt of incident Check criteria before accepting reported

incident

Response forwarded to notifier and CCG

Start/End

DecisionSub

process

Process


APPENDIX 2

Risk Assessment Matrix

GRADING TABLE

Risk Assessment Circle consequence, likelihood and total score

e.g. 2 x 3 = 6

SCORE

INCIDENT

CONSEQUENCES or POTENTIAL CONSEQUENCES

LIKELIHOOD/PROBABILITY OF REPEAT

Rare

1

Unlikely

2

Possible

3

Highly Likely

4

Almost Certain

5

1 Insignificant 1 2 3 4 5

2 Minor 2 4 6 8 10

3 Significant 3 6 9 12 15

4 Serious 4 8 12 16 20

5 Catastrophic 5 10 15 20 25

Green (score 5 or less)

(Local Management)

Low risk Low priority Manage situation by routine procedures

Amber (score 6 to 15)

(Commissioning Management lead)

Medium risk medium priority Medium priority

Management responsibility and action must be specified

Red (score 16 to 25)

Or any incident recorded as Catastrophic regardless of the likelihood/probability of repeat

(Senior Management / Governing Body involvement)

High risk high priority High priority

Immediate action – Senior Management attention required. 16+ Senior Management to consider informing the Board.


APPENDIX 3

Guidance for dealing with unreasonably persistent, or unreasonable complainant behaviour

This guidance should only be implemented by NHS Warrington Clinical Commissioning Group following advice from the Chief Clinical Officer.

Occasionally staff are presented with persistent or unreasonable behaviour from complainants. Complaints staff and investigating managers are trained to respond with patience and sympathy to complainants, but it is recognised that there are times when there is nothing further that can reasonably be done to rectify a real or perceived problem.

What process should be followed in dealing with persistent or unreasonable complainant behaviour?

It is important to appreciate that such complainants may have genuine grievances that should be properly investigated. The Cheshire, Warrington and Wirral Commissioning Support Unit complaints team must first ensure that NHS Warrington Clinical Commissioning Group’s Complaints Policy has been fully implemented and that no element of the complaint has been overlooked or not properly addressed.

If the Cheshire, Warrington and Wirral Commissioning Support Unit recognises that the complainant may be persistent or unreasonable, this concern would be discussed initially with the Head of Assurance & Risk. This should only be a last resort after all reasonable measures have been taken to try and resolve the complaint. It is good practice to make clear to a complainant the ways in which his or her behaviour is unacceptable, and the likely consequences of refusal to amend it, before referring the matter to the Chief Clinical Officer. If all reasonable measures have been taken, the Head of Assurance & Risk will discuss with the Chief Clinical Officer and request that a decision is undertaken regarding how the complaint should be managed.

If the investigation is underway, the Chief Clinical Officer may write to the complainant setting parameters for a code of behaviour, and inform the complainant that if these parameters are contravened consideration will be made to implement further action.

If the complainant is abusive or threatening, it is reasonable to inform him or her of the requirement to communicate in one way, for example in writing and not by telephone or solely with one designated member of staff.

If the complainant has received a final response and there is no further action to be taken by NHS Warrington Clinical Commissioning Group, the Chief Clinical Officer will write to the complainant informing them that a full response has been made to their complaint, that correspondence is at an end and reiterate the right of the complainant to contact the Ombudsman.


Withdrawing persistent or unreasonable status

Staff should have used discretion in recommending unreasonable status and discretion should similarly be used in recommending this status be withdrawn.


Update on Safeguarding Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Update on Safeguarding

PURPOSE OF REPORT: To update the Governing Body on current arrangements for safeguarding within the CCG

To highlight the new inspection framework arrangements for the protection of children


KEY POINTS/TEAM BRIEF: Arrangements in place for safeguarding for the CCG

New joint inspection framework arrangements for the protection of children


The Governing Body is asked to: 1. Receive assurance that the appropriate

safeguarding arrangements are in place for the CCG

2. Receive an update on the new joint inspection arrangements for the protection of children



2


It is imperative that the CCG has appropriate safeguarding arrangements in place which will ensure patient safety


Learning from safeguarding alerts can be used to improve clinical effectiveness


Patients may be subjected to continued poor experience in the event of a lack of safeguarding procedures which can be used to alert the CCG and local authority to neglect and/or abuse. Learning can be used to influence change in patient experience









Group’s Priority Workstreams? No







3



Yes

4.7














Update on Safeguarding Warrington Clinical Commissioning Group Meeting 4 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP UPDATE ON SAFEGUARDING

INTRODUCTION 1. The NHS Commissioning Board issued interim guidance in September 2012

on the arrangements to secure children’s and adults safeguarding in the future NHS1.

2. The interim guidance provides clarity about responsibilities in relation to safeguarding within the new NHS arrangements.

3. Both Warrington CCG and the NHS Commissioning Board will be statutorily responsible for ensuring that the organisations from which they commission services provides a safe system that safeguards children and vulnerable adults. This includes specific responsibilities for looked after children and for supporting the child death overview process.

4. Warrington CCG and the NHS Commissioning Board will have a statutory duty to be members of the Local Safeguarding Children Board and (subject to the Care and Support Bill) Safeguarding Adults Board in Warrington.

5. Warrington CCG must demonstrate that it has appropriate arrangements in place for discharging its responsibilities in respect of safeguarding. The arrangements are reflected in this paper.

NHS COMMISSIONING BOARD

6. The Board’s national leadership team will include the Chief Nursing Officer and the regional and local area teams will each have a Director of Nursing who will be responsible for supporting and providing assurance on the safeguarding of vulnerable children and adults.


Training

7. Safeguarding training for children and vulnerable adults is provided to all CCG staff and is available on the e-learning system. This is a statutory / mandatory requirement and compliance is monitored by the Human Resources team.

Accountability

8. The Chief Clinical Officer is accountable for safeguarding within Warrington CCG and is a member of the Governing Body.

9. The responsibility for safeguarding is delegated to the Head of Assurance & Risk who provides a monthly update to the Quality Committee on

1 Arrangements to secure children’s and adults safeguarding in the future NHS – NHS Commissioning Board September 2012



safeguarding arrangements and issues. The Head of Assurance & Risk is a voting member of the Local Safeguarding Children’s Board and Safeguarding Adults Board in Warrington.

10. The above arrangements are supported by a local GP, Dr Anita Malkhandi, who is also a member of the Governing Body and has an interest in safeguarding issues.

Specialised safeguarding posts

11. The CCG has secured the expertise of a number of staff to required posts. These include:

a) Charlie Whelan – Designated Nurse for Safeguarding Children and Children in Care;

b) Dr Ify Omenaka – Designated Doctor for Safeguarding Children;

c) Dr Nisar Mir – Designated Doctor for Child Death Overview Panel

d) Dr Natalia Bell – Designated Doctor for Children in Care

e) A Designated Nurse for Safeguarding Adults has recently been appointed and will take up the post shortly;

f) Penny Davidson – Mental Capacity Act Co-ordinator and lead for the Mental Capacity Act

12. Both Designated Nurse roles are located with the appropriate safeguarding teams at Warrington Borough Council to ensure that there is full integration between the services.

JOINT INSPECTION OF MULTI-AGENCY ARRANGEMENTS FOR THE PROTECTION OF CHILDREN

13. With effect from June 2013, Ofsted, the Care Quality Commission (CQC), Her Majesty’s Inspectorate of Constabulary, Her Majesty’s Inspectorate of Prisons and Her Majesty’s Inspectorate of Probation will begin new inspections.

14. The inspections will focus on the effectiveness of local authority and partners’ services for children who may be at risk of harm, including the effectiveness of early identification and early help.

15. The framework will focus directly on practice and the experiences of children young people, including the effectiveness of the help and protection they receive.

16. Warrington has been selected as a pilot site for the new arrangements. Four areas have been selected as pilot sites and these inspections will be undertaken in the months of December 2012 and January 2013. Warrington’s inspection will be unannounced but will take place in January 2013.



17. Weekly multi-agency meetings have been planned to help prepare for the inspection and locally, a series of meetings have been organised for health providers to ensure that we understand the work and evidence that is required and that we (as a commissioner) have full oversight of any areas that require improvement.

Summary of the main proposals

18. There will be an unannounced joint inspection of the multi-agency arrangements for the protection of children in each local authority area on a three year cycle;

19. Information relating to the quality and effectiveness of the Crown Prosecution Service (CPS) in protecting children and young people through effective liaison between the CPS and other agencies and the quality of decision making in relation to prosecutions may trigger inspection activity by Her Majesty’s Crown Prosecution Service Inspectorate;

20. Inspections will be contained in a two week period;

21. Inspections will track the experiences of individual children and young people through identifying a shared sample of children and young people which will include observing practice to understand the effectiveness of the help and protection given;

22. Inspectorates will focus on the practice of individual agencies in identifying, responding to, helping and protecting children and young people through local agreed arrangements;

23. There will be one single set of inspection judgements as an outcome of the inspection;

24. There will be a single report that identifies the strengths and areas for improvement of the multi-agency response as well as those of individual agencies.

RECOMMENDATIONS

25. The Governing Body is asked to:

a) Receive assurance that the appropriate safeguarding arrangements are in place for the CCG

b) Receive an update on the new joint inspection arrangements for the protection of children

Rebecca Knight

Head of Assurance & Risk


Risk Management Policy Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Risk Management Policy

PURPOSE OF REPORT: To present the CCG Risk Management Policy to the Governing Body for ratification


KEY POINTS/TEAM BRIEF: CCG Risk Management Policy to be implemented



1) Review and discuss the newly developed CCG Risk Management Policy;

2) Ratify the CCG Risk Management Policy



2


Identification of risk may help to improve patient safety as a result of actions implemented.


Identification of risk may help to improve clinical effectiveness as a result of actions implemented


Identification of risk relevant to patient experience may help to improve overall patient experience as a result of improvements to services



If yes, how will this impact on these requirements







All






3



Yes

All














Risk Management Policy Warrington Clinical Commissioning Group Governing Body Meeting 4 14th November 2012


RISK MANAGEMENT POLICY

INTRODUCTION 1. Warrington CCG has a statutory responsibility and regulatory obligation

to ensure that systems of control are in place to minimise the impact of all types of risk, which could affect the proper functioning of Warrington CCG.

2. This Risk Management Policy is designed to enable Warrington CCG to have a clear view of the risks affecting each area of its activity, how those risks are being managed, the likelihood of occurrence and their potential impact on the successful achievement of the CCG objectives.

3. The full Policy is attached for reference at Appendix A.

UPDATES TO THE POLICY

4. The Policy has been updated from that of the PCT to reflect the roles and responsibilities of individuals and Committees in relation to risk. It identifies the governance arrangements for risk including the reporting arrangements for all risk as well as strategic risk.

5. Assessment of risk has not changed and details are included in the Policy in relation to this and the management and monitoring arrangements of all risks on the Risk Register.

6. The Policy outlines the need for all risks to be reported to relevant Committees by senior management. Therefore, if there is a risk relating to finance, this will be reported to the Finance and Performance Committee outlining the description of risk, controls and assurances in place and any actions required to mitigate the risk further.

7. All strategic risk, risks scored at 15 and above and risks with a catastrophic impact (regardless of likelihood) will be reported to the Governing Body on a quarterly basis. This will be done via the Assurance Framework.

8. Medium risks (scored between 6-12) will be reported to the Governing Body on a six monthly basis and low level risks (scored at 5 and below) below this score will be reported annually.

9. The Assurance Framework will next be reported to the Governing Body at its meeting in January 2013.


Risk Management Policy Warrington Clinical Commissioning Group Governing Body Meeting 5 14th November 2012

RECOMMENDATIONS 10. The Governing Body is asked to:

a) Review and discuss the Risk Management Policy; and b) Approve the Risk Management Policy.

Rebecca Knight Head of Assurance & Risk

Risk Management Policy Version 3.0

Ratified By NHS Warrington Clinical Commissioning Group Governing Body

Date Ratified

Author(s) Head of Assurance & Risk

Responsible Committee / Officers

NHS Warrington Clinical Commissioning Group Audit Committee

Date Issue

Policy number RM/POL/001

Intended Audience All NHS Warrington Clinical Commissioning Group employed staff

Impact Assessed

Further information about this document: Document name Risk Management Policy Category of Document in The Policy Schedule Corporate

Author(s) Contact(s) for further information about this document

Head of Assurance & Risk [email protected] 01925 843709

This document will be read in conjunction with

Incident Reporting, Management and Review Policy Disciplinary Policy and Procedure Individual and collective grievance and disputes policy and procedure Freedom of Information Act Policy Health Records Policy Equality and Diversity Policy Claims Handling Policy Complaints Policy Communications & Engagement Strategic Plan Dignity at Work Policy Health and Safety Policy Policy for the Management of Public Interest Disclosure (Whistleblowing) Violence and Aggression Policy

Published by

NHS Warrington Clinical Commissioning Group Millennium House 930-932 Birchwood Boulevard Birchwood Warrington, WA3 7QN Main Telephone Number: 01925 843600 Main Email Address: [email protected]

Copies of this document are available from

Website: www.warringtonccg.nhs.uk

Copyright © NHS Warrington Clinical Commissioning Group, 2012. All Rights Reserved

Version Control: Version History: Version Number Reviewing Committee / Officer Date

2.1 Head of Governance & Risk – complete document refresh

January 2012

2.2 Amendments to Policy following circulation to key members of staff

January 2012

2.3 Assurance Committee review – further updates required

February 2012

2.4 Ratified by Assurance Committee April 2012

3.0 Policy refresh for CCG November 2012

3.0 Approved by CCG Governing Body November 2012

Risk Management Policy Draft Version 3.0 November 2012 Page 1

Risk Management Policy Draft Version 3.0 November 2012 Page 1

Contents

PAGE

1 Introduction 3

2 Scope of policy 3

3 Roles and responsibilities 3

4 Risk management 5

5 Valuing risk management 6

6 Risk management definitions 6

7 Risk identification 7

8 Risk assessment 7

Recording the risk assessment

Evaluation and scoring

Risk treatment

Assurance

Communication of risk with third parties

Review of risks

9

9

10

10

11

11

9 Assurance framework 12

10 Risk appetite 12

11 Dissemination and implementation 13

12 Policy approval 13

13 Monitoring compliance and effectiveness 13

14 Key performance indicators 13

15 References 14

Appendix A – Risk management process 15

Appendix B – Examples of drivers of key risks 16

Appendix C – Risk assessment template 17

Appendix D – Risk matrix for risk assessment 20

Appendix E – Risk scoring table 21

Risk Management Policy Draft Version 3.0 November 2012 - 3 -

1. INTRODUCTION

1.1 NHS Warrington Clinical Commissioning Group (CCG) has a statutory and regulatory obligation to ensure that systems of control are in place to minimise the impact of all types of risk, which could affect the proper functioning of Warrington CCG.

1.2 Every activity that the CCG undertakes or commissions others to undertake, brings with it some element of risk that has the potential to threaten or prevent the CCG achieving its objectives

1.3 NHS Warrington CCG recognises that a key factor in driving its priorities is to ensure that effective risk management arrangements are in place and embedded in the organisation’s practices and processes. Effective risk management arrangements will, in addition to helping ensure goals and objectives are met, help ensure compliance with statutory, mandatory and ‘best practice’ requirements.

2. SCOPE OF POLICY

2.1 This Policy applies to all staff employed by NHS Warrington CCG. All suppliers, contractors and providers of service to the CCG must have their own risk management system in place, which may be monitored by the contract review process.

3 ROLES AND RESPONSIBILITIES

3.1 Chief Clinical Officer (Accountable Officer) is ultimately responsible for ensuring that an effective system of risk management and internal control is in place for the CCG.

3.2 Head of Assurance and Risk has responsibility (delegated from the Chief Clinical Officer) for leading risk management within the CCG, ensuring that robust systems are in place and operating effectively. The Head of Assurance and Risk also has delegated responsibility as CCG Lead for safeguarding children and vulnerable adults.

3.3 Chief Operating Officer is nominated as the CCG Senior Information Risk Officer (SIRO). The SIRO is responsible for:

Understanding how the strategic business goals of the CCG may be impacted by information risks; acting as an advocate for information risk on the Governing Body and in internal discussions;

Ensuring the Governing Body is adequately briefed on information risk issues;

Overseeing the development of information risk policies and procedures;

Reviewing the annual information risk assessment to support and inform the Statement on Internal Control;


Taking ownership of risk assessment processes for information risks, supported by the relevant expert from Cheshire, Warrington & Wirral Commissioning Support Unit and the Caldicott Guardian;

Reviewing and agreeing action in respect of identified information risks;

Providing a focal point for the resolution and/or discussion of information risk issues; and

Ensuring that identified information security breaches / threats are followed up and incidents managed.

3.4 Chief Finance Officer has overall responsibility for the integrity of the system of internal financial controls, financial risk and other specific responsibilities set out in the Standing Financial Instructions. The Chief Finance Officer is responsible for:

Financial risk management and performance risk management;

Internal audit;

Ensuring compliance with the core Financial Management Controls Assurance standard, Auditors Local Evaluations and Key Lines of Enquiry;

Ensuring the effectiveness of the CCGs financial control systems, including counter fraud measures; and

Ensuring that the significant financial risks, including QIPP risks, faced by the CCG are identified and managed effectively.

3.5 All Managers have a responsibility to ensure that policies and procedures are followed, that areas of risk within their remit are identified, assessed and added to the CCG Risk Register and action plans are developed and monitored on a regular basis depending on the risk score. Managers must ensure that in the event of any concerns relating to risks in their remit, they escalate these to the appropriate CCG Committee for review, discussion and agreement of the steps required to mitigate the risk to a satisfactory level.

3.6 All staff are responsible for the following:

Managing risk within their sphere of responsibility. It is a statutory duty to take reasonable care of their own health and safety and the safety of others who may be affected by acts or omissions;

For carrying out any individual action plan allocated to them in relation to mitigating a risk;

To attend all mandatory training as identified;


To contribute to assessing risks in their own role and any potential risks to patients, user and visitors as well as bringing these to the attention of their managers; and

Reporting any unsafe occurrences, risks, incidents, near misses and serious incidents using the appropriate policies and procedures and taking remedial action as required.

3.7 Independent Contractors are responsible for ensuring that clinical and non clinical risk management arrangements are in place. The responsibilities for identifying and managing their own risks will be clarified through contractual arrangements through the commissioning process.

3.8 Audit Committee has a responsibility to review the establishment and maintenance of an effective system of integrated governance, internal control and risk management that supports the achievement of the CCGs objectives. The Committee will ensure the following:

Review the structure, process and responsibilities for identifying and managing key risks including the Assurance Framework;

Monitor Key Performance Indicator reports on risk management;

Monitor the development of the Assurance Framework, including continuous review to ensure that main risks have been identified; and

Monitor action plans, sources of assurance and results of assurances.

3.9 Finance and Performance Committee has a responsibility to receive monthly monitoring reports on financial and other performance areas highlighting key risks and response plans. The Committee will continually assess these risks and the measures in place to manage them.

3.10 Quality Committee has a responsibility to oversee and be assured that effective management of risk is in place to manage and address clinical governance and quality issues.

4 RISK MANAGEMENT

Overview

4.1 Risk management is the term applied to the use of a logical and systematic method of identifying, analysing, evaluating, controlling, monitoring and communicating risks associated with any activity, process or function necessary to the achievement of the CCG’s objectives. It can also be described as a method of minimising loss and maximising opportunity. Risk management is a continuous process which, if embedded and used to its full potential, will influence behaviour and develop organisational culture within which risks are recognised and addressed.

4.2 The focus of good risk management is the identification and treatment of these risks. Its objective is to add maximum sustainable value to all the


activities of the CCG. It marshals the understanding of the potential upside and downside of all those factors which can affect the CCG. It increases the probability of success, and reduces both the probability of failure and the uncertainty of achieving the CCG’s overall objectives.1

4.3 NHS Warrington CCG has a statutory responsibility to service users, the public and its staff to ensure that it has effective processes, policies and people in place to deliver its objectives and to control any risks that it may face in achieving these objectives2. A flowchart summarising the risk management process is provided in Appendix A.

5 VALUE OF RISK MANAGEMENT

5.1 Risk management protects and adds value to the CCG and its stakeholders through supporting the CCG’s objectives by:

a) Providing a framework for an organisation that enables future activity to take place in a consistent and controlled manner;

b) Improving decision making, planning and prioritisation by comprehensive and structured understanding of business activity, volatility and project opportunity / threat;

c) Contributing to more efficient use / allocation of capital and resources

within the organisation;

d) Reducing volatility in the non essential areas of the business

e) Protecting and enhancing assets and organisation image;

f) Developing and supporting people and the organisation’s knowledge base; and

g) Optimising operational efficiency

6 RISK MANAGEMENT DEFINITIONS

6.1 Risk appetite (acceptable level of risk) refers to the level of risk that the CCG is prepared to accept or tolerate after internal control is applied. If the risk score is higher than the risk appetite, further action should be taken to reduce the likelihood and / or the impact of the risk occurring. If this is not possible, contingency plans should be put in place.

1 A Risk Management standard: Institute of Risk Management (2002)

2 Health and Safety at Work etc Act 1974; Management of Health and Safety at Work Regulations 1999 (amended 2003)


6.2 Corporate risk is defined as the level of risk where potential exposure is such that visibility, monitoring and potentially intervention is required at Governing Body level. A corporate risk is defined as any risk with a score of 15 or more, or where the impact of a risk is catastrophic (regardless of the likelihood). These are currently reported under the Assurance Framework, which is reported on a quarterly basis to the CCG Governing Body.

6.3 Inherent risk is the exposure arising from a specific risk before any action is taken to manage it.

6.4 Residual risk is the risk remaining after the treatment including the controls in place and actions taken to mitigate it.

6.5 Risk tolerance is the organisation’s willingness to bear the risk after risk treatment in order to achieve its objectives (risk tolerance can be limited by legal and / or regulatory requirements).

6.6 Risk treatment describes the part of the risk assessment process relating to when decisions are made about how to treat the risk.

7 RISK IDENTIFICATION

7.1 The main areas of risk which have the potential to adversely affect staff, patients, visitors, services and resources are:

a) Clinical – any issue that may have an impact on the achievement of high quality, safe and effective care for patients;

b) Non-clinical – any issue that may have an impact on CCG objectives and / or reputation; and

c) Financial – these concern the effective management and control of the finances of the CCG (including QIPP risks)

7.2 Appendix B summarises examples of key risks and the external and internal drivers for them. Risks can also be identified through a range of proactive and reactive indicators as shown in Figure 1 overleaf.

8 RISK ASSESSMENT

8.1 Risk assessment is a step in a risk management procedure. Risk assessment is the determination of quantitative or qualitative value of risk related to a concrete situation and a recognised hazard or threat. Risks should be related to objectives.

8.2 Risk can be defined as anything that poses a threat to the achievement of objectives, programmes, service delivery to the local population, staff delivering services or an adverse incident relating to the property or assets. This may include damage or harm to the reputation of NHS Warrington CCG which could undermine public confidence. Figure 2 shows a simple risk assessment process.


Figure 1

Figure 2

Figure 3


8.3 The process shown in figure 3 (above) is the five steps to risk assessment. Additional guidance on the principles of risk assessments can be found in the National Patient Safety Agency booklet “Healthcare Risk Assessment Made Easy (March 2007)” which is available at:

www.nrls.npsa.nhs.uk/resources?EntryId45=59825

Recording the risk assessment

8.4 The risk assessment template provided in Appendix C identifies the information which should be included in a risk assessment. The template should always be used when completing the initial risk assessment.

8.5 All staff are expected to undertake risk assessments for risks which they identify using the template at Appendix C. In the event that staff require help or support in the completion of this template, they should contact the Head of Assurance & Risk or the Programme Support Officer.

8.6 Once a risk assessment has been completed, the form should be discussed and signed off with the individual’s line manager. Once the risk assessment has been agreed and signed off, the form must then be forwarded to the Programme Support Officer for entering onto Datix (risk register database).

Evaluation and scoring

8.7 The CCG uses a standard 5 x 5 risk scoring matrix for assessing the likelihood and severity of the risk. The risk matrix and impact and likelihood matrix can be found at Appendix D. Risk scores are not intended to be precise mathematical measures of risk, but are a useful tool to help in the prioritisation of control measures for the treatment of risk.

8.8 The scoring system allows the levels of risk to be easily identified and therefore prioritised. However, giving priority purely to high scoring risks may result in lower scoring and easy to manage risks, not being addressed. It may be that low scoring risks can be eliminated or reduced fairly easily, whilst higher scoring risks may be almost impossible to reduce, for example, staffing shortages due to recruitment difficulties. These risks should be clearly documented in the Risk Register so that they can be acknowledged and monitored to prevent them escalating to an unacceptable level.

8.9 The CCG uses the following guidance to manage and escalate risk:

Low risk (green) – risk is managed by operational management and routine procedures;

Moderate risk (amber) – risk is managed by the Manager and action is specified; and

High risk (red) – immediate action is required and senior management attention required. Any risks scored at 15 or above or which have been


rated as having a catastrophic impact, regardless of likelihood must be reported to the Governing Body via the Assurance Framework.

Risk treatment

8.10 The options for treating a risk include the following

a) Treat – most risks will be addressed in this way. Take direct action to reduce the level of risk to an acceptable level or eliminate it completely if possible. Existing controls should be monitored continually and any actions required implemented within the timescales identified. Actions must be allocated to the most appropriate individual, implementation dates agreed and implementation dates monitored. All risks scored at 12 and above MUST be treated. Monitoring of risk action plans must be undertaken by all managers and will be regularly overseen by the Chief Operating Officer.

b) Tolerate – a decision may be taken not to implement any additional control measures / actions. This may be that assessment of potential additional controls indicates that the cost of the control will exceed the benefits of risk reduction. The decision to tolerate a risk with a score of 10 and below must be made by the relevant manager.

c) Transfer - it may be that the risk can be transferred to another organisation by way of a contractual agreement or shared with partner organisations. In some instances, a risk may be insurable either totally or in part. However, it must be remembered that responsibility for statutory functions cannot be fully transferred and the reputational implications of risks need to be managed.

d) Terminate - the risk may be so serious that adding control measures or modifications do not reduce the risk to an acceptable level. At this stage, withdrawal from the activity should be considered.

Assurance

8.11 Assurance is an evaluated opinion, based on evidence gained from review, on the CCG’s governance, risk management and internal control framework. Another definition of assurance is where we gain evidence from that our controls / treatments, on which we are placing reliance, are effective.

8.12 Assurance can be gained from internal or external sources. External assurance is considered to be more credible as it is independent from the CCG and will therefore be more focused on looking at gaps in existing controls. Typical sources of assurance include the following:

Internal audit reviews

Management reviews

External reviews

Reports or inspections from regulators


Patient surveys / experience

Performance reports to the Governing Body and Committees

Minutes of the Governing Body and Committee meetings demonstrating review and scrutiny of controls

Monitoring of key performance indicators

Staff survey results

Planned testing of systems

Communication of risk with third parties

8.13 If a risk is identified which is shared with or wholly relates to another organisation, the risk must be shared with that organisation. Advice on the appropriate method of communicating and sharing the risk must be sought from the relevant manager. The risk must not be entered onto the Risk Register without the knowledge of the third party organisation first.

8.14 Third parties should also advise the CCG of any appropriate risks. An example of such a risk is if any provider is not complying with safeguarding standards for children and vulnerable adults and consequently has an action plan in place to address the gap, this must be alerted to the CCG so that it can include this on the CCG Risk Register as well as it being included on the provider Risk Register.

Review of risks

8.15 All staff involved in identifying and managing risk will, on a regular basis, review their identified risk, controls and action plans. The frequency for review of a risk, dependent on their risk score is outlined below:

Risk score Risk level description Reporting to the

Governing Body

Risk review

frequency

Authority to manage

risk

High Unacceptable level of risk requiring immediate corrective action. To be monitored by the Governing Body

Quarterly via Assurance Framework

Monthly

As agreed by

Governing Body

High As above. To be monitored by the Audit Committee at each meeting

As above Monthly As above

Medium

Unacceptable level of risk exposure requiring measures to be put in place and monitored by Senior

Manager

Six monthly Quarterly As agreed by Senior Manager

Low Acceptable level of risk subject to regular monitoring at management

Annually 6 monthly As agreed by


level Manager

8.16 All risks on the Risk Register should be reported to the appropriate Committee which has oversight of the programme relating to that risk. All Senior Managers should ensure that they provide oversight to the appropriate Committee of the existing risks and associated risk score, current controls, current assurances and any action plans in place to mitigate the risk.

8.17 It will be the responsibility of each Committee to escalate any risk (scored at 12 and below) to the Governing Body, in the event that it has been agreed by that Committee that the Governing Body requires oversight of the risk. These circumstances will apply when the risk needs to be reported sooner than the six monthly or annual processes as described in the table above. This will be done via the Assurance Framework when it is presented to the Governing Body.

9 ASSURANCE FRAMEWORK

9.1 In the NHS, the Board Assurance Framework is a tool that sets out the risks for each strategic objective, along with the controls in place and assurances available on their operation3.

9.2 The Assurance Framework describes the principal risks that relate to the CCGs strategic objectives and is intended to provide assurances to the CCG Governing Body in relation to the management of risks that threaten the ability of the CCG to achieve these objectives.

9.3 It is important that the Assurance Framework reflects those risks to the achievement of strategic objectives and does not include operational risks. However, operational risks are important and thus need to be highlighted to the appropriate Committees as they may be indicators of progress towards strategic objectives.

9.4 Wider consideration of the CCG Risk Register, via Committee reporting, provides the Governing Body with more comprehensive assurances on management of the totality of risk facing Warrington CCG.

9.5 Internal control is the process that provides assurance that an organisation is achieving its objectives and meeting its legal and other statutory obligations. It is the effectiveness of this that the Chief Clinical Officer is certifying when signing the Statement of Internal Control.

10 RISK APPETITE

10.1 The aim of the Risk Management Policy is not to remove all risk but to recognise that some level of risk will always exist and that these risks must be managed. It is recognised that taking risks in a controlled manner is fundamental to innovation and developing a positive culture. Risk appetite is

3 Taking it on Trust – Audit Commission April 2009


the amount of exposure to risk that the Organisation is prepared to accept or tolerate should the exposure become a reality.

10.2 All provider organisations are expected to provide safe and effective care to patients by identifying all risks relevant to them and taking appropriate action to address them. Providers are expected to escalate any high risks to the CCG as part of the contract and quality monitoring meetings.

10.3 The CCG has deemed that any risk with a risk score of 15 or more and any risk with catastrophic impact regardless of likelihood, will be made visible to the Governing Body via the Assurance Framework. All other risks will be reported as per the “review of risks” table at 8.15.

11 DISSEMINATION AND IMPLEMENTATION

11.1 The Risk Management Policy will be placed on the Warrington CCG website and will be made available to all CCG staff.

11.2 All managers will ensure that staff within their remit of responsibility are briefed on the contents of the Policy and what that means for them.

11.3 The effective implementation of this Policy will ensure that there is an improved awareness of risk and how to report, prevent, control and eradicate these as appropriate in the course of their work.

12 POLICY APPROVAL

12.1 The Risk Management Policy has been approved by the CCG Governing Body.

13 MONITORING COMPLIANCE AND EFFECTIVENESS

13.1 For each Committee identified as being responsible for elements of risk management, an annual review will be completed by the Chair of the Committee to assess the achievement of its terms of reference, including the review of risks and the Assurance Framework (for the Audit Committee).

13.2 The review will look at its duties in relation to risk management, the receipt of reports including details of risk and the audit trail of any actions agreed by the Committee in relation to risk.

14 KEY PERFORMANCE INDICATORS

14.1 There are a number of key performance indicators which help to provide assurance that the Policy has been implanted effectively. These include:

a) Total number of risks included on risk registers opened in the reporting period (provides a quantification of the numbers of risks that were identified in the period to establish if the process of risk identification needs to be strengthened). Compare against previous reporting periods.

b) Percentage of risk assessments reviewed and updated in timescale identified (provides a quantification of risks that have been updated and


monitored in line with planned arrangements). Compare against previous reporting periods.

c) Percentage of actions completed on time within timescales identified (provides a quantification of the number of planned controls which have been implemented on time). Compare against previous reporting periods

15 REFERENCES

A Risk Management Standard (Institute of Risk Management) 2002

http://www.theirm.org/publications/documents/Risk_Management_Standard_030820.pdf

Health and Safety at Work Act 1974

http://www.hse.gov.uk/legislation/hswa.htm

Healthcare Risk Assessment Made Easy NPSA (March 2007)

http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59825

Taking it on Trust (Audit Commission) April 2009

http://www.audit-commission.gov.uk/SiteCollectionDocuments/AuditCommissionReports/NationalStudies/29042009takingontrustREP.pdf


Appendix A – The Risk Management Process


Appendix B – Examples of the Drivers of Key Risks


Appendix C – Risk Assessment template

Directorate: Service: Reference no:

Date of assessment: Next review date:

Overview of hazard or threat:

Any key historical information relating to risk:

Key / strategic objective risk related to:

Employees at risk: Non employees at risk:

Total cost of funding required to mitigate risk(if appropriate):

Name of Assessor:

Signature of Assessor:

Date of signature:

Name of Line Manager:

Signature:

Date of signature:

Name Senior Manager:

Signature:

Date of signature:

Internal / external stakeholders to be communicated with:

Date risk added to Risk Register:

Reason for risk not added to Risk Register (if applicable):


Risk description Impact of risk Existing Control measures

Risk Rating

Assurance on Controls Gaps in Controls

Imp

act

Lik

elih

oo

d

Sco

re


If there are gaps in the controls, list the further actions required to mitigate or reduce the risk

Target risk rating

Lead person to complete action Date for completion

Imp

act

Lik

elih

oo

d

Sco

re


Appendix D – Risk Matrix for Risk Assessment

Choose the most appropriate descriptor for the identified risk. Following the row of the selected descriptor, select the most appropriate description for the issue.

Injury (Physical /

Psychological)

Patient Experience

Staffing & Competence

Adverse Publicity / Reputation

Complaints / Claims

Financial Objectives / Projects

Business Service Interruption

Inspection / Audit / Statutory duty

1

Insi

gn

ific

ant

- adverse event resulting in minor

injury which does not require first aid

- reduced level of patient experience which is not due to delivery of clinical

care

- short term low staffing level (<1

day) – no disruption to patient care

- rumours. Potential for

public concern

- informal complaint, locally resolved. Risk of

claim remote

- small loss

- insignificant cost increase /

insignificant schedule slippage - barely noticeable reduction in scope

or quality

- loss of service / interruption > 1 hour

- small number of recommendations

- minor non-compliance with standards

- no or minimal impact of breach of guidance /

statutory duty

2

Min

or - minor injury or illness

– first aid treatment needed

- unsatisfactory patient experience

directly due to clinical care –

readily resolvable

- ongoing low staffing level – minor reduction

in quality of patient care

- local media – short term –

minor effect on public attitudes /

staff morale

- justified complaint

peripheral to patient care

- local resolution - claim less than

£10k

- loss > 0.1% of budget

- <5% over budget / schedule slippage - minor reduction in

scope / quality

- loss of service / interruption > 8 hours

- recommendations given - non-compliance with

standards, reduced performance rating if

unresolved - breach of statutory

legislation

3

Mo

der

ate - RIDDOR / Agency

reportable incident - adverse event which

impacts on a small number of patients

- mismanagement of patient care

- late delivery of key objective / service due to

lack of staff - major error due

to ineffective training

- ongoing problems with level of staffing

- local media – long term –

impact on public perception of

Trust and staff morale

- justified complaint

involving lack of appropriate care. Local resolution with potential to

go to independent

review - claim between £10k and £100k


- 5-10% over budget / schedule

slippage - visible reduction in scope or quality

- loss of service / interruption > 1 day

- reduced rating - challenging external recommendations / improvement notice.

- non-compliance with core standards

4

Maj

or

- major injury / long term incapacity /

disability (eg. Loss of limb)

- time off work > 14 days

- serious mismanagement of

patient care with long term effects

- uncertain delivery of key

objective / service due to

lack of staff - serious error due to lack of / poor training

- national media < 3 days –

public confidence in organisation

undermined – use of services

affected

- multiple justified complaints / independent

review - claim(s)

between £100k to < £1m


- 10 – 25% over budget / schedule

slippage - failure to meet

secondary objectives

- loss of service / interruption > 1 week

- enforcement action - low rating

- critical report - major non-compliance with

core standards - multiple breaches in

statutory duty

5

Cat

astr

op

hic

- death or major permanent incapacity.

Irreversible health effects

- totally unsatisfactory

patient outcome or experience with

permanent effects

- non delivery of key objective / service due to

lack of staff - loss of key staff

- critical error due to lack of

staff / insufficient training

- national / international

adverse publicity >3 days. MP concern

(question in House)

- inquest / ombudsman

inquiry - multiple claims or single major

claim > £1m

- loss > 1% of budget. Loss of contract / payment by

results

- >25% over budget / schedule slippage

- doesn’t meet primary objectives

- permanent loss of service or facility

- prosecution - zero rating

- severely critical report - complete systems change

required


Select the likelihood of occurrence from the likelihood table using either the frequency or probability of occurrence R

atin

g

Likelihood Probability Frequency 5 Almost Certain Will occur in exceptional circumstances Expected to occur at least daily

4 Likely Unlikely to occur Expected to occur at least weekly

3

Possible Reasonable chance of occurring Expected to occur at least monthly

2

Unlikely Likely to occur Expected to occur at least annually

1

Rare More likely to occur than not Not expected to occur for years

Multiply your consequence score with the likelihood score to arrive at the risk rating as shown in the risk scoring table in Appendix E

Appendix E – Risk Scoring Table

Grading table

Impact of consequence

Likelihood Rare

1

Unlikely

2

Possible

3

Likely

4

Almost certain

5

1 Insignificant 1 2 3 4 5 2 Minor 2 4 6 8 10 3 Moderate 3 6 9 12 15 4 Major 4 8 12 16 20 5 Catastrophic 5 10 15 20 25


Authorisation Report Warrington Clinical Commissioning Group Governing Body Meeting 14th November 2012

1




14th November 2012

TITLE OF REPORT: Authorisation Report

PURPOSE OF REPORT: To inform the Governing Body of the activities undertaken by the Chief Operating Officer and management team to work towards Authorisation

REPORT PREPARED BY: Nick Armstrong Chief Operating Officer

KEY POINTS/TEAM BRIEF: To provide information and updates to the Governing Body in relation to:

National Authorisation Update Warrington Authorisation Progress Constitution And Governing Body



a) Note the contents of this report b) Note member practice sign up to the CCG

Constitution



2

















Work towards authorisation as a statutory body 4(c) Does the report contain any evidence of improved





3



Yes


5.3 4(e) For 2012-13 does this paper contain any legal implications













Authorisation Report Warrington Clinical Commissioning Group Governing Body Meeting 4 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP AUTHORISATION REPORT

PURPOSE 1. The purpose of this report is to;

inform the Governing Body of the activities undertaken by the Chief

Operating Officer and management team to work towards Authorisation

NATIONAL AUTHORISATION UPDATE CCG authorisation – all applications received by NHS Commissioning Board

2. The NHS Commissioning Board confirmed on 2nd November that all of the 211 emerging clinical commissioning groups in England have now submitted their applications for authorisation to take on their clinical commissioning responsibilities.

3. The NHS Commissioning Board received submissions from the 46 CCGs in Wave 4 – the final group to present their applications. The full list of authorisation waves is available. Each CCG will take on its commissioning responsibilities in April 2013, irrespective of which wave it is in.

Final authorisation decision-making process set out

4. The CCG authorisation governance process was finalised at the NHS Commissioning Board Authority’s meeting in Newcastle on 20 September. A paper approved by the Board detailed how the moderation, conditions and decision elements of the CCG authorisation process will operate.

5. A key proposal was to share the recommendations of the Conditions Panel with the CCG prior to decisions being made by the CCG Authorisation Sub-Committee of the NHS Commissioning Board. The proposal, which has been developed in response to CCG feedback, means CCGs will have two weeks to comment and provide any new evidence that may remove the need for a specific condition.

6. As a result, it means the final authorisation decision by the CCG Authorisation Sub-Committee of the NHS Commissioning Board will be four to five weeks later for each wave, and that first decisions on CCG authorisation are due in early December 2012.

7. The Board paper, outlines in full how the moderation and conditions/support processes will work, and how decisions will be made by the NHS Commissioning Board.



8. It also proposes that a standard review date of March 2013 will be built into all conditions and that CCGs may submit evidence to the relevant regional office which will determine whether the condition can be removed for the majority of conditions. For the more substantial conditions, the sub-committee will need to sanction their removal.

Authorisation process dates agreed

9. Dates have been agreed for the key parts of the clinical commissioning group authorisation process.

10. Meetings have been set up for each wave of CCGs for:

the moderation panel which makes recommendations as to whether a CCG should be fully authorised or authorised with conditions;

the conditions panel which considers what support is required where a CCG has not supplied sufficient evidence to meet a threshold for one or more authorisation criteria; and

the CCG authorisation sub-committee which makes the authorisation decisions.

11. All dates for Wave 1 CCG meetings are shown in the table below;

Meeting Date

Wave 1

Wave 1 Moderation Panel 23/10/2012

Wave 1 Conditions Panel 02/11/2012

Wave 1 Sub-committee 05/12/2012

12. The conclusions of each sub-committee meeting will be published immediately after each meeting, once decision letters have been issued to CCGs.

13. The full end-to-end process is described here and includes a flowchart identifying the points where CCGs will have the opportunity to submit any further evidence – where necessary – before their application is considered at the relevant NHS Commissioning Board CCG authorisation sub-committee.



WARRINGTON AUTHORISATION PROGRESS 14. Since the update to the Governing Body in September the CCG has

completed several key steps on the authorisation decision-making flowchart shown below;

15. Key dates completed by the CCG include; 20th September – Site Visit from Authorisation Team 28th September – Site Visit Report Received 3rd October – CCG Response to Site Visit Report submitted 28th October – Moderated Site Visit Report Received 6th November to 19th November – CCG 10 working day window for

submission of additional evidence



Outstanding Authorisation Actions 16. All outstanding authorisation actions relate to the submission of further

documentation to the NHS Commissioning Board, in particular these include refreshed and updated; CCG Commissioning Plan Engagement, Experience and Communications Strategy Quality Strategy Organisational Development Plan Risk Management Policy Complaints Policy Safeguarding Arrangements CCG Constitution (signed)

17. All of these documents are being discussed at the 14th November Governing

Body meeting and will be submitted to the NHS Commissioning Board as part of the 10 day working window.

CONSTITUTION AND GOVERNING BODY CCG Constitution 18. The constitution has been reviewed externally by both Hempsons Solicitors

and BMA Law. The CCG has continued to work with the Mid-Mersey Local Medical Committee throughout this process.

19. There have been no material changes to the constitution based on the national template or the original principles of governance established by member practice when Warrington Health Consortium (now the CCG) was established in February 2011. The only noticeable change to the document is the removal of standing orders, financial policies, committee terms of reference and the scheme of delegation and reservation into a separate governance manual. This allows members the flexibility to make changes to these operational documents without re-submitting the constitution to the NHS Commissioning Board.

20. Member practices have been asked to sign the constitution and the signed sheets will be available for the Governing Body to view and note at the meeting.

Outstanding Governing Body Posts 21. As confirmed in the Chief Clinical Officer report the posts of Specialist Doctor

and Registered Nurse have been appointed.

22. At the time of writing this report Healthy Warrington Federation have 2 candidates for the replacement of their practices representative on the governing body and are discussing with the LMC about the completion of an



election process for this position.

RECOMMENDATIONS 23. Members of the Governing Body are asked to:

a) Note the contents of this report b) Note member practice sign up to the CCG Constitution

Nick Armstrong Chief Operating Officer November 2012


Summary and Minutes of Committees Warrington Clinical Commissioning Group Governing Body Meeting 1 14th November 2012

WARRINGTON CLINICAL COMMISSIONING GROUP GOVERNING BODY REPORT


14th November 2012

TITLE OF REPORT: Summary of Committees of the Governing Body

PURPOSE OF REPORT: This report contains summaries of the discussions and decisions of Committees established by the Governing Body, or Joint Committees across the North West which have an influence on the CCG’s business. The minutes approved at these minutes are attached to this report.

REPORT PREPARED BY: Nick Armstrong, Chief Operating Officer

KEY POINTS/TEAM BRIEF: This report contains summaries for the following committees:

Quality Committee – summary from 16.10.12 and approved minutes from 26.9.12 and 25.7.12

Finance & Performance Committee – summary from 24.10.12 and approved minutes from 4.9.12 and 26.9.12



Note the decisions made on their behalf and support them








3. HEALTH INEQUALITIES No

4. HUMAN RIGHTS, EQUALITY & DIVERSITY REQUIREMENTS No



Achieve sustained financial balance and ensure sound business practices are at the heart of running GP CCG

Optimise health outcomes 5(b) Does this report support any of the CCG’s Priority

Workstreams? Yes

Improved Health and Healthcare, Better Patient Experience, Efficient Services 5(c) Does the report contain any evidence of improved






No



i. the corporate liabilities facing the Governing Body No

ii. the role and functions of the Primary Care Trust No iii. other legal responsibilities (i.e., Data Protection Act) No

iv. compliance with the Corporate Governance Manual No








WARRINGTON CLINICAL COMMISSIONING GROUP MINUTES OF COMMITTEES

PURPOSE 1. To provide the Governing Body with summaries which record the decisions of

Committees established by the Governing Body, or a Joint Committee across the North West, which have an influence on the CCG’s business.

BACKGROUND 2. This report provides a format for the Governing Body to consider the work of all

the various committees that work on its behalf. 3. SUMMARY OF THE QUALITY COMMITTEE HELD ON 16th OCTOBER 2012

Quality Report September 2012 – The Committee noted the Quality Report

Mid-Mersey Medicines Management Board Recommendations for Approval – The committee noted that there were no further updates to receive

Information Governance – The Committee noted that a minimum of level 2 compliance must be reached by 31 March 2013 to ensure that the CCG is Information Governance compliant as it enters 2013/14 as a statutory organisation. The Committee approved the Information Governance Strategy and Information Governance Policy. The Committee approved the Information Governance report and the related policies and work programmes referenced within.

Safeguarding Quarterly Report – The committee received and noted an update on key developments, issues and information relating to safeguarding and assurance given relating to safeguarding arrangements within the CCG and with commissioned providers. It was noted that a safeguarding update session (level 3) has been organised for all Safeguarding GP Leads. GP Attendance at Child Protection Case Conferences was discussed.

Complaints Policy – The Committee reviewed and approved the Complaints Policy.

Public, Patient Engagement & Patient Experience Report – The Committee acknowledged the positive work carried out around engagement and experience and the highly effective methods of engagement used to carry out meaningful engagement and capture patient experience. A discussion took place as to whether the public are aware of what the Warrington CCG does and is there anything the CCG can do to raise awareness.



4. SUMMARY OF FINANCE & PERFORMANCE COMMITTEE MEETING HELD ON 24TH OCTOBER 2012

Contingency Plan Update - The Committee noted the process undertaken to

develop the ‘whole system’ Contingency Plan and noted the progress against the mitigation tasks defined within the Contingency Plan.

Contract Planning 2013/14 - The Committee noted the timeline for 2013/14 Contract Planning process. The Committee agreed that Commissioning Intentions should be developed and agreed for approval in the next Finance and Performance Committee meeting.

Commissioning Strategy Plan 2013/14 onwards – The Committee noted the Commissioning Strategy Plan update.

Major Trauma Model - The Committee noted the report which outlines the impact of implementing the requirements of the Major Trauma model on the North West Ambulance Service. The Committee noted the financial pressure in the budget for next year and supported the increase in funding required to ensure that ambulance performance is maintained.

Financial Update for Month 6 - The Committee noted the Month 6 financial performance update and the position at the end of September.

Quality, Innovation, Productivity and Prevention Delivery Report – Month 6 – The Committee approved the report which covered the ten programmes being delivered through the Quality, Innovation, Productivity and Prevention programme. The actions required to address the strategic risks were considered. The development of the 2012/15 Quality, Innovation, Productivity and Prevention programme was noted.

Monthly Performance Report – Month 6 - The Committee noted the Performance update.

Authorisation Update – The Committee noted that the template has been updated and sent for approval to Moira Dumma, Director of the Local Area Team, who will then meet with the assessor to discuss.

Minutes of the Warrington and Halton Hospital Foundation Trust Contract Review Meeting, Bridgewater Community Healthcare Trust Contract Meeting, 5 Boroughs Partnership Contract Meeting, Integrated Commissioning Board and the Transformational Board were noted by the Committee.

Contract with Kirklees Council – Looking Local – the committee approved a contract with Kirklees Council for the “Looking Local” service. It was noted that the signature of the contract is in line with standing financial instructions and there is no requirement to put the service out to tender.




QUALITY MEETING HELD ON 25 JULY 2012 IN THE BOARDROOM, MILLENNIUM HOUSE: 10.30 AM

MINUTES

Present: Dr Anita Malkhandi GP Chair (Interim) Dr Sarah Baker Chief Clinical Officer John Wharton Nursing & Quality Lead Nick Armstrong Chief Operating Officer Dr Justin McCarthy Clinical Lead Nick Atkin Lay-Member Rebecca Knight Head of Assurance & Risk

In Attendance: Debbie Monfared (Minute Taker)

Executive Assistant

Guests: J Lunn Pharmaceutical Adviser C Brierley Information & Quality Assurance Manager

A Apologies for Absence Dr Neil Fisher, Paul Steele

B Declarations of Interest in Agenda Items Dr A Malkhandi and Dr J McCarthy working as GPs in Warrington

and their practice maybe mentioned in the reports.

C Minutes of the previous Meeting Minutes held on 19 June 2012 were agreed as an accurate

representation of the meeting.


E Chair’s Remarks The Chair welcomed attendees to the meeting.

0072/12 Quality Report – July 2012 No report submitted as there are no updates since the last

meeting.

0073/12 Quality Framework



The report was produced to inform the Committee of the current Quality framework reporting/exception reporting requirements of the cluster and to inform the Committee of the Quality leads terms of reference, membership and quality assurance.

The Committee queried the internal reports and questioned how

we react internally to exception reporting showing red. The Committee were assured that all Quality Exception Reporting which is marked ‘red’ which has a high impact issue is reported with immediate effect to the Cluster office. This is also fed through the quality and governing body meetings. The Accountable Officer is also Immediately informed of any issues which warrant exception reporting.

The Committee discussed and approved the report. 0074/12 Performance Framework The report is to inform the Quality Committee of the current

cluster performance framework and of the cluster local arrangements reporting processes and performance.

The same question was asked of the Performance Framework as

asked for the Quality Framework regarding reporting highlighted in red. Assurance was received around the process of the reporting and the identification of any problems being fed to the appropriate management team.

The Committee discussed and approved the report. 0075/12 Mid-Mersey Medicines Management Board

Recommendations for Approval

The report identified recommendations previously approved by

the Mid-Mersey Medicines Management Board which now requires approval by Warrington Health Consortium. The Committee are asked to approve the following Mid-Mersey Medicines Management Board recommendations

The Committee discussed, noted and approved the following

recommendations:

a) General anxiety disorder in adults guidelines b) Pharmacological Management Guideline for

Hypertension c) Tapentadol immediate release tablets (Palexia) d) Fentanyl immediate release formulations (Abstral

sublingual tablets and Pec Fent nasal spray) e) Generic ibuprofen and naproxen f) Ticagrelor tablets (Brilique)



0076/12 Merseyside Clinical Commissioning Groups Network Dabigatran and Rivaroxaban Therapy

The report identified recommendations by the Mid-Mersey

Medicines Management Board and subsequent discussions at the CCGs clinical network that require approval by the Warrington Clinical Commissioning Group. The Committee are asked to approve the recommendation of the Merseyside Clinical Commissioning Groups Network on the place of dabigatran and Rivaroxaban therapy for prevention of stroke and systemic embolism in non-valvular atrial fibrillation.

It was highlighted that there are no arrangements for community

initiation of Warfarin in Warrington. Issues to be discussed with appropriate commissioner.

J Lunn

The Committee discussed and approved the

recommendations given by the Merseyside Clinical Commissioning Groups Network on the place of dabigatran and Rivoraxaban therapy for prevention of stroke and systemic embolism in non-valvular atrial fibrillation.

0077/12 GP Practice Performance Annual Report 2011/12 The report is to advise the Committee on key GP performance

areas and the Committee is asked to decide on new indicators for the current year as there is some difficulty in obtaining data in time for the report due to collection periods 62% complete and some indicators retired within the monitoring period.

It was confirmed that WCCG are not contractually responsible for

monitoring indicators and there is no timescale with regards to what criteria we would like to be included. It was noted that there is nothing measured at the moment for patient experience and we should consider including this information in key indicators going forward.

Feedback required from J McCarthy and N Fisher with regards to

what matters in Primary Care and to investigate what measures can be put in place to monitor. Parameters indicating quality should be translated meaningfully back to practices. J McCarthy and N Fisher to meet with C Brierley to discuss further.

J McCarthy/ N Fisher/ C Brierley

Indicators should be relevant to Warrington and group headings

should reflect the 5 national outcome framework domains. Currently there are a number of indicators that have no relevance – we need to ensure we are capturing the right data.

As a Clinical Commissioning Group we need to decide what we

can provide to patients, what do we want practices to be providing and what is realistic. Work with patient engagement



regarding Warrington’s statement of good quality involving patients and GPs.

C Brierley to bring other dashboard information to the meeting

with J McCarthy and N Fisher to look at what other measures are monitored at practice level.

C Brierley

The Committee discussed the report and asked C Brierley, J

McCarthy and N Fisher to develop and agree new indicators to form the quality primary care dashboard.

0078/12 Overview of Serious Incidents & Associated Issues in

Warrington

The report updates the Quality Committee on key developments

and summaries relating to patient safety and quality. The Committee are asked to note and discuss the serious incidents within Warrington, receive assurance regarding the serious incident process and note and discuss the issues and information raised within the report.

The Committee discussed the lack of staff training and

awareness competencies on the wards around fluid balance recording at Warrington and Halton Hospitals NHS Foundation Trust. It is important that we are aware that competencies are measured and evaluated as lack of training poses a huge risk.

It was questioned by the Committee as to how do we pick up and

monitor any incidents that are under our radar and do we have the resource to do this. Rebecca advised that she will be attending the Contract and Quality Sub Group meetings from September and will be asking for a report from providers which identifies numbers of incidents reported and any themes or trends identified. It was pointed out that the response by providers regarding queries about serious incident investigation reports are very slow. This matter will be raised at the next Contract and Quality Sub Group meeting. The issue of timely responses to queries to be identified to the Contract team so that this can be included in contracts when they are agreed for the following year.

R Knight R Knight

The Committee were informed that we do not receive timely

information from NHS Blackpool regarding NWAS serious incidents. NHS Blackpool is the lead commissioner for performance management. Rebecca has asked for the Serious Incident Policy from NHS Blackpool to assess the process that they undertake for scrutiny of serious incidents. Any issues identified will be fed back to the Committee.

R Knight

In the event that Quality issues are not resolved at the Contract



and Quality meetings, these need to be escalated to Sarah Baker who will then escalate to the Chief Executive of the relevant provider Trust.

Rule 43 lessons learned that are applicable to Primary Care to be

shared within the GP Bulletin. R Knight

Discussion ensued about the reluctance from colleagues to

discuss poor practice within primary care. Primary concern is if things go seriously wrong then difficult questions could come back to the Clinical Commissioning Group. It is for the Clinical Commissioning Group to determine the culture of how members work and operate and work with providers to achieve this.

J McCarthy/ N Fisher

The Committee discussed and noted the report. 0079/12 Information Governance Toolkit Assessment The purpose of the report is to provide evidence that the

Warrington Clinical Commissioning Group has been assessed to demonstrate its capability to meet the Information Governance Toolkit requirements as part of authorisation.

It was highlighted that as an organisation we need to adhere to

Information Governance requirements but in some circumstances a pragmatic approach must be used to decisions so that they do not get in the way of making the right decisions for the patient. This statement needs to be made clear when finalising the agreement with CSS if Information Governance services.

After April 2013 the Committee were asked what, if any, are

optional or can be deleted and of the 31 pages of prescription how does this add value and at what cost.

Then CCG will have to meet the requirements of the IG Toolkit

once it becomes a statutory body. There is no additional cost and the Clinical Commissioning Group will need to ensure we have the correct policies in place.

The Committee discussed and approved the Information

Governance Toolkit Assessment and Improvement Plan to be used as evidence for authorisation arrangements.

0080/12 Public, Patient Engagement & Patient Experience Report No report submitted as there are no updates since the last

meeting.

0081/12 AOB



John Wharton wished to inform the Quality Committee of the request from the cluster, to complete the Legacy Document and the strict timelines which had been agreed. Sarah Baker questioned the necessity for this document and will be contacting the cluster management team to clarify its content and question the validity of this work when the cluster regularly receive reporting on our main providers.

Sarah Baker to contact Cathy Maddaford

Date and Time of Next Meeting Wednesday, 26 September at 1030, Boardroom, Millennium

House



WARRINGTON CLINICAL COMMISSIONING GROUP QUALITY MEETING HELD ON WEDNESDAY, 26 SEPTEMBER 2012 IN THE

BOARDROOM, MILLENNIUM HOUSE: 10.30 AM

MINUTES

Representing Warrington Clinical Commissioning Group

Present: Dr Sarah Baker Chief Clinical Officer (Chair) Nick Armstrong Chief Operating Officer Dr Justin McCarthy Clinical Lead Nick Atkin Lay-Member Dr Neil Fisher Clinical Lead Rebecca Knight Head of Assurance & Risk

In Attendance: Debbie Monfared (Minute Taker)

Executive Assistant

Representing Commissioning Support Unit

J Lunn Pharmaceutical Adviser

D O’Carroll Senior Medicines Management Technician C Brierley Information & Quality Assurance Manager

A Apologies for Absence Dr Anita Malkhandi, John Wharton, Paul Steele

B Declarations of Interest in Agenda Items GP members of the Governing Body are currently working GP’s within the

Warrington Community.

C Minutes of the previous Meeting Minutes held on 25 July 2012 were agreed as an accurate and well written

representation of the meeting.


E Chair’s Remarks None

0082/12 Quality Report – September 2012 The purpose of the report is to update the Committee on the key areas of



health care delivery relating to the CCG quality agenda since the last meeting in July 2012.

The paper covers health care provision for Acute, Community Mental

Health, Hospice and Spire Hospital.

The North of England Quality Report highlights areas where Warrington

Halton Hospital Foundation Trust (WHHFT) has been asked to improve their current red status. Areas are included within the report and assurance will be requested at the contract and quality meetings with the Trust. A copy of the Remediation plan has been asked to be brought to the next Quality Committee.

J Wharton

Bridgewater – a new version of a scorecard for monitoring quality elements

of the Bridgewater contract has been developed in line with the indicators in schedule 16. The Committee requested confirmation that the indicators will be active by Q3 2012/13.

J Wharton

Spire - CQC inspection report (carried out in July 2012) has been shared

with the commissioners and gives assurance that the organisation is meeting the standards of the 7 domains.

National cancer patient experience programme identified issues to be

addressed by WHHFT. John Wharton and Kerry Best are arranging to meet the lead at the hospital to discuss the action plan for addressing the areas identified. A copy of their Action Plan has been requested to be brought to the next Quality Committee Meeting. Dr Sue Burke should also be involved in the discussions.

J Wharton

The Committee queried if any changes have occurred regarding

Haematology services from a patient point of view. The Committee were assured that there were no major concerns apart from a number of comments regarding the journey over to Halton and some patients commented on the time it took for their GPs to commence investigations.

Nick Atkin commented that the report showed a general sense of lack of

empathy as to what is in the patient’s minds and did not reflect the patient experience that was presented at the last Governing Body meeting. There are a number of good points in the reports and it is hoped that WHHFT will pick up on any issues.

Included in the report were minutes from the sub groups – the Committee

found these reports to be beneficial and are confident that the Contracts Team are discussing quality issues with providers. Discussions need to take place with Contracts as to what needs to be included in the contract dashboards.

J Wharton

The Committee discussed and agreed the current agenda 0083/12 Mid-Mersey Medicines Management Board Recommendations for

Approval



The report identified recommendations previously approved by the Mid-

Mersey Medicines Management Board which now requires approval by Warrington Health Consortium.

Concern was expressed by Dr McCarthy regarding new drugs initiated by

WHHFT and how decisions on new drugs are communicated to hospital prescribers. This related to a recent incident in his practice that took some time to resolve. Jenny Lunn agreed to find out how the hospital cascade recommendations to their prescribers. It was also agreed that it would be helpful if such incidents were captured and that Jenny Lunn would discuss the use of Datex in this with Rebecca Knights.

J Lunn

It was noted that GPs do not also stick to agreed guidance and that

Prescribing recommendations are included in the weekly commissioning bulletin. Jenny Lunn to ensure that messages also go to other relevant partners, eg community pharmacists.

J Lunn

Jenny Lunn highlighted that the cost of the Hepatitis C drugs was likely to

be a significant cost pressure. The Committee commented that the in year effect was unlikely to be too great and most of the pressure would be in future years. The Committee asked if patients with hepatitis C were managed mainly at the Royal Liverpool. Jenny Lunn advised that patients are also being managed locally and that it had been confirmed that similar pathways were being followed by WHHFT.

The cost of implementing the Mid-Mersey Medicines Management Board

recommendations was raised. The Horizon scanning process was discussed and the Committee suggested that the recommendations brought to the Committee be mapped to the Horizon scanning carried out at the beginning of each financial year. Jenny Lunn advised that this year’s Horizon scanning process was in process and she would look at developing a financial planner to be submitted along with future reports to the Committee so that they are more aware of any financial implications. It was suggested that this planner should also be submitted to the Finance and Performance Committee.

J Lunn

The Committee discussed, noted and approved the following

recommendations:

g) Targinact modified release tablets h) Boceprevir tablets for genotype 1 chronic hepatitis C i) Telaprevir tablets for genotype 1 chronic hepatitis C j) Eviplera film-coated tablets k) Rilpivirine l) Nevirapine prolonged release tablets m) Dabigatran capsules in Atrial Fibrillation n) Fingolimod capsules o) Gluten free foods p) Phosphodiesterase type-5 inhibitors for the treatment of

erectile dysfunction



q) Colecalciferol 800 international units capsules 0084/12 Practice based Medicines Co-ordinators The purpose of the pilot initiative is to implement a standardised approach

to synthesising new and existing protocols and to improve the general efficiency of business systems. The Medicines Co-ordinators will be trained to maintain the repeat prescribing system to ensure optimum efficiency, and to provide support to the Medicines Management Team in reducing prescribing costs by ensuring continuance of the teams efficiency work. This level of support will also facilitate appropriate training that is required for any new reception/administrative staff who join the team following the launch of the pilot. The overall aims and objectives of this initiative are to improve prescribing and medicines management outcomes through effective commissioning that will ultimately benefit the organisation.

Although there are a number of Practices engaging in the pilot there are

still 4 practices that have yet to identify a suitable medicines co-ordinator. The Committee asked Dorina O’Carroll to highlight issues and problems that can be presented at the Federation meetings.

D O’Carroll

The full funding allocation will not be spent in 2012/13. The Committee

suggested capturing feedback from the training sessions and rolling this out to other practices when payment becomes effective.

Discuss with Communications a system wide leaflet to share information

with the population of Warrington. Also consider how to share as a good news story, with input from Catherine Doyle.

D O’Carroll

The Committee discussed and noted the progress to date on the

following:

a) Time frame for implementation within GP practices b) Training requirements for this role c) Allocation of financial resources for the post of medicines co-

ordinators d) Next steps

0085/12 Primary Care Quality Dashboard The report informs the Committee of a new primary care quality dashboard

and asks the Committee to agree/amend the draft quality indicators within the report. Once the Committee has reviewed and agreed the proposals it will be presented to the LMC and other colleagues to gauge opinion before they are formally launched.

The Committee discussed and agreed the proposed quality

indicators within the report however stated that it was not necessary to present to the LMC and other colleagues to gauge their opinion. A joint letter from C Brierley, Dr McCarthy & Dr Fisher to be distributed

C Brierley/ Dr McCarthy/



to all Practice Managers regarding the dashboard proposals. Dr Fisher 0086/12 Patient Relations Team Annual Report 2011-12 The report appraises the Committee of the emerging themes surrounding

complaints PALS and claims across the Commissioning Organisation itself; general practice; independent providers and other NHS Trusts and asks the Committee to discuss and note the content of the report.

The Committee discussed and noted the contents of the report 0087/12 Overview of Serious Incidents & Associated Issues in Warrington The report updates the Quality Committee on key developments and

summaries relating to patient safety and quality. The Committee are asked to note and discuss the serious incidents within Warrington, receive assurance regarding the serious incident process and note and discuss the issues and information raised within the report.

Trends and themes show for this year that the highest number of incidents

for 2012/13 at WHHFT is ward closures. Last year, the highest figure was for pressure ulcers.

WHHFT contract and quality meeting – themes and trends for serious

incidents highlighted to the Trust on 05 September 2012 with a request for an action plan as to how these will be addressed.

Analysis of SEAS submitted for QoF highlighted some themes. Highest

number of SEAs was in relation to medication errors, delays, IG issues and vaccination issues. Event being run on 26 September highlighting what a good SEA looks like.

Domestic homicide review – currently involved in review of family involving

domestic homicide which has highlighted the need for awareness raising within practices in relation to the role of the quality team One practice is still refusing to share patient notes until medical defence union has given their authorisation. R Knight to draft a letter on behalf of Dr S Baker to the said Practice asking them to release the notes.

R Knight

5BP – 4 independent investigations have been commissioned by the SHA

– involving 2 incidents from 2006 with Warrington patients. Summary sheet currently being developed to provide information in case of media attention. Currently 300 incidents remain open on StEIS, 37 of these involve Warrington patients. This will be raised at the next contract meeting. Action plan requested for signing off outstanding incidents. Liaise with Pam Broadhead regarding 5BP contract and concerns re Safety.

R Knight R Knight

Serious Case Review incident involving patient under guardianship who

removed tracheostomy tube in ITU in February may be subject to a SCR.



Evidence still being collated which will help determine whether this is required.

The Committee discussed and noted the contents of the report 0088/12 Safeguarding Quarterly Report The report updates the Quality Committee on key developments, issues

and information relating to safeguarding and assurance given relating to safeguarding arrangements within the CCG and with commissioned providers.

The Committee discussed the report in relation to funding for the

Safeguarding Adults Board. The Committee would like document to be developed which highlights what funding is required, what it will be used for and commitment from other partners that they will also contribute.

The Committee agreed to contribute £7.5k in principal however a

conversation needs to take place with the local authority as to the above paper. A paper will need to be submitted to the Integrated Commissioning Board to agree joint funding.

R Knight

The Committee approved the Bridgewater Safeguarding Assurance Group

Terms of Reference.

The Committee requested the Safeguarding Report to be added to the

Work Plan as a standing item on a quarterly basis however until the Ofsted inspection has taken place this item will appear on a monthly basis.

R Knight

The Committee discussed and noted:

a) assurance regarding the safeguarding arrangements b) issues and information raised within the report c) discussed and approved in principal additional funding for

Safeguarding Adults arrangements d) Approved the Terms of Reference for the Bridgewater

Safeguarding Assurance Group

0089/12 Quality Report Ratification of Pathways – September 2012 The purpose of the report is to request the Committee’s approval for the

ratification of Pathways to support the reduction in admissions/attendances through A&E.

The Committee requested that the Fever in Infants and Young Children

map of medicine page be amended to remove the arrow to primary care at the top of the page. All other Pathways were approved

J Wharton

The Committee discussed and agreed the current agenda



0090/12 Public, Patient Engagement & Patient Experience Report The report updates the Committee members on the engagement and

experience work programme delivered in June, July and August 2012.

The Committee commented on a well written report and excellent work

regarding the patient experience audit report.

The Committee discussed and noted the contents of the report AOB None Date and Time of Next Meeting Next Meeting to take place on Tuesday, 16 October at 1400, Boardroom,

Millennium House.




FINANCE & PERFORMANCE COMMITTEE HELD ON TUESDAY 4 SEPTEMBER 2012 AT 11.00 A.M. IN THE

BOARDROOM, MILLENNIUM HOUSE

MINUTES Present: Dr Simon Redfearn (Chair) GP Dr Sarah Baker Chief Clinical Officer Iain Crossley Chief Finance Officer Gareth Hall Lay Member of the Board In Attendance: Bryan Webb Assistant Director of Finance Pamela Broadhead Head of Contracts Nick Armstrong Chief Operating Officer Cheryl McKay Head of Programmes David Cooper Head of Financial Management Julie McCarthy Executive Assistant (minutes) A Apologies: Action: Apologies were received from Dr Dan Bunstone and Mr Matthew

Cripps

B The Chair confirmed that the meeting was quorate.

C Declarations of Interest There were no declarations of interests in agenda items. Dr Simon Redfearn confirmed that he is a GP in Warrington.

D Minutes of the previous meeting held on 25th July 2012 The minutes of the previous meeting held on 25th July 2012 were accepted as an accurate reflection of the discussions.

E Actions and matters arising from meeting held on 25th July 2012 Action 53 – Liaison Psychiatry Action on-going – it was confirmed that discussions are on-going and they are still in the six month pilot phase. Actions 57 and 58 – Breach Data and Health Checks Action complete - Breach and data and health checks are an item on the agenda for discussion. Action 64 – Understanding GP Referrals Action complete – it was confirmed that an understanding of the GP



referrals had been gained. Action 65 – 10% Variance Action complete – it was confirmed that the reduction has been capped at 8%.

F Chair’s Remarks

The Chair welcomed everyone to the meeting.

59/12 Critical Business i

Contract Transition Update

Pamela Broadhead confirmed that the Contract Transition process is ‘work in progress.’ Bryan Webb was thanked for his work on the data capture tool to disaggregate the contracts and link them to the ledger. The deadline for completion of this work is 30 September; the detail on the transfer order is awaited. The Committee were advised that each organisation did not have a choice in which contracts would be responsible for in the future; they will be allocated without choice by the National Commissioning Board/Department of Health. Pamela Broadhead reported; that going forward, it would be important to set the context for each meeting; all minutes should now detail the GPs title throughout the minutes. Sarah Baker asked for an update on the Local Authority contracts which are funded through the joint commissioning arrangements and those transferring as part of public health. Pamela Broadhead confirmed that some progress had been made but it remained a ‘red’ risk on the Assurance Framework. The contract will need to be discussed at the Integrated Commissioning Board and attendance from GPs at that meeting would be critical to ensure a full discussion takes place.

ii Framework for Collaborative Commissioning between Clinical Commissioning Groups

The committee considered the implications of the recent guidance from the National Commissioning Board on collaborative commissioning arrangements. Pam Broadhead confirmed the CCG was taking action to review its arrangements in line with the suggested models. Iain Crossley thought this would be an area for the Authorisation panel. Sarah Baker confirmed the CCG is now in possession of the Key Lines of Enquiry (KLOE). The areas that are red rated are being reviewed and updated with a deadline of 7 September for discussion



with the Governing Body. Work has been done collaboratively and evidence of this will be added to the submission. Pamela Broadhead highlighted that when the contracts are allocated the collaborative partners may change. Dr Sarah Baker encouraged the Committee to continue with collaborative working across partner organisations even if the collaborative relationship changes via the contract.

Iii Managing Conflict of Interest with GP Providers

Managing Conflict of interest with GP providers is not included on the Key Line of Enquiry list and therefore it was agreed there was no requirement for further discussion at this meeting.

60/12 Quality, Innovation, Productivity and Prevention Delivery Report

Cheryl McKay presented the Quality, Innovation, Productivity and Prevention Report to the Committee to provide a progress update in respect of the Quality, Innovation, Productivity and Prevention programme. It was reported that the six programmes being delivered through the Quality, Innovation, Productivity and Prevention programme are progressing however there has been some slippage over the holiday period. The current status is: Mental Health

First meeting of Mental Health Delivery Group scheduled in September 2012.

Acute Care Pathway – progressing well. Later Life and Memory Services Redesign – local meetings to

progress this have been scheduled with 5 Boroughs Partnership – evaluation of Wigan Pilot will be shared.

Improving Access to Psychological therapies – Eight training posts have now been recruited to.

Urgent Care

A new manager joined the Consortium yesterday to progress the Urgent Care programme.

The Urgent Care Unit (including Front Door) is due to be operational in October 2012.

Discussions will take place next week with Warrington and Halton Hospital Foundation Trust with regard to the ‘front door’ work stream; there may be a possibility of elective surgery being transferred to the Independent Sector Treatment Centre.

Cheryl McKay and Dr Neil Fisher will visit the Independent Sector Treatment Centre and Out of Hours Centre to see what would be required to run a full service.

NHS Direct have been successful in winning the bid to procure



111 provider for the North West. The uploading of the DOS entries is ahead of schedule.

End of Life

End of Life programme is progressing. Anticipatory Prescribing Policy is awaiting approval from 4MB Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

project has not progressed due to the failure of NWAS to engage. Linda Bennett will progress this issue.

Long Term Conditions

Delivery Group will be reviewing programme plan against the capacity of work stream groups.

Integrated Care Teams work stream is progressing, albeit slowly, given the impact of summer holidays and resource availability.

Self-Management work stream and Risk Stratification Work stream have not progressed due to delays with the Commissioning Support Unit in relation to business intelligence.

Children’s Programme There are seven sub-projects – plans have been made to facilitate workshops. Approval to progress with these is being sought from the Health Summit. Frail and Elderly Planned workshop for 24 September 2012 to develop the vision and programme plan for the Frail Elderly Programme. Outputs of this will be fed into the Long Term Conditions Programme. Medicines Management

The Medicines Management team are progressing with their Quality, Innovation, Productivity and Prevention target whilst dealing with considerable resource issues.

The team have been working with 5 Boroughs Partnership Trust to transfer the prescribing of dementia drugs.

Eleven practices have identified suitable candidates to commence medicine co-ordinate project training.

Primary Care

The Information Team are emailing the Federations with data on referrals, admissions and attendances on a monthly basis.

All practices have submitted their reports for GP9 relating to A&E attendances. It was confirmed that Warrington was the most informative within the Cluster.



Planned Care It was reported that in order to ensure partnership engagement the services reviews had been determined during early 2012. It was highlighted that the pre-operative clinics may need to be reviewed earlier than anticipated. It was reported that there aren’t any programmes that are due to deliver until the back end of the year except for Unscheduled Care. There is a Contingency Planning Workshop being held on 12 September with partners. General update The Committee discussed the following: It was highlighted that the zero to one day admissions have increased, discussions will take place with Warrington and Halton Hospital Foundation Trust to review this data in an effort to reduce this admission rate. Cheryl McKay reported that for the report next month, the overall Monthly Activity Report will show the status of the Warrington and Halton Hospital Foundation Trust activity as either red amber or green, this will be produced with the Information Team. Gareth Hall questioned if the Quality, Innovation, Productivity and Prevention programme is working and is the slippage a big risk to the programme. Iain Crossley replied that the projects are phased towards the end of the year; the contract activity with Warrington and Halton Hospital Foundation Trust is starting to rise, however contingency plans are being developed. A significant level of reserves has been utilised to offset the overspend and this would impact on the CCG’s ability to manage winter pressures. An Executive to Executive meeting between Warrington and Halton Hospital Foundation Trust and Warrington CCG is planned for Thursday 6 September to discuss the increase in activity and the way forward. Cheryl McKay is leading a whole system event to consider the contingency options later in September; the results will be fed back to the next F&P Committee meeting later this month. Gareth Hall asked if Warrington and Halton Hospital Foundation Trust could argue that Warrington CCG have not made the necessary Quality, Innovation, Productivity and Prevention savings. Sarah Baker advised that the over activity is equivalent to one or two patients per practice. It was reported that Warrington CCG is generally below the national average for planned referrals.



Proposals for 2012/15 Quality, Innovation, Productivity and Prevention programme.

Promote self-management A key person to review evidence and fast track documents Review telemedicine Encourage projects like the Chronic Obstructive Pulmonary

Disease project which has decreased referrals; the evidence for this should be sought from the Commissioning Support Unit.

As the CCG team is small, annual leave should be accounted for in the programme schedules.

Plan for project milestones Cheryl McKay reported that the Quality, Innovation, Productivity and Prevention project is on course, however the non-elective care could affect this but discussions are on-going. Gareth Hall asked why the CCG were not in receipt of the ambulatory reports and why only 11 GP practices have shown an interest in the medicines co-ordinator project. Sarah Baker replied that the Clinical Leaders are endeavouring to engage the GPs from each practice in the work of the CCG as they will soon be accountable. At present, there are 109 GPs in Warrington and currently there are 60 involved with the CCG. However it takes time to change culture. Gareth Hall asked if there is a good working relationship with Warrington and Halton Hospital Foundation Trust. Iain Crossley and Pamela Broadhead confirmed that it takes time to address certain issues but on the whole the relationship is working well. Both parties work hard to maintain a good working relationship. It was confirmed that the Quality, Innovation, Productivity and Prevention progress will be discussed at the next Finance and Performance Committee Meeting at the end of September.

The Committee noted the:

content of the Quality, Innovation, Productivity and Prevention programme report;

strategic risks and actions to address them development 2012/15 Quality, Innovation, Productivity and

Prevention programme.

61/12 Finance Report

i Month 04 Finance Report



David Cooper presented the Month 4 Finance Report for the period up to 31 July to the Committee and they were asked to note the current financial position:

Financial performance in line with planned year end surplus of c£1.6m.

Reserves have been offset against the over performance on the acute contract

Financial risks have been identified and work to mitigate is on-going (current over spend is £0.561m)

Year to date Quality, Innovation, Productivity and Prevention savings are £2.391m against a planned figure of £4.896m

Workshop with all key health economy partners is being held in September to develop a contingency plan.

The major variances in the contract overspend were discussed. The financial performance at the end of quarter one has been compared with that of the previous year and the planned contract levels for 2012/13, showing GP referrals for the most recent six months. It was confirmed that Warrington CCG benchmark favourably against national comparisons. The Committee were asked to be aware that Unscheduled care may affect this data in the future. Gareth Hall questioned if the bench marking should be ignored as in the past this has not proved to be an effective measure. David Cooper advised that the comparison against last year’s data was positive. Sarah Baker added that engagement with GPs is key. Support will be offered to the GP practices that require assistance in reviewing their efficiency issues. David Cooper reported that for the Spire Contract activity levels in the majority of specialities are significantly higher than those planned year to date. The number of GP referrals into Spire has increased significantly in the last twelve months. Orthopaedics have increased from 182 to 299, this increase however, was explained by an underperformance last year. Sarah Baker confirmed that work should continue with Spire to reduce the referrals; Warrington and Halton Hospital Foundation Trust will soon open the Independent Sector Treatment Centre and referrals should be encouraged to be sent there.

Action: David Cooper will produce a comparison table showing a breakdown of each provider and the total market share.

David Cooper

David Cooper reported that the Royal Liverpool and Broadgreen Financial Trust contract is also reporting an overspend year to date largely against the non PbR elements of their Contract. Dialogue with regard to this is continuing with the Cluster.



It was highlighted that the projected outturn in prescribing is based upon the achievement of the defined Quality, Innovation, Productivity and Prevention saving in year of £1.449m against 2011/12 outturn levels. Initial PPA data and phasing of planned expenditure has indicated that a pressure could be evident. The investment in Medicines Management is yet to be realised in this area. The Finance and Performance dashboard was discussed; Mr Gareth Hall queried why the Better Payment Practice payment is not being achieved for non NHNS suppliers. Iain Crossley confirmed this related to payments to the Local Authority and was being addressed.

Action: David Cooper to the Better Payment Practice payment discuss with Simon Kenton

David Cooper

The Committee noted the Month 4 Finance Report.

ii

Baseline Dashboard

Bryan Webb presented the CCG Resource Allocations for 2013/14 onwards report to the Committee. The report provided an update on the progress made with the data collection exercises to understand Primary Care Trust expenditure against the new areas of commissioning responsibility. The key points were highlighted to the Committee as being:

During 2011-12 the Department of Health conducted an exercise in which Primary Care Trusts were requested to provide information on how the 2010-11 spend on programmes would have been distributed between public health and other health services under the new commissioning structure.

A second data collection exercise to further analyse expenditure using both the 2011/12 audited accounts figures and the 2012/13 plan figures submitted to the Department of Health in May is being undertaken.

It is yet to be decided how these figures will be used to

determine allocations in 2013-14; however, this collection will inform the future resources available to the CCG so it is important that the basis and assumptions are open and transparent.

There is a current indicative allocation of £243.5m for Warrington CCG. This could be subject to change.

Any material changes can be submitted up 20 September 2012..



Allocations will not be published until the Autumn/Christmas and may be done on a different basis.

Iain Crossley queried if the population base for the allocations had yet been announced. Bryan Webb confirmed that whilst the running costs had been issued on a practice list size basis there was no indication as to the basis for the revenue allocation. The Committee noted:

the work being undertaken to baseline NHS spending the indicative CCG budget for 2012-13 of £243.5m

62/12

Monthly Performance Report

Nicholas Armstrong presented the Monthly Performance Report to the Committee to advise them of key performance areas. (The future responsibility for this report will be with Pamela Broadhead.) The Committee were advised that the key points for June 2012 for Warrington CCG to note were:

Accident and Emergency four hour or less waiting times were met at 95.69%

Target for admitted and non-admitted patients and incomplete referral to treatment pathways within 18 weeks

80.49% of patients being treated within 62 days of an urgent

GP referral for suspected cancer – this target was below the 85% required

The Annual Health Check target of 0.7% failed its target of

80%

Access to hospital services activity to be above the indicated plan, with a reported figure of GP referrals to hospitals to be 2808 against a monthly plan of 2622.

There were no incidents of MRSA and there were 2 C-difficile cases.

The Committee requested that the 18 week data is displayed by speciality and not by aggregate.

Action: Pamela Broadhead will ask Chris Brierley to display the data by speciality.

Pamela Broadhead

The Committee noted the contents of the Performance Report.

63/12

Authorisation Update



Nicholas Armstrong confirmed that Warrington CCG have now received the Key Lines of Enquiry (KLOE) for the Authorisation process. There will be a site visit from the assessors on 20 September 2012. All CCG staff are now involved in preparing the required evidence for an initial review on 7 September; this will then be presented to the Governing Body on 12 September 2013. Sarah Baker highlighted that some of the detail in the reporting required updating as some of the reports which were written in the infancy of the CCG organisation before the Government CCG guidance was available. Up to date evidence and current data with statistical information as a back-up will provide support to the evidence presented. Gareth Hall asked if patient feedback would be included in the evidence. Sarah Baker highlighted that schematic information would be presented as evidence; for example, the anti-coagulation service had been reviewed as a result of patient feedback. The Committee noted the Authorisation process update

64/12 Approved Minutes for Information

Minutes from Contract Review Meeting The Committee noted the minutes of the Warrington and Halton Hospital Foundation Trust Contract Review Meeting held on 20 June 2012.

Minutes from Bridgewater Community Healthcare Trust Community Healthcare Trust The Committee noted the minutes of the Bridgewater Community Healthcare Trust Community Healthcare NHS Trust Clinical Quality and Contract Review Meeting.

5 Boroughs Partnership Trust In draft form will be presented at the next meeting.

Minutes from Transformational Board Gareth Hall highlighted that attendance at the Transformational Board meetings is low. Sarah Baker confirmed that two senior members of the CCG should attend each meeting. The outcomes need to link into the Health Summit and Commissioning Board Meetings.

Minutes from Integrated Commissioning Board



The inaugural meeting of this Board is yet to take place.

65/12 Any Other Business

Pamela Broadhead reported that there had been one bidder in the North of England Any Qualified Provider process for the incontinence service. Bridgewater Community Healthcare Trust was the successful contractor.

66/12 Date and Time of Next Meeting The next Finance and Performance Committee meeting will take place on 26 September 2012 at 8.30 a.m. in the Boardroom at Millennium House.




FINANCE & PERFORMANCE COMMITTEE HELD ON WEDNESDAY 26 SEPTEMBER 2012 AT 8.30 A.M. IN THE

BOARDROOM, MILLENNIUM HOUSE

MINUTES Present: Dr Dan Bunstone (Chair) GP Dr Simon Redfearn GP Dr Sarah Baker Chief Clinical Officer Iain Crossley Chief Finance Officer Gareth Hall Lay Member of the Board In Attendance: Pam Broadhead Head of Contracts Nicholas Armstrong Chief Operating Officer Cheryl McKay Head of Programmes David Cooper Head of Financial Management Matthew Cripps Improvement Director Julie McCarthy Executive Assistant (minutes) Tim Ashcroft Innovas Nick Clay Innovas A Apologies: None Recorded Action:

The meeting did not run in the order of the agenda.

B The Chair confirmed that the meeting was quorate.

C Declarations of Interest There were no declarations of interests in agenda items. Dr Simon Redfearn and Dr Dan Bunstone confirmed that they are GPs in Warrington.

D Minutes of the previous meeting held on 4 September 2012 The minutes of the previous meeting held on 4th September 2012 were accepted as an accurate reflection of the discussions with the exception of: Page 9 – The action on page 9 is the responsibility of Pam Broadhead and not Nicholas Armstrong.

E Actions and matters arising from meeting held on 4th September 2012 Action No 53 – Liaison Psychiatry Action on-going – it was confirmed that discussions are continuing and they are still in the six month pilot phase. This action will now be attributed to Pam Broadhead as Lesley MacLeod is no longer with the



organisation. Outstanding Action from 25 July 2012 - Contracts and funding Action complete - Pam Broadhead will present this report to the Finance and Performance Committee in this meeting. Outstanding Action from 25 July 2012 - Winter Contingency Plan Action complete – Nicholas Armstrong confirmed that the plan will be discussed at the GP Protected Learning Time Outstanding Action from 25 July 2012 – Quality, Innovation, Productivity and Prevention Savings Action complete – David Cooper confirmed that the savings will be presented to the Committee in this meeting. Outstanding Action from 25 July 2012 – Market Analysis Report Action complete – Matthew Cripps confirmed that the Market Analysis Report had been circulated and there would also be a presentation to the Committee in this meeting. Action No 67 – Over Activity Action complete – David Cooper tabled a document which showed the activity for April – July across two financial years for the CCG registered population with contracted providers only. The table highlighted that the activity driven by Warrington and Halton Hospital Foundation Trust is:

93% accident and emergency activity 94% on-elective 70% out-patients 80% in-patients

David Cooper reported that there had been a 60% rise in referrals to Central Manchester and there had been an increase in referrals to Spire; in-patient elective care to the Royal Liverpool hospital had increased by 30%. In summary, Warrington and Halton Hospital Foundation Trust drives the total activity. Sarah Baker thanked David Cooper for the information and asked for the detail to be broken down into specialities; the information will be useful for when the contingency plan is devised. Action No 68 and 69 – Better Payment Practice/ Baseline Dashboard



Action complete – David Cooper reported that there had been a significant improvement in the number of Non-PO invoices being raised. Action No 70 - Data Action complete - This action was for Pam Broadhead and not Nicholas Armstrong - a request has been made for the data to be displayed by speciality and not aggregate.

F Chair’s Remarks

The Chair welcomed everyone to the meeting and thanked all for their support before and during the Authorisation visit. The Chair confirmed that Iain Crossley is leaving Warrington CCG to take up the Chief Finance Officer post at Greater Preston & Chorley and South Ribble CCGs. Iain Crossley advised that a leaving date is yet to be confirmed but he assured the Committee that he would continue with his role as Chief Finance Officer within Warrington CCG until a formal handover could be done, probably by Christmas; he will work jointly across Warrington and Greater Preston & Chorley and South Ribble CCGs but will relinquish responsibilities with the Cluster. Sarah Baker confirmed that a secure plan for the future of the organisation is in place; the Chief Finance Officer post will go out to external recruitment; a full time Chief Finance Officer is required. The interview process will be designed to ensure that the right person is recruited to fit in with the existing team. The Chair thanked Iain Crossley for the work he has done.

68 12

Financial Update 2012 -13 – Presentation for Month 5

Iain Crossley confirmed to the Committee that the current financial position for the CCG is that it is:

In financial balance Paying back £2m to Strategic Health Authority The Local Improvement Finance Trust buildings are complete

and there is no further capacity (the Ophthalmology Department from Warrington and Halton Hospital Foundation Trust is not moving into the Town Centre development.)

The presentation gave an overview to the Committee on:

SHA Review – Financial challenges Achievement of financial balance Current challenges from Warrington and Halton Hospital

Foundation Trust, Quality, Innovation, Productivity and



Prevention, Historic Debt, Local Improvement Finance Trust buildings, Organisational change, CCG Authorisation

Financial Strategy 2012-13 Progress at Month 5 Savings Plan Performance M5 Hospital Activity for Referrals, Electives, Non Elective,

Emergency Savings for Unplanned Care and Planned Care Reserves Reserve Forecast

It was highlighted that the activity at Warrington and Halton Hospital Foundation Trust did not reduce in August as it usually does over a holiday period; Gareth Hall suggested that it might reduce in September. Cheryl McKay stated that the hypothesis keeps changing – as the one pressure is addressed – a new set of problems arises. Iain Crossley explained the original plan had been to support the acute sector non recurrently and facilitate the development of primary and community care services in 2013/14; if the activity continued to grow at current levels the CCG was effectively committing all the reserves into the acute contract and would have no headroom to cover winter pressures and no development funds going forward. Dr Sarah Baker asked if the GPs could be appraised of this information at the Protected Learning Time Session on Thursday 27 September 2012 as the GPs need to be aware of the economy within which they are operating. Dr Simon Redfearn highlighted the importance of delivering the contingency plan; this would be considered later on the agenda. above information should be used when the contingency plan is devised. 2012-13 Quality, Innovation, Productivity and Prevention Performance – Month 5 David Cooper tabled a document highlighting the Quality, Innovation, Productivity and Prevention Performance for month 5. It was reported that:

2012-13 Transformational Quality, Innovation, Productivity and Prevention Programme collective total is £15,227,000

The Quality, Innovation, Productivity and Prevention year-end forecast delivery total is £11,087,000

The Balance of Quality, Innovation, Productivity and Prevention Savings (linked to secondary care activity) total is £4,190,000

The secondary care performance was detailed as being: Current over-performance with Warrington and Halton

Hospital Foundation Trust £3,173,000



Significant activity reductions are required to bring back in line with plans over the coming6 months: Total Planned Care Activity is £1,604,000 overspent Total Unplanned Care Activity is £1,569,000 overspent

Two graphs were presented showing the unplanned and planned care - the actual performance, historic trend and a plan for zero growth. It was reported that there was a definite increase in activity after April as this information was being reported under the full terms of payment by results although this was subject to commissioner challenge and the imposition of any contract compliance issues. Iain Crossley reported that £7m is being kept in reserve for pressures, including winter; of this amount £2.9m has already been used to buffer other pressures. Sarah Baker highlighted that the reserves need to be in a different part of the system, the cycle of over activity and how to address it needs to be addressed so that a constant inroad on reserves can be prevented. Pam Broadhead suggested that one way would be to effectively manage the contract in a challenging way. It was agreed that an urgent meeting should take place next week with Warrington and Halton Hospital Foundation Trust to discuss how the contract could be managed within the agreed activity envelope through delivery of the contingency plan. Sarah Baker confirmed that action was required to reduce the contract expenditure over the next quarter as a matter of urgency.

Action: Julie McCarthy to arrange an urgent meeting between Iain Crossley, Sarah Baker, Jonathan Stephens, Mel Pickup.

Julie McCarthy

David Cooper confirmed that there is a forecast outturn of £15m – there are 6 schemes whose budget is net of Quality, Innovation, Productivity and Prevention, these are breaking even or under spending. It was reported that from the £4.1m planned - there is a balance of £1.1m – as discussed there is £1.6m in unplanned care. If 1500 first attendances could be avoided, this would have a positive impact on the rest of the system. Dr Sarah Baker advised that this information should be mapped to contingency planning; there had been some instances where there had been significant overspends i.e. £3.5m on haematology. Pam Broadhead confirmed that Warrington and Halton Hospital Foundation Trust need to challenge themselves in light of their planned and unplanned care spending.



Dr Sarah Baker summarised that the current situation is not acceptable and a culture of income generation needs to be avoided. Urgent action needs to be taken, there is no option to use reserves and the meeting with Warrington and Halton Hospital Foundation Trust needs to take place as soon as possible. Nicholas Armstrong asked what the referral position was for Halton CCG. Pam Broadhead confirmed that the numbers are down but as yet, these figures have not been split from St Helens. David Cooper stated that it is going to be difficult to meet the 18 week targets by speciality; Dr Sarah Baker advised that this should be added to the reporting now. Pam Broadhead confirmed that this information will be added to the Performance Report. The Committee noted the financial update.

69 12 Quality, Innovation, Productivity and Prevention

Cheryl McKay presented the Quality, Innovation, Productivity and Prevention programme report to provide an update in respect of the current position as at 18 September 2012. It was reported that the total required savings from the Quality, Innovation, Productivity and Prevention for 2012/13 is £15,277m of which £6m has been identified in Warrington CCGs current projects in year service reviews. Urgent Care Programme It was reported that the Urgent Care Programme is progressing; the go-live date for the Urgent Care Unit (including Front Door) has slipped slightly. The go-live date is now proposed for November/December, this will be determined by the availability of estate and workforce; at present there is a potential delay due to the Trusts delivery of their estate plan and an issue with IT. Cheryl McKay confirmed that both interim and long term solutions to these problems are being scoped. Cheryl McKay advised that the specifications for the Acute Medical Unit and Surgical Assessment have not been shared with the Urgent Care Delivery Group or Programme Office to date, however the Warrington and Halton Hospital Foundation Trust Management Team have been asked to share the specification With the Urgent Care Delivery Group It was confirmed that GPs and Clinicians are happy with the model, It was reported that the urgent care and front door specification had been drafted by the whole system workstream group and this was being taken to the Urgent Care Delivery Group for review. A focus needs to be maintained on the Front Door project.



It was reported that the bid for transformation monies for urgent care had been unsuccessful; no feedback was given as to why the bid was unsuccessful. Long Term Conditions Programme

The Integrated Care Teams Workstream is progressing. Warrington Borough Council has implemented geographical Social Care teams (generic teams for under/over 65 years) which are co-terminus with the 4 Neighbourhood Teams and the Community Nursing Teams, a workshop is scheduled to review the model and seeks to develop this further.

In relation to the self-management workstream; we have gone back to Angela Douglas to identify it the CCG can have the health Care Scientist funding, as she has been unable to recruit this post. Angela has gone to the Department of Health to see if this is acceptable Children’s Programme Cheryl McKay reported that a meeting to progress the children’s plans took place on the 13th September 2012. The draft plans had been revised to take into consideration the plans for children in respect of the Urgent Care Programme. In terms of the wider children’s programmes , these have been put on hold for the time being while Val Shanks-Pepper discusses some issues in relation to integration with Kath O’Dwyer

Action: Sarah Baker would like to be advised of current progress in children’s services in order that she can feedback to Steve Broomhead.

Cheryl McKay

Frail Elderly Programme It was reported that thirty participants attended a planning workshop on 24 September 2012; the aim of the event was to develop the Frail Elderly Programme. The programme will now require approval from the Health Summit. Work is continuing around care homes; Therese Patten of 5 Boroughs Partnership reported at the Transformation Board, that their trust had received £770,000 of funding to invest in mental health services for care homes. Cheryl McKay stated that it would have been useful to have known about the funding at an earlier stage and it could then have been used to develop a wider range of services for older people rather than just for dementia services. (The funding had not been mentioned in any of the 5 Boroughs Partnership Contract Meeting minutes.)



Dr Sarah Baker reported that a presentation at a recent Health Summit meeting had highlighted that the wealth of work being done by volunteers in the town needs to be harnessed against the priorities of work that needs to be done. Medicines Management Cheryl McKay advised that the Medicines Management Quality, Innovation, Productivity and Prevention Programme is progressing; Cat Doyle is working with 3 practices in primary care within the Phoenix Group who have been capped at 8%.

Planned Care Cheryl McKay reported that a high level review of planned care is progressing and is due to report findings back to this Committee. The review was seeking opportunities to increase the amount of elective activity performed as day case activity, in some areas we are only achieving 20-30% activity as day case, when it should be 75%. The review was not addressing the current over performance in elective care. The services reviews that were scheduled for maternity and gynaecology have not taken place due to issues with capacity within the team. . Matthew Cripps confirmed that the Commissioning Service Unit will undertake this work.

Improving Access to Psychological Therapies Improving Access to Psychological Therapies will be discussed at the next Management Team Meeting. Pam Broadhead confirmed that funding will be paid directly to Mental Health Matters; Warrington CCG will manage the contract.

Key Performance Indicators (KPIs) The information reported from the Key Performance Indicators by Cheryl McKay highlighted that there had been a slight decrease in activity in the Monthly Activity Report (MAR) and Warrington and Halton Hospital Foundation Trust data. The data further demonstrated a decrease in the number is attendances/ admissions in relation to the over 75s. David Cooper advised that over performance for this month had gone flat and there had been no over-performance against the plan. In terms of last years programmes, the KPIs demonstrate a reduction in activity, however in relation to procedures of limited clinical priority (PLCPs), the data demonstrates an increase in activity. . Pam Broadhead advised that the procedures of limited clinical priority that have been carried out did have authorisation/approval codes.



Dr Sarah Baker replied that it would be useful to review the process centre, the CCG needs to have a view about the decisions being made and an internal process is required. A further discussion will take place outside of this meeting.

Action: Dr Sarah Baker to discuss PLCP process. Dr Sarah Baker

The Committee noted the content of the Quality, Innovation,

Productivity and Prevention Programme Report; noted the strategic risks and considered the proposed actions required to address them. The Committee noted the developing 2012/15 Quality, Innovation, Productivity and Prevention Programme. The Contingency Plan was discussed under the next agenda item.

67/12 ii

Quality, Innovation, Productivity and Prevention Contingency Plans Cheryl McKay reported that a workshop had taken place to which Warrington and Halton Hospital Foundation Trust and Bridgewater Community Healthcare Trust had been invited. The Plan was presented to the Transformational Board on 17 September 2012 for discussion. The Committee discussed the plan; it was revealed that activity at Warrington and Halton Hospital Foundation Trust is higher than the national comparators and it seems to be generated internally. David Cooper advised that it is not yet known how much or how fast the contingency plan could be put in place to make savings. Gareth Hall stated that he believed Warrington CCG had been reasonable and patient and it was now time for firm discussions to take place with Warrington and Halton Hospital Foundation Trust to request that an increase in activity is controlled. Gareth Hall asked would it be possible for the Management Team from Warrington and Halton Hospital Foundation Trust to be invited to discuss the over activity at the CCG Warrington Finance and Performance Committee. Dr Sarah Baker agreed that the current situation should be escalated to Mel Pickup. The Committee agreed that if after the joint meeting to discuss Finance the situation does not improve – relevant members of the Warrington and Halton Hospital Foundation Trust Management Team



will be invited to the Finance and Performance Committee as they need to be held to account.

The Committee noted the progress in implementing a Contingency Plan.

70/12

Performance Report

Pam Broadhead presented the Performance Report to the Committee. It was reported that:

There have been two cases of MRSA in one month (which is a concern as this is the limit for the year.)

All other issues relate to 18 weeks – trauma and orthopaedic and cancer – this target is on red and it relates to one patient.

Diabetes UK were disappointed with recent data and a report has been requested from Public Health.

Health checks - Dr Sarah Baker stated that the vague reporting surrounding health checks was inadequate and a plan should be included in the information.

Action: Cheryl McKay will meet with Dr Rita Robertson and her team to discuss the anomalies surrounding health checks, a letter should be drafted to Rita to endorse the fact that the take up needs to be improved.

Cheryl McKay/ Dr Sarah Baker

Dr Sarah Baker highlighted that the presentation style of the dashboard was good. Gareth Hall stated that we do have Memorandum of Understanding with Public Health. Iain Crossley reported that good relationships with the new Commissioning Services Unit Performance Team are being encouraged. Pam Broadhead stated that the team is aware of the information that Warrington CCG require. Dr Sarah Baker stated that the overall status for the CCG is positive with a RAG (red/amber/green) rating of green. Dr Simon Redfearn stated that the only exception is the health check system that is on red. Dr Sarah Baker emphasised that the delay with health checks needs to be addressed as the CCG Accountable Officer is responsible for the pathway within the Cluster. If necessary, Public Health will need to be performance managed to ensure that the health checks take place.



67/12 i Innovas Presentation – Market Analysis Matthew Cripps provided a context behind the invitation to Innovas to present to the Committee. They were asked 10 months ago to carry out some market analysis to gain an understanding of the healthcare market. Tim Ashcroft and Nick Clay presented the report to the Committee. It was confirmed that Warrington CCG gained a high score against other key trusts but they are not taking advantage of other providers within the market. The presentation covered:

The analysis of the current market and local provision of health services

Emerging commissioning opportunities New market opportunities Decisions and next steps on informed policy and strategy

options Potential for further analysis

David Cooper stated that to use other providers the CCG has to have a contract in place. Dr Sarah Baker thanked the team; the analysis had been helpful but it had not really provided any new information to what the CCG was already working to. The issues around workforce would be considered in more detail; however technology is already moving forward. Gareth Hall suggested that the findings are picked up separately in a Governing Body Development Session. Tim Ashcroft summarised that the information would help the Board to make informed decisions. The Committee agreed that this would be a way forward, noted the content and thanked Innovas for their time.

72 Contract Transition Update

Pam Broadhead presented a contract transition update for the Committee. It was reported that a full database holding details of agreements for all healthcare services is in place and agreements are currently being stabilised. Guidance is still awaited from the Cheshire Warrington and Wirral Cluster as to which contracts will be placed where. Contracts in the name of Warrington Primary Care Trust currently being shadow



managed by Warrington CCG or Public Health will transfer on 31 March 2013. There is a risk in this transfer period that incorrect payments to providers may result; some agreements may have a period of being managed by multiple commissioners. The Committee noted the financial risk to Warrington CCG

73 Procurement Healthcare

Iain Crossley presented to the Committee a report by the National Commissioning Board. It was reported that as part of the authorisation process the CCG will be required to declare that the CCG is compliant with current statutory and policy-led procurement requirements and will have systems in place to discharge those requirements. The CCG will therefore need to ensure that such systems are in place. The Committee noted the report.

74 i ii iii iv v

Minutes from Contract Review Meeting There were no issues to escalate from the minutes of the Contract Review Meeting that was held on 18 July 2012. The Committee noted the Minutes. Minutes from Bridgewater Community Healthcare Trust Contract Meeting There were no issues to escalate from the minutes of the Bridgewater Community Healthcare Trust Meeting held on 22 August 2012. The Committee noted the Minutes. Minutes from 5 Boroughs Partnership Trust There were no issues to escalate from the minutes of the 5 Boroughs Partnership Meeting held on 5 September 2012. The Committee noted the Minutes. Minutes from Transformational Change Board There were no issues to escalate from the minutes of the Transformational Change Board Meeting that was held on 23 July 2012. The Committee noted the Minutes. Minutes from Integrated Commissioning Board The minutes will be available for the next meeting.



71/12 Authorisation Update Nicholas Armstrong confirmed that the panel had visited on 20 September 2012. The process had been rigorous – work will continue to ensure that all Key Lines of Enquiry will all meet the requirements of the reviewing body.

75/12 Any Other Business There was no additional business to discuss

76/12 Date and Time of Next Meeting The next Finance and Performance Committee meeting will take place on 24 October 2012 at 8.30 a.m. in the Boardroom at Millennium House.

WARRINGTON CLINICAL COMMISSIONING GROUP ... Papers...Commissioning, Matthew Cripps, Improvement...

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